Alcohol 65 (2017) 63e69

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Alcohol
journal homepage: http://www.alcoholjournal.org/

Hazardous alcohol use among patients with schizophrenia and

depression
Mythily Subramaniam a, *, Mithila Valli Mahesh a, Chao Xu Peh a, Junda Tan a,
Restria Fauziana a, Pratika Satghare a, Bhanu Gupta b, Kandasami Gomathinayagam c,
Siow Ann Chong a
a
Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore
b
Department of Community Psychiatry, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore
c
National Addictions Management Service, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Aims: The current study aimed to 1) report the prevalence of hazardous alcohol use in an outpatient
Received 5 October 2016 population among those with schizophrenia and depressive disorders, 2) assess the sociodemographic
Received in revised form and clinical correlates of hazardous alcohol use, 3) examine the association of hazardous alcohol use with
18 July 2017
severity of depression, anxiety and smoking, and 4) assess the association of hazardous alcohol use with
Accepted 18 July 2017
quality of life.
Methods: Three hundred ten outpatients seeking treatment at a tertiary psychiatric institute with a
Keywords:
diagnosis of either schizophrenia spectrum disorder or depressive disorder were included in the study.
Hazardous alcohol use
Alcohol use disorders identification test
Patients were assessed for hazardous alcohol use using the Alcohol Use Disorders Identification Test.
Asian Information on sociodemographic correlates, clinical history, severity of symptoms of depression and
Depression anxiety, as well as quality of life (QOL) was collected.
Schizophrenia Results: The overall prevalence of hazardous alcohol use among the sample was 12.6%. The prevalence of
hazardous alcohol use among patients with depression and schizophrenia was 18.8% and 6.4%, respectively.
Compared to those who were students, patients who were gainfully employed or unemployed were more
likely to engage in hazardous alcohol use (Odds Ratio (OR) ¼ 5.5 and 7.7, respectively). Patients with
depression compared to those with schizophrenia (OR ¼ 11.1) and those who were current smokers
compared to those who had never smoked (OR ¼ 14.5) were more likely to engage in hazardous alcohol
use. Hazardous alcohol use was associated with lower QOL in the physical health domain (p ¼ 0.002).
Conclusion: Given the significant prevalence of hazardous alcohol use in this population, routine
screening for hazardous alcohol use and brief interventions could be an effective way of managing this
comorbidity. There is a need to develop and evaluate culturally appropriate brief interventions based on
patient preference in this setting.
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The prevalence of alcohol-use disorder (AUD) is high among

Hazardous alcohol use has been defined as a pattern of alcohol
consumption that places the individual at an increased risk for
acute or chronic harm (World Health Organization, 2000). In-
dividuals who engage in hazardous alcohol use are at increased risk
of alcohol dependence (Saha, Stinson, & Grant, 2007) and physical
conditions such as hypertension, cardiovascular disease, and
cirrhosis (Centers for Disease Control and Prevention, 2014).
* Corresponding author.
E-mail address: Mythily@imh.com.sg (M. Subramaniam).
those with psychiatric conditions (Conway, Compton, Stinson, &
Grant, 2006; Grant et al., 2004; Subramaniam et al., 2012), with
comorbid AUD adversely affecting both the course and treatment
outcomes of the psychiatric disorder (Schuckit, 2006; Vuorilehto,
Melartin, & Isomets€a, 2009). Studies have similarly found that haz-
ardous alcohol use is common among those with mental health
problems. A study from Sweden found that among patients
attending a general psychiatric clinic, 28.3% of the women and 31.3%
of the men had engaged in hazardous alcohol use (Nehlin,
Fredriksson, & Jansson, 2012), while a study from the United
Kingdom reported that 48.5% of patients consecutively admitted to

https://doi.org/10.1016/j.alcohol.2017.07.008
0741-8329/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
64 M. Subramaniam et al. / Alcohol 65 (2017) 63e69
acute general psychiatry wards had hazardous alcohol use (McCloud,
Barnaby, Omu, Drummond, & Aboud, 2004). Hulse and Tait (2002)
screened Australian psychiatric inpatients and found that 23% had
hazardous alcohol use. Prevalence of hazardous alcohol use reported
among patients in Asian countries is lower as compared to figures
reported by Western studies. A study from Taiwan showed that the
lifetime prevalence of hazardous alcohol use was 10.5% among those
with schizophrenia and mood disorder (Huang et al., 2009), while a
study from rural India found that 5.5% of patients with schizophrenia
had hazardous alcohol use in the previous year.
