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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Integrated Dual Disorders Treatment Workbook
Chapter 2: Alcohol
INTRODUCTION
Alcohol is a commonly used legal substance that is part of everyday life in our culture. Most people in the U.S. drink alcohol, and about one in five develops problems with alcohol over the lifetime. People with a mental illness experience problems related to alcohol at a higher rate and with smaller amounts of use than persons who don't have a mental illness.
This chapter begins with a vignette of a person with depression and alcohol use disorder that illustrates several features of alcohol as a drug of abuse. The chapter then discusses alcohol's effects, some features of dual disorders and dual disorder treatment.
VIGNETTE
Tanya is a 42-year-old single mother with three children. She was referred to the mental health clinic by her primary care doctor and comes to the appointment with her sister. She describes having a hard time falling asleep at night and then waking up often during the night. She feels anxious and irritable most of the day, has no appetite, has lost enjoyment in her life, and has been avoiding family and friends. Though she has felt this way off and on her whole life, it is worse now than it has ever been. Feeling anxious has interfered with her ability to work.
Tanya has been a homemaker since she had her first child at age 26. After the delivery of that child, she had a postpartum depression, was hospitalized, and did not drink for an entire year. By the time her child turned two, she was feeling better and started drinking again. She drank 3-4 glasses of wine per night for years and felt that the wine calmed her down and helped her to sleep. Over the past several years, she has been drinking more, particularly on the weekends, when she stays home and drinks up to a gallon of wine per day. Recently, she has begun to experience blackouts where she can't remember anything she did the previous day. Tanya's father is an alcoholic who stopped drinking a few years ago.
Six months ago, Tanya's primary care doctor prescribed the anti-anxiety medicine, clonazepam, once a day. Some days she takes 2 or 3 extra doses when she needs them to manage her feelings of anxiety.
Tanya divorced 2 years ago and went back to work part-time in an office. Her 16-year-old son lives with his father and her 13-year-old twin daughters live with her. Her daughters have been angry and withdrawn lately. One of them is openly using cigarettes and alcohol. Tanya responds by yelling at her, which she later regrets. Tanya's sister reports that the children are worried about their mother's drinking.
Tanya was concerned about her mood. When her sister mentioned that her children were worried about her drinking, she expressed surprise but acknowledged that her weekend drinking might be a problem. She was willing to try to cut down on her drinking if she could get some help for her anxiety and depression. She agreed to attend an intensive outpatient evening program She and the clinician developed a crisis plan before she left the office, which identified what situations worsened her symptoms and who were supports she could turn to if she needed help.. While in the intensive outpatient program, Tanya saw a psychiatrist for a medication evaluation and a therapist for individual counseling. The psychiatrist recommended that she taper off the clonazepam and start fluoxetine, an antidepressant medication. She tried to reduce the clonazepam, but found that her anxiety and depression seemed worse and that she couldn't sleep at all.
Over the next several months she struggled to reduce her use of alcohol and clonazepam. Her depressive symptoms improved only a little when the antidepressant medication dose was increased. At the same time, she worked with her counselor on her concerns about her daughters. One day, her sister called the therapist and told her that Tanya had received a ticket for driving while intoxicated the previous weekend. In the following months, she was ordered by the court to attend self-help groups and counseling. In the months of court-ordered treatment, she became completely sober, but it took several more months for her depressive symptoms to improve.
WHEN IS ALCOHOL USE A PROBLEM?
Alcohol is a legal substance almost everywhere in Western cultures, and most people in the U.S. drink socially over many years without problems. When does alcohol use become a disorder? According to most definitions, drinking alcoholic beverages constitutes alcohol use disorder (abuse or dependence) when it results in physical, interpersonal, medical, legal, or vocational problems. The Diagnostic and Statistical Manual (DSM) requires recurrent use of alcohol in the face of such problems for a diagnosis of alcohol use disorder. In addition, several other phenomena, listed in the previous chapter, are common indicators of alcohol abuse or dependence. Tanya clearly shows many of these indicators, such as increased use and unsafe behavior resulting in a ticket for driving while intoxicated.
