title: Mechanisms of behavior change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms?
abstract: BACKGROUND
  Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects.
  
  
  METHODS
  Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.
  
  
  RESULTS
  Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking.
  
  
  CONCLUSIONS
  AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.
authors.affiliation: Center for Addiction Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA. jkelly11@partners.org
authors.forename: John F
authors.initials: JF
authors.lastname: Kelly
authors.forename: Robert L
authors.initials: RL
authors.lastname: Stout
authors.forename: Molly
authors.initials: M
authors.lastname: Magill
authors.forename: J Scott
authors.initials: JS
authors.lastname: Tonigan
authors.forename: Maria E
authors.initials: ME
authors.lastname: Pagano
mesh_terms: D000328:Adult; D000339:Affect / Q000187:drug effects; D000436:Alcoholics Anonymous; D000437:Alcoholism / Q000523:psychology / Q000534:rehabilitation*; D000704:Analysis of Variance; D015928:Cognitive Behavioral Therapy / Q000379:methods; D003863:Depression / Q000175:diagnosis / Q000628:therapy*; D005260:Female; D006126:Group Processes; D006801:Humans; D016014:Linear Models; D008297:Male; D011569:Psychiatric Status Rating Scales; D055502:Secondary Prevention; D012944:Social Support; D016896:Treatment Outcome