Sign up for alerts

Winter 2008/09 | Vol 12 No 2

Q & A

Common questions about alcohol and mental health problems

By Avril Roberts

This Q&A draws on published research and interviews with clinicians to examine challenges for diagnosis, treatment and recovery related to co-occurring alcohol use and mental health problems.

What is the prevalence of co-occurring alcohol dependence and mental health disorders?

Research suggests that the prevalence of alcohol use problems among people with mental health problems is about twice that of people with no mental health problems. Of those with mental health problems, men are more than twice as likely as women to report alcohol use problems. The most common mental health problems to co-occur with alcohol use problems are anxiety disorders, particularly generalized anxiety disorder and post-traumatic stress disorder; mood disorders, particularly major depression and bipolar disorder; schizophrenia; and personality disorders. Alcohol use and mental illness each increase suicide risk, but together, they increase the risk substantially, particularly for people with major depression.

Is there a causal link between mental health problems and alcohol use problems?

The relationship between alcohol use problems and mental health problems is complex. Many scenarios are possible: First, the psychiatric disorder may result in an alcohol problem; for example, a person with depression may self-medicate with alcohol. Second, the psychiatric disorder (or its symptoms) may occur as a consequence of alcohol use; for example, a person may experience alcohol-induced hallucinations that persist after abstinence. Third, the alcohol use problems and mental health problems may develop simultaneously and follow a similar course; for example, hallucinations associated with schizophrenia may increase with alcohol use but may disappear or lessen with abstinence. It is also possible that neither disorder causes the other, but that the two have become linked over time, such that they become an integrated system and each alters the trajectory of the other. Finally, the problems may simply co-occur and co-exist with no interrelationship; for example, a person with depression and alcohol dependence may experience no relief of depression symptoms during prolonged abstinence. Whatever the nature of the relationship, alcohol use may exacerbate some mental health conditions, for example, bipolar disorder, and may make them more difficult to treat.

How difficult is it to diagnose co-occurring mental health and alcohol use problems?

Proper screening is key, says Carol Edwards, an advanced practice nurse in the Addictions Program at the Centre for Addiction and Mental Health (CAMH) in Toronto: “It is important to screen mental health clients for alcohol misuse because the combination is so prevalent. Also, be alert to the possibility that mental health problems can exist with alcohol dependence.” Diagnosis is complicated by the fact that the signs and symptoms of alcohol dependence and alcohol withdrawal can mimic psychiatric disorders. Depressive symptoms and mood instability are common in people who use alcohol and other alcohol, so those people may often be misdiagnosed or diagnosed too early with a mood disorder, when in fact their mood symptoms are being driven by their use of alcohol or other drugs. Clinicians advise that when it is questionable whether an individual has a mood disorder, it is important to observe them over a period of abstinence to get a better sense of whether the mood disorder is separate from the substance use or whether it is driven by it.

Are drinking patterns related to specific mental health problems?

Conventional wisdom suggests that people with social anxiety may initially use social drinking as a coping mechanism, and then find the alcohol use spiraling into alcohol dependence. However, the opposite can also be true. U.S. researchers have found that both long-term alcohol misuse and alcohol withdrawal can significantly increase anxiety levels. As well, having an anxiety disorder increases the risk for drinking relapse after alcohol treatment. A 2007 Canadian study that examined associations between depression and alcohol consumption in men and women found that binge drinking was strongly related to major clinical depression, particularly in women.

Do co-occurring problems complicate treatment?

Symptoms can interfere with the person’s ability to participate in a treatment program or type of program. For example, a person who is psychotic and experiencing perceptual disturbances on an ongoing basis will not do well in a residential addiction treatment facility. Similarly, a person with social anxiety may be ill-suited to living in a dormitory-type environment with communal dining.
Treatment for individuals who use alcohol to self-medicate may be challenging. For example, women who have experienced trauma such as sexual abuse may use alcohol to escape the emotional and psychological consequences. During treatment for the alcohol use problem, either the trauma recovery work or becoming sober can trigger the trauma symptoms they were trying to cope with through alcohol. With the alcohol coping mechanism gone, women often experience an increase in trauma symptoms, which, in turn, jeopardizes their abstinence.

