Alcohol and Mental Health Problems: ‘The Poison is in the Dose’

Alcohol abuse and mental health difficulties often coexist in the population and alcohol cessation is required for many mental health treatments to work

Alcohol can be described as both a tonic and a poison. The difference between ‘tonic’ and ‘poison’ lies in the dose. A common Alcoholics Anonymous (AA) saying is: ‘There is no problem that alcohol cannot make worse.’ Of all the problems that alcohol can exacerbate, mental illness is one of the most common, serious, and frequently missed. Patients with mental illness, irrespective of the diagnosis, can face profound consequences when they misuse alcohol. Alcohol causes some depressive and anxiety syndromes, worsens others, always impairs sleep, and has harmful interactions with psychiatric medications. Thus, a person who drinks any amount of alcohol while receiving psychiatric treatment, especially pharmacologic treatment, should be advised to stop all use of alcohol.

Of course, the addicted individual may not be able to stop his or her alcohol use and may need education about the interaction between addiction and mental illness, treatment of the addictive substance use, or even inpatient treatment of the addiction. Cessation of alcohol use is an important clinical goal, but will most likely not be achieved overnight. The cessation of alcohol use does not guarantee the remission of psychiatric symptoms. Nonetheless, discontinuing alcohol use for the psychiatric patient is often necessary, partly to remove an impediment to effective treatment.

Scientific studies have suggested that nearly one-third of people with mental illness experience alcohol abuse. Conversely, more than one-third of all alcohol abusers are also battling mental illness.

UNDERSTANDING HARMFUL DRINKING AND ALCOHOLISM

 Units of alcohol Alcohol is measured in units. A unit of alcohol is 10g of pure alcohol. This is about half a pint of lager or a single measure (25ml) of spirits. A small glass (125ml) of wine contains one and-a-half units of alcohol.

Increased-risk drinking

Increased-risk drinking is classified as regularly drinking 22-to-50 units of alcohol per week (men), or 15-to-35 units per week (women). However, binge drinking can be dangerous even if within the weekly limit. Binge drinking is drinking a lot of alcohol in a short time period, considered eight units in a day for men and six units in a day for women.

Harmful drinking

Regularly drinking more than 50 units of alcohol a week (men) or over 35 units a week (women) is classified as harmful drinking. This type of drinking can cause health problems like depression, alcohol-related accidents and acute pancreatitis. Many health problems caused by harmful drinking do not cause symptoms for a number of years, but can eventually lead to high blood pressure, heart disease, cirrhosis (scarring of the liver) and cancers such as mouth cancer and bowel cancer. Other problems include social issues such as relationship difficulties, unemployment, domestic violence, committing crimes, and homelessness.

Dependent drinking

Alcohol is both physically and psychologically addictive and it is easy to become dependent on it. Alcohol dependence is an inability to function without it, with drinking becoming an important or sometimes the most important aspect the person’s life. Depending on the level of dependence, withdrawal symptoms can occur if alcohol drinking is stopped abruptly. Symptoms of alcohol withdrawal can be both physical and psychological in nature.

Physical withdrawal symptoms include hand tremors (known as ‘the shakes’), nausea, sweating, visual hallucinations, and seizures. Psychological withdrawal symptoms include depression, anxiety, irritability, restlessness and insomnia.

Severely dependent drinkers can experience severe withdrawal symptoms, leading to a vicious circle of the person drinking to avoid withdrawal symptoms. Severely-dependent drinkers can tolerate very high levels of alcohol, amounts that would comatose or even kill moderate drinkers.

HOW DO YOU KNOW IF YOU’RE DRINKING TOO MUCH ALCOHOL?

 You could be drinking excessively if:

• You feel you need to cut down on drinking.

• You feel guilty or ashamed about your drinking.

• Other people are critical of how much you drink.

• Sometimes have memory loss of drinking sessions.

• You need a drink first thing in the morning to settle nerves or ease a hangover.

• Drink at least a few drinks every day.

• Regularly go binge drinking.

