Tomatoes Found to Contain Nutrient Which Prevents Vascular Diseases

Tomatoes Found to Contain Nutrient Which Prevents Vascular Diseases


They are the most widely produced fruit in the world and now scientists in Japan have discovered that tomatoes contain a nutrient which could tackle the onset of vascular diseases. The research, published in the journal Molecular Nutrition & Food Research, reveals that an extracted compound, 9-oxo-octadecadienoic, has anti-dyslipidemic affects.

The team led by Dr Teruo Kawada, from Kyoto University and supported by the Research and Development Program for New Bio-industry Initiatives, Japan, focused their research on extracts which tackle dyslipidemia, a condition which is caused by an abnormal amount of lipids, such as cholesterol or fat, in the blood stream.
"Dyslipidemia itself usually causes no symptoms," said Kawada, "however; it can lead to symptomatic vascular diseases, such as arteriosclerosis and cirrhosis. In order to prevent these diseases it is important to prevent an increased build up of lipids."
Tomatoes are already known to contain many compounds beneficial to health. In this study the team analyzed 9-oxo-octadecadienoic acid, to test its potential anti-dyslipidemia properties.
The compound was found to enhance fatty acid oxidation and contributed to the regulation of hepatic lipid metabolism. These findings suggest that 9-oxo-octadecadienoic acid has anti-dyslipidemia affects and can therefore help prevent vascular diseases.
"Finding a compound which helps the prevention of obesity-related chronic diseases in foodstuffs is a great advantage to tackling these diseases," concluded Kawada. "It means that the tomato allows people to easily manage the onset of dyslipidemia through their daily diet."

Learn About Cosmetic Dentistry and Fixing Gap Teeth

Learn About Cosmetic Dentistry And Fixing Gap Teeth

Many different people in the world have experienced what it is like to live with less than perfect teeth. Although true beauty comes from the inside, it is very common for you to want to have a picture perfect smile. Gaps are very common, and if you happen to have a gap that you have ever dreamed about fixing, then you are in luck! With recent advances in dentistry, you now have many different options to choose from if you would like to fix the gap in your teeth. There is lots to learn about cosmetic dentistry and fixing gap teeth!

If the space between your teeth is minimal, you may be able to correct the problem with braces. There are many different types and styles of braces to choose from these days, other than the traditional metal braces from years past.

Did you know that you can even have your braces applied to the backsides of your teeth now rather than the front? This is very beneficial for those who would like to conceal the fact that they are using braces to correct a gap.

Now with options such as Invisalign and porcelain braces, braces are less painful and less noticeable than they used to be. Invisalign braces are a way of fixing your gap by using a series of plastic mouthpieces that are specially fitted to your mouth in order to move the teeth into the desired positions and close the gap. Visiting an orthodontist and getting braces is one option for fixing your gap that will cost you somewhere around five thousand dollars.

You can also consider bonding for fixing a gap in your teeth. This is the process of using a composite resin filling and sculpting to create the desired look. Once the bonding is finished, the results can last for up to ten or more years. This is a wonderful way to improve your smile if the gap is small. For larger gaps, bonding may not be the best decision. The area where the gap was filled in may end up appearing too large and out of place.

You may have heard of yet another popular option called porcelain veneers. When you get veneers applied to your teeth, the porcelain is made to give the front of your teeth a new surface. If you have ever seen someone with that gorgeous movie star smile, there is a good chance that they may have had porcelain veneers applied at some time in their life.

The porcelain can fill in any gaps that you may have, and make your smile appear bright and natural. Depending on where you are located, and how much labor is required to fix your gap, you may pay approximately one thousand dollars per porcelain veneer.

Whatever option you choose for correcting the gap in your teeth, be sure to take some time to research both the pros and cons of each of the available procedures. Some options may be more expensive than others, but will require less time in order to fix the gap. Before you know it, you can have a lovely smile to show the world!

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Dental and Home Remedies For Tooth Whitening

If you can not stand the way your teeth look you have several options. It is time to say good bye to stained teeth with tooth whitening. The least expensive way is purchasing a kit from the drug store. You may decide to seek professional help by visiting your dentist. He can be a wealth of information for you. Choosing dental treatments can get very expensive.

Make an appointment with your dentist and explain how you want better looking teeth. He will tell you all the treatments and explain what happens during each one. It is best to go home and think about it for a little while instead of making a snap decision. After you come to a conclusion call and make another appointment and move forward.

The first way a dentist can change the shade of your teeth is called laser bleaching. They place a peroxide gel on the teeth and then shine a laser light into the mouth. The light makes the gel react and it begins to work. It may take more than one time to see the results that you desire. This can be quite expensive so you may have to save your money for a little while.

The second process is a little more detailed. They must make a mold of your teeth and from the mold they construct a mouth tray that fits only your mouth. They use a similar gel to fill the trays and it is placed in your mouth. You will have to sit there for a period of one to two hours. Once you see how it came out, at that point you decide if you need to come back again.

Let us talk about what you can do at home to lighten your smile. You can get this merchandise where you buy tooth paste. The first is strips that you place on the top and bottom teeth, leave on for a specified amount of time. You must read the instructions to determine how many days to use the strips. The progress is gradual and you will notice changes over time.

There is a product that is usually white in color and you brush each tooth with it and you must let it dry. After it dries out you must brush thoroughly to get it off. You will see a difference after several applications. Like the strips, it may be a week or more before you notice that the shade is getting brighter.

Most grandmothers will tell you that plain old baking soda gets rid of tooth stains. The only way to know for sure is to try it. You have to know that the taste is really bad so you could mix tooth paste with the baking soda for the mint flavor. Brush with this twice a day and you will begin to see a difference in no time.

It will be a great day when you can say good bye to stained teeth with tooth whitening products. Start by talking to your dentist because he can tell you everything you need to know about office treatments and products from the drug store. You just need to know if they are safe and will not harm the teeth in any way.

Get the Most Popular Heart of the Mission Acupuncture

Acupuncture in the Heart of the Mission

Heart of the Mission

Numerous people that don't truly make out much about acupuncture automatically accept that it originated in China. All The Same there is much skepticism interpreting this as there are varied explanations as to how acupuncture really came about. Some conceive that it come about Galore years ago when soldiers that were hurt during the variant wars were dealt with the usual arrows to control the painfulness. Its improbable though if one were to extend the heart of the Mission arena that they would discover the acupuncture clinics there practicing arrows as their kind of treatment. Mission is nowadays basking the fact that there are Galore acupuncture clinics beginning up that extend these services.

At Once as far as China's input operates with acupuncture there are records that can virtually trace it back to the stone age where in that period of time it is considered that the handling was taken out with very piercing stones in position of the needles. During the second century stone needles and bone needles which had been revealed as well were interchanged with the metal type needle. Some of the recordings are retraced back to between 305 and 204 BC so as one can realize the artwork of acupuncture has been fewer for Galore centuries. In our ongoing world in the heart of the Mission district, which is found in San Francisco, there are Many acupuncture clinics getting down to surface.

