mental health alcoholism case study

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The Healthcare Professional's

Core Resource on Alcohol

Knowledge. Impacts. Strategies.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Mental health issues: alcohol use disorder and common co-occurring conditions.

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  • Alcohol use disorder (AUD) frequently occurs with other mental health disorders, and vice versa.  Primary care providers and other clinicians are well positioned to identify these conditions, make informed clinical decisions, and refer patients to specialists, thereby improving treatment outcomes.
  • A timeline of symptoms and behaviors is a key tool for differential diagnosis.  In order to guide treatment, it is helpful to learn, if possible, whether psychiatric symptoms are present or absent during periods of abstinence to differentiate whether they are alcohol-induced or separate, primary conditions.
  • The severity of both the AUD and the co-occurring mental health disorder determines the appropriate level of care.  Patients with less severe AUD and mental health conditions may be able to receive treatment in primary care, whereas those with more severe conditions may need care from a mental health or addiction specialist or both.
  • The likelihood of recovery from both conditions is higher if both the AUD and the co-occurring mental health disorder are treated. Medications for AUD and for mild to moderate depressive and anxiety disorders can be started in a primary care setting.

Alcohol use disorder (AUD) often co-occurs with other mental health disorders, either simultaneously or sequentially. 1 The prevalence of anxiety, depression, and other psychiatric disorders is much higher among persons with AUD compared to the general population.

By far, the most common mental health conditions that co-occur with AUD are depressive disorders, anxiety disorders, trauma- and stress-related disorders, other substance use disorders, and sleep disorders. 2–4 Furthermore, psychotic disorders such as schizophrenia often co-occur with AUD and should be recognized and addressed during AUD treatment.

Here, we briefly describe the causes and effects of co-occurrence, the mental health disorders that commonly co-occur with AUD, and the treatment implications for primary care and other healthcare professionals. We start with a visual model of care that indicates when to consider a referral.

A model of care for co-occurring AUD and other mental health disorders

Brief tools are available to help non-specialists assess for AUD and screen for common co-occurring mental health conditions. You can determine whether your patient has AUD and its level of severity using a quick alcohol symptom checklist as described in the Core article on screening and assessment . You also can screen for depression, anxiety, PTSD, and other substance use disorders using a number of brief, psychometrically validated screening tools, which are described in a 2018 systematic review 5 and which may be available in your electronic health record system. As needed, you can refer to a mental health specialist for a complete assessment.

The schematic below shows when and what type of specialist care may be most appropriate for patients with co-occurring AUD and other mental health disorders. Once a patient has had an assessment to determine the diagnoses and levels of severity, the settings indicated in the schematic are appropriate for effective treatment of both the AUD and other mental health disorder. 6,7

As shown in the schematic, AUD and other mental health disorders occur across a spectrum from lower to higher levels of severity. For patients in the middle, with up to a moderate level of severity of AUD or the psychiatric disorder or both, a decision to refer should be based on the level of comfort and clinical judgment of the provider.

Causes and effects of co-occurrence

Several mechanisms may explain the common co-occurrence of AUD and psychiatric disorders:

  • Pre-existing psychiatric disorders may increase the risk of developing AUD, in part because alcohol is often used to cope with symptoms of psychiatric disorders, even if alcohol ultimately makes the problems worse. 8
  • At the same time, alcohol use—especially adolescent drinking and long-term exposure to alcohol—may predispose individuals to develop psychiatric disorders. 9
  • AUD and other psychiatric disorders often share genetic risks and environmental vulnerabilities such as trauma and adverse childhood experiences. 10–12

The co-occurrence of AUD and another mental health disorder can complicate the diagnoses and negatively impact the clinical course of both conditions. Many clinical features of AUD have significant overlap with other psychiatric disorders, including sleep disturbances and negative emotional states such as worry, dysphoria, sadness, or irritability that often occur during cycles of alcohol intoxication, withdrawal, and craving. (See Core article on neuroscience .) As described in the sections to follow, a timeline of your patient’s symptoms is a key tool for a differential diagnosis.

Moreover, AUD and psychiatric disorders may exacerbate each other, thereby producing poorer outcomes. Hence, individuals with co-occurring AUD and psychiatric disorders tend to return to using alcohol more frequently, as well as experience more severe psychiatric symptoms. 13 Without adequate treatment, this pattern may result in higher rates of hospitalization and suicide. 14

Mental health disorders that commonly co-occur with AUD

Diagnostic clarity is key to ensure appropriate treatment. For healthcare professionals who are not mental health or addiction specialists, the following descriptions aim to increase awareness of signs of co-occurring psychiatric disorders that may require attention and, often, referral to a specialist.

Anxiety disorders. Anxiety disorders are the most prevalent psychiatric disorders in the United States. The prevalence of AUD among persons treated for anxiety disorders is in the range of 20% to 40%, 2,15 so it is important to be alert to signs of anxiety disorders (see below) in patients with AUD and vice versa.

Genetic and environmental factors contribute to the co-occurrence of AUD and anxiety disorders. 16 Further, since alcohol is readily available, it is commonly used to cope with anxiety. Alcohol may appear to relieve anxiety in the short term, but over time, heavy drinking and repeated withdrawal can escalate both the anxiety symptoms and maladaptive drinking. 17

The hallmarks of anxiety disorders are excessive and recurrent fear or worry episodes that cause significant distress or impairment and that last for at least 6 months. People with anxiety disorders may have both psychological symptoms, such as apprehensiveness and irritability, and somatic symptoms, such as fatigue and muscular tension.

Three distinct anxiety disorders most commonly co-occur with AUD: 17

  • Generalized anxiety disorder typically presents with persistent and generalized worrying, poor sleep, fatigue, and difficulty relaxing.
  • Social anxiety disorder is marked by extreme fear of situations involving the possibilities of scrutiny by others or embarrassment.
  • Panic disorder involves recurrent “panic attacks” of intense fear lasting several minutes to an hour and often lead to changes in behavior to avoid precipitating circumstances.

Even among patients without an anxiety disorder, anxiety-like symptoms can occur after a single heavy drinking episode 18 (sometimes described in the popular press as “hangxiety”) and can increase between drinking episodes, reaching high levels during alcohol withdrawal. 19

When patients who drink heavily report anxiety, it helps to create a timeline with them to discern whether the anxiety is alcohol-induced or, instead, a pre-existing or primary anxiety disorder, which can help set expectations and a treatment plan. Sample timeline queries include the ages of onset of anxiety symptoms and of alcohol use, the longest period of abstinence, the presence or lack of anxiety symptoms during phases of alcohol drinking and extended phases of abstinence, and the family history of anxiety disorders and of AUD.

Mood disorders. The mood disorders that most commonly co-occur with AUD are major depressive disorder and bipolar disorder. Among people with major depressive disorder, the co-occurrence of AUD ranges from 27% to 40% for lifetime prevalence 20,21 and up to 22% for 12-month prevalence. 15 In clinical populations, people with bipolar disorder have the highest AUD prevalence, estimated at 42%. 22 As with anxiety, it’s important to be aware of the signs of mood disorders (see below) in those with AUD and vice versa.

Converging evidence suggests genetic links between AUD and mood disorders. 23,24 Further, long-term exposure to alcohol against the backdrop of depressive or manic symptoms may lead to a more severe clinical course, with longer duration of mood episodes, poorer cognitive function, and higher risk of suicide. 25 Altogether, several lines of evidence indicate that AUD and mood disorders exacerbate each other through common neurobiological substrates, as well as shared underlying genetic vulnerability and shared environmental stressors.

The hallmarks of mood disorders are recurring episodes of disruptions in mood, energy, activity, sleep, and behavior. Individuals may struggle, as a result, to maintain their ability to work and their interpersonal relationships. Here’s how major depressive and bipolar disorders are characterized:

  • Major depressive disorder is marked by one or more depressive episodes, which manifest with five or more of the following for at least 2 weeks: low mood, low energy, loss of interest or pleasure in most activities, irritability, insomnia or hypersomnia, significant weight or appetite changes, reduced ability to concentrate, thoughts of guilt or worthlessness, thoughts of death, or suicidal ideation or a suicide attempt.
  • Bipolar disorder is marked by cycles of mania or hypomania, with or without depressive episodes. Core mania symptoms are abnormally elevated, irritable, or labile mood and persistently increased energy and activity. Less severe hypomanic episodes should still be taken seriously, as they may indicate increasing instability and need for treatment. Untreated, bipolar disorder has the highest rate of suicide of all psychiatric disorders, 26 underscoring the need, if suspected, for referral to specialist care.

When patients report mood symptoms, it helps to clarify the possible relationship with alcohol use by asking, for example, about mood symptoms prior to starting alcohol use and on extended periods of abstinence. In addition, ask about current and past suicidal ideation or suicide attempts, as well as the family history of mood disorders, AUD, hospitalizations for psychiatric disorders, or suicidality.

Especially for individuals with history of suicidal ideation or psychiatric hospitalizations, work with a psychiatrist and therapist who can assist with the diagnostic and risk assessment, then recommend appropriate pharmacological and psychosocial treatment approaches. (To find addiction specialists, visit the NIAAA Alcohol Treatment Navigator and see the Core article on referral .)

Note : Be aware that the potential for suicidality is a concern not only for those with mood and other mental health disorders, but also for many people who drink heavily, whether or not they have AUD. For more information, see the 2019 NIAAA journal article on suicidal behavior . 27

Post-traumatic stress disorder (PTSD). PTSD is characterized primarily by alterations in arousal and recurrent intrusive thoughts that follow a traumatic event. Among those with AUD, about 15-30% overall have co-occurring post-traumatic stress disorder, with increased rates of 50-60% among military personnel and veterans. 28 The two conditions may worsen each other. Thus, here, too, it’s important to be cognizant of the signs of PTSD in patients with AUD, and vice versa.

PTSD may facilitate development of AUD, as alcohol is commonly used to numb memories of a traumatic event or to cope with symptoms of posttraumatic stress, and AUD may increase the likelihood of PTSD. 29 The relationship between PTSD and AUD may have multiple causal pathways. First, heavy alcohol use may increase the likelihood of suffering traumatic events, such as violence and assault. Second, AUD may undermine a person’s psychological mechanisms to cope with traumatic events, by disrupting arousal, sleep, and cognition, thus increasing the likelihood of developing PTSD. Third, AUD and PTSD have shared risk factors, such as prior depressive symptoms and significant adverse childhood events.

The symptoms of PTSD and AUD have a marked overlap, for instance, autonomic hyperactivity seen in alcohol withdrawal may resemble PTSD-related increases in arousal. Therefore, a thorough assessment is necessary for diagnostic clarity and adequate treatment of both conditions. 30

As with anxiety and mood disorders, it can help for a healthcare professional to create a timeline with the patient to clarify the sequence of the traumatic event(s), the onset of PTSD symptoms, and heavy alcohol use. One way to differentiate PTSD from autonomic hyperactivity caused by alcohol withdrawal is to ask whether the patient has distinct physiological reactions to things that resemble the traumatic event.

Other substance use disorders (SUD). Widespread availability of alcohol leads to common co-use with other substances, both legal and illegal. As expected, AUD has strong comorbidity with other SUD. More than 40% of men and 47% of women with AUD have had another SUD in their lifetime. 2 Having AUD raises the odds of another SUD by a factor of 3 to 5. 31,32

Multiple lines of evidence support a common underlying vulnerability to AUD and other SUD, mediated via overlap in neurocircuits that underly AUD and other SUD as well as via shared genetic factors. 33 Co-use of alcohol and other substances may hasten and aggravate the course of the addiction cycle in the brain (see Core article on neuroscience ). Co-use of alcohol and drugs also increases the likelihood and severity of overdose. 34–36

To have a full picture for patient care, patients with AUD should be screened for other substance use. Stigma can be reduced with normalization statements such as “Many people try (cannabis or painkillers in ways that are not prescribed) at some point in their lives; is that something you have tried?” See the Resources section, below, for SUD screening and assessment tools.

Sleep disorders. Sleep-related disturbances are often reported by people with AUD, and the co-occurrence of AUD and sleep disorders is common. Sleep-wake disorders include insomnia disorder, hypersomnolence disorder, breathing-related sleep disorders, and parasomnias, which are marked by undesirable physical events or experiences during sleep. The prevalence of sleep disorders among persons with AUD ranges from 36% to 91%. 37

Sleep disorders can facilitate the development of AUD, and AUD can cause sleep disorders. The relationship between the disorders appears to be multifactorial. 4 Even moderate doses of alcohol may alter the physiology of sleep, for instance by reducing the duration of rapid eye movement sleep. 38 In addition, alcohol use may aggravate sleep-disordered breathing 39 and periodic limb movements during sleep, 40 thereby compromising sleep quality. Notably, these multifaceted alterations in sleep may be subacute or chronic, recovering only after 30 or more days of abstinence. 4,41

Some clinical features of AUD may also precipitate sleep disorders, such as a preoccupation with obtaining alcohol and AUD-related psychosocial stressors. Moreover, tolerance to alcohol can increase alcohol intake, which in turn may exacerbate sleep symptoms.

When patients have sleep-related concerns such as insomnia, early morning awakening, or fatigue, it is wise to screen them for heavy alcohol use and assess for AUD as needed. If they use alcohol before bedtime, and especially if they shift their sleep timing on weekends compared to weekdays, they may have chronic circadian misalignment. If they report daytime sleepiness, one possible cause is alcohol-induced changes in sleep physiology.

Psychotic disorders. Psychotic disorders are characterized by delusions, or strongly held false beliefs that are not typical of the person’s cultural background; hallucinations, or experiences involving the perception of something that is not present; and thought disorganization, or disturbances in cognition that affect a person’s ability to communicate.

The two primary psychotic disorders, schizophrenia and schizoaffective disorder, affect up to 3% of the general population. Among people in treatment for schizophrenia, the current prevalence of AUD is approximately 11% and the lifetime prevalence is approximately 21%. 42

The neurobiological links between psychotic disorders and AUD are poorly understood. However, as in the general population, a family history of AUD increases the risk for developing AUD among persons with psychotic disorders. 43 As with other psychiatric disorders, AUD can also exacerbate the course of psychotic disorders, thus warranting integrated treatment of both conditions. 44

Early on, the underlying etiology of a psychosis may be uncertain. During withdrawal from heavy drinking, people may develop delirium tremens, a complication of withdrawal marked by psychotic symptoms, such as hallucinations (see Core article on AUD ). Additionally, the occurrence of auditory or visual hallucinations when a patient is alert and oriented may constitute alcohol-related hallucinosis, also called alcoholic hallucinosis . 45 Note that for a primary psychotic disorder to be diagnosed, the person must have psychotic symptoms that persist for 1 month following the last alcohol (or other substance) use.

When psychosis is suspected, a general physical and neurological exam should be performed to exclude medical causes such as subdural hematoma, seizures, or hepatic encephalopathy—any of which may be a consequence of AUD. Again, it’s important to create a timeline of mental health symptoms and alcohol use and to collaborate as needed with mental health specialists for selection of pharmacotherapies and psychosocial interventions.

Treatment implications

People with AUD and co-occurring psychiatric disorders bring unique clinical challenges tied to the severity of each disorder, the recency and severity of alcohol use, and the patient’s pressing psychosocial stressors. An overall emphasis on the AUD component may come first, or an emphasis on the co-occurring psychiatric disorder may take precedence, or both conditions can be treated simultaneously. The treatment priorities depend on factors such as each patient’s needs and the clinical resources available.

Quitting drinking on its own often leads to clinical improvement of co-occurring mental health disorders, but treatment for psychiatric symptoms alone generally is not enough to reduce alcohol consumption or AUD symptoms. Among people with co-occurring AUD and psychiatric disorders, AUD remains undertreated, leading to poorer control of psychiatric symptoms and worse outcomes.

Integrated treatment of AUD and co-occurring psychiatric disorders tends to lead to better results than fragmented treatment approaches. 46,47 Consistent with this finding, combining medications and behavioral healthcare for people with AUD and co-occurring psychiatric disorders often produces superior outcomes than either treatment alone. In particular, for patients with more severe mental health comorbidities, it is important that the care team include specialists with the appropriate expertise to design personalized and multimodal treatment plans. (See Core article on treatment ).

Of note: Not all addiction treatment programs have staff with the credentials and expertise to provide evidence-based medications and behavioral healthcare for AUD with or without co-occurring mental health issues. The NIAAA Alcohol Treatment Navigator can help you and your patients to recognize the signs of quality care and find a range of treatment options that meet their needs. (See also the Core article on referral .)

Behavioral healthcare . Interventions such as motivational enhancement therapy, cognitive behavioral therapy, contingency management, and 12-step facilitation, are the standard of behavioral healthcare for individuals with AUD (see Core article on treatment ) and are a key part of a treatment plan for patients with co-occurring AUD and other mental health disorders. 48,49 An integrated treatment plan for AUD and the co-occurring disorder might include, for example, cognitive behavioral therapy for AUD as well as for depression, anxiety, PTSD, or sleep disorders. Skills to address each disorder may be introduced in alternating sessions, although increasingly, skills to manage both disorders are being offered in the same session. 50 These integrated treatment approaches appear promising. A meta-analysis found, for example, small but clinically significant improvements in depressive symptoms and alcohol use with the combination of cognitive behavioral therapy and motivational interviewing to treat individuals with depression and AUD, compared with usual care. 51

Pharmacological treatment. A few considerations in the pharmacological treatment of AUD and co-occurring psychiatric disorders are outlined below. For patients who continue to drink, keep in mind that some psychotropic medications may interact with alcohol to produce untoward effects. (See Core article on medication interactions .)

  • Effective pharmacotherapies for AUD may be initiated in primary care settings . These include three FDA-approved medications: acamprosate , naltrexone (available as an oral and injectable extended-release formulation ), and disulfiram . No specialized training or licensing is needed to prescribe these non-addicting medications, so they are no more complicated to prescribe than those for other common medical conditions. (See Core article on treatment .)
  • Prescribing “as-needed” (PRN) medications with misuse or overdose potential should be avoided , such as benzodiazepines to treat anxiety, mood instability, or sleep disorders, and Z-drugs for sleep disorders. Benzodiazepines do, however, remain the gold standard for treating alcohol withdrawal syndrome, given their proven efficacy in relieving the acute withdrawal symptoms and preventing complications like seizures and delirium tremens. 52 (See Core article on AUD ).
  • Combining an antidepressant with an AUD medication can provide an integrated and effective approach to treating the AUD as well as depression, anxiety disorders, or PTSD. 53–56 Clinicians do not need to wait until patients become sober to start antidepressants if there is evidence of need, although it’s important to check for potential alcohol-drug interactions (see Core article on medication interactions ). Patients with bipolar or psychotic disorders in particular may require a combination of medications best prescribed under the care of a psychiatrist with expertise in dual diagnosis.

As noted previously, for patients with more severe disorders or symptoms, consult a psychiatrist (one with an addiction specialty, if available) for medication support, as well as a therapist with an addiction specialty for behavioral healthcare. See the Resources , below, for an NIAAA tool to help you locate these specialists.

In closing, AUD and mental health conditions often co-occur. When patients present with mental health problems, it is often useful to ask about alcohol use, and when they report drinking heavily, it is also useful to assess for other mental health disorders. Whether the alcohol problem caused, resulted from, or is unrelated to the other mental health diagnosis, treatment is most likely to be successful when both are addressed. (See the Core articles on screening and assessment , treatment , and referrals .)

Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

  • Journal Issue: Alcohol Use Disorder and Co-Occurring Mental Health Conditions , NIAAA, 2019 (Includes articles on anxiety, depression, suicidal behavior, and integrated treatment.)

Alcohol and Other Substances Screening, Assessment, Treatment, and Referral Resources Related to this Article

  • NIAAA Alcohol Treatment Navigator: Portal for Healthcare Professionals
  • Screening and Assessment Tools Chart , National Institute on Drug Abuse
  • Substance Use Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series No. 42 , Substance Abuse and Mental Health Services Administration, 2020
  • Implementing Care for Alcohol & Other Drug Use in Medical Settings: An Extension of SBIRT  [PDF – 1.67 MB], National Council for Mental Wellbeing, 2017

Therapy Guides for Mental Health Specialists

  • COMBINE Monograph Series Volume 1: Combined Behavioral Intervention Manual [PDF – 2.36 MB], NIAAA, 2004
  • Project MATCH Volume 1: Twelve Step Facilitation Therapy Manual [PDF – 969 KB]
  • Project MATCH Volume 2: Motivational Enhancement Therapy Manual [PDF – 1.09 MB]
  • Project MATCH Volume 3: Cognitive-Behavioral Coping Skills Therapy Manual [PDF – 712 KB]

Suicide Risk Assessment and Prevention Hotlines

  • Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment: Quick Guide for Clinicians , Substance Abuse and Mental Health Services Administration, 2015
  • Substance Use and Suicide: A Nexus Requiring a Public Health Approach , Substance Abuse and Mental Health Services Administration, 2016
  • National Suicide Prevention Lifeline Phone: 800-273-8255  
  • Veterans Crisis Line Phone: 800-273-8255, Press 1

Behavioral Interventions and Support Groups for Patients with Co-Occurring Psychiatric Disorders

  • Family Therapy Can Help: For People in Recovery from Mental Illness or Addiction , Substance Abuse and Mental Health Services Administration, 2020
  • Seeking Safety: A Treatment Manual for PTSD and Substance Abuse , Substance Abuse and Mental Health Services Administration, 2020
  • Treating Sleep Problems of People in Recovery From Substance Use Disorders [PDF – 204 KB], Substance Abuse and Mental Health Services Administration, 2014

Alcohol Use Disorder Medication Guides

  • Medication for the Treatment of Alcohol Use Disorder: A Brief Guide [PDF – 508 KB], NIAAA and the Substance Abuse and Mental Health Services Administration, 2015
  • COMBINE Monograph Series Volume 2: Medication Management Treatment Manual , NIAAA, 2004
  • Medications for Adults with Alcohol Use Disorder( Provider-facing and Patient-facing ), Agency for Healthcare Research and Quality, 2016
  • Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder ( Summary and Full guidelines ), The American Psychiatric Association, 2018

More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care .

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  • Sakurai S, Cui R, Tanigawa T, Yamagishi K, Iso H. Alcohol Consumption Before Sleep Is Associated With Severity of Sleep-Disordered Breathing Among Professional Japanese Truck Drivers. Alcohol Clin Exp Res . 2007;31(12):2053-2058. doi:10.1111/j.1530-0277.2007.00538.x
  • Brower KJ, Hall JM. Effects of age and alcoholism on sleep: a controlled study. J Stud Alcohol . 2001;62(3):335-343. doi:10.15288/jsa.2001.62.335
  • Koob GF. Neurobiology of Opioid Addiction: Opponent Process, Hyperkatifeia, and Negative Reinforcement. Biol Psychiatry . 2020;87(1):44-53. doi:10.1016/j.biopsych.2019.05.023
  • Koskinen J, Löhönen J, Koponen H, Isohanni M, Miettunen J. Prevalence of alcohol use disorders in schizophrenia – a systematic review and meta-analysis. Acta Psychiatr Scand . 2009;120(2):85-96. doi:10.1111/j.1600-0447.2009.01385.x
  • Cantor-Graae E, Nordström LG, McNeil TF. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophr Res . 2001;48(1):69-82. doi:10.1016/S0920-9964(00)00114-6
  • Petrakis IL. How to Best Treat Patients With Schizophrenia and Co-Occurring Alcohol Use Disorder. J Clin Psychiatry . 2015;76(10):0-0. doi:10.4088/JCP.14com09625
  • Narasimha VL, Patley R, Shukla L, Benegal V, Kandasamy A. Phenomenology and Course of Alcoholic Hallucinosis. J Dual Diagn . 2019;15(3):172-176. doi:10.1080/15504263.2019.1619008
  • Drake RE, O’Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat . 2008;34(1):123-138. doi:10.1016/j.jsat.2007.01.011
  • Horsfall J, Cleary M, Hunt GE, Walter G. Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence. Harv Rev Psychiatry . 2009;17(1):24-34. doi:10.1080/10673220902724599
  • Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev . 2020;2020(3). doi:10.1002/14651858.CD012880.pub2
  • Carroll KM. Behavioral therapies for co-occurring substance use and mood disorders. Biol Psychiatry . 2004;56(10):778-784. doi:10.1016/j.biopsych.2004.07.010
  • Yule AM, Kelly JF. Integrating Treatment for Co-Occurring Mental Health Conditions. Alcohol Res Curr Rev . 2019;40(1):arcr.v40.1.07. doi:10.35946/arcr.v40.1.07
  • Riper H, Andersson G, Hunter SB, de Wit J, Berking M, Cuijpers P. Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis. Addiction . 2014;109(3):394-406. doi:10.1111/add.12441
  • Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res JCDR . 2015;9(9):VE01-VE07. doi:10.7860/JCDR/2015/13407.6538
  • Pettinati HM. Antidepressant treatment of co-occurring depression and alcohol dependence. Biol Psychiatry . 2004;56(10):785-792. doi:10.1016/j.biopsych.2004.07.016
  • Mason BJ, Kocsis JH, Ritvo EC, Cutler RB. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression. JAMA . 1996;275(10):761-767.
  • Preuss UW, Gouzoulis-Mayfrank E, Havemann-Reinecke U, et al. Psychiatric comorbidity in alcohol use disorders: results from the German S3 guidelines. Eur Arch Psychiatry Clin Neurosci . 2018;268(3):219-229. doi:10.1007/s00406-017-0801-2
  • Banerjee S, Spry C. Concurrent Treatment for Substance Use Disorder and Trauma-Related Comorbidities: A Review of Clinical Effectiveness and Guidelines . Canadian Agency for Drugs and Technologies in Health; 2017. Accessed November 15, 2021.

