Alcohol and mental health - what do we know?

Jo-Anne Puddephatt and Dr Laura Goodwin are researchers at the University of Liverpool’s Addiction research group. They are working to understand the reasons why people drink alcohol and how we can help them to cut down. In this blog they explain i) the links between mental health and alcohol use, ii) what the current gaps in research are and iii) how we should provide appropriate treatment.

Around one in six adults in England have depressive and anxiety symptoms, also known as ‘common mental disorders’ (CMD) [1,2]. We also know that around 3% of adults drink harmfully or are alcohol dependent. If you are drinking at a level that causes damage to your physical and mental health it is known as ‘harmful use’ [3], and can also involve signs of addiction to alcohol (known as dependence) [4].

We often see people suffering with mental health and alcohol problems at the same time; this is called comorbidity [5]. More specifically, individuals with alcohol problems are twice as likely to have an anxiety disorder and three times as likely to have major depression [6].

So we know alcohol and mental health are linked. But does heavy alcohol use result in worsened mental health, or does a decline in mental health lead to an increase in alcohol consumption?

Low level alcohol use is often believed to have some short-term positive effects on mental wellbeing, for example stress relief and improved mood [7,8]. In the long term, however, alcohol has been shown to lower mood [9,10] and increase anxiety [11].

The self-medication theory suggests that those with a mental health problem might use alcohol as a coping technique [12]. However, coping in this way may worsen the mental health problem. Research following people over 12 years shows that a decline in someone’s mental health is often linked to an increase in alcohol use [13]. All of this suggests that there is a cyclical relationship between mental health symptoms and alcohol use.

There may be differences in drinking patterns among those with mental health problems.

Research in the UK has found that individuals who reported having given up drinking were more likely to have a mental health problem, and more than 50% reported that their main reason for not drinking was health-related [14].

However, individuals with a mental health problem are also more likely to report problematic drinking behaviours [15]. A recent review found that 20% of those admitted to hospital were drinking harmfully , with harmful use even more common in mental health inpatient units [16].

Other research also suggests that those with a mental health problem are more likely to drink at either end of the spectrum; for example, we found that personnel in the UK military with post-traumatic stress disorder were more likely to be either non-drinkers or heavy drinkers [17].

This suggests that there are differences in drinking patterns among those with a mental health problem and it may be that abstinence or problem drinking is more common among this population. The reasons for this variation could be due to the use of different coping techniques to manage mental health, though it is not clear what the differences are between those who find it helpful not to drink and those who drink heavily, or how it might relate to whether they have previously sought treatment for their mental health problem.

Despite the figures showing the association between heavy drinking and mental health problems, treatment for mental health and alcohol problems is often separate, with many alcohol treatment options being provided outside of the NHS, for example by charities [18]. This can mean that people with both alcohol and mental health problems aren’t able to access the integrated treatment that would be most beneficial. In addition, some people aren’t able to access support at all, with alcohol treatment services unable to support those with mental health problems and mental health services often require drinking to be reduced before treatment can begin.

A recent report highlighted the lack of access to treatment for people with alcohol and mental health issues and how this may have worsened due to shortages in funding. This may particularly impact vulnerable groups, such as the homeless [18].

In 2017 Public Health England released a report urging the need for an integrated pathway to treat those in a mental health crisis who might have a co-occurring alcohol problem [19]. This indicates that comorbidity is being recognised as a priority. But with research suggesting a relationship between alcohol and mental health, it is likely that alcohol and mental health problems need to be treated in parallel to improve treatment outcomes, not just at moments of crisis. Although change is moving slowly, some NHS trusts have begun to implement a plan to address and improve access to both mental health and alcohol services, regardless of whether a person has a co-occurring alcohol and mental health problem or not.

As well as improved treatment pathways, more research is needed to better understand comorbidity. As part of our PhD project funded by the Society for the Study of Addiction we will explore how common alcohol use is in those with different mental health problems compared to those without a mental health problem. This should provide a better understanding of comorbidity and how it differs across different types of mental health problems. Our published research to date can be found here.

We think that our research, using the most recent national data, will show that individuals with a mental health problem have a greater need for alcohol treatment. This will further highlight the importance of providing better integrated treatment pathways.

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[2] World Health Organization. Depression and Other Common Mental Disorders: Global Health Estimates.: World Health Organization; 2017.

[3] Drummond C, McBride O, Fear N, Fuller E. (2016) ‘Chapter 10: Alcohol dependence’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

[4] National Health Service. (2019) Overview: Alcohol misuse. Retrieved on 16^th August 2019. [Available from https://www.nhs.uk/conditions/alcohol-misuse/]

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[8] Kuntsche, E., Gabhainn, S. N., Roberts, C., Windlin, B., Vieno, A., Bendtsen, P., ... & Aasvee, K. (2014). Drinking motives and links to alcohol use in 13 European countries. Journal of Studies on Alcohol and Drugs, 75(3), 428-437.

[9] Griffin, C., Freeman, M., Adams, S., & Smith, P. (2018). ‘All suffering together’: student drinkers’ experiences of alcohol hangover. Addiction Research & Theory, 26(6), 533-540.

[10] Crum, R. M., Mojtabai, R., Lazareck, S., Bolton, J. M., Robinson, J., Sareen, J., ... & Storr, C. L. (2013). A prospective assessment of reports of drinking to self-medicate mood symptoms with the incidence and persistence of alcohol dependence. JAMA Psychiatry, 70(7), 718-726.

[11] Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clinical psychology review. 2000;20(2):149-71.

[12] Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-244.

[13] Bell, S., & Britton, A. (2014). An exploration of the dynamic longitudinal relationship between mental health and alcohol consumption: a prospective cohort study. BMC Medicine, 12(1), 91.

[14] Skogen, J. C., Mykletun, A., Ferri, C. P., Bebbington, P., Brugha, T., Coid, J., ... & Stewart, R. (2011). Mental and personality disorders and abstinence from alcohol: results from a national household survey. Psychological Medicine, 41(4), 809-818.

[15] Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W., ... & Kaplan, K. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 2004;61(8), 807-816.

[16] Roberts E, Morse R, Epstein S, Hotopf M, Leon D, Drummond C. The prevalence of wholly attributable alcohol conditions in the United Kingdom hospital system: a systematic review, meta‐analysis and meta‐regression. Addiction. 2019;114(10):1726-37.

[17] Goodwin, L., Norton, S., Fear, N. T., Jones, M., Hull, L., Wessely, S., & Rona, R. J. Trajectories of alcohol use in the UK military and associations with mental health. Addictive Behaviors, 2017;75, 130-137.

[18] Institute of Alcohol Studies. Alcohol and Mental Health: Policy and Practice in England 2018 [Available from: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp31042018.pdf]

[19] Public Health England. Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide for commissioners and service providers. 2017 [Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/625809/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf]