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Alcohol use disorder is a pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol or continuing to use alcohol even when it causes problems. This disorder also involves having to drink more to get the same effect or having withdrawal symptoms when you rapidly decrease or stop drinking. Alcohol use disorder includes a level of drinking that's sometimes called alcoholism.

Unhealthy alcohol use includes any alcohol use that puts your health or safety at risk or causes other alcohol-related problems. It also includes binge drinking — a pattern of drinking where a male has five or more drinks within two hours or a female has at least four drinks within two hours. Binge drinking causes significant health and safety risks.

If your pattern of drinking results in repeated significant distress and problems functioning in your daily life, you likely have alcohol use disorder. It can range from mild to severe. However, even a mild disorder can escalate and lead to serious problems, so early treatment is important.

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Alcohol use disorder can be mild, moderate or severe, based on the number of symptoms you experience. Signs and symptoms may include:

• Being unable to limit the amount of alcohol you drink
• Wanting to cut down on how much you drink or making unsuccessful attempts to do so
• Spending a lot of time drinking, getting alcohol or recovering from alcohol use
• Feeling a strong craving or urge to drink alcohol
• Failing to fulfill major obligations at work, school or home due to repeated alcohol use
• Continuing to drink alcohol even though you know it's causing physical, social, work or relationship problems
• Giving up or reducing social and work activities and hobbies to use alcohol
• Using alcohol in situations where it's not safe, such as when driving or swimming
• Developing a tolerance to alcohol so you need more to feel its effect or you have a reduced effect from the same amount
• Experiencing withdrawal symptoms — such as nausea, sweating and shaking — when you don't drink, or drinking to avoid these symptoms

Alcohol use disorder can include periods of being drunk (alcohol intoxication) and symptoms of withdrawal.

• Alcohol intoxication results as the amount of alcohol in your bloodstream increases. The higher the blood alcohol concentration is, the more likely you are to have bad effects. Alcohol intoxication causes behavior problems and mental changes. These may include inappropriate behavior, unstable moods, poor judgment, slurred speech, problems with attention or memory, and poor coordination. You can also have periods called "blackouts," where you don't remember events. Very high blood alcohol levels can lead to coma, permanent brain damage or even death.
• Alcohol withdrawal can occur when alcohol use has been heavy and prolonged and is then stopped or greatly reduced. It can occur within several hours to 4 to 5 days later. Signs and symptoms include sweating, rapid heartbeat, hand tremors, problems sleeping, nausea and vomiting, hallucinations, restlessness and agitation, anxiety, and occasionally seizures. Symptoms can be severe enough to impair your ability to function at work or in social situations.

What is considered 1 drink?

The National Institute on Alcohol Abuse and Alcoholism defines one standard drink as any one of these:

• 12 ounces (355 milliliters) of regular beer (about 5% alcohol)
• 8 to 9 ounces (237 to 266 milliliters) of malt liquor (about 7% alcohol)
• 5 ounces (148 milliliters) of wine (about 12% alcohol)
• 1.5 ounces (44 milliliters) of hard liquor or distilled spirits (about 40% alcohol)

When to see a doctor

If you feel that you sometimes drink too much alcohol, or your drinking is causing problems, or if your family is concerned about your drinking, talk with your health care provider. Other ways to get help include talking with a mental health professional or seeking help from a support group such as Alcoholics Anonymous or a similar type of self-help group.

Because denial is common, you may feel like you don't have a problem with drinking. You might not recognize how much you drink or how many problems in your life are related to alcohol use. Listen to relatives, friends or co-workers when they ask you to examine your drinking habits or to seek help. Consider talking with someone who has had a problem with drinking but has stopped.

If your loved one needs help

Many people with alcohol use disorder hesitate to get treatment because they don't recognize that they have a problem. An intervention from loved ones can help some people recognize and accept that they need professional help. If you're concerned about someone who drinks too much, ask a professional experienced in alcohol treatment for advice on how to approach that person.

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Genetic, psychological, social and environmental factors can impact how drinking alcohol affects your body and behavior. Theories suggest that for certain people drinking has a different and stronger impact that can lead to alcohol use disorder.

Over time, drinking too much alcohol may change the normal function of the areas of your brain associated with the experience of pleasure, judgment and the ability to exercise control over your behavior. This may result in craving alcohol to try to restore good feelings or reduce negative ones.

Risk factors

Alcohol use may begin in the teens, but alcohol use disorder occurs more frequently in the 20s and 30s, though it can start at any age.

Risk factors for alcohol use disorder include:

• Steady drinking over time. Drinking too much on a regular basis for an extended period or binge drinking on a regular basis can lead to alcohol-related problems or alcohol use disorder.
• Starting at an early age. People who begin drinking — especially binge drinking — at an early age are at a higher risk of alcohol use disorder.
• Family history. The risk of alcohol use disorder is higher for people who have a parent or other close relative who has problems with alcohol. This may be influenced by genetic factors.
• Depression and other mental health problems. It's common for people with a mental health disorder such as anxiety, depression, schizophrenia or bipolar disorder to have problems with alcohol or other substances.
• History of trauma. People with a history of emotional trauma or other trauma are at increased risk of alcohol use disorder.
• Having bariatric surgery. Some research studies indicate that having bariatric surgery may increase the risk of developing alcohol use disorder or of relapsing after recovering from alcohol use disorder.
• Social and cultural factors. Having friends or a close partner who drinks regularly could increase your risk of alcohol use disorder. The glamorous way that drinking is sometimes portrayed in the media also may send the message that it's OK to drink too much. For young people, the influence of parents, peers and other role models can impact risk.

Complications

Alcohol depresses your central nervous system. In some people, the initial reaction may feel like an increase in energy. But as you continue to drink, you become drowsy and have less control over your actions.

Too much alcohol affects your speech, muscle coordination and vital centers of your brain. A heavy drinking binge may even cause a life-threatening coma or death. This is of particular concern when you're taking certain medications that also depress the brain's function.

Impact on your safety

Excessive drinking can reduce your judgment skills and lower inhibitions, leading to poor choices and dangerous situations or behaviors, including:

• Motor vehicle accidents and other types of accidental injury, such as drowning
• Relationship problems
• Poor performance at work or school
• Increased likelihood of committing violent crimes or being the victim of a crime
• Legal problems or problems with employment or finances
• Problems with other substance use
• Engaging in risky, unprotected sex, or experiencing sexual abuse or date rape
• Increased risk of attempted or completed suicide

Impact on your health

Drinking too much alcohol on a single occasion or over time can cause health problems, including:

• Liver disease. Heavy drinking can cause increased fat in the liver (hepatic steatosis) and inflammation of the liver (alcoholic hepatitis). Over time, heavy drinking can cause irreversible destruction and scarring of liver tissue (cirrhosis).
• Digestive problems. Heavy drinking can result in inflammation of the stomach lining (gastritis), as well as stomach and esophageal ulcers. It can also interfere with your body's ability to get enough B vitamins and other nutrients. Heavy drinking can damage your pancreas or lead to inflammation of the pancreas (pancreatitis).
• Heart problems. Excessive drinking can lead to high blood pressure and increases your risk of an enlarged heart, heart failure or stroke. Even a single binge can cause serious irregular heartbeats (arrhythmia) called atrial fibrillation.
• Diabetes complications. Alcohol interferes with the release of glucose from your liver and can increase the risk of low blood sugar (hypoglycemia). This is dangerous if you have diabetes and are already taking insulin or some other diabetes medications to lower your blood sugar level.
• Issues with sexual function and periods. Heavy drinking can cause men to have difficulty maintaining an erection (erectile dysfunction). In women, heavy drinking can interrupt menstrual periods.
• Eye problems. Over time, heavy drinking can cause involuntary rapid eye movement (nystagmus) as well as weakness and paralysis of your eye muscles due to a deficiency of vitamin B-1 (thiamin). A thiamin deficiency can result in other brain changes, such as irreversible dementia, if not promptly treated.
• Birth defects. Alcohol use during pregnancy may cause miscarriage. It may also cause fetal alcohol spectrum disorders (FASDs). FASDs can cause a child to be born with physical and developmental problems that last a lifetime.
• Bone damage. Alcohol may interfere with making new bone. Bone loss can lead to thinning bones (osteoporosis) and an increased risk of fractures. Alcohol can also damage bone marrow, which makes blood cells. This can cause a low platelet count, which may result in bruising and bleeding.
• Neurological complications. Excessive drinking can affect your nervous system, causing numbness and pain in your hands and feet, disordered thinking, dementia, and short-term memory loss.
• Weakened immune system. Excessive alcohol use can make it harder for your body to resist disease, increasing your risk of various illnesses, especially pneumonia.
• Increased risk of cancer. Long-term, excessive alcohol use has been linked to a higher risk of many cancers, including mouth, throat, liver, esophagus, colon and breast cancers. Even moderate drinking can increase the risk of breast cancer.
• Medication and alcohol interactions. Some medications interact with alcohol, increasing its toxic effects. Drinking while taking these medications can either increase or decrease their effectiveness, or make them dangerous.

Early intervention can prevent alcohol-related problems in teens. If you have a teenager, be alert to signs and symptoms that may indicate a problem with alcohol:

• Loss of interest in activities and hobbies and in personal appearance
• Red eyes, slurred speech, problems with coordination and memory lapses
• Difficulties or changes in relationships with friends, such as joining a new crowd
• Declining grades and problems in school
• Frequent mood changes and defensive behavior

You can help prevent teenage alcohol use:

• Set a good example with your own alcohol use.
• Talk openly with your child, spend quality time together and become actively involved in your child's life.
• Let your child know what behavior you expect — and what the consequences will be for not following the rules.