It is important to identify psychiatric patients with hazardous
alcohol use, because brief interventions could improve their overall
management and outcomes (Hulse & Tait, 2003; Nehlin,
Gro€nbladh, Fredriksson, & Jansson, 2012), as well as prevent the
development of AUD in these patients (Hulse & Tait, 2002) and
improve their overall quality of life.
Singapore is an island city-state in Southeast Asia, with a multi-
ethnic population of about 5.6 million, 3.9 million of whom are
Singapore citizens and permanent residents (Statistics, Singapore,
2016). The resident population comprises Chinese (74.3%), Malays
(13.4%), Indians (9.1%), and other ethnic groups (3.2%). While
population data on hazardous alcohol use is lacking, a study by Lim
et al. (2013) revealed a prevalence of 12-month heavy drinking of
12.6%, and lifetime heavy drinking of 15.9% (heavy drinking was
defined in this study as the consumption of 4 or more drinks in a
day for women, or 5 or more drinks in a day for men) (Lim et al.,
2013). A recent study by Tay et al. (2016) among non-psychiatric
inpatients found that 2.8% of patients with previous year alcohol
use scored above the hazardous levels for the Alcohol Use Disorders
Identification Test (AUDIT). However, to date, no study has exam-
ined the prevalence and correlates of hazardous alcohol use among
psychiatric patients in Singapore.
The current study aimed to 1) report the prevalence of haz-
ardous alcohol use in an outpatient population among those with
schizophrenia and depressive disorders, 2) assess the sociodemo-
graphic and clinical correlates of hazardous alcohol use, 3) examine
the association of hazardous alcohol use with severity of depres-
sion, anxiety and smoking status, and 4) assess the association
between hazardous alcohol use and QOL of psychiatric patients.
Methods
Setting and sample
The study was conducted among outpatients seeking treatment at
a tertiary psychiatric hospital, the Institute of Mental Health (IMH), in
Singapore. Inclusion criteria included English speaking proficiency,
age between 18 and 40 years, and a diagnosis of either a schizophrenia
spectrum disorder or depressive disorder. Patient diagnoses were
corroborated through their medical records and clinician diagnosis.
The study was approved by the relevant participating institutional
review boards e the National Healthcare Group Domain Specific Re-
view Board (NHG-DSRB) and the IMH Clinical Research Committee
(CRC). Trained members of the study team explained the study pro-
cedures before obtaining written informed consent from both the
participants and the guardians/legally acceptable representatives of
those aged 18e20 years, as the age of majority is 21 years in Singapore.
Assessments
After the participants had understood the informed consent and
agreed to participate in the study, they completed a set of ques-
tionnaires lasting approximately 30e40 min. All questionnaires
were self-administered and participants were informed that they
could approach the researcher if either the meaning of the
questions or the instructions needed clarification. Patients were
also informed during recruitment that a researcher could admin-
ister the questionnaires if they experienced any difficulty in reading
English; however, all respondents chose to do the questionnaires
themselves. The set included a socio-demographic questionnaire
that collected data pertaining to age, gender, ethnicity, education
level, marital status, employment status, and household income as
well as the following questionnaires.
