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How are alcoholism and mood disorders linked?

A clear link exists between addiction and depression. The rates of depression are three times higher in male addicts and four times higher in female addicts than in the general population, and a third of all depressed patients suffer from an addiction. Men typically develop a substance abuse disorder first, whereas women typically develop a mood disorder first. The link between these conditions has biological, psychological, and social roots.

Biologically, many addictive substances are depressants, whereas many other addictive substances, when withdrawn, cause depression. Additionally, both addiction and depression run together in families, placing individuals with family histories of both conditions at risk. Psychologically, certain personalities are prone to addiction and depression. People who have difficulty with impulse control and who are quick to anger and are abrupt seem to be more prone to addiction, perhaps as an attempt to help modulate their feelings. Unfortunately, these self-medication attempts are only transiently beneficial and generally backfire. Alternatively, people who are shy or reserved and who become very anxious in social settings are more prone to depression and addiction as well, again because they often use substances as a way of trying to feel more comfortable "in their own skin." Socially, people who struggle with depression and addiction find themselves isolated from others and unable to hold down a job. Social isolation, job loss, and loss of access to health care and housing can lead people to further worsening symptoms of depression and addiction.

The rates of depression are three times higher in male addicts and four times higher in female addicts than in the general population, and a third of all depressed patients suffer from an addiction.

Self-medication taking medications that are not prescribed by a physician or nurse practitioner, including alcohol or other drugs, to cope with emotional distress (e.g., drinking alcohol or smoking marijuana to calm down when one is feeling anxious).

Although addiction and depression are linked, treating one problem will generally not resolve the other problem; instead, the likelihood is high that if someone is receiving treatment for one problem the other may also be present and require treatment simultaneously if progress is to be made (see Question 29). Although the concept of self-medication remains controversial, some evidence supports it, as many patients describe their use unwittingly as an attempt to "self-medicate" depression. Unfortunately, no evidence exists showing that treatment with antidepressant medication alone leads to abstinence. Although the "self-medication hypothesis" may seem right for some individuals, after an addiction develops, it takes on a life of its own. It is unlikely that medicating a mood disorder away will simultaneously medicate the addiction away. On the contrary, if one continues to use drugs or alcohol while receiving antidepressant medication, those substances render antidepressant medication essentially useless.

My spouse has mood swings along with his/her addiction problem. Could he or she have bipolar disorder?

Because of the recent surge in interest in bipolar disorder, this topic warrants separate attention than what was discussed in Question 67. Bipolar disorder, or manic depression, is a mood disorder affecting upward of 1% to 5% of the population, depending on the diagnostic criteria. Traditionally, bipolar disorder was a very serious psychiatric condition with episodes of acute mania that invariably caused psychotic symptoms and led to hospitalization. The major difficulty in diagnosing it was distinguishing it from schizophrenia, as the clinical manifestations of an acute manic episode and an exacerbation of schizophrenia were indistinguishable. With the advent of lithium, such a distinction was imperative, as lithium was a specific treatment for bipolar disorder, whereas Haldol or other antipsychotic medications treated both mania and schizophrenia alike. Condemning a patient to life-long antipsychotic medication with its attendant risks was not viewed as good practice when the patient could be effectively managed with lithium alone.

Over the years, as the commitment laws changed and psychiatry became increasingly focused on dangerousness, ever larger numbers of patients with serious impulsive behaviors became the focus. These patients rarely if ever demonstrated full-blown mania or other psychotic symptoms. Historically, they were viewed as personality disordered, as impulsive behavior appears to be inherent to the individual and less subject to change with medical intervention. Clearly, however, a great deal of overlap existed between these individuals and patients with mood disorders. Although many of these patients improved with antidepressant medications, a good number of them were made worse and responded better to anticonvulsant medications. The publication of DSM-IV broadened the category to include bipolar II disorder, a condition with predominant depression and few, largely "under-the-radar" episodes of mania. These episodes generally were associated with irritability rather than euphoria and never became severe enough for people around them to remark that they needed professional help or warranted hospitalization. In fact, what was notable was more of a magnification of the worst aspects of their personality: moody, irritable, quick tempered, and impulsive. This just drove family and friends away from them. It did not alert them that there might be some other underlying cause to their personality change.

Most of these patients presented to the psychiatrist's office depressed, and it was only through inquiry regarding past behavior that the diagnosis was generally established. This new category has relaxed the criteria and increased the number of patients with this diagnosis. The new concern is no longer distinguishing bipolar disorder from schizophrenia, but rather distinguishing bipolar disorder from either depression or a personality disorder. Complicating the problem is the fact that these patients are more prone to drug and alcohol abuse, which only exacerbates their swings from depression to irritability to euphoria, and the swings do not tend to be sustained, but rather wax and wane along with the substance abuse. These patients come to the emergency room not because of a psychotic break but because of intoxication, withdrawal, or an impulsive suicide gesture, following binge use and some interpersonal difficulty resulting from their binge use.

Alcohol, cocaine, heroin, PCP, and marijuana can all cause mood swings that make everyone using these drugs suspect of having a mood disorder in general and bipolar disorder more specifically. When these patients are hospitalized psychiatrically as a result of an impulsive, potentially dangerous behavior in the context of their drug and alcohol abuse, the likelihood of their being discharged on a "cocktail" of psychiatric medications and a diagnosis of bipolar disorder is high. With average lengths of stay in psychiatric hospitals decreasing annually to now less than a week, the accuracy of such a diagnosis is suspect at best. The proof is not even in the pudding because complicating the picture is the fact that the medications one is discharged on are symptom and not diagnostic specific. Therefore, although one may benefit from a mood stabilizer or antipsychotic (increasingly, with the new atypical antipsychotic medications, these two terms are becoming almost synonymous as both decrease irritability), that does not mean one has bipolar disorder. Unfortunately, the danger inherent in the diagnosis is that all too often these patients and their families now focus entirely on this new diagnosis and attribute their continued relapse to their bipolar disorder and an inadequate medication regimen while doing nothing to get treatment for their substance abuse or alcohol disorder. Any mood swings stand a far better chance of improvement from abstinence than from any psychotropic medication offered.

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