It would seem crazy that for something that Galore skeptics trust has no propose that it has survived this add up of time. A very occupying component is that Europe directed a survey on a 5000-year-old mummy and it was seen that there were contrary groups of tattoos on the body of the mummy. It was learnt that these groupings of tattoos were located in frequent acupuncture emplacements therefore it puts up the doubtfulness if acupuncture was the purpose of this as well.

As time extended on acupuncture notwithstanding existed as a way of treatment for variant stipulations. It did exist through a period of time where it wasn't as modern, which took place approximately the middle account of the treatment itself. An entertaining note is that there was a European writing on acupuncture that was done by a Dutch physician during the middle history and he had studied the artwork of acupuncture as a scholar for two years in Japan and a most amusing point was that the written material was placed on a consideration of arthritis. It is believed that the reasonableness for acupuncture commencing to mislay its popularity at this time was because there were less and fewer experts determining to extend on the tradition and those that were practicing it were not realizing the consequences that had been noted in the past. The contemporary acupuncture clinics Forthwith open in center of the mission are using the avails of well-trained acupuncturists.

As we have stated in todays modern world, acupuncture still lives and it is not only restrained to the eastern countries. Many other Western countries are Straight Off calculating at it as being a safe alternative compared to all the chemical drugs that are being practiced specially when it occurs to pain hold.

In All Likelihood the unsurpassable experts to detect whether acupuncture works or not are those that have had productive treatments. This is evident with the clients who have had acupuncture treatments in heart of the mission.
Although the sceptics retort it is only a brain over matter scenario.

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Breast Cancer Treatment and Fertility

Being diagnosed with breast cancer can be a devastating experience for women. Along with the fear of death, surgery and harsh cancer treatments , breast cancer also elicits fears on loss of sexuality and body image. It is of utmost importance that the patient and her physician have an in-depth discussion, so that they can make the best decisions about her care.

Most women are ill-informed about the questions they must be asking their doctor before the treatment starts. Young women who are yet to have children and mothers who are planning for more children are advised to talk to their physician about how cancer treatment can put their fertility at risk.

Chemotherapy may affect your ability to have children. Many well-informed young women decide to freeze their eggs before the chemo starts, but not all women have sufficient knowledge about how the treatment can affect their fertility or about the options that are available to preserve their fertility.

Fertility issues during breast cancer

Most physicians will advise you that breast cancer treatment must take priority over fertility. Fortunately, breast cancer does not mean that your dreams of becoming a parent are doomed forever. Even with cancer treatment as your first priority, you can still maximize your chances of becoming a parent.

It is important that the physician and the patient work together on this. If the patient is in a relationship, the partner's concerns must be factored in as well. Some of the questions that you need to answer include:

How important is it to have a baby, for you and your partner?

Do you have an optimistic prognosis that allows you to plan for your future as a parent?

Will it be safe for you to be pregnant?

If there is a recurrence or the survival is limited, will the child have enough caretakers in your absence?

Are you comfortable with adoption or consider using donor eggs to become a parent?

These are definitely tough questions for anyone to answer, even more so for someone who is already bogged down by the severe emotional toll that cancer can unleash. Nonetheless, it is important that you answer these questions as you prepare for the cancer treatment .

Chemotherapy and fertility

Will chemotherapy make you infertile? The answer to this depends on the woman's age and the type of chemotherapy drugs that are used. The younger you are, the better your chances that the ovaries will continue producing fertile eggs even after treatment. Certain chemotherapy drugs, especially those belonging to the group of alkylating agents, can cause relatively more damage to the ovaries than others. Talk to your physician about the type of drugs that will be used for your cancer treatment .

Preserving fertility

If you have been given a relatively good prognosis by your doctor, you may want to ask a fertility expert about the possible options to preserve your fertility.

Here are some questions you may want to ask your fertility expert:

Should you freeze your eggs now? What does the procedure involve?

Should you also consider freezing some of your ovarian tissue?

Are there fertility treatments that will be less risky for you?

What are the financial, medical, emotional and time-wise costs that each of these options involve?

If your doctor says it is okay to postpone your chemo, you may want to undergo ovarian stimulation during this time to harvest enough eggs. Also consider how safe fertility drugs are. Some hormones in the drugs may encourage breast cancer cell activity and cause it to spread rapidly.

With some soul-searching and discussion with your oncologist and fertility expert, you can come up with a definite plan to become a parent in future.

Indulgent Behavior You Should Enjoy in Moderation

Everybody likes to let loose occasionally and do things they would not normally do in life. These activities, done in moderation, are usually not harmful or unhealthy. Everyone likes to splurge every now and then to celebrate or indulge. Many times this behavior occurs around the holidays or a big celebration like a birthday, anniversary or wedding. You may even let loose when things have been going rough in your life. If you have been involved in some stressful situations of late, you might just want to go out with friends, let your hair down and relax. The important thing to understand when it comes to this kind of thing is to know now to control things so they do not get out of control. Indulging every now and then is great, but you need to make sure it does not become a habit. Behaviors that are fine in moderation may be unhealthy if done on the regular basis. The last thing you want is to make yourself sick or develop lung cancer or pancreas cancer because of a lot of bad life decisions.

Going out for a cocktail periodically is not going to harm you in any way. As a matter of fact, a lot of medical professionals believe an occasional glass of red wine is good for your heart. Some also believe beer is a healthy beverage when consumed in moderation. Even getting a little tipsy at a celebration will not leave any permanent scars. However, if you drink alcohol excessively, there will be lasting effects. This is especially true if it is done on a regular basis. If you find yourself consuming a lot of alcohol a few times a month, it may be a sign of a bigger problem. Likewise, if you are using alcohol to get through your day or self-medicate a serious problem, you should speak to your doctor about how you are feeling.

Overeating is another behavior a lot of people fall prey to. There is nothing wrong with ordering dessert occasionally or hitting the buffet when you are on vacation. However, if you are eating unhealthy foods and high quantities of fatty foods on the daily basis, your body is going to suffer. You will feel unhealthy and over time, the poor eating habits will take their toll. Save the sugary treats and indulgent foods for occasional splurges and special occasions and choose fruits, vegetables, whole grains and lean proteins for your regular meals.

Gambling is fun for a lot of people and when done in moderation, it is a great way to let loose with your friends and enjoy a night out. However, if you are gambling above your means or you view it as a means of earning an income, it is going to lead to a great deal of problems. Gamble for recreation, not to make a living.

Finally, relaxation is a great stress reducer and should be scheduled into everyone’s life. However, if you feel like you are always lazing about and you rarely leave your couch, you may be indulging in lethargic behavior. Save lying around for raining days and special occasions. When possible get outside and get active.

Use Subliminal Learning to Enrich Your Life

The newest and most revolutionary type of learning today is subliminal learning. In this particular learning technique, learners can easily absorb knowledge and learn even without focusing consciously on the material they are studying and without the need for formal classroom education. With this new discovery, you can now say goodbye to mental blocks and learning difficulties. Any knowledge or skill can now be learned almost instantly and with virtually no effort at all.

