Alcohol is the third largest risk factor for premature mortality and disability globally, with 70 % of alcohol-related deaths occurring in developing countries [1]. Southeast Asian countries account for 25-33 % of males consuming alcohol worldwide [2] and rapidly rising trends are observed in women [3]. In India, nearly a third of men (32 %) aged 15–54 years report consuming alcohol with 9.4 % of them classified as ‘alcohol dependent’ [4]. The effects of alcohol abuse extends beyond the physical and mental health of the drinker [5] to include other members of the family, their household expenditures and various health outcomes such as mental health disorders and injuries [6].

Common mental health disorders, such as depression and anxiety, are a leading cause of disability in the global burden of disease [7] and there is ample evidence to suggest that women are at a higher risk for anxiety disorders and depression than men [8–11]. In both men and women, there is a potential bi-directional relationship whereby alcohol use disorders increase the risk of depression and vice versa through ‘self-medication’ to reduce stress or elevate mood [12–14], as well as a reciprocal causal relationship between depression and alcohol use disorders [12, 15]. Studies in low- and middle-income countries (LMICs) have found that the gender disadvantage and lack of autonomy puts women at higher risk for intimate partner violence, common mental disorders [16, 17] as well as suicide [18]. Socio-economic factors such as poverty, lack of economic activity, limited financial and social resources have also been found to be potential risk factors for poor psychological health of women, particularly in LMICs [19–21].

Recent data suggests that India’s rising suicide rates have led to the highest estimated number of suicides in the WHO South-East Asia Region [22]. At the individual-level, mental disorders, socio-economic status, chronic health problems and terminal illness are strong risk factors for suicide attempts in women [18, 23–25]. At the family-level, population-based studies have shown a strong relationship between alcoholism in men and the presence of intimate partner violence (IPV) [26–28] leading to depression and suicide in spouses, suggesting a potential intra-household mechanism for these outcomes in women [21, 29]. This is borne out through several studies in India, which also suggest that husband’s alcohol consumption is a trigger for domestic violence [30, 31–33] and may lead to depression and suicide of their spouses and other female family members in India [5, 21, 29, 34]. In India, as with other LMIC’s, the family/household units are often defined by multiple generations, extended families, constrained resources and traditional cultural norms whereby decision-making by one person can have major consequences on other members of the same household [3, 35]. Studies in high-income countries also demonstrate the influence of alcohol abuse of one family member on other members of the household [36, 37]. We conducted this study to evaluate the intra-household associations between hazardous drinking patterns in men with depression and suicidal attempts in female family members from rural and urban communities in Chennai, India.

In this study, nearly two thirds of men reported drinking alcohol, in whom we observed a significant dose–response relationship with depression (PHQ-9). At the household level, we did not observe a significant association with depression (PHQ-9 score) in females of the same household, although there was an increasing, non-significant trend associated with suicidal attempts. Studies [5, 34] on the link between spousal alcohol use and mental health of women is mediated by many factors including intimate partner violence, chronic physical problems [46] and women’s own alcohol use [17, 21, 47, 48].

At the individual-level (associations between depression and drinking in men), our results are consistent with the evidence, and possible explanations can include difficulties in family and social life, employment, legal troubles, compromised physical health and genetic factors [49, 50]. At the household-level (associations between depression and suicidal attempts in women and drinking in men), our findings are similar to those of Schuckit and colleagues [51] who found no association between psychiatric disorders among female spouses of male alcohol abusers, and to other studies in which spouses of male alcohol abusers present with fewer psychiatric symptoms than spouses with lower consumption levels due to certain adaptive activities that provide stability in stressful situations [52, 53]. Though non-significant, the magnitude of associations for depression in our study were greater for women living with ‘low-risk’ drinkers than those living with more hazardous drinkers (Table 3). Studies indicate that the relationship between alcohol use and partner’s depression is influenced by a number of psychosocial risk factors [16] such as spouse’s attitude towards drinking, alcohol-related marital problems, social support, resilience and IPV [54, 55]. Although intra-household evaluations did not reveal any trends or association for depression in our study, an increasing trend approached significance for suicidal attempts (Table 4). While systematic reviews from developed countries suggest that persons with mental disorders constitute the majority of persons with suicidal ideation and suicidal attempts [56, 57], the proportion may be lower in developing countries, so understanding multiple pathways for suicide is critical [58].

The evaluations in this study assume potential intra-household pathways between hazardous drinking patterns in men and depression and suicidal attempts in women. Factors involved in intra-household pathways between alcohol consumption and mental health, may include social and environmental factors [59] and bi-directional models [15, 60, 61]. A recent study of problematic drinkers also demonstrated that several factors and circumstances can give rise to both; for example, job loss, family problems, financial stress or other addictions may be potential triggers for depression, even in the absence of a detrimental role of alcohol and may also simultaneously lead to consumption of alcohol [59]. A potential bi-directional relationship between alcohol use disorders and mental depression may exist such that each disorder increases the risk of the other disorder simultaneously [15, 60]. The specific underlying mechanisms that give rise to such associations are unclear, particularly in LMIC settings, where the household unit may have different structural characteristics and dynamics. Interventions to address these behavioral and health problems, both at the individual- and household-level, requires research and evidence to unpack and identify the relevant mechanisms of interest.

One strength of this study is that data were collected on all members of the household and therefore, information on alcohol use came from the drinkers themselves and questions related to mental health from spouses and other members - there were no proxy respondents - using standardized, validated tools. This enabled a more objective evaluation of intra-household effects of alcohol abuse and offers a unique contribution to the literature from a community-based setting in a developing country. One limitation of the study is that we did not measure domestic violence or inter-personal violence (IPV), which is one important mediator of the association between alcohol abuse in men and depression in other members of the household [62]. Our self-reported responses for PHQ-9 could not be validated against a gold-standard diagnostic or clinical confirmation (such as CIDI Composite International Diagnostic Interview [63] and Beck depression Inventory (BDI) [64]), although PHQ-9 is increasingly used in community-based low-resource settings as an initial screening tool to flag persons for referral, counseling and/or follow-up [65–69]. Moreover, a meta-analysis by Gilbody, Richards, Brealey, and Hewitt (2007) showed that the pooled sensitivity of PHQ-9 as a diagnostic tool for major depression was 0.80 (95 % confidence interval [CI]: .71-.87) and specificity was 0.92 (95 % CI: 0.88 0.95) [70]. Given the sensitive nature of the question, there is likely to be under-reporting of information on suicidal attempts, and therefore the sample size is very small for detecting significant associations. Another limitation is the inability to infer causality and/or direction of the relationship, as this is a cross-sectional study design.

India has the highest suicide rates and it is the leading cause of death among young and elderly in the South-east Asia region [18, 22]. Considering the magnitude of the problem, it is important to study the mulifactorial mechanisms related to social, biological and lifestyle determinants as well as potential household-level pathways. Evidence indicates alcoholism and IPV as two potential risk factors for suicide in women in LMICs [62]. Policies and strategies aimed at improving the mental health status of women should consider the association with alcohol use (and potentially IPV) by their partners, as well as other household-level influences. Routine enquiries regarding suicidal ideation, thoughts or behavior amongst spouses of men who have drinking problems and amongst women who complain of IPV, is one potential strategy. Similarly, a broader household-based approach can be considered in which the mental health of family members can be assessed alongside services designed for the alcohol abuser. The recently released National Mental Health Policy of India [71] by the government of India also acknowledges the need to address social determinants of mental health such as poverty, environmental issues and education to improve the country’s overall health status.