• Not doing as expected due to drinking, ie, missing an appointment or work due to being drunk or hung over

ALCOHOL PROBLEMS AND PSYCHIATRIC PROBLEMS

 It can be difficult to assess psychiatric complaints for patients who abuse or are dependent on alcohol because heavy drinking associated with alcoholism can coexist with, contribute to, or result from, several different psychiatric syndromes. In order to improve diagnostic accuracy, doctors can follow an algorithm that distinguishes among alcohol– related psychiatric symptoms and signs, alcohol–induced psychiatric syndromes, and independent psychiatric disorders that are commonly associated with alcoholism. The patient’s gender, family history, and course of illness over time should also be considered to attain an accurate diagnosis.

Alcoholism can complicate or mimic practically any psychiatric condition, thus making it difficult sometimes to accurately diagnose the nature of the psychiatric complaints. When alcoholism and psychiatric disorders co–occur, patients are more likely to become a dependent alcoholic, to attempt or commit suicide, and to require mental health services.

DIAGNOSTIC DIFFICULTIES IN ASSESSING PSYCHIATRIC COMPLAINTS IN ALCOHOLIC PATIENTS

In general, it is helpful to consider psychiatric complaints observed in the context of heavy drinking as falling into one of three categories: 1 . Alcohol-related symptoms and signs. Alcohol induced psychiatric syndromes. Independent psychiatric disorders that co–occur with alcoholism: These three categories are discussed in the following sections.

ALCOHOL-RELATED PSYCHIATRIC SYMPTOMS AND SIGNS

 Heavy alcohol use directly affects brain function and alters various brain chemicals (ie, neurotransmitter) and hormonal systems known to be involved in the development of many common mental disorders (ie, mood and anxiety disorders). For example, regular drinking reduces serotonin levels in the brain that can lead to lower mood and sometimes depression. Thus, alcoholism can manifest itself in a broad range of psychiatric symptoms and signs. In fact, such psychiatric complaints often are the first problems for which an alcoholic patient seeks help.

The patient’s symptoms and signs may vary in severity depending upon the amounts of alcohol used, for how long it was used, and how recently it was used, as well as on the patient’s individual vulnerability to experiencing psychiatric symptoms in the setting of excessive alcohol consumption.

For example, during acute intoxication, smaller amounts of alcohol may produce euphoria, whereas larger amounts may be associated with more dramatic changes in mood, such as sadness, irritability, and nervousness. Alcohol’s disinhibiting properties may also impair judgment and unleash aggressive, antisocial behaviours that may mimic certain externalising disorders, such as antisocial personality disorder (ASPD). In addition to the direct pharmacological effects of alcohol on brain function, psychosocial stressors that commonly occur in heavy-drinking alcoholic patients (ie, legal, financial, or interpersonal problems) may indirectly contribute to ongoing alcohol-related symptoms, such as sadness, despair, and anxiety.

ALCOHOL-INDUCED PSYCHIATRIC SYNDROMES

 Given the broad range of effects heavy drinking may have on psychological function, these alcohol–induced disorders span several categories of mental disorders, including mood, anxiety, psychotic, sleep, sexual, delirious, amnestic, and dementia disorders. The essential feature of all these alcohol induced disorders is the presence of prominent and persistent symptoms, which are judged — based on their onset and course, as well as on the patient’s history, physical exam, and laboratory findings — to be the result of the direct physiological effects of alcohol.

Alcohol-induced psychiatric disorders may initially be indistinguishable from the independent psychiatric disorders they mimic. However, what differentiates these two groups of disorders is that alcohol-induced disorders typically improve on their own within several weeks of abstinence without requiring therapies beyond supportive care. Thus, the course and prognosis of alcohol-induced psychiatric disorders are different from those of the independent major psychiatric disorders.

ALCOHOLISM WITH COMORBID, INDEPENDENT PSYCHIATRIC DISORDERS

Alcoholism is also associated with several psychiatric disorders that develop independently of the alcoholism and may precede alcohol use and abuse. These independent disorders may make certain vulnerable patients more prone to developing alcohol-related problems. One of the most common of these comorbid conditions is personality disorder, often marked by a long-standing pattern of irresponsibility and violating the rights of others that generally predates the problems with alcohol.