What It Can Do For You. Subliminal learning is now being used for many purposes, and it can also be used to enrich your life. A lot of people are already reaping the benefits of this new learning technique. With it, you can:

• Learn new skills that will boost your performance in your profession
• Learn new languages
• Build a more impressive vocabulary
• Learn how to play musical instruments
• Solve mathematical equations more easily

A lot of people do not think much about this amazing new learning technique. After all, it does seem a bit far-fetched? How can you really learn something without having to consciously study it? Well, a brief look at how subliminal learning works will make you an instant believer.

How It Works. Subliminal learning works pretty much like how your brain absorbs songs that get stuck in your head even without you consciously storing it. This shows us that beneath our conscious minds, there is another mental facility that can absorb information on its own and without conscious prompting from us. This mental facility is what sets to work in subliminal learning.

The material to be studied is sent straight to the subconscious mind. The subconscious mind is like a sponge; it absorbs anything without filtering them out unlike the conscious mind. The main challenge is to quiet down the conscious mind to access the subconscious and then to design the knowledge to be learned in a way that is easily understood and accepted by the subconscious.

How It Is Done. There are many methods through which subliminal learning is applied, such as:

• Displaying images briefly in between video frames
• Playing almost inaudible sounds beneath MP3 songs

Subliminal videos and MP3 or other audio files can easily be downloaded over the Internet. Investing in especially designed videos or MP3s can help you meet various learning goals in a short time.

So if you’re looking to improve your performance at work and boost your chances of getting a promotion, or if you want to have the language skills necessary to grab global work opportunities, then you can rely on subliminal learning. This way, you can enrich your mind and use it to enrich your life without having to go back to the classroom. This way, you can learn new skills and languages while you have a full time job. This new learning technique has indeed come in handy and has effectively paved the way for many employees and entrepreneurs to reach higher goals in their careers and businesses.

Separation of Treatment Systems

In colonial times in the United States, people with mental illness were described as“lunatics” and were largely cared for by families. There was no concerted effort to treat mental illness until urbanization in the early 19th century created a societal problem that previously had been relegated to families scattered among small rural communities. Social policy assumed the form of isolated asylums where persons with mental illness were administered the reigning treatments of the era. By the late 19th century, mental illness was thought to grow“out of a violation of those physical, mental and moral laws which, properly understood and obeyed, result not only in the highest development of the race, but the highest type of civilization” (cited in Grob, 1983). Throughout the history of institutionalization in asylums (later renamed mental hospitals), reformers strove to improve treatment and curtail abuse. Several waves of reform culminated in the deinstitutionalization movement that began in the 1950s with the goal of shifting patients and care to the community.

Public Attitudes About Mental Illness: 1950s to 1990s

Nationally representative surveys have tracked public attitudes about mental illness since the 1950s (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981). To permit comparisons over time, several surveys of the 1970s and the 1990s phrased questions exactly as they had been asked in the 1950s (Swindle et al., 1997).

In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as“mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981).

By 1996, a modern survey revealed that Americans had achieved greater scientific understanding of mental illness. But the increases in knowledge did not defuse social stigma (Phelan et al., 1997). The public learned to define mental illness and to distinguish it from ordinary worry and unhappiness. It expanded its definition of mental illness to encompass anxiety, depression, and other mental disorders. The public attributed mental illness to a mix of biological abnormalities and vulnerabilities to social and psychological stress (Link et al., in press). Yet, in comparison with the 1950s, the public’s perception of mental illness more frequently incorporated violent behavior (Phelan et al., 1997). This was primarily true among those who defined mental illness to include psychosis (a view held by about one-third of the entire sample). Thirty-one percent of this group mentioned violence in its descriptions of mental illness, in comparison with 13 percent in the 1950s. In other words, the perception of people with psychosis as being dangerous is stronger today than in the past (Phelan et al., 1997).

The 1996 survey also probed how perceptions of those with mental illness varied by diagnosis. The public was more likely to consider an individual with schizophrenia as having mental illness than an individual with depression. All of them were distinguished reasonably well from a worried and unhappy individual who did not meet professional criteria for a mental disorder. The desire for social distance was consistent with this hierarchy (Link et al., in press).

Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past (Phelan et al., 1997).

This finding begs yet another question: Are people with mental disorders truly more violent? Research supports some public concerns, but the overall likelihood of violence is low. The greatest risk of violence is from those who have dual diagnoses, i.e., individuals who have a mental disorder as well as a substance abuse disorder (Swanson, 1994; Eronen et al., 1998; Steadman et al., 1998). There is a small elevation in risk of violence from individuals with severe mental disorders (e.g., psychosis), especially if they are noncompliant with their medication (Eronen et al., 1998; Swartz et al., 1998). Yet the risk of violence is much less for a stranger than for a family member or person who is known to the person with mental illness (Eronen et al., 1998). In fact, there is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder. Because the average person is ill-equipped to judge whether someone who is behaving erratically has any of these disorders, alone or in combination, the natural tendency is to be wary. Yet, to put this all in perspective, the overall contribution of mental disorders to the total level of violence in society is exceptionally small (Swanson, 1994).

Because most people should have little reason to fear violence from those with mental illness, even in its most severe forms, why is fear of violence so entrenched? Most speculations focus on media coverage and deinstitutionalization (Phelan et al., 1997; Heginbotham, 1998). One series of surveys found that selective media reporting reinforced the public’s stereotypes linking violence and mental illness and encouraged people to distance themselves from those with mental disorders (Angermeyer & Matschinger, 1996). And yet, deinstitutionalization made this distancing impossible over the 40 years as the population of state and county mental hospitals was reduced from a high of about 560,000 in 1955 to well below 100,000 by the 1990s (Bachrach, 1996). Some advocates of deinstitutionalization expected stigma to be reduced with community care and commonplace exposure. Stigma might have been greater today had not public education resulted in a more scientific understanding of mental illness.

Mental Health and Mental Illness: Points on a Continuum

As will be evident in the pages that follow, “mental health” and “mental illness” are not polar opposites but may be thought of as points on a continuum. Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and contribution to community or society. It is easy to overlook the value of mental health until problems surface. Yet from early childhood until death, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem. These are the ingredients of each individual’s successful contribution to community and society. Americans are inundated with messages about success—in school, in a profession, in parenting, in relationships—without appreciating that successful performance rests on a foundation of mental health.

Many ingredients of mental health may be identifiable, but mental health is not easy to define. In the words of a distinguished leader in the field of mental health prevention, “. . . built into any definition of wellness . . . are overt and covert expressions of values. Because values differ across cultures as well as among subgroups (and indeed individuals) within a culture, the ideal of a uniformly acceptable definition of the constructs is illusory” (Cowen, 1994). In other words, what it means to be mentally healthy is subject to many different interpretations that are rooted in value judgments that may vary across cultures. The challenge of defining mental health has stalled the development of programs to foster mental health (Secker, 1998), although strides have been made with wellness programs for older people (Chapter 5).

