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Addiction and dependence of drugs is important in mental health.

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I. Addiction Psychiatry
Alcohol
Epidemiology: One year prevalence rates of alcohol misuse & dependence have been found
to be 7 to10%, and one year incidence rates are around 14 ­20%. Rates of alcohol misuse and
dependence are higher in men compared to women. In the recent years drinking by women
has increased, leading to a change in the drinking ratios of men and women. Women are
more vulnerable to develop alcohol related disorders and mortality compared to men. Some
occupations like chefs, barmen, brewery workers, doctors, journalists and salesmen are at
increased risk of misuse, though there is no correlation with increased risk of cirrhotic
disease.
Aetiology:
Many factors have been evaluated for aetiology of alcohol and drug misuse,
including birth trauma, abandonment by parents, death of parent, death of sibling, sexual or
emotional abuse in childhood, broken families, genetics, personality traits of novelty seeking
and impulsivity and biochemical factors. It is important to remember that the aetiology of
alcohol dependence has biological, psychological and social factors.
Concordance rate for monozygotic twins is approx 60%. There is no causal relationship
between maternal deprivation and alcoholism though it is commonly believed to be
associated. P300 shows a reduced amplitude, but it is found in other conditions and is
considered as a putative trait marker for alcohol dependence, as it is found to be diminished
in people with alcohol dependence, their first degree relatives (who are not dependent) as
well as in people prior to the onset of dependence. 1
Asians and Orientals with a particular variant of the isoenzyme of aldehyde dehydrogenase
(ALDH2 gene), and hence loss of aldehyde dehydrogenase activity, experience a flush
reaction when they drink alcohol and are at less risk of excess drinking and alcohol related
disorders.2 Alcoholics have lower levels of platelet 5HT and low levels of 5HT HIAA in CSF.
There is also evidence of a polymorphism in the 5HT transporter gene in alcoholics and the
5HT system is thought to play a role in craving. A locus on chromosome 16 is associated
with severe alcoholism. 3
Psychological and social factors include dissocial PD, social learning to drink, certain highrisk
occupations, ethnicity and the general level of alcohol consumption within the
population. The Whitehall study of civil servants showed that effort/reward imbalance is a
risk factor for developing alcoholism.
According to Cloninger (1987) the type 1 alcoholic scores high on harm avoidance and
reward dependence and low on novelty seeking, and is typically more dependent, anxious
and less aggressive than type 2 who is less dependent, less anxious, more aggressive and a
natural thrill seeker (features of dissocial PD).
Studies suggest that around 6% of older adults are heavy users of alcohol, with about 1/3 of
the elderly alcoholics developing this problem in later life, and the rest beginning drinking as
younger adults. 4
Clinical features and sequelae:
Alcohol dependence to be diagnosed by ICD10 does not require `Withdrawal Delirium' as a
criterion, though withdrawal features are criteria.
Criteria in ICD 10 are strong desire or sense of compulsion to consume alcohol, difficulty in
controlling the intake or cessation of drinking, tolerance, withdrawal symptoms, use despite
knowledge of harm, preoccupation with alcohol use to exclusion of pleasurable activities.

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This is based on Edwards and Gross's 7 key features described in 1976.
Consequences of alcohol misuse include physical, psychological and social.
Physical consequences include:
Neurological:
Polyneuropathy.
Alcoholic myopathy.
Alcohol increases the amount of REM sleep and decreases the amount of stage 4
sleep, hence alcohol induced sleep may be more disturbed.
Cerebellar degeneration, central pontine myelinolysis, Marchiafava Bignami disease
(fits, coma and dementia)
Wernicke's encephalopathy: Is the acute form of the syndrome.…read more

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Infertility
Testicular atrophy
Other:
Foetal Alcohol syndrome occurs in some children born to mothers who drink
excessively during pregnancy. Features include facial abnormality, small stature, low
birth weight, low intelligence & overactivity. There is also an excess of stillbirths
Accidents
Psychiatric/psychological sequelae include:
Delirium tremens occurs 2 to 4 days after cessation or reduction of drinking in a person
with chronic alcohol use.…read more

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Usually non directive, non prescriptive,
aimed at enabling the patient to go through the pros and cons of substance use, and improve
the patients own perceptions of risk rather than tell them about the risks of substance use.
The management of alcohol dependence can be divided into detoxification, maintenance and
relapse prevention, and involves psychological, pharmacological and social strategies.
The treatment of withdrawal, is mainly pharmacological, with use of long acting
benzodiazepines like chlordiazepoxide, given in decreasing doses for 5 7 days.…read more

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Opioids
Includes Heroin, morphine, codeine, methadone and pethidine (last two are synthetic
analogues, while the others are naturally occurring substances). Heroin is the most abused
opiate. Heroin is around three times more potent than morphine, and causes euphoriant
effects within seconds ­ minutes of usage. Side effects of acute intoxication include
nausea/vomiting, constipation, pupillary constriction, drowsiness and resp depression.…read more

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CBT, group therapy). Cochrane review in 2005 concluded that no
available treatment has been shown to be effective in the treatment of amphetamine
withdrawal. Of greatest potential benefit are those medications that increase dopamine,
noradrenaline and/or serotonin activity, although SSRIs have been shown to have no
efficacy.
Cocaine is a stimulant, which causes increased energy, increased confidence, euphoria,
diminished need for sleep. Its effects can be analogous to mania. Cocaine acts by blocking
the reuptake of dopamine into presynaptic dopamine terminals.…read more

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Buproprion works on dopamine and/or noradrenaline neurones to reduce craving during
nicotine withdrawal. Trials show 1 year abstinence rates of 30% with buproprion, 16% with
nicotine patches and 15% for placebo. Combination of buproprion and nicotine patches
increased abstinence rate to 35%. 16
Benzodiazepines can produce physical dependency after relatively short periods of use. A
withdrawal state can occur with symptoms including hyperacuity to light, sound and smell
and psychological disturbance. Treatment consists of a reducing dose of a long acting BZD,
such as diazepam.…read more

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