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• Published: 22 December 2022

Hazardous drinking and alcohol use disorders

• James MacKillop   ORCID: orcid.org/0000-0002-8695-1071 1 , 2 ,
• Roberta Agabio   ORCID: orcid.org/0000-0001-7395-6845 3 , 4 ,
• Sarah W. Feldstein Ewing 5 , 6 ,
• Markus Heilig 7 ,
• John F. Kelly 8 ,
• Lorenzo Leggio 9 , 10 ,
• Anne Lingford-Hughes 11 , 12 ,
• Abraham A. Palmer 13 ,
• Charles D. Parry 14 , 15 ,
• Lara Ray 16 &
• Jürgen Rehm   ORCID: orcid.org/0000-0001-5665-0385 17 , 18 , 19 , 20 , 21 , 22  

Nature Reviews Disease Primers volume  8 , Article number:  80 ( 2022 ) Cite this article

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Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual’s social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.

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Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A. & Sellers, E. M. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br. J. Addict. 84 , 1353–1357 (1989).

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Kirouac, M. & Witkiewitz, K. Revisiting the drinker inventory of consequences: an extensive evaluation of psychometric properties in two alcohol clinical trials. Psychol. Addict. Behav. 32 , 52–63 (2018).

Stockwell, T., Murphy, D. & Hodgson, R. The severity of alcohol dependence questionnaire: its use, reliability and validity. Br. J. Addict. 78 , 145–155 (1983).

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Acknowledgements

J.M. is supported by the Peter Boris Chair in Addictions Research, a Tier 1 Canada Research Chair in Translational Addiction Research, and grants from the Canadian Institutes of Health Research, Health Canada, and the National Institutes of Health (NIH; R01AA024930, R01AA025911, R21 AA027679, R01AA025849). S.W.F.E. is supported by NIH grant K24AA026876. M.H. is supported by the Swedish Research Council (2013-07434, 2019-01138) and is a Clinical Scholar supported by the Knut and Alice Wallenberg Foundation. J.F.K. is supported by NIH grants K24AA022136 and R01AA025849 L.L. is a US federal employee at the National Institutes of Health, and is supported by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. C.D.P. is supported by the South African Medical Research Council. A.A.P. is supported by NIH grants P50DA037844, R01AA02628 and R01AA029688. L.R. is supported by NIH grant K24AA025704. The views expressed herein are those of the authors and do not reflect the official policy or position of the funding sources.

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James MacKillop

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Roberta Agabio

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Introduction (J.M., A.A.P. and M.H.); Epidemiology (J.M., C.D.P. and J.R.); Mechanisms/pathophysiology (J.M., A.L.-H., A.A.P. and M.H.); Diagnosis, screening and prevention (J.M., A.L.-H., L.L., R.A., S.W.F.E., J.R. and M.H.); Management (J.M., A.L.-H., L.L., R.A., S.W.F.E., L.R., J.F.K. and M.H.); Quality of life (J.M., A.A.P. and M.H.); Outlook (J.M., A.A.P. and M.H.); Overview of Primer (J.M.).

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J.M. is a principal and senior scientist in BEAM Diagnostics, Inc. and a consultant to Clairvoyant Therapeutics, Inc.; no associated products or services are discussed in the article. Outside his federal employment, L.L. receives an honorarium from the UK Medical Council on Alcoholism (Editor-in-Chief for Alcohol and Alcoholism ) and royalties from Routledge for a textbook. A.A.P. is on the Scientific Advisory Board of Vivid Genomics and is listed as an inventor on US patent US20160038559A1. M.H. is a member of the scientific advisory council of the Swedish Medical Products Agency, and Scientific Advisor to the Board of Health and Social Welfare; his views expressed here do not represent those of these agencies; M.H. has received consulting fees, research support or other compensation from Indivior, Camurus, Molteni, BrainsWay, Aelis Farma, Lundbeck and Janssen Pharmaceuticals. A.L.-H. has received honoraria paid into her Institutional funds for speaking and chairing engagements from Lundbeck, Lundbeck Institute UK, Janssen-Cilag, Pfizer and Servier; has received honoraria to deliver training and education for the British Association for Psychopharmacology; has received research grants or support from Lundbeck and GSK, and unrestricted funding from Alcarelle for a PhD; has been consulted by but received no monies from Dobrin; and is a member of a group producing UK Alcohol Clinical Guidelines, UK Government (Office for Health Improvement and Disparities, Department of Health and Social Care). R.A., S.W.F.E., J.F.K., C.D.P., L.R. and J.R. declare no competing interests.

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MacKillop, J., Agabio, R., Feldstein Ewing, S.W. et al. Hazardous drinking and alcohol use disorders. Nat Rev Dis Primers 8 , 80 (2022). https://doi.org/10.1038/s41572-022-00406-1

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Binge drinking is a growing public health crisis − a neurobiologist explains how research on alcohol use disorder has shifted

Assistant Professor of Biology, Biomedical Engineering and Pharmacology, Penn State

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Nikki Crowley receives funding from The National Institutes of Health, The Brain and Behavior Research Foundation, and the Penn State Huck Institutes of the Life Sciences endowment funds.

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With the new Amy Winehouse biopic “Back to Black ” in U.S. theaters as of May 17, 2024, the late singer’s relationship with alcohol and drugs is under scrutiny again. In July 2011, Winehouse was found dead in her flat in north London from “death by misadventure” at the age of 27. That’s the official British term used for accidental death caused by a voluntary risk.

Her blood alcohol concentration was 0.416%, more than five times the legal intoxication limit in the U.S. – leading her cause of death to be later adjusted to include “alcohol toxicity” following a second coroner’s inquest.

Nearly 13 years later, alcohol consumption and binge drinking remain a major public health crisis , not just in the U.K. but also in the U.S.

Roughly 1 in 5 U.S. adults report binge drinking at least once a week, with an average of seven drinks per binge episode . This is well over the amount of alcohol thought to produce legal intoxication, commonly defined as a blood alcohol concentration over 0.08% – on average, four drinks in two hours for women, five drinks in two hours for men.

Among women, days of “heavy drinking” increased 41% during the COVID-19 pandemic compared with pre-pandemic levels , and adult women in their 30s and 40s are rapidly increasing their rates of binge drinking , with no evidence of these trends slowing down. Despite efforts to comprehend the overall biology of substance use disorders, scientists’ and physicians’ understanding of the relationship between women’s health and binge drinking has lagged behind.

I am a neurobiologist focused on understanding the chemicals and brain regions that underlie addiction to alcohol . I study how neuropeptides – unique signaling molecules in the prefrontal cortex , one of the key brain regions in decision-making, risk-taking and reward – are altered by repeated exposure to binge alcohol consumption in animal models.

My lab focuses on understanding how things like alcohol alter these brain systems before diagnosable addiction, so that we can better inform efforts toward both prevention and treatment.

The biology of addiction

While problematic alcohol consumption has likely occurred as long as alcohol has existed, it wasn’t until 2011 that the American Society of Addiction Medicine recognized substance addiction as a brain disorder – the same year as Winehouse’s death. A diagnosis of an alcohol use disorder is now used over outdated terms such as labeling an individual as an alcoholic or having alcoholism.

Researchers and clinicians have made great strides in understanding how and why drugs – including alcohol, a drug – alter the brain. Often, people consume a drug like alcohol because of the rewarding and positive feelings it creates, such as enjoying drinks with friends or celebrating a milestone with a loved one. But what starts off as manageable consumption of alcohol can quickly devolve into cycles of excessive alcohol consumption followed by drug withdrawal.

While all forms of alcohol consumption come with health risks, binge drinking appears to be particularly dangerous due to how repeated cycling between a high state and a withdrawal state affect the brain. For example, for some people, alcohol use can lead to “ hangxiety ,” the feeling of anxiety that can accompany a hangover.

Repeated episodes of drinking and drunkenness, coupled with withdrawal, can spiral, leading to relapse and reuse of alcohol. In other words, alcohol use shifts from being rewarding to just trying to prevent feeling bad.

It makes sense. With repeated alcohol use over time, the areas of the brain engaged by alcohol can shift away from those traditionally associated with drug use and reward or pleasure to brain regions more typically engaged during stress and anxiety .

All of these stages of drinking, from the enjoyment of alcohol to withdrawal to the cycles of craving, continuously alter the brain and its communication pathways . Alcohol can affect several dozen neurotransmitters and receptors , making understanding its mechanism of action in the brain complicated.

Work in my lab focuses on understanding how alcohol consumption changes the way neurons within the prefrontal cortex communicate with each other. Neurons are the brain’s key communicator, sending both electrical and chemical signals within the brain and to the rest of your body.

What we’ve found in animal models of binge drinking is that certain subtypes of neurons lose the ability to talk to each other appropriately. In some cases, binge drinking can permanently remodel the brain. Even after a prolonged period of abstinence, conversations between the neurons don’t return to normal .

These changes in the brain can appear even before there are noticeable changes in behavior . This could mean that the neurobiological underpinnings of addiction may take root well before an individual or their loved ones suspect a problem with alcohol.

Researchers like us don’t yet fully understand why some people may be more susceptible to this shift, but it likely has to do with genetic and biological factors, as well as the patterns and circumstances under which alcohol is consumed.

Women are forgotten

While researchers are increasingly understanding the medley of biological factors that underlie addiction, there’s one population that’s been largely overlooked until now: women.