Mental illness is the term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning. Alzheimer’s disease exemplifies a mental disorder largely marked by alterations in thinking (especially forgetting). Depression exemplifies a mental disorder largely marked by alterations in mood. Attention-deficit/hyperactivity disorder exemplifies a mental disorder largely marked by alterations in behavior (overactivity) and/or thinking (inability to concentrate). Alterations in thinking, mood, or behavior contribute to a host of problems—patient distress, impaired functioning, or heightened risk of death, pain, disability, or loss of freedom (American Psychiatric Association, 1994).

This report uses the term“mental health problems” for signs and symptoms of insufficient intensity or duration to meet the criteria for any mental disorder. Almost everyone has experienced mental health problems in which the distress one feels matches some of the signs and symptoms of mental disorders. Mental health problems may warrant active efforts in health promotion, prevention, and treatment. Bereavement symptoms in older adults offer a case in point. Bereavement symptoms of less than 2 months’ duration do not qualify as a mental disorder, according to professional manuals for diagnosis (American Psychiatric Association, 1994). Nevertheless, bereavement symptoms can be debilitating if they are left unattended. They place older people at risk for depression, which, in turn, is linked to death from suicide, heart attack, or other causes (Zisook & Shuchter, 1991, 1993; Frasure-Smith et al., 1993, 1995; Conwell, 1996). Much can be done—through formal treatment or through support group participation—to ameliorate the symptoms and to avert the consequences of bereavement. In this case, early intervention is needed to address a mental health problem before it becomes a potentially life-threatening disorder.

Mental Health

The gifted Dutch Post-Impressionist artist, Vincent van Gogh, had his life shattered by mental illness. Vincent van Gogh suffered from Bipolar I Disorder at a time in history when there was no treatment for this common disorder. Tragically, van Gogh died of suicide. Today, mental illnesses can be successfully treated; hence we can now prevent these tragic suicides. In memory of Vincent van Gogh, we display his art on this website.

Famous People Who Have Had Mental Illness

Hans Christian Anderson, Ludwig Von Beethoven, Winston Churchill, Kurt Cobain, Charles Darwin, Emily Dickenson, Thomas Edison, F. Scott Fitzgerald, Betty Ford, Paul Gauguin, King George III, Johan Goethe, Ernest Hemingway, Victor Hugo, Ignatius of Loyola, Thomas Jefferson, John Keats, Abraham Lincoln, Martin Luther, Michelangelo, Florence Nightingale, King Saul, Robert Louis Stevenson, Sir Isaac Newton.

To avoid any conflict of interest, we have never accepted any corporate funding for our website. We believe that it is especially important that our website not be sponsored in any way by pharmaceutical companies.

Mental Health and Mental Illness: A Public Health Approach

The Nation’s contemporary mental health enterprise, like the broader field of health, is rooted in a population-based public health model. The public health model is characterized by concern for the health of a population in its entirety and by awareness of the linkage between health and the physical and psycho- social environment. Public health focuses not only on traditional areas of diagnosis, treatment, and etiology, but also on epidemiologic surveillance of the health of the population at large, health promotion, disease prevention, and access to and evaluation of services (Last & Wallace, 1992).

Just as the mainstream of public health takes a broad view of health and illness, this Surgeon General's Report on Mental Health takes a wide-angle lens to both mental health and mental illness. In years past, the mental health field often focused principally on mental illness in order to serve individuals who were most severely affected. Only as the field has matured has it begun to respond to intensifying interest and concerns about disease prevention and health promotion. Because of the more recent consideration of these topic areas, the body of accumulated knowledge regarding them is not as expansive as that for mental illness.

Mental Disorders are Disabling

The burden of mental illness on health and productivity in the United States and throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study,¹ conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide,² ranks second in the burden of disease in established market economies, such as the United States (Table 1-1).
Mental illness emerged from the Global Burden of Disease study as a surprisingly significant contributor to the burden of disease. The measure of calculating disease burden in this study, called Disability Adjusted Life Years (DALYs), allows comparison of the burden

Table 1-1. Disease burden by selected illness categories in established market economies, 1990

	Percent of Total DALYs*
All cardiovascular conditions	18.6
All mental illness**	15.4
All malignant diseases (cancer)	15.0
All respiratory conditions	4.8
All alcohol use	4.7<
All infectious and parasitic diseases	2.8
All drug use	1.5

*Disability-adjusted life year (DALY) is a measure that expresses years of life lost to premature death and years lived with a disability of specified severity and duration (Murray & Lopez, 1996).

**Disease burden associated with“mental illness” includes suicide.

of disease across many different disease conditions. DALYs account for lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, major depression is equivalent in burden to blindness or paraplegia, whereas active psychosis seen in schizophrenia is equal in disability burden to quadriplegia.

By this measure, major depression alone ranked second only to ischemic heart disease in magnitude of disease burden (see Table 1-2 ). Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder also contributed significantly to the burden represented by mental illness.

Table 1-2. Leading sources of disease burden in established market economies, 1990

		Total DALYs (millions)	Percent of Total
.	All causes	98.7	.
1	Ischemic heart disease	8.9	9.0
2	Unipolar major depression	6.7	6.8
3	Cardiovascular disease	5.0	5.0
4	Alcohol use	4.7	4.7
5	Road traffic accidents	4.3	4.4

Source: Murray & Lopez, 1996.

Mind and Body are Inseparable

Considering health and illness as points along a continuum helps one appreciate that neither state exists in pure isolation from the other. In another but related context, everyday language tends to encourage a misperception that “mental health” or“mental illness” is unrelated to“physical health” or“physical illness.” In fact, the two are inseparable.

Seventeenth-century philosopher Rene Descartes conceptualized the distinction between the mind and the body. He viewed the “mind” as completely separable from the “body” (or“matter” in general). The mind (and spirit) was seen as the concern of organized religion, whereas the body was seen as the concern of physicians (Eisendrath & Feder, in press). This partitioning ushered in a separation between so-called“mental” and“physical” health, despite advances in the 20th century that proved the interrelationships between mental and physical health (Cohen & Herbert, 1996; Baum & Posluszny, 1999).

Although“mind” is a broad term that has had many different meanings over the centuries, today it refers to the totality of mental functions related to thinking, mood, and purposive behavior. The mind is generally seen as deriving from activities within the brain but displaying emergent properties, such as consciousness (Fischbach, 1992; Gazzaniga et al., 1998).

One reason the public continues to this day to emphasize the difference between mental and physical health is embedded in language. Common parlance continues to use the term“physical” to distinguish some forms of health and illness from“mental” health and illness. People continue to see mental and physical as separate functions when, in fact, mental functions (e.g., memory) are physical as well (American Psychiatric Association, 1994). Mental functions are carried out by the brain. Likewise, mental disorders are reflected in physical changes in the brain (Kandel, 1998). Physical changes in the brain often trigger physical changes in other parts of the body too. The racing heart, dry mouth, and sweaty palms that accompany a terrifying nightmare are orchestrated by the brain. A nightmare is a mental state associated with alterations of brain chemistry that, in turn, provoke unmistakable changes elsewhere in the body.