We invite healthcare professionals including  physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

Correctly Answer 3 of the 4 Post-Test Questions to Earn CME/CE Credit for This Article

Released on 5/6/2022 Expires on 5/10/2025

This activity provides 0.75 CME/CE credits for physicians, physician assistants, nurses, pharmacists , and psychologists .  Learn more about credit designations here .

Please note that you will need to log into or create an account on CME University in order to complete this post-test.

Learning Objectives

After completing this activity, the participant should be better able to:

  • Identify common mental health conditions that often co-occur with AUD.
  • Describe a framework for determining which care setting may be most appropriate for patients with co-occurring AUD and other mental health disorders.
  • Describe what strategy you would use for a differential diagnosis between alcohol-induced or primary mental health conditions.


Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

External Writers

João P. De Aquino, MD Assistant Professor of Psychiatry, Yale University School of Medicine West Haven, CT

Ismene L. Petrakis, MD Professor of Psychiatry, Yale University School of Medicine, New Haven, CT

External Reviewers

Anika A. Alvanzo, MD, MS, FACP, DFASAM Managing Partner, Uzima Consulting Group LLC, Middle River, MD; Eastern Region Medical Director, Pyramid Healthcare, Inc., Duncansville, PA

Douglas Berger MD, MLitt Staff Physician, VA Puget Sound, Associate Professor of Medicine, University of Washington, Seattle, WA

Katharine A. Bradley, MD, MPH Senior Investigator Kaiser Permanente, Washington Health Research Institute, Seattle, WA

Geetanjali Chander, MD, MPH Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

Anne C. Fernandez, PhD Assistant Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI

NIAAA Reviewers

George F. Koob, PhD Director, NIAAA

Patricia Powell, PhD Deputy Director, NIAAA

Nancy Diazgranados, MD, MS, DFAPA Deputy Clinical Director, NIAAA

Lorenzo Leggio, MD, PhD NIDA/NIAAA Senior Clinical Investigator and Section Chief; NIDA Branch Chief; NIDA Deputy Scientific Director; Senior Medical Advisor to the NIAAA Director

Aaron White, PhD Senior Scientific Advisor to the NIAAA Director, NIAAA

Editorial Team

Raye Z. Litten, PhD Editor and Content Advisor for the Core Resource on Alcohol, Director, Division of Treatment and Recovery, NIAAA

Laura E. Kwako, PhD Editor and Content Advisor for the Core Resource on Alcohol, Health Scientist Administrator, Division of Treatment and Recovery, NIAAA

Maureen B. Gardner Project Manager, Co-Lead Technical Editor, and Writer for the Core Resource on Alcohol, Division of Treatment and Recovery, NIAAA

Contractor Support

Elyssa Warner, PhD Co-Lead Technical Editor, Ripple Effect

Daria Turner, MPH Reference and Resource Analyst, Ripple Effect

Lia Bennett, MPH Educational Consultant, Ripple Effect

To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page . You may also click here to learn more about contributors .

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Psychiatry Online

  • February 01, 2024 | VOL. 181, NO. 2 CURRENT ISSUE pp.83-170
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Alcohol and the Etiology of Depression

  • Edward V. Nunes , M.D.

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In the clinical context, alcohol use is typically a problem to be reduced or eliminated. Patients presenting with depression, anxiety, or other non-substance-related mental disorders often have co-occurring alcohol or other substance use. Community-based surveys show that having an alcohol use disorder at least doubles the odds of depressive, anxiety, and other non-substance-use disorders ( 1 ). Cessation of alcohol use is associated with substantial reductions in depressive symptoms, as demonstrated, for example, in the classic studies of Brown, Schuckit, and colleagues among veterans hospitalized with alcohol use disorder ( 2 , 3 ). This suggests a toxic effect of alcohol on depression. DSM-IV and DSM-5 ( 4 , 5 ) introduced the diagnosis of substance-induced disorders, including depression, based on such evidence. Trials of antidepressant medications in patients with co-occurring depressive disorders and alcohol use disorder often have high placebo response rates—reduction in alcohol use and improvement in mood on placebo—particularly when manual-guided counseling focused on substance use is offered to all patients in the trial ( 6 – 8 ). This can be interpreted as suggesting that treatment-related reduction in alcohol use leads to improvement in depression, again consistent with a toxic effect of alcohol on depression. Populations under stress or trauma are at increased risk for alcohol use and use disorders ( 9 , 10 ), as are those with co-occurring psychiatric disorders ( 1 ). Self-medication may be invoked as a mechanism. Alcohol lies on a pharmacological continuum with other anxiolytic tranquilizers but is a poor anxiolytic due to its short duration of action and rapid elimination accompanied by rebound symptoms, setting up a cycle where alcohol use may be driven by alcohol-induced negative affect ( 11 ), not to mention its side effects, and dangers. Alcohol use is associated with enormous morbidity, mortality, and social costs.

All that said, in the general population, drinking behavior exists on a continuum from abstinence to low-risk drinking to what is considered risky drinking exceeding public health guidelines—defined as more than four standard drinks per day and 14 drinks total per week for men and more than three drinks per day and seven drinks in total per week for women. Thresholds are lower for women because of smaller body size and greater absorption of alcohol through the gut than men. These guidelines for risky drinking reflect the public health imperative to prevent heavy drinking and the substantial morbidity and mortality associated with it. In this context, the article by Visontay and colleagues in this issue of the Journal ( 12 ) presents intriguing evidence that low to moderate drinking, below the guideline-defined level of risky drinking, across early and middle adulthood may be protective against the development of depression in midlife (age 50) when compared with abstinence from alcohol.

Observational studies applying traditional regression methods have detected J- or U-shaped relationships between levels of drinking and risk of depression, with the lowest risk among light or moderate drinkers and higher risk among abstainers as well as above-guideline or risky drinkers ( 13 ). Visontay et al. sought to challenge these findings by examining data from the National Longitudinal Survey of Youth 1979 (NLSY1979), which followed a U.S.-based cohort of teenagers and young adults first interviewed at ages 14–22 and followed until age 50, applying the new statistical technique of marginal structural modeling (MSM). The authors reason that previous findings may be due to the confounding and bias that are pitfalls of traditional statistical methods and would be better addressed by MSM. They hypothesize that applying MSM with a robust set of covariates will reveal a simple linear relationship between alcohol consumption and subsequent risk of depression, with the risk lowest for abstainers and increasing from there in proportion to level of alcohol consumption. Instead, their work replicates a U-shaped pattern. The subgroup of the sample that had consistently abstained from alcohol over young and middle adulthood had a modestly increased mean score on the Center for Epidemiological Studies Depression Scale–Short Form (CES-D-SF) and a modestly increased probability of a clinically significant CES-D-SF score at age 50, compared with the subgroup that reported light or moderate alcohol intake, below guideline-based thresholds for risky drinking. The subgroup reporting risky drinking also had modestly increased depression.

MSM is one of several newer statistical techniques, including propensity score matching, that seek to establish a stronger case for a causal relationship between an exposure (in this case alcohol use over time) and an outcome (depression in midlife) from observational data. Such approaches provide an alternative where a randomized trial would not be feasible. Designed for longitudinal data with both fixed and time-varying covariates, MSM assigns weights to each observed case at each time point, based on the covariates, creating in effect a “pseudo population” control condition ( 13 ). Randomized trials are arduous and expensive, are more suited to short-term interventions and outcomes over weeks or months rather than years, and may not select representative samples ( 14 ). The study by Visontay et al. is valuable as a demonstration of applying MSM to a relevant clinical problem.

A statistical technique such as MSM is only as good as the data available to it, and Visontay et al. are circumspect in acknowledging the limitations, such as unmeasured confounders. Analysis of observational data produces associations from which causality is a conjecture but cannot be proven. For example, the analysis sought to correct for the “sick quitter” phenomenon by controlling for heavy drinking during adolescence, prior to measurements of drinking and depression in subsequent waves. More than half of the group that abstained during early and middle adulthood had an early history of above-guideline or risky drinking, and there could be other mental health vulnerabilities in the abstainer group that were not measured.

But how important is causality in this context, as opposed to prediction, or delineation of mechanism? As clinicians, we are not going to recommend that abstainers begin to drink, or encourage low-level drinking, given, among other reasons, the risk that some may go on to problem drinking and its manifest harms, as well as potential medical risks of long-term alcohol exposure. Rather, the association of low-level drinking with reduced risk of depression begs the question of mechanism, the exploration of which could lead to new strategies for treatment or prevention. If low-level drinking is indeed associated with reduced risk of depression, what are the mediators or moderators? Visontay et al. offer two potential explanations for a protective effect of low-level alcohol consumption. One is biological, related to putative salutary impacts on GABA or dopamine systems or inflammatory mechanisms. Future research on biological effects of sustained low-level drinking might offer clues toward medication development or toward development of biomarkers of risk for depression or targets for intervention.

The other explanation, arguably more parsimonious, is that low-level drinking reflects a healthy social life, which protects against depression. Alcohol consumption is normative in many societies worldwide, ingrained in our cultures. One potential avenue for future research would be to sample individuals from cultures where drinking is proscribed and abstinence is normative. Future research should explore what is different about persistent abstainers as opposed to low-level “social” drinkers. The possibility remains that some of the individuals in our culture who do not drink at all carry risks, perhaps abstaining due to family history of drinking (family history was not assessed in the NLSY1979) or mental health problems, or are perhaps more socially isolated. Better understanding of such pathways could lead to screening or interventions to reduce risk of depression.

Clinically, the data may be viewed as providing some reassurance that low-level, below-guideline drinking is safe for most individuals, at least regarding risk of depression, as long as it stays low. For clinicians, the priority remains to screen patients for escalation from low-level to problem-level drinking. Screening for above-guideline drinking has demonstrated efficacy in primary care settings and is a recommended practice ( 15 , 16 ). Screening for alcohol and other substance use and misuse is particularly important in psychiatric practice given the potential for disordered substance use to worsen the course of psychiatric disorders or produce substance-induced mental disorders.

Dr. Nunes has served as an investigator on NIH-funded studies to which in-kind medication was provided by Alkermes, Braeburn-Camurus, and Indivior and in-kind digital therapeutics by CHESS Health and Pear Therapeutics, and he has served as a consultant without compensation for Alkermes, Camurus, Indivior, and Pear Therapeutics.

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12. Visontay R, Mewton L, Slade T, et al. : Moderate alcohol consumption and depression: a marginal structural model approach promoting causal inference . Am J Psychiatry 2023 ; 180:209–217 Abstract ,  Google Scholar

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  • Ned H. Kalin , M.D.

mental health alcoholism case study

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Article Contents

Introduction, acknowledgements.

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Mental health and alcohol use: a cross-sectional study of the Finnish general population

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Pia Mäkelä, Kirsimarja Raitasalo, Kristian Wahlbeck, Mental health and alcohol use: a cross-sectional study of the Finnish general population, European Journal of Public Health , Volume 25, Issue 2, April 2015, Pages 225–231,

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Background: The connections between alcohol use, mental health problems and mental well-being have been under-researched. We examined the links between different aspects of alcohol use and positive and negative aspects of mental health, and the effect of protective social factors on these links. Methods: A cross-sectional general population survey of Finns aged 15–69 years was carried out in 2008 ( n = 2725, response rate 74%). The included aspects of alcohol use were the frequency and volume of drinking, binge drinking and hazardous drinking using Alcohol Use Disorders Identification Test (AUDIT). The included aspects of mental health were subjective well-being (life satisfaction), self-efficacy (sense of mastery) and psychological distress using the General Health Questionnaire. The protective social factors examined were social support (loneliness, having a confidant) and socioeconomic status. Results: Binge drinking and, particularly, hazardous drinking were associated with different aspects of mental health. The proportion of respondents with poor mental well-being increased when binge drinking was more frequent than monthly, and when respondents scored ≥6 on the AUDIT scale. Abstainers reported poor sense of mastery and former drinkers additionally reported poor satisfaction with life. Frequency and volume of drinking did not have a consistent connection with mental health. These associations between alcohol use and mental health did not depend on the protective social factors. Conclusions: Frequent binge drinking and alcohol problems are associated with poor mental health, especially with a lack of life satisfaction and psychological distress. This result applies equally to lower and higher social status groups.

Alcohol use is an established determinant of disability and death globally. 1–3 In the extensive literature on various health effects of alcohol, the weight of the evidence is on illness and death. Correspondingly, in the area of mental health, the effects of alcohol on mental disorders such as depression have been more extensively studied than effects on positive mental health and subjective well-being. Positive mental health has been described as the ‘foundation for well-being and effective functioning for both the individual and the community’ and defined as a state ‘which allows individuals to realise their abilities, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their community’. 4

Mental well-being and mental health problems are determined by a range of interacting determinants, e.g. childhood environment, socioeconomic factors and lifestyle, including alcohol and drug use. Indeed, alcohol use is closely linked to poor mental health. People with psychological distress may seek momentary relief in alcohol consumption. On the other hand, excess alcohol consumption is known to lead to psychological distress and mental disorders and increase the risk of suicide. 1 , 5 , 6 In empirical studies on the link between alcohol use and mental health, mental disorders, life satisfaction and health-related quality of life, moderate drinking has often been associated with better mental health and heavy drinking with poorer mental health. 7–11

Protective factors may modify an individual’s response to stressors. Correspondingly, the connection between heavy alcohol use and mental health may vary by protective factors. Social support has been shown to be connected to good mental health and it has also been postulated to have stress-buffering effects 12 . Another potential buffering factor could be socioeconomic status. It has been found to be systematically associated with health 13–14 and severe mental disorders, 15–16 but not as systematically with common mental disorders. 17 For severe alcohol-related outcomes, a given level of alcohol consumption has been reported to be associated with a higher risk among manual than among non-manual workers. 18 Whether such effect modification exists for the effect of alcohol use on mental health is not known.

Aspects of mental health

Mental well-being typically consists of two distinct perspectives: the hedonic perspective, which focuses on subjective well-being (affect and life satisfaction), and the eudaimonic perspective, which focuses on psychological functioning, resources and stress resilience. 19 Sense of mastery, which is a core feature of the latter perspective and a vital psychological resource in stressful situations, 20 refers to the perception of being able to control the forces affecting one’s life. It is a measure of self-efficacy, which is an important component of eudaimonic mental well-being. A lack of sense of mastery is linked to depression 21 and general health problems. 22 Mastery is conceptually closely linked to self-control in alcohol use, but little is known about the links between sense of mastery and drinking patterns.

Mental health problems constitute one aspect of the mental health continuum. Typically, mental health problems cause psychological distress, which tends to predict mental disorders. To provide a comprehensive picture of the links between alcohol use and mental health, an examination of the link between alcohol use and psychological distress is also warranted.

Aims of the study

We set out to examine the links between alcohol use and mental health and ask which aspects of alcohol use are most closely linked with different aspects of mental health, and do the associations suggest that the risks rise in a linear fashion, or only beyond some threshold? We also examine the possible modifying effect of protective social factors on these links. The aspects of alcohol use to be studied include the frequency and volume of drinking, binge drinking and hazardous drinking. The aspects of mental health studied are (i) hedonic well-being/life satisfaction, (ii) eudaimonic well-being/sense of mastery and (iii) psychological distress. The potential protective social factors include social support and good socioeconomic status.

The data came from the Finnish Drinking Habits Survey, a general population survey of Finns aged 15–69 years. The sample was drawn from population census using simple random sampling excluding Åland Islands (0.5% of the population), the homeless and the institutionalized (1.5%). The survey was carried out in 2008 by Statistics Finland as face-to-face interviews. Response rate was 74%. Weights calculated by post-stratification for sex, age and geographical region were used to restore the population representation. The study protocol was approved by the ethical committees of the National Research and Development Center for Welfare and Health STAKES (later THL) and Statistics Finland.


Outcome measures.

‘Psychological distress’ was measured with the 12-item General Health Questionnaire (GHQ-12). The GHQ 23 , 24 is a generic self-assessment measure of poor mental health, developed for screening of mental health problems in a community setting. The GHQ-12 25 assesses psychological distress, such as anxiety and depression. A GHQ-12 score was obtained by summing item scores. Psychological distress was defined as scores of ≥4 26 (11% of respondents).

‘Self-efficacy’, a eudaimonic dimension of mental well-being, was measured with Pearlin's seven-item Sense of Mastery scale, 21 which has been widely used in population studies. 27 The total score was obtained by summing item scores. Typically, a good sense of mastery has been defined as a score of ≥23. 28 To obtain a corresponding prevalence, we defined a good sense of mastery as a score of >20 (19% of respondents).

The hedonic component of mental well-being was measured with a question on ‘life satisfaction’. This was asked with a question ‘How would you assess your satisfaction with the life you lead? (i) very satisfied, … (v) very unsatisfied’. Life satisfaction was defined as response categories 3–5 (9% of respondents).

Alcohol use measures

The overall ‘frequency of drinking’ was asked providing 11 response options from never to daily. The ‘volume of drinking’ over the past 12 months was measured by graduated frequency questions, which measured the frequency of drinking 1–2, 3–4, 5–7, 8–12, 13–17 and >18 units of alcohol (one unit contains 12 grams of 100% alcohol). When frequencies were multiplied with the mid-points of the quantity levels (e.g. 5–7 units: 6) and the result was summed across the levels, an estimate of the annual volume of drinking was derived and scaled to volume per day. Volume was categorized to five mutually exclusive categories: 0 g/day (abstainers), <10, 10–20, 20–40 and >40 grams/day.

‘Heavy episodic drinking or binge drinking’ was defined as drinking ≥8 units at a time for men and ≥5 for women (these are the closest available cutoff points to the Finnish binge drinking definition of ≥7 for men and ≥5 for women). The frequency of heavy episodic drinking was derived by first transforming the categorized frequencies of drinking to times per year for each level exceeding 5 or 8 units of alcohol, i.e. the frequencies of drinking 5–7 (for women), 8–12, 13–17 and >18 units, and then summing across the levels. The summed frequency was categorized to 0, 1–4, 5–12 and >12 times per year.

‘Hazardous drinking’ was measured using the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization. 29 The AUDIT score derived from the 10 questions (range 0–40) was categorized to <8 (low risk), 8–10 (moderate risk) and >11 (high risk); the recommended cutoff of 8 has been shown to have good sensitivity and specificity for various indices of problematic drinking. 29

Protective social factors

Socioeconomic status was based on occupation given by the respondent or, when missing ( n = 16), on register-based occupation in 2006. It was categorized to non-manual workers, manual workers and others.

Social support was measured by two questions. Its structural aspect was measured using the question: ‘Do you have one or more close people with whom you can discuss confidentially all or nearly all of your problems? (1) yes, always or almost always when I need it, (2) sometimes in some matters, (3) not usually or not in that many matters or (4) no, I cannot almost ever discuss my problems’. Categories 2–4 were combined as poor social support (13% of respondents). The cognitive aspect of social support was measured by feelings of loneliness, using the question: ‘Do you feel lonely? (1) constantly, (2) quite often, (3) sometimes, (4) seldom or (5) never?’ Loneliness was defined as responses 1–2 (4% of respondents).

Statistical methods

The associations between independent and dependent variables were described using local polynomial regression fitting, i.e. fitting and drawing smoothed regression curves for continuous independent variables. Also, logistic regression was used to model these associations, and the interactions, with results presented as odds ratios (ORs). Because in 11 of the 12 cases interactions between sex and alcohol use variables on the three aspects of mental health were not significant, we present analyses for men and women combined. Generally, criterion P = 0.05 was used for statistical significance. To reduce problems with multicollinearity, P = 0.01 was used when simultaneously introducing different alcohol use variables in the same model.

The characteristics of the study population are shown in table 1 . Women more often reported psychological distress ( P < 0.001) and poor sense of mastery ( P < 0.001), but not poor life satisfaction ( P = 0.72) compared with men. Young people, compared with older people, more often reported psychological distress and poor life satisfaction, but less often poor sense of mastery ( P < 0.01 for each).

Distribution of respondents’ characteristics and the proportion of respondents (%) with psychological distress (GHQ), poor sense of mastery (SOM) and poor life satisfaction by these characteristics

a: The percentages shown may not add up to 100 because of rounding.

b: Frequency of drinking five or more (women) or eight or more (men) drinks.

Of the four aspects of alcohol use, hazardous drinking (AUDIT score) was most strongly and systematically associated with different aspects of mental health ( table 2 , age and sex adjusted OR). Additionally, frequent binge drinkers and high-volume drinkers reported psychological distress and poor life satisfaction more often than others. Poor sense of mastery, on the other hand, was reported most often by abstainers. There were too few abstainers for proper analyses by abstainers’ previous drinking status, but suggestive results can be mentioned. Life satisfaction was clearly worse among former drinkers than among life-long abstainers (% with poor satisfaction: 15 vs. 3%; P < 0.01). Differences for psychological distress were similar but not significant, while poor sense of mastery was reported equally often by life-long abstainers and former drinkers.

ORs for psychological distress (GHQ), poor sense of mastery (SOM) and poor life satisfaction by alcohol use factors, demographics and protective social factors

a: Model 1: of the alcohol use variables, age and sex, those that remained significant after removing non-significant estimates one at a time.

b: Model 2: of the alcohol use variables, age, sex and social resource factors, those that remained significant after removing non-significant estimates one at a time.

*95% confidence interval does not include 1.0.

Figure 1 depicts unadjusted associations between aspects of mental health and aspects of alcohol use. That one curve is higher than another merely reflects the chosen cutoff scores. More relevant is the shape of the associations and possible threshold values beyond which alcohol use is associated with mental health.


Locally fitted regression curves for the three outcome variables psychological distress (GHQ), poor sense of mastery (SOM) and life satisfaction by volume of consumption (top figure), annual binge drinking frequency (middle figure) and AUDIT score (bottom figure), with 95% confidence intervals

For volume of drinking, the associations were relatively weak, and it was difficult to separate the real effect from random variation. For binge drinking, the associations were clearer: the proportion of respondents with psychological distress rose quite linearly with the annual number of binge drinking occasions and the proportion of respondents with poor life satisfaction and poor sense of mastery rose when binge drinking was more frequent than monthly. Also, for hazardous drinking, the association with mental health was clear: the proportion of respondents reporting psychological distress and poor life satisfaction rose in a linear fashion when the AUDIT score was more than about 6.

To study which of the alcohol use variables could be considered to have an independent effect on mental health, they were introduced in the same logistic regression model simultaneously, together with sex and age, and removed one at a time until the remaining variables were all statistically significant ( table 2 , Model 1). For psychological distress and life satisfaction, the AUDIT score was the only alcohol use variable that remained in the model. For sense of mastery, overall frequency of drinking remained significant together with the AUDIT score: with the AUDIT score held constant, a higher frequency of drinking was associated with a smaller probability of poor sense of mastery.

Of the social support factors, loneliness in particular, and also having a confidant were associated with all three measures of mental health. When the support variables were introduced in the models ( table 2 , Model 2), this had a quantitative rather than a qualitative impact on the results: the ORs for high AUDIT scores were somewhat reduced but remained significant, and the low ORs for drinking frequency were further lowered. There were no statistically significant interaction effects between the protective social factors and the alcohol use variables on mental health.

