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Core Resource on Alcohol

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Mental Health Issues: Alcohol Use Disorder and Common Co-occurring Conditions

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    Takeaways

    • Alcohol use disorder (AUD) frequently occurs with other mental health disorders, and vice versa. Primary care providers and other clinicians are well positioned to identify these conditions, make informed clinical decisions, and refer patients to specialists, thereby improving treatment outcomes.
    • A timeline of symptoms and behaviors is a key tool for differential diagnosis. In order to guide treatment, it is helpful to learn, if possible, whether psychiatric symptoms are present or absent during periods of abstinence to differentiate whether they are alcohol-induced or separate, primary conditions.
    • The severity of both the AUD and the co-occurring mental health disorder determines the appropriate level of care. Patients with less severe AUD and mental health conditions may be able to receive treatment in primary care, whereas those with more severe conditions may need care from a mental health or addiction specialist or both.
    • The likelihood of recovery from both conditions is higher if both the AUD and the co-occurring mental health disorder are treated. Medications for AUD and for mild to moderate depressive and anxiety disorders can be started in a primary care setting.

    Alcohol use disorder (AUD) often co-occurs with other mental health disorders, either simultaneously or sequentially.1 The prevalence of anxiety, depression, and other psychiatric disorders is much higher among persons with AUD compared to the general population.

    By far, the most common mental health conditions that co-occur with AUD are depressive disorders, anxiety disorders, trauma- and stress-related disorders, other substance use disorders, and sleep disorders.2–4 Furthermore, psychotic disorders such as schizophrenia often co-occur with AUD and should be recognized and addressed during AUD treatment.

    Here, we briefly describe the causes and effects of co-occurrence, the mental health disorders that commonly co-occur with AUD, and the treatment implications for primary care and other healthcare professionals. We start with a visual model of care that indicates when to consider a referral.

    A note on drinking level terms in this Core article: Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    A model of care for co-occurring AUD and other mental health disorders

    Brief tools are available to help non-specialists assess for AUD and screen for common co-occurring mental health conditions. You can determine whether your patient has AUD and its level of severity using a quick alcohol symptom checklist as described in the Core article on screening and assessment. You also can screen for depression, anxiety, PTSD, and other substance use disorders using a number of brief, psychometrically validated screening tools, which are described in a 2018 systematic review5 and which may be available in your electronic health record system. As needed, you can refer to a mental health specialist for a complete assessment.

    The schematic below shows when and what type of specialist care may be most appropriate for patients with co-occurring AUD and other mental health disorders. Once a patient has had an assessment to determine the diagnoses and levels of severity, the settings indicated in the schematic are appropriate for effective treatment of both the AUD and other mental health disorder.6,7

    Mental health four quadrant model chart

    As shown in the schematic, AUD and other mental health disorders occur across a spectrum from lower to higher levels of severity. For patients in the middle, with up to a moderate level of severity of AUD or the psychiatric disorder or both, a decision to refer should be based on the level of comfort and clinical judgment of the provider.

    Causes and effects of co-occurrence

    Several mechanisms may explain the common co-occurrence of AUD and psychiatric disorders:

    • Pre-existing psychiatric disorders may increase the risk of developing AUD, in part because alcohol is often used to cope with symptoms of psychiatric disorders, even if alcohol ultimately makes the problems worse.8
    • At the same time, alcohol use—especially adolescent drinking and long-term exposure to alcohol—may predispose individuals to develop psychiatric disorders.9
    • AUD and other psychiatric disorders often share genetic risks and environmental vulnerabilities such as trauma and adverse childhood experiences.10–12

    The co-occurrence of AUD and another mental health disorder can complicate the diagnoses and negatively impact the clinical course of both conditions. Many clinical features of AUD have significant overlap with other psychiatric disorders, including sleep disturbances and negative emotional states such as worry, dysphoria, sadness, or irritability that often occur during cycles of alcohol intoxication, withdrawal, and craving. (See Core article on neuroscience.) As described in the sections to follow, a timeline of your patient’s symptoms is a key tool for a differential diagnosis.

