Sunday, May 22, 2011

When Substance Use Butts Heads with Mood

As you probably know by now, I have been replacing a lot of the old articles on mcmanweb with brand new ones. More recently, my focus has been on disorders that overlap with mood, including schizoaffective and anxiety. This time around, it's alcohol and substance use. Following is an edited extract ...

Walk into any AA or NA meeting, and you will hear people talking about their cravings. Walk into a DBSA group and you will find some of these very same people talking about "self-medicating." Two different problems altogether or two faces of the same problem? It's hard to tell.

Fifty percent of those with lifetime mental illness also have a lifetime history of at least one substance use disorder. Six in ten of those with bipolar have experienced a substance use disorder some time during their life, more than five times the rate of the general population.

Perhaps you can see where I am going with this. If all alcohol and substance abuse is strictly genetic, then why would these genes be so unevenly distributed? Why would they so heavily cluster in the mood disorders population? That can't possibly be right, can it? So what else can be going on?

A Desperate Need for Release?

In the initial going at least, individuals tend to indulge in alcohol and drugs to feel better than they are currently feeling right now. Some may continue this way, but for many the situation has changed. The crying need is for the chemical fix, not the feel-good state (which the brain may have built up a tolerance to).

With a mood disorder (not to mention vulnerability to stress) this is turned around. The overwhelming compulsion is for release from the psychic pain, be it depression or runaway mania or anxiety. A bit of feel-good (or feel less-bad) may be involved, but one is left with the sense of an individual putting out a fire or fleeing a burning building.

But life is complicated. Addicts may claim they are self-medicating. Those who started off self-medicating may not recognize they have have turned into addicts.

Messed Up vs Clear Head

Some over-zealous participants in AA and NA caution that taking psychiatric meds is another form of chemical dependency.

But people take psychiatric meds for entirely different reasons than those talking alcohol or recreational drugs. For the most part, there is no feel-good effect from a psychiatric med. Whereas an addict may start with an initially clear head for the purpose of getting it messed up, a person with a mental illness tends to be coming from the opposite direction.

Of all things, when researchers began investigating the inordinately high rates of cigarette smoking in those with schizophrenia, they discovered that nicotine had the momentary effect of restoring lost cognitive function. Think about it - for the first time in years or decades your brain is suddenly coming in loud and clear. To these individuals, the medically horrendous side effects are well worth the few precious seconds of mental clarity.

If nicotine came in a pill prescribed by doctors, with similar results, would you dare accuse these individuals of having a chemical addiction or dependency? (Nicotine agonists are in development.)

The Craving and Self-Medicating Factors

The inhibitory neurotransmitter GABA quiets down activity in the neuron, which is vital for keeping the brain in healthy stable state (homeostasis). Its tag team partner glutamate achieves a similar end through ramping up neural activity. Inevitably, when things go wrong, the two neurotransmitters are complicit in a range of mental illnesses and conditions, from anxiety to schizophrenia, with depression and mania thrown in for good measure.

When alcohol molecules bind to the neuron's GABA receptors, GABA transmission is increased. Because GABA is active throughout the brain, effects can range from euphoria to sluggish thinking to loss of muscle control. Over time, the neuron structurally changes to accommodate increased GABA supply, setting up the conditions for a craving.

Next neurotransmitter ...

Dopamine is central to pleasure and reward, motivation, alertness, executive function, and muscular control. Dopamine dysregulation (too much or too little) has been implicated in depression, bipolar, ADHD, OCD, aggression, novelty-seeking, schizophrenia, and Parkinson's.

Dopamine surges account for the highs from street drugs such as cocaine and crystal meth and prescription drugs of abuse such as methamphetamines, but these effects tend to wear off as the neuron structurally changes to compensate, again setting up the conditions for a craving.

Then there are brain systems involving serotonin (LSD and ecstasy work on this neurotransmitter), THC (cannabis), and stress regulation.

Since all these systems are intricately interconnected and interdependent, an addiction to one substance may involve an addiction to other substances. Likewise, mental illness and addictions share many of the same pathways. Serotonin has received most of the attention regarding depression, and it is no coincidence that ecstasy provides instant relief. Likewise, for vegetative depressions, a methamphetamine may offer a quick dopamine jump start.

Self-medication, then, is a clumsy and ultimately self-defeating attempt to bring the various brain systems into alignment. Think of alcohol, for instance, as an anti-anxiety med with an outrageous side effects profile. Ultimately, the short-term neurotransmitter surge sets up the conditions for the long-term depletion. Self-medication and craving become one.


Moira said...

Thank you for this. Self medication is seen as more socially acceptable than being in treatment, eh?

John McManamy said...

Hey, Moira. My impression is saying you're in treatment will always be the most acceptable, as others interpret this as the person taking responsibility. Then there is the issue of self-medicating vs not controlling a craving. Does one carry more stigma than the other. We're seeing more acceptance of bipolar. Does this mean that people these days are more likely to say they self-medicate? I welcome further discussion.

Tony Previte said...

One thing that has always irked me, is that while acceptance of things like Bipolar have become more common place, they have become accepted on the backs of celebrities who become de-facto mouthpieces for ALL of us.

People like Charlie Sheen for example certainly don't do us any favors by making a public display of being a wealthy spoiled brat and rubbing our noses in it.

Others do it smartly, but go largely unnoticed.

In my exploration of my various clinical diagnosis' and possible work in public mental health there certainly is a tendency for caregivers to "control" what a person chooses to do to self medicate. There is an emphasis on paying attention to what things "look-like" vs how they really are. It's NOT an easy road to not cast judgment, but caregivers sometimes need to step back a bit and let people fail of their own accord.

Some of us ARE brutally honest with ourselves and others, and it can come off as being a know-it-all. But sometimes one's background isn't completely known for completely legitimate reasons. Once those details emerge, more emphasis on letting people be who they're going to be needs to be more commonplace that it currently is.

Lizabeth said...

Waaaay back in l986 my first job as a new grad RN was on a mentally ill, chemically dependant adolescent unit in a state hospital. If you think the treatment drugs now are sometimes useless, you should see what we had then. There were whispers of something new in the pipeline called Prozac which was an SSRI. Huh? Much RN headscratching at new med category.
Anyway, among ourselves we nurses debated which came first, the illness or the dependency. Given the huge amounts of both alchol and illegal substances those kids had put into themselves, I still think sometimes this is a valid question. Especially since we now KNOW those kids brains had not finished growing yet.
Anyway, it was the damage I saw there that kept me way away from selfmedicating when my symptoms became active later in my life. A strange benefit of my first nursing job, but a benefit all the same.

John McManamy said...

Very interesting, Lizabeth. The population data (Kessler) indicates the mental illness tends to come first (around age 11) and the substance use later (around age 21), but this is by no means definitive.

It can also work the other way - repeated drug use inducing the brain into spontaneous psychosis and depression.

Then there are people who self-medicate their stress rather than their mental illness. On and on it goes.

But any way you look at it, where you see one, the other is bound to be lurking around somewhere. So glad you didn't fall into the trap.