COVID-19’s Continuing Toll: Increasing Alcohol Use and Liver Disease Disproportionately Affect Women

Fatty liver, conceptual illustration. Fatty liver is commonly associated with alcohol or metabolic syndrome (diabetes, hypertension and obesity), but can also be due to any one of many causes. Fatty liver disease is a reversible condition wherein large vacuoles of fat (pale yellow circles) accumulate in liver cells.
To discuss the potential factors driving the increasing alcohol use among women as well as potential solutions, we interviewed David Streem, MD, and Leena P. Mittal, MD, FACLP.

Substantial increases in mental health concerns and substance abuse have been widely noted since the start of the COVID-19 pandemic. Public survey results have demonstrated elevated rates of depression and anxiety after the crisis began, and other research has revealed drastic increases in cases of drug overdose and related deaths.1,2

Alcohol consumption has increased considerably in the context of COVID-19. There was a 54% surge in national alcohol sales during first week of pandemic, and subsequent reports indicated persistent increases in rates of alcohol intake.3 A survey-based study published in September 2020 in JAMA Network Open found that the frequency of alcohol consumption increased by 14% overall among US adults during the period of May 28 to June 16, 2020, when compared with a baseline period during the previous year.4

Especially high increases were observed among women in terms of frequency (17% vs 11% among men), days of heavy drinking (41% vs 7% among men), and alcohol-related consequences. Women also demonstrated a 39% increase (compared to 27% among men) in scores on the 15-Item Short Inventory of Problems scale, which is “indicative of increased alcohol-related problems independent of consumption level for nearly 1 in 10 women,” according to the paper.4

However, previous findings had revealed increasing rates of alcohol use, abuse, and dependence, along with related consequences — including alcohol-associated liver disease (ALD) — among women even before the pandemic began.5 Although ALD has historically had a higher prevalence in men compared with women, women now “represent a rapidly growing subset of patients with alcohol-associated liver disease,” as stated in a review published in April 2021 in Mayo Clinic Proceedings.6

The risk of developing ALD is higher in women compared with men across all levels of alcohol consumption.7 “Studies show that women develop liver disease with lesser alcohol exposure and suffer worse disease as compared with men,” the study authors wrote.6 Although rates of mortality related to ALD remain higher in men compared with women, this gap has also narrowed in recent decades, especially among adults aged 25 to 34 years.8

To discuss the potential factors driving the increasing alcohol use among women as well as potential solutions, we interviewed the following experts: David Streem, MD, chief of psychiatry at Cleveland Clinic Lutheran Hospital, medical director of the Alcohol and Drug Recovery Center at Cleveland Clinic, and clinical associate professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; and Leena P. Mittal, MD, FACLP, chief of the Division of Women’s Mental Health at Brigham and Women’s Hospital and an instructor in the department of psychiatry at Harvard Medical School in Boston.

In regard to the reported increases in alcohol use and abuse among women, what are believed to be the reasons for these trends?

Dr Streem: The presence of co-occurring psychiatric problems is higher among females with alcohol use disorder (AUD) as compared to males.9 We know that in the last year, the availability of interpersonal support for these women — including individual psychotherapy as well as in-person peer support — has been lower due to the pandemic. When AUD patients do not get the therapy they require to sustain their sobriety, relapse rates can increase. These barriers likely have disproportionately affected women.

Dr Mittal: Alcohol use in women is complicated, as there is a social acceptance of alcohol use as a coping strategy, and this is reflected even in the marketing of alcohol products to women, such as “Mommy Wine Culture.” In the early days of the pandemic, there was continued access to alcohol even when other substances were harder to obtain.    

In the pandemic we have also seen that the multiple roles and functions taking place in the home — childcare, education, household responsibilities, and wage-earning responsibilities — have fallen disproportionately to women, resulting in higher stress levels.   

How might this increase in alcohol use interact with other mental health issues in women?

Dr Mittal: There is a bidirectional relationship between mental health symptoms and alcohol use. There is an increased risk of alcohol use amongst those with psychiatric diagnosis, and also an increased risk of mental health symptoms and disorders among those who use alcohol and other substances.10

In COVID-19, with increased stress, many people experienced a desire to seek behavioral health care but the need has outstripped capacity; wait times for therapy and medication treatment are very long. The expansion of telemedicine options has served to increase access in some ways, but this can be harder for more vulnerable populations.