Our results showed that heavy-volume drinking, binge drinking and hazardous drinking (AUDIT score) were associated with poorer mental health. Among these, hazardous drinking had the strongest association. These associations were not linear, but rather the proportion of respondents with poor mental health started to increase after a threshold level, i.e. in the light to moderate range, there were practically no associations, and it was the more extreme forms of binge and hazardous drinking that were associated with increased prevalence of poor mental health. With hazardous drinking adjusted, frequency of drinking was actually associated with a better sense of mastery. However, this association was explained by protective social factors, i.e. that those who drink frequently yet not hazardously have more protection of these social factors and hence a better sense of mastery.

Overall, our results are in accordance with previous findings in the literature that moderate drinking is often associated with mental well-being, whereas heavy drinking and/or binge drinking is associated with poor mental health, depressive symptoms, poor life satisfaction and poor well-being in general. 7–11 What this study adds is a better understanding of which aspects of alcohol use are most closely associated with mental health, considering not only one but three different aspects of mental health.

Another contribution of the current study was to examine the role of protective social factors and whether these modified the associations between alcohol use and mental health. Social support and high socioeconomic status were shown to have protective effects, and they explained a part of the associations between alcohol use and mental health, but no signs of effect modification were found. In other words, these factors did not change the relationship between drinking and mental health, even if such effect modification has been reported for alcohol use and severe alcohol-induced health outcomes in studies using registers for outcome definition. 18 Methodological differences may be a partial explanation for this, as register studies do not suffer from selective drop-out and have a strong statistical power to detect differences. In addition, socioeconomic status has been shown to be very differently connected to lighter and more extreme versions of binge drinking. 30 Correspondingly, it is possible that even if effect modification by socioeconomic status was not found for the mental health measures we used, it could potentially occur for more severe mental health problems.

The limitations of the current study include that the results were derived using cross-sectional self-reported data. Self-reports of alcohol use are known to under-report drinking, 31 but this does not automatically bias estimates of associations. Analysis of cross-sectional data does not allow assessment of the temporal order or the direction of effect in the observed associations. It is plausible that beyond some level, alcohol use has a causal detrimental impact on mental health. But it is also possible that people with mental health challenges resort to non-healthy ways to use alcohol. Additionally, we were unable to control for many factors affecting mental health, some of which may be connected with alcohol use. Therefore, uncontrolled confounding could account for some of the associations found.

It is not surprising that hazardous drinking was the aspect of alcohol consumption that was most closely associated with psychological distress because they are conceptually connected: substance abuse disorder is in itself a mental disorder, and the AUDIT has been developed to function as a screener to capture hazardous and harmful drinking. It is useful for those who use the AUDIT for primary and secondary prevention to know that high scores are also indicative of poor mental health.

Our results indicate that hazardous drinking is strongly connected to psychological distress and loss of hedonic mental well-being (life satisfaction). However, the link to self-efficacy (sense of mastery), which is a component of eudaimonic mental well-being, was somewhat weaker. Self-efficacy reflects psychological resources, which may be more strongly influenced by early life-related mental health determinants than linked to current level of alcohol use. Conversely, our finding may indicate that hazardous drinking is more often triggered by psychological distress and a search for hedonic well-being than by a lack of psychological coping mechanisms. In other words, seeking positive affective states may play a more decisive role as triggers for hazardous drinking than lack of alternative coping mechanisms in stressful situations.

According to our results, abstainers—both lifelong abstainers and former drinkers—reported poor self-efficacy, and the results suggested that former drinkers suffered from loss of hedonic mental well-being. These findings are in accordance with the commonly found result that abstainers and in particular former drinkers have a higher level of mortality and morbidity compared with light drinkers. 32 The relatively small number of abstainers in the current data did now allow us to dig deeper into this question, but a potential explanation is that the former drinkers may have become abstainers owing to problems with alcohol, which would be also reflected in their negative assessments with life satisfaction.

A common self-reported motivation for binge drinking is drinking for enjoyment. 33 Yet, frequent binge drinkers report clearly worse mental health than less frequent binge drinkers. This lends credence to the view that binge drinking may be a short-sighted way of enjoyment.

In the mental health literature, there has been a shift of balance in the past decades from focusing on severe mental disorders, which are rare, to focusing more on the common challenges with mental health, such as psychological distress and mental well-being. 4 This is also relevant when thinking of the impact of mental health on the productivity of individuals and societies. Addressing more benign forms of poor mental health may prevent more severe problems at a stage when interventions may still be efficient. Excess alcohol use is known to have adverse consequences on sleep and in the long-term on stress and anxiety, 34 , 35 so even if in this study we were unable to address the causality of effects, it seems likely that reducing excess alcohol use is also a good bet for efforts to improve population mental health.

In conclusion, to protect and promote mental health, binge drinking would be best avoided or at least restricted to a maximum of few occasions annually. Hazardous drinking as measured by the AUDIT predicts poor mental health well. These results apply to lower and higher status groups of the population alike: the well-off are not able to escape the adverse effects of harmful alcohol use on mental health.

This work was supported by internal funds, and partial support for data collection was granted by the Finnish Foundation for Alcohol Research, for which funds had been obtained from the Finnish state-owned off-premise retail alcohol monopoly Alko.

Conflicts of interest : None declared.

Binge drinking and, particularly, the AUDIT score were associated with poorer mental health, while frequency and volume of drinking did not have as consistent a connection.

Abstainers—both lifelong abstainers and former drinkers—reported poor sense of mastery, and former drinkers had a particularly poor satisfaction with life.

Protective social factors could not prevent the negative consequences of binge or problem drinking on mental well-being.

Reducing excess alcohol use is a good approach to improving population mental health.

An earlier version of the paper was presented in the 38th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society, Stavanger, Norway, 4–8 June 2012.

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  • alcohol drinking
  • mental health
  • personal satisfaction
  • socioeconomic factors
  • binge drinking
  • mastery learning

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Assessment of anxiety and depression among substance use disorder patients: a case-control study

  • Ikram I. Mohamed 1 ,
  • Hossam Eddin Khalifa Ahmad 2 ,
  • Shehab H. Hassaan 2 &
  • Shymaa M. Hassan 1  

Middle East Current Psychiatry volume  27 , Article number:  22 ( 2020 ) Cite this article

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Several evidences from epidemiologic and treatment studies indicate that anxiety disorders, depression, and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders, depression, and substance use disorders .

The mean age was 28.1 ± 6.5 years. The majority belonged to the moderate socioeconomic status (52%). Substance use disorder (SUD) patients expressed higher levels of anxiety and depression in comparison to the control group. Most of the study group (97%) expressed different levels of anxiety. Eighty percent of them expressed high and moderate anxiety levels, and 20% of caregivers were having mild anxiety levels. Ninety-three percent of the substance users expressed different levels of depression, either mild 12%, moderate 9%, or severe 72%. The Drug Use Disorder Identification Test scores were positively correlated with anxiety ( r = 0.256 and p = 0.010) and depression ( r = 0.330 and p = 0.001). Moreover, it was found that anxiety and depression are positively correlated with each other’s ( r = 0.630 and p = 0.001).

Substance use disorders are associated with high levels of anxiety and depression. More specifically, it is associated with severe depression and anxiety. There is an obvious association between the presence of anxiety and depression on the one hand and the severity of drug-related problems on the other hand. Depression and anxiety are commonly present together in patients with SUDs.

The lifetime prevalence of any substance use in Egypt varies between 7.25% and 14.5% [ 1 ]. Substance use disorders, mood, and anxiety disorders are widespread among the general population [ 2 , 3 , 4 ] and are associated with substantial social, economic, and health loss [ 5 , 6 , 7 , 8 ]. Reports published in the Journal of the American Medical Association indicate that roughly 50% of individuals with severe mental disorders are affected by substance abuse, 37% of alcohol abusers, and 53% of drug abusers who also have at least one serious mental illness, and of all people diagnosed as mentally ill, 29% abuse either alcohol or drugs [ 9 ].

Anxiety and depression are among the most common problems reported by persons seeking treatment for drug addiction. Primary psychiatric symptoms persist behind detoxification and remission of addictive behavior. From an addiction perspective, there may be significant risks associated with concurrent depression and anxiety symptoms, regardless of etiology [ 10 ].

Anxiety can be caused by drug addiction. Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism [ 11 ]. Depression and anxiety symptoms are among the most common problems reported by persons seeking treatment for drug addiction. Drug addiction, anxiety, and depression account for three-quarters of the disability attributed to mental disorders [ 12 ]. Depression and drug addiction are critical, not only because of their high prevalence but also because of their negative consequences. Individuals with co-morbid mental health and drug addiction often experience severe illness, disability, and poor treatment outcomes [ 13 ].

This study was done with the aim to assess levels of anxiety and depression among drug addict people.

Study design

This is a descriptive case-control study conducted at Assiut University Neuropsychiatry Hospital. This is an educational health facility, which provides both inpatient and outpatient mental health services to the entire population of Upper Egypt. The study was conducted from December 2015 until the end of May 2016.


The study included a selective sample of 100 patients with substance use disorder. Patients had to meet the following criteria to be included in the study: (i) to be 18 years or older, (ii) to be currently diagnosed with substance use disorder (SUD) according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and (iii) to accept the participation in the study. Exclusion criteria included the following: (i) the patient had a known psychiatric diagnosis before being diagnosed with SUD, (ii) the patient was mentally retarded or has an organic brain disorder, and (iii) the patient has a chronic medical illness. The control group included 50 subjects without a history of the current or past history of SUD and free from chronic illnesses as well. They were recruited from the patients’ relatives and the hospital staff.

Data were collected using face-to-face interviews conducted by a trained study team including a psychiatrist and psychologist. The researchers introduced themselves to participants before the interview and clearly expressed the purpose of the study, and consent was obtained from every participant.

Socioeconomic assessment scale for the family

We gathered information about socio-demographic information using this scale, which is prepared by Professor Abdel Tawab Abdullah, Faculty of Education, Assiut University, in 1998 and modified in 2010. It includes four main variables: [ 1 ] the educational level of the father and mother, [ 2 ] the occupation of the father and mother, [ 3 ] total family income, and [ 4 ] lifestyle of the family [ 14 ].

Drug Use Disorder Identification Test (DUDIT) Arabic version

This scale has been developed in the original English language version by Berman in 2007 [ 15 ]. It was translated into Arabic and validated by Sfendla and colleagues in 2017 [ 16 ]. The purpose of the Drug Use Disorder Identification Test was to identify the use of patterns and various drug-related problems. It consists of 11 items, and the total score of this test was 44 points. A patient with 6 points or more probably has drug-related problems (for example, risky or harmful drug habits that might be diagnosed as substance abuse/harmful use or dependence), while a patient with 25 points or more is probably heavily dependent on drugs. The scale was reported to have good reliability using Cronbach’s alpha (0.780) and possesses a high validity using Pearson correlation, ( r = 88%) for the total scale [ 15 ].

Hamilton Anxiety Rating Scale (HAM-A)

This scale has been developed by Max Hamilton in 1959 [ 17 ] and was translated into the Arabic language by Fatim in 1994 [ 18 ]. The purpose of this scale was to measure the severity of anxiety. The Hamilton Anxiety Rating Scale consists of 14 items; each item was scored based on a five-point Likert scale ranging from (0) = Not Present to [ 4 ] = Very Severe. The total score of this scale ranged from 0 to 56 and was divided into four levels: 17 or less indicated mild anxiety, from 18 to 24 indicated mild to moderate anxiety, 25 to 29 indicated a moderate to severe anxiety, and more than 30 indicated severe anxiety.

Hamilton Depression Rating Scale (HAM-D)

The Hamilton Rating Scale for Depression (HRSD), sometimes called the Hamilton Depression Rating Scale (HDRS) and abbreviated HAM-D, is based on a multiple item questionnaire and addresses depression indicators with special attention to the evaluation of recovery from depression [ 19 ]. Initially developed by Max Hamilton in1960 [ 20 ], it has gone through numerous revisions since then. The Arabic version has high reliability and validity [ 21 , 22 ]. The Hamilton Depression Rating Scale consists of 21 items to rate the severity of depression. Mild depression is ranging from 13 to 16, moderate depression is ranging from 17 to 19, and severe depression is ranging from 20 to above.

Statistical analysis

Data were analyzed using the Statistical Package for Social Studies (SPSS) software version 20. A descriptive analysis using means with standard deviation, frequency counts, and percentages was carried out. Pearson correlation coefficients ( r ) were employed to address the relationship between caregiver burden and study variables [ 23 ].

Sociodemographic characteristics

The study included 100 SUD patients and 50 healthy control; 73% live in rural areas and 27% in urban ones. Their mean age was 28.1 years (SD = 6.5). Most of the patients were married (62%) while 38% were singles. Most of the patients were graduates of either secondary school or its equivalent (67%) or held a university degree (23%). Fourteen percent of them have no job apart from the domestic affairs, and the rest are either employed (20%), manual workers (52%), or students (10%) (Table 1 ). The majority of the participants in this study belonged to the moderate socioeconomic status group (52%), while 22% belong to the low socioeconomic class and 26% were in the high socioeconomic class. A comparison between sociodemographic data shows no statistically significant difference between the SUD patients and healthy controls ( p = 0.643) (Table 1 ).

Clinical characteristics of the study sample

The results showed that the majority of drug addict people (83%) are polydrug addict; they used several types of substances (e.g., tramadol-cannabis-opiates-alprazolam-heroin-nalbuphine), while 17% of them used only tramadol. The majority of the drug users prefer the oral route (68%), while 32% of them used drugs through several routes ( oral-inhalation-injection).

As regards the duration of substance use, 93% of the patients used a drug for more than 1 year. Sixty-seven percent of them reported that they started drug use because of many reasons such as the effect of bad friends, as an experiment, to give them strength and activity, to forget problems and feel relaxed, to improve sexual ability, to spend excessive money, and to relieve chronic pain. However, 12% of them reported that they used drugs because of the effect of bad friends only, 13% to give the patient strength and activity only, and 8% of them reported that they used drugs to forget problems and feel relaxed (Table 2 ).

The drug-related problems

The DUDIT results of the study group revealed that 95% of drug addict people are probably heavily dependent on a drug, with the mean score is 31.45 ± 2.47 . While 5% of them have probable drug-related problems, with the mean score is 22.20 ± 2.49 (Table 3 ).

Levels of anxiety and depression

According to HAM-D scale results, 72% of the study sample was found to have severe depression in comparison to 6% of the control group ( p < 0.001). It is worth noting that only 7% of the SUD group did not have depressive symptoms in comparison to 64% of the control group ( p ≤ 0.001). The results were similar as regards to anxiety. The prevalence of severe anxiety was 67% in the study group in comparison to 14% in the control group ( p < 0.001). Five percent only of the SUD group have mild anxiety symptoms in comparison to 52% of the control group ( p ≤ 0.001) (Table 4 , Figs. 1 and 2 ).

figure 1

Comparison between the SUD group ( n = 100) and control group ( n = 50) regarding anxiety levels according to the HAM-A rating scale

figure 2

Comparison between the SUD group ( n = 100) and control group ( n = 50) regarding depression levels according to the HAM-D rating scale

Correlation between socio-economic status, DUDIT, anxiety, and depression

The socio-economic status is positively but non-significantly correlated with Drug Use Disorder Identification Test scores ( r = 0.070 and p = 0.487), anxiety ( r = 0.008 and p = 0.935), and depression ( r = 0.048 and p = 0.638). Drug Use Disorder Identification Test score is positively and significantly correlated with anxiety ( r = 0.256 and p = 0.010) and depression ( r = 0.330 and p = 0.001). Moreover, it was found that anxiety and depression are positively and significantly correlated with each other ( r = 0.630 and p = 0.001) (Table 5 ).

The purpose of this study was to assess the levels of anxiety and depression among SUD patients. Another objective of this study was to determine the correlation between the level of anxiety and depression on the one hand and the socio-demographic variables and drug use-related problems on the other side.

The current study revealed that the majority of drug addict people were polydrug addict. This might be due to the fact that one drug is used as a base or primary drug, with additional drugs to leaven or compensate for the side effects of the primary drug and make the experience more enjoyable with drug synergy effects or to supplement for the primary drug when supply is low [ 24 ]. These results are consistent with the findings of Panebiance et al. who revealed that the majority of drug addict people were polydrug addicts [ 25 ]. On the opposite side, Jabeen et al. found that more than half of drug addict people were single drug users [ 26 ].

The present study showed that about most of the drug users’ sample had severe levels of depression in comparison to the non-users’ and about more than two thirds of the drug users’ group had a severe level of anxiety as well while the majority of drug non-addict people had a mild level of anxiety. Many theories have tried to explain the relationship between SUDs and mental illness such as causality theory [ 27 ], multiple risk factor/environmental triggers theory [ 28 ], and genetics/supersensitivity theory [ 29 ].

Some studies indicated that substance use has been linked to some kind of emotional distress prior to consumption [ 30 , 31 ]. Others indicated that substance use is often used as a method to relieve emotional problems [ 32 ], although its effects are not very durable or effective in the long term, as consumption tends to enhance depressive symptoms [ 33 ].

Many studies are in concordance with our results. For example, Hodgson et al. showed that more than two thirds of drug addict people had a severe level of anxiety [ 34 ], while the majority of drug non-addict people had a mild level of anxiety. Additionally, Pakhtunkhwa et al. demonstrated that most of the drug addict people tend to have severe levels of depression [ 35 ].

The results of this study showed a positive correlation between the presence of anxiety, depression, and substance-related problems elicited by DUDIT. Considering the mutual maintenance pattern of this comorbidity, it is not surprising that both anxiety, depression, and substance use disorders impact the course and treatment outcome for the counterpart condition. For example, studies have shown that anxiety and depressive disorders are related to increased severity of lifetime alcohol use disorders, increased lifetime service utilization among individuals with a substance use disorder, increased the severity of alcohol withdrawal, and higher relapse rates following substance abuse treatment [ 36 , 37 , 38 , 39 , 40 ].

The correlation between anxiety and depression in this study can be explained by the direct causation model which states that one disorder causes or lowers the threshold for the expression of the other disorder [ 41 ]. The shared etiology model also referred to as the correlated liabilities model [ 42 ] indicated that a common set of risk factors leads to the development of both depression and anxiety.

These findings are similar with the previous study reported by Grant et al. who found that anxiety is positively and significantly correlated with depression [ 43 ], whereas these findings are contradicted with Bellos et al. who found that anxiety is positively but non-significantly correlated with depression [ 44 ].

The prevalence of anxiety and depression among patients with substance use disorders is considerably high, and to be more specific, the level of severe depression and severe anxiety is the one we mean. There is an obvious association between the presence of anxiety and depression on the one hand and the severity of drug-related problems on the other hand. Depression and anxiety are commonly present together in the patients with SUDs. These findings throw the light on the problem of dual diagnosis and its impact on the prognosis and treatment process.


The findings of this study should be cautiously interpreted because a small sample was used. The restriction of the sample prevents the findings from being generalized to the larger population. This study relies completely on self-reports.

Availability of data and materials

The datasets that were generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


Diagnostic and Statistical Manual of Mental Disorders

Drug Use Disorder Identification Test

Hamilton Anxiety Rating Scale

Hamilton Depression Rating Scale

Substance use disorder

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Ikram Mohamed contributed to the study design, interpretation of the data, and preparation and revision of the manuscript. HK contributed to the study design, collection and analysis, interpretation of the data, and preparation of the main manuscript. S. Hassaan and H. Khalifa contributed to the study design, interpretation of the data, and writing of the manuscript. Shymaa M. Hassan contributed to the analysis and interpretation of the data and revision of the manuscript. All authors approved the final manuscript.

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mental health alcoholism case study

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Stigma kills people with alcohol addiction

mental health alcoholism case study

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One of my patients, Emma (not her real name), recently told me that she didn’t seek help for her alcohol problem because she was ashamed. She said that she didn’t want to waste anyone’s time on a self-inflicted problem. She lived with it for years, hiding bottles of alcohol so her partner wouldn’t find out. Only when she turned yellow and vomited blood did she call an ambulance.

What stopped Emma from asking for help? The answer, in large part, is stigma. The word stigma comes from ancient Greek, meaning a mark of shame or disgrace. Originally used to label slaves and criminals, these days, stigma is used to mean a sign of something socially undesirable – in this case, alcoholism.

Alcoholism, or alcohol use disorder , as it is known in medical terms, is the compulsion to drink alcohol even when it can cause physical or mental health problems.

Alcohol use disorder is a medical condition, not a lifestyle choice. This is different from heavy drinking and shouldn’t be used to describe someone who drinks too much by choice.

In people with alcohol use disorder, there may be a physical need to drink alcohol to stop withdrawal symptoms like the sweats or shakes. There may be psychological reasons including uncontrollable craving.

Most of the patients I see in hospital with alcohol-related liver disease have alcohol use disorder. We don’t fully understand why some people develop alcohol use disorder. It is partly genetic but other factors such as social support and mental health conditions play a role.

Why does the stigmatisation of people with alcohol use disorder matter? As Emma’s story shows, the problem is that people don’t come forward to ask for help until it is too late and irreversible damage is already done – the case in around half of all people diagnosed with alcohol-related liver disease.

Worse still, one in six people diagnosed late die on their first admission to hospital and more than a third within a year of their diagnosis.

Woman holding a glass of white wine

Stigma is common

Most people with liver disease have experienced stigma first hand .

Several types of stigma are important to understand. First, there is public stigma. This is the most common type of stigma, where people believe in negative stereotypes, develop prejudice, and avoid or look down on people with alcohol use disorder – the drunk on the street might be aggressive so best to avoid him.

Second, there is stigma from healthcare professionals. Some of us do not appreciate that alcohol use disorder is a disease of addiction. We see people with alcohol use disorder time and again coming into hospital in a terrible state and perhaps consider them a hopeless cause, a drain on medical resources or a waste of our valuable time. It is disappointing that this attitude can come from doctors, nurses and other trained healthcare professionals, but it is a sad reality that my patients report.

Third, there is structural stigma. This is the way services are designed that might exclude certain groups of people. For example, same-day appointments with general practitioners may only be available to book early in the morning, and some people may not be able to access them.

All this external stigmatisation of the person with alcohol use disorder drives self-stigma: a feeling of low self-worth and self-esteem.

The more stigma they experience, the more self-stigma they develop and the more they feel that they deserve such treatment. They conceal and deny their alcohol use and are six times more likely to avoid healthcare . They enter a vicious cycle of increasing alcohol use causing more mental and physical harm to themselves.

Things may have turned out differently

Let me come back to Emma. She battled her addiction for several years and with the support of alcohol services and her family, managed several months at a stretch without alcohol. Sadly, she relapsed into heavy drinking and a few months later had a serious bleed from her gullet (a side-effect of severe liver disease), which couldn’t be controlled. Sadly, she died.

I can’t help but think that if Emma hadn’t experienced all that stigma, things may have turned out differently for her. She may have been able to get help to control her addiction and prevent liver disease from taking her life.

What do we learn from Emma’s story? We should remember that alcohol use disorder is not a lifestyle choice. We, the public and healthcare professionals, should reflect on how we treat people with alcohol addiction.

The first step in removing stigma is to recognise the prejudices and stereotypes that we hold and try to overcome these by seeing the person behind the bottle. If we work together, we can eliminate stigma and support people with this terrible medical condition.

Read more: What happens to your liver when you quit alcohol

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David* has shared his story of recovery from alcohol addiction, sex and love addiction and unresolved childhood trauma. He talks through his life with addiction and how Priory allowed him to gain a better understanding of himself and his addiction, and set him up with tools and strategies for sustaining his recovery in the outside world.

David’s story

By the age of 40 most people would have said I led a happy and successful life. I was married with teenage children, had a well-paid professional job and was actively pursuing hobbies in my free time.

But behind the façade things were far from right.

My adolescent years had been unhappy ones, though I’d kept it all to myself - the loneliness, oversensitivity, bullying, low self-esteem and a desperate desire to be seen as successful by others.

As a student and later at work there were times when I found myself drinking too much and making a fool of myself, but I thought everyone did that sometimes. In my 20s and 30s, as the demands and responsibilities of adult life increased, the occasions when I drank too much became more regular, and when I’d been drinking I lost my inhibitions and my sexual behaviour became increasingly promiscuous.

