Depression, Anxiety and Drinking: How Alcohol Consumption and Psychological Disorders are Related—a Review of Current Literature

It seems that, at this point, there is little debate as to whether or not a relationship exists between alcohol and the brain. Study after study has shown that comorbidity of alcohol consumption and psychological effects are high. The incidence of both anxiety and depression is often shown to be increased in individuals who consume alcohol. To what degree this is true, however, and in what capacity, is not yet certain. Are people who consume alcohol more like to become depressed, or does depression foster the likelihood of alcoholism? While many studies offer many different results, depending upon various factors, it does seem that alcohol is a definite concern for those battling depression and anxiety, specifically. Taking into account a sample of recent research, it becomes apparent that the connection is important but unclear. Certain studies aim to find if there is a connection between gender, consumption and psychological disorders, while others do not even consider gender. Others hope that a study of cognitive function as it relates to consumption and psychological disorders will make for a better understanding of how each is connected. There are some studies that have argued there is no relevant connection between alcohol consumption and others have responded in kind.

Alcohol abuse and dependency are very problematic issues, and it is likely that they do play a role in anxiety disorders and depressions; however, to what extent any alcohol consumption (not just excessive levels) affects an individual’s likelihood of experiencing anxiety and/or depression is definitely unclear. It is apparent that all of these issues (e.g. consumption, dependence, depression, anxiety, gender, etc.) play a role. It is apparent they are connected. The following research aims to understand just how. It is not always successful, and much research is still needed, but any well thought out, competent addition to the discussion should be welcome.

Shuckit’s 1994 study told its readers that nearly 90 percent of adult Americans drink alcohol with “perhaps” anywhere between one third and one half of them experiencing some temporary to long-term alcohol-related issue (p. 28). The “perhaps” does not instill confidence in the study; however, the article admitted that most people, whether or not they admit to alcohol consumption of any amount, do report having mood swings periodically and that nearly everyone—again, independent of alcohol consumption—have experienced depression at severe levels such as major depression, whether clinical or not (e.g., during periods of grief), so it can be difficult to separate this from information regarding alcohol’s involvement. The study further clarifies these findings:

The high prevalences of drinking and of sadness mean that a very large proportion of individuals in western cultures have both had experience with alcohol, sometimes including problems, and demonstrated moodiness, sometimes including severe depression related to adverse life circumstances.

Of course, it is important to distinguish these experiences from the severe and persistent alcohol-related life problems that form the core of alcohol dependence (seen in 5 % to 10 % of the general population), and the intense experience of months on end of debilitating mood and vegetative symptoms consistent with major depressive disorders. (p. 28)

The study stressed the importance of being able to make a distinction between depression related to alcohol consumption and major depressive disorders which occur independently of alcohol consumption. It cited a study done of 577 men who had recently entered rehab. It found that more than 80 percent of the men stated that they had been “very sad” during at least one point in their lives. One-third of them reported depression lasting longer than two weeks. What is interesting to note is that after a history of each patient was taken, around 5 percent could report depression at a time when they weren’t also consuming alcohol. Shuckit believed this shows that the remaining 75 percent were experiencing complications from their heavy drinking (29). Studies like this help to show that depression is likely brought on by heavy drinking, and not, in most cases, the other way around. They do also, however, offer few treatment options for this kind of depression (e.g., depression brought on by drinking) as these periods of depression are usually short-lived and would be over before medication could take hold. This was an important study as it brought to light the fact treatment for these types of depression is difficult, but that most depression brought on by heavy drinking is temporary. However, what it also calls for is the need for specificity of language in studies.

Boden and Fergusson’s 2010 study brought to light some interesting findings regarding alcohol use disorder and major depression, but these findings are not necessarily accurate. Boden and Fergusson claimed, rightly so, that there are three possible relationships between alcohol use disorder. They listed: “(i) AUD causes MD; (ii) MD causes AUD (referred to as the ‘self-medication’ hypothesis [42]); and (iii) a reciprocal causal relationship between AUD and MD, such that each disorder increases the risk of the other disorder simultaneously” (p. 909). The study comes out on the side of alcohol use disorder causing depression. They offer several reasons as to why, including genetic factors and alcohol causing metabolic changes in the individual. These factors contributing to major depression may be true, but whether it is enough to make the claim that AUD causes MD is still up for debate.