AUDIT
This brief screening instrument is designed specifically for use in
primary care settings, although it has been used across various
settings including psychiatric populations (Maisto, Carey, Carey,
Gordon, & Gleason, 2000). Developed from a World Health Orga-
nization (WHO) collaborative project as a screening questionnaire
for hazardous and harmful drinking, this 10-item self-report
questionnaire covers the domains of alcohol consumption (items
1e3), drinking behaviors (items 4e6) and alcohol-related problems
(items 7e10). Each question is scored from 0 to 4 with a maximum
score of 40, where non-hazardous drinking levels are 0e5 points
for women and 0e7 points for men. ‘Hazardous alcohol use’ is
defined as 6e12 points for women and 8e14 points for men. Scores
of 13e18 in women and 15e18 in men indicate a ‘heavy abuse’.
Scores of 19 or more indicate ‘dependence’ (Babor, Higgins-Biddle,
Saunders, & Monteiro, 2001; Reinert & Allen, 2002). For the pur-
pose of this study, cut-offs of 6 and 8 were used to identify females
and males with hazardous alcohol use, respectively.
Beck's depression inventory-II (BDI-II)
The BDI-II is a 21-item self-report instrument that measures
severity of depression in the 2 weeks preceding its administration.
Items are related to symptoms of depression based on the criteria
found in the Diagnostic and Statistical Manual of Mental Disorders
4th Edition (DSM-IV) for depressive disorders. Responses to items
are based on a scale ranging from an absence of symptoms (0) to
severe symptoms (3). A total score is summed for all 21 items, with
scores ranging from 0 to 63. Scores of 0e13 indicate minimal
depression, 14e19 indicate mild depression, 20e28 indicate mod-
erate depression, and 29e63 indicate severe depression (Beck,
Steer, & Brown, 1996).
Beck's anxiety inventory (BAI)
The BAI is a 21-item self-report instrument that measures the
severity of anxiety in the past week. Questions in the scale focus on
the emotional, physiological, and cognitive symptoms of anxiety.
Responses to each item range from ‘not at all’ (0) to ‘severely’ (3). A
total score is summed for all 21 items with scores ranging from 0 to
63. Scores of 0e7 indicate minimal anxiety, 8e15 indicate mild
anxiety, 16e25 indicate moderate anxiety, and 26e63 indicate se-
vere anxiety (Beck, Epstein, Brown, & Steer, 1988).
WHO quality of life-BREF (WHOQOL-BREF)
This 26-item questionnaire measures QOL based on four do-
mains: physical health (7 items), psychological health (6 items),
social relationships (3 items), and environment (8 items) (WHOQOL
Group, 1998). Two items that ask about an individual's ‘overall
perception of quality of life’ and ‘overall perception of their health’
are examined separately. The other 24 items contribute to the
domain scores. Examples of questions pertaining to the various
domains include (physical health) e ‘How well are you able to get
around?’ and ‘How satisfied are you with your capacity for work?,
(psychological) e ‘How much do you enjoy life?’, ‘How well are you
able to concentrate?’, (social relationships) e ‘How satisfied are you
with your personal relationships?’, (environmental) e ‘To what
extent do you have the opportunity for leisure activities?’ and ‘How
 M. Subramaniam et al. / Alcohol 65 (2017) 63e69 65

satisfied are you with your transport?’ Table 1

Each item of the WHOQOL-BREF is scored on a 5-point ordinal Sociodemographic characteristics of the study sample.