Women may be more likely than men to have some of the most catastrophic health effects caused by alcohol use, such as liver issues, cardiovascular disease and cancer . Middle-aged women are now at the highest risk for binge drinking compared with other populations.

When women consume even moderate levels of alcohol, their risk for various cancers goes up, including digestive, breast and pancreatic cancer , among other health problems – and even death. So the worsening rates of alcohol use disorder in women prompt the need for a greater focus on women in the research and the search for treatments.

Yet, women have long been underrepresented in biomedical research.

It wasn’t until 1993 that clinical research funded by the National Institutes of Health was required to include women as research subjects. In fact, the NIH did not even require sex as a biological variable to be considered by federally funded researchers until 2016. When women are excluded from biomedical research, it leaves doctors and researchers with an incomplete understanding of health and disease, including alcohol addiction.

There is also increasing evidence that addictive substances can interact with cycling sex hormones such as estrogen and progesterone . For instance, research has shown that when estrogen levels are high, like before ovulation, alcohol might feel more rewarding , which could drive higher levels of binge drinking. Currently, researchers don’t know the full extent of the interaction between these natural biological rhythms or other unique biological factors involved in women’s health and propensity for alcohol addiction.

Looking ahead

Researchers and lawmakers are recognizing the vital need for increased research on women’s health. Major federal investments into women’s health research are a vital step toward developing better prevention and treatment options for women.

While women like Amy Winehouse may have been forced to struggle both privately and publicly with substance use disorders and alcohol, the increasing focus of research on addiction to alcohol and other substances as a brain disorder will open new treatment avenues for those suffering from the consequences.

For more information on alcohol use disorder, causes, prevention and treatments, visit the National Institute on Alcohol Abuse and Alcoholism .

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Alcohol and Your Brain: The Latest Scientific Insights

Want to protect your brain here's what you need to know about alcohol consumption..

Posted March 18, 2024 | Reviewed by Devon Frye

• What Is Alcoholism?
• Find a therapist to overcome addiction
• Transient memory loss, “blackouts,” and hangovers related to alcohol consumption are brain health risks.
• Alcohol use disorder (alcoholism) is a risk factor for developing dementia.
• Heavy or excessive alcohol consumption is dangerous to the brain for a number of reasons.
• The impact of mild to moderate alcohol consumption (1-3 drinks a day) on brain function is less clear.

Depending on who you ask, you might be told to drink a few glasses of red wine a day or to avoid alcohol altogether. The reasons for such recommendations are many, but, by and large, they tend to stem from a study someone read about or saw reported in the news.

So why is it so hard to know whether alcohol is good or bad for us—especially for our brains? In this post, we’ll explore the current science and some practical ideas on how to approach the topic.

What Is Alcohol Anyway?

When people talk about drinking “alcohol,” they’re almost always referring to the consumption of ethanol. Ethanol is a natural product that is formed from the fermentation of grains, fruits, and other sources of sugar. It’s found in a wide range of alcoholic beverages including beer, wine, and spirits like vodka, whiskey, rum, and gin.

Evidence for human consumption of alcohol dates back over 10,000 years. Consumption of alcohol has and continues to serve major roles in religious and cultural ceremonies around the world. But unlike most food products, in the last century, alcohol has been wrapped up in nearly perpetual controversy over its moral effects and health implications.

How Does Alcohol Impact the Brain?

As anyone who’s consumed alcohol knows, ethanol can directly influence brain function. Ethanol is classified as a “depressant” because it has a generally slowing effect on brain activity through activation of γ-aminobutyric acid (GABA) pathways.

In an acute sense, consumption of alcohol can lead to uninhibited behavior, sedation, lapses in judgment, and impairments in motor function. At higher levels, the effects can progress to coma and even death.

The Known Brain-Damaging Effects of Excess Alcohol

There is no debate here: Excessively high levels of alcohol consumption over short periods of time are toxic and potentially deadly, specifically because of its effects on the brain.

One critical fact to understand about the overall and brain-specific effects of alcohol is that the entirety of the debate around the risk/benefit ratio concerns mild to moderate alcohol consumption. As it relates to the effects of high amounts of alcohol on the body and brain, the research is consistent: It’s a very bad choice.

High amounts of alcohol use are causal risk factors in the development of disease in the heart, liver, pancreas, and brain (including the brains of children in utero). In fact, 1 in 8 deaths in Americans aged 20-64 is attributable to alcohol use. When it comes to adults, excessive alcohol use can cause multiple well-defined brain issues ranging from short-term confusion to dementia .

What Is “Excessive” or “High” Alcohol Use?

Key to the nuance in the conversation about alcohol use are definitions. Across the board, “excessive” or “high” alcohol use is linked to worse overall and brain health outcomes. So what does that mean?

While definitions can be variable, one way to look at this is the consumption of 4 or more drinks on an occasion (for women) and 5 or more for men. Additionally, excess alcohol is defined as drinking more than 8 drinks a week (women) and 15 a week (men), or consuming alcohol if you are pregnant or younger than age 21.

Beyond this, by definition, consuming enough alcohol to cause a “brownout,” “blackout,” hangover, or other overt brain symptomatology is evidence that the alcohol you’ve consumed is creating problems in your brain. Alcohol use disorder (or alcoholism ) is also a clear issue for the brain. It has been linked to a higher risk for dementia, especially early-onset dementia in a study of 262,000 adults, as well as to smaller brain size .

Is There a “Safe” Amount of Alcohol for the Brain?

In a highly publicized article from Nature Communications , researchers looked at brain imaging data from nearly 37,000 middle-aged to older adults and cross-referenced their brain scans with their reported alcohol consumption. The findings were profound: People who drank more alcohol had smaller brains, even in people drinking only one or two alcoholic beverages a day.

Conversely, other recent data suggest a lower risk for dementia in people consuming a few alcoholic beverages a day. This includes a 2022 study showing that in around 27,000 people, consuming up to 40 grams of alcohol (around 2.5 drinks) a day was linked to a lower risk for dementia versus abstinence in adults over age 60. A much larger study of almost 4 million people in Korea noted that mild to moderate alcohol consumption was linked to a lower risk for dementia compared to non-drinking.

How Do We Make Sense of This Data?

When it comes to the bottom line as it relates to alcohol consumption and brain health, the data are rather solid on some fronts, and a bit less so on others. There’s also the potential for confounding variables, including the fact that many people like to drink alcohol to enjoy and enhance social bonds (which we know are beneficial for the brain). Here’s a summary of what the most recent research is telling us.

• Experiencing transient memory loss, “blackouts,” or hangovers related to alcohol consumption is overt evidence of threats to brain health.
• The impact of mild to moderate alcohol consumption (1-3 drinks a day) on brain function is less clear, but it seems unreasonable to start alcohol use for brain health.

Austin Perlmutter, M.D. , is a board-certified internal medicine physician and the co-author of Brain Wash .

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• Alcohol Use and Your Health
• Underage Drinking
• Publications
• About Surveys on Alcohol Use
• About Standard Drink Sizes
• CDC Alcohol Program
• Alcohol Outlet Density Measurement Tools
• Resources to Prevent Excessive Alcohol Use
• Alcohol Applications and Online Tools
• Funding to Prevent Excessive Alcohol Use
• Alcohol-Related Disease Impact (ARDI) Application
• Check Your Drinking. Make a Plan to Drink Less.
• Controle su forma de beber. Haga un plan para beber menos.
• Deaths from Excessive Alcohol Use in the United States
• Addressing Excessive Alcohol Use: State Fact Sheets
• Excessive alcohol use can have immediate and long-term effects.
• Excessive drinking includes binge drinking, heavy drinking, and any drinking during pregnancy or by people younger than 21.
• Drinking less is better for your health than drinking more.
• You can lower your health risks by drinking less or choosing not to drink.

Why it's important

• The rest of the alcohol can harm your liver and other organs as it moves through the body.
• Using alcohol excessively on occasion or over time can have immediate and long-term health risks.
• By drinking less alcohol, you can improve your health and well-being.

Deaths from excessive alcohol use‎

Understanding alcohol use, excessive alcohol use.

Excessive alcohol use is a term used to describe four ways that people drink alcohol that can negatively impact health. Excessive drinking can also be deadly.

Excessive alcohol use includes:

• Binge drinking—Four or more drinks for women, or five or more drinks for men during an occasion.
• Heavy drinking—Eight or more drinks for women, or 15 or more drinks for men during a week.
• Underage drinking —any alcohol use by people younger than 21.
• Drinking while pregnant—any alcohol use during pregnancy .

Moderate alcohol use

Moderate drinking is having one drink or less in a day for women, or two drinks or less in a day for men.

Keep in mind‎

Effects of short-term alcohol use.

Drinking excessively on an occasion can lead to these harmful health effects:

• Injuries— motor vehicle crashes , falls, drownings, and burns.
• Violence—homicide, suicide, sexual violence, and intimate partner violence.
• Alcohol poisoning—high blood alcohol levels that affect body functions like breathing and heart rate.
• Overdose—from alcohol use with other drugs , like opioids.
• Sexually transmitted infections or unplanned pregnancy—alcohol use can lead to sex without protection, which can cause these conditions.
• Miscarriage, stillbirth, or fetal alcohol spectrum disorder (FASD) —from any alcohol use during pregnancy.

