{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T05:54:58Z","timestamp":1787032498784,"version":"build-2736575974"},"posted":{"date-parts":[[2026,7,29]]},"group-title":"Epidemiology","reference-count":78,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:00:00Z","timestamp":1785283200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.medrxiv.org\/about\/FAQ#license"}],"funder":[{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"crossref","award":["UH3AI133675"],"award-info":[{"award-number":["UH3AI133675"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"crossref","award":["RF1MH132360"],"award-info":[{"award-number":["RF1MH132360"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"crossref"}]},{"name":"National Institute of Child Health and Human Development","award":["P2C HD050924"],"award-info":[{"award-number":["P2C HD050924"]}]},{"id":[{"id":"https:\/\/ror.org\/01xdqrp08","id-type":"ROR","asserted-by":"publisher"}]},{"name":"CUNY Institute for Implementation Science in Population Health"},{"name":"CUNY Graduate School of Public Health and Health Policy Department of Epidemiology and Biostatistics"},{"name":"COVID-19 Grant Program of the CUNY Graduate School of Public Health and Health Policy"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,7,29]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Observational studies frequently report a J- or U- shaped association between alcohol use and anxiety and depression, with moderate drinkers appearing to have lower risk than abstainers. However, this pattern may be driven in part by confounding due to health-related selection into abstinence or low-risk drinking (sick-quitter bias), whereby individuals reduce or stop drinking in response to declining health that is independently associated with worse mental health outcomes. We aimed to evaluate whether this association reflects a causal effect or residual confounding driven by sick-quitter bias.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We analyzed data from 4,673 participants in the CHASING COVID Cohort, a U.S. longitudinal study with repeated measures from September 2021 through December 2023. Alcohol use was assessed at five timepoints using the AUDIT-C and categorized as abstinent, low-risk, moderate-risk, or high\/severe-risk. Using a target trial emulation framework, we estimated the effects of sustained alcohol use strategies on anxiety and depression symptom severity (GAD-7 and PHQ-8) at follow-up. Artificial censoring and stabilized inverse probability weighting were applied to account for time-varying confounding and loss to follow-up. To assess the role of sick-quitter bias, we compared the abstinent versus moderate-risk contrast across strata of health status at time zero.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>In the full sample, a J-shaped pattern was observed, with moderate-risk drinkers having the lowest predicted symptom scores. The abstinent versus moderate-risk symptom score contrast was 1.38 for depression (PHQ-8: 95% CI: 0.65, 2.14), and 0.95 for anxiety (GAD-7: 95% CI 0.24, 1.65). Among participants without underlying conditions or poor self-rated health, this pattern attenuated, with contrasts near zero for both outcomes. In contrast, the J-shaped pattern was amplified among participants with poorer baseline health, with abstinent versus moderate-risk contrasts of 3.31 for depression (95% CI: 2.14, 4.32) and 2.83 for anxiety (95% CI: 1.61, 3.86). High-risk drinking was consistently associated with higher symptom scores across all analyses.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>The J-shaped pattern between alcohol use and anxiety and depression symptoms observed in the full cohort was attenuated among participants without poorer baseline health, consistent with sick-quitter bias. Findings underscore the importance of addressing confounding due to declining health in observational alcohol research and caution against interpreting moderate drinking as beneficial for symptoms of anxiety and depression.