| | Investigating the Association Between Moderate Drinking and Mental HealthIn an attempt to relate “moderate drinking” to “mental health,” inadequacies of definition for both terms become apparent. Moderate drinking can be variously defined by a certain number of drinks to “nonintoxicating” to “noninjurious” to “optimal,” whereas mental health definitions range from “the absence of psychopathology” to “positive psychology” to “subjective well-being.” Nevertheless, we evaluated the relation by conducting an electronic search of the literature from 1980 onwards using the terms “moderate drinking,” “moderate alcohol consumption,” “mental health,” and “quality of life.” Most studies report a “J-shaped curve,” with positive self-reports of subjective mental health associated with moderate drinking but not with heavier drinking. The relevance of expectancies has been unevenly acknowledged, and studies on the cultural differences among expectancies are largely lacking. The potential role of moderate drinking in stress reduction and studies of social integration have yielded inconsistent results as previous levels of drinking, age, social isolation, and other factors have often not been adequately controlled. Future anthropological, epidemiological, and pharmacological interactions preferably must be studied through a prospective design and with better definitions of moderate drinking and mental health. Introduction  Difficulties in capturing the concept of “moderate drinking” 1, 2 are matched by the challenges in identifying valid indicators of mental health. While mental health can be simply defined as “the absence of psychopathology,” Vaillant and Vaillant (3) have reviewed 6 empirical approaches to mental health, which are outlined. Among these approaches, studies of “moderate drinking” have investigated psychosocial benefits, including positive subjective health and positive mood effects, both anticipated and experienced. Another line of investigation has been the reduction of psychopathology. The current body of research integrates large epidemiological studies with anthropological data. Most studies use the definitions of “moderate drinking” as set out in available guidelines, expressed as a number of drinks. Main methodological caveats reviewed include the array of definitions of “moderate drinking” and “mental health,” the need to differentiate between “lifestyle” abstinence and those abstainers recovering from drinking problems, and the assessment of psychological benefits in the context of expectancies, social context and cultural norms. Further study is required of the risks-benefits of moderate drinking in non-Western countries, as well as the directions of causality and their policy implications. Method An electronic search of the available literature from 1980 onwards was conducted using the terms “moderate drinking,” “moderate alcohol consumption,” “mental health,” and “quality of life.” The search engines involved were MEDLINE, PyschInfo, and CINAHL. The search was complemented by a retrieval of the references cited in previously published literature reviews. Challenges of Definition What Is “Moderate” Drinking? The conceptual evolution and meanings of “moderate” consumption has been summarized by Eckardt et al. (1). Moderate drinking can be defined as any drinking that is “nonintoxicating;” in other words, consumption that is controlled or restrained, for example, as evident in current campaigns against drinking-driving (Social motivation). Another meaning includes “noninjurious” drinking, or consumption, the cumulative effect of which does not result in health deterioration or harm. Herein, consumption is below an upper limit beyond which some health malfunction occurs (Medical motivation). In another meaning, moderate drinking is defined as “statistically normal.” In this case, it is defined by the norm or mean value of consumption for a particular age or other population group and within a standard deviation of the group mean. Finally, moderate drinking levels may be viewed by some as those that are “optimal,” consumption levels that have some beneficial effect specific to particular diseases identified in comparisons with both nondrinkers and heavier drinkers. This level is also represented by the nadir of the J-curve for health outcomes. More recently, the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) in the United States endorsed the above typology and listed a number of caveats related to current national definitions of “moderation” (2). In the United States, for example, official dietary guidelines define moderate drinking as no more than one drink per day for women and no more than two drinks per day for men (4). Difficulties with this definition arise from a number of factors. There is a range of differences among individuals in drinking experience and tolerance. For example, two- to four-fold differences have been described among individuals in the pharmacokinetics and pharmacodynamics of alcohol metabolism. Differences also