Effects of long-term alcohol use

Over time, drinking alcohol can have these effects:

• The risk of some cancers increases with any amount of alcohol use. 2 This includes breast cancer (in women). 2 A
• More than 20,000 people die from alcohol-related cancers each year in the United States. 3

Other chronic diseases

Excessive alcohol use can lead to:

• High blood pressure.
• Heart disease.
• Liver disease.
• Alcohol use disorder—this affects both physical and mental health. B
• Digestive problems.
• Weaker immune system—increasing your chances of getting sick.

Social and wellness issues

• Mental health conditions, including depression and anxiety.
• Learning problems, and issues at school or work.
• Memory problems, including dementia.
• Relationship problems with family and friends.

You can take steps to lower your risk of alcohol-related harms.

The less alcohol you drink, the lower your risk for these health effects, including several types of cancer.

Check your drinking‎

• The risk of alcohol use leading to breast cancer in men has not been established.
• Most people who drink excessively do not have alcohol use disorder (also known as "alcohol dependence" or "alcoholism"). Many people who drink excessively can lower their alcohol use without specialized medical treatment. Facts about alcohol use disorder are available at: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder .
• Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from excessive alcohol use — United States, 2016-2021. MMWR Morb Mortal Wkly Rep . 2024;73:154–161. doi: http://dx.doi.org/10.15585/mmwr.mm7308a1
• Bagnardi V, Rota M, Botteri E, et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. Br J Cancer . 2015;112(3):580-593. doi: 10.1038/bjc.2014.579
• Esser MB, Sherk A, Liu Y, Henley SJ, Naimi TS. Reducing alcohol use to prevent cancer deaths: estimated effects among U.S. adults. Am J Prev Med . 2024;66(4):725–729. doi: 10.1016/j.amepre.2023.12.003

Alcohol Use

Excessive alcohol use can harm people who drink and those around them. You and your community can take steps to improve everyone’s health and quality of life.

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How Binge Drinking Shifted Research On Alcohol Use Disorders

"roughly 1 in 5 u.s. adults report binge drinking at least once a week.".

With the new Amy Winehouse biopic “Back to Black ” in U.S. theaters as of May 17, 2024, the late singer’s relationship with alcohol and drugs is under scrutiny again. In July 2011, Winehouse was found dead in her flat in north London from “death by misadventure” at the age of 27. That’s the official British term used for accidental death caused by a voluntary risk.

Her blood alcohol concentration was 0.416%, more than five times the legal intoxication limit in the U.S. – leading her cause of death to be later adjusted to include “alcohol toxicity” following a second coroner’s inquest.

Nearly 13 years later, alcohol consumption and binge drinking remain a major public health crisis , not just in the U.K. but also in the U.S.

Roughly 1 in 5 U.S. adults report binge drinking at least once a week, with an average of seven drinks per binge episode . This is well over the amount of alcohol thought to produce legal intoxication, commonly defined as a blood alcohol concentration over 0.08% – on average, four drinks in two hours for women, five drinks in two hours for men.

Among women, days of “heavy drinking” increased 41% during the COVID-19 pandemic compared with pre-pandemic levels , and adult women in their 30s and 40s are rapidly increasing their rates of binge drinking , with no evidence of these trends slowing down. Despite efforts to comprehend the overall biology of substance use disorders, scientists’ and physicians’ understanding of the relationship between women’s health and binge drinking has lagged behind.

I am a neurobiologist focused on understanding the chemicals and brain regions that underlie addiction to alcohol . I study how neuropeptides – unique signaling molecules in the prefrontal cortex , one of the key brain regions in decision-making, risk-taking and reward – are altered by repeated exposure to binge alcohol consumption in animal models.

My lab focuses on understanding how things like alcohol alter these brain systems before diagnosable addiction, so that we can better inform efforts toward both prevention and treatment.

The Biology Of Addiction

While problematic alcohol consumption has likely occurred as long as alcohol has existed, it wasn’t until 2011 that the American Society of Addiction Medicine recognized substance addiction as a brain disorder – the same year as Winehouse’s death. A diagnosis of an alcohol use disorder is now used over outdated terms such as labeling an individual as an alcoholic or having alcoholism.

Researchers and clinicians have made great strides in understanding how and why drugs – including alcohol, a drug – alter the brain. Often, people consume a drug like alcohol because of the rewarding and positive feelings it creates, such as enjoying drinks with friends or celebrating a milestone with a loved one. But what starts off as manageable consumption of alcohol can quickly devolve into cycles of excessive alcohol consumption followed by drug withdrawal.

While all forms of alcohol consumption come with health risks, binge drinking appears to be particularly dangerous due to how repeated cycling between a high state and a withdrawal state affect the brain. For example, for some people, alcohol use can lead to “ hangxiety ,” the feeling of anxiety that can accompany a hangover.

Repeated episodes of drinking and drunkenness, coupled with withdrawal, can spiral, leading to relapse and reuse of alcohol. In other words, alcohol use shifts from being rewarding to just trying to prevent feeling bad.

It makes sense. With repeated alcohol use over time, the areas of the brain engaged by alcohol can shift away from those traditionally associated with drug use and reward or pleasure to brain regions more typically engaged during stress and anxiety .

All of these stages of drinking, from the enjoyment of alcohol to withdrawal to the cycles of craving, continuously alter the brain and its communication pathways . Alcohol can affect several dozen neurotransmitters and receptors , making understanding its mechanism of action in the brain complicated.

Work in my lab focuses on understanding how alcohol consumption changes the way neurons within the prefrontal cortex communicate with each other. Neurons are the brain’s key communicator, sending both electrical and chemical signals within the brain and to the rest of your body.

What we’ve found in animal models of binge drinking is that certain subtypes of neurons lose the ability to talk to each other appropriately. In some cases, binge drinking can permanently remodel the brain. Even after a prolonged period of abstinence, conversations between the neurons don’t return to normal .

These changes in the brain can appear even before there are noticeable changes in behavior . This could mean that the neurobiological underpinnings of addiction may take root well before an individual or their loved ones suspect a problem with alcohol.

Researchers like us don’t yet fully understand why some people may be more susceptible to this shift, but it likely has to do with genetic and biological factors, as well as the patterns and circumstances under which alcohol is consumed.

Women are Forgotten

While researchers are increasingly understanding the medley of biological factors that underlie addiction, there’s one population that’s been largely overlooked until now: women.

Women may be more likely than men to have some of the most catastrophic health effects caused by alcohol use, such as liver issues, cardiovascular disease and cancer . Middle-aged women are now at the highest risk for binge drinking compared with other populations.

When women consume even moderate levels of alcohol, their risk for various cancers goes up, including digestive, breast and pancreatic cancer , among other health problems – and even death. So the worsening rates of alcohol use disorder in women prompt the need for a greater focus on women in the research and the search for treatments.

Yet, women have long been underrepresented in biomedical research.

It wasn’t until 1993 that clinical research funded by the National Institutes of Health was required to include women as research subjects. In fact, the NIH did not even require sex as a biological variable to be considered by federally funded researchers until 2016. When women are excluded from biomedical research, it leaves doctors and researchers with an incomplete understanding of health and disease, including alcohol addiction.

There is also increasing evidence that addictive substances can interact with cycling sex hormones such as estrogen and progesterone . For instance, research has shown that when estrogen levels are high, like before ovulation, alcohol might feel more rewarding , which could drive higher levels of binge drinking. Currently, researchers don’t know the full extent of the interaction between these natural biological rhythms or other unique biological factors involved in women’s health and propensity for alcohol addiction.

Looking Ahead

Researchers and lawmakers are recognizing the vital need for increased research on women’s health. Major federal investments into women’s health research are a vital step toward developing better prevention and treatment options for women.

While women like Amy Winehouse may have been forced to struggle both privately and publicly with substance use disorders and alcohol, the increasing focus of research on addiction to alcohol and other substances as a brain disorder will open new treatment avenues for those suffering from the consequences.

For more information on alcohol use disorder, causes, prevention and treatments, visit the National Institute on Alcohol Abuse and Alcoholism .

Nikki Crowley is an Assistant Professor of Biology, Biomedical Engineering and Pharmacology at Penn State. This article is republished from The Conversation under a Creative Commons license . Read the original article .

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Common Comorbidities with Substance Use Disorders Research Report Part 1: The Connection Between Substance Use Disorders and Mental Illness

Many individuals who develop substance use disorders (SUD) are also diagnosed with mental disorders, and vice versa. 2,3 Although there are fewer studies on comorbidity among youth, research suggests that adolescents with substance use disorders also have high rates of co-occurring mental illness; over 60 percent of adolescents in community-based substance use disorder treatment programs also meet diagnostic criteria for another mental illness. 4

Data show high rates of comorbid substance use disorders and anxiety disorders—which include generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. 5–9 Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder, 6,9–11 attention-deficit hyperactivity disorder (ADHD), 12,13 psychotic illness, 14,15 borderline personality disorder, 16 and antisocial personality disorder. 10,15 Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population. 17 As Figure 1 shows, the overlap is especially pronounced with serious mental illness (SMI). Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities. Serious mental illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment. 18 Around 1 in 4 individuals with SMI also have an SUD.