For women who are disproportionately the primary care providers for family (children, aging parents), it is difficult to access care from home when privacy and competing responsibilities make it challenging. Another challenge is finding childcare coverage to enable engagement in care; it is either unavailable or not affordable.    

What are the implications for mental health professionals about how to address these issues in practice?  

Dr Streem: It is very important that virtual services continue to be reimbursed and supported after the pandemic ends. The rapid adoption of this technology has improved the availability of services to people in rural and isolated areas, as well as to people with transportation limitations.

However, it is equally important that mental health professionals do what they can to reintroduce impactful in-person therapy services for those who may need it. Virtual services won’t be adequate for everyone, and this is particularly true for mutual help meetings like Alcoholics Anonymous and family support groups.

Dr Mittal: Mental health care and substance use treatment have been siloed in the past, so it is ever more important for behavioral health providers to screen patients for alcohol and substance use at regular intervals.  

What are other notable needs in this area in terms of treatment, public health measures, or research?  

Dr Streem: I don’t think we can begin any discussion of needed public health measures in 2021 without starting with the absolutely essential COVID-19 vaccination effort. All needed improvements in services are facilitated by a high vaccination rate.

I also think there is a need for progress in discovering factors which differentiate people who are likely to benefit from specific medication treatments vs the general population. Right now, naltrexone is typically offered to nearly all AUD patients because studies show a small but statistically significant benefit in a general population of adult AUD patients.

If we could consistently identify some gene or other characteristic that would allow us to exclude patients who would not benefit from naltrexone, and increase the effect size of the remaining cohort, we could offer more benefit at lower risk and cost to society.

Dr Mittal: Regular screening for alcohol use is needed, and there is a lack of consensus about how much alcohol is too much. We also need more treatment availability, more access to treatment, and less stigmatization of treatment. There are significant barriers to engagement in care, including a paucity of gender-responsive and trauma-informed care settings.

Women have particular needs in recovery that often differ from the needs of males in recovery, and only about one-third of people in mutual help meetings identify as female.11 That’s one reason why supporting women-only mutual help groups is so important. 


  1. Rodriguez T. Suicide prevention in the context of COVID-19. Psychiatry Advisor. Published online January 20, 2021. Accessed May 14, 2021.
  2. Rodriguez T. The epidemic within the pandemic: increasing overdose deaths. Psychiatry Advisor. Published online April 2, 2021. Accessed May 14, 2021.
  3. Avena NM, Simkus J, Lewandowski A, Gold MS, Potenza MN. Substance use disorders and behavioral addictions during the COVID-19 pandemic and COVID-19-related restrictions. Front Psychiatry. Published online April 14, 2021. doi:10.3389/fpsyt.2021.653674
  4. Pollard MS, Tucker JS, Green HD Jr. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942
  5. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013: results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(9):911-923. doi:10.1001/jamapsychiatry.2017.2161
  6. Kezer CA, Simonetto DA, Shah VH. Sex differences in alcohol consumption and alcohol-associated liver disease. Mayo Clin Proc. 2021;96(4):1006-1016. doi:10.1016/j.mayocp.2020.08.020
  7. Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2020;71(1):306-333. doi:10.1002/hep.30866
  8. Yoon YH, Chen CM, Slater ME, Jung MK, White AM. Trends in premature deaths from alcoholic liver disease in the U.S., 1999-2018. Am J Prev Med. 2020;59(4):469-480. doi:10.1016/j.amepre.2020.04.024
  9. Castillo-Carniglia A, Keyes KM, Hasin DS, Cerdá M. Psychiatric comorbidities in alcohol use disorder. Lancet Psychiatry. 2019;6(12):1068-1080. doi:10.1016/S2215-0366(19)30222-6
  10. Jeanblanc J. Comorbidity between psychiatric diseases and alcohol use disorders: impact of adolescent alcohol consumptionCurr Addict Rep. 2015;2:293-301. doi:10.1007/s40429-015-0076-5
  11. Donovan DM, Ingalsbe MH, Benbow J, Daley DC. 12-step interventions and mutual support programs for substance use disorders: an overview. Soc Work Public Health. 2013;28(3-4):313-332. doi:10.1080/19371918.2013.774663

This article originally appeared on Psychiatry Advisor