Subject: Alcohol

Short Description: Self-Medication of Mood Symptoms with Alcohol is a Risk Factor for Alcohol Dependence

Background:
Patients often report alcohol use as a way to “self-medicate” mood symptoms. A new study demonstrates that this self-medication may serve as a precursor to the development or persistence of alcohol dependence, as defined by the DSM-IV.

Researchers evaluated the 43,093 adults who participated in the NESARC survey, a national survey of American adults consisting of face-to-face interviews at two time points, in 2001–2002 and in 2004–2005. Participants were asked about their drug and alcohol use and psychiatric history; a total of 5,768 reported mood symptoms (depression, hypomania, or mania) at both the first and second interviews. Most of these (N=4,221) were not dependent on alcohol at baseline. All were asked whether they used alcohol to “improve their mood” (if depressive symptoms were present) or to “calm down” (if there were manic symptoms).

Individuals who developed alcohol dependence (N=226) were more likely to have reported using alcohol to self-medicate than those who did not become dependent (odds ratio 4.81, 95%CI 3.09-7.49). Similarly, those whose alcohol dependence persisted from the first to second surveys (N=455) were also more likely to have endorsed self-medication (OR 5.39; 3.98-7.28). The relationship held true regardless of sex, age, or race.

Whether mood symptoms met criteria for a mood disorder (40.5% of the total) or not (59.5%), self-medication drinking, when present, was strongly associated with the development or persistence of an alcohol use disorder. Individuals who reported a history of any treatment for mood disorder (3,260 of the total) and who endorsed self-medication drinking were far more likely to develop alcohol dependence than those who had never received treatment.

The authors acknowledge that some individuals who drink may be reluctant, or lack the insight, to admit that they do so to relieve affective symptoms; indeed, only 610 participants (10.6% of the total who endorsed mood symptoms) endorsed any self-medication drinking. The study also did not address quantities of alcohol consumed, and it used a single question for “self-medication,” which has not been independently validated in other studies.

Finally, the number of individuals who developed alcohol dependence or whose dependence persisted was quite low (11.8% of the total sample) and, surprisingly, fewer than half of these (15.4% and 48.5%, respectively) endorsed self-medication drinking (Crum RM et al, JAMA Psychiatry 2013; online ahead of print).

TCPR’s Take: While the concept of “self-medication” requires further clarification and validation, this study supports the hypothesis that individuals who self-medicate their mood symptoms have a significant risk of developing or maintaining alcohol dependence. So in addition to asking about your patients’ alcohol use, you should probably ask whether they drink to manage mood symptoms, and if so, provide appropriate counseling and education to prevent future alcohol-related problems.