OTHER SEDATING DRUGS
Medications that are sedating or induce sleep are called "sedative-hypnotics." Sedative-hypnotic medications are a chemically diverse group of substances, including benzodiazepines such as clonazepam, that are prescribed to reduce anxiety and insomnia. Sedative-hypnotic medications are also prescribed to treat agitation and mania and to reduce some side effects of antipyschotic medications, such as tardive dyskenesia (abnormal movements) and akathesia (restlessness). Abuse of these medications can lead to the same symptoms and problems that people get from alcohol abuse or dependence.
ALCOHOL AND SEVERE MENTAL ILLNESS
People with a mental illness experience problems related to alcohol use with lower amounts of use than persons who don't have a mental illness. Those with a severe mental illness, such as schizophrenia or bipolar disorder, are especially likely to develop a substance use disorder involving alcohol. It is unclear if anyone with a severe mental illness can drink socially over time without running into difficulties, but most who drink (probably over 90%) either develop problems related to alcohol or opt for abstinence. Moreover, their alcohol use disorders are strongly associated with a variety of negative outcomes, such as destabilization of mental illness, abuse of illicit drugs, homelessness, violence, victimization, incarceration, suicidal behaviors, and hospitalizations. For all of these reasons, alcohol should be avoided by people with severe mental illness, and clinicians should recognize and vigorously treat alcohol use disorders in these individuals.
INTOXICATION AND SHORT-TERM EFFECTS OF ALCOHOL
A few facts about alcohol are important for every clinician to know. Alcohol affects every organ in the body, but the brain is particularly sensitive to alcohol. The more alcohol a person consumes the greater effect it has on the body. In lower doses (e.g., one or two drinks), alcohol often leads to relaxation and increased confidence. However, slightly higher levels of use (or blood levels) typically produce euphoria, giddiness, impaired motor (physical) control, and disinhibition, the combination of which people recognize as being intoxicated, or "drunk." Similarly, low doses of alcohol can produce relaxation, while higher amounts cause drowsiness. Women are affected by alcohol to a greater degree than men because their bodies process alcohol differently, resulting in higher blood concentrations.
As the dose (or blood level) increases, all of the effects of alcohol are often reversed or exaggerated, often dangerously so. For example, euphoria can turn into depression and suicidal behavior, and extreme disinhibition often results in poor judgment, such as getting into physical fights or engaging in sexual relations with dangerous partners. Motor dyscontrol can lead to severe lack of coordination and serious accidents. Sedation can be so severe as to cause death by suppressing the breathing center in the brain.
For people with severe mental illness, many of these negative effects occur at low doses of alcohol. For example, people with a mental illness may experience impaired judgment, cognitive problems, or dishibited behavior even when they are not intoxicated, and alcohol rapidly worsens these problems. Alcohol may also precipitate symptomatic relapses of depression or psychosis, and may interact negatively with medications.
ALCOHOL TOLERANCE AND WITHDRAWAL
People who drink heavily for years often lose control of their drinking and orient their life more and more around drinking behaviors. In addition, they drink more rapidly, consume larger amounts, drink more often, and experience withdrawal symptoms when they decrease drinking. This latter set of behaviors, which involve physiological and psychological dependence on alcohol, is called the alcohol dependence syndrome.
The amount of alcohol that Tanya drinks has increased over the past several years, but the effect she feels from alcohol hasn't changed. This indicates that she has developed an increased tolerance to alcohol. With regular drinking, the body breaks down and gets rid of alcohol more quickly and changes occur in the brain, so a person needs to drink more to get the same effect. Tolerance to alcohol generalizes to other drugs and medications that affect the brain in ways similar to alcohol, such as benzodiazepines.
Persons who have developed tolerance to alcohol will have a physiological reaction called withdrawal when they reduce the amount they drink or stop drinking completely. For Tanya withdrawal symptoms include anxiety, insomnia, and depression. Other common symptoms include nausea, headache, and tremor. When alcohol or sedative hypnotics are used over a longer period of time or in larger amounts, withdrawal symptoms are worse and include vomiting, fever, and increased blood pressure. In severe cases, people can experience seizures or a life threatening illness called delirium tremens, or the DTs.