What is the best treatment approach for co-occurring mental health and alcohol use problems?

Historically, the problem has been that many alcohol treatment programs exclude people with mental health problems and that mental health programs refuse treatment to people with active alcohol use. Persisting differences in treatment philosophy may hinder access to appropriate treatment and supports. For example, some 12-step addiction recovery programs may be wary of people taking required medications for their mental health problem because they are drugs. Some mental health programs require abstinence and do not recognize that relapse is common during recovery.

A lack of integrated services in addiction and mental health means that many people living with co-occurring mental health and alcohol use problems, as well as other substance use problems, receive inadequate and uncoordinated care, bounce between the substance use and mental health systems, have high rates of emergency department visits and hospitalizations and have poorer treatment compliance and outcomes. However, comprehensive, co-ordinated and integrated treatment that uses evidence-based approaches can improve outcomes for individuals with concurrent disorders. Early identification and treatment allow services to provide prompt assessment, treatment and support and potentially reduce the duration of untreated illness. If a person has schizophrenia and an alcohol use problem, the mental health disorder requires medication treatment and ongoing supportive therapy and the alcohol use problem may be treated using substance use management principles, such as behavioural management.

Are there any medications used for alcohol problems or mental health problems that can be used to treat both problems?

The current options for the pharmacological treatment of alcohol dependence are naltrexone, acamprosate and disulfiram (see pp. 8–9). There are currently very limited options for medications that are helpful for both mental health and alcohol use problems. Despite the high rates of concurrent disorders, very few controlled treatment studies have been conducted in people with co-existing alcohol dependence and psychiatric disorders. There is some data suggesting a modest benefit with antidepressant medication for the treatment of depression and alcohol dependence, however, it is recommended that treatment for depression be combined with alcohol-specific interventions. Many clinicians agree that medication should not be the mainstay of treatment for a person with alcohol dependence but that it should be used in conjunction with psychosocial rehabilitation.

Other medications used in the treatment of mental health disorders (e.g., topiramate, carbamazepine, valproate) are being studied for the treatment of alcohol dependence. The most promising evidence to date is for topiramate, although the studies have included only people with alcohol dependence.

Has the rise in treatments for concurrent disorders increased the risk of negative drug interactions? If so, how can clinicians avoid such problems?

Although the potential for interactions between medications used in the treatment of mental health disorders is significant, the reality is that often more than one medication is needed. Often these combinations can be managed by carefully evaluating and adjusting each medication. Fortunately, the medications currently used in the treatment of alcohol dependence, particularly acamprosate, are associated with fewer interactions. Clinicians should always check for the possibility of interactions whenever a new medication is added to a pharmacotherapy regimen. Pharmacists are a great resource to help with this. It is also important to consider the potential for drug interactions with alcohol among clients with mental health problems. This risk varies depending on the mental health medication. It is important for clinicians to discuss the level of risk with clients. If clients are simply told that they should not drink while taking the medication, they may choose to stop the medication instead.

Sources: Best Practices: Concurrent Mental Health and Substance Use Disorders, Health Canada, 2002; Beth Sproule, advanced practice pharmacist, Centre for Addiction and Mental Health (CAMH), Toronto; Carol Edwards, advanced practice nurse, Addictions Program, CAMH; “Comorbidity of alcoholism and psychiatric disorders: An overview,” Alcohol Research and Health, 2002; “Follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients,” Alcoholism: Clinical and Experimental Research, 2005;
Dr. Paul Casola, consulting psychiatrist, Salvation Army Harbour Light Centre, Toronto; “Prevalence of Co-occurring Substance Use and Other Mental Disorders in the Canadian Population,” Canadian Journal of Psychiatry, 2008; “Use of health care services by patients with co-occurring severe mental illness and substance use disorders,” Mental Health and Substance Use: Dual Diagnosis, 2008.