As Kenneth Conner argues in his 2011 review of their study, “Commentaries on Boden and Fergusson: Clarifying the relationship between alcohol and depression,” their findings are possibly specious, as they are mostly based on only one prior study. He also notes that running their numbers against the adjusted odds ratio shows nearly identical findings for both AUD causing MD and MD being a cause of AUD. Conner calls for clarification of terms and a better understanding of the data in order to get a better, more accurate, understanding of the relationship between AUD and MD. This is obviously an important issue to be working on, as the treatment of both AUD and MD will be hampered by an inaccurate understanding of both.

Trine Flensborg-Madsen also weighed in on Boden and Fergusson’s study with her commentary, “Alcohol use disorders and depression – The chicken or the egg?” but found it to be slightly less problematic. While she agreed with the fact that their data was not comprehensive enough, she did applaud their attempt to “deal with the issues of a feedback loop where AUD and MD are related to each other reciprocally,” and noted, “The proposal that causality is mainly in the direction from AUD to MD is an important contribution to the literature” (p. 916). It would, definitely, be an important contribution if it were founded on good evidence, but one study does not give us an accurate picture of how these two issues interact. Conner’s review of the study is a more realistic interpretation of the findings.

The previous studies discussed here have set out to find what correlation, if any, can be found between alcohol consumption and major depression. As it does seem that most are in agreement that the correlation does exist, the next question that must be answered is how are psychologists to use this information? It follows that treating one (either AUD or MD) should, in turn, help treat the other, as the two are likely somehow linked, but we cannot say this for sure without further research. “Neurocognitive profiles of people with comorbid depression and alcohol use: Implications for psychological interventions,” set out to see how cognitive function is affected in adults who suffer from depression and engage in alcohol consumption and what effect treatment has on said cognitive function.

The study expressed that individuals who entered treatment did better on cognitive function tests of logical reasoning than did those who did not seek treatment. The study also predicted greater reductions in depression for individuals over an extended course of seventeen weeks. Surprisingly enough, however, the study found that those who did abuse alcohol still showed normal cognitive functioning despite the fact of their alcohol abuse. As the study concluded, “Findings suggest that improvement in depression following psychological treatment is enhanced by greater fluid reasoning ability and is predicted by executive functioning, regardless of the treatment length or problem focus” (Hunt, 2009, p. 884). It seems that greater fluid reasoning ability helps to ease depression in individuals who also suffer from alcohol abuse. This is likely the case, too, for those who do not abuse alcohol consumption, but, as the study itself admitted, one limitation of the study is the fact that there was no healthy control group with which to directly compare the data (Hunt, 2009, p. 885). More research about the interplay of alcohol, depression, and cognitive function will be necessary to truly understand how each is affected by the others.

The 2001 study, “The effect of a history of alcohol dependence in adult major depression,” conducted by Alma M. Rae et. al., is a more accurate study of comorbidity, as a control group was made use of. The study aimed to see the effects of either fluoxetine or nortriptyline on the patients in regards to depression. The study also managed to explain, better than any of those studies discussed prior, exactly why said studies are so important. From the introduction: “Depression and alcohol dependence is common in Western society, are associated with considerable morbidity and chronicity, and co-occur more commonly than expected by chance. The relationship between these two disorders is therefore of both academic and clinical importance” (Alma, 2001, p. 281). The study showed that, regarding most psychometric data, those who had ever been dependent on alcohol did show a greater likelihood of paranoia, interpersonal sensitivity, and novelty-seeking; however, aside from novelty-seeking, none of these were significantly different between the two groups. While persistence and cooperation were both lower in the dependent group, again, this number was not significant. In addition to this, neither group seemed to be affected by receiving nortriptyline or fluoxetine over the other. The study did find a greater incidence of schizotypal personality disorder among individuals who were alcohol dependent as well as greater use of cannabis (Alma, 2001, p. 281).