DETOXIFICATION
During detoxification, medications and medical monitoring can be used to reduce the severity of symptoms and maintain safety while a person is experiencing withdrawal from a substance. Because of the serious nature of withdrawal in people who have been using large amounts of alcohol or sedative hypnotics, medical supervision during withdrawal is important, and can be provided while a person is in a hospital or as an outpatient. Medications can prevent symptoms, seizures, and DTs.
LONGER-TERM EFFECTS OF ALCOHOL
Heavy use of alcohol over time can cause a variety of difficulties over the long term, including the alcohol dependence syndrome described above as well as other physical, medical, psychological, and functional problems. Remember that people with a psychiatric illness are more likely to develop an alcohol use disorder than people who do not have a psychiatric disorder, and that they may develop alcohol abuse or dependence with a relatively small amount of intake or after using over a shorter period of time. Simply put, having a mental illness makes people more vulnerable to the adverse effects of alcohol.
Medical problems: Numerous medical problems can result from drinking. Every organ in the body is susceptible to illness from alcohol. Problems range from cirrhosis (scarring and inability to function) of the liver, dementia (loss of ability to remember and solve problems), neuropathy (pain and burning in the arms and legs due to nerve damage), and cancer. Alcohol use increases blood pressure, which can worsen hypertension and put stress on the heart, leading to heart disease. Alcohol affects hormones in men and women, resulting in fertility problems. If a pregnant woman drinks regularly or occasional large amounts of alcohol, the fetus may develop fetal alcohol syndrome. Fetal alcohol syndrome includes mental retardation, developmental delays, and physical defects. Women are more vulnerable to the effects of alcohol than men. As a general rule of use over time, medical problems develop in women after using more than one drink a day, whereas for men medical problems develop after drinking four or more drinks a day.
Another common problem related to alcohol use is insomnia. Tanya began using alcohol to relax and help with asleep. In the short term, alcohol helps people to fall asleep, but it quickly disturbs sleep and causes awakenings later in the night. In the long term, alcohol interrupts normal sleep, as it did with Tanya.
Mental illness: Alcohol is a central nervous system depressant, and long-term alcohol use can produce depression or worsen the symptoms of an independent mental illness, especially mood problems such as depression and anxiety. Alcohol abuse and dependence are intertwined with mood in several ways. First, long-term, regular drinking in moderate to large amounts causes most people to feel depressed or anxious, to lose their appetite, to have body aches and pains, and to feel despair. Between 10 and 20% of persons with alcoholism commit suicide, usually when they are drinking. Second, abusing alcohol contributes to other problems that cause stress, such as Tanya's interpersonal problems with her daughter and her legal problems from the drinking while driving. Tanya's story is typical of someone with mood and alcohol problems. Alcohol provides a brief escape from feeling bad, but ultimately makes everything worse.
Tanya's other symptom problem is anxiety. Alcohol can reduce anxiety in the short-term, but as the effect of alcohol wears off, anxiety can get worse. Anxiety problems are common in people who have alcohol problems, but in the end alcohol usually worsens the anxiety as it did for Tanya.
Whether alcohol causes symptoms of psychosis is unclear, though people with psychotic disorders often appear more symptomatic over time when they are drinking, probably due to disinhibition and not taking antipsychotic medications.
Functional problems: Tanya's drinking has resulted in social and interpersonal problems, such as difficulties with her husband which led to divorce, and now difficulties with her daughter. She has experienced dangerous behavior and legal problems, indicated by a charge for driving while intoxicated. She has also had difficulty working. People with alcohol abuse and dependence typically experience social and vocational problems. For people with severe mental illness, alcohol abuse typically leads to loss of familial supports and social isolation, behavioral problems, inability to work, inability to make use of treatment, difficulties managing money, unstable housing and many other problems.
SUBSTANCE ABUSE, MENTAL ILLNESS, OR DUAL DISORDERS?
It is often difficult to figure out whether alcohol abuse causes depression and anxiety or whether these symptoms are due to a separate and distinct co-occurring disorder. Are Tanya's depression and anxiety problems truly independent of her drinking, or might they just be the consequence of heavy drinking? If the symptoms are caused by drinking, they should go away within one month of becoming abstinent (no alcohol or other substances at all). Clinicians should look for periods of abstinence in the client's life and ask the client whether depressive or anxiety symptoms were present during that time. Including family or supports in the assessment can help you get an accurate history. They may be able to remember a client's symptoms and level of function during periods of sobriety better than the client can. Tanya's year-long period of abstinence is incredibly valuable information. It was during this period that she experienced a post-partum depression, strongly suggesting that her depressive illness is distinct from her alcohol dependence.