    Moreover, AUD and psychiatric disorders may exacerbate each other, thereby producing poorer outcomes. Hence, individuals with co-occurring AUD and psychiatric disorders tend to return to using alcohol more frequently, as well as experience more severe psychiatric symptoms.13 Without adequate treatment, this pattern may result in higher rates of hospitalization and suicide.14

    Mental health disorders that commonly co-occur with AUD

    Diagnostic clarity is key to ensure appropriate treatment. For healthcare professionals who are not mental health or addiction specialists, the following descriptions aim to increase awareness of signs of co-occurring psychiatric disorders that may require attention and, often, referral to a specialist.

    Anxiety disorders. Anxiety disorders are the most prevalent psychiatric disorders in the United States. The prevalence of AUD among persons treated for anxiety disorders is in the range of 20% to 40%,2,15 so it is important to be alert to signs of anxiety disorders (see below) in patients with AUD and vice versa.

    Genetic and environmental factors contribute to the co-occurrence of AUD and anxiety disorders.16 Further, since alcohol is readily available, it is commonly used to cope with anxiety. Alcohol may appear to relieve anxiety in the short term, but over time, heavy drinking and repeated withdrawal can escalate both the anxiety symptoms and maladaptive drinking.17

    The hallmarks of anxiety disorders are excessive and recurrent fear or worry episodes that cause significant distress or impairment and that last for at least 6 months. People with anxiety disorders may have both psychological symptoms, such as apprehensiveness and irritability, and somatic symptoms, such as fatigue and muscular tension.

    Three distinct anxiety disorders most commonly co-occur with AUD:17

    • Generalized anxiety disorder typically presents with persistent and generalized worrying, poor sleep, fatigue, and difficulty relaxing.
    • Social anxiety disorder is marked by extreme fear of situations involving the possibilities of scrutiny by others or embarrassment.
    • Panic disorder involves recurrent “panic attacks” of intense fear lasting several minutes to an hour and often lead to changes in behavior to avoid precipitating circumstances.

    Even among patients without an anxiety disorder, anxiety-like symptoms can occur after a single heavy drinking episode18 (sometimes described in the popular press as “hangxiety”) and can increase between drinking episodes, reaching high levels during alcohol withdrawal.19

    When patients who drink heavily report anxiety, it helps to create a timeline with them to discern whether the anxiety is alcohol-induced or, instead, a pre-existing or primary anxiety disorder, which can help set expectations and a treatment plan. Sample timeline queries include the ages of onset of anxiety symptoms and of alcohol use, the longest period of abstinence, the presence or lack of anxiety symptoms during phases of alcohol drinking and extended phases of abstinence, and the family history of anxiety disorders and of AUD.

    Mood disorders. The mood disorders that most commonly co-occur with AUD are major depressive disorder and bipolar disorder. Among people with major depressive disorder, the co-occurrence of AUD ranges from 27% to 40% for lifetime prevalence20,21 and up to 22% for 12-month prevalence.15 In clinical populations, people with bipolar disorder have the highest AUD prevalence, estimated at 42%.22 As with anxiety, it’s important to be aware of the signs of mood disorders (see below) in those with AUD and vice versa.

    Converging evidence suggests genetic links between AUD and mood disorders.23,24 Further, long-term exposure to alcohol against the backdrop of depressive or manic symptoms may lead to a more severe clinical course, with longer duration of mood episodes, poorer cognitive function, and higher risk of suicide.25 Altogether, several lines of evidence indicate that AUD and mood disorders exacerbate each other through common neurobiological substrates, as well as shared underlying genetic vulnerability and shared environmental stressors.

    The hallmarks of mood disorders are recurring episodes of disruptions in mood, energy, activity, sleep, and behavior. Individuals may struggle, as a result, to maintain their ability to work and their interpersonal relationships. Here’s how major depressive and bipolar disorders are characterized:

    • Major depressive disorder is marked by one or more depressive episodes, which manifest with five or more of the following for at least 2 weeks: low mood, low energy, loss of interest or pleasure in most activities, irritability, insomnia or hypersomnia, significant weight or appetite changes, reduced ability to concentrate, thoughts of guilt or worthlessness, thoughts of death, or suicidal ideation or a suicide attempt.
    • Bipolar disorder is marked by cycles of mania or hypomania, with or without depressive episodes. Core mania symptoms are abnormally elevated, irritable, or labile mood and persistently increased energy and activity. Less severe hypomanic episodes should still be taken seriously, as they may indicate increasing instability and need for treatment. Untreated, bipolar disorder has the highest rate of suicide of all psychiatric disorders,26 underscoring the need, if suspected, for referral to specialist care.

