Presentation: Alcohol: from public health to psychiatric comorbidity

PRESENTATION

Alcohol: from public health to psychiatric comorbidity

Ronaldo Laranjeira

Departamento de Psiquiatria da UNIFESP, Coordenador da UNIAD (Unidade de Pesquisa em Álcool e Drogas), E-mail: [e-mail]

The history of the responses of societies to alcohol is intertwined with psychiatry's' history. Suffice it to remind that Benjamin Rush, one of the fathers of American Psychiatry was at the same time one of the proponents of the beginning of response of American society to alcohol. At the end of the 18^th century he already noticed that more than 35% of patients admitted to American psychiatric hospitals were there due to excessive consumption of alcohol. His suggestion to minimize the problem already contemplated measures for environmental control such as restriction on the number of points of sale of alcohol and price control of alcoholic beverages. These ideas have greatly influenced the response of society and reverberate up to nowadays.

Unfortunately, in Brazil we do not have such a rich history to tell. We still pay a high price for the social lack of control regarding alcohol. Under several aspects we live in a similar situation to that of the US two centuries ago. Nearly 50% of our psychiatric hospitalizations among males are due to alcohol, and several social problems such as violence are associated with it. Our lack of control may be seen by some data: 1 – one liter of cachaça (firewater) costs, at most places, less than half a dollar (no developed country has a distilled beverage even near to ten dollars); 2 – alcoholic beverages may be bought everywhere, anytime and by anyone, of any age (all developed countries have well-defined criteria about when, where or by whom alcohol can be consumed); 3 – TV advertisement in Brazil is very aggressive and aims clearly to enlarge the market among children and adolescents (in no developed country it would be admitted the ad 'try it, try it').

This RBP supplement aims to show how much Brazilian psychiatry has progressed in the last years regarding alcohol. A new generation of psychiatrists inspired by several excellence centers in Brazil and with formation abroad is making a big difference in the debate about the best policies to be developed. A good example is the publication of the first Brazilian consensus about the public policies regarding alcohol. A work of several professional organizations (Brazilian Association of Studies on Alcohol and other Drugs, Department of Chemical Dependence of the Brazilian Psychiatric Association, and university psychiatric departments at several Brazilian states), this consensus aimed to discuss the best policies based on scientific evidence to be implemented in the medium-term in the country. These policies have been analyzed in the technical literature for more than 30 years, in a project financed by the World Health Organization. The Brazilian consensus was based on the last book of this series, which has been recently published ⁽¹⁾, and is an excellent list of the actions which should inevitably be implemented in any civilized society aiming to decrease the social cost of alcohol.

There are three important parts in this supplement. In the first one are debated the epidemiological importance and the social cost of alcohol consumption. Very good data on alcohol have started to appear and the CEBRID (Brazilian Information Center on Psychotropic Drugs) has had an extremely important role in this task. There is little information about the social cost of alcohol, but data collected by international agencies suggest that Brazil pays a high price for alcohol. WHO's indices show that Brazil has twice as much the social cost regarding alcohol as the U.S.

In the second part of the supplement, and the larger one, we present several articles which can help general psychiatrists to keep be up-to-date with the treatment of alcohol dependence. Currently, there are specialists in the treatment of dependences in general and in alcohol dependence in particular. But according to the epidemiological data it is clear that ultra specialists will never be in a sufficient number to treat so many people with alcohol dependence. The general clinician and the general psychiatrist will not be able to escape from the responsibility of treating a substantial number of dependent subjects. Thus, they should be acquainted with several concepts such as: diagnosis of dependence, neurochemical bases, motivational and cognitive-behavioral models, pharmacological treatment, psychiatric comorbidities and alcohol use, clinical course of dependence, alcohol in adolescence, brief intervention, neuropsychological harm, psychiatric complications, genetic aspects.

In the third part, two articles discuss the innovations in the organization of services for alcohol-dependent subjects. Much of the skepticism regarding the treatment of alcohol is due to the fact that in Brazil there is no good network for this type of patients. In the article on the organization of services the most efficient ways of planning and implementing the treatment are discussed. We should not remain at a stage of dilettante amateurism to treat complex pictures such as alcohol dependence. Services should be more organized and, moreover, the management of cases should be more professional. The concept of case management when applied to mental health, and especially in the case of alcohol-related problems, facilitates compliance with and effectiveness of the treatment. One of the important evidence regarding treatment is that the higher the adherence to the service, the higher the chances of success. Therefore, better organized services and better managed cases could make a big difference in the care of these patients.

A last word to thank all the colleagues who worked in the development of this supplement, all of them very generous with their time and extremely professional in the form and content of the texts. Brazilian psychiatry is thankful to these colleagues. RBP's editors must be thanked for their correct evaluation that alcohol should be the object of a journal supplement. This editorial outlook shows the quality of the debate of Brazilian psychiatry which increasingly searches the improvement of the country's mental health.

1. Babor T, et cols. Alcohol: no ordinary commodity – research and public policy. Oxford University Press; 2003.

Publication Dates

• Publication in this collection
  04 Jan 2005
• Date of issue
  May 2004