Often the available information is insufficient to tell whether a mental illness is primary or secondary. In this case, we suggest that you assume that both the mental illness and substance abuse are important, and go ahead with assessment and treatment of both disorders in an integrated fashion. You may learn more information over time that suggests that the symptoms of mental illness are caused by substance abuse, and the diagnoses and treatment can be changed.
FAMILY HISTORY
Both alcoholism and depression have genetic components, meaning that these illnesses run in families and that a person's genetic make-up contributes to each of these illnesses. Neither mental illnesses nor substance use disorders are due to a "character defect." Alcoholism seems to run in Tanya's family; her father is a recovering alcoholic and her daughter has started to abuse alcohol. Children of alcoholics are four-times-more likely to develop alcohol use disorder. Children of parents who have depression are also more likely to develop a mood disorder.
Finding out whether family members have had substance abuse or mental illness is important to help you understand a client's disorder. If there is a strong family history of mood problems, then the client is at risk for having a mood problem. If there is a strong family history of alcohol problems, the client is at risk for having an alcohol problem. Some families have both problems in multiple family members. Because of Tanya's family's problems, the clinician should talk with her about why her family members are vulnerable to develop substance abuse and mood disorders and how to prevent these problems.
SHOULD PEOPLE WITH ALCOHOL PROBLEMS TAKE SEDATIVE-HYPNOTIC MEDICATIONS?
This vignette raises several interesting issues about treatment, but most of these are covered in later chapters. We address medications in relation to alcohol use disorder here.
People with alcohol and anxiety problems, like Tanya, are often prescribed sedative-hypnotic medications (such as the benzodiazepine, clonazepam) for their anxiety. Use of these kinds of medications may make the alcohol problem worse and lead to abuse, however, because they have a similar effect on the brain as alcohol (they are "cross reactive"). Benzodiazepines, in particular, tend to be overused and abused in the same way as alcohol. Once a person is taking a sedative-hypnotic medication regularly, he or she may have a hard time stopping it because they experience increased anxiety and withdrawal symptoms when they do. This happened to Tanya, who had a hard time stopping the clonazepam. For some individuals with severe anxiety, the use of benzodiazepines might be necessary, but experts believe that antidepressant medications, which are very effective for treating anxiety, and behavioral treatments should be tried first.
MEDICATIONS FOR PEOPLE WITH ALCOHOL ABUSE OR DEPENDENCE
Other medications can be helpful when they are used in combination with integrated dual disorders treatment. Disulfiram (Antabuse), causes a very uncomfortable physical reaction if a person drinks while taking it. Disulfiram is intended to help clients avoid taking a drink because they want to avoid the toxic reaction they will get to alcohol when they have disulfiram in their system. The medication provides a psychological barrier to drinking. Many clients will drink soon after starting disulfiram. Experiencing a disulfiram-alcohol reaction may help them avoid drinking in the future.
Disulfiram is most effective if it is monitored: someone should watch the client take the medication to be sure they actually take it. Practitioners or staff can observe clients take disulfiram on some days or family members can provide even more frequent supervision.
Naltrexone (Revia) is an opiate antagonist that blocks the effects of certain natural chemicals in the brain and thereby reduces craving for alcohol. Like disulfiram, naltrexone does not have abuse potential. Naltrexone helps to reduce craving for alcohol as clients are trying to reduce their alcohol use. There are no symptoms and no danger to clients if they use alcohol while taking naltrexone, so this medication is appropriate for clients who are still drinking and have not yet developed a strong commitment to sobriety. Naltrexone also blocks the effects of opiate drugs like heroin and morphine. It can be used to treat people with opiate abuse or dependence.
Other medications are being studied for potential use to reduce drinking, but none are commonly used in persons with dual disorders as of 2002.
Recommended reading
There are many helpful books on alcohol and alcoholism. Loosening the Grip: A Handbook of Alcohol Information by Jean Kinney is a good place to start.
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