Other psychiatric disorders associated with alcoholism include obsessive-compulsive disorder, anxiety, anxiety disorders (ie, social phobia, panic disorder, and post-traumatic stress disorder), eating, mood, psychotic, sleep, and drug-related disorders, schizophrenia, and major depression. It is important for clinicians to know which disorders are most likely to coexist with alcoholism so that they may specifically probe for these conditions when evaluating the patient’s complaints.

PSYCHIATRIC DISORDERS COMMONLY ASSOCIATED WITH ALCOHOLISM

Independent major depression According to drinkaware.co.uk, people in Britain who experience anxiety or depression are twice as likely to be heavy or problem drinkers.

Warning signs that alcohol is affecting mood include:

• Disturbed sleep. u Feeling lethargic and tired all the time.

• Low mood.

• Experiencing anxiety in situations where you would normally feel comfortable.

Mood disturbances (which frequently are not severe enough to qualify as ‘disorders’) are arguably the most common psychiatric complaint among treatment-seeking alcoholic patients, affecting upwards of 80 per cent of alcoholics at some point in their drinking careers (Brown and Schuckit 1988; Anthenelli and Schuckit 1993). In keeping with the three broad categories described above into which such complaints may fall, mood problems may be characterised as one of the following:

• An expected, time-limited consequence of alcohol’s depressant effects on the brain.

• A more organised constellation of symptoms and signs (ie, a syndrome) reflecting an alcohol-induced mood disorder with depressive features.

• An independent major depressive disorder coexisting with or even pre-dating alcoholism.

Approximately 30-to-40 per cent of alcoholics experience a major depressive disorder (Anthenelli and Schuckit 1993; Schuckit et al 1997). Some controversy exists as to the precise cause-and-effect relationship between depression and alcoholism, with some authors pointing out that depressive episodes frequently predate the onset of alcoholism, especially in women (Kessler et al 1997; Helzer and Przybeck 1988; Hesselbrock et al 1985). Several studies found that approximately 60 per cent of alcoholics who experience a major depressive episode, especially men, found that the depressive episode was induced by alcohol (Schuckit et al 1997; Davidson 1995). The remaining approximately 40 per cent of alcoholic women and men who suffer a depressive episode are likely have an independent major depressive disorder — that is, they experienced a major depressive episode before the onset of alcoholism or continue to exhibit depressive symptoms and signs even during lengthy periods of abstinence.

Among manic patients, 50-to-60 per cent abuse or become dependent on alcohol or other drugs (AODs) at some point in their illness (Brady and Sonne, 1995). Diagnosing bipolar disorder in alcoholic patients can be particularly challenging. Several factors, such as the under-reporting of symptoms (particularly symptoms of mania), the complex effects of alcohol on mood states, and common features shared by both illnesses (ie, excessive involvement in pleasurable activities with high potential for painful consequences) reduce diagnostic accuracy.

Bipolar patients are also likely to abuse drugs other than alcohol (ie, stimulant drugs such as cocaine or methamphetamine), further complicating the diagnosis. It can be helpful for an accurate diagnosis to obtain a careful history of the chronological order of both illnesses, because approximately 60 per cent of patients with both alcoholism and bipolar disorder started using AODs before the onset of affective episodes (Strakowski et al 2000).

Although it is important to distinguish major depression from depression due to alcohol consumption, clinicians rarely have the opportunity to wait three weeks to delineate the two disorders. Allowing a patient to suffer depressive symptoms any longer than necessary while waiting for a firm diagnosis is unnecessary. Rather than waiting for depressive symptoms to resolve, clinicians should treat both alcoholism and depression simultaneously and in an integrated manner. For example, the cessation of drinking should be treated as an essential component of recovery from depression.

The clinician should provide clear instruction on how to avoid drinking. This instructive style often involves a paradigm shift for the therapist more attuned to the mental illness alone. Rather than remain neutral or give interpersonal or instructional interpretations, the person offering the treatment should involve a coaching role, where direct suggestions are made and behavioural change is strongly supported and encouraged. This psychotherapeutic stance is well-described in the motivational interviewing literature.