Instead of dividing physical from mental health, the more appropriate and neutral distinction is between “mental” and “somatic” health. Somatic is a medical term that derives from the Greek word soma for the body. Mental health refers to the successful performance of mental functions in terms of thought, mood, and behavior. Mental disorders are those health conditions in which alterations in mental functions are paramount. Somatic conditions are those in which alterations in nonmental functions predominate. While the brain carries out all mental functions, it also carries out some somatic functions, such as movement, touch, and balance. That is why not all brain diseases are mental disorders. For example, a stroke causes a lesion in the brain that may produce disturbances of movement, such as paralysis of limbs. When such symptoms predominate in a patient, the stroke is considered a somatic condition. But when a stroke mainly produces alterations of thought, mood, or behavior, it is considered a mental condition (e.g., dementia). The point is that a brain disease can be seen as a mental disorder or a somatic disorder depending on the functions it perturbs.

The Roots of Stigma

Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Penn & Martin, 1998; Corrigan & Penn, 1999). It reduces patients’ access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its most overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society.

Explanations for stigma stem, in part, from the misguided split between mind and body first proposed by Descartes. Another source of stigma lies in the 19th-century separation of the mental health treatment system in the United States from the mainstream of health. These historical influences exert an often immediate influence on perceptions and behaviors in the modern world.

Stigma and Seeking Help for Mental Disorders

Nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). Stigma surrounding the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment (Sussman et al., 1987; Cooper-Patrick et al., 1997). Concern about stigma appears to be heightened in rural areas in relation to larger towns or cities (Hoyt et al., 1997). Stigma also disproportionately affects certain age groups, as explained in the chapters on children and older people.

The surveys cited above concerning evolving public attitudes about mental illness also monitored how people would cope with, and seek treatment for, mental illness if they became symptomatic. (The term “nervous breakdown” was used in lieu of the term “mental illness” in the 1996 survey to allow for comparisons with the surveys in the 1950s and 1970s.) The 1996 survey found that people were likelier than in the past to approach mental illness by coping with, rather than by avoiding, the problem. They also were more likely now to want informal social supports (e.g., self-help groups). Those who now sought formal support increasingly preferred counselors, psychologists, and social workers (Swindle et al., 1997).

Stigma and Paying for Mental Disorder Treatment

Another manifestation of stigma is reflected in the public’s reluctance to pay for mental health services. Public willingness to pay for mental health treatment, particularly through insurance premiums or taxes, has been assessed largely through public opinion polls. Members of the public report a greater willingness to pay for insurance coverage for individuals with severe mental disorders, such as schizophrenia and depression, rather than for less severe conditions such as worry and unhappiness (Hanson, 1998). While the public generally appears to support paying for treatment, its support diminishes upon the realization that higher taxes or premiums would be necessary (Hanson, 1998). In the lexicon of survey research, the willingness to pay for mental illness treatment services is considered to be“soft.” The public generally ranks insurance coverage for mental disorders below that for somatic disorders (Hanson, 1998).

Reducing Stigma

There is likely no simple or single panacea to eliminate the stigma associated with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved. Knowledge of mental illness appears by itself insufficient to dispel stigma (Phelan et al., 1997). Broader knowledge may be warranted, especially to redress public fears (Penn & Martin, 1998). Research is beginning to demonstrate that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Overall approaches to stigma reduction involve programs of advocacy, public education, and contact with persons with mental illness through schools and other societal institutions (Corrigan & Penn, 1999).

Another way to eliminate stigma is to find causes and effective treatments for mental disorders (Jones, 1998). History suggests this to be true. Neurosyphilis and pellagra are illustrative of mental disorders for which stigma has receded. In the early part of this century, about 20 percent of those admitted to mental hospitals had“general paresis,” later identified as tertiary syphilis (Grob, 1994). This advanced stage of syphilis occurs when the bacterium invades the brain and causes neurological deterioration (including psychosis), paralysis, and death. The discoveries of an infectious etiology and of penicillin led to the virtual elimination of neurosyphilis. Similarly, when pellagra was traced to a nutrient deficiency, and nutritional supplementation with niacin was introduced, the condition was eventually eradicated in the developed world. Pellagra’s victims with delirium had been placed in mental hospitals early in the 20th century before its etiology was clarified. Although no one has documented directly the reduction of public stigma toward these conditions over the early and later parts of this century, disease eradication through widespread acceptance of treatment (and its cost) offers indirect proof.

Ironically, these examples also illustrate a more unsettling consequence: that the mental health field was adversely affected when causes and treatments were identified. As advances were achieved, each condition was transferred from the mental health field to another medical specialty (Grob, 1991). For instance, dominion over syphilis was moved to dermatology, internal medicine, and neurology upon advances in etiology and treatment. Dominion over hormone-related mental disorders was moved to endocrinology under similar circumstances. The consequence of this transformation, according to historian Gerald Grob, is that the mental health field became over the years the repository for mental disorders whose etiology was unknown. This left the mental health field“vulnerable to accusations by their medical brethren that psychiatry was not part of medicine, and that psychiatric practice rested on superstition and myth” (Grob, 1991).

These historical examples signify that stigma dissipates for individual disorders once advances render them less disabling, infectious, or disfiguring. Yet the stigma surrounding other mental disorders not only persists but may be inadvertently reinforced by leaving to mental health care only those behavioral conditions without known causes or cures. To point this out is not intended to imply that advances in mental health should be halted; rather, advances should be nurtured and heralded. The purpose here is to explain some of the historical origins of the chasm between the health and mental health fields.

Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises to be an effective antidote. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate. Still, fresh approaches to disseminate research information and, thus, to counter stigma need to be developed and evaluated. Social science research has much to contribute to the development and evaluation of anti-stigma programs (Corrigan & Penn, 1999). As stigma abates, a transformation in public attitudes should occur. People should become eager to seek care. They should become more willing to absorb its cost. And, most importantly, they should become far more receptive to the messages that are the subtext of this report: mental health and mental illness are part of the mainstream of health, and they are a concern for all people.

---

¹ Murray & Lopez, 1996.

² The Surgeon General issued a Call to Action on Suicide in 1999, reflecting the public health magnitude of this consequence of mental illness. The Call to Action is summarized in Figure 4-1.

Mental Health Disorders Mental health (MH) disorders today are appropriately called "brain disorders." Typical disorders such as depression, bipolar disorder, schizophrenia and even borderline personality disorder are medical disorders of the brain. Links to genetics are being found in addition to environmental factors. These kinds of disorders are still widely misunderstood by most of society and as a result, many people with mental health disorders continue to be stigmatized. These disorders "...are common in the United States and internationally. An estimated 22.1 percent of Americans ages 18 and older�about 1 in 5 adults�suffer from a diagnosable.." MH disorder "...in a given year. When applied to the 1998 U.S. Census residential population estimate, this figure translates to 44.3 million people. In addition, 4 of the 10 leading causes of disability in the U.S. and other developed countries are .." MH disorders "-major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder. Many people suffer from more than one...disorder at a given time." NIMH "Individuals with co-occurring disorders (about 3 percent of the population in 1 year) are more likely to experience a chronic course and to utilize services than are those with either type of disorder alone. Clinicians, program developers, and policy makers need to be aware of these high rates of comorbidity�about 15 percent of those with a" MH"... disorder in 1 year (Regier et al., 1993a; Kessler et al., 1996)." Report of the Surgeon General

Alcoholism

Alcohol Dependence is a condition characterized by the harmful consequences of repeated alcohol use, a pattern of compulsive alcohol use, and (sometimes) physiological dependence on alcohol (i.e., tolerance and/or symptoms of withdrawal). This disorder is only diagnosed when these behaviors become persistent and very disabling or distressing.

