Alcohol and Mental Health in Ireland
Prof Ian Robertson, Trinity College Dublin
A few weeks ago, I was sitting outside of a pub enjoying a warm summer evening pint when a young man in his very early twenties was ushered out of the pub by one of the barmen.
“You’ve had enough to drink, S…,” the barman said, gently but firmly.
“OK, L..,” the lad said, his well-spoken voice only a little slurred and his gait only slightly swaying as the well-dressed, handsome youngster headed off into the dusk.
A few minutes later, the lad reappeared and made a beeline towards me as I was getting up to leave after my single, late-evening pint.
“Could you go in and buy me a pint of lager?” he said, holding out some notes and coins.
“No, sorry, I can’t.”
He followed me along the road; part belligerent, but mainly desperate. I realized that he must have rushed round the corner to the supermarket but found it closed – as was the off-license further down the road. These cursed licensing laws! That interfering barman following some pesky rules he had learned about not serving people who were drunk. Drunk! – I’m not drunk, he was probably thinking as I finally shook him off.
That young man had a very big problem, one potentially as life threatening as a heroin habit, if my guess that he was well known to the barman was right.
Later that week, I met another young lad of about the same age who certainly wasn’t a “loner”. He told me that his problem was that his close group of friends he had known since school were calling him a “lightweight” because sometimes he couldn’t quite keep up with the lead drinkers in the group. After several vodka “prinks” (pre-drinks) early in the evening, they would go on to drink 10 to 15 pints of lager on a Friday evening – the equivalent of between one and one and a half bottles of vodka each.
Some of his friends drank throughout the week, albeit at a bit lower level, though others couldn’t do this and also hold down their jobs, so kept their very heavy drinking confined to weekends, when Saturday and Sunday sore heads were the norm. My “lightweight” lad was recently beaten up and stabbed on the way home but he was so drunk that he remembers little about it. If you were to meet this boy, as I did, you would have no idea that he had a drink problem – and nor did he or his friends. In fact this pattern of drinking is so widespread among many groups of young men and women that it is seen as “normal”.
Take a moment to ask yourself this: do you know someone who drinks too much? If so, then you are in the company of 72% of the Irish population. And for four out of 10 of those with such a concern, the person they are worried about is an immediate family member [i]. This means that almost three out of every 10 people – over a million people – in Ireland are worried about the alcohol consumption of someone very close to them. I hope someone in S..’s family was worried about him – they badly need to.
In 1979, I instigated the first alcohol education course for young offenders in Britain; young men whose largely minor crimes were believed by the local judge to have been committed because of excessive drinking[ii]. These young men were compelled to attend a weekly class with me on six successive evenings. During this class they learned, among other things, about the effects of alcohol on the body and brain.
Each week they kept a drink diary and at the next session I would help them use charts to calculate what blood alcohol levels they had reached on each drinking session, depending on how many drinks they had consumed over what period of time. They could then read off these levels against descriptions of the corresponding likely effects on their behaviour and their brains:
40 mg % Begin to feel relaxed – increased chance of accidents.
60 mg% Cheerful – poorer judgment
80 mg% Feelings of warmth and well-being – some loss of inhibition and self control, driving much worse
120 mg% Talkative, excited, emotional – clumsy, uninhibited
150mg% Silly and befuddled – speech slurred, may be aggressive
200 mg% Just plain drunk – staggering, double vision, memory loss
300 mg% Unconsciousness possible
400 mg% Unconsciousness likely, occasionally death
500 mg% Death possible
600 mg% Death probable.
Compulsory attendance on a grim February evening in a cheerless municipal hall with five other luckless young men from hard backgrounds was not conducive to free-flowing psychotherapeutic to and fro, and so I was particularly pleased when one hitherto wordless youth un-hunched his shoulders to volunteer the outcome of his calculations from his week’s drinking diary.
“Yes, Douglas?” (not his real name), I said brightly.
“Accordin’ tae yer cherts, ah wis deid twice on Setterday.”
Why would I want to make you laugh through this (true) story, when talking about a problem which is a silent epidemic blighting the lives of hundreds of thousands of people in Ireland? – I want to make you laugh because the funny, enjoyable aspects of drinking alcohol are every bit as real a phenomenon as is the palpable misery, pain and death caused by hundreds of thousands of people drinking too much, too often, and in the wrong circumstances.
Alcohol is a central part of the social fabric of this country and there are many positives about it. I really enjoy drinking alcohol, let me acknowledge here – and sometimes I drink more than I should. The World Health Organisation, for instance, defines binge drinking as consuming more than six standard units of alcohol (one unit equals one small glass of wine, or one small measure of spirits, or one half pint of normal strength beer) on one occasion. Let me be honest here, according to this definition, I have engaged in binge drinking.