Among manic patients, 50-to-60 per cent abuse or become dependent on alcohol or other drugs at some point in their illness

Bipolar disorder

 Bipolar disorder co-occurs with alcohol dependence more than any other mental illness. In a study of patients with bipolar disorder and alcoholism, patients who had primary alcoholism (unrelated to their bipolar disorder) were less likely to experience remission from their alcoholism. Bipolar patients with alcoholism have been shown to suffer more cognitive dysfunction and attempt suicide more often.

The high prevalence and serious consequences of bipolar disorder combined with alcoholism necessitate aggressive treatment for this combination of illnesses. Since impaired judgment, grandiosity, and irritability all promote excessive alcohol use, the clinician must address the mania and alcohol use together. Psychoeducation often serves as a useful warning about the dangers of further alcohol use. Psychotherapeutic methods can include group therapies with others who suffer from bipolar disorder, and relapse-prevention teaching. Medications such as sodium valproate (Epilim) and carbamazepine (Tegretol) are often used as mood stabilisers and can also serve as detoxification agents from alcohol.

Anxiety disorders

Overall, anxiety disorders do not seem to occur at much higher rates among alcoholics than among the general population (Schuckit and Hesselbrock 1994). Specific anxiety disorders, such as panic disorder, social phobia, and PTSD, however, appear to have an increased co–occurrence with alcoholism (Schuckit et al 1997; Kranzler 1996; Brady et al 1995). For example, even though panic disorder with agoraphobia occurs in the general population at approximately 6.1 per cent, alcoholics suffer from panic disorder at a rate of up to 21 per cent.

The problem for the anxious alcoholic remains that alcohol initially treats anxiety, but worsens it later on. The immediate-term relief of medicating alcohol withdrawal with a drink in the morning or the reduction of painful anxiety with a few drinks overwhelms the intellectual understanding that alcohol will only make matters worse down the line. At a deeper level, the use of alcohol may function as a medication, as well as a way for the sufferer to assert control over their emotions.

As with alcohol-induced depression, it is important to differentiate alcohol-induced anxiety from an independent anxiety disorder. This can be achieved by examining the onset and course of the anxiety disorder. Thus, symptoms and signs of alcohol-induced anxiety disorders typically last for days to several weeks, tend to occur secondary to alcohol withdrawal, and typically resolve relatively quickly with abstinence and supportive treatments (Kranzler 1996; Brown et al 1991). In contrast, independent anxiety disorders are characterised by symptoms that predate the onset of heavy drinking and which persist during extended sobriety.

As always, less potentially harmful treatments are preferred initially, including supportive psychotherapy, cognitive-behavioural psychotherapy, hypnosis, and acupuncture. However, there are some cases where a potentially addictive substance such as a benzodiazepine must be used to treat an anxiety syndrome in an addicted person. In this circumstance, the treating clinician must carefully weigh the risk-benefit profile of the particular medication for a particular patient, and closely monitor the patient for side-effects and addictive behaviours.

Opinions on whether benzodiazepines should ever be used in the addicted patient vary widely in the field, and few studies examine this question. There is scant data-based evidence to support any clear perspective, so each clinician is obliged to make an individual decision based on the patient’s best interests.

Schizophrenia

 Patients with schizophrenia frequently use and misuse alcohol. For patients with schizophrenia, the lifetime prevalence of alcohol use disorder is in the 50 per cent range, according to studies. First psychotic breaks are difficult to diagnose and treat, and the addition of alcohol or any other mood-altering substance confuses the issue even further. Avoiding premature diagnostic closure in this scenario is even more important than with other psychiatric illnesses: The person misdiagnosed with schizophrenia because of intervening intoxicant use will face a lifetime of attempting to shed the diagnosis and receive the proper treatment.