Complications:

School and job performance may suffer either from hangovers or from actual intoxication on the job or at school; child care or household responsibilities may be neglected; and alcohol-related absences may occur from school or job. The individual may use alcohol in physically hazardous circumstances (e.g., drunk driving or operating machinery while intoxicated). Legal difficulties may arise because of alcohol use (e.g., arrests for intoxicated behavior or for drunk driving). Individuals with this disorder may continue to abuse alcohol despite the knowledge that continued drinking poses significant social or interpersonal problems for them (e.g., violent arguments with spouse while intoxicated, child abuse). Alcohol intoxication causes significant intellectual impairment (and stupid behavior). Once a pattern of compulsive use develops, individuals with this disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages. These individuals continue to use alcohol despite evidence of adverse psychological or physical consequences (e.g., depression, blackouts, liver disease, or other complications). Individuals with this disorder are at increased risk for accidents, violence, and suicide. It is estimated that 1 in 5 intensive care unit admissions in some urban hospitals is related to alcohol and that 40% of people in U.S.A. experience an alcohol-related accident at some time in their lives, with alcohol accounting for up to 55% of fatal driving events. More than one-half of all murderers and their victims are believed to have been intoxicated with alcohol at the time of the murder. Severe Alcohol Intoxication also contributes to disinhibition and feelings of sadness and irritability, which contribute to suicide attempts and completed suicides.

Only 5% of individuals with Alcohol Dependence ever experience severe complications of withdrawal (e.g., delirium, grand mal seizures). However, repeated intake of high doses of alcohol can affect nearly every organ system, especially the gastrointestinal tract, cardiovascular system, and the central and peripheral nervous system. Gastrointestinal effects include gastritis, stomach or duodenal ulcers, and, in about 15% of those who use alcohol heavily, liver cirrhosis and pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract. One of the most common associated general medical conditions is low-grade hypertension. There is an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased peripheral sensation. Most persistent central nervous system effects include cognitive deficits, severe memory impairment, and degenerative changes in the cerebellum (leading to poor balance and coordination). One devastating central nervous system effect is the relatively rare Alcohol-Induced Persisting Amnestic Disorder (Wernicke-Korsakoff syndrome) in which there is a dramatic impairment in short-term memory. Men may develop erectile dysfunction and decreased testosterone levels. Repeated heavy drinking in women is associated with menstrual irregularities and, during pregnancy, with spontaneous abortion and fetal alcohol syndrome (leading to mentally retarded, hyperactive children). Alcohol Dependence can suppress immune mechanisms and predispose individuals to infections (e.g., pneumonia) and increase the risk for cancer.

Comorbidity:

Individuals with Alcohol Dependence are at increased risk for Major Depressive Disorder, other Substance-Related Disorders (e.g., drug addiction), Conduct Disorder in adolescents, Antisocial and Emotionally Unstable (Borderline) Personality Disorders, Schizophrenia, and Bipolar Disorder.

Associated Laboratory Findings:

The most direct test available to measure alcohol consumption is blood alcohol concentration, which can also be used to judge tolerance to alcohol. An individual with a concentration of 100 mg of ethanol per deciliter of blood who does not show signs of intoxication can be presumed to have acquired tolerance to alcohol. At 200 mg/dL, most non-alcoholic individuals would demonstrate severe intoxication. An elevation (> 30 units) of gamma-glutamyltransferase (GGT) is a sensitive laboratory test for heavy drinking. At least 70% of individuals with a high GGT level are persistent heavy drinkers (i.e., consuming 8 or more drinks daily on a regular basis). Another sensitive test for heavy drinking is an elevation (> 20 units) in carbohydrate deficient transferrin (CDT). Both GGT and CDT levels return toward normal within days to weeks of stopping drinking, thus are useful tests to monitor abstinence. The combination of GGT and CDT may have even higher levels of sensitivity and specificity in diagnosing heavy drinking than either test used alone. Another useful laboratory test for heavy drinking is an elevated mean corpuscular volume (MCV). However, the MCV is a poor method of monitoring abstinence because it takes weeks to return to normal after the individual stops drinking. Liver function tests (e.g., alanine aminotransferase [ALT] and alkaline phosphatase) can reveal liver injury that is caused by heavy drinking. High fat content in the blood also contributes to the development of fatty liver.

Prevalence:

Alcohol use is highly prevalent in most Western countries. However, in most Asian cultures, the overall prevalence of Alcohol-Related Disorders is relatively low. In Muslim countries, the Islamic religion strictly prohibits alcohol (hence the rates of Alcohol-Related Disorders are very low). In the Western countries, this disorder occurs much more commonly in males (with a male-to-female ratio of 5:1). The lifetime risk of Alcohol Dependence is approximately 15% in the general population. In any year, 5% of the general population will actively be suffering from Alcohol Dependence.

Course:

Alcohol Dependence has a variable course that is frequently characterized by periods of remission and relapse. The first episode of Alcohol Intoxication is likely to occur in the mid-teens, with the age at onset of Alcohol Dependence peaking in the 20s to mid-30s. The large majority of those who develop Alcohol Dependency do so by their late 30s.

Familial Pattern:

Alcohol Dependence often has a familial pattern, and it is estimated that 40%-60% of the variance of risk is explained by genetic influences. The risk for Alcohol Dependence is 3 to 4 times higher in close relatives of people with Alcohol Dependence. Most studies have found a significantly higher risk for Alcohol Dependence in the monozygotic twin than in the dizygotic twin of a person with Alcohol Dependence. Adoption studies have revealed a 3- to 4-fold increase in risk for Alcohol Dependence in the children of individuals with Alcohol Dependence when these children were adopted away at birth and raised by adoptive parents who did not have this disorder.

Treatment:

Follow-up studies of the typical person with an Alcohol Use Disorder show a higher than 65% 1-year abstinence rate following treatment. Even among less functional and homeless individuals with Alcohol Dependence who complete a treatment program, as many as 60% are abstinent at 3 months, and 45% at 1 year. Some individuals (perhaps 20% or more) with Alcohol Dependence achieve long-term sobriety even without treatment.

National Institute on Alcohol Abuse and Alcoholism (NIAAA).

The following image details deaths while intoxicated.

Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Pathophysiology

Alcohol affects virtually every organ system in the body and, in high doses, can cause coma and death. It affects several neurotransmitter systems in the brain, including opiates, GABA, glutamate, serotonin, and dopamine. Increased opiate levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic and sedative effects.