    When patients report mood symptoms, it helps to clarify the possible relationship with alcohol use by asking, for example, about mood symptoms prior to starting alcohol use and on extended periods of abstinence. In addition, ask about current and past suicidal ideation or suicide attempts, as well as the family history of mood disorders, AUD, hospitalizations for psychiatric disorders, or suicidality.

    Especially for individuals with history of suicidal ideation or psychiatric hospitalizations, work with a psychiatrist and therapist who can assist with the diagnostic and risk assessment, then recommend appropriate pharmacological and psychosocial treatment approaches. (To find addiction specialists, visit the NIAAA Alcohol Treatment Navigator and see the Core article on referral.)

    Note: Be aware that the potential for suicidality is a concern not only for those with mood and other mental health disorders, but also for many people who drink heavily, whether or not they have AUD. For more information, see the 2019 NIAAA journal article on suicidal behavior.27

    Post-traumatic stress disorder (PTSD). PTSD is characterized primarily by alterations in arousal and recurrent intrusive thoughts that follow a traumatic event. Among those with AUD, about 15-30% overall have co-occurring post-traumatic stress disorder, with increased rates of 50-60% among military personnel and veterans.28 The two conditions may worsen each other. Thus, here, too, it’s important to be cognizant of the signs of PTSD in patients with AUD, and vice versa.

    PTSD may facilitate development of AUD, as alcohol is commonly used to numb memories of a traumatic event or to cope with symptoms of posttraumatic stress, and AUD may increase the likelihood of PTSD.29 The relationship between PTSD and AUD may have multiple causal pathways. First, heavy alcohol use may increase the likelihood of suffering traumatic events, such as violence and assault. Second, AUD may undermine a person’s psychological mechanisms to cope with traumatic events, by disrupting arousal, sleep, and cognition, thus increasing the likelihood of developing PTSD. Third, AUD and PTSD have shared risk factors, such as prior depressive symptoms and significant adverse childhood events.

    The symptoms of PTSD and AUD have a marked overlap, for instance, autonomic hyperactivity seen in alcohol withdrawal may resemble PTSD-related increases in arousal. Therefore, a thorough assessment is necessary for diagnostic clarity and adequate treatment of both conditions.30

    As with anxiety and mood disorders, it can help for a healthcare professional to create a timeline with the patient to clarify the sequence of the traumatic event(s), the onset of PTSD symptoms, and heavy alcohol use. One way to differentiate PTSD from autonomic hyperactivity caused by alcohol withdrawal is to ask whether the patient has distinct physiological reactions to things that resemble the traumatic event.

    Other substance use disorders (SUD). Widespread availability of alcohol leads to common co-use with other substances, both legal and illegal. As expected, AUD has strong comorbidity with other SUD. More than 40% of men and 47% of women with AUD have had another SUD in their lifetime.2 Having AUD raises the odds of another SUD by a factor of 3 to 5.31,32

    Multiple lines of evidence support a common underlying vulnerability to AUD and other SUD, mediated via overlap in neurocircuits that underly AUD and other SUD as well as via shared genetic factors.33 Co-use of alcohol and other substances may hasten and aggravate the course of the addiction cycle in the brain (see Core article on neuroscience). Co-use of alcohol and drugs also increases the likelihood and severity of overdose.34–36

    To have a full picture for patient care, patients with AUD should be screened for other substance use. Stigma can be reduced with normalization statements such as “Many people try (cannabis or painkillers in ways that are not prescribed) at some point in their lives; is that something you have tried?” See the Resources section, below, for SUD screening and assessment tools.

    Sleep disorders. Sleep-related disturbances are often reported by people with AUD, and the co-occurrence of AUD and sleep disorders is common. Sleep-wake disorders include insomnia disorder, hypersomnolence disorder, breathing-related sleep disorders, and parasomnias, which are marked by undesirable physical events or experiences during sleep. The prevalence of sleep disorders among persons with AUD ranges from 36% to 91%.37

    Sleep disorders can facilitate the development of AUD, and AUD can cause sleep disorders. The relationship between the disorders appears to be multifactorial.4 Even moderate doses of alcohol may alter the physiology of sleep, for instance by reducing the duration of rapid eye movement sleep.38 In addition, alcohol use may aggravate sleep-disordered breathing39 and periodic limb movements during sleep,40 thereby compromising sleep quality. Notably, these multifaceted alterations in sleep may be subacute or chronic, recovering only after 30 or more days of abstinence.4,41

    Some clinical features of AUD may also precipitate sleep disorders, such as a preoccupation with obtaining alcohol and AUD-related psychosocial stressors. Moreover, tolerance to alcohol can increase alcohol intake, which in turn may exacerbate sleep symptoms.