I didn’t want to hear that I should stop drinking

I realised that things were out of control and sought help through my GP and various counsellors. But I didn’t want to hear what they told me - that the solution for me involved stopping drinking.  I couldn’t imagine my life without drink and the escape it gave me.  I wanted to believe that I could control my drinking and associated behaviour, despite all the evidence that I couldn’t.

My wife and children suffered enormously, I missed work through sickness, I had periods of memory loss after drinking and I felt increasingly hopeless. Attempts to stop drinking provided brief periods of respite, but they always failed and the drinking, uncontrolled behaviour and my sense of shame and despair spiralled out of control.  

Turning to Priory for support with alcohol addiction

I found myself in the Priory after attempting suicide while under the influence of alcohol. I was diagnosed with alcohol addiction, sex and love addiction and unresolved childhood trauma. To start with I wasn’t convinced about the sex and love addiction and just thought I did some bad things after drinking too much. But I did accept that if I continued doing what I’d been doing it would cost me my life, and I embraced the alcohol addiction treatment feeling I’d nothing to lose.

Initially, I found it confusing, wondering what I was supposed to say in the group therapy sessions and puzzled by some of the language, the rules and procedures. But the mist soon cleared. I’d imagined the Priory as a place for the rich and famous, but what I found were people from all walks of life, whose lives – like mine - were being destroyed by addiction of one kind or another.

For the first time I found I was able to be honest and open with my peers and the therapists about my addiction and its consequences. The programme introduced me to Alcoholics Anonymous and other 12 step programmes, where I met people leading happy and successful lives in recovery. I’d always dismissed AA but now I wondered what I could learn from the people I met.

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As well as gaining a better understanding of myself and my addiction, the Priory gave me a set of tools and strategies for sustaining my recovery in the outside world. At the heart of the Priory’s approach is the importance of addicts supporting each other in recovery. I found the weekly Aftercare sessions with other patents who’d been through the Addiction Treatment Programme immensely valuable. I supplemented these with one to one therapy with an addiction therapist recommended by the Priory.

I’ve been in recovery for over two years now and my outlook on life has changed completely. I’m at peace with myself and those around me in a way I never thought possible. Life has its ups and downs, but I take it as it comes without trying to escape from the world or myself by reaching for a drink. I no longer feel the need to drink and take pleasure in living each day for what it has to offer.

If I have one piece of advice for anyone struggling with substance or behavioural addiction it is to ask for help. The Addiction Treatment Programme at the Priory helped me to face the reality of my addiction and to begin my recovery journey and the new way of life it’s brought.  

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The Lived Experience of Codependency: an Interpretative Phenomenological Analysis

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Codependency is a complex and debatable concept, which has been used over the years by mental health professionals to inform their practices. Researchers have attempted to identify the main problems associated with codependency; however, their evidence is still inconclusive. This is the first time that interpretative phenomenological analysis (IPA) has been used to explore the lived experience of codependency from the perspective of self-identified codependents. Eight participants recruited from local support groups for codependency in the UK, offered in-depth information about their subjective experiences, and embedded in their lifeworld. Data was gathered through interviews and a visual method. The shared experience of codependency was portrayed by the participants as a complex but tangible multidimensional psychosocial problem in their lives. It incorporated three interlinked experiences: a lack of clear sense of self, an enduring pattern of extreme, emotional, relational, and occupational imbalance, and an attribution of current problems in terms of parental abandonment and control in childhood.

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Codependency is a complex and contested concept, which has been used over the years by mental health professionals to inform their practices (Harkness 2003 ; Sadock and Sadock 2004 ; Dear et al. 2004 ; Denning 2010 ; Marks et al. 2012 ). It has had a strong presence in the psychological self-help literature (Schaef 1986 ; Mellody 1989 , 1992 ; Beattie 2011 , 1992 ; Jellen 2014 ).

The concept of codependency emerged in the 1940s in the context of treatment for substance misuse in the USA. Its resilience has been demonstrated by the amount of academic papers and exploratory research published across the world, for example: in Italy (Lampis et al. 2017 ), in Iran (Askian et al. 2016 ), India (Bhowmick et al. 2001 ; Sarkar et al. 2015 ; Kaur 2016 ), Taiwan (Chang 2012 , 2018 ), Australia (Marks et al. 2012 ), Brazil (Bortolon et al. 2016 ), Turkey (Ançel and Kabakçi 2009 ; Ulusoy and Guçray 2017 ), Korea (Kwon 2001 ), and Sweden (Zetterlind and Berglund 1999 ).

Our review of the literature elicited a complex and interconnected range of definitions, assumptions, and models associated with codependency (Wegscheider-Cruse 1981 ; Whitfield 1984 ; Cermak 1986 ; Potter-Efron and Potter-Efron 1989 ; Wright and Wright 1991 ; Fischer et al. 1991 ; O'Brien and Gaborit 1992 ; Dear and Roberts 2005 ; Abadi et al. 2015 ).

A review of the historical development of the term demonstrated that early interpretations of codependency began to appear in the 1940s in the USA. These were associated with behaviours presented by wives of alcoholics (Price 1945 ; Mac Donald 1956 ). The development of the concept of codependency was influenced by the perspectives associated with the Alcoholic Anonymous’ (AA) communities in the USA during the 1960–1970s. The influence of the AA culture in shaping the concept of codependency as an illness offered the idea that people who were close to the substance user were themselves suffering from an illness (O’Briean and Gaborit 1992 ). These people were viewed as enablers and coalcoholics (Cotton 1979 ). Codependency began to appear more prominently in the clinical and popular literature from the 1980s onward. Three models came to the forefront in this period, providing different viewpoints in codependency. These are termed and well-documented in the literature of codependency as the disease model (Whitfield 1984 , 1987 ), the personality model (Cermak 1986 ), and the interactionist model (Wright and Wright 1991 ). The disease model considers codependency within the boundaries of clinical interventions and is concerned with diagnosis and treatment. The personality model of codependency highlighted the role of personality and constitutional factors in predisposing individuals to develop codependency (Cermak 1986 ). The interactionist model proposes a combination of both interpersonal and intrapersonal factors in the development and maintenance of codependency (Wright and Wright 1991 ).

Although these models form the basis of some quantitative research carried in the field (Abadi et al. 2015 ; Mark et al. 2012 ; Wells et al. 2006 ; Martsolf et al. 2000 ; Hughes-Hammer et al. 1998 ; O’Brien and Gaborit 1992 ), they arguably have a reductionist perspective, limiting the understanding of the experience of codependency within the boundaries of psychological categories, traits, and illness.

A systematic analysis of the main definitions of codependency found in the literature to date identified a thread of four elements repeatedly mentioned by the different theorists: external focusing, self-sacrifice, interpersonal conflict and control, and emotional constraint (Dear et al. 2004 ). However, there are no universally used definitions or diagnostic criteria, and codependency is not listed in the DSM-V (Diagnostic Statistical Manual V, American Psychiatric Association 1994 ). The concept has attracted much criticism due to lack of clarity, strong stereotyping, and negative labelling attributes (Gierymski and Williams 1986 ; Chiauzzi and Liljegren 1993 ; Uhle 1994 ; Anderson 1994 ; Orford 2005 ; Calderwood and Rajesparam 2014 .

The literature review demonstrated that the concept of codependency lacks a clear theoretical conceptualisation and, as a result, has generated a fair amount of discussion and contradictory evidence and theory among researchers. Most of the empirical evidence is formed by a body of quantitative research, attempting to categorise and quantify this contentious human experience. For example, across decades, researchers have attempted to identify the main psychological factors associated with codependency without clear agreement (O’Brien and Gaborit 1992 ; Carson and Baker 1994 ; Irvin 1995 ; Hughes-Hammer et al. 1998 ; Wells et al. 2006 ; Hoeningmann-Lion and Whithead 2007 ; Marks et al. 2012 ; Lampis et al. 2017 ). There has been an attempt to provide evidence for codependency in families with substance misuse problems (Prest and Storm 1988 ; Bhowmick et al. 2001 ; Sarkar et al. 2015 ; Bortolon et al. 2016 ; Askian et al. 2016 ). The results of these studies highlight that the evidence is still inconclusive. Codependency appears to take many forms; like a chameleon concept, it does not seem to be fully understood within the confines of pre-determined psychological traits, categories, or measurement tools.

Current studies still follow traditional routes of enquire, attempting to categorise the concept quantitatively and within the framework provided by debatable early models of codependency. For example, Chang ( 2018 ) used self-reported measures to assess the link between codependency, differentiation of self, and family dysfunction in sample of Taiwanese University students; Hawkins and Hawkins ( 2014 ) examined the relationship between codependency, assessment measures, gender traits, personality, and family alcoholism in American undergraduate students; Abadi et al. ( 2015 ) conducted a systematic review of treatment interventions for codependency and Reyome and Ward ( 2007 ) explored the relationship between childhood maltreatment and codependency in nursing students. Although offering useful insights, these studies are limited to populations of students or people with not real experience of codependency. They are also based on self-report scales, measuring traits with limited psychometric validation. Overall, they still reflect a rather limited and arguably superficial perspective of this complex experience and do not offer an understanding of the concept informed by the individual lived experience. A more in depth, qualitative perspective is needed considering the wholeness and individuality of the person, capturing the depth of their unique views, experiences, personal contexts, and narratives. This idiographic perspective is needed to complement the nomothetic perspective presented in the literature so far.

Moreover, the literature review identified a clear lack of qualitative research investigating the lived experience of codependency from the perspective of people who identify themselves as codependents. A close examination of this literature revealed that most qualitative studies were limited to a sociological perspective (Rice 1992 ; Irvine 2000 ; Blanco 2013 ). They were mostly concerned with social political and cultural aspects of 12 steps groups for codependency. As a whole, they offered a rather negative view of codependency, implying acceptance of unhelpful stereotyping and did not capture participants’ own understandings. These studies did not address the idiographic experiences of individuals who consider themselves to be codependents and who may seek recovery groups as a way of dealing with difficulties in their lifeworlds. They left many questions unanswered and invited further psychosocial research investigating how codependency is internalised, experienced, and shared by people who identify with it. These limitations suggest that a phenomenological and idiographic study was needed, focusing on the meaning of codependency for self-identified codependents and considering their perspectives and experiences of recovery.

One of the aims of qualitative research is to offer an in-depth perspective of an individual’s lived experience, which leads to a more empathic informed practice (Cassidy et al. 2011 ). The debates and uncertainties about the subjective meanings of codependency and the lack of research from an insider’s perspective suggested that an inquiry into individuals’ experiences from the perspective of the self-identified codependent was pertinent. The research study presented in this paper offered a response to this call. The aim of this research was to explore the meanings, and personal understandings associated with codependency, as understood by the individuals who identify with this concept, shown by seeking support from a recovery group, and who find it meaningful to explain the origins and development of their lived experiences. This paper furthermore will suggest how the findings of this phenomenological study might be useful to inform mental health clinical practice.

This is the first time that interpretative phenomenological analysis (IPA), as a specific research methodology has been used to explore the experience of codependency. Currently, there is an increasing development of IPA research looking to obtain insiders’ perspectives into mental health (Knight et al. 2003 ; Horn et al. 2007 ; Hagen and Nixon 2011 ) and addiction problems (Larkin and Griffiths 2002 ; Rodriguez and Smith 2004 ; Shinebourne and Smith 2008 , 2010 , 2011 ; Hill and Leeming 2014 ). These authors have agreed that the methodology seeks both an empathic and critical understanding of the lived experience, not often captured by other forms of research.

Methodological Approach

At the initial consultative stage of this research project, it was important to determine which qualitative methodology would be most suitable to address the proposed research question: What is the lived experience of codependency among people who have sought support from a recovery group for codependents?

Several methodologies were explored, for example: biography, ethnography, phenomenology, grounded theory, case study, and discourse analysis (DA). A phenomenological position was considered most suitable to guide this exploration. This is because the researchers were concerned in capturing an in-depth perspective of the individual who finds the term codependency useful to frame their lived experiences. They were interested in obtaining the insider’s perspective of a number of self-identified codependents, with shared experience of attending recovery groups. For this aim, the researchers looked for methodology which addressed the detailed and specific narrative accounts of their lived experience of codependency, fostering an in-depth understanding of the complex, idiographic, and shared aspects of this.

IPA is an approach to qualitative research, concerned with the personal lived experience, and the meanings attributed by the participants, in so far as they can be interpreted by the researcher (Smith et al. 2009 ). It is a methodology in its own right and offers an in-depth exploration of the participants’ lifeworlds. Given the negative assumptions widespread in the quantitative literature on codependency, it was deemed helpful to take an empathic, albeit questioning approach, following the argument (Smith and Osborn 2003 ; p.51) that IPA “is concerned with trying to understand what it is like, from the point of view of the participants, to take their side.”

There are three key fundamental theoretical principles in IPA: phenomenology, hermeneutics, and idiography (Smith 2004 ; Smith et al. 2010 ). IPA adopts a hermeneutic approach to phenomenology (Larkin et al. 2006 ). This interpretative component situates the IPA analysis within an interpretative circle, involving the perspectives of both the participant and the researcher (Smith 2004 ). Reflexivity is a fundamental aspect of IPA research (Langdridge 2007 ; Finlay 2008 ). In this study, through ongoing reflexivity, the researchers became critically aware of their position and reflected on how their personal experience, thoughts, beliefs, opinions, and interpretations, influenced the research process and outcome (Finlay 2008 ). For example, authors were familiar with the concept and its critiques through clinical practice and teaching in mental health.

The IPA methodology values purposive and small samples, as there is a strong idiographic approach and commitment to in-depth data analysis (Smith 2011a , b ). Specific contexts with small sample sizes are encouraged to ensure the richness of the information collected and appropriate analysis (Larkin et al. 2006 ; Eatough and Smith 2006 ). Adhering to this, eight participants (five women and three men) were recruited from local support groups for codependency in the UK. The decision to recruit from local support groups was informed by our review of the popular literature available, which informed that individuals who consider themselves to be codependents typically seek codependency anonymous groups as a way of dealing with their codependency (Beattie 2011 , 1992 ; Mellody 1992 , 1989 ). The support group selected for this study follows an eclectic theoretical framework underpinned by medical, spiritual, and behavioural principles.

The participants were selected based on their shared the experience of codependency. This was deemed sufficient to enhance the homogeneity of the sample, as required in IPA studies (Smith et al. 2010 ), although it is accepted that participants’ network of other relationships would be intertwined with their lived experience of codependency. Therefore, sensitivity to participants’ perspectives, relational experiences, and interpreted contexts was an important aspect of this IPA research, which aimed to capture their unique and shared experiences of codependency (Yardley 2008 ). This recruitment procedure was fully compatible with IPA methodology (Smith et al. 2010 ).

All of the participants were fluent speakers of the English Language. The inclusion criteria for the study specified that participants identified themselves as codependents. This was important because the study intended to understand subjective process, which led these participants to frame their own experiences in terms of codependency, with a shared recovery philosophy. To ensure the welfare of the participants and researcher, participants were also expected to be receiving some form of support for codependency, i.e. attending self-support groups, or receiving individual counselling or support.

See Table 1 below for more information on participants.

The study conformed with the host university’s Ethics Committee’s requirements and received full approval, adhering to principles of autonomy, confidentiality, beneficence, non-maleficence, and justice. Potential participants who had their names and contact details on the group website were sent a message explaining the purpose of the study and inviting their participation. After this initial contact, if agreed, the participants received an information pack explaining the process of the study, the inclusion criteria, and the consent form. A limited amount of snowballing was also used, which included referrals from participants (Smith et al. 2010 ). All of the participants gave written and verbal consent. Anonymity was ensured as participants were given pseudonyms, and all identifiable information was removed from the data. The research project was informed by a team of advisors composed of three self-identified codependents, who volunteered to offer an insider’s perspective and to contribute to the research in a consultative and collaborative role, for example by advising on information sheets and interview questions.

Data Collection Procedure

In IPA studies, data collection is a dynamic process that seeks to uncover and understand in depth the participants’ lived experience in so far as they can narrate this. In this study, the data collection process occurred over 6 months by means of a maximum of three in-depth semi-structured interviews and a visual method (for more information on the visual method see Bacon et al. 2017 ). The first author was the interviewer throughout. Each one of the interviews lasted approximately one and half hours. The repeated interviews had the intention to promote in-depth conversations over an extended period of time, as well as allowing time for the explorations of the experience through the visual methods. The visual method invited participants to bring an image or object that characterised their experience of codependency to be discussed during the second interview. This was a useful method to access a more in-depth narrative from participants and potentially encourage new insights and metaphorical understandings (Shinebourne and Smith 2011 ). A brief interview topic guide, with pre-determined (6–10) questions was used as a guiding tool for the interviews. The schedule was designed to offer guidance regarding possible questions to be explored over the three interviews. Questions were open ended and aimed at encouraging participants to express themselves in their own words. During the participant’s interview, the phrasing of some questions of the topic guide was changed or omitted, depending on the details already offered, and no particular order was followed. See Table 2 for an example of interview topic guide.

Data Analysis

The interviews were transcribed verbatim and were analysed following a distinctive, systematic but flexible process recommended by Smith et al. ( 2010 ) and Smith ( 2011a , b ), namely: initial encounter with the text, case by case analysis, with the identification of themes, clustering of themes, refinement of clustering of themes, cross case analysis identifying superordinate themes, labelling of super-ordinate themes, and writing of a narrative report. The researchers had an attitude of openness and immersed themselves in the data, consistent with the attitude taken on data collection. The case was very much central to the analysis, and the researchers attempted to understand as much as possible about each individual case before moving to the next. At the cross-case analysis stage, the researchers remained faithful to the individual case, focusing on the lifeworld of each participant, whilst searching for commonalities or convergences of meaning (Eatough and Smith 2006 ). The researchers corroborated the themes inferred through discussion.

Having clarified the theoretical and practical aspects of the IPA methodology and procedure, the following section offers a detailed examination of the findings.

The eight participants offered in-depth, vivid, and rich information about their subjective experiences of codependency embedded in their lifeworld. Four main themes are presented in the Diagram 1 below:

figure 1

The lived experience of codependency

Codependency feels real and tangible: “It explains everything.”

Firstly, all participants revealed an understanding and lived experience of codependency as something that to them felt real and tangible, forming an important and central feature in their lifeworlds. They had all struggled to understand their enduring social and emotional difficulties until they discovered the concept of codependency. Adopting the codependency way of framing experience did not happen easily for these participants. It was gradual discovery which offered meaning to complex and confusing experiences. For them, it came as a relief to understand codependency as a socially recognised psychological problem which exerted distinct influences over their lives. The quote below from Selma demonstrates the significance that codependency held in their lives:

… but I needed something to explain it, I needed something to explain everything. And it (codependency) doesn’t explain nothing, it (codependency) explains everything!

The participants all appeared to have found in “codependency” a simple, singular, and all-embracing explanation for a range of life difficulties and problems. For them, codependency was something so real that it felt concrete and touchable, like an illness or an underlying addiction problem, related to many forms of addictive behaviours, as illustrated by Misha:

I think all addiction patterns come from codependency. Codependency is the mother ship of all addictions!

None of the participants expressed stigma in relation to framing their experiences in this way. Instead, the concept of codependency offered meaning and hope that they could manage their difficulties more effectively.

The Chameleon-Self, Who Blends In

For all participants, the experience of codependency was associated with their enduring difficulties with self-concept. They all shared the experience of struggling to locate and define a clear sense of self. The participants spoke about the frustration with their lack of self-definition, which according to them resulted from an over-willing blending into situations. Several used the metaphor “chameleon” to describe this process of adaptation to the social environment and relationships. Selma’s quote illustrates the theme:

… it is like the chameleon, you know, trying to fit in with every situation rather than allowing myself to be who I am …

Participants spoke about their attempts to change and modify themselves to fit in socially, in order to feel liked, to belong and feel accepted, to gain a sense of self-esteem, yet taking this to an extreme where they lost sight of self.

Modifying myself in a chameleon like fashion to fit in, losing a sense of constancy around my values, my needs … (Selma)

All participants expressed feeling locked in to subservient and passive roles within close relationships. These relational difficulties had various negative consequences; for example, participants expressed feeling overruled, staying in the relationship in spite of its detrimental and often destructive effects, and choosing partners who had problematic psychological issues. They described the experience of becoming imprisoned in their relationships and finding themselves “locked” into these situations, feeling powerless, and unable to break free. For example, Mathias conveyed a sense of being locked into the relationship and unable to dissociate himself from his partner. He remained in the relationship in spite of feeling that it was not working. He described his over-riding sense of obligation, as something that was similar to an arduous military duty that was given to him by God.

I would be in relationships that were unhealthy, unequal, umm unpleasant umm and I would stay in them, you know, no matter what, like a marine, umm … It’s my duty, God gave me this!

He suggested that as a codependent, he became too adapted to each role, to a point where he would become the role and lose a sense of self. All participants described experiencing a dysfunctional degree of adapting themselves to situations as something negative and related to their codependency. Resonating with this need to subsume personal needs within relationships, most of the participants explained further various, and sometimes dysfunctional attempts to obtain a clear and better defined sense of self, as described next.

Seesawing Through Extremes in Life: “Like a Seesaw … I Feel Very Out of Control”

The experience of codependency, according to participants, was manifested through difficulties in living a balanced existence, suggesting a perceived lack of internal stability. Participants all related their lack of self-definition with continuing occupational and emotional unmanageability. Participants described the experience of lack of balance in their lives, with an excessive tendency to go to extremes of engagement in activities, and oscillating from one extreme to the other in a range of situations, for example working too much, using drugs or not looking after themselves. This was portrayed by the metaphor of the seesaw:

Maybe (my life) is a seesaw, maybe is something like a seesaw, you know … I can swing from self-care to self-deprivation, self-care to self-deprivation. … And it’s not very consistent, the two ends of it … if I push, and put too much weight on one end, you know, I feel very out of control, but if it is balanced, it would be easier (Misha).

Participants spoke about the experience of imbalance as a negative, portraying a sense of duality, or split; for example, stating that they felt “up and down emotionally,” swinging “from self-care to self-deprivation.” This experience of imbalance caused a sense of struggle as they searched for more stability as explained by Helena:

I actually think, I needed to go down that particular path to come back to the middle, that is my experience in almost everything to be honest. I tend to flick to each end of the scale and eventually balance somewhere in the middle.

They described a “need or urge” to do activities in what they regarded as excess and intensively, such as excessive drinking, drugs, and sex with multiple partners, seeing this as self-destructive, but associated with a need to escape feelings of inner emptiness:

… I would drink too much, and then smoke too much weed, and like the sexual acting out as well … big part of the highs and the lows and all of it, just combined to it, just this craziness it was all. The majority of it was internal … a constant feeling of devastation … it’s just like this paradox of devastation and emptiness … (Selma)

Participants spoke about a series of possibly destructive actions and compulsions that they had eventually attributed to codependency. They described not coping well with a quiet, routine, or empty life. It is possible that they may have needed to experience the rush of activities, so as to escape this experience of inner emptiness or to experience a sense of being alive.

In order to relax I have to burn out almost, I don’t know how to just relax, ‘cause I somehow have to go to the extremes … Yeah, I don’t work very brilliantly with the mundane; it is the steady life … … if I don’t get to the edge of what it feels like to be alive, then I don’t feel alive, then I get grumpy … anything that feels like life stops, it’s a terrifying space … (Helena)

Participants recounted what they perceived as an excessive tendency to go to extremes of engagement in activities. It appeared that, for some participants, this heightened activity was associated with a need to escape a sense of void or inner emptiness, described by Patricia as “… that feeling of a hole in the soul.”

They interpreted this as a problem related to their codependency and spoke about their struggle to establish a more balanced life experience.

Finding meaning in codependency through exploring childhood experiences: “down to childhood.”

The last convergent theme related to participants’ attributions for their problems to experiences in their family of origin. Participants had all clearly engaged in a deep analysis of their childhood experiences to provide causal attributions for their perceived difficulties, framed as codependency.

I do believe that it is down to childhood experiences and the individual child’s perception of those experiences … considering that all of my siblings are messed up as well … (Selma)

Participants shared a negative perception of being raised in home environments where they experienced various forms of excessive control, criticism, and perfectionism. Most recalled a rather paradoxical interpersonal family dynamic described as excessive parental rigidity and control combined with lack of support.