Alcohol inhibits the receptor for glutamate. Long-term ingestion results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the central nervous system experiences increased excitability. Persons who abuse alcohol over the long term are more prone to alcohol withdrawal syndrome than persons who have been drinking for only short periods. Brain excitability caused by long-term alcohol ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures. Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and the number of receptors correlates with cravings for alcohol.

Frequency

United States

These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population:

• Current drinkers - 44%
• Former drinkers - 22%
• Lifetime abstainers - 34%
• Abuse and dependency in the past year - 7.5-9.5%
• Lifetime prevalence - 13.5-23.5%

Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years.¹

According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed).

International

The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.

Mortality/Morbidity

Alcohol use is the third leading cause of preventable death in the United States (after smoking and obesity). Annually, 85,000 deaths are attributable to alcohol at a cost of $185 billion.^2,3 Almost half of these deaths are attributable to alcohol-related injury.

Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows:

• Cirrhosis - 32%
• Motor vehicle accidents - 20%
• Mouth and oropharyngeal cancers - 19%
• Esophageal cancer - 29%
• Liver cancer - 25%
• Breast cancer - 7%
• Homicide - 24%
• Suicide - 11%
• Hemorrhagic stroke - 10%

Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows:

• Cirrhosis - For men, 7.5; for women, 4.8
• Injuries - For men, 1.3
• Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3

Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30%.^4,5,6 The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers).

Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.

No benefits are noted in people at low risk for coronary disease (men <40>7 This effect was exacerbated by binge drinking.

Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.)

More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related.

Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol.

With regard to pregnancy, fetal alcohol syndrome is the leading known cause of mental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems.⁸ In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors.⁹ All women who are pregnant or planning to become pregnant should avoid alcohol.

Race

The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans.

Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans.

Sex

Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women.

Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men.

Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk.

Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking.

Age

The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.

Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.

Clinical

History

Diagnosis

The diagnosis of an alcohol problem is best made by the history. Laboratory tests have a sensitivity of no better than 50%, and physical examination is helpful only after the consequences of alcoholism are apparent. Early diagnosis based on a careful history can prevent such consequences. Physicians should use terms such as "person with an alcohol problem" rather than "alcoholic," which is a commonly used but demeaning shorthand term.

Although the dangers of alcoholism are well known, data suggest that physicians frequently fail to make the diagnosis. Less than 50% of people who went to their doctor because of alcohol-related issues were asked about the problem. Multiple studies on medical inpatients and surgical patients in university and community hospitals, as well as outpatients in internal medicine and family medicine practices, show a low recognition rate and an even poorer treatment rate. The following are possible reasons that alcohol-related problems are missed during diagnosis.

• Patient factors contribute to the failure to diagnose alcohol problems. Patients frequently deny they have a problem. They might not link alcohol with its consequences. Patients may be unaware that a positive family history increases their risk for the disease. They might fear being reported to their employers. Patients might be too ashamed to report their problem.
• Physicians frequently share the responsibility for the failure to diagnose alcoholism. Many physicians have a negative attitude toward persons with alcohol problems. They view these patients as demanding and feel that they waste society's resources.
• Recognized substance abuse patients tend to have an antisocial personality disorder (type 2 alcoholism, characterized by an association with criminal behavior [sociopathy], onset in teen years, and drinking to get high), while those whose diagnosis is missed tend to have depression or anxiety. During residency training, physicians see a fair number of persons with type 2 alcoholism; these patients are often not truthful and have a poorer prognosis. This contributes to the belief among many physicians that alcoholism is not treatable, despite good evidence to the contrary (see Treatment). Also, physicians might hesitate to label a patient as alcoholic because of negative consequences. Physicians who have a problem with alcohol themselves are less likely to discuss alcoholism and its consequences with patients.
• Physicians might not know how to screen for and diagnose alcoholism. However, screening for alcoholism is important (see CAGE questionnaire and AUDIT).
• "How much do you drink?" is probably the question asked most commonly by doctors. This question has less than 50% sensitivity for alcohol problems. Blood tests, such as liver function tests and mean corpuscular volume, are not particularly effective; even the best test, gamma glutamyl transferase, has a sensitivity of only approximately 50%. Recently, sialic acid and carbohydrate-deficient transferrin levels have been touted as possible tests, but the sensitivities of both appear to be too low to be useful.

Screening

The CAGE ([need to] cut down [on drinking], annoyance, guilt [about drinking], [need for] eye-opener) questionnaire is the best-known and most-studied short screening test for alcohol problems. The CAGE questions should be given face-to-face (not as a paper and pencil test) and should be asked before questions on quantity and frequency (the sensitivity of the questions drops if quantity questions precede them).

• The following 4 questions make up the CAGE questionnaire:
  • Have you ever felt the need to cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you ever felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
• Patients who answer affirmatively to 2 questions are 7 times more likely to be alcohol dependent than the general population. Those who answer negatively to all 4 questions are one-seventh as likely to have alcoholism as the general population.
• The sensitivity of the CAGE questionnaire was thought to be 75%. More recent studies, however, show that the sensitivity is lower, particularly in populations with a lower prevalence, such as among female and elderly populations. The CAGE questionnaire also may fail to identify binge drinkers and cannot identify those who have not experienced the consequences of alcoholism. Nevertheless, the CAGE questionnaire is brief and easy to administer
• The CAGE questions are not useful for diagnosing hazardous drinking. Women should consume no more than 3 standard alcohol drinks on any one occasion and no more than 7 drinks per week¹⁰ and men younger than 65 years should consume no more than 4 drinks on any one occasion and no more than 13 standards drinks per week. Men older than 65 years should follow recommendations for women. Other drinking considered hazardous is any use of alcohol by children, teens, by those with a personal or family history of alcohol dependence, women who are pregnant or breastfeeding, and use before or during situations requiring attention or skill (eg, driving)
• By itself, the CAGE questionnaire is not an adequate screening for alcohol problems.

The AUDIT (alcohol use disorders identification test) is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

Table 1. AUDIT Questions and Scoring System

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Table

Questions	0 Points	1 Point	2 Points	3 Points	4 Points
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7-9	10 or more
3. How often do you have 6 or more drinks on 1 occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or has someone else been injured as a result of your drinking?	No		Yes, but not in the past year		Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the past year		Yes, during the past year

Questions	0 Points	1 Point	2 Points	3 Points	4 Points
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7-9	10 or more
3. How often do you have 6 or more drinks on 1 occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or has someone else been injured as a result of your drinking?	No		Yes, but not in the past year		Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the past year		Yes, during the past year

The AUDIT can be administered as a paper-and-pencil test, but the CAGE questionnaire should be administered face to face. The CAGE questionnaire is less reliable when given after asking questions on frequency. If the patient answers questions on the CAGE questionnaire or AUDIT affirmatively, following up with additional questions about circumstances and reasons is important. Additional useful questions are found below (see Additional questions).

The diagnosis of alcohol dependence relies more on the consequences of alcohol use and less on the amount of alcohol consumed. Thus, if one suspects alcohol problems from answers to screening questions, attempt to determine what consequences of alcohol abuse the patient has experienced.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria are required to make the diagnosis of alcohol dependence. The diagnosis requires 3 of the following criteria in the DSM-IV-TR.

• A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring at any time in the same 12-month period:
  • Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of the substance to achieve intoxication or desired effect
    • Markedly diminished effect with continued use of the same amount of the substance
  • Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
    • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • The substance is often taken in larger amounts or over a longer period than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control substance use
  • A great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), or recover from its effects
  • Important social, occupational, or recreational activities are given up or reduced because of substance use
  • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Specify if:
    • With physiological dependence - Evidence of tolerance or withdrawal (ie, either item 1 or 2 is present)
    • Without physiological dependence - No evidence of tolerance or withdrawal (ie, neither item 1 nor 2 is present)

The following reasons illustrate the importance of screening for alcohol and drug abuse.

• Alcoholism is common and serious.
• Failure to screen leads to misdiagnosis. Approximately 50-90% of alcohol problems are missed in the office.
• Effective and simple screening tests are available.
• Effective treatments are available, especially if the diagnosis is made early.
• Early identification can prevent physical and psychosocial problems.

Additional questions, as present below, may be helpful when screening for alcoholism.

• Have you ever had a drinking problem?
• When was your last drink? (Less than 24 h is a red flag.)
• Do you use alcohol to relieve pain, anxiety, or insomnia?
• Have you ever been arrested for drinking, such as driving under the influence?
• Have you ever lost friends or girlfriends/boyfriends because of your drinking?
• Have you ever been to an Alcoholics Anonymous (AA) meeting?
• The following are additional questions specific to the geriatric population:
  • Did your drinking increase after someone close to you died?
  • Does alcohol make you sleepy so that you often fall asleep in your chair?
• The following are additional questions specific to the adolescent population:
  • Do you drink alone?
  • Do you ever miss school to go drinking or because you have a hangover?

Physical

• The following are signs and symptoms of alcohol withdrawal:
  • Nausea and vomiting
  • Diaphoresis
  • Agitation and anxiety
  • Headache
  • Tremor
  • Seizures
  • Visual and auditory hallucinations: Many patients who are not disoriented, and who therefore do not have delirium tremens, have hallucinations.
• The following are signs of delirium tremens (ie, alcohol withdrawal delirium):
  • Tachycardia and hypertension
  • Temperature elevation
  • Delirium
• The following are signs of chronic alcoholism:
  • Gynecomastia
  • Spider angiomata
  • Dupuytren contractures (also may be congenital)
  • Testicular atrophy
  • Enlarged or shrunken liver
  • Enlarged spleen
• Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion indicate Wernicke encephalopathy.
• Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy, indicates Korsakoff syndrome.
• Asterixis and confusion suggest hepatic encephalopathy.

Causes

Patients commonly use a psychiatric disorder to deny alcohol abuse. Unless strong evidence indicates that the psychiatric disorder clearly precedes the alcoholism or is present during a long period of sobriety, the best plan is to proceed as if alcoholism is the primary diagnosis. Arrange a consultation with a psychiatrist for difficult cases because some patients who are treated for psychiatric conditions stop drinking and do very well.

The physician should, nonetheless, perform a brief mental status exam to help guide the referral process. Basic elements that should be covered in the mental status exam include an assessment of mood, perceptual problems such as hallucinations, and a safety screen. The use of a standardized instrument helps ensure important questions are asked and the results transmitted with some degree of objectivity. Several validated instruments exist, including The Patient Health Questionnaire from the Primary Care Evaluation of Mental Disorders (PRIME-MD)¹¹ and the Cornell Psychiatric Screen.¹²

Genetic psychiatric disorders, such as schizophrenia and bipolar disorder, are associated with alcoholism.¹³ The presence of both a serious, persistent mental illness and alcoholism is called dual diagnosis. The physician must address both. Family history commonly reveals members with bipolar disorder, alcoholism, or both. Despite this and despite an intensive search for a gene for alcoholism, study results remain inconclusive. Nevertheless, some evidence indicates that genetics plays a major role in alcohol abuse.

• Twin studies
  • Identical twins have a higher concordance for drinking behavior and possibly alcoholism than fraternal twins.
  • In a well-conducted twin study of 542 families, a single underlying trait for conduct disorder, antisocial personality, alcohol dependence, and drug dependence was found, which was highly heritable and was observed in both sexes.¹⁴ Additionally, the study found that maximal alcohol consumption of fathers was predictive of their children having behavior and substance abuse problems (>24 drinks in 24 h yielded especially high risk). Not all at-risk children developed substance use or behavior problems. The environment seemed to determine which, if any, manifested. Deviant peers and poor parent-child relationships predicted early use (age <15>
• Adoption studies
  • Whether reared by biologic or adoptive parents, sons of males with alcoholic problems are 4 times more likely to have problems with alcohol than sons of persons who are not.
  • Two Swedish studies have suggested the following 2 types of male alcoholism:
    • Type 1 characteristics include (1) onset in adulthood (early twenties), (2) drinking to relieve anxiety, and (3) inherited but requires an environmental trigger.
    • Type 2 characteristics include (1) an association with criminal behavior (sociopathy), (2) onset in teen years, and (3) drinking to get high.
    • Sons of persons with type 2 alcoholism are 7 times more likely to develop type 2 alcoholism compared with the general population.
    • The theories suggested from these studies are controversial and require confirmation in additional populations.
  • Data from adoption studies on daughters of persons with alcohol problems are less clear. Daughters might be at increased risk if the biological mother has alcoholism. A recent twin study in women found higher concordance in monozygotic twins than in dizygotic twins.
• Experimental studies
  • Schuckit and Smith found that sons of persons with alcoholism respond differently to an alcohol challenge.¹⁵ They report decreased subjective ratings for feeling intoxicated, and they objectively have less body sway when given the same amount of alcohol as sons of persons without alcoholism. The study population consisted of white, male college students who drank alcohol but were not alcohol dependent themselves. The fathers in this study could not have psychopathology other than alcoholism (ie, no sociopathy, no bipolar illness).
  • Ten-year follow-up data have been published recently for the first half of this cohort. Of the sons of persons with alcoholism, 26% were alcohol dependent by age 30 years, as opposed to 9% of the control group. Furthermore, 56% of the sons of persons with alcoholism with lesser objective and subjective responses to alcohol became alcohol dependent, as opposed to 14% of the sons of persons with alcoholism who did not demonstrate these decreased responses. This also held true for the sons of fathers who did not have alcoholism, although the numbers were small.
  • Positive family history and lesser response to alcohol increased the likelihood of later development of alcohol dependence.
• Psychological studies
  • Behavioral models explain alcohol abuse in terms of learning theory. Through operant conditioning, the reinforcing elements of alcohol use become habitual.
  • Cognitive models explain alcohol abuse in terms of “automatic thoughts,” which precede the person’s more identifiable feelings about alcohol. For example, an automatic thought might be “I deserve a drink because I’ve had a rough day."
  • Psychoanalytic models explain alcohol abuse in terms of ego defenses and intrapsychic conflicts. The alcohol serves as a way to escape the uncomfortable internal conflict.