scale. Mean domain score is then multiplied by 4 in order to Variables Mean SD

transform the domain score into a scaled score, with a higher score Age (in years 28.4 5.7
indicating a higher QOL. BMI (kg/m2) 25.4 6.0
Gender n %
Body mass index (BMI) Male 155 50.0
Female 155 50.0
Ethnicity
BMI was assessed by measuring the weight and height of all Chinese 218 70.3
participants on the same scale and calculated by dividing mass (in Malay 51 16.5
kilograms) by the square of height (in meters); a BMI below 18.5 Indian 29 9.4
Others 12 3.8
indicates underweight, 18.5e24.9 indicates normal weight,
Marital status
25.0e29.9 indicates overweight, and 30 and above indicates Never married 259 83.5
obesity (WHO, 2016). Currently married 32 10.3
Separated 6 1.9
Smoking history Divorced 13 4.2
Employment status
Student 62 20.0
Smoking was assessed by asking the participants whether they Employed 152 49.0
smoked, and, if they did, they were asked to state the number of Unemployed 95 30.6
cigarettes smoked in the previous month; past smokers were asked Education
about the last time they had smoked, and both current and past Secondary and below 95 30.6
Post secondary 152 49.0
smokers were asked about the period of time for which they had University and above 62 20.0
been smoking. Smoking status
Current smoker 121 39.0
Statistical analysis Past smoker 16 5.2
Non-smoker 173 55.8
Diagnosis
For the analysis, respondents were categorized by the following Schizophrenia 156 50.3
socio-demographic correlates: gender (female and male), ethnicity Depressive disorder 154 49.7
(Chinese, Malay, Indian, and others), marital status (single, married, Hazardous alcohol use
and divorced), employment status (student, employed, and unem- Yes 39 12.6
No 271 87.4
ployed), education (secondary and below, post-secondary, and Beck depression inventory
university and above), and household income (below Singapore Minimal (0e13) 121 39.0
Dollar [SGD] 2000 and above SGD 2000). Descriptive statistics were Mild (14e19) 29 9.4
used to estimate the prevalence of hazardous alcohol use. To Moderate (20e28) 57 18.4
Severe (29e63) 98 31.6
examine the sociodemographic and clinical correlates of hazardous
Beck anxiety inventory
alcohol use, multivariate logistic regression was conducted to Minimal (0e7) 92 29.7
examine if hazardous alcohol use (yes/no) was associated with age, Mild (8e15) 65 21.0
gender, ethnicity, marital status, education, employment, BMI, and Moderate (16e25) 69 22.3
psychiatric diagnosis. These variables were chosen based on their Severe (26e63) 84 27.1

clinical and theoretical relevance. Separate logistic regressions were
conducted to examine the association between hazardous alcohol
use with severity of anxiety and depression, as well as to examine
the association with the lifestyle correlate of smoking after
including sociodemographic correlates and BMI categories to adjust
for their effect. Finally, logistic regression was conducted to examine
the association between hazardous alcohol use and QOL domains
after adjusting for socio-demographic correlates, BAI and BDI
scores, as well as smoking status. Statistical significance was defined
as p  0.05. All analyses were conducted using SPSS version 23.
Results
Sociodemographic and clinical details of the sample are
described in Table 1. In all, 310 patients were successfully recruited
for the study. The mean (SD) age of the patients was 28.4 (5.7)
years. They were equally distributed in terms of gender, and ethnic
proportions observed in the sample were largely similar to that
observed in Singapore's population. The patients were also equally
distributed by diagnosis (Table 1).
BMI ¼ Body mass index, SD ¼ Standard deviation.
with schizophrenia. The prevalence of hazardous alcohol use was
13.5% among females and 11.6% among males.
Demographic risk factors associated with hazardous alcohol use
Compared to those who were students, patients who were
gainfully employed were about 6 times more likely to engage in
hazardous alcohol use (OR ¼ 5.5), while patients who were un-
employed were about 8 times more likely to engage in hazardous
alcohol use (OR ¼ 7.7). Those with university and higher education
were significantly less likely to engage in hazardous alcohol use as
compared to those with secondary and lower education (OR ¼ 0.2).
In addition, compared to patients with schizophrenia, patients with
depression were 11 times more likely to engage in hazardous
alcohol use (OR ¼ 11.1).
Age, gender, ethnicity, marital status, household income, and
BMI were not associated with hazardous alcohol use (p > 0.05)
(Table 2).

