The price of care: alcohol misuse as a moderator of financial hardship and mental health outcomes of U.S. women caregivers

PURPOSE: Financial hardship and alcohol misuse are well-established predictors of caregiver mental health. The purpose of this study was to examine if alcohol misuse influenced the associations between financial hardship and mental health outcomes (depression diagnosis and poor mental health days). METHODS: A retrospective data analysis was conducted from 4,212 U.S. women caregivers utilizing 2023 Behavioral Risk Factor Surveillance System dataset. RESULTS: Alcohol misuse when measured dichotomously was not independently associated with depression diagnosis or poor mental health days. However, more frequent alcohol misuse substantially strengthened the food insecurity–psychological distress relationship among women caregivers. Financial hardship—particularly food insecurity—was strongly associated with depression and more days in the past month with worse mental health, especially among women with lower income, lower educational attainment, and heavier caregiving responsibilities. CONCLUSIONS: This study contributes to international research by demonstrating the value of using frequency-based rather than binary substance use measures, thereby enhancing data comparability across health systems. Findings align with evidence from countries that economic vulnerability and maladaptive coping, such as alcohol misuse, can have negative impacts on caregiver well-being. Trauma-informed, harm-reduction, and culturally sensitive public health strategies could reduce both financial and behavioral risks for substance misuse and mental health symptoms among women caregivers globally.