A closer investigation of their accounts revealed a further interesting aspect: reference to a parental figure who was perceived as physically and/or emotionally absent by most of the participants. This absence of a safe parental figure, typically the father, was portrayed by five participants and associated with their later experience of codependency.

… my father who was, quite passive, actually often quite absent, he worked, sometimes he worked in the evenings, sometimes he worked at weekends … he wasn’t the men’s man … my mother bossed him about, my mother ran the house … (Jonathan)

The theme also conveys a sense of extreme duality, as participants described the paradoxical experience of feeling both controlled and abandoned. This duality was portrayed most explicitly by Misha, as she reflected on both her parents’ contribution to her upbringing, conveying a sense of “split” felt as a result of difficulties experienced when growing up:

Maybe there was a sort of half factor, maybe one half of my family was not supporting me and maybe (the other half) my mother was judging me … (Misha)

In summary, as participants sought to understand the difficulties they experienced in their lives they felt the need to revisit their childhood experiences. In doing this, they looked for possible faults and gaps in their upbringing as it offered meaning to their experience of the complex and varied experiences that they had come to frame as codependency.

The IPA methodology helped the researchers to understand how a small sample of self-identified codependents made sense of experiences in their particular lifeworlds, searching for the meaning they attribute to these. The shared experience of codependency was portrayed by the participants as a real and tangible psychological problem in their lives, which appeared to follow a pattern, incorporating three interlinked subjective factors: a profound lack of clear sense of self, an enduring pattern of extreme, emotional, relational, and occupational imbalance, and an attribution of current problems in terms of parental abandonment and control in childhood. Participants reflected on the dynamic of abandonment and control as leading them to feel a sense of duality or split. They described a lack of internal instability, as they lived their lives between extremes of experience, encountering difficulties in locating and defining self, behaving like chameleons, and overly adapting to environments and relationships to obtain a sense of safety and belonging.

The main themes which emerged from the analysis of the interviews created a rich picture of the lived experience of codependency shared by the participants and revealed participants’ understandings of codependency as something real, forming an integral part of their lives. It was a concept that gave meaning to a complex set of confusing and compulsive behaviours. The interpretations suggested that the participants in part carried a rather medical understanding of codependency and found relief in encountering a diagnostic label for their previously unexplained and enduring problems. They understood codependence as a socially recognised form of addiction, which explained and offered meaning to their painful and hitherto puzzling lived experiences. This contradicted the views of early critics in the field who suggested that these individuals became labelled or stigmatised, and as such would become disempowered or lost in the sick role attributed to the label (Gierymski and Willams 1986 ; Gomberg 1989 ; Harper and Capdevilla 1990 ; Collins 1993 ; Chiauzzi and Liljegren 1993 ; Anderson 1994 ; Uhle 1994 ; Irvine 2000 ). On the contrary, the findings revealed that for these participants, codependency offered a controllable socially shared meaning for their complex and chaotic lived experiences. The concept’s lack of conceptual clarity and simplistic framing device may have served to make it attractive and suitable to capture, attribute meaning, and socially validate a diverse range of experiences. Codependency served as a chameleon concept adapting to the needs of the people who identified with it.

The participants attended codependency groups, individual therapy, and read widely on the topic. They acted as “meaning makers” (Langdridge 2007 p. 30), using their received understandings of codependency to make sense of their personal lived experiences. Symbolic interactionism posits that meanings are central to human life and are formed through a process of social interpretation, with people adopting the socially accepted metaphors and scripts available in their reference groups (Blumer 1986 ; Giugliano 2004 ). This is noticed by the way participants acted in relation to finding relief in the common understandings of codependency achieved in their support groups, therapy, and associated reading. Medical or psychiatric labels can be stigmatising and yet by objectifying codependency as a delineated psychosocial problem, these participants benefited from attributing a more widely accepted, socially shared meaning to their own varied and distressing life difficulties.

Social attribution theory may also be applicable as it describes people’s need for a label, such as codependency to explain distressing, non-normative experiences (Heider 1958 ; Kelley 1973 ; Kelley and Michella 1980 ; Weiner 2008 ). Attribution theorists argue that when faced with adversity, people ask themselves causality questions, which in turn prompt causal searches (Kelley 1973 ; Kelley and Michella 1980 ). The theory proposes also that explanations for undesired situations are likely to be attributed to causes outside one’s control to protect self-esteem (Elliott et al. 2012 ). Here, the participants appeared to have engaged in an ongoing process of resolving some of their intra- and interpersonal problems through their identification with the codependency label. The codependency attributions may have provided a way to explain and understand situations that happened in their lives in the past, serving also as a framework for future actions, decisions, and behaviours.

In addition, from the perspective of these participants, codependency went beyond the medical model; it was also associated with existential issues associated with problems with a sense of self. The second theme revealed the participants’ struggles and search to obtain a better defined, more authentic sense of self. They portrayed some of their struggles in finding themselves behaving like chameleons, adapting and conforming over-readily to situations, which caused frustration and dysfunction in their lives. The issues associated with an undefined sense of self played an important part in the lived experience of the participants of this study; nevertheless, research in the field offered only a partial perspective on this, failing to capture the depth and significance of this experience for the self-identified codependent (Carson and Baker 1994 ; Crothers and Warren 1996 ; Irvine 2000 ; Dear and Roberts 2005 ; Chang 2018 ).

The IPA methodology grants that diverse and psychological and philosophical perspectives are integrated into the research to interpret and elucidate the findings (Smith et al. 2010 ; Smith 2011a , b ). Two further traditional theoretical frameworks have been useful to interpret the participants’ existential and relational difficulties identified as codependency (Winnicott 1960a , b , 1965a , b ; Bowen 1974 , 1978 ). Bowen ( 1974 , 1978 ) proposed that the degree to which the person develops a cohesive and differentiated sense of self is determined by the differentiation this person obtained from the family of origin. People with low level of differentiation may have internalised a more fragile sense of their own thoughts, emotion, and needs, tending to accommodate and conform to the situations to a point that they lose their sense of individuality and authenticity. Here, we suggest that by behaving like chameleons, the participants highlighted their undifferentiated sense of self.

Furthermore, Winnicott’s ( 1965a , b ) views resonate with the notion of the inauthentic, non-validated, and undifferentiated sense of self described by the participants. He posited that when individuals do not have their needs validated in childhood, they tend to accommodate to the needs of their parents, developing a defensive or undifferentiated organisation of self, termed “false self,” similar to the chameleon type of behaviour described by the participants here. He added that people with a “false sense of self” present a tendency to obtain a sense of value and esteem through excessive engagement in activities. Interestingly, this was described by the participants as they believed that their codependency was manifested in the marked occupational and emotional imbalance in their lives. They spoke about having difficulties with balance, sharing a perceived lack of internal stability, communicating a profound fragility of self, which they thought fostered experiences of intense and enduring emotional and occupational imbalance. Participants described engaging in activities to obtain a sense of esteem and validation. These participants experienced a “sense of void,” described by one as a “hole in the soul,” and seemed to have engaged in a frantic pursuit of activities in order to fill this. These rich accounts add further insights into some of the generalisations about codependency (e.g. emotional suppression and external focusing) previously associated with codependency in the quantitative research literature (Dear and Roberts 2005 ).

Finally, the study also uncovered the participants’ specific social attributions of their difficulties to dynamics within their family of origin, perceived as control by one parent and abandonment by the other. Like naïve psychologists (Heider 1958 ), the participants appeared to have engaged also in the process of external causal attribution (Kelley 1973 ; Kelley and Michella 1980 ), whereby they searched for past childhood experiences as distal causes for their identified codependency. However, the identified contradictory parenting pattern of control and abandonment was not necessarily associated with parental substance misuse as suggested by early theorists in the field (Mellody 1989 ; Beattie 1989 , 2011 ; Whitfield 1984 , 1987 , 1991 ), nor by quantitative researchers who have examined the relationship between childhood family experiences and codependency in populations of students (Crothers and Warren 1996 ; Cullen and Carr 1999 ; Fuller and Warren 2000 ; Reyome and Ward 2007 ; Knudson and Terrell 2012 ; Hawkins and Hawkins 2014 ).

The personal significance of early family interactions in the lives of participants can be better understood within Bowen’s ( 1974 , 1978 ) and Winnicott’s ( 1960a , b ) theoretical views about differentiation in childhood. Winnicott suggested that the presence of a “holding environment” is key to facilitating optimal psychological development (Winnicott 1960a , b , p. 591). Here, participants reflected on their family environments as negative, rigid, and unsupportive. Such environments may have prompted them to feel that they may have no other option rather than conform to an unauthentic existence and to resent the freedom to make choices and express themselves.

Critical Evaluation and Limitations

A number of quality measures were used to ensure the rigour, trustworthiness, and credibility of the study (Yardley 2008 ; Smith 2011a , b ). The process of multiple interviewing helped to gain deeper insights and go beyond rehearsed narratives likely to have been told many times in support group meetings. In spite of this, the study is limited by factors related to methodological and participants’ sensitivities. According to Shinebourne and Smith ( 2011 ), support group forms a good sample representation, as it adequately meets the IPA criteria of a purposive, context-specific, expert knowledge group. This recruitment procedure was planned with the positive intention of increasing homogeneity within the small sample; nonetheless, it may have limited the study in some ways. Limitations around received, rehearsed, and edited narratives had to be considered, as this group appeared to be well informed about lay and psychological theories about codependency, for example they attended groups and read widely about codependency. It was not possible to entirely disentangle “first hand” experience from the framing applied from this learning within the support group and beyond. Despite its aim to stay experience-close, IPA research into other contested conditions, such as chronic fatigue syndrome and addictions, has faced similar issues (Dickson et al. 2007 , 2008 ; Shinebourne and Smith 2008 ). However, concurring with other research carried out in support groups (Shinebourne and Smith 2011 ), participants’ accounts varied considerably, and were not in any obvious sense scripted.

In addition, although the sample was large for IPA research (Smith et al. 2010 ), it could nonetheless be considered relatively small and specific, and therefore findings are not straightforwardly generalizable to other contexts. The participants volunteered to take part in the study, so they may have been highly motivated to share their experiences and understandings of codependency. Other self-identified codependents may have different views and experiences, especially those who have not yet encountered or found value in support groups.

This is a qualitative study, so we are not claiming that the findings can be generalised simplistically, in particular to people who identify with codependency yet do not attend formal support groups. We nonetheless argue for a theoretical transferability (Smith et al. 2010 ). Smith ( 2011a , b ; p7) suggested that the particular aspects explored through IPA “takes us closer to the universal.” Therefore, we propose that the findings may guide further research and inform clinical practice.

Conclusion and Clinical Implications

It is important that therapists working in this field need to be sensitive to the importance of this label, and the attributions that it implies, to this client group. Receiving such a label may not necessarily come with negative connotations despite some previous sociological and feminist debate on this matter; on the contrary, it may offer a socially recognised explanation for complex, enduring, and distressing life experiences. The findings highlighted the need for therapists to be aware of issues related to fragile self-concept and the experience of problematic parenting experiences in childhood when offering support to codependents. People with codependency issues would benefit much from empathic listening as it can bring a sense of acknowledgement and validation of their life experiences, contributing to the restoring of their sense of self. A thoughtful therapist–client relationship, focusing on embracement, holding, and support thereby proving a stable secure therapeutic environment could help these individuals as they engage in a process of self-construction. Therapists working with these clients should be conscious of their extreme oscillation in engagement in activities. They can plan psycho-educational interventions, which are aimed to assist these clients to consider a more balanced lifestyle. Stress management techniques and emotional regulation strategies can be offered to assist to regulate their emotional and occupational instability. The extremes of oscillation in feelings and activities may also create barriers to forming a strong therapeutic alliance and therapists may need to use supervision to manage the emotional effects of such oscillations on self.

It is hoped that the results of this study will provide a base for developing a more empathic and contextualised understanding of the experience of codependency, which in turn will enable mental health professionals to offer support which is relevant to these individuals’ experiences.

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  • Published: 19 February 2024

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study

  • Bo Kim 1 , 2 ,
  • Jennifer L. Sullivan 3 , 4 ,
  • Madisen E. Brown 1 ,
  • Samantha L. Connolly 1 , 2 ,
  • Elizabeth G. Spitzer 1 , 5 ,
  • Hannah M. Bailey 1 ,
  • Lauren M. Sippel 6 , 7 ,
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Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3–4 years after implementation support had concluded.

We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends.

CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): “Collaborativeness/Teamwork [Recipients],” “Staff/Leadership turnover [Recipients],” and “Having a consistent/strong internal facilitator [Facilitation]” during and after active implementation. At most high-sustainability sites only, (i) “Having a knowledgeable/helpful external facilitator [Facilitation]” was variably present and enabled sustainability when present, while (ii) “Clarity about what CCM comprises [Innovation],” “Interdisciplinary coordination [Recipients],” and “Adequate clinic space for CCM team members [Context]” were somewhat or less present with mixed influences on sustainability.


MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

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We examined the ways in which the sustainability of the evidence-based Collaborative Chronic Care Model differed across nine outpatient mental health clinics where it was implemented.

This work demonstrates a unique application of the Matrixed Multiple Case Study (MMCS) method, originally developed to identify factors and their combinations that influence implementation, to investigate the long-term sustainability of a previously implemented evidence-based practice.

Contextual influences on sustainability identified through this work, as well as the systematic approach to multi-site examination offered by MMCS, can inform future efforts to sustainably implement and methodically evaluate an evidence-based practice’s uptake and continued use in routine care.

The sustainability of evidence-based practices (EBPs) over time is crucial to maximize the public health impact of EBPs implemented into routine care. Implementation evaluators focus on sustainability as a central implementation outcome, and funders of implementation efforts seek sustained long-term returns on their investment. Furthermore, practitioners and leadership at implementation sites face the task of sustaining an EBP’s usage even after implementation funding, support, and associated evaluation efforts conclude. The circumstances and influences contributing to EBP sustainability are therefore of high interest to the field of implementation science.

Sustainability depends on the specific EBP being implemented, the individuals undergoing the implementation, the contexts in which the implementation takes place, and the facilitation of (i.e., support for) the implementation. Hence, universal conditions that invariably lead to sustainability are challenging to establish. Even if a set of conditions could be identified as being associated with high sustainability “on average,” its usefulness is questionable when most real-world implementation contexts may deviate from “average” on key implementation-relevant metrics.

Thus, when seeking a better understanding of EBP sustainability, there is a critical need for methods that examine the ways in which sustainability varies in diverse contexts. One such method is Matrixed Multiple Case Study (MMCS) [ 1 ], which is beginning to be applied in implementation research to identify factors related to implementation [ 2 , 3 , 4 , 5 ]. MMCS capitalizes on the many contextual variations and heterogeneous outcomes that are expected when an EBP is implemented across multiple sites. Specifically, MMCS provides a formalized sequence of steps for cross-site analysis by arranging data into an array of matrices, which are sorted and filtered to test for expected factors and identify less expected factors influencing an implementation outcome of interest.

Although the MMCS represents a promising method for systematically exploring the “black box” of the ways in which implementation is more or less successful, it has not yet been applied to investigate the long-term sustainability of implemented EBPs. Therefore, we applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM), previously implemented using implementation facilitation [ 6 , 7 , 8 ], at nine VA medical centers’ outpatient general mental health clinics. An earlier interview-based investigation of CCM provider perspectives had identified key determinants of CCM sustainability at the sites, yet characteristics related to the ways in which CCM sustainability differed at the sites are still not well understood. For this reason, our objective was to apply MMCS to examine the interview data to determine factors associated with CCM sustainability at each site.

Clinical and implementation contexts

CCM-based care aims to ensure that patients are treated in a coordinated, patient-centered, and anticipatory manner. This project’s nine outpatient general mental health clinics had participated in a hybrid CCM effectiveness-implementation trial 3 to 4 years prior, which had resulted in improved clinical outcomes that were not universally maintained post-implementation (i.e., after implementation funding and associated evaluation efforts concluded) [ 7 , 9 ]. This lack of aggregate sustainability across the nine clinics is what prompted the earlier interview-based investigation of CCM provider perspectives that identified key determinants of CCM sustainability at the trial sites [ 10 ].

These prior works were conducted in VA outpatient mental health teams, known as Behavioral Health Interdisciplinary Program (BHIP) teams. While there was variability in the exact composition of each BHIP team, all teams consisted of a multidisciplinary set of frontline clinicians (e.g., psychiatrists, psychologists, social workers, nurses) and support staff, serving a panel of about 1000 patients each.

This current project applied MMCS to examine the data from the earlier interviews [ 10 ] for the ways in which CCM sustainability differed at the sites and the factors related to sustainability. The project was determined to be non-research by the VA Boston Research and Development Service, and therefore did not require oversight by the Institutional Review Board (IRB). Details regarding the procedures undertaken for the completed hybrid CCM effectiveness-implementation trial, which serves as the context for this project, have been previously published [ 6 , 7 ]. Similarly, details regarding data collection for the follow-up provider interviews have also been previously published [ 10 ]. We provide a brief overview of the steps that we took for data collection and describe the steps that we took for applying MMCS to analyze the interview data. Additional file  1 outlines our use of the Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist [ 11 ].

Data collection

We recruited 30 outpatient mental health providers across the nine sites that had participated in the CCM implementation trial, including a multidisciplinary mix of mental health leaders and frontline staff. We recruited participants via email, and we obtained verbal informed consent from all participants. Each interview lasted between 30 and 60 min and focused on the degree to which the participant perceived care processes to have remained aligned to the CCM’s six core elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support [ 12 , 13 , 14 ]. Interview questions also inquired about the participant’s perceived barriers and enablers influencing CCM sustainability, as well as about the latest status of CCM-based care practices. Interviews were digitally recorded and professionally transcribed. Additional details regarding data collection have been previously published [ 10 ].

Data analysis

We applied MMCS’ nine analytical steps [ 1 ] to the interview data. Each step described below was led by one designated member of the project team, with subsequent review by all project team members to reach a consensus on the examination conducted for each step.

We established the evaluation goal (step 1) to identify the ways in which sustainability differed across the sites and the factors related to sustainability, defining sustainability (step 2) as the continued existence of CCM-aligned care practices—namely, that care processes remained aligned with the six core CCM elements. Table  1 shows examples of care processes that align with each CCM element. As our prior works directly leading up to this project (i.e., design and evaluation of the CCM implementation trial that involved the very sites included in this project [ 6 , 15 , 16 ]) were guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework [ 17 ] and i-PARIHS positions facilitation (the implementation strategy that our trial was testing) as the core ingredient that drives implementation [ 17 ], we selected i-PARIHS’ four domains—innovation, recipients, context, and facilitation—as relevant domains under which to examine factors influencing sustainability (step 3). i-PARIHS posits that the successful implementation of an innovation and its sustained use by recipients in a context is enabled by facilitation (both the individuals doing the facilitation and the process used for facilitation). We examined the data on both sustainability and potentially relevant i-PARIHS domains (step 4) by conducting directed content analysis [ 18 ] of the recorded and professionally transcribed interview data. We used the six CCM elements and the four i-PARIHS domains as a priori codes.

Additional file  2 provides an overview of data input, tasks performed, and analysis output for MMCS steps 5 through 9 described below. We assessed sustainability per site (step 5) by generating CCM code summaries per site, and reached a consensus on whether each site exhibited high, medium, or low sustainability relative to other sites based on the summary data. We assigned a higher sustainability level for sites that exhibited more CCM-aligned care processes, had more participants consistently mention those processes, and considered those processes more as “just the way things are done” at the site. Namely, (i) high sustainability sites had concrete examples of CCM-aligned care processes (such as the ones shown in Table  1 ) for many of the six CCM elements, which multiple participants mentioned as central to how they deliver care, (ii) low sustainability sites had only a few concrete examples of CCM-aligned care processes, mentioned by only a small subset of participants and/or inconsistently practiced, and (iii) medium sustainability sites matched neither of the high nor low sustainability cases, having several concrete examples of CCM-aligned care process for some of the CCM elements, varying in whether they are mentioned by multiple participants or how consistently they are a part of delivering care. For the CCM code summaries per site, one project team member initially reviewed the coded data to draft the summaries including exemplar quotes. Each summary and relevant exemplar quotes were then reviewed by and refined with input from all six project team members during recurring team meetings to finalize the high, medium, or low sustainability designation to use in the subsequent MMCS steps. Reviewing and refining the summaries for the nine sites took approximately four 60-min meetings of the six project team members, with each site’s CCM code summary taking approximately 20–35 min to discuss and reach consensus on. We referred to lists of specific examples of how the six core CCM elements were operationalized in our CCM implementation trial [ 19 , 20 ]. Refinements occurred mostly around familiarizing the newer members of the project team (i.e., those who had not participated in our prior CCM-related work) with the examples and definitions. We aligned to established qualitative analysis methods for consensus-reaching discussions [ 18 , 21 ]. Recognizing the common challenge faced by such discussions in adequately accounting for everyone’s interpretations of the data [ 22 ], we drew on Bens’ meeting facilitation techniques [ 23 ] that include setting ground rules, ensuring balanced participation from all project team members, and accurately recording decisions and action items.

We then identified influencing factors per site (step 6), by generating i-PARIHS code summaries per site and identifying distinct factors under each domain of i-PARIHS (e.g., Collaborativeness and teamwork as a factor under the Recipients domain). For the i-PARIHS code summaries per site, one project team member initially reviewed the coded data to draft the summaries including exemplar quotes. They elaborated on each i-PARIHS domain-specific summary by noting distinct factors that they deemed relevant to the summary, proposing descriptive wording to refer to each factor (e.g., “team members share a commitment to their patients” under the Recipients domain). Each summary, associated factor descriptions, and relevant exemplar quotes were then reviewed and refined with input from all six project team members during recurring team meetings to finalize the relevant factors to use in the subsequent MMCS steps. Finalizing the factors included deciding which similar proposed factor descriptions from different sites to consolidate into one factor and which wording to use to refer to the consolidated factor (e.g., “team members share a commitment to their patients,” “team members collaborate well,” and “team members know each other’s styles and what to expect” were consolidated into the Collaborativeness and teamwork factor under the Recipients domain). It took approximately four 60-min meetings of the six project team members to review and refine the summaries and factors for the nine sites, with each site’s i-PARIHS code summary and factors taking approximately 20–35 min to discuss and reach consensus on. We referred to lists of explicit definitions of i-PARIHS constructs that our team members had previously developed and published [ 16 , 24 ]. We once again aligned to established qualitative analysis methods for consensus-reaching discussions [ 18 , 21 ], drawing on Bens’ meeting facilitation techniques [ 23 ] to adequately account for everyone’s interpretations of the data [ 22 ].

We organized the examined data (i.e., the assessed sustainability and identified factors per site) into a sortable matrix (step 7) using Microsoft Excel [ 25 ], laid out by influencing factor (row), sustainability (column), and site (sheet). We conducted within-site analysis of the matrixed data (step 8), examining the data on each influencing factor and designating whether the factor (i) was present, somewhat present, or minimally present [based on aggregate reports from the site’s participants; used “minimally present” when, considering all available data from a site regarding a factor, the factor was predominantly weak (e.g., predominantly weak Ability to continue patient care during COVID at a medium sustainability site); used “somewhat present” when, considering all available data from a site regarding a factor, the factor was neither predominantly strong nor predominantly weak (e.g., neither predominantly strong nor predominantly weak Collaborativeness and teamwork at a low sustainability site)], and (ii) had an enabling, hindering, or neutral/unclear influence on sustainability (designated as “neutral” when, considering all available data from a site regarding a factor, the factor had neither a predominantly enabling nor a predominantly hindering influence on sustainability). These designations of factors’ presence and influence are conceptually representative of what is commonly referred to as magnitude and valence, respectively, by other efforts that construct scoring for qualitative data (e.g., [ 26 , 27 ]). Like the team-based consensus approach of earlier MMCS steps, factors’ presence and type of influence per site were initially proposed by one project team member after reviewing the matrix’s site-specific data, then refined with input from all project team members during recurring team meetings that reviewed the matrix. Accordingly, similar to the earlier MMCS steps, we aligned to established qualitative methods [ 18 , 21 ] and meeting facilitation techniques [ 23 ] for these consensus-reaching discussions.