I could have come here and – as I am about to do – tell you about the terrible – and they are indeed terrible – consequences of heavy drinking for individuals, their children and partners. I could have done this without mention of my own drinking patterns – this would be the norm for experts – and could have left you with the impression of my being a blamelessly sober professional who drinks little.
But that would be untrue. I consider myself to be a moderate drinker who tries to keep to the recommended limit in Ireland of 17 units [iii] of alcohol per week (the equivalent figure for women is 11), but who occasionally exceeds this weekly limit and who every so often, drinks more than the equivalent 3 pints of stout on one occasion – ie, I “binge”.
But I tell you this – it isn’t easy to keep to this limit. Ireland is a very sociable little pond and the pond is full of alcohol. It is also cheap – ridiculously cheap – and has become steadily cheaper as Ireland has become richer. And the stuff is everywhere – garages, supermarkets, school parents’ evenings, charity dos, teenage discos, sports events. It is also glamorous – our sporting heroes have alcohol emblazoned on their chests and the names of alcoholic drinks are on the lips of every sporting commentator, every fan, every child.
Ireland is a world leader in drinking alcohol – tenth in the world (out of 194 World Health Organization members) in total consumption. The average male drinker over 15 in Ireland drank 19.8 litres of pure alcohol in 2010, while the average female drinker drank 9.3 litres.[iv] Alcohol-related harm costs the country more than our annual bailout interest payments – €3.7 billion per year [v].
No wonder I am feeling the pressure sticking to my 17 units per week limit – almost everyone round me is drinking like a fish!
Let me come back to the young man I began with. First of all, let me say that he is not typical of young drinkers, who, like the second young man I mentioned, mainly drink in groups – he was unusual in being alone and the quality of desperation as he searched for alcohol was much closer to what I have seen in much older alcoholics.
In fact, inside the pub there were several such older men and one or two women, whom I know to be, to all intents and purposes, alcoholic. Several are holding down jobs and don’t appear to be drunk even though they will have drunk up to the equivalent of a bottle of whisky over the course of the evening.
If some of these were to stop drinking suddenly, a few would develop Delirium Tremens – the DT’s – a ghastly state of psychosis, terrifying hallucinations, and bodies wracked with the shakes that I have witnessed myself when working in a hospital ward.
This is the sign of a body addicted to the drug alcohol and reacting very badly to being deprived of the drug. Many if not most of the men and women who go into the DT’s would seem normal, sociable, rational people if you were to meet them in the pub – you might be astonished and disbelieving to hear that they had been drinking at such levels.
I remember working in Scotland in an acute psychiatric ward, when a very well known local Church of Scotland minister who appeared often on television, was admitted in the DT’s – yet only two days before had been seen lucid and witty on the screen. But now I was looking at him, a pathetic, shaking, terrified, psychotic wreck – just because he had suddenly stopped drinking for a short period.
Most people dependent on alcohol are people like you and me – the down and outs with their wine bottles are the minority. And some can function at a very high level. They can do this because of tolerance – their body’s adaptation to alcohol, which is a key mechanism of addiction.
The late British Prime Minister Sir Winston Churchill, for instance, was to all intents and purposes a high functioning alcoholic who drank from morning until evening, keeping his blood alcohol levels at a constant, high level, so as to avoid the fate of my Scottish minister patient.
What then, you might ask, is the problem? If Winston Churchill can defeat Hitler and drink at alcoholic levels, doesn’t this mean that we are exaggerating the effects of drinking?
Unfortunately not – Churchill was an exception, a remarkable man who managed to defy all sorts of medical grim reapers that would have cut down anyone else attempting the same.
It’s time to consider some of the facts about mental health and alcohol:
Relationships – the Canary in the Mine
One of the first casualties of drinking problems is the drinker’s relationships outside his or her drinking circle. Let’s consider some reasons for this in greater depth:
There are many other problems apart from relationship ones, but family relationships are the canary in the mine as far as alcohol problems are concerned. And the cost of these fractured relationships and the depression, anxiety, neglect and abuse that follow in their wake is one of the most under-recognised consequences of the alcohol dependence epidemic and one which is seldom quantified in economic analyses of the effects of alcohol.
What is to be done?
The first thing to recognize is the potential alcoholic in every single one of us who drinks. That doesn’t mean that we all have to stop drinking – but for sure we all have to know exactly how much we are drinking. It is possible to do this [x] [xi], and many years ago I wrote a self-help manual for people who were concerned about their drinking, so learn to bring it under control[xii].
But exhorting you and I to keep our drinking at safe levels is useless without government policy to support us, otherwise we are swimming against an alcoholic tide. Think back to the young man at the beginning of this talk: he couldn’t get any more alcohol that night because of licensing laws, because of the civilized way in which that public house was run, because his pint of lager cost 5 euro and not a quarter of that. Yes, he had big problems but running up against these constraints might just help him come to an awareness that he had a problem and to seek some help to beat it.
