Research

Disentangling the impact of alcohol and co-occurring psychological and medical disorders on quality of life

Alcohol use disorder co-occurs with a host of psychological and medical conditions, all of which diminish health-related quality of life. At the same time, the complex ways alcohol use disorder interacts with other conditions to impact quality of life is not always considered in care management. This study sought to disentangle the respective influences of alcohol use disorder, co-occurring psychological and medical problems, and their combination on health-related quality of life to inform more specific, targeted clinical practices and care for individuals with alcohol use disorder.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Alcohol use disorder commonly co-occurs with other psychological and medical conditions. In some instances, alcohol use disorder is responsible for the co-occurring condition (e.g., cirrhosis, pancreatitis). In other instances, alcohol use disorder may be caused or exacerbated by another condition (e.g., post-traumatic stress disorder). In other instances, it is hard to determine the exact nature of the causal connection between alcohol use disorder and other conditions (e.g., anxiety and depressive conditions). On their own, each these conditions can have a major impact on psychological and physiological health, which in turn can be highly detrimental to quality of life.

Alcohol use disorder care practices often strongly emphasize alcohol use cessation and relapse prevention, which is of course important. At the same time, co-occurring psychological and medical conditions have the potential to dramatically impact health-related quality of life regardless of the individual’s alcohol use disorder status (e.g., in active addiction, in early remission, in sustained remission). Teasing out the ways alcohol use disorder interacts with other conditions to affect health-related quality of life might help improve treatment practices and in turn quality of life for individuals with alcohol use disorder. For example, a comprehensive alcohol use disorder recovery plan may involve a host of interventions and services that address the alcohol use disorder as well as the psychological and medical conditions that are caused by it or accompany it. To help inform the potential benefit of a comprehensive health and recovery-oriented approach to alcohol use disorder care, this study aimed to disentangle the respective influences of alcohol use disorder, commonly co-occurring conditions, and their interaction on health-related quality of life.

HOW WAS THIS STUDY CONDUCTED?

This was a secondary analysis of the National Epidemiological Survey on Alcohol and Related Conditions-III dataset (NESARC-III), a nationally representative survey of 36,309 non-institutionalized, United States adults 18 years and older residing in households and selected group living situations. NESARC-III data were collected from April 2012 to June 2013. The NESARC-III focused on diagnoses using the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.

For this study, the authors derived the following psychological assessment measures from the NESARC-III: 1) Past year, prior to past year, and lifetime alcohol use disorder measured using the Alcohol Use Disorder and Associated Disabilities Interview Schedule, 2) lifetime and past year alcohol consumption, 3) lifetime and past year medical conditions, self-assessed and self-reported as confirmed by a health care provider, 4) lifetime, past year, and prior to past year Diagnostic and Statistical Manual of Mental Disorders-defined psychological health conditions including substance use disorders, and 5) the Short-Form 12 Version 2 to assess health-related quality of life.

Short-Form 12 Version 2 scores were converted to Short-Form Six-Dimension (SF-6D) scores using a well-established algorithm. SF-6D scores are widely used in epidemiology and economics research as indicators of health-related functioning and well-being. This measure captures individuals’ level of physical functioning, role participation, social functioning, bodily pain, psychological health, and vitality. A score of 0.0 indicates the worst possible overall health state, while a score of 1.0 indicates the best.

Figure 1. SF-6D scale dimensions, explained.

First, to compare health-related quality of life for those with alcohol use disorder versus other commonly co-occurring conditions, the authors calculated each participant’s SF-6D health score, and then classified them as having alcohol use disorder, a co-occurring condition (e.g., cancer, high blood pressure, substance use disorders for drugs other than alcohol, post-traumatic stress disorder), or both alcohol use disorder with each respective co-occurring condition. Then, they examined the associations between each of these conditions with participants’ health scores while adjusting for the other variables to obtain the unique contribution each variable made to health-related quality of life.

Of the 36,163 individuals in the sample, 29% of individuals reported alcohol use disorder at some point in their lifetime. Eleven percent reported never drinking, 40% were currently abstinent, 40% were low risk drinkers, 4% were medium risk, and 5% were high or very high risk. About half (54%) reported at least one physical health condition, 29% reported at least one psychological health condition.

WHAT DID THIS STUDY FIND?