Prevalence of hazardous alcohol use
The overall prevalence of hazardous alcohol use among the
sample was 12.6%. The prevalence of hazardous alcohol use was
18.8% among patients with depression and 6.4% among patients
Association between hazardous alcohol use and severity of anxiety
and depression and smoking status
Compared to patients with minimal anxiety, patients with se-
vere anxiety were 9 times more likely to engage in hazardous
66 M. Subramaniam et al. / Alcohol 65 (2017) 63e69

Table 2 Association between hazardous alcohol use and QOL

Association of socio-demographic and clinical factors with hazardous alcohol use
(Multivariate logistic regression analysis).
Hazardous alcohol use was associated with a lower QOL in the
Variables OR 95% CI p valuea physical health domain (p ¼ 0.002). There were no associations
Age 1.0 0.9e1.1 0.740 between hazardous alcohol use and QOL in the psychological, social
Gender relationships, or environment domain (p > 0.05) (see Table 4).
Female Reference
Male 0.5 0.2e1.4 0.159
Ethnicity Discussion
Chinese Reference
Malay 0.5 0.1e2.2 0.328 The present study is the first to report on hazardous use of
Indian 0.4 0.04e4.2 0.447 alcohol among psychiatric outpatients in Singapore. Hazardous
Others 7.2 0.9e58.7 0.067
Marital status
alcohol use was not uncommon in this population, with 12.6% of
Single Reference patients reporting it. The prevalence in the current study was
Married 0.0 0.00 0.998 similar to that of heavy drinking reported in the Singapore popu-
Divorced 1.3 0.2e7.8 0.773 lation (12.6%) (Lim et al., 2013), as well as that reported by Huang
Employment status
et al. (2009) among patients in Taiwan with severe mental illness,
Student Reference
Employed 5.5 1.1e28.6 0.044 where 10.5% of patients met criteria for hazardous alcohol use. The
Unemployed 7.7 1.4e42.1 0.019 prevalence in the current study was, however, much lower than
Education that reported among Swedish psychiatric outpatients screened by
Secondary and below Reference Eberhard, Nordstro €
€ m, and Ojehagen (2015) (22% of women and 30%
Post-secondary 0.7 0.2e2.4 0.572
University and above 0.2 0.03e0.9 0.036
of men), psychiatric inpatients screened by Hulse and Tait (2002)
Household income (17%) in three general hospitals in Australia, and among patients
Below SGD 2000 Reference presenting at acute psychiatric wards in two London hospitals (UK)
Above SGD 2000 0.8 0.3e2.3 0.639 by Barnaby, Drummond, McCloud, Burns, and Omu (2003) (49%).
Diagnosis
Surprisingly, age, sex, ethnicity, marital status, education, income,
Schizophrenia Reference
Depression 11.1 3.1e40.4 <0.001 and BMI were not associated with hazardous alcohol use. This was
BMI WHO criteria in contrast to the population study of heavy drinking in Singapore,
<18.50 Reference where men, those belonging to younger age groups, those who
18.50e24.99 3.8 0.8e18.4 0.097 were single (versus married), and those with higher education and
25.00e29.99 2.3 0.4e12.3 0.347
higher incomes were more likely to drink heavily, while Malays
30.00 0.4 0.03e4.9 0.438
were less likely to drink as compared to Chinese (Lim et al., 2013).
BMI ¼ Body mass index, CI ¼ Confidence interval, OR ¼ Odds ratio, SGD ¼ Singapore
Singapore has always had strict liquor control laws which were
Dollar.
a
Multivariate logistic regression. further strengthened in 2015 under the Liquor Control (Supply and
Consumption) Bill, whereby drinking has been banned in all public
places after 10:30 p.m. to 7:00 a.m. Retail shops are not allowed to
alcohol use (Adjusted Odds Ratio [AOR] ¼ 8.7). Mild to moderate
sell alcohol not consumed on the premises during this period, and
anxiety was not associated with hazardous alcohol use (p > 0.05).