Data from a large nationally representative sample suggested that people with mental, personality, and substance use disorders were at increased risk for nonmedical use of prescription opioids. 19 Research indicates that 43 percent of people in SUD treatment for nonmedical use of prescription painkillers have a diagnosis or symptoms of mental health disorders, particularly depression and anxiety. 20

Youth—A Vulnerable Time

Although drug use and addiction can happen at any time during a person’s life, drug use typically starts in adolescence, a period when the first signs of mental illness commonly appear. Comorbid disorders can also be seen among youth. 21–23 During the transition to young adulthood (age 18 to 25 years), people with comorbid disorders need coordinated support to help them navigate potentially stressful changes in education, work, and relationships. 21

Drug Use and Mental Health Disorders in Childhood or Adolescence Increases Later Risk

The brain continues to develop through adolescence. Circuits that control executive functions such as decision making and impulse control are among the last to mature, which enhances vulnerability to drug use and the development of a substance use disorder. 3,24 Early drug use is a strong risk factor for later development of substance use disorders, 24 and it may also be a risk factor for the later occurrence of other mental illnesses. 25,26 However, this link is not necessarily causative and may reflect shared risk factors including genetic vulnerability, psychosocial experiences, and/or general environmental influences. For example, frequent marijuana use during adolescence can increase the risk of psychosis in adulthood, specifically in individuals who carry a particular gene variant. 26,27

It is also true that having a mental disorder in childhood or adolescence can increase the risk of later drug use and the development of a substance use disorder. Some research has found that mental illness may precede a substance use disorder, suggesting that better diagnosis of youth mental illness may help reduce comorbidity. One study found that adolescent-onset bipolar disorder confers a greater risk of subsequent substance use disorder compared to adult-onset bipolar disorder. 28 Similarly, other research suggests that youth develop internalizing disorders, including depression and anxiety, prior to developing substance use disorders. 29

Untreated Childhood ADHD Can Increase Later Risk of Drug Problems

Numerous studies have documented an increased risk for substance use disorders in youth with untreated ADHD, 13,30 although some studies suggest that only those with comorbid conduct disorders have greater odds of later developing a substance use disorder. 30,31 Given this linkage, it is important to determine whether effective treatment of ADHD could prevent subsequent drug use and addiction. Treatment of childhood ADHD with stimulant medications such as methylphenidate or amphetamine reduces the impulsive behavior, fidgeting, and  inability to concentrate that characterize ADHD. 32

That risk presents a challenge when treating children with ADHD, since effective treatment often involves prescribing stimulant medications with addictive potential. Although the research is not yet conclusive, many studies suggest that ADHD medications do not increase the risk of substance use disorder among children with this condition. 31,32 It is important to combine stimulant medication for ADHD with appropriate family and child education and behavioral interventions, including counseling on the chronic nature of ADHD and risk for substance use disorder. 13,32

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Alcohol's Effects on Health

Research-based information on drinking and its impact.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Genetics of alcohol use disorder.

How do genes influence alcohol use disorder?

Alcohol use disorder (AUD) often seems to run in families, and we may hear about scientific studies of an “alcoholism gene.” Genetics certainly influence our likelihood of developing AUD, but the story isn’t so simple.

Research shows that genes are responsible for about half of the risk for AUD. Therefore, genes alone do not determine whether someone will develop AUD. Environmental factors, as well as gene and environment interactions account for the remainder of the risk.

Multiple genes play a role in a person’s risk for developing AUD. There are genes that increase a person’s risk, as well as those that may decrease that risk, directly or indirectly. For instance, some people of Asian descent carry a gene variant that alters their rate of alcohol metabolism, causing them to have symptoms like flushing, nausea, and rapid heartbeat when they drink. Many people who experience these effects avoid alcohol, which helps protect them from developing AUD.**

As we have learned more about the role genes play in our health, researchers have discovered that different factors can alter the expression of our genes. This field is called epigenetics. Scientists are learning more and more about how epigenetics can affect our risk for developing AUD.

Can our genes affect alcohol treatment?

Scientists are also exploring how genes may influence the effectiveness of treatments for AUD. For instance, the drug naltrexone has been shown to help some, but not all, patients with AUD to reduce their drinking. Research has shown that patients with AUD who also have variations in a specific gene respond positively to treatment with the drug, while those without the specific gene do not. A fuller understanding of how genes influence treatment outcomes will help doctors prescribe the treatment that is most likely to help each patient.***

What is NIAAA doing to learn more?

NIAAA has funded the Collaborative Studies on Genetics of Alcoholism (COGA) since 1989, with the goal of identifying the specific genes that influence alcohol use disorder. In addition, NIAAA funds investigators’ research in this important field, and also has an in-house research emphasis on the interaction of genes and the environment. NIAAA is committed to learning more about how genes affect AUD so that treatment—and prevention efforts—can continue to be developed and improved.

* Spectrum 1: 1 .

** AR&H Volume 31, Number 4, 2008

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What Are the Long-Term Effects of Alcohol on the Body?

• Effects on Body
• Long-Term Risks
• Psychological Effects
• Consequences
• Addiction and Withdrawal

From a glass of wine with dinner to a night out with friends or a celebratory toast, alcohol consumption is deeply ingrained in many social practices and cultural traditions worldwide. In the United States, over 84% of adults report drinking alcohol at least once in their lifetime.

While casual to moderate drinking may be a part of life for some, excessive or chronic alcohol consumption can significantly impact your body and long-term health.

This article discusses the long-term effects of alcohol, including the risks to your physical health and mental well-being. 

Morsa Images / Getty Images

How Alcohol Affects the Body

Alcohol  is a central nervous system depressant that has immediate effects on the body, like intoxication (feeling drunk) and hangovers (unpleasant aftereffects from drinking). While these effects are short-lived, long-term alcohol use can  trigger systemic (bodywide) inflammation , which damages the body's tissues and vital organs over time.  

Cardiovascular System

Alcohol use impacts the cardiovascular system in several ways. In the short term, drinking alcohol increases your heart rate, and even moderate alcohol consumption can increase your blood pressure.

Chronic alcohol use and binge drinking damage the heart muscle, making it harder for the heart to pump blood effectively. Alcohol can also contribute to arrhythmias (irregular heartbeats) and hypertension (high blood pressure), increasing the risk of heart attack, stroke, and heart failure.

The  liver  metabolizes most of the alcohol you consume, breaking it down into acetaldehyde . Acetaldehyde is a toxin that can damage the body's organs and tissues before it is further broken down into acetate. This damage is most evident in the liver. Years of moderate to heavy drinking can cause liver scarring (fibrosis), increasing the risk of liver diseases like cirrhosis, alcoholic hepatitis, fatty liver disease, and liver cancer.

Gastrointestinal (GI) System

Alcohol consumption irritates the lining of the stomach and intestines. A night of drinking can cause uncomfortable symptoms like diarrhea, nausea, and vomiting. Chronic and excessive alcohol use disrupts the balance of bacteria in the gut microbiome (dysbiosis). Over time, this imbalance triggers chronic gastrointestinal inflammation, leading to a higher risk of gastrointestinal diseases.  

Excess alcohol use can also impair nutrient absorption in the small intestine and increase the risk of malnutrition.

The brain is highly vulnerable to the damaging effects of alcohol, which disrupts communication between brain cells. Excessive or chronic alcohol use can lead to a steady decline in cognitive function, causing memory problems, difficulty learning new information, mood changes, and behavior changes.

Long-term alcohol use is associated with a higher risk of progressive cognitive decline and age-related neurological conditions like dementia.

Reproductive System

Alcohol use can cause sexual dysfunction, such as difficulty achieving or maintaining an erection and decreased sexual sensations. The impact alcohol has on the reproductive system extends beyond these temporary effects. Chronic alcohol use causes hormone imbalances in both men and women and leads to problems with fertility. 

In people assigned male at birth, alcohol consumption can decrease testosterone production and sperm quality. In people assigned female at birth, alcohol use can interfere with regular ovulation and menstrual cycles and make it difficult to get pregnant.

Long-Term Health Risks

Alcohol is one of the leading causes of death in the United States, contributing to approximately 178,000 deaths annually. Over time, alcohol use takes a toll on your body and increases your risk of over 200 health conditions.  

While the risk of health problems is higher in people who drink excessively, there is no safe level of alcohol consumption, and even light to moderate drinking comes with health risks. Long-term health risks associated with alcohol include:

• Heart disease :   Alcohol consumption raises blood pressure and narrows the heart's arteries, decreasing blood flow and increasing the risk of heart disease, heart attack, and stroke. 
• Liver disease :   Alcohol use  damages the liver  over time, increasing the risk of liver diseases like fatty liver disease, alcohol-associated hepatitis, cirrhosis, and liver failure. 
• Gastrointestinal disease : Alcohol damages the lining of the GI tract, causing inflammation that can impair gut function, cause GI bleeding, and increase the risk of GI diseases, such as gastroesophageal reflux disease (GERD). 
• Cancer :   Alcohol is a carcinogen that damages cellular DNA, impairs the absorption of essential nutrients, and triggers systemic inflammation. Research shows that alcohol consumption is associated with an increased risk of head and neck cancers, esophageal cancer, liver cancer, breast cancer, and colorectal cancer.
• Weakened immune system : Alcohol use can impair the body's immune response and alter signaling between immune cells. This, in turn, can increase the risk of infection, slow wound healing time, and trigger systemic inflammation (inflammation throughout the body) that contributes to organ damage and disease. 

Moderate and Excessive Drinking Defined

The National Institute on Alcohol Abuse and Alcoholism defines moderate drinking as two or fewer drinks in a day for men and one or less in a day for women. Excessive (binge) drinking is defined as four or more drinks on a single occasion for women and five or more drinks on a single occasion for men.