Health scores were generally worse for conditions other than alcohol use disorder.

Overall, mean health scores for those with conditions other than alcohol use disorder were generally lower (i.e., worse) than those with alcohol use disorder.

For example, the mean health score associated with having any physical health condition was 0.75, compared to 0.76 for lifetime alcohol use disorder. Similarly, the mean health score for any psychological health condition was 0.71 and any substance use disorder was 0.74, which are both lower than scores for lifetime, past year, and prior to past year alcohol use disorder.

Figure 2. Mean SF-6D health-related quality of life scores.

Alcohol use disorder in combination with other conditions was generally associated with worse health-related quality of life than alcohol use disorder alone.

Mean health scores for alcohol use disorder in combination with other psychological and physical health problems were generally lower than health scores for either alcohol use disorder alone or the health condition/disorder without alcohol use disorder. In other words, health scores for joint health states of alcohol use disorder and a co-occurring condition were oftentimes lower (i.e., worse) than the health scores for either of the contributing health states.

For instance, having any alcohol use disorder status in combination with any physical health condition was associated with a lower health score than either condition on its own. The combined mean health score for alcohol use disorder with any physical health condition was 0.72, while separately they were approximately 0.76 and 0.74 for alcohol use disorder and physical health conditions respectively. A similar pattern was seen for the combination of alcohol use disorder and any psychological health condition and alcohol use disorder and any substance use disorder.

After controlling for individual factors, alcohol use disorder leads to slightly worse health-related quality of life.

Compared to never having alcohol use disorder, individuals with past year or prior to past year alcohol use disorder had slightly worse health-related quality of life: prior to past year alcohol use disorder was associated with a 0.02 lower health score, and past year alcohol use disorder was associated with a 0.03 point lower health score.

By comparison, having had any physical health condition was associated with a 0.06 point decrement in health score, any psychological health condition with a 0.08 point decrement, and any substance use disorder with a 0.04 point decrement. Though the authors didn’t explicitly test whether these associations between health scores the respective conditions were statically significant, these findings suggest other psychological and medical conditions may have greater impact on health-related quality of life relative to the alcohol use disorder.

Resolving an alcohol use disorder in and of itself did not improve health-related quality of life but may give rise to improvements in co-occurring conditions that lead to gains.

Before controlling for physical and psychological health conditions and any substance use disorder, findings in this study suggest that former alcohol use disorder (i.e., prior to past year) may be associated with the same health-related quality of life as current alcohol use disorder (i.e., past year).

However, after controlling for physical and psychological health conditions and any other substance use disorder (e.g., stimulant or opioid use disorders, etc.), prior to past year alcohol use disorder was associated with a small improvement in health-related quality of life relative to past year alcohol use disorder. In other words, resolution of current alcohol use disorder symptoms was associated with improved health-related quality of life once the effects of co-occurring conditions were controlled.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Estimating the impact of alcohol use disorder on health-related quality of life is complicated by the prevalence of co-occurring health conditions. This descriptive study of the NESARC-III database, a United States population survey, demonstrates the health-related quality of life of alcohol use disorder as it commonly occurs among the population with other psychological and physical health conditions.

The research team showed that alcohol use disorder is associated with diminished health-related quality of life, but to a somewhat lesser extent than the other psychological, and physical health conditions, including substance use disorder for drugs other than alcohol. In fact, among all conditions reported in NESARC-III, in absolute terms, psychological health conditions as a group were found to be associated with the largest decrement in health-related quality of life, followed by physical health conditions, any substance use disorder, and then past year alcohol use disorder.

These findings also highlight the nuanced ways alcohol use disorder interacts with other psychological and physical health conditions to affect health-related quality of life. Moreover, these results reflect how many of alcohol use disorder’s harms on health-related quality of life occur via other conditions arising from alcohol use disorder. Though not explicitly tested in this study, alcohol use disorder is believed to exert much of its harm through intermediary states or conditions like anxiety and depression, and/or diseases like hepatitis, cirrhosis, cancer, pancreatitis, and cardiovascular problems.