Most notable about this study, was its findings regarding the amount of alcohol consumed and scores on psychometric tests. Those in the ever-dependent group who were still consuming 280 g of ethanol or more each week scored significantly higher than others in their group as well as those in the never-dependent group. A better collection of data may have occurred if those still dependent on alcohol were separated from those who had once been as these two groups do differ in the results found. A recommendation of dividing the subjects into three groups, i.e., ever-dependent, currently-dependent, and never-dependent would probably allow for more specifically accurate results.

A 2005 study “The prevalence and impact of alcohol problems in major depression: a systematic review” was conducted and set out to answer the following questions, posed in their abstract, “How common are alcohol problems in patients with depression? Does alcohol affect the course of depression, response to antidepressant therapy, risk of suicide/death, social functioning and health care utilization? In which alcohol categories and treatment settings have patients with depression and alcohol problems been evaluated” (Sullivan, p. 330)? Through a review of current studies which met their own criteria, those conducting the study found that those suffering from depression are more likely to struggle with alcohol dependence, as most have already concluded, but they did not attempt to discover why this is the case (Sullivan, 2009, p. 340). This review was accurate and well-structured but did little to add to the discussion of alcohol dependence and depression.

While the relationship between depression and alcohol has often been studied, it is definitely not the only one in which studies are interested. The roles of alcohol consumption and anxiety are, like alcohol and depression, inextricably linked, but to what extent, and in what capacity, are still highly contested issues. The 2012 study, “Relationships of alcohol use and alcohol problems to probable anxiety and mood disorder” found that individuals with alcohol problems were more likely to have anxiety and mood disorder (AMD), but that those who totally abstained from alcohol were also more likely to have AMD than individuals who reported to engage in a moderate consumption of alcohol of no more than two drinks per day (Mann, 2012, p. 256). The study did agree that there were possible issues with selection bias that lead to this outcome, as well as the fact that since the data relied on self-report, it is possible that individuals were not eager to disclose personal information about alcohol consumption or emotional problems (Mann, 2012, 259). There is always a risk of this in studies that use self-reporting to collect data, but there is not always a better option, and so it is simply important to be sure that data collected this way is interpreted in light of that knowledge.

A study, “Comorbid alcohol dependence and anxiety disorders: a national survey” published in 2013 by The Journal of Dual Diagnoses, set out, like the studies before it, to gain an understanding of comorbidity of alcohol consumption and the onset of anxiety disorders. This one differed, however, in its attempt to see how gender plays a role in this. The study found that there was no difference found in the age of onset of the anxiety disorders between genders but did note that women were more likely to report having multiple anxiety disorders. Interestingly, the study did find that in the patients studied, 65 percent of the individuals reported having an anxiety disorder before they began having issues with alcohol. This may shed some light on the earlier “chicken or the egg” argument from earlier studies. Moving forward, it will be important to consider this factor during similar studies. The study also argued that this knowledge (i.e., the higher likelihood of anxiety disorders presenting before alcohol dependency) might allow for more preventative treatment of alcoholism. In either case, the fact that the connection between alcoholism and anxiety disorders is not affected by gender is an important distinction to make.

In light of conflicting information in many different studies, the 2012 article published in The British Journal of Psychiatry is especially important, as it asks, in its very title, the important question, “Is alcohol consumption irrelevant to outcome in anxiety and depression” (Bailey, 2012, p. 326)? The article addresses a study done by Boschloo and colleagues, that stated that alcohol abuse does not necessarily appear to be a risk factor in anxiety disorders and depression. These findings are surprising, in that they seem to conflict with many other studies. Bailey posits that since the study does not take into account long-term alcohol abuse, its findings are inaccurate. The article also points out several other problems with the data collection in the study, namely that there was no report of just how much alcohol each patient consumed, and that no record of treatment administered to patients was made. The article, (as well as this review) does not believe that Boschloo was able to accurately or convincingly show that alcohol is (or is not) a factor in the onset of anxiety and depression. A more thorough reporting of details may have lent the study more credibility, but since the study seemed to ignore certain information, it is difficult to give the outcome of the study any real consideration. A lesson for the researchers here is to be sure that they are addressing any issues they believe those reviewing the study may find an issue with. These are layered, complex issues that must be handled as such.