lastly, in designated areas known as liquor control zones, public
Compared to patients with minimal depression, patients with se-
drinking is also banned during weekends and public holidays. The
vere depression and moderate depression were 5 times more likely
low prevalence of hazardous drinking identified in this patient
to engage in hazardous alcohol use (AOR ¼ 5.0 and 5.3, respec-
population may thus be the result of these stringent liquor control
tively). Mild depression was not associated with hazardous alcohol
laws.
use (p > 0.05). Current smokers and ex-smokers were about 15
Another factor that may have played a role, although unex-
times and 13 times more likely to engage in hazardous alcohol use
plored in the current study, is the ‘alcohol flushing response’, which
as compared to non-smokers (OR ¼ 14.5 and 13.1, respectively)
has been observed in one-third of East Asians (Japanese, Chinese,
(Table 3).
and Koreans). This response is characterized by facial flushing,
nausea, and tachycardia in response to drinking alcohol (Eng,
Table 3 Luczak, & Wall, 2007), and is mainly due to an inherited defi-
Association between hazardous alcohol use and severity of anxiety, depression, and ciency in the enzyme aldehyde dehydrogenase 2 (Harada, Agarwal,
smoking status. & Goedde, 1981). It is possible that a significant proportion of the
AORa 95% CI p value patient population (the sample being predominantly Chinese)
Beck anxiety inventory
would have an unpleasant reaction to alcohol drinking and thus
Minimal anxiety Reference may have limited or avoided alcohol consumption.
Mild anxiety 1.9 0.3e11.9 0.488 Hazardous alcohol use was significantly associated with
Moderate anxiety 4.4 0.9e20.7 0.061 employment status in the current study with both the employed
Severe anxiety 8.7 2.0e37.5 0.004
Beck depression inventory
Minimal depression Reference Table 4
Mild depression 1.5 0.1e16.9 0.728 Association between hazardous alcohol use and quality of life.
Moderate depression 5.3 1.4e20.8 0.017
QOL Domains AORa 95% CI p value
Severe depression 5.0 1.5e16.9 0.010
Smoking status Physical health 0.9 0.8e0.9 0.002
Never smoked Reference Psychological 1.1 0.9e1.1 0.078
Current smoker 14.5 4.1e50.8 <0.001 Social relationships 1.0 0.9e1.0 0.917
Ex-smoker 13.1 1.4e124.5 0.025 Environment 0.9 0.9e1.0 0.507
a
AOR ¼ Adjusted odds ratio, CI ¼ Confidence interval. Adjusted for age, gender, ethnicity, marital status, employment, education,
a
Adjusted for age, gender, ethnicity, marital status, employment, education, household income, BMI categories, smoking status, diagnosis, anxiety and depres-
household income and BMI categories. sion severity.
 M. Subramaniam et al. / Alcohol 65 (2017) 63e69
and the unemployed being more likely to engage in hazardous
alcohol use as compared to students. A number of studies have
investigated the association between employment status and
hazardous alcohol use. While it is possible that hazardous alcohol
use affects employment adversely (Johansson, Alho, Kiiskinen, &
Poikolainen, 2007), it is also possible that unemployment places
considerable stress on an individual due to the financial challenges,
anxiety, and family discord, which leads to increased alcohol use
among those who are unemployed (Catalano et al., 2011; Peirce,
Frone, Russell, & Cooper, 1994). However, others argue that
alcohol may be used to relieve stress caused by long work hours
(Virtanen et al., 2015). These proposed mechanisms may account
for the higher association observed in both the employed and un-
employed categories. The current study also found that those with
higher education were less likely to have hazardous alcohol use.
Results from other studies suggest that educational attainment and
alcohol use may differ by both gender and country. Data from most
countries found that men with lower education were more likely to
be hazardous and heavy episodic drinkers, whereas more educated
women seem to be at higher risk (Bloomfield, Grittner, Kramer, &
Gmel, 2006; Kuntsche et al., 2006).