The importance of understanding the interaction of alcohol use disorder and co-occurring psychological and physical health conditions is highlighted by contrasting the health-related quality of life decrements associated with past year alcohol use disorder, with prior to past year alcohol use disorder. Before controlling for psychological and physical health conditions and any other substance use disorder, findings in this study suggested that former alcohol use disorder (i.e., prior to past year) may be associated with the same health-related quality of life as current alcohol use disorder (i.e., past year), implying that resolving symptoms of alcohol use disorder may not necessarily be associated with any improvement in health-related quality of life, which is counterintuitive. However, after controlling for psychological and physical health conditions, prior to past year alcohol use disorder was associated with a small improvement in health-related quality of life relative to past year alcohol use disorder. It is therefore likely that improvements in health-related quality of life were a function of how resolving an alcohol use disorder led to improvements in other psychological and physical health conditions.

Together, the findings in this study point to the value of a comprehensive approach to helping individuals with alcohol use disorder. Even after resolving an alcohol problem, which is likely to have its own positive impacts on health and well-being, individuals are likely to benefit even further from a person-centered approach that incorporates an array of psychiatric and medical services.

LIMITATIONS

As noted by authors:

  1. The NESARC-III study sampled only individuals in non-institutional settings, excluding individuals who are incarcerated and living in long-term institutional settings for whom health-related quality of life may be different. Thus, these findings may not reflect the experience of these populations.
  2. All data in NESARC-III are self-reported, with the accompanying caveats of self-reported data.
  3. The authors were necessarily limited to assessing health-related quality of life for the physical, psychological health, and substance use disorders included in NESARC-III.

Also:

  1. It is well established that “toxicity is in the dose” but this study did not examine severity or chronicity of alcohol use disorder or extent of intensity of alcohol use which all have substantial bearings on the degree of harms caused by alcohol exposure.
  2. Though not a limitation per se, it should be noted that the mean differences in health-related quality of life scores between alcohol use disorder and other conditions were generally very small, as were the sizes of overall effects in the statistical models in the study. While this is common in population-level research as was the case here, it is unclear how differences and effects of this magnitude translate to real-world behavior and experience.

BOTTOM LINE

Alcohol use disorder commonly co-occurs with a host of psychological and physical health conditions, with which it interacts in nuanced ways to impact health-related quality of life. In this representative sample of US adults, having an alcohol use disorder history alone was found to impair health-related quality of life, though not as much as some other psychological and physical health conditions. When alcohol use disorder co-occurred with other conditions there was additive impact such that individuals endorsed worse health-related quality of life than if they had alcohol use disorder or psychological or physical health condition alone.

  • For individuals and families seeking recovery: Much alcohol use disorder treatment focuses on helping individuals stop drinking and avoid returning to alcohol use. While resolving alcohol use disorder will generally lead to gradual improvements in quality of life, findings from this study highlight the importance of managing, where possible, psychological and physical health problems that are often caused by alcohol use disorder to impact health-related quality of life.
  • For treatment professionals and treatment systems: Much alcohol use disorder treatment focuses on helping individual stop drinking and avoid returning to alcohol use. While resolving alcohol use disorder will generally lead to gradual improvements in quality of life, findings from this study highlight the importance of helping individuals manage, as much as is possible, psychological and physical health problems that are often caused by with alcohol use disorder to impact health-related quality of life. Collaborative models that can link individuals to substance use disorder, psychological health, and medical services may be positioned to help more individuals with alcohol use disorder and to improve overall community health.
  • For scientists: Alcohol use disorder interacts with a host of psychological and physical health conditions in complex ways. More work is needed to better disentangle these nuanced interactions. Research can also help determine optimal combinations of clinical and community services, and strategies to create linkages between and among these services, to maximally help individuals with alcohol use disorder. 
  • For policy makers: While the massive public health burden of alcohol use disorder is widely acknowledged, it is likely under-appreciated due to the ways this disorder gives rise to and interacts with other psychological and physical health conditions. Improving access to treatment, and providing resources that help substance use disorder, psychological health, and medical services collaborate with one another, will not only improve alcohol use disorder outcomes, it is also likely to reduce the public health burden associated with numerous co-occurring conditions. 

CITATIONS

Wittenberg, E., Barbosa, C., Hein, R., Hudson, E., Thornburg, B., & Bray, J. W. (2021). Health-related quality of life of alcohol use disorder with co-occurring conditions in the US population. Drug and Alcohol Dependence, 221, 108558. DOI: 10.1016/j.drugalcdep.2021.108558

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