<\/jats:p>\n                <\/jats:sec>","DOI":"10.64898\/2026.07.25.26358931","type":"posted-content","created":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T15:15:16Z","timestamp":1785338116000},"source":"Crossref","is-referenced-by-count":1,"title":["The Role of Sick-Quitter Bias in the Association Between Alcohol Use and Anxiety and Depression Symptoms: A Causal Analysis in a U.S. National Cohort"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-3726-3724","authenticated-orcid":false,"given":"Jenna","family":"Sanborn","sequence":"first","affiliation":[{"name":"Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA"},{"name":"Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3280-5386","authenticated-orcid":false,"given":"Denis","family":"Nash","sequence":"additional","affiliation":[{"name":"Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA"},{"name":"Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8426-6572","authenticated-orcid":false,"given":"McKaylee","family":"Robertson","sequence":"additional","affiliation":[{"name":"Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA"},{"name":"Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4321-125X","authenticated-orcid":false,"given":"Angela","family":"Parcesepe","sequence":"additional","affiliation":[{"name":"Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA"},{"name":"Department of Maternal and Child Health, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA"},{"name":"Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8673-6759","authenticated-orcid":false,"given":"Zachary","family":"Shahn","sequence":"additional","affiliation":[{"name":"Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA"},{"name":"Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"54368","reference":[{"key":"2026080102451079000_2026.07.25.26358931v1.1","unstructured":"Mental Illness - National Institute of Mental Health (NIMH). Accessed July 11, 2024. https:\/\/www.nimh.nih.gov\/health\/statistics\/mental-illness"},{"key":"2026080102451079000_2026.07.25.26358931v1.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(20)30925-9"},{"key":"2026080102451079000_2026.07.25.26358931v1.3","unstructured":"Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic - The Lancet. Accessed June 7, 2024. https:\/\/www.thelancet.com\/article\/S0140-6736(21)02143-7\/fulltext"},{"key":"2026080102451079000_2026.07.25.26358931v1.4","unstructured":"Major Depression - National Institute of Mental Health (NIMH). Accessed September 17, 2025. https:\/\/www.nimh.nih.gov\/health\/statistics\/major-depression"},{"key":"2026080102451079000_2026.07.25.26358931v1.5","unstructured":"Any Anxiety Disorder - National Institute of Mental Health (NIMH). Accessed September 17, 2025. https:\/\/www.nimh.nih.gov\/health\/statistics\/any-anxiety-disorder"},{"issue":"4","key":"2026080102451079000_2026.07.25.26358931v1.6","doi-asserted-by":"crossref","first-page":"391","DOI":"10.35946\/arcr.v34.4.03","article-title":"Stress and alcohol: epidemiologic evidence","volume":"34","year":"2012","journal-title":"Alcohol Res"},{"key":"2026080102451079000_2026.07.25.26358931v1.7","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.187.6.544"},{"key":"2026080102451079000_2026.07.25.26358931v1.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2008.05.025"},{"key":"2026080102451079000_2026.07.25.26358931v1.9","doi-asserted-by":"publisher","DOI":"10.1007\/s00127-008-0323-3"},{"key":"2026080102451079000_2026.07.25.26358931v1.10","doi-asserted-by":"publisher","DOI":"10.1097\/PSY.0b013e31803cb862"},{"key":"2026080102451079000_2026.07.25.26358931v1.11","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.bp.108.054866"},{"key":"2026080102451079000_2026.07.25.26358931v1.12","doi-asserted-by":"publisher","DOI":"10.1007\/s00127-010-0313-0"},{"key":"2026080102451079000_2026.07.25.26358931v1.13","doi-asserted-by":"publisher","DOI":"10.1097\/JGP.0b013e31818254eb"},{"key":"2026080102451079000_2026.07.25.26358931v1.14","doi-asserted-by":"publisher","DOI":"10.1016\/S0022-3999(99)00086-0"},{"key":"2026080102451079000_2026.07.25.26358931v1.15","doi-asserted-by":"publisher","DOI":"10.1002\/gps.1669"},{"key":"2026080102451079000_2026.07.25.26358931v1.16","doi-asserted-by":"publisher","DOI":"10.1097\/00006842-199901000-00003"},{"key":"2026080102451079000_2026.07.25.26358931v1.17","unstructured":"Alcohol Use in the United States: Age Groups and Demographic Characteristics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed September 17, 2025. https:\/\/www.niaaa.nih.gov\/alcohols-effects-health\/alcohol-topics-z\/alcohol-facts-and-statistics\/alcohol-use-united-states-age-groups-and-demographic-characteristics"},{"key":"2026080102451079000_2026.07.25.26358931v1.18","unstructured":"Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed December 18, 2024. https:\/\/www.niaaa.nih.gov\/alcohols-effects-health\/alcohol-topics\/alcohol-facts-and-statistics\/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics"},{"key":"2026080102451079000_2026.07.25.26358931v1.