We then conducted a cross-site analysis of the matrixed data (step 9), assessing whether factors and their combinations were (i) present across multiple sites, (ii) consistently associated with higher or lower sustainability, and (iii) emphasized at some sites more than others. We noted that any factor may have not come up during interviews with a site because either it is not pertinent or it is pertinent but still did not come up, although we asked an open-ended question at the end of each interview about whether there was anything else that the participant wanted to share regarding sustainability. To adequately account for these possibilities, we decided as a team to regard a factor or a combination of factors as being associated with high/medium/low sustainability if it was identified at a majority (i.e., even if not all) of the sites designated as high/medium/low sustainability (e.g., if the Collaborativeness and teamwork factor is identified at a majority, even if not all, of the high sustainability sites, we would find it to be associated with high sustainability). Like the team-based consensus approach of earlier MMCS steps, cross-site patterns were initially proposed by one project team member after reviewing the matrix’s cross-site data, then refined with input from all project team members during recurring team meetings that reviewed the matrix. Accordingly, similar to the earlier MMCS steps, we aligned to established qualitative methods [ 18 , 21 ] and meeting facilitation techniques [ 23 ] for these consensus-reaching discussions. We acknowledged the potential existence of additional factors influencing sustainability that may not have emerged during our interviews and also may vary substantially between sites. For example, adaptation of the CCM, characteristics of the patient population, and availability of continued funding, which are factors that extant literature reports as being relevant to sustainability [ 28 , 29 ], were not seen in our interview data. To maintain our analytic focus on the factors seen in our data, we did not add these factors to our analysis.

For the nine sites included in this project, we found the degree of CCM sustainability to be split evenly across the sites—three high-, three medium-, and three low-sustainability. Twenty-five total influencing factors were identified under the i-PARIHS domains of Innovation (6), Recipients (6), Context (8), and Facilitation (5). Table  2 shows these identified influencing factors by domain. Figure  1 shows 11 influencing factors that were identified for at least two sites within a group of high/medium/low sustainability sites—e.g., the factor “consistent and strong internal facilitator” is shown as being present at high sustainability sites with an enabling influence on sustainability, because it was identified as such at two or more of the high sustainability sites. Of these 11 influencing factors, four were identified only for sites with high CCM sustainability and two were identified only for sites with medium or low CCM sustainability.

figure 1

Influencing factors that were identified for at least two sites within a group of high/medium/low sustainability sites

Key trends in influencing factors associated with high, medium, and/or low CCM sustainability

Three factors across two i-PARIHS domains exhibited strong trends by sustainability status. They were the Collaborativeness and teamwork and Turnover of clinic staff and leadership factors under the Recipients domain, and the Having a consistent and strong internal facilitator factor under the Facilitation domain.

Recipients-related factors

Collaborativeness and teamwork was present with an enabling influence on CCM sustainability at most high and medium sustainability sites, while it was only somewhat present with a neutral influence on CCM sustainability at most low sustainability sites. When asked what had made their BHIP team work well, a participant from a high sustainability site said,

“Just a collaborative spirit.” (Participant 604)

A participant from a medium sustainability site said,

“We joke that [the BHIP teams] are even family, that the teams really do function pretty tightly and they each have their own personality.” (Participant 201)

At the low sustainability sites, willingness to work as a team varied across team members; a participant from a low sustainability site said,

“… I think it has to be the commitment of the people who are on the team. So those that are regularly attending, we get a lot more out of it than those that probably don't ever come [to team meetings].” (Participant 904)

Collaborativeness and teamwork of BHIP team members were often perceived as the highlight of pursuing interdisciplinary care.

Turnover of clinic staff and leadership was present with a hindering influence on CCM sustainability at most high, medium, and low sustainability sites.

“We’ve lost a lot of really, really good providers here in the time I’ve been here …,” (Participant 102)

said a participant from a low-sustainability site that had to reconfigure its BHIP teams due to clinic staff shortages. Turnover of mental health clinic leadership made it difficult to maintain CCM practices, especially beyond the teams that participated in the original CCM implementation trial. A participant from a medium sustainability site said,

“Probably about 90 percent of the things that we came up with have fallen by the wayside. Within our team, many of those remain but again, that hand off towards the other teams that I think partly is due to the turnover rate with program managers, supervisors, didn’t get fully implemented.” (Participant 703)

Although turnover was an issue for high sustainability sites as well, there was also indication of the situation improving in recent years; a participant from a high sustainability site said,

“… our attrition rollover rate has dropped quite a bit and I would really attribute that to [the CCM being] more functional and more sustainable and tolerable for the providers.” (Participant 502)

As such, staff and leadership turnover was deemed a major challenge for CCM sustainability for all sites regardless of the overall level of sustainability.

Facilitation-related factor

Having a consistent and strong internal facilitator was present with an enabling influence on CCM sustainability at high sustainability sites, not identified as an influencing factor at most of the medium sustainability sites, and variably present with a hindering, neutral, or unclear influence on CCM sustainability at low sustainability sites. Participants from a high sustainability site perceived that it was important for the internal facilitator to understand different BHIP team members’ personalities and know the clinic’s history. A participant from another high sustainability site shared that, as an internal facilitator themselves, they focused on recognizing and reinforcing the progress of team members:

“… I'm often the person who kind of [starts] off with, ‘Hey, look at what we've done in this location,’ ‘Hey look at what the team's done this month.’” (Participant 402)

A participant from a low sustainability site had also served as an internal facilitator and recounted the difficulty and importance of readying the BHIP team to function in the long run without their assistance:

“I should have been able to get out sooner, I think, to get it to have them running this themselves. And that was just a really difficult process.” (Participant 301)

Participants, especially from the high and low sustainability sites, attributed their BHIP teams’ successes and challenges to the skills of the internal facilitator.

Influencing factors identified only for sites with high CCM sustainability

Four factors across four i-PARIHS domains were identified for high sustainability sites and not for medium or low sustainability sites. They were the factors Details about the CCM being well understood (Innovation domain), Interdisciplinary coordination (Recipients domain), Having adequate clinic space for CCM team members (Context domain), and Having a knowledgeable and helpful external facilitator (Facilitation domain).

Innovation-related factor

Details about the CCM being well understood was minimal to somewhat present with an unclear influence on CCM sustainability.

“We’ve … been trying to help our providers see the benefit of team-based care and the episodes-of-care idea, and I would say that is something our folks really have continued to struggle with as well,” (Participant 401)

said a participant from a high sustainability site. “What is considered CCM-based care?” continued to be a question on providers’ minds. A participant from a high sustainability site asked during the interview,

“Is there kind of a clearing house of some of the best practices for [CCM] that you guys have … or some other collection of resources that we could draw from?” (Participant 601)

Although such references are indeed accessible online organization-wide, participants were not always aware of those resources or what exactly CCM entails.

Recipients-related factor

Interdisciplinary coordination was somewhat present with a hindering, neutral, or unclear influence on CCM sustainability. Coordination between psychotherapy and psychiatry providers was deemed difficult by participants from high-sustainability sites. A participant said,

“We were initially kind of top heavy on the psychiatry so just making sure we have … therapy staff balancing that out [has been important].” (Participant 501)

Another participant perceived that BHIP teams were helpful in managing.

… ‘sibling rivalry’ between different disciplines … because [CCM] puts us all in one team and we communicate.” (Participant 505)

Interdisciplinary coordination was understood by the participants as being necessary for effective CCM-based care yet difficult to achieve.

Context-related factor

Having adequate clinic space for CCM team members was minimal to somewhat present with a hindering, neutral, or unclear influence on CCM sustainability. COVID-19 led to changes in how clinic space was used/assigned. A participant from a high sustainability site remarked,

“Pre-COVID everything was in a room instead of online. And now all our meetings are online and so it's actually really easy for the supervisors to be able to rotate through them and then, you know, they can answer programmatic questions ….” (Participant 402)

Participants from another high sustainability site found that issues regarding limited clinic space were both exacerbated and alleviated by COVID, with the mental health service losing space to vaccine clinics but more mental health clinicians teleworking and in less need of clinic space. Virtual connections were seen to alleviate some physical workspace-related concerns.

Having a knowledgeable and helpful external facilitator was variably present; when present, it had an enabling influence on CCM sustainability. Participants from a high sustainability site noted how many of the external facilitator’s efforts to change the BHIP team’s work processes very much remained over time. An example of a change was to have team meetings be structured to meet evolving patient needs. Team members came to meetings with the shared knowledge and expectation that,

“… we need to touch on folks who are coming out of the hospital, we need to touch on folks with higher acuity needs.” (Participant 402)

Implementation support that sites received from their external facilitator mostly occurred during the time period of the original CCM implementation trial; correspondence with the external facilitator after that trial time period was not common for sites. Participants still largely found the external facilitator to provide helpful guidance and advice on delivering CCM-based care.

Influencing factors identified only for sites with medium or low CCM sustainability

Two factors were identified for medium or low sustainability sites and not for high sustainability sites. They were the factors Ability to continue patient care during COVID and Adequate resources/capacity for care delivery . These factors were both under i-PARIHS’ Context domain, unlike the influencing factors above that were identified only for high sustainability sites, which spanned all four i-PARIHS domains.

Context-related factors

Ability to continue patient care during COVID had a hindering influence on CCM sustainability when minimally present. Participants felt that their CCM work was challenged when delivering care through telehealth was made difficult—e.g., at a medium sustainability site, site policies during the pandemic required a higher number of in-person services than the BHIP team providers expected or desired to deliver. On the other hand, this factor had an enabling influence on CCM sustainability when present. A participant at a low sustainability site mentioned the effect of telehealth on being able to follow up more easily with patients who did not show up for their appointments:

“… my no-show rate has dropped dramatically because if people don’t log on after a couple minutes, I call them. They're like ‘oh, I forgot, let me pop right on,’ whereas, you know, in the face-to-face space, you know, you wait 15 minutes, you call them, it’s too late for them to come in so then they're no shows.” (Participant 102)

The advantages of virtual care delivery, as well as the challenges of getting approvals to pursue it to varying extents, were well recognized by the participants.

Adequate resources/capacity for care delivery was minimally present at medium sustainability sites with a hindering influence on CCM sustainability. At a medium sustainability site, although leadership was supportive of CCM, resources were being used to keep clinics operational (especially during COVID) rather than investing in building new CCM-based care delivery processes.

“I think that if my boss came to me, [and asked] what could I do for [the clinics] … I would say even more staff,” (Participant 202)

said a participant from a medium sustainability site. At the same time, the participant, as many others we interviewed, understood and emphasized the need for BHIP teams to proceed with care delivery even when resources were limited:

“… when you’re already dealing with a very busy clinic, short staff and then you’re hit with a pandemic you handle it the best that you can.” (Participant 202)

Participants felt the need for basic resource requirements to be met in order for CCM-based care to be feasible.

In this project, we examined factors influencing the sustainability of CCM-aligned care practices at general mental health clinics within nine VA medical centers that previously participated in a CCM implementation trial. Guided by the core CCM elements and i-PARIHS domains, we conducted and analyzed CCM provider interviews. Using MMCS, we found CCM sustainability to be split evenly across the nine sites (three high, three medium, and three low), and that sustainability may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators.

In comparison to most high sustainability sites, participants from most medium or low sustainability sites did not mention a knowledgeable and helpful external facilitator who enabled sustainability. Participants at the high sustainability sites also emphasized the need for clarity about what CCM-based care comprises, interdisciplinary coordination in delivering CCM-aligned care, and adequate clinic space for BHIP team members to connect and collaborate. In contrast, in comparison to participants at most high sustainability sites, participants at most medium or low sustainability sites emphasized the need for better continuity of patient-facing activities during the COVID-19 pandemic and more resources/capacity for care delivery. A notable difference between these two groups of influencing factors is that the ones emphasized at most high sustainability sites are more CCM-specific (e.g., external facilitator with CCM expertise, knowledge, and structures to support delivery of CCM-aligned care), while the ones emphasized at most medium or low sustainability sites are factors that certainly relate to CCM sustainability but are focused on care delivery operations beyond CCM-aligned care (e.g., COVID’s widespread impacts, limited staff availability). In short, an emphasis on immediate, short-term clinical needs in the face of the COVID-19 pandemic and staffing challenges appeared to sap sites’ enthusiasm for sustaining more collaborative, CCM-consistent care processes.

Our previous qualitative analysis of these interview data suggested that in order to achieve sustainability, it is important to establish appropriate infrastructure, organizational readiness, and mental health service- or department-wide coordination for CCM implementation [ 10 ]. The findings from the current project augment these previous findings by highlighting the specific factors associated with higher and lower CCM sustainability across the project sites. This additional knowledge provides two important insights into what CCM implementation efforts should prioritize with regard to the previously recommended appropriate infrastructure, readiness, and coordination. First, for knowledge retention and coordination during personnel changes (including any changes in internal facilitators through and following implementation), care processes and their specific procedures should be established and documented in order to bring new personnel up to speed on those care processes. Management sciences, as applied to health care and other fields, suggest that such organizational knowledge retention can be maximized when there are (i) structures set up to formally recognize/praise staff when they share key knowledge, (ii) succession plans to be applied in the event of staff turnover, (iii) opportunities for mentoring and shadowing, and (iv) after action reviews of conducted care processes, which allow staff to learn about and shape the processes themselves [ 30 , 31 , 32 , 33 ]. Future CCM implementation efforts may thus benefit from enacting these suggestions alongside establishing and documenting CCM-based care processes and associated procedures.

Second, efforts to implement CCM-aligned practices into routine care should account for the extent to which sites’ more fundamental operational needs are met or being addressed. That information can be used to appropriately scope the plan, expectations, and timeline for implementation. For instance, ongoing critical staffing shortages or high turnover [ 34 ] at a site are unlikely to be resolved through a few months of CCM implementation. In fact, in that situation, it is possible that CCM implementation efforts could lead to reduced team effectiveness in the short term, given the effort required to establish more collaborative and coordinated care processes [ 35 ]. Should CCM implementation move forward at a given site, implementation goals ought to be set on making progress in realms that are within the implementation effort’s control (e.g., designing CCM-aligned practices that take staffing challenges into consideration) [ 36 , 37 ] rather than on factors outside of the effort’s control (e.g., staffing shortages). As healthcare systems determine how to deploy support (e.g., facilitators) to sites for CCM implementation, they would benefit from considering whether it is primarily CCM expertise that the site needs at the moment, or more foundational organizational resources (e.g., mental health staffing, clinical space, leadership enhancement) [ 38 ] to first reach an operational state that can most benefit from CCM implementation efforts at a later point in time. There is growing consensus across the field that the readiness of a healthcare organization to innovate is a prerequisite to successful innovation (e.g., CCM implementation) regardless of the specific innovation [ 39 , 40 ]. Several promising strategies specifically target these organizational considerations for implementing evidence-based practices (e.g., [ 41 , 42 ]). Further, recent works have begun to more clearly delineate leadership-related, climate-related, and other contextual factors that contribute to organizations’ innovation readiness [ 43 ], which can inform healthcare systems’ future decisions regarding preparatory work leading to, and timing of, CCM implementation at their sites.

These considerations informed by MMCS may have useful implications for implementation strategy selection and tailoring for future CCM implementation efforts, especially in delineating the target level (e.g., system, organizational, clinic, individual) and timeline of implementation strategies to be deployed. For instance, of the three factors found to most notably trend with CCM sustainability, Collaborativeness and teamwork may be strengthened through shorter-term team-building interventions at the organizational and/or clinic levels [ 38 ], Turnover of clinic staff and leadership may be mitigated by aiming for longer-term culture/climate change at the system and/or organizational levels [ 44 , 45 , 46 ], and Having a consistent and strong internal facilitator may be ensured more immediately by selecting an individual with fitting expertise/characteristics to serve in the role [ 15 ] and imparting innovation/facilitation knowledge to them [ 47 ]. Which of these factors to focus on, and through what specific strategies, can be decided in partnership with an implementation site—for instance, candidate strategies can be identified based on ones that literature points to for addressing these factors [ 48 ], systematic selection of the strategies to move forward can happen with close input from site personnel [ 49 ], and explicit further specification of those strategies [ 50 ] can also happen in collaboration with site personnel to amply account for site-specific contexts [ 51 ].

As is common for implementation projects, the findings of this project are highly context-dependent. It involves the implementation of a specific evidence-based practice (the CCM) using a specific implementation strategy (implementation facilitation) at specific sites (BHIP teams within general mental health clinics at nine VA medical centers). For such context-dependent findings to be transferable [ 52 , 53 ] to meaningfully inform future implementation efforts, sources of variation in the findings and how the findings were reached must be documented and traceable. This means being explicit about each step and decision that led up to cross-site analysis, as MMCS encourages, so that future implementation efforts can accurately view and consider why and how findings might be transferable to their own work. For instance, beyond the finding that Turnover of clinic staff and leadership was a factor present at most of the examined sites, MMCS’ traceable documentation of qualitative data associated with this factor at high sustainability sites also allowed highlighting the perception that CCM implementation is contributing to mitigating turnover of providers in the clinic over time, which may be a crucial piece of information that fuels future CCM implementation efforts.

Furthermore, to compare findings and interpretations across projects, consistent procedures for setting up and conducting these multi-site investigations are indispensable [ 54 , 55 , 56 ]. Although many projects involve multiple sites and assess variations across the sites, it is less common to have clearly delineated protocols for conducting such assessments. MMCS is meant to target this very gap, by offering a formalized sequence of steps that prompt specification of analytical procedures and decisions that are often interpretive and left less specified. MMCS uses a concrete data structure (the matrix) to traceably organize information and knowledge gained from a project, and the matrix can accommodate various data sources and conceptual groundings (e.g., guiding theories, models, and frameworks) that may differ from project to project – for instance, although our application of MMCS aligned to i-PARIHS, other projects applying MMCS [ 2 , 5 ] use different conceptual guides (e.g., Consolidated Framework for Implementation Research [ 57 ], Theoretical Domains Framework [ 58 ]). Therefore, as more projects align to the MMCS steps [ 1 ] to identify factors related to implementation and sustainability, better comparisons, consolidations, and transfers of knowledge between projects may become possible.

This project has several limitations. First, the high, medium, and low sustainability assigned to the sites were based on the sites’ CCM sustainability relative to one another, rather than based on an external metric of sustainability. As measures of sustainability such as the Program Sustainability Assessment Tool [ 59 , 60 ] and the Sustainment Measurement System Scale [ 61 ] become increasingly developed and tested, future projects may consider the feasibility of incorporating such measures to assess each site’s sustainability. In our case, we worked on addressing this limitation by using a consensus approach within our project team to assign sustainability levels to sites, as well as by confirming that the sites that we designated as high sustainability exhibited CCM elements that we had previously observed at the end of their participation in the original CCM implementation trial [ 19 ]. Second, we did not assign strict thresholds above/below which the counts or proportions of data regarding a factor would automatically indicate whether the factor (i) was present, somewhat present, or minimally present and (ii) had an enabling, hindering, or neutral/unclear influence on sustainability. This follows widely accepted qualitative analytical guidance that discourages characterizing findings solely based on the frequency with which a notion is mentioned by participants [ 62 , 63 , 64 ], in order to prevent unsubstantiated inferences or conclusions. We sought to address this limitation in two ways: We carefully documented the project team’s rationale for each consensus reached, and we reviewed all consensuses reached in their entirety to ensure that any two factors with the same designation (e.g., “minimally present”) do not have associated rationale that conflict across those factors. These endeavors we undertook closely adhere to established case study research methods [ 65 ], which MMCS builds on, that emphasize strengthening the validity and reliability of findings through documenting a detailed analytic protocol, as well as reviewing data to ensure that patterns match across analytic units (e.g., factors, interviewees, sites). Third, our findings are based on three sites each for high/medium/low sustainability, and although we identified single factors associated with sustainability, we found no specific combinations of factors’ presence and influence that were repeatedly existent at a majority of the sites designated as high/medium/low sustainability. Examining additional sites on the factors identified through this work (as we will for our subsequent CCM implementation trial described below) will allow more opportunities for repeated combinations and other factors to emerge, making possible firmer conclusions regarding the extent to which the currently identified factors and absence of identified combinations are applicable beyond the sites included in this study. Fourth, the identified influencing factor “leadership support for CCM” (under the Context domain of the i-PARIHS framework) substantially overlaps in concept with the core “organizational/leadership support” element of the CCM. To avoid circular reasoning, we used leadership support-related data to inform our assignment of sites’ high, medium, or low CCM sustainability, rather than as a reason for the sites’ CCM sustainability. In reality, strong leadership support may both result from and contribute to implementation and sustainability [ 16 , 66 ], and thus causal relationships between the i-PARIHS-aligned influencing factors and the CCM elements (possibly with feedback loops) warrant further examination to most appropriately use leadership support-related data in future analyses of CCM sustainability. Fifth, findings may be subject to both social desirability bias in participants providing more positive than negative evidence of sustainability (especially participants who are responsible for implementing and sustaining CCM-aligned care at their site) and the project team members’ bias in interpreting the findings to align to their expectations of further effort being necessary to sustainably implement the CCM. To help mitigate this challenge, the project interviewers strove to elicit from participants both positive and negative perceptions and experiences related to CCM-based care delivery, both of which were present in the examined interview data.

Future work stemming from this project is twofold. Regarding CCM implementation, we will conduct a subsequent CCM implementation trial involving eight new sites to prospectively examine how implementation facilitation with an enhanced focus on these findings affects CCM sustainability. We started planning for sustainability prior to implementation, looking to this work for indicators of specific modifications needed to the previous way in which we used implementation facilitation to promote the uptake of CCM-based care [ 67 ]. Findings from this work suggest that sustainability may be related most strongly to (i) provider collaboration, (ii) knowledge retention during staff/leadership transitions, and (iii) availability of skilled internal facilitators. Hence, we will accordingly prioritize developing procedures for (i) regular CCM-related information exchange amongst BHIP team members, as well as between the BHIP team and clinic leadership, (ii) both translating knowledge to and keeping knowledge documented at the site, and (iii) supporting the sites’ own personnel to take the lead in driving CCM implementation.

Regarding MMCS, we will continuously refine and improve the method by learning from other projects applying, testing, and critiquing MMCS. Outside of our CCM-related projects, examinations of implementation data using MMCS are actively underway for various implementation efforts including that of a data dashboard for decision support on transitioning psychiatrically stable patients from specialty mental health to primary care [ 2 ], a peer-led healthy lifestyle intervention for individuals with serious mental illness [ 3 ], screening programs for intimate partner violence [ 4 ], and a policy- and organization-based health system strengthening intervention to improve health systems in sub-Saharan Africa [ 5 ]. As MMCS is used by more projects that differ from one another in their specific outcome of interest, and especially in light of our MMCS application that examines factors related to sustainability, we are curious whether certain proximal to distal outcomes are more subject to heterogeneity in influencing factors than other outcomes. For instance, sustainability outcomes, which are tracked following a longer passage of time than some other outcomes, may be subject to more contextual variations that occur over time and thus could particularly benefit from being examined using MMCS. We will also explore MMCS’ complementarity with coincidence analysis and other configurational analytical approaches [ 68 ] for examining implementation phenomena. We are excited about both the step-by-step traceability that MMCS can bring to such methods and those methods’ computational algorithms that can be beneficial to incorporate into MMCS for projects with larger numbers of sites. For example, Salvati and colleagues [ 69 ] described both the inspiration that MMCS provided in structuring their data as well as how they addressed MMCS’ visualization shortcomings through their innovative data matrix heat mapping, which led to their selection of specific factors to include in their subsequent coincidence analysis. Coincidence analysis is an enhancement to qualitative comparative analysis and other configurational analytical methods, in that it is formulated specifically for causal inference [ 70 ]. Thus, in considering improved reformulations of MMCS’ steps to better characterize examined factors as explicit causes to the outcomes of interest, we are inspired by and can draw on coincidence analysis’ approach to building and evaluating causal chains that link factors to outcomes. Relatedly, we have begun to actively consider the potential contribution that MMCS can make to hypothesis generation and theory development for implementation science. As efforts to understand the mechanisms through which implementation strategies work are gaining momentum [ 71 , 72 , 73 ], there is an increased need for methods that help decompose our understanding of factors that influence the mechanistic pathways from strategies to outcomes [ 74 ]. Implementation science is facing the need to develop theories, beyond frameworks, which delineate hypotheses for observed implementation phenomena that can be subsequently tested [ 75 ]. The methodical approach that MMCS offers can aid this important endeavor, by enabling data curation and examination of pertinent factors in a consistent way that allows meaningful synthesis of findings across sites and studies. We see these future directions as concrete steps toward elucidating the factors related to sustainable implementation of EBPs, especially leveraging data from projects where the number of sites is much smaller than the number of factors that may matter—which is indeed the case for most implementation projects.