    When patients have sleep-related concerns such as insomnia, early morning awakening, or fatigue, it is wise to screen them for heavy alcohol use and assess for AUD as needed. If they use alcohol before bedtime, and especially if they shift their sleep timing on weekends compared to weekdays, they may have chronic circadian misalignment. If they report daytime sleepiness, one possible cause is alcohol-induced changes in sleep physiology.

    Psychotic disorders. Psychotic disorders are characterized by delusions, or strongly held false beliefs that are not typical of the person’s cultural background; hallucinations, or experiences involving the perception of something that is not present; and thought disorganization, or disturbances in cognition that affect a person’s ability to communicate.

    The two primary psychotic disorders, schizophrenia and schizoaffective disorder, affect up to 3% of the general population. Among people in treatment for schizophrenia, the current prevalence of AUD is approximately 11% and the lifetime prevalence is approximately 21%.42

    The neurobiological links between psychotic disorders and AUD are poorly understood. However, as in the general population, a family history of AUD increases the risk for developing AUD among persons with psychotic disorders.43 As with other psychiatric disorders, AUD can also exacerbate the course of psychotic disorders, thus warranting integrated treatment of both conditions.44

    Early on, the underlying etiology of a psychosis may be uncertain. During withdrawal from heavy drinking, people may develop delirium tremens, a complication of withdrawal marked by psychotic symptoms, such as hallucinations (see Core article on AUD). Additionally, the occurrence of auditory or visual hallucinations when a patient is alert and oriented may constitute alcohol-related hallucinosis, also called alcoholic hallucinosis.45 Note that for a primary psychotic disorder to be diagnosed, the person must have psychotic symptoms that persist for 1 month following the last alcohol (or other substance) use.

    When psychosis is suspected, a general physical and neurological exam should be performed to exclude medical causes such as subdural hematoma, seizures, or hepatic encephalopathy—any of which may be a consequence of AUD. Again, it’s important to create a timeline of mental health symptoms and alcohol use and to collaborate as needed with mental health specialists for selection of pharmacotherapies and psychosocial interventions.

    Treatment implications

    People with AUD and co-occurring psychiatric disorders bring unique clinical challenges tied to the severity of each disorder, the recency and severity of alcohol use, and the patient’s pressing psychosocial stressors. An overall emphasis on the AUD component may come first, or an emphasis on the co-occurring psychiatric disorder may take precedence, or both conditions can be treated simultaneously. The treatment priorities depend on factors such as each patient’s needs and the clinical resources available.

    Quitting drinking on its own often leads to clinical improvement of co-occurring mental health disorders, but treatment for psychiatric symptoms alone generally is not enough to reduce alcohol consumption or AUD symptoms. Among people with co-occurring AUD and psychiatric disorders, AUD remains undertreated, leading to poorer control of psychiatric symptoms and worse outcomes.

    Integrated treatment of AUD and co-occurring psychiatric disorders tends to lead to better results than fragmented treatment approaches.46,47 Consistent with this finding, combining medications and behavioral healthcare for people with AUD and co-occurring psychiatric disorders often produces superior outcomes than either treatment alone. In particular, for patients with more severe mental health comorbidities, it is important that the care team include specialists with the appropriate expertise to design personalized and multimodal treatment plans. (See Core article on treatment).

    Of note: Not all addiction treatment programs have staff with the credentials and expertise to provide evidence-based medications and behavioral healthcare for AUD with or without co-occurring mental health issues. The NIAAA Alcohol Treatment Navigator can help you and your patients to recognize the signs of quality care and find a range of treatment options that meet their needs. (See also the Core article on referral.)

