Midlife-Onset Alcohol Dependence: Causes and Consequences

What drives the onset of alcohol dependence in midlife? How does it present unique challenges, and what strategies can help when it disrupts the lives of individuals and their families?  

In this episode of Under the Cortex, host Özge Gürcanlı Fischer Baum speaks with Lara Khalifeh and Leah Richmond-Rakerd from the University of Michigan, authors of a recent article in Clinical Psychological Science. Together, they discuss the role of aging, life transitions, and retirement as possible contributors to the distinct profile of midlife-onset alcohol dependence.

Send us your thoughts and questions at [email protected].

Unedited Transcript

[00:00:00.270] – APS’s Özge Gürcanlı Fischer Baum

[00:00:00.270] – APS’s Özge Gürcanlı Fischer Baum

Alcohol dependence is a widespread problem that affects many individuals globally. While it is common to hear about this issue in younger years, dependence can also develop later in life. Does alcohol dependence that arises later bring unique challenges and affect overall health and well-being in distinct ways? This is Under the Cortex. I’m Özge Gürcanlı Fischer-Baum with the Association for Psychological Science. To discuss what factors make individuals more vulnerable to develop alcohol problems later in life, I’m joined by Lara Khalifeh and Leah Richmond-Rakerd from University of Michigan. Lara recently published an article on midlife onset alcohol dependence in APS’s journal, Clinical Psychological Science, in collaboration with Leah. Lara and Leah, thank you for joining me today. Welcome to Under the Cortex.

[00:01:03.460] – Leah Richmond-Rakerd

Thank you for having us.

[00:01:04.620] – Lara Khalifeh

Yeah. Thank you for hosting us.

[00:01:06.990] – APS’s Özge Gürcanlı Fischer Baum

Could you tell us a bit about yourself? What type of psychologist are you?

[00:01:12.040] – Lara Khalifeh

I’m a doctoral student in clinical science at the University of Michigan. I feel like as a doctoral student, you wear many hats, but the two primary ones are the researcher hat and the clinician hat. Research-wise, I really just want to focus on understanding the developmental origins of problematic substance use, and specifically alcohol use, and uncovering the why behind people resorting to alcohol at different stages in their life.

[00:01:41.960] – APS’s Özge Gürcanlı Fischer Baum

What about you, Leah?

[00:01:44.040] – Leah Richmond-Rakerd

Yes, I’m a clinical psychologist and assistant professor at the University of Michigan. I’m also Lara’s doctoral mentor. I study the development of self-regulation difficulties such as substance misuse, antisocial behavior, and self-harm, as well as their impacts on life health. I use different methodologies in my research. Those include longitudinal, genetically informative, and nationwide administrative register study designs.

[00:02:11.510] – APS’s Özge Gürcanlı Fischer Baum

Yeah, thank you. What initially got you What are your thoughts on studying alcohol dependence, Lara?

[00:02:19.290] – Lara Khalifeh

Well, a great question. I think I’ve always had this long term interest in understanding externalizing disorders, generally. As I was exploring the world of externalizing disorders that led me to the world of substance use disorders, specifically problematic alcohol use. And as I was examining the literature, I noticed that in our field, we often look at alcohol-related problems as a young person’s problem. So I dug deeper into that research, and I realized it doesn’t just belong to one developmental stage in life, and it can come up in unexpected stages of life, like midlife, at a time when people are expected to have things figured out. That’s when I really became fascinated by this idea and wanted to understand this understudied group more.

[00:03:10.920] – APS’s Özge Gürcanlı Fischer Baum

Yeah. Can you highlight the key differences in the prevalence of alcohol independence at various life stages then? What are the differences that we see?

[00:03:21.960] – Lara Khalifeh

I feel like many of us may be familiar with the alcohol curve, where alcohol tends to peak in the late teens and early 20s. And that’s when most of us are experiencing the highs and lows of this newfound freedom. We move out of our house, we’re off to college, we have that freedom that we never had. There is a belief that after that stage of life, so that after the early 20s, the alcohol use tapers off. And that is what we see if we follow people up until early adulthood, up until age 32, but not everyone follows that pattern. And prior research just has not followed people enough into their midlife. And growing research, including our own, did that. And then that’s when we saw the significant uptick at midlife, where it seems like some of us hit our late 30s and early 40s to mid-40s and face the realities of growing older, and suddenly people start finding themselves resorting to alcohol to cope with the stress of this new stage of life. And we see this pattern not in just one country, but in multiple countries like the United States, the UK, and New Zealand.

