Research reportSelf-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions
Introduction
Mood disorders and substance use disorders are common in the general population, with lifetime prevalence rates of 20.8% and 14.6%, respectively (Kessler et al., 2005a). They are associated with considerable disability, poor quality of life, and inadequate treatment (Ormel et al., 2008, Saarni et al., 2007). In addition to being highly prevalent, mood and substance use disorders frequently co-occur in individuals (Conway et al., 2006, Grant et al., 2004b, Kessler et al., 2005b, Sbrana et al., 2005). In the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), 20.1% of people with an alcohol or drug use disorder had a co-occurring mood disorder (Grant et al., 2004b). In the same sample, 20% of people with a mood disorder also had a substance use disorder.
There are several hypotheses that may explain why two disorders co-occur in individuals at higher than expected rates (Kraemer et al., 2001). One such hypothesis is a direct causal relationship; this postulates that the presence of one disorder may predispose to the development of the second disorder. This explanation is often used to account for the comorbidity seen in alcohol and anxiety disorders and has been described as the “self-medication hypothesis” (Quitkin et al., 1972), whereby anxious individuals misuse alcohol or drugs to reduce distressing symptoms.
Although self-medication has been extensively studied in anxiety disorders (Bolton et al., 2006, Himle et al., 1999, Robinson et al., 2009, Thomas et al., 2003), little is known about self-medication of mood disorders. This is surprising given recent findings in the general population that the rates of substance use disorders are higher in people mood disorders (20%) than they are in those with anxiety disorders (15%) (Grant et al., 2004a). Some evidence suggests that mood disorders precede substance use disorders (Kuo et al., 2006), a necessary caveat for self-medication. However, in studies that have directly assessed self-medication in mood disorders, evidence for the behavior is mixed. Some studies find that people with bipolar disorder use drugs and alcohol to relieve depression or enhance their mood (Bizzarri et al., 2007, Weiss et al., 2004). Other studies suggest that people do not necessarily use substances to relieve depressive symptoms, or else do not achieve the desired antidepressant effect (Arendt et al., 2007, Leibenluft et al., 1993). These discrepancies are likely due in part to sampling differences: studies have examined self-medication in people with primary mood disorders, primary substance use disorders, or the dually diagnosed. Furthermore, the study of self-medication of affective symptoms has been limited to clinical samples and thus the prevalence in the general population is unknown. There is essentially no knowledge of the sociodemographic characteristics and mental disorder comorbidity pattern among individuals who attempt to reduce their mood symptoms with alcohol or drugs.
This study uses data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large nationally representative survey of mental illness in American adults. The goal of this study is to examine self-medication behavior among individuals with mood disorders in the general population. Specifically, we aim to determine its prevalence, the sociodemographic characteristics, and mental disorder correlates of individuals who attempt to reduce their symptoms using alcohol or drugs. Based on previous research on self-medication in mood disorders, we expect to find a substantial proportion of individuals using substances to relieve affective symptoms, and that the behavior will be associated with higher rates comorbid psychiatric illness.
Section snippets
Sample
The NESARC was a nation-wide household comorbidity survey (n = 43,093) conducted in 2001–2002 by the National Institute on Alcohol Abuse and Alcoholism. The target population was the United States civilian, non-institutionalized, adult population. The overall response rate was 81%. It used a multistage sampling design that oversampled specific racial groups including African-Americans and Hispanics, and also oversampled young adults. The weighted data was then adjusted to be representative of the
Results
Prevalence figures for self-medication among mood disorders are displayed in Table 2. One quarter of individuals in the general population with a mood disorder used alcohol, drugs, or both in an attempt to reduce affective symptoms. The highest rates of self-medication occurred in people with bipolar I disorder: a total of 41.0% used alcohol or drugs to relieve symptoms. High prevalences of self-medication occurred during depressive episodes within both bipolar I and II (40.8% and 32.2%,
Discussion
This study is the first to explore the prevalence and correlates of self-medication among individuals with mood disorders in the general population. High prevalence rates of self-medication in a population that has been minimally studied suggest a potentially important clinical problem that has not received due attention. Although these individuals may engage in the behavior with the intention of improving their moods, self-medication is a strategy associated with significantly more mental
Role of funding source
Preparation of this article was supported by:
- 1)
Health Sciences Centre Foundation grant awarded to Dr. Bolton.
- 2)
Canadian Institutes of Health Research (CIHR) New Investigator awarded to Dr. Sareen.
Conflict of interest
Dr. Sareen: member of the speaker's bureau of Wyeth, Astra Zeneca and Bioval.
Other authors: none.
Ms. Belik and Dr. Cox: none.
Acknowledgements
The authors acknowledge Ms. Shay-Lee Belik's assistance with statistical analysis, and Dr. Brian Cox for his input on the project.
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