Alkoholi, kofeiini, nikotiini ja mielenterveys

Alcohol, nicotine, and caffeine are the most widely consumed psychotropic drugs worldwide. They are largely consumed by normal individuals, but their use is even more frequent in psychiatric patients, Thus, patients with schizophrenia tend to abuse all three substances. The interrelationships between depression and alcohol are complex. These drugs can all create dependence, as understood in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Alcohol abuse is clearly deleterious to the brain, provoking acute and chronic mental disorders, ranging from intoxication with impairment of cognition, to delirium tremens, halluosis, and dementia. In contrast, the main health consequences of nicotine, notably cancer and cardiovascular disases, lie outside the realm of psychiatry However, the mes of nicotine dependence and motivation to smoke or quit are of concern to psychiatrists.

Alcohol, nicotine, and caffeine share several common features. Being palatable for their mild psychotropic properties, they are the most widely consumed drugs worldwide. As licit psychoactive drugs, they are used mostly by “normal” people, in contrast to Illicit “hard drugs,” which are traditionally viewed as the province of the deviant. Known to mankind for several centuries, alcohol, nicotine, and caffeine have become an important part of culture, serving as a vehicle for social Interaction, shaping the urban landscape with dedicated places - from the Ottoman coffeehouse to the German Brauhaus and the Parisian café - stimulating the opening of International trade routes and bringing substantial tax revenues to governments.

Abnormal patterns of substance use have been described since antiquity Aristotle recorded the effects of alcohol withdrawal and warned that drinking could be Injurious during pregnancy1; the Roman physician Celsus held that dependence on intoxicating drink was a disease.2 Today, alcohol and nicotine are public health problems because of their association with physical ailments such as cirrhosis, cancer, and cardiovascular disease. Of these three substances, only alcohol causes clear neuropsychiatrie sequelae. Frequent heavy drinking, especially when associated with malnutrition, has been shown to lead to central nervous system (CNS) deterioration.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),3 the current nomenclature of the American Psychiatric Association, has specific diagnostic categories for alcohol-, nicotine-, and caffeine-related disorders. According to DSM-IV's definition, all three substances can Induce dependence. Conversely, patients presenting with various mental disorders may be more prone than the general population to use or abuse these three common substances. Thus, patients with bipolar depression are more likely to abuse alcohol at certain times In the course of their Illness. Patients with schizophrenia have high rates of consumption of all three substances, which they use to relieve dysphoria.4

The consumption of alcoholic beverages, In the form of beer or wine, Is mentioned In the records of the earliest known civilizations. Physicians' prescriptions of beer were found on Sumerlan clay tablets (c 2100 bc). Egyptian doctors In their medical papyri (c 1500 bc) Included beer or wine In about 15% of their prescriptions.5 Alcohol - an Inebriating substance - is consumed because It relieves the mind from anxiety and Inhibitions. In the 19th century medical literature, alcohol was recognized as a major cause of mental morbidity, and the phenomenology of acute and chronic alcoholism was already well known. Ball,6 a renowned professor of psychiatry in Paris, wrote in 1880 that “of all the poisons that, to a variable degree, exert a deleterious Influence on the constitution, alcohol Is without doubt the substance whose effects have been most thoroughly described and meticulously Investigated.”

DSM-IV offers two categories of alcohol use disorders: alcohol abuse and alcohol dependence. Abuse Is a maladaptive pattern of drinking, resulting In adverse consequences (neglect of children or work, marital problems) or dangerous behavior (driving while drunk). Dependence Is Indicated by loss of control and continued drinking despite alcohol-related problems, and by evidence of tolerance or symptoms of withdrawal Typically, the dependent subject wants to stop drinking but cannot, and morning drinking Is characteristic. The disorders Induced by alcohol are well known, and will not be detailed here. DSM-IV lists withdrawal delirium (delirium tremens), psychotic disorders with delusions or hallucinations, persisting dementia, and persisting amnestic disorder. Recognizing the frequent association between alcohol and depression, DSM-W also Includes the category alcohol-induced mood disorder to diagnose mood disorders developing during, or within a month, of alcohol intoxication or withdrawal

Depression ami alcohol

The Interrelationship between depression and alcohol Is complex, but highly Important in clinical practice. About 100 years ago, the readers of a booklet written by Bode, a German physician,7 could learn that depression and alcohoi abuse are often linked. The author thought that regular drinking could be a consequence of the “depression” caused by an unfavorable climate, stating for instance that alcoholism had been observed in Italians moving to the fog and rain of London, or in German colonial officers posted In tropical countries. In a more modern vein, Bode also added that alcohol abuse could be one of the first symptoms of “melancholia,” the usual term at the time for today's major depression. He wrote that the melancholic patient “turned to the bottle” to alleviate feelings of anxiety, guilt, sorrow, sadness, and mental vacuity. This statement would still be considered pertinent today Intuitively, the association between depression and alcohol seems to have good face value.

However, this association Is much more complex than meets the eye. Interestingly, a Ushaped relationship of depression and alcohol consumption has been observed In large population samples. It was found that lower-level drinkers had lower depression scores than both nondrinkers and heavy drinkers.8 The fact that moderate alcohol users are merrier than teetotalers Is Illustrated by Sir John's comment in Shakespeare's play, Henry IV, Part 2 (act 4): “A man cannot make him laugh; but that's no marvel; he drinks no wine.”

The causal element In the association between depression and alcoholism is debatable. Is depression secondary to alcoholism, or vice versa? Or, are both possible? In the case of alcohol-Induced mood disturbances, alcoholism Is clearly primary, and depression secondary. Mood disturbances are characteristic of heavy drinkers, particularly during withdrawal. When not drinking, alcoholics often report depression, Irritability, suspiciousness, lethargy, apprehension, anxiety, and poor concentration. About a quarter of recently detoxified alcoholics have a depressive syndrome.

Alcohol-induced depression usually remits In less than 1 month without specific treatment. The clinical course of depression when it coexists with alcoholism Is generally benign and self-limited, with most patients becoming euthymlc within 2 to 3 weeks of abstention without antidepressant treatment. In some depressed alcoholics, however, a more chronic depression persists, and may predict a worse outcome for the alcoholism. In that case, antidepressants should definitely be used, since they may lower the relapse rate.

The reverse of alcohol-Induced depression, namely depression-induced alcoholism, can also be observed. Drinking may be secondary to depression, when alcohol Is used as self -medication by the patient. The alcoholic may drink to relieve his mind from sorrow, fear, and despondency, or to combat loneliness or the blues. Since alcohol absorption may have a transient arousing or mood-lifting effect, this strategy has some short-term benefit, but It Is doomed in the long run. In fact, as described In the paragraph above, the paradox is that chronic use of alcohol Is more likely to make the subject more withdrawn, more depressed, or more anxious. However, It should be remembered that, although depression can lead to alcoholism, most cases of alcoholism are not explained by primary depression, contrary to popular belief.

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