Mental Health and Psychological Effects

While alcohol is seen as a way to relax or cope with stress, it can have severe effects on your mental health and well-being in the long run, including: 

• Alcohol and mental health disorders : Some people use alcohol to self-medicate mood disorders like anxiety or depression, but this can lead to an unhealthy dependence on alcohol and worsening symptoms. Alcohol disrupts the brain's chemistry, leading to mood swings, irritability, and difficulty regulating emotions. Alcohol use also increases the risk of developing mood disorders, including anxiety, depression, and bipolar disorder.
• Alcohol use disorder (AUD) :   Regular and excessive alcohol use can lead to AUD, a condition characterized by an inability to control alcohol consumption despite adverse consequences. People with AUD experience intense cravings and difficulty stopping drinking and may prioritize alcohol use over responsibilities and relationships.
• Cognitive function decline :   Chronic alcohol consumption disrupts communication pathways in the brain and damages brain cells. Over time, this can lead to a decrease in cognitive function and increase the risk of  alcohol-related dementia , which causes problems with memory, learning, focus, and concentration.
• Decision-making :   Alcohol impairs judgment and decision-making abilities, increasing the likelihood of engaging in risky behaviors and making poor choices. Chronic alcohol use or misuse diminishes your ability to weigh the consequences of your actions and exercise self-control, leading to a cycle of destructive behaviors and adverse outcomes.

Social and Interpersonal Consequences

From strained family dynamics to work-related and financial troubles, the social and interpersonal consequences of alcohol use can be profound and far-reaching, such as:

• Relationships :   Alcohol misuse often leads to strained relationships with family members, friends, and romantic partners. Alcohol-related conflicts, unpredictable behavior, and mood swings can erode trust and communication within relationships, leading to feelings of resentment, sadness, and fear. Children of parents who struggle with alcohol misuse are particularly vulnerable, experiencing emotional distress and psychological and behavioral problems.
• Work performance and productivity : Alcohol misuse can have a significant impact on your work performance. You may experience fatigue, trouble focusing, or difficulty completing your work tasks effectively. Chronic absenteeism due to alcohol-related issues can also jeopardize job security and career advancement.
• Finances : Financial troubles are common in people with AUD. Making impulsive purchases, spending excessive amounts on alcohol, having additional healthcare expenses, or losing wages due to decreased work productivity can contribute to significant financial burdens. 
• Legal troubles :   Driving under the influence (DUI), public intoxication, and other drinking-related behaviors can have lasting legal repercussions that affect employment opportunities, housing options, and personal freedoms.

Alcohol Addiction and Withdrawal

Alcohol addiction, or  alcohol use disorder , is a complex and chronic brain disorder characterized by compulsive alcohol use, loss of control over drinking, and an intense craving for alcohol despite negative consequences.

AUD develops gradually. Over time, your brain's structure and function change, leading to tolerance, meaning you may require higher amounts of alcohol to achieve the desired effects. These brain changes contribute to the compulsive nature of addiction, making it difficult to abstain from alcohol.

If you have AUD and stop drinking, you may experience withdrawal symptoms that can affect your physical and mental health, including:  

• Hand tremors (shakes) 
• Irritability 
• Loss of appetite
• Mood swings
• Nausea and vomiting 
• Pale, clammy skin 
• Rapid heart rate
• Trouble sleeping 

At this point, you may have alcohol cravings or drink to avoid the low feelings withdrawal causes rather than for the pleasurable feelings alcohol consumption may offer. 

A Word From Verywell

Life is a matter of moderation. It's not human to be perfect. The same concept applies to alcohol intake. It's been proven that alcohol isn't healthy to consume. If you can appreciate this fact and limit yourself, then you generally will keep your risk of alcohol-associated diseases low. If you feel you can't limit yourself despite this information, then you need to rethink your relationship with alcohol.

How Alcohol Use Disorder Is Treated

Treatment for AUD addresses the physical, psychological, and social impacts of alcohol addiction to help people with AUD achieve and maintain sobriety. If you are concerned about your alcohol use—or that of someone you care for—talk to a healthcare provider. They can assess your drinking pattern and help develop a treatment plan that may include:

• Behavioral treatments : Individual and group counseling sessions help develop the skills and strategies needed to manage cravings, cope with triggers, and prevent relapse. Common forms of behavioral counseling for alcohol addiction include cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET).
• Medications : Several prescription medications can effectively help reduce cravings, manage withdrawal symptoms, and prevent relapse. These medications interfere with how the body processes alcohol or regulates brain chemicals involved in reward and motivation. 
• Support groups :   Groups like Alcoholics Anonymous (AA) and other 12-step programs provide a sense of community and connection for people cutting back or quitting alcohol and those who are in recovery. Sharing experiences, offering encouragement, and holding each other accountable can be a powerful way to maintain sobriety. 
• Inpatient and outpatient treatment programs : Treatment programs can help people quit drinking and maintain sobriety. Inpatient programs offer intensive therapy and support in a residential setting, while outpatient programs allow people to continue living at home while receiving treatment.

Alcohol use, especially excessive alcohol consumption, can harm your physical and mental health. From damaging vital organs to impairing brain function and jeopardizing relationships, the negative consequences of excessive alcohol use are far-reaching. Chronic alcohol use raises your risk for health problems, including heart disease, liver disease, cancer, and mental health disorders. 

If you choose to drink, do so in moderation: one drink per day or less for women and people assigned female at birth and two drinks or less daily for men and people assigned male at birth. 

Talk to a healthcare provider if you are concerned about your drinking or that of a loved one. Professional treatments and support can help you overcome alcohol misuse and alcohol use disorder and improve your overall health and well-being. 

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American Heart Association. Is drinking alcohol part of a healthy lifestyle? December 30, 2019.

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Osna NA, Donohue TM Jr, Kharbanda KK. Alcoholic liver disease: pathogenesis and current management . Alcohol Res . 2017;38(2):147-161.

Haber PS, Kortt NC. Alcohol use disorder and the gut . Addiction . 2021;116(3):658-667. doi:10.1111/add.15147

Barve S, Chen SY, Kirpich I, Watson WH, Mcclain C. Development, prevention, and treatment of alcohol-induced organ injury: the role of nutrition . Alcohol Res . 2017;38(2):289-302.

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Wiegmann C, Mick I, Brandl EJ, Heinz A, Gutwinski S. Alcohol and Dementia - What is the Link? A Systematic Review . Neuropsychiatr Dis Treat . 2020;16:87-99. doi:10.2147/NDT.S198772

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Salari N, Hasheminezhad R, Almasi A, et al. The risk of sexual dysfunction associated with alcohol consumption in women: a systematic review and meta-analysis . BMC Womens Health . 2023;23(1):213. doi:10.1186/s12905-023-02400-5

MedlinePlus. Reproductive hazards . March 22, 2024.

National Institute on Alcohol Abuse and Alcoholism. Medical complications: common alcohol-related concerns . March 13, 2024.

Centers for Disease Control and Prevention. What is excessive drinking? February 29, 2024.

National Cancer Institute. Alcohol and cancer risk . July 14, 2021.

National Institute on Alcohol Abuse and Alcoholism. Drinking levels defined . 2023.

National Institute on Alcohol Abuse and Alcoholism. Mental health issues: alcohol use disorder and common co-occuring conditions . January 12, 2024.

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Ridley NJ, Draper B, Withall A. Alcohol-related dementia: an update of the evidence . Alzheimers Res Ther . 2013;5(1):3. doi:10.1186/alzrt157

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McCrady BS, Flanagan JC. The role of the family in alcohol use disorder recovery for adults . Alcohol Res . 2021;41(1):06. doi:10.35946/arcr.v41.1.06

Thørrisen MM, Bonsaksen T, Hashemi N, Kjeken I, van Mechelen W, Aas RW. Association between alcohol consumption and impaired work performance (presenteeism): a systematic review . BMJ Open . 2019;9(7):e029184. doi:10.1136/bmjopen-2019-029184

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By Lindsay Curtis Curtis is a writer with over 20 years of experience focused on mental health, sexual health, cancer care, and spinal health.

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Alcohol Use Disorder and Depressive Disorders

Alcohol use disorder (AUD) and depressive disorders are among the most prevalent psychiatric disorders and co-occur more often than expected by chance. The aim of this review is to characterize the prevalence, course, and treatment of co-occurring AUD and depressive disorders. Studies have indicated that the co-occurrence of AUD and depressive disorders is associated with greater severity and worse prognosis for both disorders. Both pharmacologic and behavioral treatments have demonstrated efficacy for this population. However, treatment response is somewhat modest, particularly for drinking outcomes, highlighting the importance of further research on the etiology and treatment of co-occurring AUD and depressive disorders. Key future directions include studies to understand the heterogeneity of both AUD and depressive disorders, research on novel treatment approaches to enhance outcomes, and better understanding of sex and gender differences.

Introduction

Psychiatric disorders, such as anxiety and mood disorders, commonly co-occur with alcohol use disorder (AUD). Depressive disorders are the most common psychiatric disorders among people with AUD. 1 The co-occurrence of these disorders is associated with greater severity and worse prognosis than either disorder alone, 2 , 3 including a heightened risk for suicidal behavior. 4 This review provides an overview of the literature on the co-occurrence of AUD and depressive disorders and includes data on prevalence, course, and treatment outcomes. High-priority future research directions are suggested to better understand the co-occurrence of these conditions and to improve treatments.

Much of the published literature on the co-occurrence of AUD and depressive disorders uses the classifications from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 5 Where possible, this review specifies if the cited literature used the DSM-IV classifications for diagnosis (alcohol abuse or alcohol dependence) or the fifth edition (DSM-5) classification for diagnosis (AUD). 6 If a study reported results based on the combined DSM-IV diagnoses (i.e., included participants with alcohol abuse and participants with alcohol dependence), this review refers to the diagnosis as “DSM-IV AUD.” Although DSM-IV and DSM-5 AUD share many symptoms, the diagnoses are defined differently. In the DSM-5, AUD requires at least two symptoms, whereas DSM-IV alcohol abuse required only one symptom. Also, from DSM-IV to DSM-5, modifications were made to the symptoms that were included as diagnostic criteria. For example, the criterion of legal problems related to alcohol was removed, and the criterion of alcohol craving was added. Thus, where possible, this review identifies which version of the DSM was used in a study.

Overview of Depressive Disorders

Depressive disorders are complex and heterogeneous syndromes. These disorders are characterized by disrupted mood (e.g., low, numb, or irritable), along with an array of cognitive (e.g., feelings of worthlessness and difficulty concentrating) and physical (e.g., fatigue and lack of energy) symptoms. The DSM-5 includes seven distinct disorders under the category of depressive disorders, including major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, disruptive mood dysregulation disorder, other specified depressive disorder, and unspecified depressive disorder. 6 This review focuses on major depressive disorder, dysthymia, and substance-induced depressive disorder, which are the depressive disorders that have been studied most often in both the general population and among people with AUD.

Major depressive disorder is characterized by the presence of five or more symptoms that are present for at least 2 weeks. One of these symptoms must include depressed mood or anhedonia (significant loss of interest or pleasure in activities). Other symptoms are disturbances in appetite, sleep, psychomotor behaviors, energy, concentration, and decision-making; beliefs about worthlessness or guilt; and thoughts of suicide or suicide attempt. Dysthymia is more chronic than major depressive disorder, yet it is typically a milder disorder, characterized by at least 2 years of depressed mood and at least two additional symptoms, including dysfunction in appetite, sleep, energy, self-esteem, concentration, or decision-making, and feelings of hopelessness. Alcohol-induced depressive disorder refers to a depressive-like syndrome (characterized by depressed mood or anhedonia) that occurs only during and shortly after alcohol intoxication or withdrawal, remits after 3 to 4 weeks of alcohol abstinence, and is associated with significant distress and impairment.

Prevalence of depressive disorders and AUD

Major depressive disorder is the most common psychiatric disorder, affecting an estimated 10% to 15% of people in their lifetime, according to U.S. and international population-based surveys. 7 , 8 Dysthymia is less common than major depressive disorder, affecting less than 2% of people in their lifetime. 9

Likewise, major depressive disorder is the most common co-occurring psychiatric disorder among people with DSM-IV AUD. 1 Considering the prevalence of major depressive disorder and AUD in the general population, co-occurrence of these disorders is more frequent than can be expected based on chance, with odds ratios indicating a small effect size. Specifically, people with DSM-IV AUD, relative to those with no AUD, are 2.3 times more likely to also have major depressive disorder in the previous year, and they are 1.7 times more likely to have dysthymia in the previous year. 1 The prevalence of depressive disorders is greater among those with alcohol dependence, as compared to those diagnosed with alcohol abuse, with high prevalence of depression reported among treatment-seekers. People with DSM-IV alcohol dependence are 3.7 times more likely to also have major depressive disorder, and 2.8 times more likely to have dysthymia, in the previous year. Among people in treatment for DSM-IV AUD, almost 33% met criteria for major depressive disorder in the past year, and 11% met criteria for dysthymia. However, major depressive disorder is the most common co-occurring disorder among people who have AUD, partly because it is among the most common disorders in the general population.

Data from large population-based surveys suggest that the prevalence of alcohol-induced depression is small. For example, among people who also had a substance use disorder, less than 1% of their depressive disorders were classified as substance induced. 1 Studies have found a much higher prevalence of substance-induced depressive disorder among patients with AUD who were in treatment settings, when compared with studies of general population samples. One study reported that more than 25% of patients experienced a substance-induced depressive episode in their lifetime. 10 Nonetheless, studies have found that many cases initially diagnosed as substance-induced depression were later reclassified as independent depression (i.e., not substance induced) because the condition persisted after a period of abstinence. 11

Disproportionately affected populations

Several groups are disproportionately affected by co-occurring AUD and depressive disorders. For example, women are 1.5 to 2 times more likely in their lifetime to experience major depressive disorder than men. 12 Likewise, women with DSM-IV AUD are more likely than men with DSM-IV AUD to meet the criteria for major depressive disorder or dysthymia. 13 , 14 Sex differences are not limited to prevalence; they also are observed in the course of depressive disorders. A longitudinal study of young adults found that depression predicted alcohol problems in women but not in men. 15 This finding is consistent with reports from retrospective studies that examined relative age of onset for AUD and depressive disorders, in which women were more likely to experience depression before AUD, whereas men were more likely to develop AUD before depression. 16 , 17

Although race and ethnicity are clearly factors in the risk for developing AUD or depressive disorders, studies examining racial and ethnic differences in the prevalence of co-occurring AUD and depressive disorders have been hampered by small sample sizes, which make group comparisons difficult. 18 Nonetheless, data strongly support significant disparities in health care for co-occurring AUD and depressive disorders among racial and ethnic minority groups. The likelihood of receiving AUD care is similar across racial and ethnic groups, but people who identify as Black or Latino are significantly less likely than people who identify as White to receive services for mood and anxiety disorders or to receive integrated mental health and substance use disorder care. 19 , 20

Pathways to Co-Occurrence

Several potential developmental pathways have been proposed to explain the high rate of co-occurring AUD and depressive disorders, including: (1) depressive disorders increase risk for AUD, (2) AUD increases risk for depressive disorders, and (3) both conditions share pathophysiology or have common risk factors. Although evidence supports all three of these pathways, much research is still needed to understand the development of co-occurrence.

Much of the research on the development of co-occurring AUD and depressive disorders has relied on retrospective and longitudinal studies that examine the age of onset of the disorders. These studies have yielded mixed evidence. Some studies indicate that depressive disorders typically precede the onset of AUD, 21 others suggest that AUD generally precedes depressive disorders, 22 and still others report that the order of onset varies by gender (with women more likely to have earlier onset of depression than men). 17

Literature on the onset of substance use among youth and young adults has indicated that internalizing symptoms (e.g., depression and anxiety) generally protect against the onset of alcohol misuse in adolescents. 23 However, the association between internalizing symptoms and risk for alcohol use and misuse is influenced by key moderating factors, such as the presence of both internalizing and externalizing symptoms (e.g., impulsivity and aggression), 23 motives for substance use, 24 and gender. 25 For example, research has indicated that internalizing symptoms are a risk factor for the development of AUD in women but not in men. 25

AUD has been associated with risk for the onset of depressive symptoms and disorders. In one review, regular or heavy drinking in adolescents was shown to be associated with the risk for developing depressive symptoms and disorders. 26 In studies of adults, DSM-IV AUD was associated with risk for the onset of major depressive disorder and with dysthymia. 22 , 27

Research on the possibility of a common pathophysiology of co-occurring AUD and depressive disorders is limited, yet it is a growing area of inquiry. Studies of genetic liability have identified some evidence that AUD and depressive disorders share susceptibility. 28 – 30 Although much remains to be understood about the possible shared pathophysiology for these conditions, a number of candidate systems and processes have been identified, such as dysfunction in the reward and stress systems. 31

Data from studies of depressive disorders suggest that specific symptom profiles may reflect distinct pathophysiology. For example, different symptom types have been associated with electrical activity (measured by electroencephalogram) in the brain while patients are at rest. 32 A diagnosis of major depressive disorder can involve 227 unique symptom combinations; 6 thus, the combination of symptoms from AUD and depressive disorders can take many forms. Consideration of disorder heterogeneity is essential to better understand the development of the co-occurring disorders.

Course and prognosis

The prognosis of co-occurring AUD and depression is highly variable and depends on several factors, such as age of onset and the severity of the disorders. For example, DSM-IV alcohol dependence (particularly severe dependence) has been associated with persistence of depressive disorders, whereas alcohol abuse has not. 33 Furthermore, the association between depressive disorders and AUD outcomes depends on how depression was measured. A diagnosis of major depressive disorder typically has been associated with worse AUD treatment outcomes, 2 , 3 whereas more severe depressive symptoms alone have not been associated with worse AUD treatment outcomes, when compared to less severe depressive symptoms. 2 Depressive symptoms have been shown to significantly improve after a period of abstinence from alcohol (typically 3 to 4 weeks), 34 which may explain the lack of association between symptoms and drinking outcomes outside of the context of a depressive disorder.

Evidence from longitudinal data on whether AUD worsens depression outcomes is somewhat mixed, with some studies finding evidence for worse outcomes and others finding no difference. 35 However, large studies have suggested that recovery from both conditions is linked, with remission from one condition strongly related to remission from the other. 36 For example, results from a large ( N = 2,876) multisite trial of treatment for depressive disorders found that patients who had co-occurring substance use disorder had a lower likelihood of depressive disorder remission and had a longer time to remission, when compared to patients with no substance use disorder. 37

Although alcohol-induced depressive disorder is defined by remission of the depression after discontinuation of alcohol, the disorder has been associated with risk for onset of later major depressive disorder. 11 Another study reported that patients with alcohol-induced depressive disorders experienced worse alcohol-related outcomes than patients with alcohol dependence who had other types of depressive disorders. 38

Treatment of Co-Occurring AUD and Depressive Disorders

Many randomized trials have investigated treatments for co-occurring AUD and depressive disorders. In this section, trials that used medication and psychotherapy treatments are discussed, as are the effects of those treatments on depressive symptoms and AUD symptoms.

Medication trials

Medication trials for co-occurring AUD and depressive disorders have focused mostly on antidepressant medications. Several meta-analyses have integrated these findings. 39 – 42 In general, the research shows that for people with co-occurring AUD and depressive disorders, antidepressants are more effective than placebo at reducing symptoms of depression. The magnitude of the benefit of medication over placebo is similar to the benefit reported in studies of people diagnosed with depression alone. 40 , 41 Few medication trials have compared treatments directly; most trials compare a single medication with a placebo. Thus, little is known about the comparative effectiveness of active treatments. 39 However, meta-analyses have suggested that older antidepressant medications, such as tricyclic antidepressants, are more effective at reducing depressive symptoms than newer agents, such as selective serotonin reuptake inhibitors (SSRIs). 40 , 42 These results may be attributable—at least in part—to a large placebo response reported in studies of SSRIs. 41

The effects of antidepressants on drinking outcomes are modest. 40 , 42 However, the effect of antidepressant medications on drinking outcomes may be dependent on how those medications affect depression. Some evidence indicates that depression mediates the effect of antidepressants on drinking outcomes. 43 Consistent with these findings, a meta-analysis of trials of antidepressant treatment for people with AUD only (i.e., without co-occurring depression) did not demonstrate a significant effect on drinking outcomes when compared to treatment with placebo. 42

Studies of patients with co-occurring AUD and depressive disorders have demonstrated that treatments using medications (e.g., naltrexone) for AUD are safe and effective for reducing drinking and depression symptoms. 44 , 45 A meta-analysis of studies that used acamprosate to treat AUD found similar effects among people with and without depression, but these researchers also found a strong effect of alcohol abstinence on remission of depression. 46 Combinations of antidepressants and AUD medications (e.g., sertraline with naltrexone and acamprosate with escitalopram) 47 , 48 have also shown some promise for the treatment of these co-occurring disorders, with positive outcomes for both AUD and depressive symptoms.

Psychosocial treatments and mutual help

Researchers have examined the effects of behavioral and psychosocial therapies on co-occurring AUD and depressive disorders, although many of these studies have had small sample sizes. A meta-analysis of 12 studies that examined combined motivational interviewing and cognitive behavioral therapy for AUD and depression found significant, but modest, improvements in both depression and drinking outcomes. 49 These results are consistent with an earlier meta-analysis of several psychotherapies (e.g., interpersonal psychotherapy and cognitive behavioral therapy) that also indicated relatively modest, but positive, effects for depression and drinking outcomes. 50

Several studies have examined a transdiagnostic behavioral approach to treatment, which integrates the treatments for AUD and depressive symptoms. Behavioral activation is a behavioral therapy that specifically targets reward dysfunction to improve mood through better engagement with natural reinforcers. Treatment with behavioral activation therapy has demonstrated efficacy for depressive disorders 51 and for AUD; 52 thus, it may be particularly promising for treating the co-occurring disorders. A therapy called “life enhancement treatment for substance use,” or “LETS ACT,” is a modification of behavioral activation therapy for people with substance use disorders. This therapy has been shown to reduce substance-related consequences and improve likelihood of abstinence in samples of adults with substance dependence (including alcohol dependence). 52 In another study, an integrated cognitive behavioral therapy treatment for depressive disorders and substance use disorders was associated with greater reduction in alcohol use, but similar reductions in depression, when compared with the control condition, which was a 12-step facilitation therapy. 53

Some researchers have suggested that the effects of psychotherapy may account for some of the pill placebo response observed in medication studies. Specifically, for medication trials in which all participants also received some form of psychotherapy, pill placebo response rates were higher than they were for studies that did not include psychotherapy in the pill placebo condition. 41 Likewise, in a study of sertraline and naltrexone in which all participants received weekly psychotherapy, sertraline had no additive benefit. 54 These findings suggest that the psychotherapies used in these trials may have provided some antidepressant effect, either directly or through their effects on drinking.

Mutual-help groups also can be effective elements of treatment for co-occurring AUD and depressive disorders. Attendance at Alcoholics Anonymous (AA) meetings has been shown to decrease symptoms of depression. 55 In one study, researchers found that a reduction in depression mediated the effect that AA meeting attendance had on drinking outcomes, 56 indicating that a change in depression symptoms may be a mechanism through which attendance at AA meetings improves drinking outcomes.

Future Research Directions

Research has substantially improved understanding of the etiology, course, and treatment of co-occurring AUD and depressive disorders. However, significant gaps remain in our understanding of these two disorders, and these gaps present important opportunities for future research.

More knowledge about optimal treatments for co-occurring AUD and depressive disorders is needed. Although medication and behavioral therapy have both shown promise, response rates have been somewhat modest. Efforts to enhance treatment outcomes would benefit from investigation into the characteristics of people who do not respond to existing treatments. A better understanding of the heterogeneity within this population will inform more personalized treatment approaches and might ultimately improve treatment response.

The substantial variability in the course of co-occurring AUD and depressive disorders may reflect discrete underlying mechanisms, requiring distinct treatment approaches. For example, AUD that develops after the onset of a depressive disorder and is characterized by coping motives for alcohol use may differ critically from a depressive disorder that develops following chronic alcohol administration. Data from studies of depression indicate that the substantial variability in the symptoms presented reflects a heterogeneous pathophysiology, 32 yet research on heterogeneity in co-occurring AUD and depressive disorders remains limited. Although little is known about the possible shared pathophysiology of AUD and depressive disorders, preclinical research has identified common disruptions in reward and stress processing that are important candidates for further research. 31 Efforts to better characterize the mechanistic processes that may underlie observed clinical presentations will help identify more precise and personalized interventions.

Future research that leverages novel technologies, such as ecological momentary assessment and multimodal neuroimaging, will enhance our understanding of the interactions between mood and alcohol use and how those interactions may influence the nature, course, and treatment of co-occurring AUD and depressive disorders. Assessment of co-occurring AUD and depressive disorders using dimensional measures rather than discrete, categorical measures will be critical to understanding the full spectrum of severity of these conditions, including subclinical presentations.

Finally, the etiology, course, and treatment of both AUD and depression differ substantially by gender. Women have been underrepresented in much of the research on co-occurring AUD and depressive disorders, particularly in the early research on this topic. The research needs more representation of women to increase understanding of the sex differences and to better characterize the mechanisms underlying women’s heightened vulnerability for depressive disorders. For example, an important area for future research could be women who have co-occurring AUD and premenstrual dysphoric disorder, which is a depressive disorder characterized by a fluctuation of mood symptoms across the menstrual cycle. 6 Likewise, research is urgently needed to better understand co-occurring AUD and depressive disorders among racial and ethnic minorities. These populations experience disparities in access to care for AUD and depressive disorders but are underrepresented in studies of these disorders.

People with AUD have a heightened risk for depressive disorders, which are the most common co-occurring psychiatric disorders for this population. AUD and depressive disorders appear to share some behavioral, genetic, and environmental risk factors, yet these shared risks remain poorly understood.

Diagnosis and treatment of the commonly co-occurring AUD and depressive disorders have many challenges. Diagnosis is particularly challenging because of overlapping symptoms, such as the depressant effects of alcohol, and because of features that are common to both alcohol withdrawal and depressive disorders, such as insomnia and psychomotor agitation. The DSM-5 distinguishes a substance-induced disorder from a primary depressive disorder based on whether “the substance is judged to be etiologically related to the symptoms.” 6 (p180) Accordingly, any diagnosis of depression during active periods of drinking or during acute alcohol withdrawal should be made provisionally. Attempts to diagnose depression should focus on identifying periods of depression outside periods of drinking or withdrawal and should use collateral information (e.g., reports from family members or significant others) when possible. If depressive symptoms persist after a period of abstinence—4 weeks is the typical recommendation—a diagnosis of an independent (i.e., not substance-induced) depressive disorder can be made with more confidence. 6

Nonetheless, substance-induced depression is also associated with the risk for independent depressive disorders. Thus, treatment of depression should be considered, along with close monitoring of mood, for people who have substance-induced depression. 11 Treatment studies have supported the effects of both AUD medications (e.g., naltrexone) 44 and antidepressants 47 for the treatment of co-occurring AUD and depressive disorders. However, because of a lack of comparative trials on effectiveness (i.e., studies comparing more than one active treatment), the most effective approach is unknown. Behavioral therapy is understudied in this population despite evidence supporting the therapy as treatment for depressive disorders 51 and AUD 57 separately. Indeed, in placebo-controlled studies of medications for co-occurring AUD and depression, the inclusion of behavioral therapy as part of the standard treatment may explain the small effect sizes often observed. Behavioral activation therapy—a treatment that targets disruption in reward functioning, which is a common dysfunction in both AUD and depressive disorders—may have particular promise for treating the co-occurring disorders. 52

Despite the availability of several evidence-based medications and behavioral therapy approaches for treating co-occurring AUD and depressive disorders, improvements in treatment for this population are clearly needed. Consideration of disorder heterogeneity and key subgroup differences may help develop more targeted and personalized treatments to improve outcomes for this population.

Acknowledgments

This article was supported by the Charles Engelhard Foundation and National Institute on Drug Abuse grants K23DA035297 and K24DA022288.

Financial Disclosure

Dr. McHugh declares no competing financial interests. Dr. Weiss has been a consultant to Alkermes, Braeburn, Daiichi-Sankyo, GW Pharmaceuticals, Indivior, Janssen, and US WorldMeds.

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