Correlations are manipulated to try to construct a system of diagnosis in a field where knowing the origin of the illness is only a small piece of knowing how to treat it. One recent study, for example, looked at sleep patterns and determined that shortened latency for rapid eye movement (REM) sleep (the length of time before one enters the first REM stage after falling asleep) indicated that depression was the primary illness, while a protracted latency for REM sleep indicated that alcoholism was the primary illness. Some clinicians claim that early-onset alcoholism is more likely to be the consequence of depression than is later-onset alcoholism. Some tests measure metabolites of serotonin, or levels of cortisol and other hormones, and hope to demonstrate through these measurements the presence of a “real” depression—but since much real depression does not manifest itself in such metabolites, the tests are of limited utility. An incredibly broad range of statistics is available, but it seems that about a third of all substance abusers suffer from some kind of depressive disorder; and it is evident that a high number of depressives abuse substances. Substance abuse frequently begins in early adolescence, at a stage at which people with a predisposition for depression may not yet have developed the complaint. Abuse may begin as a defense against a developing depressive tendency. Sometimes, depression makes someone who has been a user of an addictive substance into an addict. “People who are taking things because they’re anxious or because they’re depressed are much more likely to develop a real dependence,” Kleber says. People who have recovered from substance abuse are far more likely to relapse when they’re depressed than otherwise. R. E. Meyer has proposed five possible relationships between substance abuse and depression. Depression may be the cause of substance abuse; depression may be the result of substance abuse; depression may alter or exaggerate substance abuse; depression may coexist with substance abuse without affecting it; depression and substance abuse may be two symptoms of a single problem.
It is extremely confusing that substance use, withdrawal from substance use, and depression have overlapping symptoms. Depressants such as alcohol and heroin relieve anxiety and aggravate depression; stimulants such as cocaine relieve depression and aggravate anxiety. Patients with depression who abuse stimulants may have behavior that appears schizophrenic, though that behavior will remit with either a discontinuation of substance use or a successful treatment of the depression. In other words, the symptoms of the combination are worse than the combined symptoms of the two component diseases. In dual-diagnosis cases, the alcoholism is often more severe than average alcoholism, and the depression is also often more severely symptomatic than average depression. Fortunately, people with dual diagnosis are more likely to seek help than those with either problem alone. They are also, however, more likely to relapse. Though substance abuse and depression may be separate problems, unquestionably each of them has physiological consequences in the brain that may severely exacerbate the others. Some substances (cocaine, sedatives, hypnotics, and anxiolytics) that do not cause depression when they are being used do affect the brain in such a way that they cause depression during withdrawal; some substances (amphetamines, opioids, hallucinogens) cause depression as part of their immediate intoxicating effect. Some (cocaine, ecstasy) cause a high and then a compensatory low. This is not a tidy matter. All of these substances, and alcohol in particular, will exacerbate suicidality. All of them blur minds enough to disrupt compliance with prescription regimens, which can create real chaos for people ostensibly on sustained antidepressant treatment.
All of this being said, depression remits more or less permanently in some people after they detoxify themselves, and the correct treatment for such people is abstinence. Other people’s interest in drugs and alcohol simply peters out when their depression is brought under control, and the correct treatment for such people is antidepressant medication and therapy. Most substance abusers, like most depressives, require psychosocial intervention, but this is not invariably the case. Unfortunately, clinicians still have inadequate understanding of how many antidepressant medications may interact with substances of abuse. Alcohol accelerates the absorption of medications, and this rapid absorption significantly raises the side effects of drugs. Tricyclic antidepressants, an older form of treatment, may in combination with cocaine cause significant stress to the heart. It is important, when prescribing antidepressants to a substance abuser who has gone sober, to assume that that person could return to his substance of choice, and to exercise caution in prescribing drugs that may in combination with substances cause significant harm. In some instances, psychodynamic therapy may be the safest way initially to address depression in substance abusers.
