Alcohol misuse and global mental health: Achieving parity in research and practice

Unhealthy alcohol use and disorder are significant contributors to the global burden of disease due to the disabling nature of living with an alcohol use disorder and its role in the etiology of over 200 health conditions. Alcohol use problems commonly co-occur with mental disorders, yet alcohol remains neglected from research and programming in the field of global mental health. The objective of this dissertation is to explore the significance and impact that alcohol use may have on existing mental health research and programming in low- and middle-income countries and identify alcohol interventions that may be amenable for integration into global mental health to address this neglected public health challenge. In Chapter One we will introduce the problem of neglecting unhealthy alcohol use in global mental health research and practice and further detail the specific aims of this dissertation. In Chapter Two we will review the literature on concepts related to the three specific aims, which examine the relationship between alcohol use and partner violence, the role of alcohol use as a moderator of the effects of psychosocial interventions on depression, and treatment options for addressing hazardous alcohol use and disorder. In Chapter Three we examine the public health significance of co-occurring alcohol use and partner violence, an outcome of interest in global mental health by estimating an unbiased measure of the association between alcohol use and partner violence in 31 low- and middle-income countries using propensity score and meta-analytic methods. We found that partner alcohol use is associated with a 2.6-fold increase in odds of experiencing partner violence in low- and middle-income countries, with substantial heterogeneity observed between world regions. In Chapter Four we investigate whether a perinatal home visiting intervention in South Africa is as effective in reducing depressive symptoms for women with unhealthy alcohol use relative to women who do not drink or display non-problematic alcohol use patterns using structural equation modeling. We found that this perinatal psychosocial intervention was associated with significant reductions in depressive symptoms for women with no or non-problematic alcohol use; however, there was no impact of the intervention on depressive symptoms for women reporting hazardous alcohol use patterns. In Chapter Five we conduct a systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of alcohol treatment and indicated prevention interventions (pharmacological and non-pharmacological) in low- and middle-income countries to identify promising strategies for reducing the burden of alcohol use in these settings. Brief interventions are the most commonly evaluated intervention for alcohol use problems in low- and middle-income countries. In general, interventions were associated with marginally significant or significant improvements in alcohol-related outcomes. Lastly, in Chapter Six, we discuss the implications of these findings when considered together for both research and practice in global mental health