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugalcdep.2015.05.031"},{"key":"2026080102451079000_2026.07.25.26358931v1.20","doi-asserted-by":"publisher","DOI":"10.1111\/add.15735"},{"key":"2026080102451079000_2026.07.25.26358931v1.21","doi-asserted-by":"publisher","DOI":"10.1080\/09595230600944461"},{"key":"2026080102451079000_2026.07.25.26358931v1.22","doi-asserted-by":"publisher","DOI":"10.1001\/archgenpsychiatry.2008.543"},{"key":"2026080102451079000_2026.07.25.26358931v1.23","doi-asserted-by":"publisher","DOI":"10.1111\/j.1360-0443.2010.03351.x"},{"key":"2026080102451079000_2026.07.25.26358931v1.24","doi-asserted-by":"publisher","DOI":"10.1016\/S0272-7358(99)00027-6"},{"key":"2026080102451079000_2026.07.25.26358931v1.25","doi-asserted-by":"publisher","DOI":"10.1046\/j.1360-0443.2002.00092.x"},{"key":"2026080102451079000_2026.07.25.26358931v1.26","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0104384"},{"key":"2026080102451079000_2026.07.25.26358931v1.27","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2458-12-954"},{"key":"2026080102451079000_2026.07.25.26358931v1.28","doi-asserted-by":"publisher","DOI":"10.1016\/j.psychres.2016.05.049"},{"key":"2026080102451079000_2026.07.25.26358931v1.29","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychires.2015.05.004"},{"key":"2026080102451079000_2026.07.25.26358931v1.30","doi-asserted-by":"publisher","DOI":"10.1186\/1741-7015-11-192"},{"key":"2026080102451079000_2026.07.25.26358931v1.31","doi-asserted-by":"publisher","DOI":"10.1111\/acps.13034"},{"key":"2026080102451079000_2026.07.25.26358931v1.32","doi-asserted-by":"publisher","DOI":"10.1111\/add.14935"},{"key":"2026080102451079000_2026.07.25.26358931v1.33","doi-asserted-by":"publisher","DOI":"10.1111\/j.1360-0443.2009.02659.x"},{"key":"2026080102451079000_2026.07.25.26358931v1.34","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.22010043"},{"key":"2026080102451079000_2026.07.25.26358931v1.35","unstructured":"How Bad Is Drinking for You, Really? - The New York Times. Accessed July 12, 2024. https:\/\/www.nytimes.com\/2024\/07\/05\/podcasts\/the-daily\/alcohol-health-risks.html"},{"key":"2026080102451079000_2026.07.25.26358931v1.36","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.6185"},{"key":"2026080102451079000_2026.07.25.26358931v1.37","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(22)00317-6"},{"key":"2026080102451079000_2026.07.25.26358931v1.38","unstructured":"No level of alcohol consumption is safe for our health. Accessed July 12, 2024. https:\/\/www.who.int\/azerbaijan\/news\/item\/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health"},{"key":"2026080102451079000_2026.07.25.26358931v1.39","unstructured":"Rabin RC. Moderate Drinking Has No Health Benefits, Analysis of Decades of Research Finds. The New York Times. April 4, 2023. Accessed August 11, 2024. https:\/\/www.nytimes.com\/2023\/04\/04\/health\/alcohol-health-effects.html"},{"key":"2026080102451079000_2026.07.25.26358931v1.40","doi-asserted-by":"publisher","DOI":"10.15288\/jsa.2005.66.246"},{"key":"2026080102451079000_2026.07.25.26358931v1.41","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.77.6.704"},{"key":"2026080102451079000_2026.07.25.26358931v1.42","doi-asserted-by":"publisher","DOI":"10.1177\/070674379804300509"},{"key":"2026080102451079000_2026.07.25.26358931v1.43","doi-asserted-by":"publisher","DOI":"10.1001\/jamapsychiatry.2017.4602"},{"key":"2026080102451079000_2026.07.25.26358931v1.44","doi-asserted-by":"publisher","DOI":"10.1001\/jamapsychiatry.2015.0584"},{"key":"2026080102451079000_2026.07.25.26358931v1.45","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugalcdep.2019.01.009"},{"key":"2026080102451079000_2026.07.25.26358931v1.46","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2004.053199"},{"key":"2026080102451079000_2026.07.25.26358931v1.47","doi-asserted-by":"publisher","DOI":"10.1002\/cpp.2171"},{"key":"2026080102451079000_2026.07.25.26358931v1.48","doi-asserted-by":"publisher","DOI":"10.1080\/16066350500497983"},{"key":"2026080102451079000_2026.07.25.26358931v1.49","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwi111"},{"key":"2026080102451079000_2026.07.25.26358931v1.50","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugalcdep.2016.02.032"},{"key":"2026080102451079000_2026.07.25.26358931v1.51","doi-asserted-by":"publisher","DOI":"10.1093\/alcalc\/agp080"},{"key":"2026080102451079000_2026.07.25.26358931v1.52","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugalcdep.2015.03.008"},{"key":"2026080102451079000_2026.07.25.26358931v1.53","doi-asserted-by":"publisher","DOI":"10.1016\/j.amepre.2005.01.011"},{"key":"2026080102451079000_2026.07.25.26358931v1.54","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(88)92890-5"},{"key":"2026080102451079000_2026.07.25.26358931v1.55","doi-asserted-by":"publisher","DOI":"10.1017\/S0033291710001388"},{"key":"2026080102451079000_2026.07.25.26358931v1.56","unstructured":"Avenue 677 Huntington, Boston, Ma 02115. Causal Inference: What If (the book). Miguel Hernan\u2019s Faculty Website. October 19, 2012. Accessed September 6, 2024. https:\/\/www.hsph.harvard.edu\/miguel-hernan\/causal-inference-book\/"},{"key":"2026080102451079000_2026.07.25.26358931v1.57","doi-asserted-by":"publisher","DOI":"10.2307\/2669978"},{"key":"2026080102451079000_2026.07.25.26358931v1.58","doi-asserted-by":"publisher","DOI":"10.1111\/ajps.12417"},{"key":"2026080102451079000_2026.07.25.26358931v1.59","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2015.9566"},{"key":"2026080102451079000_2026.07.25.26358931v1.60","doi-asserted-by":"publisher","DOI":"10.1186\/s12874-021-01486-5"},{"key":"2026080102451079000_2026.07.25.26358931v1.61","doi-asserted-by":"publisher","DOI":"10.1016\/S2215-0366(19)30222-6"},{"key":"2026080102451079000_2026.07.25.26358931v1.62","unstructured":"A longitudinal study of reciprocal risk between mental and substance use disorders among Mexican youth - PubMed. Accessed August 9, 2024. https:\/\/pubmed.ncbi.nlm.nih.gov\/30149219\/"},{"key":"2026080102451079000_2026.07.25.26358931v1.63","doi-asserted-by":"publisher","DOI":"10.1111\/j.1742-7843.2006.pto_329.x"},{"key":"2026080102451079000_2026.07.25.26358931v1.64","doi-asserted-by":"publisher","DOI":"10.1093\/ckj\/sfab158"},{"key":"2026080102451079000_2026.07.25.26358931v1.65","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2021-048778"},{"key":"2026080102451079000_2026.07.25.26358931v1.66","unstructured":"CHASING COVID Cohort Study. CUNY ISPH. Accessed March 11, 2024. https:\/\/cunyisph.org\/chasing-covid\/"},{"key":"2026080102451079000_2026.07.25.26358931v1.67","doi-asserted-by":"publisher","DOI":"10.1186\/1940-0640-9-2"},{"key":"2026080102451079000_2026.07.25.26358931v1.68","unstructured":"Administration UD of VA Veterans Health. VA.gov | Veterans Affairs. Accessed August 5, 2024. https:\/\/www.prevention.va.gov\/Healthy_Living\/Limit_Alcohol.asp"},{"key":"2026080102451079000_2026.07.25.26358931v1.69","doi-asserted-by":"publisher","DOI":"10.30773\/pi.2019.02.01"},{"key":"2026080102451079000_2026.07.25.26358931v1.70","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2016.12.012"},{"key":"2026080102451079000_2026.07.25.26358931v1.71","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyg.2018.01741"},{"key":"2026080102451079000_2026.07.25.26358931v1.72","doi-asserted-by":"publisher","DOI":"10.1186\/s40359-021-00657-9"},{"key":"2026080102451079000_2026.07.25.26358931v1.73","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.166.10.1092"},{"key":"2026080102451079000_2026.07.25.26358931v1.74","doi-asserted-by":"publisher","DOI":"10.1111\/add.13386"},{"key":"2026080102451079000_2026.07.25.26358931v1.75","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyg.2023.1191286"},{"key":"2026080102451079000_2026.07.25.26358931v1.76","doi-asserted-by":"publisher","DOI":"10.4172\/2155-6105.1000124"},{"key":"2026080102451079000_2026.07.25.26358931v1.77","doi-asserted-by":"publisher","DOI":"10.15288\/jsad.2016.77.185"},{"key":"2026080102451079000_2026.07.25.26358931v1.78","doi-asserted-by":"publisher","DOI":"10.1515\/jci-2012-0002"}],"container-title":[],"original-title":[],"link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.64898\/2026.07.25.26358931","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T09:45:19Z","timestamp":1785577519000},"score":1,"resource":{"primary":{"URL":"http:\/\/medrxiv.org\/lookup\/doi\/10.64898\/2026.07.25.26358931"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,29]]},"references-count":78,"URL":"https:\/\/doi.org\/10.64898\/2026.07.25.26358931","relation":{},"subject":[],"published":{"date-parts":[[2026,7,29]]},"subtype":"preprint"}}