• Up to 40 per cent of people who drink heavily have symptoms that resemble a depressive illness.
• However, when these same people are not drinking heavily, only 5 per cent of men and 10 per cent of woman have symptoms meeting the diagnostic criteria for depression - not that different from the rates of depression in the general population.
• About 5 to 10 per cent of people with a depressive illness also have symptoms of an alcohol problem.

Why might alcohol problems and depression occur together?

Alcohol can briefly produce a pleasant and relaxed state of the mind. However, alcohol problems and depression commonly occur together. There are several reasons for this:

• both alcohol problems and depression are extremely common. They may occur together completely independently.
• people with depression sometimes use alcohol as a form of self-medication, for example either in an attempt to cheer themselves up, or sometimes to help them sleep. Although in small quantities alcohol can briefly lift mood, if used to try to cope with a depressive illness, problems arise. Tolerance to the effects of alcohol can lead to individuals needing it in larger quantities to have an effect.
• alcohol in large quantities, whether taken to treat a depression or not, produces a depressant effect on people's mood.

Why is an alcohol problem together with depression a particular worry?

Alcohol compromises judgment and makes people impulsive and likely to take risks. Alcohol also causes a loss of inhibition and increases aggressive behavior and violent acts. Because increased alcohol consumption often occurs together with a depressed mood, this is a particular concern. Depression can lead to thoughts of suicide. The lack of self-control, compromised judgment and impulsivity from the alcohol can increase the chances of a person attempting suicide. Generally, a much higher incidence of suicide, both completed and attempted, is associated with alcohol.

The common problems of depression and alcohol are frequently complicated by social problems. Alcohol can often lead to problems at work in the form of absenteeism, sickness and under performance. The loss of a job has a profound negative impact on a person's financial status and family life. Marital problems often arise because of an alcohol problem, although it may be difficult to say which started first.

Alcohol can also cause a large number of physical problems. Few, if any organs in the body are spared. Liver problems commonly arise from heavy alcohol intake and can take the form of jaundice (a yellow discoloration of the skin) resulting from hepatitis, cirrhosis of the liver or liver failure. Unchecked these will lead to death. Other common problems include:

• stomach ulcers
• anemia
• an irregular heartbeat
• impotence.

Both alcohol intoxication and withdrawal have a damaging effect on the brain, and can cause:

• loss of sensation in the arms or legs
• loss of muscle power
• profound memory disturbances
• a shrunken brain.

Although alcohol can cause you to fall asleep, the quality of the sleep that follows tends to be poor. This is why people with depression should not use alcohol to try to improve their sleep, since it will actually have the opposite effect.

Excessive alcohol intake can also lead to legal problems. These may result from driving offences, drunk and disorderly behavior, or violent crime due to the impulsivity and lack of self-control caused by alcohol. Involvement with the legal establishment does not tend to help a depressed mood.

Alcohol problems account for:

• 33 per cent of domestic accidents
• 40 per cent of fatal domestic fires
• 15 to 30 per cent of workplace accidents.

Depression is also associated with an increased rate of accidents and so the combination can be worrying.

Some antidepressants are sedative. If they are taken with alcohol, a person can be seriously sedated and at risk of their breathing stopping. In addition, many antidepressants are broken down in the liver. Because alcohol can damage the liver, the levels of these antidepressants in the body will be higher in people who are also drinking heavily. This can lead to an increase in side effects from the antidepressants.

What causes the link between alcohol and depression?

There are a number of ways in which alcohol and depression may be linked.

Links with brain function

Over the last decade new research has shed light on the way alcohol affects the brain, and in the ways in which the brain is affected in depression. It is now known that some of the systems that are involved in producing the symptoms of low mood, anxiety, poor sleep and reduced appetite in depression are also affected by alcohol. This is one explanation of why alcohol can cause depression.

Psychosocial links

There are many potential psychological and social reasons for links between alcohol and depression.

• Stressful life events can precipitate both alcohol problems and depression.
• People with alcohol problems report more incidences of neglect and poor parenting as children than those without. These factors may also increase the risk of developing depression.

Genetic links

It is possible to inherit an increased likelihood of both alcohol problems and depression.

• Alcohol problems are more frequent in the children of those who have severe alcohol problems. It is difficult to know what exactly is inherited. It could be a tolerance (or lack of it) to the effects of alcohol, or differences in the way alcohol affects various systems in the brain.
• The genetic basis of depression is also well established. It is well known that having a first-degree relative (ie a parent or sibling) with depression increases your chances of having depression in later life.
• Studies of depressed patients show that their relatives not only have an increased risk of depression, but also a number of other conditions including alcohol problems.

How much alcohol do you need to drink to affect the brain?

Many of the effects of alcohol on the systems of the brain depend on the 'dose' of alcohol taken.

