Alcohol and mental health: how can we better support those with co-occurring problems?

It often comes as a surprise to some to learn that our mental health can be affected by how much we drink. There are still lots of unknowns around the complexities of the relationship between alcohol use and mental health but here we explore some of the main issues.

When feeling depressed, some people may use alcohol to help relieve tension and to overcome feelings of social isolation, due to its short-term effects. Alcohol is more likely to be used to self-medicate many different mental health symptoms, compared to other illicit substances, due to its availability and social acceptability.

Research shows that those of us with different mental health problems are more likely to drink more harmfully than those without, including those with depression, anxiety, post-traumatic stress disorder (PTSD) and psychosis [1-3]. Much of my research has focused on the association between PTSD symptoms and alcohol use, finding that individuals who experience avoidance symptoms - who are trying to block out previous traumatic experiences - are more likely to drink harmfully. However, we also know that if you have a mental health problem you are more likely not to drink, so not everyone responds in the same way [4].

A potential consequence of using alcohol to cope with mental health problems is that it may delay formal help seeking. In a collaborative project between the University of Liverpool and King’s College London (funded by Forces in Mind Trust), we investigated who recognises and then seeks help for alcohol problems among UK serving and ex-serving personnel, who are known to be more likely to have mental health and alcohol problems compared to the general population. We found that only about half of serving and ex-serving personnel who were drinking at a harmful level thought that they had a problem with their drinking, suggesting that the other half were therefore unlikely to try and reduce their drinking or to do anything about the problem. We found that those with a co-occurring mental health problem were more likely to recognise their alcohol problem.

Of those who said they had an alcohol problem only a third had sought any help or support, with GPs being the most common source of support accessed. Individuals who had a mental health problem as well as an alcohol problem were no more likely to seek help, even though they had a greater need for this support. Our research suggests that there is an unmet need in this population, requiring better awareness of available alcohol treatment services within military personnel and a need to change the conversation around alcohol in a military context to reduce the stigma.

Harmful drinking increases the risk of most physical health problems [5] and those of us with a mental health problem, such as depression, also tend to have poorer physical health and live around 10 years less than those without a mental health problem [6]. Despite the fact that mental health problems and harmful drinking often occur together, we know less about the future physical health of those who have experienced both. So, this is an area of work that we’ll be exploring in collaboration with King’s College London, the University of Sheffield and Columbia University. As part of this, we will also explore how we can change current healthcare practices, for example from the GP, to identify physical health problems earlier on and to try and reduce the life expectancy gap for those with co-occurring problems.

Given all of the above it may be surprising to learn that it is currently not typical for individuals with a mental health problem to receive more support around their drinking compared to those without a mental health problem.

For example, whilst GPs are required to conduct alcohol screening (i.e. ask people how much they drink) in individuals who have a serious mental illness (SMI), such as schizophrenia, this is not the case for those with a common mental disorder (such as depression or anxiety), experienced by around 1 in 6 individuals and much more common than SMIs [7]. So we’ll be looking into this too to examine whether alcohol screening is more likely to be conducted in individuals with a CMD, SMI or those without a mental health problem, what the outcomes of this screening are, and to determine if the guidance for GPs should be updated to also cover individuals with a CMD.

Due to the complexities surrounding these issues, there is an urgent need to do more to integrate mental health and alcohol services so that people with co-occurring problems do not lose out from receiving the best care. This is not an easy problem to resolve and there has been some progress made in the past 10 years [8]. However, following the 2012 Health and Social Care Act, all alcohol and substance use services are now commissioned by Local Authorities which has resulted in many changes to the treatment landscape. Yet mental health services continue to be commissioned through the NHS which presents a challenge for policy-makers trying to better integrate mental health and alcohol services. This together with the subsequent reductions in funding for alcohol treatment services by Local Authorities [9] could allow some of the most vulnerable people in society to fall through the cracks.

As well as more joined-up services, there is a need for more integrated training packages given that mental health professionals report that they have not received the training they need on how to support people with alcohol problems and those in alcohol treatment services report the same knowledge gap regarding provision of mental health support [10]. We hope that our research will highlight the need for this and provide guidance to healthcare commissioners on the changes required to existing services that will benefit those with co-occurring problems.

This blog was updated on 1 December 2020.

[1] Lai, H.M., et al., Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990-2014: A systematic review and meta-analysis. Drug Alcohol Depend, 2015. 154: p. 1-13.

[2] Debell, F., et al., A systematic review of the comorbidity between PTSD and alcohol misuse. Soc Psychiatry Psychiatr Epidemiol, 2014. 49(9): p. 1401-25.

[3] Hartz, S.M., et al., Comorbidity of severe psychotic disorders with measures of substance use. JAMA psychiatry, 2014. 71(3): p. 248-254.

[4] Goodwin, L., et al., Trajectories of alcohol use in the UK military and associations with mental health. Addict Behav, 2017. 75: p. 130-137.

[5] Griswold, M.G., et al., Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 2018. 392(10152): p. 1015-1035.

[6] Chang, C.K., et al., Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One, 2011. 6(5): p. e19590.

[7] Stansfeld S, et al., Common mental disorders: Adult Psychiatric Morbidity Survey 2014. . 2016, NHS Digital.

[8] Public Health England, Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide for commissioners and service providers. 2018, PHE: London.

[9] Roberts, E., M. Hotopf, and C. Drummond, The relationship between alcohol-related hospital admission and specialist alcohol treatment provision across local authorities in England since passage of the Health and Social Care Act 2012. The British Journal of Psychiatry, 2020: p. 1-3.

[10] Institute of Alcohol Studies, Alcohol and Mental Health: Policy and Practice in England 2018, IAS: London.