result from the time period over which alcohol is consumed, or its interaction with genetic vulnerability for a particular medical condition. Additional confounders may be introduced by lifestyle variables between drinkers and nondrinkers, demographics, including age or gender, as well as variation in drinking patterns. Furthermore, methodological differences arise from variation in patterns of consumption, drink sizes, in vivo and in vitro reactivity and extrapolation from animal models. Finally, cultural dimensions are another source of variability and include interaction of food, traditions and taboos, as well as drinking settings. Bearing in mind the above caveats, the NIAAA report, however, does not suggest a need to modify the existing guidelines in the United States. It is interesting to note that this review highlights the relative consistency of the drinking levels suggested as “moderate,” at least in Western societies. In 1862, Sir Francis Anstie set the upper limit of safe drinking at 1.5 ounces of absolute alcohol, that is, approximately three 5-oz glasses of wine, three 12-oz bottles of beer and three 1-oz shots of 80% proof whiskey (5). A century and a half of extensive research has reduced these levels by only one third. While past studies focused on comparisons between moderate and heavy drinkers, current epidemiological surveys have also added the comparison with abstainers. What Is Mental Health? Difficulties in capturing the concept of “moderate drinking” are matched by the challenges in identifying valid indicators of mental health. Vaillant and Vaillant (3) contrast 6 empirical approaches to mental health. While mental health was initially merely defined as “the absence of psychopathology,” empirical approaches have further conceptualized mental health in a number of ways. One definition looks at mental health as “above normal,” a mental state that is objectively desirable. This is in keeping with Sigmund Freud's definition of mental health as the capacity to work and to love. A second view looks at mental health as “positive psychology,” epitomized by the presence of multiple human strengths. “Maturity,” part of healthy adult development, is another dimension of mental health, as is “socioemotional intelligence,” accurate and conscious perception that monitors the social adaptation of one's own emotions. Additional approaches define mental health as “subjective well-being,” the subjective experience of happiness, contentment and being desired, and “resilience,” the capacity for successful adaptation and homeostasis. In addition to searching for “absence of psychopathology,” the studies reviewed have mostly investigated psychosocial benefits. These also include a range of dimensions. Psychosocial benefits include, for example, positive subjective health, a self-perception of good health, whether or not moderate drinking enhances it. Positive psychology, such as mood effects, both anticipated and experienced, is another important aspect. Expectancy research is of particular relevance in investigations of psychosocial benefits. Brown et al (6) have identified six independent expectations by drinkers of their drinking. These include: 1.Positive transformation of experience 2.Enhanced social and physical pleasure 3.Enhanced sexual performance and experience 4.Increased power and aggression 5.Increased social assertiveness 6.Reduced tension According to Brown and colleagues, nonproblematic drinkers emphasize expectations of social and physical pleasure (6), while problem drinkers anticipate reduced tension reduction. Gustafson (7) reported that consumers of high levels of alcohol had higher expectations along all dimensions than those consuming low levels of alcohol. Expectations and experiences are both subject to substantial cultural differences. Moderate Drinking and Mental Health Within the constraint of the above challenges in definition, the association of moderate drinking and mental health has been the topic of a number of research lines. The initial studies were mostly of a social-anthropological nature and were reviewed by Baum-Baicker (8). Overall small samples were generally involved, interestingly, involving medical students in several cases. The review is considered to be mainly of historical interest. Fifteen years later, comprehensive reviews by Chick (9), as well as by Peele and Brodsky (10) present a more sophisticated body of research that integrate larger epidemiological studies with anthropological data. The following tables are largely based on the review by Peele and Brodsky, modified to fit the focus of this paper and updated as required (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7). | | |  | Study and sample | Method and controls | Results | |