• At low doses (say one to two units of alcohol), alcohol has a relaxing and euphoric effect that makes a person feel confident, more social and jovial.
• However, even small amounts of alcohol (one to five units) produce poor coordination, slowed reaction times and increased risk taking.
• The legal driving limit in the UK is 80mg of alcohol per 100ml of blood. It is impossible to say exactly what this is in units. This is because the concentration of alcohol in the blood will depend on the size of the person, how quickly they drink and many other factors. On average, the legal limit will be reached after drinking around three to five units. But the legal driving limit is not a 'safe amount' of alcohol. Somebody with an alcohol level of between 50 and 80mg (ie below the legal limit) has a risk of a non-fatal accident twice that of a sober driver and is six times more likely to have a fatal accident.
• With levels of alcohol above twice the legal driving limit, memory is affected and seriously poor coordination starts occurring.
• At three to four times the legal driving limit, the breathing centre in the brain can be affected leading to death.

These effects may occur at very different blood alcohol concentrations in different people because drinking alcohol produces tolerance to its effects. This means that people who regularly drink large quantities develop effects at higher blood alcohol concentrations.

What is a safe amount to drink?

Current recommendations are that risks of problems (both physical and psychological) are greatly increased in men consuming more that 28 units of alcohol per week, and women more than 21 units. A unit of alcohol is:

• half a pint of beer
• half a pint of a lager or cider (strong lagers and ciders can be up to two units per half pint)
• a single pub measure of a spirit (a 'home' measure can easily be three to four units)
• a small glass of wine.

These recommendations are not a 'safe' limit - it is simply a level above which the risks get significantly greater.

• 28 units (or 21 units for women) consumed all at once is certainly not safe and can cause serious problems.
• You should aim for at least one or two days each week when you do not drink any alcohol.

When should I be worried if I have an alcohol problem?

There are a number of pointers that should lead you to consider if you have an alcohol problem. These include:

• using alcohol to try to escape from your worries and troubles.
• using alcohol to help you sleep.
• if you drink every day.
• if you are drinking more than the recommended units a week.
• if having a drink starts being one of the most important things in your life.
• if you are regularly drinking alone.
• if people are advising you to cut down the amount you drink.
• if you get annoyed by people criticising your drinking.
• if you feel guilty about drinking.
• if you need a drink in the morning to be able to face the world.
• if you feel shaky in the morning after drinking heavily.
• if you have periods when you were drinking that you cannot recall.
• if you have ever had problems at work because of drink.
• if you have ever been arrested or charged with any drink-related offence.

How are alcohol problems and depression treated?

Many of the symptoms reported by people drinking heavily resemble those of depression such as:

• fatigue
• disturbed sleep
• early morning waking
• poor energy levels
• poor appetite.

These are simply due to heavy alcohol intake. This makes it difficult to be clear if a person is suffering from an alcohol problem plus depression or simply an alcohol problem.

The situation is further complicated because heavy alcohol intake can lead to depression. As a result, it is normal practice to deal with the alcohol problem first and see if the depression gets better. If it does not, then specific treatment for the depression would be started.

Treatment with a serotonin selective reuptake inhibitor (SSRI) antidepressant can improve both depression and an alcohol problem. This may point towards a common cause for both disorders.

There are a number of things that can be done to help people with alcohol problems.

1. Detoxification to help a person come off alcohol safely.

This involves the person stopping all alcohol intake, usually covered by the administration of medication such as diazepam (Valium) or chlordiazepoxide (Librium) to prevent a withdrawal syndrome.

Withdrawal symptoms include:

• tremor
• anxiety
• restlessness
• sweating
• nausea
• seizures
• delirium tremens (DTs).

DTs usually occur three days or so after stopping alcohol and can last for up to seven days. The symptoms of DTs include those described above plus disorientation (being unaware of where you are, what time, day or year it is, and who other people are), hallucinations (seeing or hearing things that are not there) and delusions (having false beliefs about things, especially being frightened of certain situations and people).

2. Counselling

Support and counselling is used to help the person achieve abstinence or 'controlled drinking' within safe limits. More formal psychological therapies can be helpful, such as cognitive behavioural therapy.

3. Medication

Occasionally, medication can be helpful. This includes disulfiram (Antabuse) and acamprosate (Campral). Disulfiram can aid abstinence because it causes a person to have an unpleasant, and potentially dangerous reaction, if they drink while taking it. Acamprosate may help to decrease the craving for alcohol. Both of these medicines will only be helpful if the person taking them is motivated to give up alcohol. They are certainly not magic wands.

What should I do if I think that I have developed an alcohol problem?

If you think you have a problem with alcohol, you may well have managed the first and hardest step in sorting it out - acknowledging the problem to yourself. What you need to do now is to speak to somebody about your concerns. Support and help for alcohol problems can come from a number of sources. These include:

• your GP.
• a counselor in your GP practice.
• a local alcohol counseling service (these are often advertised in GP surgeries and can be found in the 'Counseling and Advice' section of the Yellow Pages, and under 'Alcohol' in the business section of The Telephone Directory).
• Alcoholics Anonymous (can be found in the business section of The Telephone Directory).
• a drug and alcohol clinic run by the local mental health services. You may be able to self-refer, or you may need your GP to refer you  ask at your doctor's surgery.