Alcohol Dependence and Mental Illness: A High-Risk Comorbidity

Prepared by Dr. Alvyda Pilkauskienė

Introduction

Sometimes it is necessary to diagnose comorbid conditions and record two diagnoses in the medical history – alcohol dependence and a mental disorder. Some epidemiological studies (Regier, Farmer) show that the prevalence of addictions among patients with mental illnesses is about 30%. This percentage is even higher in patients with schizophrenia (47%), bipolar affective disorder (61%), and antisocial personality disorder (84%). Regier and colleagues state that when it comes to severe mental illnesses, addiction is more the rule than the exception. Among addictions, alcohol use plays a particularly significant role.

Such a combination of disorders is unfavorable for both the physician and the patient – it complicates diagnosis and treatment selection, worsens treatment outcomes, and leads to adverse consequences (Table 1).

More severe symptoms of the disease Decreased motivation for treatment Treatment is often not completed More frequent relapses and hospitalizations Increased incidence of violence and suicide Increased risk of incarceration More frequent homelessness Increased unemployment Increased risk of HIV transmission More family-related problems Increased treatment costs

Anxiety, Depression, and Alcohol

Psychiatric practice shows that alcohol consumption often accompanies mood and anxiety disorders. One explanation is that patients experiencing severe symptoms attempt to alleviate them with alcohol. This form of self-medication may eventually lead to addiction.

This issue has attracted significant research interest. In 2018, Sarah Turner and colleagues published the results of a study analyzing articles (published from January 1997 to April 2018) on the prevalence and correlations of self-medication with drugs and alcohol among patients with anxiety or mood disorders in the general population (n=22). The Scopus and PsycINFO databases were used.

The results showed that the prevalence ranged from 21.9% to 24.1%. It was also observed that younger individuals, men, divorced or widowed individuals, and Caucasians were more likely to use drugs or alcohol for self-medication when experiencing anxiety or depression. Long-term data indicated that anxiety or mood disorders typically develop first, while self-medication with alcohol occurs later and may eventually lead to addiction.

Researchers emphasize the importance of offering patients alternative coping methods, as studies confirm that these can effectively alleviate severe symptoms of anxiety and depression.

Challenges in Diagnosis

It is not easy for clinicians to determine whether depressive symptoms are primary or have developed as a result of prolonged alcohol use. It is also unclear how depression would manifest if the patient did not consume alcohol, and vice versa.

When collecting medical history, patients may be uncooperative, deny alcohol-related problems, or fail to recognize the link between alcohol use and their mental health symptoms. It should also be considered that some patients may avoid acknowledging addiction due to potential secondary benefits that sobriety could affect (e.g., disability benefits, hospitalization, social support, subsidized medications).

Diagnosis is further complicated by the fact that both alcohol dependence and mental illness may present with similar symptoms – insomnia, anxiety, depression, mania, or psychosis.

How should clinicians proceed?

First, when taking a medical history, it is essential to focus on the chronological development of symptoms for both conditions (addiction and mental illness). Second, objective information from close relatives (with patient consent) and medical records (e.g., test results, trauma history, hospital discharge summaries, social worker consultations) can be extremely helpful.

It is also important to evaluate previous treatment outcomes. For example, if a patient repeatedly relapses during addiction treatment, this may indicate the need for more effective treatment of underlying depression.

According to DSM-V criteria, a mental disorder can be diagnosed if the patient has not used addictive substances for at least one month. However, verifying abstinence is often difficult, and clinicians must rely primarily on patient reports.

In clinical practice, when patients present with anxiety, depression, or insomnia without admitting alcohol use, diagnosis must be based on the clinical picture (symptoms of mental illness), and treatment should be initiated accordingly.

Unfortunately, experience shows that when alcohol use is suspected, a precise diagnosis often remains unclear for a prolonged period despite the physician’s efforts. In such cases, clinical observation and ongoing assessment are necessary.

Treatment Challenges

Studies on comorbid conditions indicate that the most effective treatment approach is integrated rather than parallel – meaning both disorders should be treated simultaneously by a multidisciplinary team.

Evidence-based psychotherapy tailored to addiction – including motivational interviewing, cognitive-behavioral therapy, relapse prevention, contingency management, skills training, and case management – should be combined with pharmacotherapy for both addiction and mental illness.

Although these approaches are promising, implementing them in clinical practice is challenging. Individuals with both addiction and mental illness often do not recognize their health problems, lack motivation to change, and do not seek professional help.

For example, in 2016, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that 52% of individuals with both addiction and mental illness did not receive any treatment.

Patients who do seek help are often treated by psychiatrists who focus primarily on mental disorders, while addiction treatment is left to the patient (e.g., referral to addiction centers or support groups such as Alcoholics Anonymous).

Even when patients seek help for anxiety, depression, withdrawal symptoms, or psychosis, they often do not acknowledge their alcohol dependence.

Issues with Pharmacotherapy

There is a lack of evidence-based treatment guidelines for patients with coexisting mental illness and addiction, as these populations are often excluded from clinical trials.

Selecting appropriate treatment is challenging because medications should not be combined with addictive substances. This contributes to poor treatment adherence.

Some patients are resistant to psychotropic medications, sometimes influenced by self-help groups or non-professional advice.

For alcohol dependence, medications such as disulfiram, naltrexone, and acamprosate are used, but there are limited studies on their use in patients with comorbid mental disorders.

For mental illnesses, antidepressants, anxiolytics, and antipsychotics are prescribed, but evidence in this population is also limited.

Selective Serotonin Reuptake Inhibitors (SSRIs) have been widely discussed. Berman et al. (1999) suggested that SSRIs have few side effects and should be considered first-line treatment. Other researchers observed that SSRIs may reduce alcohol consumption, likely because they alleviate anxiety and depressive symptoms, thereby reducing the need for self-medication.

However, this effect is mainly seen in patients with depression and not in those without it. Currently, SSRIs are indicated for various depressive and anxiety disorders.

Benzodiazepines (BZDs) are usually prescribed for short-term relief of anxiety. However, both theory and clinical practice show a high risk of dependence in patients with alcohol addiction.

Studies on buspirone have produced conflicting results, and there are no strong recommendations for its use in this population.

There are no controlled studies demonstrating that any specific antipsychotic is superior in treating patients with both mental illness and alcohol dependence. Therefore, treatment should follow general psychiatric principles, considering possible interactions with alcohol and informing patients accordingly.

Conclusion

Addictions, particularly alcohol dependence, frequently coexist with mental illness. This leads to worse clinical outcomes and poorer overall functioning compared to when these conditions occur separately.

These patients are less likely to seek medical help, and when they do, it is usually for symptom relief (e.g., anxiety, depression, psychosis).

There is limited and often conflicting evidence on how best to treat individuals with both alcohol dependence and mental illness. Therefore, treatment should be based on general psychiatric principles, with careful consideration of potential interactions between medications and alcohol.

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