Compared to patients with schizophrenia, patients with
depression were 11 times more likely to engage in hazardous
alcohol use. The risk of hazardous alcohol use was also associated
with the severity of the depressive symptoms; those with moderate
or severe depressive symptoms were more likely to engage in
hazardous alcohol use as compared to those with minimal
depression. The association between alcohol problems and
depression is well established. Several possible explanations for
this relationship have been proposed, including shared common
environmental or genetic causes (Boden & Fergusson, 2011). The
self-medication hypothesis suggests that alcohol may be used by
people to “treat” undiagnosed and underlying distressing and dis-
turbing emotions because of its role in alleviating negative symp-
toms (Harris & Edlund, 2005; Khantzian, 1997). People with
depression may drink alcohol as a coping strategy for dealing with
negative feelings, or alcohol problems may affect the development
of depression through negative effects on a drinker's marital, eco-
nomic, and social status (Boden & Fergusson, 2011; McEachin,
Keller, Saunders, & McInnis, 2008). Studies on the temporal rela-
tionship between alcohol use and psychiatric disorders are not
conclusive. A longitudinal study on a population-based twin sam-
ple found that in most cases, especially in women, the onset of
major depression preceded that of alcohol dependence. However,
alcohol dependence had negligible effects on the risk of future
major depression (Kuo, Gardner, Kendler, & Prescott, 2006). In
contrast, a study by Fergusson, Boden, and Horwood (2009)
collected longitudinal data from a birth cohort of children from
New Zealand and used structural equation models to ascertain the
direction of causality. Their findings suggest that the associations
between AUD and major depression were best explained by a causal
model in which problems with alcohol led to increased risk of
major depression.
A number of epidemiological studies have found an association
between anxiety disorders and AUD (Grothues et al., 2008; Rodgers
et al., 2000), and the reasons for the comorbidity are similar to
those proposed for the comorbidity of AUD and depressive disor-
der. However, few studies have examined the association of
severity of anxiety symptoms and AUD. A study by Fischer and
Goethe (1998) on depressed inpatients found a strong association
between anxiety and alcohol abuse for women, and a weaker as-
sociation for men, which was independent of severity of depres-
sion. Book and Randall (2002) suggest that people use alcohol as a
means of coping with social fears as well as with stress. According
to the tension reduction hypothesis, alcohol acts as an anxiolytic,
67
which leads to its hazardous use among those with anxiety disor-
ders (Conger, 1956; Young, Oei, & Knight, 1990). Conger (1956) was
the first to suggest that “alcohol serves to reduce tension or anxiety,
possibly because of the depressing or tranquilizing effects of
alcohol on the nervous system”. The hypothesis provides a plau-
sible explanation for the association between hazardous alcohol
use and severe anxiety observed in the current study.
A significant body of research suggests that heavy smoking and
excess alcohol use occur together (Hart, Davey Smith, Gruer, &
Watt, 2010; Picco, Subramaniam, Abdin, Vaingankar, & Chong,
2012; Room, 2004). Using data from a 30-year longitudinal study,
Hart et al. (2010) concluded that comorbid smoking and alcohol use
of 15 or more units/week was the most risky behavior for all causes
of death. The association between smoking and hazardous alcohol
use in the current study was consistent with existing studies and is
a cause of concern, emphasizing the need for screening, brief
intervention, and appropriate referral for patients.
