People with internalizing mental health disorders like anxiety and depression tend to experience more symptoms related to drinking alcohol, even if they drink the same amount as people without these disorders, according to new research published in the journal Alcohol: Clinical & Experimental Research.
This study aimed to investigate the relationship between internalizing disorders and alcohol use disorder, which commonly co-occur. The hypothesis was that individuals with internalizing disorders are more susceptible to developing alcohol use disorder symptoms due to partially shared neurobiological dysfunctions underlying both conditions.
“When I was a graduate student in the mid-1980s, I was looking for a topic for my dissertation. My main interest was anxiety, but I also had an interest in alcohol abuse,” said study author Matt G. Kushner, a professor of psychiatry at University of Minnesota.
“Both areas were already being vigorously studied by many others in the field, which made it challenging to find an original topic. One of my advisers suggested that I might find more room for making an original contribution if I combined my two areas of interest: the nexus of anxiety and alcohol abuse. I took this advice and have been studying the association of anxiety and alcohol problems ever since – over 30 years now.”
The study used data from Wave 3 of the National Epidemiological Survey on Alcohol-Related Conditions (NESARC), consisting of 36,309 individuals in the United States. The participants were classified into three groups: those who were never diagnosed with an internalizing disorder, those who had remitted (met diagnostic criteria more than 12 months ago only), and those who currently had an internalizing disorder (met diagnostic criteria within the last 12 months).
The researchers found that people with an internalizing disorder were more likely to experience negative consequences from drinking alcohol, even if they consume the same amount as people without these disorders. Importantly, the findings held after controlling for characteristics that have been shown to be correlated with both alcohol-related symptoms and internalizing symptoms, such as socioeconomic status, gender, binge drinking, and a family history of alcohol use disorder.
Alcohol-related symptoms includes things such as trying unsuccessfully to stop or cut down on drinking, having trouble falling/staying asleep after drinking, feeling unusually restless when effects of alcohol were wearing off, and experiencing times when drinking interfered with taking care of home or family.
“Two primary discoveries provided the greatest impetus for the ‘harm paradox’ work we recently published,” Kushner told PsyPost. “First was the work I did with my former advisor at the University of Missouri, Kenneth Sher, Ph.D. This work showed that having either an alcohol use disorder or an anxiety disorder earlier in life greatly increased the chances of newly developing the other disorder later in life. The other key development was work by George Koob, Ph.D., and his colleagues who described a neurobiological opponent-process model of addiction in which chronic substance use dysregulates brain systems related to stress and mood.”
“Working from these findings and theory, we reasoned that those with anxiety and depression, who are already suffering from the neurobiological dysregulations in the brain’s stress and mood systems before using any addictive substances, may develop addiction more efficiently (more quickly and with less overall exposure) than do others.”
“In some earlier studies, we supported this idea by showing that individuals with anxiety and depression progress from regular use of alcohol and drugs to addiction in less time than do those without these mental conditions,” Kushner explained. “In the present study, we supported this idea further by showing that individuals with an anxiety or depression disorder experience more alcohol-related symptoms than do others who drink at the same level (the “harm paradox” effect). We believe these findings reflect some degree of overlap in the neurobiology that underlies both addiction and anxiety/depression.”
The harm paradox effect was seen in people who currently or previously had anxiety or depression disorders, and was even stronger in those with more than one of these disorders.
“The most surprising thing was that the harm paradox effect held not only for people whose anxiety/depression problems were current but also for those whose symptoms had resolved. This suggests that the vulnerability to develop alcohol-related symptoms is a longer-term feature of the brains of those who are prone to anxiety and depression problems, even when these conditions are not actively symptomatic.”
The harm paradox effect was seen in both men and women with anxiety or depression disorders, suggesting that these mental health conditions may affect alcohol-related harm regardless of gender.
The researchers suggest that there may be two different neurobiological pathways underlying the harm paradox effect. The first pathway is “congenital,” meaning that neurobiological factors present since birth may make an individual vulnerable to developing both internalizing disorders and alcohol abuse. An example of this is dysregulated stress responding.
The second pathway is the “scar” pathway, meaning that the manifestation of internalizing disorders may produce an enduring neurobiological change that renders individuals more vulnerable to alcohol addiction. For example, experiencing acute or chronic stress due to internalizing disorders may increase the risk of alcohol use disorder.
But Kushner noted that “our study did not demonstrate directly that the harm paradox effect results from a shared neurobiology. This will be a question for additional research to resolve.”
Despite that caveat, the research has some important practical implications.
“Individuals with anxiety or depression disorders should be aware that they may be more sensitive to the ill effects of alcohol use than others,” Kushner told PsyPost. “This can be hard to detect sometimes because the association between alcohol use and some common problems (e.g., sleep difficulties, relationship problems, and even worsening anxiety and depression) may not be obvious.”
“If you’re not sure, I recommend trying a one-month period of abstinence from drinking to evaluate what effects may be caused or worsened by alcohol use. If problems improve after a period of abstinence, this is reasonably good evidence that alcohol is involved. If you find you are unable to go without drinking for a month, this may be a sign that professional addiction treatment is needed.”
But does everyone who has experienced anxiety or depression need to permanently stay away from alcohol? That isn’t necessarily the case, Kushner explained.
“It’s important to understand that research like ours considers the behavior of large groups,” Kushner said. “This approach ‘washes out’ many individual differences (that is, individuals whose responses don’t reflect those of the larger group(s) to which they belong). Because of this, some individuals that have struggled with anxiety and/or depression may drink moderately and responsibly without undue adverse consequences and some people without anxiety or depression may experience significant problems from alcohol use even when drinking moderately.”
“Another way of saying this is that our findings should not be taken to mean that it is unsafe for anyone with anxiety and depression to use alcohol moderately (commonly defined as no more than one standard drink a day for women and two drinks a day for men),” the researcher explained. “However, our findings do suggest that those with anxiety and depression have a greater risk of experiencing alcohol-related problems than do others, even when drinking moderately.”
The study, “Evidence for an alcohol-related “harm paradox” in individuals with internalizing disorders: Test and replication in two independent community samples“, was authored by Justin J. Anker, Paul Thuras, Ruichong Shuai, Lee Hogarth, and Matt G. Kushner.