Patients with schizophrenia use alcohol for a number of reasons. First, alcohol is an easily available, fast-acting agent that quells the fears and pain of becoming psychotic. Second, alcohol use can be one of the few easy social experiences available to longterm schizophrenics with few friends and impaired social skills. The rituals of drinking, whether in a bar or on a street corner, fosters an easy acceptance among ‘drinking buddies’.

Finally, alcohol is legal, easily obtainable, and relatively inexpensive, making it an attractive intoxicant for the schizophrenic, who may not be able to muster the skills or cash to obtain other substances. Since all antipsychotics are metabolised by the liver, patients with schizophrenia may need vigilant monitoring of their liver functioning and a dosage adjustment if they are in liver failure. A period of abstinence from alcohol is important in making definite diagnoses in forming a treatment plan.

Psychosis

 Extreme levels of drinking (such as more than 30 units per day for several weeks) can occasionally cause ‘psychosis’. It’s a severe mental illness where hallucinations and delusions of persecution develop. Psychotic symptoms can also occur when very heavy drinkers suddenly stop drinking and develop a condition known as ‘delirium tremens’ — symptoms include body tremors and confusion.

Alcohol-related psychosis spontaneously clears with discontinuation of alcohol use and may resume during repeated alcohol exposure. Distinguishing alcohol-related psychosis from schizophrenia or other primary psychotic disorders through clinical presentation often is difficult. It is generally accepted that alcohol-related psychosis remits with abstinence, unlike schizophrenia.

Some characteristics that may help differentiate alcohol-induced psychosis from schizophrenia are that alcohol-induced psychosis shows later onset of psychosis, higher levels of depressive and anxiety symptoms, fewer negative and disorganised symptoms, better insight and judgment, and less functional impairment.

Alcohol withdrawal psychosis is a symptom of alcohol withdrawal and should be treated in the context of alcohol withdrawal. Treatment is initiated with cautious use of oral or intramuscular benzodiazepines. Lorazepam (Ativan) at 1-2mg or chlordiazepoxide (Librium) at 25-50mg PO or IM is used commonly and should be under the guidance of an expert in this area. The dose of benzodiazepine is tapered over the next five-to-seven days.

In the event patients are in danger of harming themselves or others, rapid sedation should be initiated with a high-potency antipsychotic drug such as haloperidol at 5-10mg PO or IM, frequently given with anticholinergics (ie, Biperiden), which can be given PO or IM to prevent extrapyramidal adverse effects.

Antipsychotics may lower the seizure threshold and should not be used to treat withdrawal symptoms unless absolutely necessary and used in combination with a benzodiazepine or anti-seizure medications (ie, sodium valproate (Epilim) or carbamazepine (Tegretol).

Treatment may include thiamine at 100mg parentally followed by supplemental thiamine at 100mg three times a day, folic acid at 1mg, and a daily multivitamin.

ASPD

 ASPD has long been recognised to be closely associated with alcoholism (Lewis et al 1983). Epidemiologic analyses found that compared with non-alcoholics, alcohol-dependent men are four-to-eight times more likely, and alcoholic women are 12-to-17 times more likely, to have comorbid ASPD (Helzer and Przybeck 1988; Kessler et al 1997). Thus, approximately 15-to-20 per cent of alcoholic men and 10 per cent of alcoholic women have comorbid ASPD, compared with 4 per cent of men and approximately 0.8 per cent of women in the general population. Patients with ASPD are likely to develop alcohol dependence at an earlier age than their non-antisocial counterparts and are also more prone to having other drug use disorders (Cadoret et al 1984; Anthenelli et al 1994).

INQUIRING ABOUT ALCOHOL USE WHEN EVALUATING PSYCHIATRIC COMPLAINTS

 Patients seldom volunteer information about their alcohol use patterns and problems when they present their psychiatric complaints (Helzer and Przybeck 1988; Anthenelli and Schuckit 1993; Anthenelli 1997). Unless they are asked directly about their alcohol use, the patients’ denial and minimisation of their alcohol-related problems lead them to withhold this important information, which makes assessment and diagnosis difficult. In addition, heavy alcohol use can impair memory, which may make the patient’s information during history-taking less reliable. Therefore, clinicians should gather information from several resources when assessing patients with possible alcohol-related problems, including collateral informants (ie, a spouse, relative, or close friend), the patient’s medical history, laboratory tests, and a thorough physical examination.