[00:04:33.720] – APS’s Özge Gürcanlı Fischer Baum

Yeah, your population is really very interesting. As you said, you looked at a cross-cultural sample, which is very important in terms of understanding these issues. It is important that the research reflects what we observe, what we see in real life. You are talking about my age group. I definitely see people using alcohol. I’m not saying everybody is dependent on it, but is definitely alcohol usage. Then, Lara, can you tell us what distinguishes individuals with midlife onset alcohol dependence from those with early onset alcohol dependence?

[00:05:12.290] – Lara Khalifeh

Well, so based on the findings from our study, it seems like people with early onset alcohol problems often have a back story shaped by a lot of early life struggles. In their early life, in their childhood and teen years, they have experiences of both internalizing issues like depression and negative affect, and they also exhibit externalizing behaviors like drug use and impulsivity. These patterns do not just remain confined to their early lives, and they extend well into their midlife. At midlife, we find that people who are engaging in early problematic alcohol use, for example, they’re aging biologically faster than those who don’t drink, and they’re not taking any steps towards the preparation for the transition for old age. That’s a bit about the early onset group. When we look at the midlife onset group, we see a bit of a different narrative. In their early life, people who start drinking at midlife may show some externalizing tendencies. They show some marijuana use in their teen years, and they also show a profile of impulsivity. But they don’t look like they’re struggling much with internalizing issues. They’re not endorsing high rates of depression depression or negative effect.

[00:06:32.300] – Lara Khalifeh

Instead, their struggle with internalizing begins later at life. So as they move into middle adulthood, that’s when they start experiencing things like anxiety, depression, and perceived levels of high stress. And at that stage of life, so at midlife, they start reporting that alcohol use is becoming a coping tool to deal with different stressors in life. And for this group, for the midlife onset group, they may show They know that they’re not aging faster than the early onset group or the never-diagnosed group, so they’re aging quite relatively well, but they’re still facing significant challenges in managing the demands that come with older age.

[00:07:14.760] – Leah Richmond-Rakerd

Lara highlighted something which I think is important, which is we were able to measure individuals pace of biological aging. We had a variety of biomarkers that have been measured over time that allowed us to track whether individuals are aging biologically biologically more quickly than their chronologically same-aged peers. And so individuals with midlife onset alcohol dependence didn’t show an accelerated pace of biological aging at midlife, but they did report poor preparedness to manage later life demands. So I think it’s an open question whether we might see greater declines in their physical health if we were to track them into later life.

[00:07:59.110] – APS’s Özge Gürcanlı Fischer Baum

Yeah. So this That is quite interesting. Your explanation was very clear, Lara, and we definitely look at different stories, it looks like. Let me ask you some follow-up questions on that. How do factors like family history, adolescent behaviors, and adult stressors contribute to mid-life onset alcohol dependence? I know you mentioned some of these in passing, but can we talk about this a little bit more?

[00:08:28.200] – Lara Khalifeh

Yeah, absolutely. I think about this as a three-legs tool where each leg represents a different risk factor. If these legs get wobbly, you’re at a high risk of falling into alcohol problems or developing alcohol problems. Family history can provide that genetic or environmental framework or groundwork to predispose individuals for these problems. We have adolescent behaviors like dysregulation and substance use that can really lay the path to future dependence. Then we have adult stressors like planning for retirement and aging concerns that might be pushing people towards drinking as a coping tool.

[00:09:12.010] – Leah Richmond-Rakerd

I think Lara described that really nicely. Something that I think is worth noting is that individuals with midlife onset alcohol dependence didn’t actually report experiencing more stressful life events than individuals without alcohol dependence, but they did perceive their lives to more stressful. It seems like that experience of perceived stress is something that’s important for this group.

[00:09:36.340] – APS’s Özge Gürcanlı Fischer Baum

Perceived stress. Can we talk a little bit more about that, Lea? How do you folks measure that?

[00:09:44.750] – Leah Richmond-Rakerd

Yes. Asking about different experiences that people have had. For instance, with respect to finances or their relationships and the extent to which they experience those events as stressful. It goes beyond asking just how many these kinds of experiences have you had to ask, How stressful were they for you?

[00:10:06.510] – APS’s Özge Gürcanlı Fischer Baum

You are taking a subjective perspective, which is important, right? Highlighting the individual. I would like to talk about your findings a little bit. Your study found that individuals with midlife onset alcohol dependence have more adult alcohol-related impairment than those with early onset alcohol dependence. Why do you think this is the case?

[00:10:32.430] – Lara Khalifeh

Great question. The way I interpret it and make sense of it is that midlife is a time in life when many people have a lot of established lives. They have careers and they have relationships that are well-established. When problematic alcohol use happens at that stage, it might disrupt a lot of these established structures, so impairment can be deeper and more consequential. An important thing to What we found is that about two-thirds of individuals with early-onset alcohol dependence did not meet criteria for problematic alcohol use at midlife, meaning that by midlife, they were admitted. That might be another reason why we didn’t see as much impairment, alcohol-related impairment, for that group at midlife.

