Is Alcoholism a Mental Illness?

Alcohol addiction is a complex disease with psychological, biological and social components, and like other chronic illnesses, addiction often involves cycles of relapse and remission. Some people can drink alcohol—and even over-indulge on occasion—without it becoming an issue. For others, drinking can turn into mild, moderate or severe alcohol use disorder, the term doctors and clinicians now use instead of alcoholism, alcoholic or alcohol abuse.

Why do some people become addicted to alcohol or other drugs while other people don't?

Multiple risk factors come into play, including age, genetics, biology, environment and social influences, but one aspect applies across the board: alcohol affects our brain's reward center. When we eat good food, listen to music or exercise, our brain releases bursts of dopamine, a feel-good chemical that urges us to "do that again!" According to research by biological psychologists, individuals who are more susceptible to addiction—as well those who are genetically susceptible to certain mental health disorders—likely have lower levels of dopamine in their brains. These biological differences in brain chemistry are not choices.

Research also shows that when the brain reward centers for these individuals are flooded with alcohol- or drug-induced levels of dopamine, the connection between drinking, the resulting pleasure and cues linked to the experience "teach" the brain to seek drugs or alcohol at the expense of healthier goals and activities. In short, the need for addictive substances becomes hardwired in the brain, to the point that the brain can't distinguish between healthy rewards and drug rewards.

According to the National Institute on Drug Abuse, "This is why a person who misuses drugs eventually feels flat, without motivation, lifeless and/or depressed, and is unable to enjoy things that were previously pleasurable. The person needs to keep taking drugs to experience even a normal level of reward—which only makes the problem worse, a vicious cycle." 

Does the medical community recognize alcoholism as a disease?

Yes. Since 1956, the American Medical Association (AMA) has identified alcoholism as a disease characterized by compulsive decision-making, impulsive behavior and relapse. The AMA's disease theory of alcoholism is based on the following criteria:

• Biological in nature (illness exists in and of itself)
• Does not go away or heal on its own
• Exhibits observable signs or symptoms
• Is progressive (can get worse—even fatal—if left untreated)
• Has a predictable timeline of development and recovery

When was alcoholism recognized as a mental illness and not just "drunkenness"?

In 1980, the American Psychiatric Association identified substance use disorder as a primary mental health disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the authoritative guide to the diagnosis of mental health disorders in the United States. In earlier versions of the DSM, alcoholism was categorized as a subset of personality disorders.

In what way is alcoholism a mental health disorder?

Like depression and other mental illnesses, addiction is a very real medical disorder that is rooted in brain changes—but the condition is so much more complex than that. According to a definition by the American Society of Addiction Medicine (ASAM), "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors."

The past president of ASAM, Michael Miller, MD, DFASAM, explained it this way: "At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas. Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions."

Mental and emotional symptoms occur long before physical symptoms appear. If behavioral or mental symptoms aren't appropriately treated, long-term alcohol abuse can lead to physical complications such as cirrhosis of the liver, chronic brain deterioration and, the most serious consequence of all, death.

How do mental illnesses (namely depression) and alcoholism play into each other?

Rather than thinking in terms of cause-and-effect, it's helpful to view the co-occurring nature of these conditions. Mental illnesses can contribute to substance use disorders, and substance use disorders can contribute to the development of mental illnesses. For example, individuals might drink because they're depressed (to alleviate symptoms of mental health disorders). On the other hand, excessive drinking could stimulate symptoms of depression or anxiety.

According to the National Institute on Drug Abuse, "about half of all people who have one condition also have the other." When the conditions occur simultaneously, professionals refer to the diagnosis as a co-occurring disorder, comorbidity or dual diagnosis.

The National Alliance on Mental Illness reports that, "Among the 20.2 million adults in the U.S. who experienced a substance use disorder, 50.5 percent—10.2 million adults—had a co-occurring mental illness." To make the condition even more challenging, co-occurring disorders tend to exacerbate each other. When a mental health problem is ignored, the drug or alcohol addiction can worsen. When alcohol or drug use increases, the symptoms of mental illness can intensify. Having a co-occurring disorder can make treatment more complicated, but recovery is possible—particularly when your mental health and behavioral health conditions are treated at the same time by professional, licensed providers.

How is treatment for alcohol and drug abuse different from mental health treatment?

Many of the same treatment approaches and therapies are used to address substance use and mental health disorders. In fact, many treatment professionals are integrated providers, trained in both addiction and mental health treatment. A comprehensive approach to integrated treatment can also be delivered by a multidisciplinary team of clinicians and professionals working together on an individual's treatment plan.

Some differences do exist between the two types of treatment. Mental health treatment often focuses on and exploration of a person's thoughts, feelings and behaviors, focusing on ways to improve those feelings through one-on-one counseling or group therapy. This type of treatment often includes medication paired with psychotherapy.

However, integrated treatment for substance use disorders and mental health disorders share a focus on mind, body and spirit. Components that are typical of treatment of substance use disorders (and parallel components for the treatment of mental health disorders) typically include:

• Assessment – The treatment provider conducts an initial assessment, including a mental and medical screening and full-use history. This initial assessment is used to build an individualized treatment plan. Ongoing assessments are needed to ensure treatment needs are met.
• Stabilization – Detox from alcohol or other drugs can be uncomfortable and, when unsupervised, even life-threatening. Addiction treatment providers should provide medical observation during the detox process—as well as medication—to ease the discomfort of withdrawal and cravings. Stabilization, often with medications, and at times hospitalization, is also a crucial first step in addressing co-occurring mental health disorders.
• Education – Understanding the diseases of addiction and co-occurring disorders is important for dispelling myths about these diseases and helping patients shed feelings of guilt and shame.
• Behavioral therapy – Both one-on-one and group therapy can help patients explore issues and find alternative ways of thinking to positively influence future behaviors.
• Fellowship – Twelve Step Facilitation, an evidence-based therapy used in many addiction treatment programs, is rooted in the positive influence of fellowship and mutual support. You are not alone. Fellowship and group therapies are equally important in addressing mental health disorders.
• Continuing Care – Because addiction and mental health disorders are chronic diseases, the ongoing management of symptoms is a necessary aspect of the recovery process. While there is no cure, these illnesses can be effectively managed just like other diseases.