A review of the patient’s medical records is another potentially rich source of information. This review should look for evidence of previous psychiatric complaints, or of laboratory results that might further implicate alcohol in the patient’s psychiatric problems (Allen et al 2000). Pertinent laboratory results could include positive breath or blood alcohol tests; an elevation in biochemical markers of heavy drinking, such as the liver enzyme gammaglutamyl transferase (GGT); and changes in the mean volume of the red blood cells (ie, mean corpuscular volume), which also is an indicator of heavy drinking.

ALCOHOL’S EFFECT ON MEMORY

 Soon after drinking alcohol, your brain processes slow down and memory can be impaired. After large quantities of alcohol, the brain can stop recording into the ‘memory store’. That’s why people can wake up the next day with a ‘blank’ about what they said or did and even where they were. This short-term memory failure or ‘blackout’ doesn’t mean that brain cells have been damaged, but frequent heavy sessions can damage the brain because of alcohol’s effect on brain chemistry and processes.

Drinking heavily over a long period of time can also have long-term effects on memory. As a person ages, the brains shrinks at an average of approximately 2 per cent per decade. However, heavy drinking accelerates the shrinkage of key areas in the brain, leading to memory loss and other symptoms of dementia. Heavy drinking can also lead to mild but potentially debilitating problems, including a person’s ability to plan, make judgments, solve problems and perform complex tasks which most people can perform to allow normal function. As well as causing damage to the brain, heavy drinking can cause nutritional deficiencies such a vitamin B deficiency, which when severe, can cause dementia.

Medications tailored for the treatment of alcoholism can be of significant use in the mentally ill population

TREATMENT FOR ALCOHOL WITHDRAWAL

 Medications tailored for the treatment of alcoholism can be of significant use in the mentally ill population. Psychiatric medications rarely have interactions with anti-alcoholism medications. Medications such as benzodiazepines and barbiturates may be used in the acute phase of detoxification. A mood stabiliser can simultaneously effectively treat withdrawal and bipolar mania. Naltrexone may be used with the mentally ill patient, as with other patients, with the hope that it will act as an anti-craving agent, which also increases time to first drink and amount that the relapsing patient drinks.

Disulfiram, while arguably more effective than naltrexone, does present some problems for the mentally ill alcoholic. Patients prescribed disulfiram must understand that alcohol combined with disulfiram will cause an uncomfortable reaction. The patient must be motivated to avoid that reaction.

If the depressed patient is so cognitively impaired that he/she cannot understand the risk/benefit profile of disulfiram, the medication should not be prescribed. A special consideration for the schizophrenic patient is that disulfiram inhibits aldehyde dehydrogenase activity, which might cause an increase in synaptic dopamine and a worsened psychosis. Similarly, if the treating physician believes that the patient exhibits self-destructive traits and might provoke a disulfiram reaction intentionally, the medication should not be prescribed. These problematic scenarios are extremely rare: Most mentally ill alcoholics are candidates for a discussion about disulfiram.

One study that appeared in the American Journal of Addiction found that of 33 severely mentally ill patients administered disulfiram, 64 per cent experienced remission for at least one year. The medication was also associated with a decrease in days hospitalised. However, 28 per cent of schizophrenic subjects experienced disulfiram reactions, and there was no change in work status. The benefits shown in the study demonstrated that although disulfiram must be carefully considered for the mentally ill individual, it has a place in the treatment programme. (Mueser KT, Noordsy DL, Fox L, Wolfe R)

Disclaimer: Brands mentioned in this article are meant as examples only and not meant as preference to other brands.

Written by Eamonn Brady MPSI (Pharmacist) owner of Whelehans Pharmacies, 38 Pearse St and Clonmore, Mullingar. Tel 04493 34591 (Pearse St) or 04493 10266 (Clonmore). www.whelehans.ie