Using MMCS, we found that provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators may be most strongly related to CCM sustainability in VA outpatient mental health clinics. Informed by these findings, we have a subsequent CCM implementation trial underway to prospectively test whether increasing the aforementioned factors within implementation facilitation enhances sustainability. The MMCS steps used here for systematic multi-site examination can also be applied to determining sustainability-related factors relevant to various other EBPs and implementation contexts.

Availability of data and materials

The data analyzed during the current project are not publicly available because participant privacy could be compromised.


Behavioral Health Interdisciplinary Program

Collaborative Chronic Care Model

Consolidated Criteria for Reporting Qualitative Research

coronavirus disease

evidence-based practice

Institutional Review Board

Integrated Promoting Action on Research Implementation in Health Services

Matrixed Multiple Case Study

United States Department of Veterans Affairs

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The authors sincerely thank the project participants for their time, as well as the project team members for their guidance and support. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

This project was funded by VA grant QUE 20–026 and was designed and conducted in partnership with the VA Office of Mental Health and Suicide Prevention.

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Concept and design: BK, JS, and CM. Acquisition, analysis, and/or interpretation of data: BK, JS, MB, SC, ES, and CM. Initial drafting of the manuscript: BK. Critical revisions of the manuscript for important intellectual content: JS, MB, SC, ES, HB, LS, KW, and CM. All the authors read and approved the final manuscript.

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Data input, tasks performed, and analysis output for MMCS Steps 5 through 9.

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Recent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.

Cross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.

Service users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.


The assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

Peer Review reports

The number of people attending emergency departments (EDs) in England has continued to rise, aside from the COVID-19 period. In 2019/20, there were 25.0 million ED attendances compared to 21.5 million in 2011/12 1 . In April 2022, waiting time performance in EDs was the worst recorded in modern data collections [ 1 ], and people with mental health problems had to wait substantially longer than those with physical health problems. Although mental health presentations decreased during lockdown, there was a bounce back post-lockdown with even greater numbers attending ED than before [ 2 ].

There are relatively few studies of people’s experiences of liaison mental health services (LMHS) in the UK. A recent internet survey of respondents’ experiences of LMHS in England showed that only 31% of service users found their contact with such services helpful [ 3 ]. Latent class analysis identified three types of experience; those who had a positive experience, those who reported a negative experience and those who were non-committal. Suggestions for improvement included the provision of a 24/7 service, reduced waiting times for assessment, and clearer communication about treatment or care post-assessment.

Prior studies of user satisfaction of LMHS in the UK have also been mixed [ 4 ]. One previous study which involved in-depth qualitative interviews with service users found that people complained about long waiting times before being able to access liaison services [ 5 ]. Some service users reported good experiences characterised by close collaboration between the service user and liaison practitioner whilst others described po or experiences.

In contrast with the UK, studies from Australia have reported positive service user experiences of LMHS with high levels of service user satisfaction [ 6 , 7 , 8 ]. In one study, service users reported timely access to being seen by a liaison practitioner and reported feeling listened to, understood and helped in a positive fashion, with an emphasis on problem solution [ 6 ].

All 170 hospitals in England with an ED now have at least a rudimentary LMHS [ 9 ]. These services have undergone substantial growth in the last seven years following significant investment from NHS England [ 10 ]. There has been particular expansion in acute services, and a “Core-24” service model has been developed, with staffing ratios based upon hospital size in terms of bed numbers [ 11 ]. These Core-24 teams usually consist of at least one liaison psychiatrist and several liaison mental health nurses. They focus on emergency work, providing 24-hour cover for EDs and acute ward referrals, with an emphasis on one-off assessments followed by signposting.

These new developments have been accompanied by rigorous performance targets for response times and throughput. In 2016, NHS guidance stated that a person experiencing a mental health crisis should receive a response from a LMHS within a maximum of 1 h of receipt of referral, and within 4 h the person should have received: “ a full biopsychosocial assessment if appropriate, and have an urgent and emergency mental health care plan in place, and as a minimum, be en route to their next location if geographically different, or have been accepted and scheduled for follow-up care by a responding service, or have been discharged because the crisis has resolved” [ 11 ]. Further review of access standards for mental health services in 2021 maintained the 1-hour target [ 9 ], although waiting time targets for all patients attending EDs are under review due to consistent and increasing failures to meet them.

While many hospitals have benefitted from the introduction of Core-24, especially where there were no or only rudimentary services previously, other established liaison services have had to change or modify their ways of working to meet targets. In addition to acute cover, these established services previously offered lower volume, higher intensity work involving the assessment, treatment and co-management of patients with complex physical and mental health problems seen in either inpatient or outpatient settings.

We previously completed interviews with 73 NHS staff from 11 hospital trusts in England who were either LMHS staff or worked closely with them and found that interviewees most valued being able to spend time with patients to carry out therapeutic interventions [ 12 ]. Some staff provided continued treatment for patients admitted to acute hospitals over several weeks. For example, in one service mental health nurses regularly visiting older adult patients or those on stroke wards to provide encouragement with eating and rehabilitation, both vital components of ensuring recovery. Teams with psychologists, therapists or mental health nurses trained in specific interventions (like cognitive behavioural therapy) offered brief interventions while the patient was admitted to an acute hospital bed, or a follow-up appointment after discharge. Staff reported problems with continuity of care across the secondary-primary interface; a lack of mental health resources in primary care to support discharge; a lack of shared information systems; a disproportionate length of time spent recording information instead of face-to-face patient contact; and a lack of a shared vision of care. Similar issues were identified across different liaison service types.

The aim of the present study was to better understand the experiences of users and providers of LMHS, and to explore hospital staff’s experiences of the changes brought about by the NHS England’s investment in Core-24 and any impact on patient care. We were particularly interested in improving our understanding of the mechanisms and trade-offs involved in relation to meeting one key performance target, the one-hour response time set by NHS England for LMHS. Recent programme theory suggests that the imposition of such fixed targets may have unintended consequences for liaison services and other parts of the health care system [ 13 ].

This work formed part of the first phase of a programme funded through the NIHR Health Services and Delivery Research scheme to evaluate the cost-effectiveness and efficiency of different configurations of liaison psychiatry services in England (LP-MAESTRO) [ 14 ]. The Consolidating Criteria for Reporting Qualitative Research (COREQ) guidelines [ 15 ] have been followed.

This was a cross-sectional qualitative study with service users of hospital-based LMHS and hospital staff with either experience of working in, or working closely with, LMHS.

Setting and sample

Service users were recruited from two Northern cities in England. We aimed to recruit 8–10 service user participants and developed a purposive sampling frame to ensure maximum variation. Potential participants were approached by either LMHS staff to determine their interest, or by local service user organisations who were invited to identify participants for the project through their own contacts. Once consent to contact had been provided by the service users, they were contacted directly by a member of the research team, who explained the study and provided a study information sheet. The potential participant was given at least 48 h to decide whether to participate. All participants provided written informed consent and there were no dropouts. No relationship was established with participants prior to study commencement. Participants were not informed of any of the interviewers’ personal goals for conducting the research.

Hospital staff were recruited from two hospitals in Northern England, both with EDs and within the same city. A maximum-divergence sampling frame was developed to maximise diversity according to professional background, sub-specialism within the LMHS, clinical or managerial focus and whether liaison team member or referrer to the service. Overall, we planned to recruit 8–10 staff participants. All staff participants provided written informed consent and there were no dropouts.

Data collection

Service users.

Nine service users were individually interviewed using a semi-structured topic guide. The service user topic guide was developed for this study (LP MAESTRO) and not published elsewhere (see Additional file 1 ). It consisted of a list of key topic areas with open-ended questions and additional prompts covering the following areas: introductory questions identifying the contact the participant had had with acute care; experiences of the acute care received from acute hospital staff; accounts of care received from LMHS staff; and views on desirable changes and ways to achieve them. They were not asked specifically about Core-24 developments, as it was unlikely that they would be familiar with such policy and staffing changes. However, staffing and waiting times were included as part of the topic guide.

Hospital Staff

Eight hospital staff were individually interviewed using a semi-structured topic guide. The hospital staff topic guide was adapted from an earlier topic guide used in the LP-MAESTRO study in relation to a previous investigation of liaison psychiatry and hospital staff experiences of liaison services [ 12 ]. The adapted topic guide, which focuses primarily on staff experiences of CORE-24 is provided in Additional file 2 . The following key topic areas were covered: introductory questions about the staff member’s work history and the nature of their involvement with LMHS; experiences of LMHS prior to introduction of Core-24; description of any changes resulting from Core-24; impact of these changes on the service; impact on patient care; and views on how the service could be improved.

Interviews lasted 30–90 min and took place via telephone between September 2017 and February 2019. Participant interviews were conducted first, followed by interviews with hospital staff. With permission all interviews were audio-recorded and transcribed verbatim. There were no repeat interviews. Transcripts were not returned to participants for comment or correction. Only the interviewer and participant were present at each interview. No field notes were recorded.

Interviews were conducted by three researchers, all from the Leeds Institute of Health Sciences and qualified by experience and training (CCG, SS, EG). None were involved in the delivery of acute LMHS at the time of the study. EG is a female Professor of Psychological Medicine and Consultant Psychiatrist. CCM is a female Senior Research Fellow and SS is a female Research Fellow. EG had previously worked in an acute liaison mental health team and was generally supportive of the Core-24 developments prior to the study. Neither SS nor CCM had a priori views or identified biases. The form and content of the topic guides were developed in collaboration with people with personal experience of mental health problems and accessing LMHS.

Data analysis

The semi-structured interviews were interpreted independently by DR and EG using framework analysis [ 16 ]. This is a qualitative method that is useful in research that has specific questions, a limited time frame and a pre-determined sample; it is therefore well-suited to applied policy research. First, DR and EG independently read all transcripts with the study’s aim in mind. Each then independently reviewed all transcripts line by line identifying relevant experiences, opinions, descriptions of incidents and emotions (codes). DR collated codes into a draft theoretical framework which was refined through discussion with EG. It became apparent to base several framework categories around the key areas of interest in the interview schedule as we wanted to be open to issues arising from the data. DR then matched the data to the provisional framework. Each example was independently included under one or more theme in the thematic chart by DR and EG who then met to resolve any disparities. In the final stage, findings were reviewed by AH. Relevant supporting quotations were then extracted from interview transcripts to illustrate each theme and sub-theme. Data from service users and staff were analysed separately but are presented together if relevant to the theme or sub-theme. Participants were not asked to provide feedback on the findings.

Sample characteristics

Seventeen in-depth interviews were conducted, nine with LMHS users and eight with healthcare professionals. Service user participants consisted of 3 men and 6 women with varying age ranges (Table  1 ). Presenting problems included self-harm, psychosis, mania, long-term physical health problems and medically unexplained symptoms. The interviewed professionals were mental health liaison nurses ( n  = 3), consultant liaison psychiatrists ( n  = 2), general nurses ( n  = 2) and one consultant in emergency medicine.

Main findings

Participants discussed a range of topics surrounding the provision and experience of mental healthcare in general hospitals. They illustrated the complexity involved in meeting mental health needs in this setting. Below we outline our findings in terms of themes and sub-themes that emerged from the interviews; the four themes and their constituent subthemes are summarised in Table  2 . The staff topic guide included specific questions about Core-24 that were not included in the service users’ topic guide, so most of the sub-themes around the Core-24 service standard are only relevant to staff participants.

Theme one: the emergency department (ED)

Healthcare professionals and service users discussed their views of the ED as a site for mental healthcare provision. The content of their discourse comprised the sub-themes of ED staff, physical environment, appropriateness for mental health problems and desired characteristics.

Service users recounted highly variable experiences of ED staff when seeking help for their mental health problems. Some were described as kind and compassionate people who acknowledged distress and evoked feelings of validation:

“ They recognised I wasn’t putting things on, that I did feel acutely suicidal as I was saying ” – Participant 1.

Others disclosed negative views of ED staff, describing them as unpleasant and harsh. Three participants reported that ED staff withheld treatment that they thought was needed. Others reported that staff did not allow the service user to speak and failed to provide any guidance or support on discharge.

“The GP referred me to A&E and when I arrived there, they were very very harsh” – Participant 6.

LMHS professionals generally had negative perceptions of ED staff, reporting that they had poor psychiatric knowledge and skills. Several felt that ED staff did not appreciate the role of LMHS and frequently made inappropriate referrals. Some suggested that ED staff had little interest in mental health problems:

“I think sometimes they don’t ask more questions about mental health, and I don’t know if that is because they don’t feel confident to, or they just don’t want to” – Participant 13.

Physical environment

The ED environment was discussed exclusively by service users, and their opinions were overwhelmingly negative. Common issues were that the assessment room was uncomfortable and small:

“You’re brought into this really small room with no windows, it was tiny, it was also not necessarily painted, it was very scruffy ” – Participant 5.

A lack of provision of refreshments contributed to a sense of discomfort. The privacy of the assessment environment varied; two individuals reported that they were assessed in a private space, and one was not:

“In the department with just a curtain pulled around, so it wasn’t very private” – Participant 1.

Appropriateness for mental health problems

Both service users and providers questioned the appropriateness of the ED for people with mental health needs. No participants felt that the ED was an appropriate place for these needs.

“A lot of them are quite vulnerable, and more at risk of accidental self-harm or sort of vulnerable from other people in the department and it’s A&E isn’t it, I wouldn’t it consider a very nice environment for people that are experiencing psychosis” – Participant 13.

Service users described their experiences of seeking care in the ED as anxiety-provoking and lonely. They acknowledged that attending the department was an undesirable last resort, only done when other services and professionals could not be accessed in the community.

“It’s not the best solution by any stretch of the imagination but, but it’s the only place that’s available” – Participant 8.

Desired characteristics

Participants suggested ways that the ED could be improved to better care for those with mental health needs. These included a more comfortable environment, the option to wait outside, better communication of next steps and knowledge of community-based support. One participant suggested the provision of company while awaiting input from the mental health team.

“I don’t know what else they could do apart from have somebody sit with you all the time until the psychiatrist came or somebody to assess you” – Participant 7.

Liaison practitioners also felt that the ED could be improved by providing more staff training in mental health assessments and improving referrals to the LMHS. This could reduce the volume of referrals and facilitate referral triage while reducing wait times for service users.

“If you upskill the ED people to even basic then liaison psychiatry should be able to turn down referrals… And we have to remember in the middle of all of this is a patient” – Participant 15.

Theme two: Liaison mental health services (LMHS)

The second theme refers to participants’ views and experiences of liaison mental health services (LMHS). There are three sub-themes: experiences of LMHS, barriers to contact and desired characteristics.

Service users described variable experiences of the help they received from LMHS. Contact with LMHS helped some individuals to feel more comfortable and to understand the next steps. Some described a therapeutic benefit of talking in depth about their issues:

“It helps me mental health, being able to talk about it and stuff” – Participant 3.

Others voiced that LMHS were either unhelpful or contributed to them feeling worse. This was related to the feeling of not being listened to and the perception that no tangible help or support was offered.

“ I’ve not got time for them as they do nothing for me” – Participant 9.

Some service users held the view that LMHS complete little more than a “box-ticking” exercise that offers little benefit to the service user. This was echoed by one of the physical healthcare professionals.

Common problems were that the professionals seemed rushed and incompetent. Three participants shared the view that LMHS staff were dismissive or disinterested. This led them to feel guilty and as though they had wasted the professional’s time.

“Sometimes the mental health staff can be very dismissive and treat me like I’ve just wasted everybody’s time, and I should have just looked after myself at home” – Participant 8.

Others described LMHS staff in a more positive light, reflecting that they allowed them to speak freely while listening carefully and acknowledging their needs. In some interviews, LMHS staff were described as caring and comforting. One participant felt that LMHS staff are underappreciated:

“I know with my experiences with liaison psychiatry that they do a lot more than people may think” – Participant 4.

Generally, interviewed professionals were complimentary towards LMHS staff, describing them as hard-working, knowledgeable, experienced, accessible, and committed to high-quality patient care. Participants had conflicting views on whether LMHS staff have a good relationship with the ward teams and whether they meet their expectations, although this was often attributed to a rise in demand for the service.

Barriers to contact

Participants discussed barriers to accessing LMHS. Some service users recounted how input from LMHS was postponed or withheld because they were under the care of a community mental health team. This sometimes resulted in interactions with a “diversion team”, which was described as a frustrating, obstructive experience.

“You just can’t get past diversion because they’ve been put in place to stop people like me who are known to the system… They’re basically there to go, ‘there, there, you’re ok, you go home and speak to your care coordinator tomorrow.’” – Participant 8.

Staff felt that significant barriers to contact with LMHS included insufficient staffing levels, particularly out of hours, and a seemingly excessive amount of time completing documentation.

“The [LMHS] team spend a long time writing things up and reporting… If we do make a referral for later in the evening or overnight, I don’t work nights, but they’re often told, ‘oh we can’t come and see the patient because we’re writing up our reports!’” – Participant 12.

Service users outlined factors that would improve their experience of receiving care from LMHS. Several participants described dissatisfaction with being discharged without a clear treatment plan and called for the provision of aftercare and more information about third sector organisations.

“If someone’s self-harming or whatever they shouldn’t just be discharged. They need aftercare and everything. It should be in their care plan.” – Participant 2.

Some described desirable characteristics of LMHS staff, which included compassion, knowledge, and clearer communication of delays and anticipated next steps. Service users expressed a desire to be treated as an individual and to be listened to attentively.

“You need front-line staff who have the personal interactive skills to acknowledge, to offer comfort and explain what is going to happen, not front-line staff who make you more agitated or that they are confused” – Participant 5.

Other desirable characteristics of the service identified include universal service provision across the country, a switch of focus from medications to psychosocial interventions, and a separate service for those who do not meet the criteria for admission but who feel unsafe to return home. Some service users voiced support for an acute mental health service separate from the ED.

Theme three: core-24 service standard

This theme encapsulates views towards the Core-24 service standard and the subthemes are the 1-hour wait, perceived benefits, unintended consequences , and policymaker detachment.

1-hour wait

Although professionals acknowledged the importance of targets, many felt that the one-hour target was unattainable, particularly for those with complex presentations or substance issues. Some felt that it was inappropriate to assume that service users’ needs are constant throughout the day. There was a consensus that immediacy was prioritised over clinical importance, which manifests as brief introductions within the hour instead of careful, comprehensive assessments.

“It’s not about how quickly you are seen, it’s about the quality of the interaction and I think if you are having to respond to patients in an hour that can sometimes compromise the quality” – Participant 16.

In contrast, service users almost universally expressed a wish to receive contact from the LMHS as soon as possible, and even a one hour wait felt too long to wait if someone was very distressed.

“When you are thinking of taking your own life, an hour is a lifetime” – Participant 1.

Perceived benefits (staff only)

The most salient benefit reported by the healthcare professionals was investment in the LMHS. They described more financial investment into the service, and the creation of staff posts to expand the workforce, contributing to feelings of reassurance and comfort. Although participants acknowledged the associated challenges of training new staff, overall, this change was perceived as positive.

“The investment within the services has enabled us to, erm you know, to broaden out what we do” – Participant 17.

Generally, professionals explained that the service standard improved patient flow. They felt that one-hour reviews were conducive to faster discharges and the prevention of unnecessary hospital admissions. They also reported a greater focus on the service user experience and acknowledged the target as an opportunity to improve the service further.

“I think that’s been a huge positive for the team because it’s made them think, actually, okay, we need to do this. How are we going to do it in the best way possible to get the service users experience and the standard of care for them as best as we can?” – Participant 14.

Unintended consequences (staff only)

Professionals also reported numerous undesired sequelae to the Core-24 one hour target. The first was that the target acted as an incentive for people to use the ED for their mental health needs in the knowledge that they would be seen quickly. This contributed to a rise in the clinical workload for both ED and LMHS staff.

“It was an odd thing to do when you’re trying to decrease attendances, it’s like a bit of an incentive to [attend the ED]” – Participant 11.

Some explained that the target had a detrimental impact on servicing providing ward cover, as LMHS staff are diverted from wards to the ED for initial reviews for new presentations. This results in delays on the wards and subsequently prolongs admissions.

“They used to see people who were in the beds before the parvolex (a treatment following a paracetamol overdose) ended, but they’re just unable to do that now because of the amount of people in A&E to be seen” – Participant 10.

The target has also had ramifications on working hours, with some participants reporting that their shifts were extended from eight to twelve hours, resulting in more lone working and reduced staff morale. This was identified as the reason for some staff members deciding to leave their jobs.

Policymaker detachment (staff only)

Generally, professionals felt that Core-24 was implemented poorly by policymakers and commissioners who were disconnected from the service. They described that no attempts were made to seek the views of clinicians, and that it was delivered as a compulsory change.

“The way that this change was brought in was very top-down, there was very little engagement with the team” – Participant 16.

One professional reported that they were informed with little notice that older people would be included in the remit of LMHS following the standard, and they received no formal training for this. The disconnect between policymakers and clinicians resulted in resentment among staff.

Service users echoed this idea by suggesting that policymakers were detached from the views and priorities of those seeking care. Some mentioned that these should be incorporated into decisions about LMHS provision:

“I think that the service should get more involvement from the service user’s experience” – Participant 6.

Theme four: stigma of mental illness

The final theme describes the stigma associated with mental health problems. The subthemes were discrimination and the mental-physical dichotomy .


Service users commonly felt discriminated against for having mental health problems. They described being treated differently to those with physical health problems, with their issues not being taken as seriously. Some recalled being dismissed and feeling guilty for accessing services.

“If you’re physically ill that counts, it’s given a higher priority over mental illness” – Participant 4.

Professionals also acknowledged the discrimination against those with mental health problems in the general hospital setting. They commented that service users with mental health needs are generally perceived as problematic and unwanted in the ED.

“Patients with mental health difficulties in the emergency department are the difficult ones, the bad ones, the ones that upset the data, or the ones that don’t move out quick enough” – Participant 15.

The mental-physical dichotomy

This subtheme describes the clear delineation between physical and mental health in the context of healthcare services. Both professionals and service users commented that mental health needs are frequently neglected in physical healthcare settings. This is attributed to a perceived unwillingness to enquire about psychiatric symptoms and a tendency to ignore biopsychosocial determinants of health.

“If I was to mention mental state, your consultants turn their faces away from me” – Participant 9.
“The traditional method of dealing with a lack of liaison psychiatry in the general hospital is to ignore the problem and just pretend it’s not there, to not notice that the patient is sad, not notice that they are anxious, to blame the patient, to discharge them early, to not take care of the wider side of psychosis difficulties that have prompted this admission” – Participant 15.

Clinicians also perceived a divide between mental and physical healthcare professionals. Some LMHS staff felt that ED clinicians had poor psychiatric knowledge and skills, that they often made inappropriate referrals with minimal information, and that their service was not understood or appreciated.

“I don’t think mental health is respected within the A&E department as a proper profession” – Participant 13.

Final analysis

The final stage of analysis is summarised in Table  3 , which shows comparisons across the service user and staff groups whilst also reflecting the strength of the signals from the data (determined by the proportion of participants who voiced these opinions). It shows some striking differences in patterns but also several areas of agreement. The one-hour access target is seen differently by service users and staff whilst issues related to stigma are perceived as important by both groups.

How our results compare

There are relatively few qualitative studies of LMHS, so this study is an important addition to the field. The variable experiences of LMHS users in this study are similar to those described by Eales and colleagues [ 5 ] and consistent with the recently published online survey of LMHS users [ 3 ]; some people reported good treatment and care from LMHS, whilst others report poor care and an unhelpful experience. Despite the increased funding for LMHS in recent years, people’s experiences remain patchy and well below the satisfaction levels reported by users of services in Australia [ 7 , 17 , 18 , 19 ]. However, it is difficult to compare services between countries with different healthcare systems.

Most service users felt that the ED environment contributed to additional stress and was an inappropriate place for people with acute mental health problems. This is consistent with previous studies [ 20 , 21 ], which have highlighted the negative and stressful aspects of the ED for people with mental health issues and described the ED as overstimulating and lacking in comfort and privacy. This is set against a backdrop of a recent survey carried out by the Royal College of Psychiatrists which reported that more than three quarters of people referred to mental health services resort to using emergency services because their mental health deteriorates whilst waiting for an initial assessment [ 22 ].