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| Poikolainen et al (14), random study of 6040 Finns, age 25–64 y | Regression; controls: age, sex, education, marital status, isolation, disability pension, smoking, ex-drinker, decrease in drinking for health reasons | Adjusted OR, subjective health 40–99 g/wk = 0.7 (3.3–9 drinks) | | | Power et al (15), 1958 cohort of all UK births (3/3–3/9), 9605 of whom reported alcohol consumption | Within prospective study, cross-sectional self-reports at 33 y of age; controls: heavy/problem drinkers at age 23 y | Poor-fair self-rated health (units/week; men/women) Moderate (11–35/6–20) = 9%/11% | | | Poikolainen and Vartiainen (16), FINRISK Study, random sample of 6040 Finns age 25–64 y | Regression; controls: age, sex, education, marital status, no friends, sickness pension, smoking, lifelong abstinence/ex-drinker, decrease in drinking last 12 mo | Adjusted OR, suboptimal health (drinks/d), wine only, men: lowest at 5–9 = 0.67 Suboptimal health (drinks/d), wine only, women: lowest at 0–4 = 0.81 | | | Grønbæk et al (17), WHO Copenhagen survey, random sample of 12,039 Danes age 18–100 y | Regression; controls: age, sex, intake of other alcoholic beverages, physical activity, body mass, education, social networks, chronic disease, smoking | Adjusted OR, suboptimal health (drinks/d, wine only): 3–5 = 0.65 | | | Guallar-Castillon et al (11), 1993 Spanish National Health Survey of 19,573, age ≥16 y | Regression; controls: age, sex, education, job status, social support, location, drinking, leisure time and chronic disease; ex-drinkers included | With Mediterranean lifestyle and wine with meals, the higher the consumption of wine and beer (not spirit), the lower the prevalence of suboptimal health; no “J” shape | | | | |
| ∗ Adapted from Peele and Brodsky (10) and updated by author. |
| | | | Study and sample | Methods and controls | Results | |
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| Naturalistic research | | | Culbert (29) | Drinking and life stressors | Moderate drinkers do not increase and even reduce drinking in response to major life stressors | | | De Castro (30) | Daily activities report of moderate drinking | Moderate alcohol use has a calming effect even if use does not aim at reducing anxiety | | | Cooper et al (31) | Moderate vs. problem drinkers | Moderate drinkers report that alcohol creates a general calming sensation, while problem drinkers use alcohol to cope with major life issues. Is it pharmacological effect, social learning or expectancy? | | | | |
| | | | Study and sample | Methods and controls | Results | |
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| Camacho et al (32), probability sample of 4590 residents of Alameda County, Calif, ≥35 y | Covariates with alcohol consumption; inclusion of people in recovery? | Not married (drinks/mo) 0 = 35%; 1–30 = 23% (1–2/d) | | | | | No group membership (drinks/mo); 0 = 46%; 1–30 = 32% | | | Leifman et al (33), N = 45,746, all Swedish military conscripts 18–19 yr old males over 2-y period | Percentage in each drinking category indicating various social integration/sociability indicators; controls: alcoholic father, rural vs. urban | Often insecure with others (U shape) | | | | | Abstain = 7%; 26–100 g alcohol/wk = 3%; >250 g/wk = 7% | | | | | No intimate conversations | | | | | Abstain = 8%; 26–100 g/wk = 3%; >250 g/wk = 9% | | | Elderly | | | Alexander and Duff (34) | Retirement communities | Greater social interaction associated with heavier drinking | | | Hanson (35) | Elderly men born in 1914 | Isolation associated with greater consumption and problem drinking | | | Graham (36) | Elderly in small Ontario community. Lifetime abstainers and former drinkers removed from study | Current drinkers engaged in more social activities | | | Cassidy et al (37); cross section of 278 community dwelling women, age ≥70, recruited through media and clubs | Beck Depression and Anxiety Inventories (BDI & BAI), SF/36, Cambridge Cognitive Exam for Mental Disorders of Elderly | Physically active women half as likely to be depressed; more likely if ever smoking ≥20 cigarettes/d; no association of alcohol with mood or quality of life but better cognition | | | Youth | | | Murphy et al (38); sample of 353 college students receiving credits | Regression; Daily Drinking Questionnaire; Rutgers Alcohol Problem Index; two Life Satisfaction Scales (LS) | Drinking among young men but not women associated with positive curvilinear relation with social satisfaction but no other LS scale, i.e., school, family, dating, and future | | | | |
| | | | Study and sample | Methods and controls | Results | |
|---|
