Friday, June 12, 2009

Which Comes First - Alcoholism or Depression?

A great research article by Dr. Fergusson from my Medical School in Christchurch, New Zealand came out this year which helps us answer the question of whether depression leads to alcoholism—or whether it is the other way around. It is an important question because often depression and addiction co-exist.

Many patients who come to us for their drug and alcohol problems also suffer from depression. As clinicians, we have to recognize and treat both problems if we want to have the best possible outcomes for our patients.

Some physicians talk about alcoholics and drug addicts “self medicating.” They believe that addicts are “self medicating” themselves with their drugs or alcohol. This seems to make sense since alcohol and drugs are mood-altering substances—that is, they alter moods or feelings. They relieve (or, in actual fact, “mask and cover up”) feelings that we don’t want. Feelings like anxiety or fear or sadness or anger or guilt. So, of course, people with addiction use their chemicals when they want to cover up unwanted feelings. They are in fact “self medicating.”

The problem that I have with the idea of “self medicating” is not that it happens. The problem I have is that the concept of “self medicating” can lead some people down a false path. It is important to see that addiction is a primary disease and not just a problem of “self medicating.” The natural extension of the concept of “self medicating” can be, for some clinicians, the idea that if patients just got a better control of their feelings—if they resolved their anxiety and depression—then they wouldn’t have to use addictive chemicals; their addiction would just go away. This seems to make sense in theory, but it does not bear fruit in practice. In practice, if an alcoholic or a drug addict goes to therapy but keeps using their mood altering chemicals, they are almost never successful. Firstly, they usually don’t make much progress on resolving their feelings because they are continuing to use mood-altering chemicals:

“You can’t heal what you can’t feel,
and you can’t feel what you medicate.”

Secondly, the disease hasn’t actually gone away. So, with therapy but no abstinence, there may be a temporary lull in the amount of using and a temporary decrease in the negative consequences of using, but there is usually a rapid return to using and more negative consequences.

So, working on the depression, the anxiety, and the other painful feelings doesn’t resolve the chemical dependence. But treating the chemical dependence first usually does relieve the depression and the other painful feelings. One study showed that 80% of alcoholics entering a 28-day alcohol rehab had a diagnosis of depression. But after only 28 days of treatment and no medications, only 20% were still depressed. So, over 75% of depressed alcoholics resolve their depression just by being sober and working a recovery program. We see the dame thing in clinical practice every day. As people get abstinent, go to therapy, go to their 12-step meetings and work their program, their psychiatric problems often go away. It makes total sense, of course.

The study by Dr. Fergusson, published in the Archives of General Psychiatry (2009; 66:260-6) backs this up. When I was in medical school Dr. Fergusson and others started up a fantastic long term study, The Christchurch Health and Development Study. They recruited over 1300 boys and girls born in 1977, and they have been studying these boys and girls every year since then. They have a unique perspective on being able to watch them grow up. Of course some of the boys and girls have developed different diseases. They found that, at age 24/25, about 14% were abusing or dependent on alcohol, and 14% were depressed. The interesting thing is that they found that the depression did not seem to lead to alcohol problems, but the alcohol abuse and alcohol dependence clearly did cause an increase in depression.

At the Coleman Institute, we believe that Alcoholism and Drug Addiction are actually one disease, Chemical Dependence. The disease is caused by an abnormality of the reward system in the brain (the pleasure center) and is strongly linked to genetics. It is a primary disease and not caused by depression or other psychiatric diseases. It is best treated as the primary disease, because when patients recover from their addiction, their other psychiatric problems often go away--often their high blood pressure and liver disease do, as well! Of course, some patients have two primary diseases: addiction and depression. As clinicians we need to recognize this and treat both diagnoses.

-Peter Coleman M.D.

1 comment:

  1. Thought this was very insightful and hopeful for the parent of a teenager abusing drugs who is in treatment