The Relationship
It is generally recognized that the relationship between alcoholism and depression is complex and this relationship has been studied extensively in psychiatry. Depression is a frequent experience in the lives of alcoholics and alcoholism is often seen as a symptom of depression. Some people when depressed turn to alcohol as a form of self-medication, while alcoholics become depressed as a result of the problems caused by their drinking behaviour.
Yet given the complexity of the alcoholic’s life and the fact that depression is not a fully understood condition, it is not surprising that it is difficult to establish the exact link between these two disorders. While many young people are heavy drinkers, only a small minority go on to become alcoholics, and though stress is a common experience in life only relatively few people succumb to clinical depression when faced with stress.
Family research studies have discovered that there is a relationship between alcoholism and depression and have found a high incidence of alcoholism in the families and relatives of patients with depressive disorder and conversely have uncovered the fact that there is a high incidence of depression in the families of alcoholics.
Depression and Drinking Behaviour
For those alcoholics who also suffer from depression, we would expect that successful treatment of the depression would result in an improvement in their drinking behaviour. Research however has produced mixed results. One study revealed that women alcoholics who suffered from primary depression and secondary alcoholism did much better when followed-up, compared to those whose problem was primarily alcoholism. Another study of alcoholics undergoing treatment for their alcoholism showed that while treatment improved their drinking behaviour, this treatment however had no influence on their depression. Yet another study which compared alcoholics with a mood disorder with those who had only alcoholism found that while patients with a mood disorder received more intensive treatment, this extra treatment was not translated into an improvement in their alcoholism. The findings of this study suggested that stabilization and treatment of the mood disorder may not necessarily be followed by an improvement in drinking behaviour.
The Chemical Effects of Alcohol
From a strictly scientific point of view, alcohol is described as a central nervous system depressant yet in reality, its effect on a given individual varies enormously. It is well known that the effect of alcohol on behaviour and mood depends on the concentrations of alcohol in the body: the more you drink, the greater the impact. At first alcohol exerts a relaxing effect by the release of inhibition and the person becomes more talkative, sociable and even euphoric. Later however, with further drinking individuals may become argumentative, withdrawn and morose. Previous drinking experiences are also important and this impacts on the expectations that the person will have when drinking, as will the environment in which the drinking takes place. Personality makeup may also contribute to the person’s response to alcohol and so we see the shy introverted person becoming self-confident and outgoing while the extrovert personality may become a troublesome social nuisance.
As noted earlier, people who are depressed may turn to alcohol as a form of self-medication and sometimes they do have a positive result from drinking, with a reduction in tension and anxiety. This early positive experience with alcohol may of course result in their turning to this substance in the future, more and more for relief of their psychological problems including depression and eventually they may end up with two problems given the addictive potential of alcohol. The cure in turn becomes an illness as they develop alcoholism in addition to their original depression.
An interesting finding is the research that reveals that people with more severe depressions are less likely to benefit even temporarily from an improved sense of wellbeing after drinking. Excessive alcohol consumed by the more severely depressed person results in diminishing returns, alcohol becoming more often a contribution to the depression rather than a solution. The traditional assumption that drinking produces an improvement in mood in alcoholics is not always correct. In fact, bouts of heavy drinking may cause insomnia and may be followed by states of sadness and anxiety, while persistent heavy drinking can cause almost any psychiatric disorder including severe depression, auditory hallucinations and paranoid delusions.
Depression and Alcoholism: Treatment Dilemmas
When faced with the challenge of treating depression in the alcoholic or alcoholism in the depressed person, the therapist needs to be on full alert. The evaluation of depression is often difficult, as alcoholics are frequently seen by the therapist immediately after a drinking bout when the results of alcohol overindulgence predominates. The therapist may be seeing the pharmacologically induced depression of heavy drinking or the depression associated with the withdrawal phase of treatment. Often these depressions are very similar to the depression of major depressive disorder.
Attempting to identify stress factors in the alcoholic’s life is also difficult as he or she may have difficulty recalling stressful events that may have occurred immediately prior to the period of intoxication. Once again the therapist has to deal with separating out those stressors that have been caused by heavy drinking from stress factors or pressures that may have resulted in the individual turning to alcohol in the first place as a means of relief from stress.
