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COVID-19, Chronic Stress, and Alcohol Use

Our Looming Secondary Crises and Finding a Path to Recovery

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Last October, two experienced public health scientists at McLean Hospital at Harvard University published an open letter in the Journal of General Internal Medicine called “Alcohol and COVID-19: How Do We Respond to This Growing Public Health Crisis?” In the letter, they discussed the dangers of an increase in alcohol use in response to the stress caused by the coronavirus pandemic.

Back in the fall of 2020, the researchers – Dawn Sugarman, PhD, and Shelly Greenfield, MD – indicated that a potential increase in alcohol use during the pandemic raised “significant public health concerns.”

At that point, here in the U.S., we did not have enough reliable data to confirm or deny whether the pandemic was causing people to drink more. We certainly didn’t have enough data to label it a crisis or an emergency, but for those who chose to look and read, the writing was most definitely on the wall. Several surveys and initial studies offered preliminary indications that across the board, in most demographics, people were, indeed, increasing the amount of alcohol they consumed during the pandemic.

By last fall, we knew alcohol sales were up by more than 30 percent compared to the same time in 2019. Millions were unemployed or experiencing income insecurity. We also had this data from the Centers for Disease Control (CDC), published in August 2020, which showed that, among adults in the U.S.:

  • 40% reported struggling with mental health or substance abuse problems
  • 31% reported increased anxiety/depression symptoms
  • 26% reported trauma or stress-related symptoms
  • 13% reported they started or increased substance use
  • 11% reported they seriously considered suicide

In addition to these obvious red flags – which were not necessarily a direct measure of alcohol consumption, but disturbing nonetheless – the Harvard researchers discussed reported increases in alcohol consumption in the U.K. and Australia, warning that we should be on the lookout for similar increases here at home.

They also raised the issue of the treatment gap here in the U.S. for people with alcohol use disorder (AUD). Data shows that only about ten percent of people diagnosed with AUD receive the specialized treatment they need to address their problem alcohol use. If more people begin drinking – and develop problem drinking – during the pandemic, they reasoned, then that treatment gap would increase.

Which would not be a good thing.

Then their letter took an interesting turn. They discussed the effect of mass trauma on the U.S. population, and went back 10 years to find reliable – and telling – data on how a nationwide stressor affects alcohol consumption among U.S. citizens.

Trauma, Chronic Stress, and Alcohol Use

They reminded us that drinking alcohol is a common response to trauma, stress, and events involving large-scale suffering, injury, or death. A study published in 2009 analyzed the use of alcohol and drugs in response to one of the most infamous mass trauma events in U.S. history – the 911 terrorist attacks – and concluded the following:

  • Around 14% of adults in the U.S. are at risk of drinking more alcohol immediately after a mass trauma event
  • More than 16% of adults in the U.S. are likely to increase use of both prescription and narcotic drugs following a mass trauma event
  • Just over 7% of adults in the U.S. are likely to drink more alcohol in the first two years following an event involving mass trauma event

Evidence regarding the impact of the 911 attacks on alcohol use among adults in the U.S. is germane to our current circumstances because, although the coronavirus pandemic was not a terrorist attack, it was, and continues to be, an ongoing event that causes massive loss of life. At the time Drs. Sugarman and Greenfield wrote their open letter, more than 200,000 people in the U.S. had died of the illness caused by the SARS-COV-2 virus.

As I sit and write this article, the numbers are so astounding they make me numb. More than 500,000 people have lost their lives. That’s hard to wrap my mind around. That’s the numeric equivalent of more than 150 9/11s.

Sugarman and Greenfield made another point that’s important for us to understand: unlike the 911 attack, the coronavirus pandemic is ongoing. And although we seem to be nearing the end of this crisis, with the arrival and widespread distribution of effective vaccines, it’s not over yet.

In terms of the mental health impact, which is directly connected to increased alcohol use and the potential increase in problem drinking and AUD, the end of the coronavirus crisis may mean the beginning of a new addiction crisis. And I’m not even mentioning the opioid epidemic, which did not go away over the past year.

Chronic Stress, Ongoing Grief, Isolation, and Mental Health

We appear to be nearing the end of the worst part of the pandemic.

However, the continuous nature of the public trauma we’ve all experienced over the past year cannot be overstated. Isolated, one-off events like 9/11 cause significant distress and trauma. However, the fact they’re one-time events allow people to process the stress, resolve the trauma, and learn to manage the associated emotions and move on. The trauma may persist, but those who experience it can place the event in context and process it with the clarity of distance and the benefit of perspective.

The pandemic is different, though. In their letter, Sugarman and Greenfield outlined five pandemic-related stressors that had the potential to lead to increased alcohol consumption. Their goal, in identifying these elements, was to drive home the point that these stressors were ongoing. Therefore – unlike a one-time event like 9/11 – they had a greater potential to create negative mental health consequences, which, in turn, had greater potential to lead to problem drinking or AUD.