| Bell et al (39); random sample, 2029 adults in 3 southern US counties | Group mean comparisons; controls: race, sex, age, marital status, social class; separate analyses for experience of different stressful life events | Anxiety scale: moderate<light<heavy<abstainDepression scale: moderate<light<abstain<heavy but no definition of drinking category | | | Neff and Husaini (40); random sample, 713 adults in Tennessee | Regression on depression scores (CES-D scale) by drinking categories; controls: race, sex, education | Depressive symptoms: moderate<abstain<heavy | | | Neff (41); random sample, 1784 residents of San Antonio, Tex | Analysis of variance by drinking; controls: fatalism, religiosity, social desirability | Depressive scale: abstain<light<heavy Abstainers: “recovery” excluded | | | Lipton (42); random sample, 928 non-Hispanic white, Epidemiological Catchment Area Study (Los Angeles) | Regression on time 2 scores by drinking; controls: sex, age, physical health, depression at time 1; life stressors | Depression scale: moderate<light/moderate<heavy<abstain<light | | | Green et al (43); random HMO Oregon in 1990: 3074 males, 3947 females | Predictability of alcohol consumption by MHI-5 and BSI-8 Depression screens | MHI-5 more predictive than depression alone specifically among women; women with prior diagnosis of depression drink less; “very heavy drinkers excluded” | | | Caldwell et al (44); random sample, 2404 adults age 20–24, Canberra region, Australia | Goldberg Depression and Anxiety Scales; Positive and Negative Affect Schedule and AUDIT | For young men, nondrinker/occasional and hazardous/harm consumption both associated with higher levels of anxiety and depression. Male abstainers less extroverted and healthy, unrelated to past alcohol use or current tobacco or marijuana use; female abstainers did not show more distress | | | Paschall et al (45); from US longitudinal study of adolescent health, i.e., in 1995 adolescents from middle and high schools and then 2002 | 9 items from CES-D scale for general population; 7 categories of alcohol use | Adjusted for health and socioeconomic factors; frequency of depressive symptoms similar for moderate drinkers and long term abstainers but higher for heavy drinkers | | | Alati et al (46); 812 patients attending emergency department in Queensland over 14 days, age 16–84 y; Australia | AUDIT and HADS | U-shaped relation for men between alcohol consumption and anxiety/depression; more linear relation for women | | | | |
| | | | Study and sample | Methods and controls | Results | |
|---|
| Power et al (15), 1958 cohort of all UK births (3/3–3/9), 9605 of whom reported alcohol consumption | Within prospective study, cross-section of psychological distress at 33 y; controls: heavy/problem drinkers at age 23 y | Psychological distress (units/wk; men/women) | | | | | Abstain = 10%/15% (U-shaped relation) | | | | | Moderate (11–35/6–20) = 5%/9% | | | | | Heavy (35+/20+) = 11%/23%; U shape | | | Roberts et al (47), Whitehall II study of 10314 UK civil servants | Cross-section of psychosocial measures at screening in longitudinal study; light drinkers: men 1–10; women 1–6 units/wk | Psychological measures: light drinkers > abstainers; Men > women, overall and for positive affect, level of upset; men and women = for hostility | | | Vaillant (48), 50-y longitudinal study of 443 inner city Boston men | Percentage of each lifetime drinking group with each mental health indicator | Psychiatric diagnosis: abstain = 35%; | | | | | Moderate < 21 drinks/wk = 17% | | | | | Abuse = 39% | | | | | Lower psychological adjustment: HSRS < 60 | | | | | Abstain = 19%; moderate = 1%; abuse = 19% | | | Abstainers and culture | | | Leifman et al (33), Swedish conscripts who abstain | Young conscript abstainers whose fathers abstained vs. those whose fathers drank | No psychiatric/anxiety/emotional disadvantage among abstainers whose fathers abstained | | | | |
| | | | Study and sample | Methods and controls | Results | |
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| Camacho et al (32), panel study of probability sample of 4590 residents of Alameda County, Calif, ≥35 y of age | Covariates with alcohol consumption | Disabled (drinks/mo) 0 = 27%; 61–90 = 10% (2–3 drinks/d); >91 = 17% | | | Vasse et al (49) 471 participants at 3 sites in worksite health project, Netherlands | Regression on sickness absence by stress × alcohol consumption; controls: age, gender, education, marital status, blue-collar vs. white-collar worksite, smoking | OR, sickness absence Abstainers = 4.6; Moderate = 1.0 (<3 drinks/d for men and 2 for women); Excessive = 2.0 | | | Mansson et al (50), 5 complete birth-year cohorts of 3751 men aged 47–48 y in Malmö, Sweden | 11-y prospective study; controls: smoking, hypertension, cholesterol and body mass; MAST scale; “Sick Abstainer” ruled out | Adjusted RR, disability pension | | | | | Abstainers = 1.8; low = 1.0; high 1.3 | | | Marchand et al (51), sample constituted 10,387 employees from 422 occupations from 1998 Quebec Health & Social Survey (QHSS) | Regression; Ilfeld Scale for psychological distress over past week; work strains from Karasek's skill utilization; decision authority and psychological demands, etc | 6.1% variance of psychological distress between occupations; alcohol use U-shape relation with distress, i.e., moderate intake not associated with distress | | | Riise et al (52), cross-section of 23,312 individuals aged 40–47 y, Hordaland, Norway | Covariance analysis; SF12 Health Survey, with physical and mental components | Difference between occupations with managers in top health category; U-shape relation with alcohol | | | | |