The language of addiction has become vague over the last twenty years, so that one can now be addicted to work, to sunshine, to foot massage. Some people are addicted to eating. Some are addicted to money—both getting and spending. One anorexic girl I met had been diagnosed with an addiction to cucumbers, a complaint about which, one cannot help feeling, Dr. Freud would have much to say. Howard Shaffer, director of the division on addictions at Harvard Medical School, has studied compulsive gambling, and he believes that the addiction pathways are in the brain and that the object of the compulsion is not really significant; for him, addiction to behaviors does not differ significantly from addiction to substances. It is the helpless need to keep repeating something damaging that drives dependence, rather than the physiological response to the thing repeated. “You don’t talk about addictive dice,” he says.
Bertha Madras, however, from Harvard’s department of psychiatry, says that the most frequently abused substances tap into pathways that exist in the brain, enabled by their similarity to substances that more naturally occur there. “The chemical structure of drugs happens to resemble the chemical structure of the brain’s own neurotransmitters,” she says. “I call them ‘the great brain impostors.’ They target the same communications systems as the brain’s natural messages. But the complex communication and control systems in the brain are geared for the natural message, not the impostor. As a result, the brain adapts to, and compensates for, the abnormal signals generated by the drug. Here is where the addictive process begins. Brain adaptation is central to addiction. In the case of drugs that produce physical or psychological withdrawal, there is a compulsion to restore the brain to the status it had when it was awash with drugs.” Addictive dice notwithstanding, physical addiction involves the activation of addiction pathways in the brain, and many of those pathways lead to physiological alterations that may in turn cause depression.
People with family histories of alcoholism tend to have lower levels of endorphins—the endogenous morphine that is responsible for many of our pleasure responses—than do people genetically disinclined to alcoholism. Alcohol will slightly raise the endorphin level of people without the genetic basis for alcoholism; it will dramatically raise the endorphin level of people with that genetic basis. Specialists spend a lot of time formulating exotic hypotheses to account for substance abuse. Most people who abuse substances do so because it feels good. There are, the experts point out, strong motivations for avoiding drugs; but there are also strong motivations for taking them. People who claim not to understand why anyone would get addicted to drugs are usually people who haven’t tried them or who are genetically fairly invulnerable to them.
“People are very poor judges of their own susceptibility,” Herbert Kleber of Columbia says. “No one wants to be an addict. The problem in treatment is that the goal of the therapist—abstinence—and the goal of the patient—control—are not the same. All the crack addict wants is to be able to take an occasional hit off the pipe. And one of the problems is that they were once able to do that. Every addict had a honeymoon, during which they could control use. For an alcoholic, that might have been five or ten years; for the crack addict it may have been as little as six months.” Feeling the wish to repeat something because it is pleasurable is not quite the same as feeling the need to repeat something be
cause being without it is intolerable. Frequently, the determinant of need is an external circumstance such as depression; a depressed individual is likely, therefore, to become addicted much more rapidly than is a nondepressed person. If you’re depressed, the ability to get gratification from ordinary life is diminished. Substance abusers may be classed as precontemplative—which means they’re not even thinking of giving up their drug of choice—or contemplative, or externally motivated, or internally motivated. Most have to go through these four stages before they can achieve freedom from dependency.
The medical literature claims that addiction comes from problems with “(1) affects, (2) self-esteem, (3) self-other relationships, and (4) self-care.” I would propose that what is extraordinary, really, is how many of us manage to avoid addiction. We are motivated in part by the knowledge of just how harmful and unpleasant addiction can be, by fear of losing relationships, and by pleasure in self-control. Nonetheless, it is the physical side effects of substance abuse that make the biggest difference of all. If there were no such thing as a hangover, there would be a lot more alcoholics and cocaine addicts around. Drugs reward and punish, and the border between the level of use in which the rewards are greater than the punishments, and the level of use in which the punishments overtake the rewards, is fuzzy. The depressant effects of a drink help people to unwind and deal with social situations without crippling anxiety, and this kind of use is socially sanctioned in most non-Muslim societies. The stimulant effects of occasional cocaine use are to depression what alcohol is to anxiety, though the illegality of cocaine reflects our social discomfort with it. The most common addictions by far are caffeine and nicotine. A doctor who specializes in addiction described to me visiting friends abroad and having a paralytic hangover and a terribly depressed feeling for a full two days before he realized that his friends had only herbal tea in the house and that he was going through not an alcohol-based dehydration problem, but caffeine withdrawal symptoms. A few cups of full-strength coffee later and he was back on his feet. “I’d never even thought about it, but coffee was not simply an acquired taste: it was an addiction and any messing around with it was going to entail withdrawal.” As a society, we don’t object to addictions that are not disabling; we do object to the use of certain addictive substances even when that use is occasional and nonaddictive in nature. The debates over the legalization of marijuana and the illegalization of tobacco point to our split views on this subject.
Genes are not destiny. Ireland has an extremely high rate of alcoholism; it also has an extremely high rate of teetotalism. Israel has an extremely low rate of alcoholism but almost no teetotalers. In a society in which people are prone to alcoholism, they may also be prone to exercising great self-control in the face of substances. “Alcoholism,” Kleber says, “is not a disease of the elbow. It’s not muscular spasms that bring the glass to your mouth. An alcoholic does have choices. The ability to exercise those choices, however, is influenced by many variables, one of which may be a mood disorder.” If you take drugs, you do it deliberately. You know when you’re doing it. It involves volition. And yet do we have choice? If one knows that there is ready relief for immediate pain, what does it mean to deny oneself? T. S. Eliot wrote in “Gerontion,” “After such knowledge, what forgiveness?” In the dark night of the soul, is it best not to know what cocaine can do for you?
Part of what is most horrendous about depression, and particularly about anxiety and panic, is that it does not involve volition: feelings happen to you for absolutely no reason at all. One writer has said that substance abuse is the substitution of “comfortable and comprehensible pain” for “uncomfortable and incomprehensible pain,” eliminating “uncontrollable suffering which the user does not understand” in favor of “a drug-induced dysphoria which the user does understand.” In Nepal, when an elephant has a splinter or spike in his foot, his drivers put chili in one of his eyes, and the elephant becomes so preoccupied with the pain of the chili that he stops paying attention to the pain in his foot, and people can remove the spike without being trampled to death (and in a fairly short time, the chili washes out of his eye). For many depressives, alcohol or cocaine or heroin is the chili, the intolerable thing the horror of which distracts from the more intolerable depression.
Caffeine, nicotine, and alcohol are the primary legal addictive substances incorporated to varying degrees into the norms of our society and advertised to consumers. Caffeine, we largely ignore. Nicotine, though highly reinforcing, is not an intoxicant and is therefore relatively untroubling to daily life; it is the effects of the tar that accompanies the usual intake of nicotine that is worrying to the leaders of the antismoking movement. The delayed negative side effects of smoking make nicotine an easy drug to abuse: if people got horrendous hangovers every time they smoked cigarettes, they would smoke a lot fewer of them. Since the adverse effects—most notably emphysema and lung cancer—are the ultimate result of long-term smoking, they are more easily ignored or denied. The high rate of smoking among depressed people seems to reflect not any particular attribute of nicotine, but a general self-destructiveness among people for whom the future is only bleak. The lower oxygenation of the blood that occurs as part of smoking may also have an active depressant effect. Smoking appears to lower serotonin levels, though it is possible that low serotonin levels in fact cause people to be attracted to nicotine and to take up smoking.
Of the significantly disabling substances of abuse, the most common is alcohol, which can do an excellent job of drowning out pain. While drinking during depression is not unusual, some people drink less when they are depressed, often because they recognize that alcohol is a depressant and that excessive drinking during a depression can severely exacerbate the depression. My experience is that alcohol is not particularly tempting when you are experiencing pure depression, but that it is very tempting when you are experiencing anxiety. The problem is that the same alcohol that takes the edge off anxiety tends to exacerbate depression, so that you go from feeling tense and frightened to feeling desolate and worthless. This is not an improvement. I’ve gone for the bottle under these circumstances and have survived to tell the truth: it doesn’t help.
Having lived with various norms of alcohol consumption, I believe that what constitutes an addiction is highly socially determined. I grew up in a household in which wine was served with dinner, and I had two sips in my glass starting when I was about six. When I got to college, I found that I was a pretty good drinker: I could handle liquor well. On the other hand, drinking was more or less discouraged at my school, and people who drank too much were thought of as “troubled.” I conformed to the standards. At the university I subsequently attended in England, drinking was all the rage, and people who held back were thought of as “stiff” and “unamusing.” I do not like to consider myself a sheep, but I conformed perfectly to this new system. A few months after I began my graduate work in England, I was initiated into a dining society, and as part of a rather stupid ritual I was made to drink a half gallon of gin. It was something of a breakthrough for me and broke down an incipient fear of drunkenness that had previously afflicted me. At that stage of my life, I did not suffer from depression to any great extent, but I was an anxious person given to paroxysms of trepidation. A few months later I went to a dinner and was seated next to a girl with whom I was infatuated, and believing that alcohol would take the edge off the intense self-consciousness she caused me, I agreeably downed about two and a half bottles of wine during dinner. Apparently self-conscious as well, she drank nearly as much, and we both woke up on a pile of coats in the small hours of the morning. No particular shame was attached to this. If you were willing to pay out in headaches and could get the reading done for your next essay, you were most welcome to drink yourself into a stupor every night of the week. It never occurred to me or my friends that I was in danger of becoming an alcoholic.
When I was twenty-five, I started working on my first book, which was about vanguard Soviet a
rtists. While my English drinking had been sporadic and intense, my Russian drinking was steady. It was not, however, depressive: the society in which I lived in Russia was one of alcoholic exhilaration. Moscow water was almost undrinkable, and I can remember saying that I thought the real miracle would be for someone to turn my wine to water, not the other way around. I spent the summer of 1989 living in a squat with a group of artists on the outskirts of Moscow, and I would guess that I drank a quart of vodka a day. By the end of a month, I didn’t notice how much I was drinking; I was accustomed to stumbling out of bed at noon and finding a circle of friends smoking cigarettes, boiling water for tea on a little electric burner, and drinking vodka out of dirty glasses. I thought the tea was disgusting—like warm water with bits of mud floating in it—and so I would have the morning vodka and the day would go on, getting softer with the steady consumption of alcohol. This sustained drinking never made me feel drunk, and I can say in retrospect that it did a lot for me. I had grown up in a rather protected way in the United States, and my feeling of camaraderie with my Russian friends was very much enabled by the combination of communal living and persistent drinking. Of course, a few people among us drank too much even by the standards of the society we inhabited. One man would drink himself into a stupor, wander around incoherent, then pass out every night. He snored like the percussion section of a heavy-metal band. The great trick was to make sure he didn’t pass out in your room and especially on your bed. I can remember standing with six other men and heaving the enormous bulk of this unconscious character onto the floor; once we hauled him down three flights of stairs without his ever waking up. To have stuck to my U.S. drinking standards would have been not only rude but also peculiar in these circles. Perhaps more significantly, the drinking liberated my Moscow friends from their social diet of boredom and dread. They were leading marginal lives in an oppressive society at a confusing moment in history, and to express ourselves freely and to dance and laugh in the way we did, to achieve a certain exaggerated intimacy, we had to keep drinking. “In Sweden,” one of my Russian friends said after he had visited that country, “people drink to avoid intimacy. In Russia, we drink because we love one another so much.”
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