It is quite simply a fallacy to say that alcoholics will get their drink no matter what – make alcohol cheap and easy enough, and you will turn half the population into alcoholics, as happened indeed in 18th century London when gin could be bought from taps in the street at a farthing a squirt[xiii].
My anecdotes from the Dublin pub are themselves now unfortunately somewhat outliers: this well-run pub was a controlled environment – across the other side of town, children hide in their bedrooms while their parents drink can after can of below-cost, high-octane alcohol they had bought in the garage or supermarket down the road. No barman there to refuse to serve them – no closing time in their living room. And so no respite for their frightened children and no check on their drinking and its dreadful effects on the mental health of hundreds of thousands of Irish citizens.
And quite simply the best way to improve mental health in Ireland would be for the government to implement the recommendations of its own Steering Group on a National Substance Misuse Strategy for alcohol [xiv]. I will end this lecture with just some of their policy recommendations and urge everyone to lobby for this potentially catastrophic epidemic of problem drinking to be nipped in the bud by effective public policy.
* Increase the price of alcohol over the medium term to ensure that alcohol becomes less affordable, using some or all of the following approaches:
* Introduce a legislative basis for minimum pricing per gram of alcohol.
* With respect to Section 16 of the Intoxicating Liquor Act 2008 (sale, supply and consumption of alcohol) develop and implement an enforcement mechanism;
* make regulations under Section 16 (1) (b) and (c) of that Act.
* Provide that the HSE may object to the granting of a court certificate for a new licence and to renewal of licences.
* Introduce a statutory code of practice on the sale of alcohol in the off-licence sector.
* Establish standards for server training programmes in the on-trade and off-trade sectors. Provide that participation by licensees and staff in such programmes is a condition of the licensing process.
* With a particular focus on impacting on the age of the onset of alcohol consumption, and the consumption levels of under-18 year olds, develop a statutory framework with respect to the volume, content, and placement of all alcohol advertising in all media in Ireland (including the advertising of pubs or clubs). This will involve the utilisation of existing legislation (such as the Broadcasting Act 2009) as well as the development of new legislation. Regard should be had to the impact of any statutory framework containing the provisions immediately below on Irish industry vis-á-vis firms from other jurisdictions.
At a minimum, the legislation and statutory codes should provide for:
* Drinks industry sponsorship of sport and other large public events in Ireland should be phased out through legislation by 2016. In the intervening time, it should not be increased.
[i] Health Research Board/IPSOS MRBI (2012) Alcohol: Public Knowledge, Attitudes and Behaviours.
[ii] Robertson, I and Heather, N (1982) An alcohol education course for young offenders: preliminary report. British Journal on Alcohol and Alcoholism, 17, 32-38.
[iii] The equivalent figures for the UK are 21 units for men and 14 for women, but the standard Irish drink, at 10 grams of pure alcohol, is bigger than its UK equivalent: see – Steering Group on a National Substance Misuse Strategy (alcohol) (2012) Dublin: Department of Health.
[iv] Global Status Report on Alcohol and Health. World Health Organisation, 2011 http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf
[v] Byrne, S. (2010) Costs to Society of Problem Alcohol Use in Ireland. Dublin: HSE
[vi] Lyons S, Lynn E, Walsh S, Sutton M and Long J (2011) Alcohol-related deaths and deaths among people who were alcohol dependent in Ireland, 2004 to 2008. Dublin: Health Research Board.
[vii] Martin J, Barry J, Goggin D, Morgan K, Ward M and O’Suilleabhain T (2010) Alcohol-attributable mortality in Ireland. Alcohol Alcohol. 45: 379-86.
[viii] DeWit, D.J., Adlaf, E.M., Offord, D.R., Ogborne, A.C. 2000. Age at first alcohol use: a risk factor for the development of alcohol disorders. American Journal of Psychiatry 157. 745-750.
[ix] Watson D and Parsons S (2005) Domestic abuse of women and men in Ireland. Dublin: Stationery Office.
[x] Heather,N and Robertson,I (1986). Problem Drinking. London: Penguin Books. (Second edition of above book: Oxford University Press, 1989; Third edition, OUP 1998)
[xi] Heather,N, Robertson,I, Mcpherson,B, Allsop,S, and Fulton,A (1987) Effectiveness of a controlled drinking self-help manual: one year follow-up results. British Journal of Clinical Psychology 26, 279-287.
[xii] Robertson, I., Heather, N., Watts, D. 1987. Let’s Drink to Your Health!: A Guide to Safe & Sensible Drinking. Angus & Robertson.
[xiii] Rodin, A.E. 1981. Infants and gin mania in 18th-century London. JAMA 245(12), 1237-9.
[xiv] Steering Group on a National Substance Misuse Strategy (alcohol) (2012) Dublin: Department of Health.