An investigation of the multimorbidity of mental disorders and alcohol attributable conditions

Alcohol is the main cause of death in young people. In England in 2017 there were almost 6000 deaths across all age groups caused by alcohol, with around a fifth of the population drinking more alcohol than is recommended by government guidelines. We know that individuals who drink too much are also more likely to have a mental health problem, but we know less about the future health of people who have both of these problems and specifically whether physical diseases caused by alcohol are more common in this group. We do know that individuals with both alcohol and mental health problems may not always be able to access the treatments they need and that GPs currently do not routinely ask people with depression and anxiety about their drinking. This work will help us to understand what diseases are more common in this group of people and how best to treat them.

Multimorbidity refers to people having at least two health conditions at the same time and it is important we understand how these multiple conditions interact to affect someone's overall health. This work will investigate the most common patterns of multimorbidity, including mental health problems, depending on whether someone does or does not drink excessively. We know that people may use alcohol to help cope with mental health problems and conversely that drinking too much can make mental health worse. We will therefore look at whether the ordering of the alcohol and mental health problem, in addition in addition to other information regarding employment, housing, smoking, and physical health affects whether people die earlier than they should.

Our research will use national surveys, cohort studies (which follow people throughout their lives) and electronic healthcare records (which include data from when you visit your GP or are admitted to hospital). We will use statistical methods to understand more about multimorbidity in relation to alcohol and mental health and to identify different groups of individuals who have experienced similar types of health conditions. We will also conduct workshops with healthcare staff to ask them whether our findings reflect what they see in their practice. We will then determine whether individuals who have experienced many disadvantages in their lives and those with other behavioural risk factors (e.g. smoking and poor diet) are more likely to experience multimorbidity and whether they develop these conditions at a younger age.

We will follow individuals who have been admitted to hospital who already have a disease caused by alcohol to look at whether they are more likely to experience particular patterns of multimorbidity, and which of these people use the most health services and treatments and so may require support at an earlier stage. We will then use what we have discovered about the patterns and pathways of multimorbidity to think about what effect that changes in the way we treat people who drink excessively or have mental health problems might have on outcomes for those patients and the impact this might have on the NHS.

Our work may show that we need to do more to ensure that alcohol and mental health services are better joined up than they currently are. Further impacts of our work will be in developing web-tools that can be used by GPs to understand which patients are likely to have the poorest outcomes and in selecting the best treatment options for their patients. We can also help inform the development of government policies and in selecting which treatments and services to provide, to avoid individuals with mental health problems experiencing more harms as a result of their drinking.

The compounded health risks for patients with comorbid alcohol and mental health problems are not established. We will use several secondary data sources to identify multimorbidity clusters of physical non-communicable diseases with common and severe mental disorders, focusing on clusters of Wholly or Partially Alcohol Attributable Conditions. This research is paramount given significant reductions in life expectancy for individuals with alcohol problems and with mental disorder. The timing is salient given cuts to primary care alcohol screening and to alcohol treatment services.

We will use population surveys, cohort data and electronic healthcare records to investigate how alcohol attributable conditions cluster with mental disorders and the most common transitions to these multimorbidities. We will determine the socioeconomic, social (e.g. employment, social networks) and behavioural (e.g diet) risk factors for these transitions. Hospital records will then be analysed to determine patterns of multimorbidity, frequency of healthcare use and risk of mortality in individuals originally admitted for an alcohol attributable condition.

Our focus will move to treatment provision to investigate how primary care treatment for excessive drinking differs based on an individual's mental health and experience of multimorbiidty. All work will feed into economic models evaluating how accounting for multimorbidity affects existing policy appraisals (e.g. taxation or specialist alcohol treatment access) and the impact of new policies linked to mental health.

This work will i) inform GPs what conditions they should screen for based on an individual's previous mental health and alcohol use, ii) provide evidence on the utility of alcohol screening across different mental disorders and whether financial incentives should be expanded to common mental disorders and iii) determine the best interventions to avoid alcohol-related harms in individuals with a mental disorder.