So the important step in treatment is to determine quickly and accurately the type of intervention that is required by the alcoholic patient and this does require a careful evaluation. This evaluation needs to establish if the drinking problem is secondary to a hidden depressive disorder, or alternatively is the depression secondary to a primary alcoholic problem. In the majority of cases depression when present, is likely to be secondary to alcoholism and this type of depression will improve once drinking is brought under control. It is important to emphasize however that although temporary in nature, this type of depression may be serious and not without risk, including suicide risk. These patients need a lot of support until they are free of depressive symptoms and fully recovered from the effects of both alcohol overindulgence and alcohol withdrawal.
In a smaller percentage of cases, the depression may persist and require specific treatment and these are people where a diagnosis of primary depressive disorder with secondary alcoholism may be considered. They may have a family history of depression or bipolar mood disorder and are likely to report that their first major life difficulty was a depressive episode rather than problem drinking. They may also complain that they experience serious depressions even during those times when they are not drinking. Once this small group has been identified, they will require treatment with appropriate strategies after their alcohol withdrawal symptoms have cleared; this is usually five to ten days after they have stopped drinking.
Treatment of Depression and Mood Disorder
In patients who have primary depression or a primary mood disorder, the indications for the use of antidepressant Lithium and other mood stabilizing medications, are the same as for non-alcoholic patients with a mood disorder. It is important however to stress that medication should be introduced only as part of a comprehensive treatment program and not as the only treatment that the alcoholic receives. It is a mistake to consider one illness simply as a consequence of the other and to focus all treatment efforts on one to the exclusion of the other. It is worth repeating that although a mood disorder may benefit from antidepressant treatment, stabilization of mood in the alcoholic patient is not necessarily followed by an improvement in drinking behaviour. This, in part may explain why the use of antidepressants and Lithium in the treatment of alcoholism has frequently been disappointing in the past.
Treatment of Alcoholism
Treatment goals for their alcoholism should be negotiated with the patient in the context of a trusting and helping relationship. Previously, abstinence from alcohol was the major criterion for the successful outcome of treatment and other issues tended to be ignored in the drama which so often accompanies acute alcohol excess and the struggle to recovery. This is now recognized as a restricted perception of therapeutic improvement. Level of functioning in all areas of life must be carefully monitored as this will indicate the degree to which the patient has successfully rehabilitated himself or herself, from previous faulty patterns of behaviour and has achieved the goal of contented sobriety. In the early phase of therapy, control over drinking takes priority. Once the alcoholic has achieved successful abstinence, underlying psychological problems previously concealed can be expected to emerge and may be dealt with over time. The type of treatment offered the patient, will depend on many factors including the patient’s capacity for insight, the intactness of his personality and the presence or absence of intellectual damage.
Family and Supports
A history obtained from a relative or close acquaintance is always very valuable as the therapist is unlikely to get a full account of the drinking problem from the alcoholic due to problems with memory or denial. The presence of support figures in the patient’s life in the form of family members or employers should be identified as they become important resources during the early months of abstinence when the alcoholic is at risk to situational depression as he struggles to cope with the demands of reality without the buffer of alcohol.
In addition, family dynamics are likely to require attention, as previous patterns of communicating and relating were probably distorted as a result of the patient’s drinking practices and acting out behaviour. Also, changes in family dynamics can be expected, as the now sober patient attempts to assume responsibilities previously neglected, forcing family members to redefine their roles in the home.
Conclusion
Although the majority of alcoholics lead productive lives, they are frequently seen as unrewarding patients to treat. Therapists, psychiatrists and physicians are sometimes ambivalent about involving themselves in their treatment and long-term follow-up. This traditional pessimism about treatment has probably arisen from the indiscriminant mixing in treatment programs of individuals with poor prognosis with those having a good prognosis, resulting in mediocre overall picture of treatment effectiveness.
Failure to carry out a careful evaluation and define specific treatment strategies may lead to ineffective or unachievable treatment goals. It is worth remembering that the treatment outcome of alcoholics may range from very modest changes in life habits, to a successful rehabilitation into a new lifestyle. Alcoholism is a chronic disorder and recovery not cure is the goal of treatment. Relapses may be a feature of the alcoholic’s life. These, however, need not induce therapeutic despair because with quick intervention and prompt treatment, their disruptive impact can be minimalized.
