Multiple Paths to Recovery Among Patients With Co-Occurring Alcohol Use and Mental Health Disorders

A study has revealed diverse routes to recovery among people with co-occurring substance use and mental health disorders admitted for psychiatric inpatient care, while highlighting that some patients need additional support. Problem drinkers who also have a psychiatric condition — such as major depressive disorder (MDD) — often struggle to sustain long-term recovery following treatment. Mutual health groups such as Alcoholics Anonymous (AA) can provide an ongoing source of recovery support for alcohol misuse, and involvement with AA is also linked to improvement in depression. However, it was not known how depression and involvement influence drinking during and after inpatient psychiatric treatment, and how they predict recovery. The new study, reported in Alcoholism: Clinical and Experimental Research, investigated long-term trajectories of alcohol use, depression, and AA involvement over time among patients with co-occurring diagnoses.

The data were from 406 US veterans (90% male) with co-occurring substance use and mental health disorders, all of whom received inpatient psychiatric treatment with a typical hospital stay of one week. Patients completed surveys on admission (baseline) and again after 3, 9 and 15 months’ follow up to report on recent substance use (including drinking frequency), AA involvement (engagement in “12-step” practices), and depression symptoms. Researchers used advanced statistical modelling to examine changes in each factor over time, and to group patients into classes based on the long-term trajectories.

Although individual patterns of change varied widely, the researchers could identify three distinct classes of trajectory that best fitted the sample data. The most common trajectory class (applicable to 62% of patients) was characterized by low AA involvement over time, and typically high alcohol use and depression at baseline which both improved rapidly before stabilizing. Around a quarter (27%) of patients fitted a second trajectory class characterized by high AA involvement throughout,  and similar improvement over time in drinking and depression to that observed in the low AA class. Patients in both groups were drinking at less than half their baseline level at all follow-ups, as well as having substantially reduced depression symptoms — suggestive of substance-induced depression of a transitory nature. The smallest trajectory class (11% of patients) was characterized by severe depressive symptoms and high baseline drinking — neither of which improved over time — and by unstable AA involvement across the study period. The ongoing mental health issues in these patients may have hindered their engagement with AA.

It is encouraging that most patients with co-occurring conditions did show significant improvement in both drinking and depression following inpatient psychiatric treatment —  sometimes with and sometimes without AA involvement. However, some patients, particularly those with severe depression symptoms and alcohol use, may need additional support from clinicians to fully engage with AA. Other strategies may also benefit these patients, including mutual support alternatives to AA, and treatments such as integrated CBT that are designed to treat co-existing MDD and alcohol use disorder. Future research may examine whether medications for MDD can also impact alcohol-related outcomes in the absence of mutual support group involvement, and assess factors such as PTSD that may also influence long-term outcomes among this vulnerable patient population.

Depression, alcoholics anonymous involvement, and daily drinking among patients with co-occurring conditions: A longitudinal parallel growth mixture model

N.A. Vest, A.H.S. Harris, M. Ilgen, K. Humphreys, C.Timko (pages xxx).

ACER-20-4395.R2