    Behavioral healthcare. Interventions such as motivational enhancement therapy, cognitive behavioral therapy, contingency management, and 12-step facilitation, are the standard of behavioral healthcare for individuals with AUD (see Core article on treatment) and are a key part of a treatment plan for patients with co-occurring AUD and other mental health disorders.48,49 An integrated treatment plan for AUD and the co-occurring disorder might include, for example, cognitive behavioral therapy for AUD as well as for depression, anxiety, PTSD, or sleep disorders. Skills to address each disorder may be introduced in alternating sessions, although increasingly, skills to manage both disorders are being offered in the same session.50 These integrated treatment approaches appear promising. A meta-analysis found, for example, small but clinically significant improvements in depressive symptoms and alcohol use with the combination of cognitive behavioral therapy and motivational interviewing to treat individuals with depression and AUD, compared with usual care.51

    Pharmacological treatment. A few considerations in the pharmacological treatment of AUD and co-occurring psychiatric disorders are outlined below. For patients who continue to drink, keep in mind that some psychotropic medications may interact with alcohol to produce untoward effects. (See Core article on medication interactions.)

    • Effective pharmacotherapies for AUD may be initiated in primary care settings. These include three FDA-approved medications: acamprosate, naltrexone (available as an oral and injectable extended-release formulation), and disulfiram. No specialized training or licensing is needed to prescribe these non-addicting medications, so they are no more complicated to prescribe than those for other common medical conditions. (See Core article on treatment.)
    • Prescribing “as-needed” (PRN) medications with misuse or overdose potential should be avoided, such as benzodiazepines to treat anxiety, mood instability, or sleep disorders, and Z-drugs for sleep disorders. Benzodiazepines do, however, remain the gold standard for treating alcohol withdrawal syndrome, given their proven efficacy in relieving the acute withdrawal symptoms and preventing complications like seizures and delirium tremens.52 (See Core article on AUD).
    • Combining an antidepressant with an AUD medication can provide an integrated and effective approach to treating the AUD as well as depression, anxiety disorders, or PTSD.53–56 Clinicians do not need to wait until patients become sober to start antidepressants if there is evidence of need, although it’s important to check for potential alcohol-drug interactions (see Core article on medication interactions). Patients with bipolar or psychotic disorders in particular may require a combination of medications best prescribed under the care of a psychiatrist with expertise in dual diagnosis.

    As noted previously, for patients with more severe disorders or symptoms, consult a psychiatrist (one with an addiction specialty, if available) for medication support, as well as a therapist with an addiction specialty for behavioral healthcare. See the Resources, below, for an NIAAA tool to help you locate these specialists.

    In closing, AUD and mental health conditions often co-occur. When patients present with mental health problems, it is often useful to ask about alcohol use, and when they report drinking heavily, it is also useful to assess for other mental health disorders. Whether the alcohol problem caused, resulted from, or is unrelated to the other mental health diagnosis, treatment is most likely to be successful when both are addressed. (See the Core articles on screening and assessment, treatment, and referrals.)

    Resources

    Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

    Alcohol and Other Substances Screening, Assessment, Treatment, and Referral Resources Related to this Article

    Therapy Guides for Mental Health Specialists

    Suicide Risk Assessment and Prevention Hotlines

    Behavioral Interventions and Support Groups for Patients with Co-Occurring Psychiatric Disorders

    Alcohol Use Disorder Medication Guides

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

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    • Identify common mental health conditions that often co-occur with AUD.
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    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writers

    João P. De Aquino, MD
    Assistant Professor of Psychiatry, Yale
    University School of Medicine
    West Haven, CT

    Ismene L. Petrakis, MD
    Professor of Psychiatry, Yale University School
    of Medicine, New Haven, CT

    External Reviewers

    Anika A. Alvanzo, MD, MS, FACP, DFASAM
    Managing Partner, Uzima Consulting
    Group LLC, Middle River, MD;
    Eastern Region Medical Director, Pyramid
    Healthcare, Inc., Duncansville, PA

    Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound,
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    Katharine A. Bradley, MD, MPH
    Senior Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    Geetanjali Chander, MD, MPH
    Professor of Medicine, Johns Hopkins
    University School of Medicine, Baltimore, MD

    Anne C. Fernandez, PhD
    Assistant Professor, Department of Psychiatry, University of Michigan,
    Ann Arbor, MI

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Nancy Diazgranados, MD, MS, DFAPA
    Deputy Clinical Director, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    Lia Bennett, MPH
    Educational Consultant,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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