By Paul Kettl, M.D.
Director, of the Geriatric Inpatient Unit
M. S. Hershey Medical Center

What do alcoholism and drug abuse have to do with affective disorders? That question has been hotly debated among psychiatrists over the last several decades.

But recently, definitive information on the question became available from the Epidemiologic Catchment Area Survey. At five sites around the country (one of which was Baltimore), researchers in this study went literally from door to door conducting psychiatric interviews. One surprising finding was that 32 percent of people with an affective disorder had also experienced an addictive disorder-either alcoholism or drug abuse. People with bipolar I disease (classic manic depression) had the highest rate of dual disorders-- 61 percent of them had also been diagnosed with an addictive disorder. Of people with unipolar disorder (major depression), 27 percent had also been diagnosed with an addictive disorder.

So about one-third of the people who have an affective disorder will at some point also abuse alcohol or drugs. An illness this common, with the potential to cause so much pain and suffering for persons already burdened with an affective disorder, cannot be ignored.

Psychiatrists still don't know what an "alcoholic" or a "drug abuser" is. Are these people with a genetically driven disease who have biological urges leading them to alcohol abuse or drug abuse? (The rate of affective disorder among alcoholics and drug abusers is significantly greater than in the general population.) Or are these people simply misbehaving with alcohol or drugs as other people misbehave in other facets of their lives? The answer to both questions is "yes," depending on the person. So while psychiatrists debate about just what an alcoholic or drug abuser really is, we merely need to look at our own lives, our own behavior.

Perhaps it is best to consider yourself as a problem drinker or drug abuser if you've had problems related to alcohol or drugs. Such problems are usually focused in one of three categories: health (problems such as stomach disorders, tremor, or heart disease); relationships (problems such as marital difficulties fueled by alcohol, complaints from friends or dating partners); or money (problems such as having been fired or losing money at work because of drinking or drug abuse). If you've ever had such experiences at a time of alcohol or drug use, then you have an alcohol or drug problem. The only way to be sure you will not continue to have such problems is simply not to drink or to abuse drugs. (Only a small number [less than 5 percent] of people who have been "problem drinkers" can turn themselves into "social drinkers.") Abstinence is essential-and the only solution. It is important to remember that although most people with alcohol or drug problems can quit for a while, they can't remain abstinent. So if you can abstain for some time but then find yourself drifting back into alcohol or drug abuse, you can be sure you have an alcohol or drug problem.

People who have an affective disorder need to be especially careful; alcohol is a foreign substance that can affect the brain, and people who already have one brain disease certainly don't need another. Alcohol use can lead to poor judgment as well as family and interpersonal problems. Prolonged alcohol use can even cause hallucinations. Persons who are already forced to deal with the consequences of one illness need to know what can happen when alcohol or drug abuse is added to the mix. Just as persons with heart disease need to be more careful of their cholesterol level, exercise regimen, or blood pressure, persons with an affective disorder need to be especially careful of alcohol or drug use.

If you've ever had problems from drinking, abstinence is key. If you've never had problems with alcohol, abstinence is still advisable-but not essential. Your use of alcohol must, however, be moderate; it's a good idea never to get drunk. Alcohol intoxication can lead to a variety of problems including alcohol abuse, hallucinations, alcohol-related sleep problems, or interpersonal problems.

Anyone with an affective disorder should be careful to abstain from all street drugs of abuse, including marijuana. Marijuana has many dangers; among them is its ability to cause hallucinations and mental disorders all by itself. Moreover, you are never certain what you are buying: there is no "FDA-approved" marijuana or cocaine or any other street drug. What you buy on the street may be marijuana, but it also may be PCP or some other compound. These compounds are more likely than marijuana to cause psychosis, and even on their own, they can cause the eruption of an affective disorder.

So while psychiatrists continue to debate what alcoholism or drug abuse is or how these disorders are linked with affective disorders, a simple message for the patient remains obvious. Health maintenance for people with affective disorders mandates abstinence from the use of street drugs and a careful look at the use of alcohol.