Positive self-reports of subjective mental health associated with moderate drinking (Table 1) are complemented by lower reports of suboptimal health. Among the studies examined, the only one that found no J-shaped association also did not control for ex-drinkers (11). Overall, an association of positive mood with moderate drinking is consistent in a number of surveys from different countries (Table 2). Of note, Demers et al (12) reported an interesting difference between descriptions of “personal experience” of drinking as usually enjoyable, as compared to an “objective” assessment of drinking effects, where harm was more frequently cited. The relevance of expectancies in this line of research has been unevenly acknowledged. Studies on the cultural differences among expectancies are largely lacking and those that are available are often based on immigrant minorities in different countries. Drinking plays a role in the potential for stress reduction (Table 3) and a popular way to conceptualize the benefits of drinking has been with regard to people drinking alcohol to “relax.” Several theoretical psychological models have been developed around this concept that include stress response dampening, social learning, expectancy, and attention allocation. Studies in this area often show inconsistent results 10, 13. Studies of social integration have been complemented by studies into drinking and the reduction of social anxiety (Table 4), supporting a positive influence of moderate drinking. However, there are some caveats around these data. Some data sets do not explicitly control for ex-drinkers who may be in recovery. Age-specific studies have been carried out, but evidence among the elderly is mixed. For some, moderate drinking may be associated with reduced isolation, perhaps linked with the general consumption of alcohol in social venues. Among young people, one study of students reports that the social impact of drinking appears to be more apparent in men than in women (38). Investigations into the “reduction of psychopathology” have targeted the prevalence of symptoms of depression and anxiety with positive associations reported from moderate drinking (Table 5). The same positive association is reported with broader studies of psychological distress and/or psychiatric diagnoses (Table 6). Of importance is that abstainers in cultures or family settings where abstinence is normative are not likely to show mental health deficiencies. Lastly, another indicator of mental health may be work performance associated with higher income or absence of disability and/or stress (Table 7). The moderate drinking category appears to be associated with higher income, less sickness, absence, disability, or distress. However, a data analysis of cause or consequence has not been conducted. Conclusions In this review of studies around the association of moderate drinking and mental health, several methodological caveats are evident. These relate, first, to the existing array of definitions of “moderate drinking” and “mental health.” Most studies appear to use definitions of “moderate drinking” as laid out in dietary guidelines, favoring those that refer to the number of drinks. Studies into mental health mostly highlight subjective well-being, positive psychological attributes and the absence or reduction of psychopathology. Another caveat relates to the complexity in the assessment of psychological benefits within the context of expectancies, and social and cultural norms. Furthermore, there is a need to differentiate between “lifestyle” abstainers and those abstainers who are recovering from drinking problems. Several challenges and questions also remain. Cross-fertilization is required between investigations of mental health outcomes associated with moderate social drinking (such as subjective health or stress reduction) with investigations into the prevention and/or reduction of clinical syndromes such as depression or social phobia. One unanswered question is: What are the upper limits of “moderate drinking” in psychiatric comorbidities? In addition, the risk-benefits of moderate drinking in non-Western countries are “terra incognita.” They cannot be extrapolated from studies of immigrants to Western countries. Future anthropological, epidemiological, and pharmacological interactions preferably must be studied through a prospective design. Current studies of the association of psychological benefits with moderate drinking in major demographic and socio-cultural groups are mostly cross-sectional and may also require more sophisticated prospective designs. 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From the Addiction Centre, Foothills Hospital  Address correspondence to: Nady el-Guebaly, MD, Foothills Hospital, Addiction Centre, 1403 29th St NW, Calgary, Alberta T2N 2T9, Canada.
PII: S1047-2797(07)00015-4 doi:10.1016/j.annepidem.2007.01.013 © 2007 Elsevier Inc. All rights reserved. | |
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