[00:11:22.320] – APS’s Özge Gürcanlı Fischer Baum

What do we learn from the specific population of your study? Are there any cultural trends?

[00:11:28.030] – Lara Khalifeh

We employed a New Zealand-based cohort. It was Western, primarily white, born in the ’70s. With that cohort, we can highlight some important cultural trends. There is some evidence that our findings or extent to other industrialized nations and countries like the US, where we see similar prevalence rates of psychiatric conditions and alcohol use conditions as well. In these countries, drinking tends to be more socially acceptable. Maybe there’s something about the norms these countries that is contributing to the onset of these alcohol problems. That being said, there may be variations within country, so across different groups within a country. There is some evidence from the literature that minoritized individuals in both New Zealand and the US might experience higher rates of alcohol-related harm, and they can also face greater barriers to accessing treatment. While this is not something we were able to look at in our study, I think it highlights an important question for future research.

[00:12:36.480] – APS’s Özge Gürcanlı Fischer Baum

Yeah, that’s an important question about future research for sure. Let’s go back to what you have in your research because you have really interesting trends. I would like to know, across these two cultures, how does socioeconomic status influence alcohol dependence in different regions?

[00:12:55.990] – Lara Khalifeh

That’s a question I, unfortunately, could not look at in my study, but I found the existing literature on it fascinating. So I interpret what I read from the literature is that individual socioeconomic status can act as both a shield and a sword. So in higher income regions, people with higher socioeconomic status tend to drink less. And we could maybe explain that and make sense of that by having more responsibilities and job pressures and social expectations. But we see a very different pattern in low-income countries, where high individual socioeconomic status tends to be associated with higher rates of alcohol use. And that may be explained by more limited access to mental health resources or less information about the harms of alcohol. And while this is not a question we looked at, but I think it’s very interesting, and it raises the need to not just look at people’s individual SES, but also examine the broader income of the country and how that interacts with SES.

[00:14:10.110] – Leah Richmond-Rakerd

As Lara has highlighted, this relationship is complex. The The relationship that we find also depends on the alcohol outcome that we’re looking at. Some data from high-income countries indicate that low-income groups are more likely to abstain from alcohol use. But if they do drink, they tend to engage in higher risk drinking and have more adverse health consequences. Really, that relationship between individual level socioeconomic status and alcohol use within different country income levels varies function of what’s the outcome that you’re looking at. Are you looking at just any use or are you actually looking at alcohol-related problems?

[00:14:54.720] – APS’s Özge Gürcanlı Fischer Baum

Yeah, it sounds like it interacts with the systemic context. There is not a clear black and white answer to this, how the socioeconomic status affects it. You mentioned this a little bit, Lara, but I would like to highlight that because I think it is important for us to talk about midlife within its context. You mentioned that midlife is a period of role transitions, preparing for financial and health demand for older age, retirement, et cetera. How do these transitions contribute to the development of alcohol dependence?

[00:15:37.210] – Lara Khalifeh

Yeah, it’s a great question. The way I think about it is that midlife is like reaching off work in the road where different paths for the future meet, each bringing new choices and challenges. At this stage of life, people often deal with a lot of changes in their family rules, or they need to start planning for the future and their security in the future. With these new responsibilities, disabilities, things like taking care of their health, saving money for the future, so planning for retirement, and building strong support networks becomes more important. And while navigating these changes, people may also start as seeing signs of life shifting, whether it’s through changes in their own health, whether it’s in shifting family rules, like seeing their kids move out to college, or seeing their parents grow older. And these moments can bring a lot of distress, as many transitions do. For some, the pressures and uncertainty of that stage of life can lead them to starting to drink more as a way to cope with these challenges. These are some of the examples that we have about how we think these transitions may be related to alcohol use, but more research is needed to systematically investigate exactly what’s going on at that stage.

[00:16:53.910] – Leah Richmond-Rakerd

Lara, I think, described really nicely how those kinds of role changes might contribute to problematic problematic alcohol consumption at this life stage. I think it’s also worth noting that it could be reciprocal. Stress related to these shifting roles could lead individuals to drink more. At the same time, problematic alcohol consumption could lead to more difficulty managing these kinds of factors. I think Lara noted the need for future research, and I think that work could also evaluate those kinds of bi-directional associations.

[00:17:26.870] – APS’s Özge Gürcanlı Fischer Baum

Yeah, there is definitely many There are more directions that you can go with this, Lara. So great research. I have more questions, though. What interventions then do you believe are most effective in preventing or treating alcohol dependence at this particular stage of life?

[00:17:45.330] – Lara Khalifeh

Great question. We always need to think about the implications for interventions when we do studies like this. Well, based on the findings from my study, for individuals with midlife onset alcohol dependence, it seems like the use of alcohol is serving as a way to cope as they endorse that they drink to cope. And that can be explained by their higher also rates of depression and anxiety and perceived stress. I think effective interventions at that stage should not only focus on their problematic alcohol use, but should focus on the underlying emotional struggles that this population is going through. Therapies that target maybe mood regulation, like CBT, could help people find healthier ways to cope and manage their stress. I think an important thing to note is that many people in this group are less prepared to handle the financial and social demands of later life. So interventions should be more holistic, and they should, again, not only focus on alcohol treatment, but they should also focus on support for planning for the future, like retirement planning and building stronger social networks. I want to highlight that strengthening social networks and connections is especially crucial for this group, as we found that those with midlife onset alcohol dependence are often less likely to be married and have children, so they may have more social isolation.

[00:19:15.250] – Lara Khalifeh

But that’s something that future research should definitely investigate more.

[00:19:20.600] – APS’s Özge Gürcanlı Fischer Baum

Yeah, great answer. What I’m hearing is that there might be many different underlying problems that might surface as alcohol dependence, but looking at the individual understanding, what is going on in a broader setting, seems to be an important perspective on this. What about direct suggestions for individuals without an intervention? If there are people listening to us, what are the potential long-term consequences for individuals with mid-life onset alcohol dependence as they age? What are the best practices for them to get prepared for old age?

[00:20:00.330] – Lara Khalifeh

Well, again, I think it’s really about that piece that’s crucial to not only address drinking behaviors, but also improving their overall life skills. So I think building financial management skills, building stronger social networks, and even engaging in more proactive health care would be really important for this population. And I want to note that while we didn’t find that individuals in that midlife onset group have this accelerated pace of biological aging, we They would expect that if they continued drinking at a problematic level, they might start showing these detrimental effects of alcohol use. That’s why we shouldn’t ignore this group, and we need more long-term studies that follows these individuals beyond midlife to see how they’re doing after.

[00:20:49.890] – APS’s Özge Gürcanlı Fischer Baum

Yeah.

[00:20:50.960] – Leah Richmond-Rakerd

I think as Lara has highlighted, I think it’s important to emphasize that it’s never too late. Midlife is a really fruitful window to start getting being prepared for later life. There’s good evidence that behavior change, even at midlife, can have lasting benefits. For instance, individuals who have smoked for much of their life, if they quit in middle age, we see significant health benefits of that later on. We also know that, for instance, chronic diseases of aging, at least in industrialized countries, don’t tend to onset until the ’60s on average. This is a really a window of opportunity. It’s never too late to start getting prepared for later life or to address other kinds of health behaviors that might be causing stress or challenges like excessive alcohol consumption in middle age.

[00:21:45.280] – APS’s Özge Gürcanlı Fischer Baum

Leah, I really appreciate that because this is my age group, this is population we are talking about. I like how you frame it as a window of opportunity. Yes, it is not too late. We are in our prime. We are still living our Yeah, I really appreciate that.

[00:22:01.360] – Leah Richmond-Rakerd

I am approaching this stage as well.

[00:22:03.220] – APS’s Özge Gürcanlı Fischer Baum

Yes, here we are. Lara and Leah, this was a wonderful conversation. I would like to ask, finally, if there are any takeaways or final thoughts that you would like to share with our listeners.

[00:22:19.590] – Lara Khalifeh

I think a key takeaway that I want people to take from my study is that alcohol use disorder is not just a problem of youth. It can emerge at stages of life midlife, including midlife, when people are managing new stressors and road transitions. This really highlights the importance of recognizing and addressing unique challenges people face as they age, whether they’re dealing with emotional struggles or shifting social roles or financial uncertainties. We should always approach alcohol-related problems with compassion and an understanding that is often a way for people to try to cope with the difficulties of life. There’s always It’s an opportunity for change, especially at this stage of life. Midlife can really be a powerful time for people to seek support, for them to build healthier coping strategies, and prepare for a more fulfilling future.

[00:23:13.690] – APS’s Özge Gürcanlı Fischer Baum

Yeah. Thank you very much. This was a pleasure. I’m looking forward to seeing the next steps of your research, Lara. Thank you so much for joining Under the Cortex. Thank you.

[00:23:23.650] – Leah Richmond-Rakerd

Thank you for having us.

[00:23:25.760] – APS’s Özge Gürcanlı Fischer Baum

This is Özge Gürcanlı Fischer Baum with APS. I have speaking to Lara Khalifeh and Leah Richmond-Rakerd from University of Michigan. If you want to know more about this research, visit psychologicalscience.org. Do you have questions or suggestions for us? Please contact us at [email protected].