This study found that women who experienced alcohol flushing were 1.3 times more likely to exhibit anxiety symptoms compared to their non-flushing counterparts. Similarly, women who consumed three or more drinks per occasion faced a 1.38-fold higher risk of experiencing anxiety symptoms compared to those who consumed fewer drinks. Moreover, both genders showed a positive association between anxiety symptoms and increased drinking frequency: men who drank four or more times per week faced a 1.87-fold higher risk of experiencing anxiety symptoms; for women, the risk was 2.42 times higher.
Despite South Korea’s high alcohol consumption rate [1] and the Korean population’s genetic vulnerability to alcohol [24], research on the association between mental health, particularly anxiety, and alcohol consumption has been lacking in Korea. However, this study shows a notable association between alcohol consumption characteristics and anxiety in the Korean population. We also highlight significant gender disparities, with alcohol flushing and quantity consumed per occasion showing significant correlation with anxiety symptoms only for women. Moreover, those identified as heavy drinkers, as defined by the Korean Alcohol Guidelines [18], exhibited pronounced association with anxiety symptoms.
Initially, we found a positive correlation between drinking frequency and anxiety for both men and women. Several explanations can be offered for this. Heavy drinkers, defined as those who drink more than four times a week, may exhibit anxiety due to alcohol withdrawal symptoms [25]. Studies on the high comorbidity of alcohol dependence and anxiety disorder [26] have suggested the need for regular exposure to drinking-related anxiety reduction and induction strategies [27]. Studies have also found that excessive and frequent alcohol consumption alters the nervous system, rendering individuals more susceptible to anxiety [28]. While some studies on the correlation between drinking frequency and anxiety, particularly in the context of social anxiety disorders, have shown a negative correlation [29, 30], this may be attributed to social facilitation expectancies acting as suppressor in individuals with high social anxiety [29]. An epidemiological study found that alcohol dependence and both social and generalized anxiety disorders have high comorbidity [26], supporting this study’s finding of positive correlation between drinking frequency and anxiety.
As for differences by gender, women are more vulnerable to alcohol-induced anxiety than men. For example, the US National Comorbidity Survey found the co-occurrence of anxiety disorders for alcohol-dependent men to be about 35.8% and that for alcohol-dependent women to be as high as 60.7% [15]. Several factors could contribute to this difference by gender. First, men and women drink for different psychological reasons. Women are more likely to drink heavily to overcome unpleasant emotions or psychological distress, to face the stress of conflicts with others, or to relieve internal tension, whereas men more often drink in response to pleasant emotions or from social pressure [31]. Thus, women are more likely to rely on alcohol to manage anxiety compared to men.
Furthermore, the alcohol-metabolizing enzymes act differently by gender. The alcohol dehydrogenase activity in the gastric mucous membrane of women is approximately half that of men. Therefore, with a lower rate of alcohol metabolism, women absorb greater amount of alcohol than men, even though they might consume alcohol equally [32]. Moreover, the blood alcohol concentration tends to be higher for women than men when drinking [14]. This explains the significant correlation between alcohol flushing and anxiety in women as found in this study. Alcohol flushing is caused by acetaldehyde, an intermediate alcohol breakdown metabolite. Acetaldehyde may directly contribute to anxiety or depressive states through the activity of two major stress-related peptides: corticotropin-releasing hormone and neuropeptide Y [33]. Given that women’s alcohol metabolism is less efficient [32, 34], they could be more affected by high blood acetaldehyde levels, that is, alcohol flushing.
The significant correlation between number of drinks per occasion and anxiety found only for women in this study could be attributed to the fact that we categorized both men and women who consumed more than three glasses as heavy drinkers. As women generally have less body water and lower alcohol breakdown rates than men [35], they could be more susceptible to the negative effects of alcohol consumption, such as acetaldehyde.
Covariates other than the alcohol consumption characteristics also play significant roles. Anxiety levels decrease with age for men. This decrease in anxiety with age, which is consistent with a previous research finding [36], could be due to the reduction in acute stress perception with age [37]. Unmarried women exhibit higher anxiety than married women. Women, regardless of race, experience chronic stress from being unmarried [38]. This study, found a high OR for anxiety in the stress perception group, regardless of gender is also consistent with a previous research [39]. Chronic medical illnesses were found to be positively correlated with anxiety levels for both genders, underscoring the multi-dimensional nature of mental health and the need for comprehensive intervention [40].
One of the strengths of this study is its utilization of comprehensive and nationally representative data from KNHANES. Moreover, the analysis, by focusing on the differences in association between alcohol consumption characteristics and anxiety by gender, enriches our understanding of the disparities and nuances between men and women. Furthermore, the study’s broad perspective by investigating various covariates and their differential association with anxiety across gender offers a more comprehensive understanding of the factors. Nevertheless, the study has several limitations. The cross-sectional nature of the data used impedes us from establishing definitive causality between the studied variables. Moreover, recall bias could have affected the self-reported alcohol consumption and flushing characteristics data. Our categorization of participants based on the Korean alcohol guideline, especially regarding drinking frequency and quantity, may not fully encapsulate the inherent metabolic differences by gender.
In conclusion, this study shows that alcohol flushing and number of drinks per occasion are positively associated with anxiety symptoms only in women, while drinking frequency is significantly associated with anxiety symptoms for both genders in South Korea. These findings offer crucial insights for mental health practices in regions with high alcohol consumption rates that pay limited attention to mental health. They also lay the foundation for creating targeted intervention focusing alcohol flushing and gender factors to minimize the negative mental health impacts of excessive drinking.