What the previous ten studies all share is an agreement that alcohol plays a role in psychological disorders. To what extent, and how important this is, is what is debatable. How we can use this information in regards to treatment is another issue entirely. There is so much to be considered when looking at these issues. Some researchers, such as Shuckit and his colleagues, only look at the fact of the relationship, and attempt to determine what that relationship really means. Others find fault with the very fact that researchers like Shuckit have even attempted to decide what that relationship is, as the balance is, in fact, complex. There are researchers who, having accepted the connection between alcohol consumption and these disorders, hope to see what the physical effect on the brain is—testing cognitive function. There are issues regarding the amount of consumption and even the role that gender plays (according to the study reviewed here—none). What each study needs to be aware of is the complexity of these issues. It is easy to ignore certain factors that do not necessarily fall in line with the research one is attempting to conduct, but it is not the researcher's job to be correct, only accurate.

Any new information that adds, in a constructive way, to the conversation, is valid and important, even if it is not what the researchers hope to find. Alcohol is not going anywhere. Neither, unfortunately, are depression and anxiety. Treatment is very important, and anything that can be discovered about how these issues work together must be taken into consideration. Any new research can be helpful, as long as it is relevant. The world is a long way to solving these issues. This review does not seek to find any concrete answers, as currently, there are none. It merely hopes to present a cross-section of current research—its innovations and setbacks—in order to express the layers of interconnectedness between the many issues that make up this debate.

References

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M., R. A., R., J. P., E., L. S., & T., M. R. (2001). The effect of a history of alcohol dependence in adult major depression. Journal of Effective Disorders, 70, 281-290. Retrieved from the EbscoHost database.

Bailey, J., Poole, R., Ruben, S., & Robinson, C. A. (2012). Is alcohol consumption irrelevant to outcome in anxiety and depression?. The British Journal of Psychology, 201, 326-328. Retrieved from bjp.rcpsych.org

Conner, K. (2011). Commentaries on Boden & Ferguson. Addiction, 106, 915-918. Retrieved from the EbscoHost database.

Flensborg-Madsen, T. (2011). Alcohol use and depression - the chicken or the egg?. Addiction, 106, 915-918. Retrieved from the EbscoHost database.

Hunt, S. A., Baker, A. L., Michie, P. T., & Kavanagh, D. J. (2009). Neurocognitive profiles of people with comorbid depression and alcohol use: implications for psychological interventions. Addictive Behaviors, 34(10), 878-886.

Mann, R. E., Ialomiteanu, A. R., Chan, V., Cheung, J. T., Stoduto, G., Ala-Leppilampi, K., et al. (2012). Relationships of alcohol use and alcohol problems to probably anxiety and mood disorder. Contemporary Drug Problems, 39(summer), 247-263. Retrieved from the EbscoHost database.

Pacek, L. R., Storr, C. L., Mojtabai, R., Green, K. M., La Flair, L. N., Alvanzo, A. A., et al. (2013). Comorbid alcohol dependence and anxiety disorders: A national survey. Journal of Dual Diagnosis, 9(4), 271-280. Retrieved from the EbscoHost database.

Schuckit, M. A. (1994). Alcohol and depression: A clinical perspective. Acta Psychiatrica Scandinavica, 89(s377), 28-32.

Sullivan, L., Fiellin, D., & Oconnor, P. (2005). The prevalence and impact of alcohol problems in major depression: A systematic review. The American Journal of Medicine, 118(4), 330-341.