In accordance with our findings, studies both among psychiatric
patients (Nehlin, Gro€ nbladh, Fredriksson, & Jansson, 2013) and in the
population have found significant associations between smoking
and alcohol use (Chiolero, Wietlisbach, Ruffieux, Paccaud, & Cornuz,
2006; Falk, Yi, & Hiller-Sturmho €fel, 2006). This shared vulnerability
may be due to common genetic contributions to both conditions
(Schlaepfer, Hoft, & Ehringer, 2008) or due to a mutually enhancing
effect of alcohol and nicotine on each other (Kouri, McCarthy, Faust, &
Lukas, 2004; Rose et al., 2004). The concurrent use is a cause for
concern because it increases the risk of some cancers and cardio-
vascular diseases. Treatment outcomes for patients with comorbid
alcohol and nicotine addiction are also generally worse than for
people with only one addiction (Drobes, 2002). Treatment providers
thus need to consider promotion of smoking cessation during
treatment of hazardous alcohol use. Hazardous alcohol use was
significantly associated with poorer QOL in the physical health
domain. The physical health domain of the WHOQOL-BREF includes
items on mobility, daily activities, functional capacity, energy, pain,
and sleep. The effects of hazardous alcohol use on the physical health
domain are self-explanatory e excessive drinking has been associ-
ated with a multitude of physical health conditions, including
hypertension, heart disease, liver disease, and digestive problems
(Rehm et al., 2010; WHO, 2014), which could affect the physical
health domain of quality of life. The association observed between
hazardous alcohol use and severity of depression and anxiety in the
current study would also adversely affect sleep, energy, and func-
tional capacity, explaining the association with a low physical health
domain.
The results of this study need to be interpreted in view of certain
limitations. The study was conducted in a single, tertiary psychi-
atric institution, among those aged 18e40 years, and hence the
results may not be generalizable to other clinical settings. We were
unable to collect any data among those who refused to participate
in the study, which again limits the generalizability of the findings.
As the questionnaires were available only in English, we recruited
only those who could read and understand English. Singapore has a
high English literacy rate, as suggested by data from the 2010
Census of Population, which showed that English literacy among
those aged 15 years and over was 79.9% (Department of Statistics,
Singapore, 2010). As the cohort of patients recruited for this
study were young, we did not encounter significant issues in terms
of language ineligibility, but unfortunately, reasons for refusal and
ineligibility were not captured and thus we are unable to provide
accurate numbers of patients who could not speak English. The
AUDIT has been criticized for lacking sensitivity as compared to
structured diagnostic interviews for alcohol-use disorders (Hearne,
Connolly, & Sheehan, 2002). Participants may have under-reported
hazardous alcohol use due to social desirability bias (Beich, Gannik,
68 M. Subramaniam et al. / Alcohol 65 (2017) 63e69
& Malterud, 2002) and the study did not use any objective mea-
sures to determine the extent of alcohol use. However, in the cur-
rent study, AUDIT was embedded within a longer questionnaire,
which may have reduced some of the biases while maintaining the
validity of the questionnaire (Daeppen, Yersin, Landry, Pe coud, &
Decrey, 2000). Lastly, the study had a cross-sectional design that
limits us from drawing any conclusions on temporal relationships
between hazardous alcohol use and comorbid psychiatric illnesses.
The strengths of the study include that it is a single-site study,
conducted by trained researchers using structured instruments that
included a multi-ethnic population of psychiatric patients in an Asian
setting. Furthermore, the study adds to the growing body of litera-
ture that states that the prevalence of hazardous alcohol use among
psychiatric patients in Asian countries is lower than that reported in
the West. The study also found that hazardous alcohol use is higher
among those with depressive disorder as compared to those with
schizophrenia; a finding that needs further investigation. The study
replicates the findings of association of hazardous alcohol use with
depression, anxiety, and smoking among psychiatric patients while
identifying some unique and intriguing aspects of differences on QOL
among those with and without hazardous alcohol use.
Conclusion
Comorbidity is best treated when both conditions are addressed
concurrently (National Institute of Drug Abuse, 2010), which em-
phasizes the need for hazardous alcohol use to be identified early
and treated effectively. The first step toward this would be to
include routine screening for hazardous alcohol use; there is
increasingly more evidence that supports brief interventions as an
effective way of managing hazardous alcohol use, which must be
adopted based on patient preference and clinical setting.
Acknowledgments
Funding for this study was provided by Ministry of Health, Na-
tional Medical Research Council, Singapore (NMRC) under its
Centre Grant program (Grant no.: NMRC/CG/004/2013).
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