Wait-time targets

Opinions about the appropriateness and helpfulness of the one-hour performance target for LMHS varied between service users and staff. Service users highlighted the importance of being seen as quickly as possible in ED, particularly because the environment was stressful, but also because they were in a heightened state of distress and needed urgent relief. Some staff, however, believed the one-hour target distorted clinical practice with performance taking precedence over clinical need. This resulted in many unintended consequences including encouraging an increase in mental health ED attendances and a detrimental effect on other parts of the liaison service.

These findings support a logic model we previously developed to explain the impact an increase in liaison mental health provision may have on specific target response times [ 13 ]. Increased staffing levels initially enable LMHS to see more service users within the designated response target time, but various tensions and trade-offs within the system become apparent over time. If more service users attend ED due to the quicker response time, coupled with long waits in the community, pressure on the system increases again. This pressure causes a tension between the balance of ED work and the needs of patients with severe mental health problems who are inpatients in the acute hospital. The focus on ED and meeting the response target may result in potential disruptions to the care of hospital inpatients with deleterious clinical consequences and increased length of hospital stays. The introduction of a response target inevitably leads to unintended consequences in other parts of the healthcare system; the balance of advantages and disadvantages of the target across the whole system needs to be considered.

Public stigma and discrimination against people with mental illness is not a new phenomenon and is still widespread in society [ 23 ]. A review of 42 studies of ED staff attitudes towards service users presenting with mental health problems, 14 of which were conducted in the UK, reported widespread perceived negativity, although positive experiences were also acknowledged [ 24 ]. The findings from our study suggests negative attitudes towards people with mental health problems are still problematic in the ED setting. A recent qualitative systematic review exploring stigma and discrimination experienced by mentally ill individuals seeking care for physical and mental health concerns suggests that stigma and discrimination significantly compromise the quality of healthcare relationships with services users [ 25 ].

What can be done?

The Royal College of Emergence Medicine has produced a useful toolkit for improving care of people with mental health problems whilst in the ED, which stresses that all people with either a physical or mental health problem should have access to ED staff that understand and can address their condition [ 21 ]. There is a clear driver from both the Royal College of Emergency Medicine and the Royal College of Psychiatrists to improve the care of people with mental health problems who attend ED. There has also been recognition of this problem by NHS England with funding in 2017–2018 of £18 million for 234 winter mental health schemes to help alleviate pressures in ED for people with mental health problems [ 26 ]. Most of the funding was allocated to mental health liaison schemes, community crisis resolution and discharge and step-down schemes. Although many individual schemes reported local positive benefits, there were no robust evaluations which would support national rollout of any of these schemes.

There is some evidence that small positive attitude changes towards people with mental illness can be achieved by specific stigma reduction interventions [ 27 ], although relatively few interventions have been evaluated in the ED. Most educational interventions have focused solely on knowledge acquisition for specific conditions such as substance misuse disorders [ 28 ]. However, the endemic nature of stigma towards mental illness suggests that multi-level changes are required at organisational and personal levels. The Lancet Commission on ending discrimination in mental health included a review of all forms of stigma and discrimination against people with mental health conditions in all settings and societies globally [ 23 ]. The authors made several recommendations including policy and societal changes and workplace changes. Of relevance to the ED setting, they recommend that all healthcare staff receive mandatory training on the needs and rights of people with mental conditions, co-delivered by people with lived experience of mental health issues.

The staffing recommendations for Core-24 LMHS were largely based upon the size of hospital and the knowledge that mental health issues account for 4% of ED attendances. However, recent work suggests a further 4% of ED attendances consist of people attending with a physical health problem but who also have significant mental health issues [ 2 ]. This suggests that current LMHS staffing levels need to be reviewed, as Core-24 guidance may have underestimated the workload demands on LMHS, and workload is better estimated by patient throughput than the size of the hospital in terms of bed numbers or the presumed percentage of people in ED who may require liaison services [ 29 ].

Strengths and limitations

This study has several strengths. First, we met our recruitment targets, although, recruitment of service users took longer than we anticipated. There are no patient organisations that represent liaison service users, so recruitment can be challenging. However, we achieved a wide diversity of service user participants in terms of demographic characteristics and clinical problem areas. The most common clinical problems seen by liaison services in England are co-morbid physical and mental health problems, self-harm and cognitive problems [ 29 ]. Participants with co-morbid physical and mental health problems were represented in our participant sample. However, service users with cognitive problems were excluded from this study due to the inability to provide informed consent to participate. Second, the staff participants came from a range of professional backgrounds, including those who worked within LMHS and those who referred to LMHS. Third, we were able to explore both service user and staff perspectives about an important aspect of current service provision – the one-hour access target.

There were several limitations to the study. First, our sample size was relatively small and service user participants were only recruited from two geographical areas, and hospital staff from only two hospitals. We required members of staff who had experience of LMHS both prior to and subsequent to the introduction of Core-24, which limited the number of staff who we could interview and were willing to participate in the study. This also limited our ability to interview to the point of saturation. A larger staff sample may have resulted in other themes emerging so the findings of this study cannot therefore be generalised to other services in England, although many of the findings do accord with previous work in this area. Second, as discussed above, we were unable to recruit people with cognitive problems, making findings less relevant to liaison services for older adults. Third, interviews with participants and staff were conducted before the COVID-19 pandemic and its impact upon healthcare delivery. There was a marked drop-off in ED attendances during lockdown and the many liaison ED services were moved to other parts of the hospital to minimise spread of infection. Although there has been a clear bounce back in ED attendances among people with mental health problems post-pandemic [ 2 ], it is unclear to what extent services and service users have changed.

This study provides compelling evidence that the assessment and treatment of people who attend ED with mental health problems needs to further improve. The negative staff attitudes described are unacceptable, services for aftercare following assessment are inadequate, and the immediate experience in ED is often negative.

Particular attention should also be given to the stressful nature of the ED environment for those who are agitated or distressed. It can be argued that the ED is not the most appropriate place for people with acute mental health needs, but at present, there is often no clear alternative. Diversion schemes are under development in some areas. However, there will always be a need for many people with mental health problems to attend ED, as people with mental health issues commonly also have physical health problems, which require investigation and management in parallel with their mental health difficulties. Whilst ED service users emphatically support the one-hour response target, the imposition of such targets can have unintended consequences on other parts of the liaison service which need to be balanced to ensure parity for LMHS users in ED and those admitted in the acute hospital as inpatients.

Availability of data and materials

Data from this study are not available due to the qualitative nature of the study.


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This project is funded by the National Institute for Health Research (NIHR) HS&DR programme (project reference 13/58/08). The work was also supported by a legacy provided by the family of Dr James Haigh. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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AH, JH and EG conceived of the research. AH was the programme lead. CCM, SS and EG conducted the interviews. DR and EG conducted the analysis. DR and EG wrote the first draft of the manuscript. All authors (DR, EG, SS, CCM, JH, AH) contributed to the manuscript. All authors have read and approved the final manuscript.

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Romeu, D., Guthrie, E., Saraiva, S. et al. Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study. BMC Health Serv Res 24 , 191 (2024).

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mental health alcoholism case study

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Fetal Alcohol Spectrum Case Studies

Review and utilize these case studies for guidance on patient care and procedural steps that may be implemented in the pediatric medical home.

Case study 1: 3-year-old male with growth restriction, language delay, and emotional dysregulation

Case study 2: 8-year-old male with fas and caregivers’ concerns about behavior at home and school, case study 3: 11-year-old female with parent concerns about attention, hyperactivity, and sleep.

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CDC report finds teens use drugs — often alone — to ease stress and anxiety

Teenagers with suspected substance use problems say they turn to drugs because of a crushing need to relax and escape worries, according to research published Thursday by the Centers for Disease Control and Prevention.

The new findings follow reports of rising anxiety and depression among the nation's youth, including unprecedented levels of hopelessness .

Because those conditions are often linked to substance use in adolescence, said Sarah Connolly, lead author of the new report and an epidemic intelligence service officer within the CDC's Division of Overdose Prevention, "it might make sense that teens are looking for ways to reduce stress and anxiety."

Connolly's study, the first of its kind, expands on limited research previously done on why kids use drugs. It is based on data from the National Addictions Vigilance Intervention and Prevention Program . It includes self-assessments from 15,963 teenagers, ages 13 to 18, who answered questions online about their motivations for drug and alcohol use from 2014 through 2022.

The findings do not reflect why teenagers might experiment with drugs for the first time; all were flagged for substance use disorder and subsequent treatment.

Nearly three-quarters — 73% — said they used "to feel mellow, calm or relaxed." Forty-four percent used drugs, such as marijuana, as sleep aides.

The same percentage cited drug use as a way to "stop worrying about a problem or forget bad memories." And 40% said they used to cope with depression or anxiety.

Dr. Leslie Walker-Harding, chief academic officer and senior vice president at Seattle Children's Hospital, said that 75% of young people with a substance use disorder also have a mental health condition.

"We know that the two go together," she said. "If you have a kid who you think might not be using very much, but say they're using to feel less depressed or to stop worrying, that's a really big warning sign" that they need help.

The findings are consistent with previous research and point to an ongoing need for mental health services that target kids.

It's important to understand why teens use or misuse drugs, so the right resources and education can help them, Dr. Nora Volkow, director of the National Institute on Drug Abuse, wrote in an email.

"Early prevention interventions are crucial to support teens who may turn to drug use to cope with stress, anxiety or depression," Volkow said. Neither Volkow nor Walker-Harding were involved with the new research.

The majority — 84% — used a form of marijuana. This comes amid growing evidence linking cannabis use and psychotic disorders .

Less than half (49%) said they drank alcohol and 19% of surveyed teens reported misusing prescription drugs like pain relievers and sedatives.

"We worry about kids using cannabis, alcohol and nicotine because we know long term, it's going to take a toll on their mental health and their physical health," said Dr. Sharon Levy, chief of the Division of Addiction Medicine at Boston Children's Hospital. "What's really scary is the opioids, because the consequences of opioid use are immediate and can be fatal." Levy was not involved with the CDC report.

Half of the teens said they did drugs by themselves, without anyone else around — greatly increasing their risk for deadly overdoses , "especially given the proliferation of counterfeit pills resembling prescription drugs and containing illegal drugs," the study authors wrote.

"Parents need to know this," Walker-Harding said. "A lot of kids, when they die and overdose in their home, they're in their room and nobody saw it happening."

Addiction experts, including those at the CDC , urge parents and caregivers to educate kids about the risks of using drugs alone. That includes providing naloxone to reverse opioid overdoses.

"Sometimes people perceive that this is a hard conversation. It's only hard because of our own internal difficulty with it," Walker-Harding said. "Kids will talk if they think somebody's willing to listen."

Levy advised examining the culture of drugs and alcohol in the U.S.: "If you're happy, drink to celebrate. If you're stressed, drink to relax. Oh my gosh, this candidate that I don't like is winning. I better go have a drink."

"You hear that all the time. This is the soup kids are swimming in," she said. "Parents are one of the very few potential places for counterbalance."

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A Case Study Using a Behavioural Contract in Alcohol Dependence within a Crisis Home Treatment Team

Andrew john howe.

South London and Maudsley NHS Foundation Trust, UK

Cholan Anandarajah

Associated data.

This paper is a case study and has no underlying data.

In this case study, we present a novel approach to care within a Home Treatment Team, using a behavioural contract. This is a signed, written agreement that targets specific behaviours for change. The concept draws on social learning theory in that it requires social interaction and a relationship to work. In psychiatric settings, the behavioural contract often finds use in Democratic Therapeutic Communities but rarely in crisis or acute services. In this case study, we attempted to use a behavioural contract within our Home Treatment Team to help a patient address his alcohol dependence and its subsequent effect on his daily living activities. The behavioural contract provided an alternative way to manage a crisis episode. We hope that other crisis service staff reading this case study may use a behavioural contract in their work to a similar beneficial effect.

1. Introduction

Crisis Home Treatment Teams were created in the 1980s but did not find their way into National Health Service (NHS) policy until 2000 [ 1 ]. They aim to reduce the number and duration of inpatient psychiatric admission and allow services to manage individuals in crisis better. As their name suggests, they do not engage in long term work but attempt to resolve and support patients through a crisis with an expected short duration of treatment. Home Treatment Teams (HTT) are cheaper than inpatient admissions and often have higher patient satisfaction ratings (Ibid.). The HTT in this case study covers a large borough of South London that has a diverse population. It treats between thirty to fifty patients between ages 18-65 at any one time with many different psychiatric diagnoses. Team members are from multiple health care professional backgrounds, including psychiatrists, mental health nurses, occupational therapists, social workers, drug and alcohol specialists, and psychologists. The HTT also signposts to relevant welfare and housing services as these are often critical precipitants to crises.

In this case study, we present a novel approach to care within a HTT, using a behavioural contract. This is a signed, written agreement that targets specific behaviours for change. The concept draws on social learning theory in that it requires social interaction and a relationship to work ([ 2 ], Chapter 6). Traditional contracts require that every statement within a contract is objectively verified and that there is an element of reward for success. Behavioural contracts have found use in multiple settings historically, including smoking cessation, hypertension control, lower serum cholesterol, appointment keeping, and adherence with brain and spine injury rehabilitation [ 3 – 6 ]. In psychiatric settings, the behavioural contract finds use in Democratic Therapeutic Communities (DTC) [ 2 ]. Here, the community and wish to belong are the underpinnings of the behavioural change in relation to contracts. Within DTC culture, choice-based contracts instead of coercion-based ones encourage responsible agency. Haigh and Pearce suggest that written contracts must contain phrases such as “I undertake to do x/not to do y” (Ibid, p211). If the contract includes a positive injunction, i.e., to do x, the contract must specify the frequency and circumstances. The person to whom the contract applies often proposes it. Within the DTC, all members, including staff and patients, will then consider and vote on the contract. If it is agreed on, then the community will hold the person on the contract to account.

Due to these factors above, behavioural contracts are less likely to be found in acute or crisis services. One can surmise that this is due to the lack of long-term relationships with healthcare professionals over time or the ability to foster a feeling of belonging. The HTT is relatively unique within acute services, be they for physical or mental health, in that treatment is intense, allowing relationships to be built up, and takes place in patients' home environments. Psychologically, one has the feeling of being taken on by a team that can help people in crisis. Given they operate on a consent to treatment basis, it is a team by which patients agree to treatment. This wish to be treated and get out of a crisis period relates to belonging to the team. The loss of the team in this context would therefore be something that patients would wish to avoid. In the following case, we attempted to use a behavioural contract within our HTT to help a patient address his alcohol dependence and its subsequent effect on his daily living activities.

2. Case Vignette

The following vignette details are anonymised and changed where not essential to the history to mask identity. The patient discussed has given his consent for the case to be shared in this anonymised format.

Mr. Y is a 58-year-old man who became known to the secondary mental health services following a presentation of low mood and suicidal thoughts in the context of difficulties dealing with his deceased partner's financial affairs with her family members.

Mr. Y was born in the UK with no complications and had no delays reaching his developmental milestones. He grew up with his parents and three siblings with no significant issues during his childhood. Mr. Y struggled academically at school but still achieved a few qualifications. After school, he completed a vocational qualification and worked in his chosen industry for twenty years before changing his profession due to needing to look after his father.

Mr. Y had been in a relationship for 16 years before his partner passed away, six months before his presentation to our team. Following a period of bereavement, Mr. Y initially returned to work. However, he started to have difficulties when they began to deal with his partner's will. As a result, Mr. Y started to become worried about being made to leave the house.

He received a letter from his partner's sister that she was unhappy with him living in the house and using her personal items, which triggered his low mood and subsequent suicidal thoughts. He went on sick leave but started to think about taking an overdose, jumping in front of a train or crashing his car at high speed. Mr. Y contacted his General Practitioner (GP) expressing thoughts of walking in front of a bus and was referred to accident and emergency. Initially, he was discharged back home with advice about counselling services and online cognitive behavioural therapy (CBT).

Mr. Y returned to A&E the following day with ongoing suicidal thoughts and had stopped eating. He reported that he had been consuming four-five cans of beer daily for the previous two weeks. He declined to work with HTT and was placed on the waiting list for informal admission. As a bed was still not available the following day, he was reassessed and he reported sleeping well overnight, and the suicidal thoughts were becoming less intense. As such, the least restrictive option of HTT was rediscussed, and he agreed on this occasion.

The following day, Mr. Y was assessed and accepted for HTT and then medically reviewed the day after and commenced on Mirtazapine. On this occasion, he reported consuming three cans of lager per night, but not on days when he had to work the following day.

He was initially seen daily by various members of HTT, and Mr. Y continued to express fleeting suicidal thoughts. This included seeing members of the psychology team where there were discussions about coping strategies and distraction techniques. He highlighted two goals for the future as getting back to work in the next one-two weeks and tolerating the uncertainty around the probate, which he was aware could take around two years in total.

Mr. Y's presentation worsened as he started to consume more alcohol. He would meet staff intoxicated, show clear signs of self-neglect, and at one point was noted to have injuries to his face from a fall. He was admitted informally to a psychiatric hospital to manage his risk and provide an inpatient alcohol detox. After this short admission, he was discharged back to HTT care. However, he relapsed shortly after discharge and became a dependent user of alcohol again. Given the increase in risk, this caused another admission to a psychiatric hospital to be considered, but we recognised that there was little overall benefit from this intervention previously, and the problem of alcohol use upon discharge would remain. While Mr. Y had contacted local drug and alcohol services, the contact was erratic, and options such as alcohol detox were not available. Transfer to a Community Mental Health Team (CMHT) at that particular time was also unlikely to address his problems. In terms of what a crisis service could offer, we had few options.

3. The Behavioural Contract

Given that Mr. Y had been with us for two months already, he was well known to the team members. We felt he wanted to work with us and wanted things to change, but lacked the structure and support. We came to the idea of using a behavioural contract to help Mr. Y reduce his alcohol intake at a rate that was considered safe based on approved guidelines, attend local alcohol services, and attend to his activities of daily living. We drafted a contract that we introduced to Mr. Y, who suggested removing attendance to Alcoholics Anonymous services as he did not wish to use these groups, but agreed to attend other alcohol services. We considered that alternate day contact would be an essential part of the contract as it would help foster a sense of autonomy. The contract (see Box 1 ) was then instigated with mutual agreement between the team and Mr. Y. We noted that for two weeks, Mr. Y was able to reduce his alcohol intake as per the contract and attend his local alcohol service for further support. He was no longer presenting to the team intoxicated and started to report on the various activities and goals he had achieved between visits. His living environment slowly improved to reflect this change in alcohol use and engagement with services. At the end of the two week contract period, Mr. Y was safe to be discharged back to the care of a CMHT and attend local alcohol services. He reported the contract to be beneficial and stated that he would recommend it to others to motivate change.

An external file that holds a picture, illustration, etc.
Object name is CRIPS2022-6796380.figbox.001.jpg

Behavioural contract.

Box 1 Behavioural contract.

4. Discussion

While the behavioural contract is not a novel creation, we believe its use at a time of crisis and within a crisis service is. Our case illustrates that HTT can develop significant relational attachments to their patients that they can then use to foster change. This contrasts with the common feedback we receive from patient evaluation forms that they see many different staff and do not form therapeutic relationships. While it is true that staff members do change, patients will see the team daily initially, and we inform them that they can call HTT if needed in working hours. Furthermore, we have handovers with the whole team daily where we discuss every patient, so all patients on our caseload are held in mind by the team.

One part of our contract that is different from the usual behavioural contract noted above is that we did not objectively observe Mr. Y's alcohol intake. Practically, this would have been impossible for a team that visits for around thirty minutes at a time. We did not monitor his contact with drug and alcohol services either, choosing to trust Mr. Y's account instead. Besides the practical limitations, we felt this was an appropriate course of action as it made it clear that we were operating from a mutual place of trust. While paternalistic approaches have their place, we supposed that our approach further fostered Mr. Y's autonomy in addressing his drinking. We hoped that this would promote a longer-lasting change in Mr. Y's life. This approach is in line with the use of behavioural contracts in some democratic therapeutic communities. We feel that the presumption of trust between Mr. Y and our team was also significant in the contract's success. There were some concerns from people in other teams that this may be a wasted exercise since we were not paternalistically checking his adherence via other sources. We consider the position of mutual trust can foster autonomy beyond the short time that we used the contract. The results suggest that Mr. Y did not mislead us in his reports about engagement with other services. His presentation also supports his adherence to the contract. When it comes to patient trust, one is reminded of statements around mental capacity that one must assume capacity unless there is evidence to the contrary.

We are working in a time of unprecedented demands on psychiatric services. In our Trust, there is constant pressure on inpatient beds and acute services as a whole. HTT are one solution to the inpatient bed problem, but at times, there is little practical work that can be done, and some patients can become stuck in a crisis episode. If we had not used the contract, then Mr. Y would have been a risky discharge in the context of not being able to meaningfully help him any further or he would have been admitted to a hospital bed. The behavioural contract provided an alternative way to manage a crisis episode. However, we recognise that it would be unreasonable to generalise their usability to every patient. In the case of Mr. Y, we knew him well as a team, and we had many weeks to build up a therapeutic relationship. This is not the case for many patients with HTT, where contact can be more sporadic, or patients do not want to engage with staff deeper than medication provision. Mr. Y's presentation, complicated by alcohol use, is seen reasonably frequently on our caseload. As a team, we will use this intervention again in select cases to see if we can make it a routine part of practice. Given its use in DTCs and their treatment of personality disorder, a behavioural contract may be used in crisis for this population. However, we must balance this with patients becoming attached to a crisis service that cannot hold them in the long term like a community mental health team can. In some cases, the eventual separation can be very distressing and precipitate a further crisis. With these caveats in mind, we hope that other crisis service staff reading this paper may use a behavioural contract in their work to a similar beneficial effect.

Data Availability

Conflicts of interest.

The authors declare that they have no conflicts of interest.

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Grandparents can impact mom’s mental health, study says, and El Pasoans agree

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EL PASO, (Texas) — Many agree that parents need to support their children — but what about grandparents? According to a new study, recently published , grandparents can be an important factor in the positive mental health of a mother.

The study was focused mainly on how mothers handle depression -- and anti-depressant usage. The study looked at the mother's relationship to their own parents, and how the parents/grandparents lived, behaved, supported and interacted with the young mother.

The research was conducted in Finland, and followed over 480,000 moms with young children over 14 years. From 2000-2014, the researchers collected data on mothers. They looked at whether the grandparents were in a committed relationship, age, health, employment and other factors.

What they found was that mothers could be less likely to use antidepressants, especially for those moms who had separated from their partner.

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Avery Martinez covers mental health in the Borderland as part of ABC-7’s Be Mindful initiative. He is also a Report for America corps member. RFA places talented, emerging journalists in newsrooms like ABC-7’s to report on under-covered issues and communities. Report for America is an initiative of The GroundTruth Project, an award-winning nonprofit journalism organization dedicated to rebuilding journalism from the ground up .

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Prevention of cerebrovascular diseases and cognitive impairment in psychiatric and neurological practice: A literature review

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Merkin A.G., Kazhin V.A., Komarov A.N., Fonarev A.V., Priyatel V.A., Nikiforov I.A. Prevention of cerebrovascular diseases and cognitive impairment in psychiatric and neurological practice: A literature review. Neurology, Neuropsychiatry, Psychosomatics . 2016;8(3):95-100. (In Russ.)

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A. G. Merkin Institute for Advanced Training, Federal Biomedical Agency of Russia, Moscow, Russia 91, Volokolamskoe Shosse, Moscow 125371 Russian Federation

V. A. Kazhin Institute for Advanced Training, Federal Biomedical Agency of Russia, Moscow, Russia 91, Volokolamskoe Shosse, Moscow 125371 Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia, Perm, Russia 26, Petropavlovskaya St., Perm 614990 Praxis Schaffhausen, Switzerland Bachstrasse 40, 8200 Schaffhausen, Switzerland Russian Federation

A. N. Komarov Clinical Hospital, Presidential Administration of the Russian Federation, Moscow, Russia 45, Losinoostrovskaya St., Moscow 107150 Russian Federation

A. V. Fonarev N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia, Moscow, Russia 1, Ostrovityanov St., Moscow 117997 Russian Federation

V. A. Priyatel Central Mental Hospital, Federal Biomedical Agency of Russia, Moscow, Russia 12, Kriulinsky Passage, Elektrostal, Moscow Region 144001 Russian Federation

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