‘How ready are you to change your drinking right now out of 10, where 10 is ready to change now and 0 is not at all ready to change my drinking?’
If patients are clearly resistant to the idea of changing their alcohol use, respectfully acknowledge their decision and offer to be of assistance in future if they later choose to change their drinking.
If patients are ambivalent about changing their drinking, further assess the pros and cons of drinking versus changing their drinking habits, increase their belief in their ability to change and offer information about the effects of alcohol on their health if they agree to this.
If patients are ready to change their drinking right now, offer advice and suggestions on how to achieve this and set concrete measurable drinking goals. There are a number of telephone and online support services for patients who wish to change their alcohol use, and for carers and treatment providers including GPs. Some of these resources are listed in Box 3.
Other key questions to ask patients regarding their alcohol consumption during the COVID-19 pandemic are provided in Box 4.
Comorbid mental health problems
Alcohol use and mental health problems often occur together, with depression and anxiety the most commonly co-occurring conditions.20 Globally, mental health has worsened during the COVID-19 pandemic. Increased rates of stress, anxiety, depression, post-traumatic stress disorder and insomnia have been reported, even among people without a pre-existing mental health problems.21-23 Rates of suicide have not increased since the pandemic in Australia as originally expected; however, rates of help-seeking for suicidal ideation increased dramatically during 2020.24
Given the negative impact of the COVID-19 pandemic on the mental health of people in Australia and the co-occurrence of mental health and alcohol problems, it is vital that GPs are prepared to assess and manage mental health problems in addition to alcohol use.
GPs can confidently ask about symptoms using mental health screeners, such as the Kessler Psychological Distress Scale (K10) and the Depression, Anxiety and Stress Scale 21 (DASS21), which can be used routinely to assess patients who overuse alcohol.25,26 The relationship between a patient’s level of social isolation and anxiety, depression and alcohol use may be assessed during consultations. GPs should also routinely assess suicide risk and implement suicide prevention plans for patients presenting with suicidal ideation.
Elevated levels of the following biomarkers are only seen in a minority of patients with excessive alcohol use:
- serum gamma glutamyl transferase (GGT) level
- mean corpuscular volume (MCV)
- aspartate aminotransferase (AST) level.
Normal results do not exclude significant AUD. It is important for the patient to understand this may be a false reassurance as these tests do not identify alcohol-related damage to social function, mood, brain function or cardiovascular health.
Even when elevated, biomarkers may reflect nonalcohol-related pathology, but if AUD is confirmed, they do suggest liver disease or other physical toxicity. Results from the above tests can be used to motivate patients with AUD who may be ambivalent about moderating their alcohol intake, and appropriate biochemical testing should be considered before embarking on a goal of reduced drinking, to exclude significant health problems. If test results are abnormal, additional investigation may be warranted. Progress testing is very helpful in identifying response to intervention.