Here are the five stressors they identified:

  1. Fear/Anxiety. Concern over contracting SARS-COV-2 includes/included fears of:
    1. Developing a serious or life-threatening case
    1. Passing the virus to friends or family
    1. Unmanageable medical bills.
  2. Isolation. The isolation associated with social distancing and stay-at-home orders had the potential to cause increases in anxiety and depression.
  3. Loss of community support. For people in addiction recovery, public health measures had the potential to reduce participation in groups like Alcoholic Anonymous (AA).
  4. Loss of access to treatment. For people in recovery, public health measures had the potential to impact access to specialized treatment for AUD, which can increase chance of relapse.
  5. Financial burden. Job loss, income insecurity, and worry about finances had the potential to increase risk of excess drinking, sleep disruption, changes in eating habits, and elevated levels of depression.

That was the situation as they saw it back in October: a minefield of stress that had the potential to lead a nationwide mental health crisis, which could lead to a nationwide alcohol addiction crisis. In other words, they warned about two secondary public health crises that would overlap with and extend beyond the coronavirus pandemic.

As it turned out, they were right. Research conducted during the pandemic, published in late 2020 and early 2021, in this study here, this report here, and this study here, confirm what Sugarman and Greenfield feared. The data from these studies show:

  • A 36% increase in symptoms of an anxiety disorder during the pandemic, compared to before the pandemic
  • A 29% increase in symptoms of depressive disorder during the pandemic, compared to before the pandemic
  • A 60% overall increase in drinking during the pandemic, compared to before the pandemic
  • A 41% overall increase in days of heavy drinking among women during the pandemic, compared to before the pandemic

The studies also showed another troubling phenomenon. Among binge drinkers, each successive week of the pandemic meant a 20% chance they’d increase their level of alcohol consumption. This data gives teeth to the warnings we all heard last year: the symptoms of mental health disorders associated with AUD increased. Overall alcohol consumption increased.

Which means that now, as we near the end of the pandemic, we need to heed the advice mental health and addiction experts offered last year – and tailor it to meet the challenges we face in 2021.

Steps to Take: Awareness, Assessment, and Treatment

Last fall, Sugarman and Greenfield recommended a series of proactive steps to “moderate and reduce alcohol consumption in the face of this pandemic.” Now that the data is in, and it’s clear that both mental health issues and alcohol consumption have increased significantly over the past year, we would do well to heed their advice.

Here are the six steps they recommended then, which – in my opinion – we should implement now:

  1. Recognize the stress related to the coronavirus pandemic creates a population-level risk of increased alcohol consumption. This increase poses a general public health risk.
  2. Understand that our response to this risk needs to be comprehensive and address the various needs of our diverse population.
  3. Embrace responsible public health messaging. This is crucial. Media should work to temper cultural norms that celebrate alcohol consumption as a go-to pandemic coping mechanism.
  4. Prepare for a surge in treatment demand that includes alcohol, drug addiction, and exacerbated co-occurring disorders.
  5. Enhance identification and assessment initiatives by screening for financial risk factors like unemployment, and mental health risk factors like depression, anxiety, and trauma.
  6. Prioritize support for people with AUD who are at increased risk of relapse, which means, among other things, increasing access to virtual treatment and online community support.

They ended their letter by advising that all of these steps – rather than being temporary, pandemic-specific measures – should continue after the pandemic and form the foundation for how we respond to the increase in mental health and addiction problems we’re likely to see in the latter half of 2021, the beginning of 2022, and beyond.

Partnership, Cooperation, and Integration: The Path to Sustained Recovery

Sugarman and Greenfield gave us an important reminder that while we navigate our national response to the coronavirus pandemic, we need to prepare for what’s next: managing its secondary effects, which include an increase in mental health disorders and a concordant increase in alcohol use, misuse, and alcohol use disorder.

We need to understand that these secondary complications can lead to physical, emotional, and social problems that last for years. They’ll likely persist long after we achieve the herd immunity promised by the vaccines and get the emerging COVID variants under control.

When we recognize the reality of these additional crises, which we should realize present here, now, as we speak, rather than in the future, we can work proactively to counter them. We can identify high-risk populations, screen for the presence of mental health or alcohol/drug addiction across health care points of contact and care, and offer appropriate treatment and support in a timely manner.

Evidence shows that the earlier people with mental health or addiction disorders receive an accurate diagnosis and evidence-based treatment, the more likely they are to learn to manage those disorders and sustain their health and wellness over the long term. Steps we take now will have an enormous impact in the future. They’ll help us recover from this stressful period in history in a comprehensive and holistic way, and allow us, as a nation, to heal physically, psychologically, and emotionally.

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