In light of the continuing controversy surrounding Whitney Houston's death, including questions of blame and responsibility for what the coroner may determine was an overdose involving drugs and alcohol, here is a look at the science behind the central and often misunderstood concept of self-medication in mental illness, addiction and recovery. My interest in this is both professional and personal. My sister Rita died of a multiple drug cocktail at age 38 -- after a downward slide that began over 20 years earlier and finally caught up with her. She was, like Whitney Houston, a victim of her own demons and a culture that favors self-medication over getting mental health treatment. As both of their premature deaths demonstrate, self-medication and aging don't mix well.
Mystery of the Missing Spoons
When spoons began to disappear from my mother's silverware drawer in the late 1960s, neither my mother nor I suspected my younger sister Rita's dope use. It didn't dawn on us that heroin had be mixed with water and cooked over a flame before it was injected. At that time, my friends and I smoked pot regularly, and we had also tried psychedelics, mushrooms and acid -- tried being the operative word. Rita went further and did it much faster and more overtly. She flew through pot and discovered barbiturates, speed and cocaine.
Heroin was too pricey without help from an older dealer-boyfriend. Nonetheless, by the time she was 16, Rita had made it her drug of choice. Between boyfriends, she stole to finance her new habit. Mom's wedding band was one of the first casualties. Soon, cash could no longer be left in a drawer or purse. This was before drug rehab as a concept had entered the American cultural lexicon, certainly that of the suburban northeast, leaving my mother baffled and ashamed at the behavior of the prettier and once the easier of her two daughters. My mother was an unknowing soldier in what had become all-out guerrilla combat.
When President Richard Nixon declared his war on drugs in 1971 -- hopelessly lost in the
four decades since -- it did one constructive thing by creating a new and favorable climate for
research into the causes of addiction. This research gave birth to the field of drug rehabilitation, and out of this wave of new treatments came the theory of self-medication -- the idea that addiction comes about because people are attempting to alleviate the distress of preexisting mental disorders. The concept had come originally from Freud, in 1884, after he noted the antidepressant properties of cocaine.
By the 1970s, the theory of self-medication formally arrived, and immediately caused a storm
of controversy because it challenged views then held by the medical community and law
enforcement that attributed drug abuse to peer pressures, family breakdown, affluence, escapism and lax policing. For the first time, the nation's newly minted white, middle-class drug addicts (typified by my sister) were joining their less affluent urban counterparts, who were already populating U.S. jails and hospitals. Junkies -- hippies, rich and poor, black and white, addicts and alcoholics -- constituted an equal-opportunity mental health crisis for public health doctors on the front lines of treatment in big-city hospital emergency rooms.
The father of the self-medication hypothesis is Edward J. Khantzian, a founding member of the
Psychiatry Department at Harvard's Cambridge Hospital. Writing in 1985, Khantzian stated
his belief that addicts weren't victims of random selection. Instead, he explained, they had a
drug of choice: a specific drug affinity dictated by "psychopharmacologic action of the drug
and the dominant painful feelings with which they struggle." Like Freud, he pointed to the
energizing effect of cocaine and other stimulants in response to the depletion and fatigue of
addicts dealing with preexisting depression. In his patients who abused opiates, including heroin, Khantzian noted their calming effect on the addicts' typically problematic impulsivity. This point particularly hit home for me as I recalled my sister Rita's tendency to get into fist fights with her arresting officers, crash her car and land in the E.R. after passing out in public places.
The idea that human psychological vulnerabilities had anything to do with addiction was a
new piece of the puzzle, and it reflected Khantzian's psychoanalytic background as much as
his clinical work at the Cambridge Clinic. Decades later, self-medication is accepted medicine
within the mental health field. However, broader cultural understanding of its implications
for individuals with undiagnosed mental disorders who may be self-medicating has lagged far
behind; not unlike continuing popular resistance to addiction as a disease over which the addict has little or no control, and widespread refusal to accept the robustly established precept that treatment for addiction is effective.
One of the major stumbling blocks to greater understanding of the principle of self-medication appears to be the culture's continuing confusion about which comes first: the mental illness or the addiction.
One sign of this missing understanding has to be the recent vitriolic "debate" over New Jersey's decision to fly its flag at half-staff in honor of Whitney Houston, one of the century's greatest musical artists; a celebrity whose cause of death will no doubt reflect her two-decade struggle with the disease of addiction but is not likely to include any recognition of an underlying mental disorder.
Chicken or Egg?
The fundamental question of which comes first when someone has what is now called a "dual
diagnosis" remained unanswered up until the 1990s. In 1992, with a first-of-its-kind national
survey of the state of the nation's mental health called the National Comorbidity Survey (NCS),
scientific understanding of comorbid addiction and mental illness went mainstream. The NCS
evaluated 8,098 average Americans, ages 15 to 54, interviewed in face-to-face home settings by trained laypersons -- making them far less able to lessen or deny symptoms and patterns.
Among the striking results of the NCS survey: 45 percent of those people with an alcohol-use
disorder and 72 percent with a drug-use disorder also had at least one other mental disorder.
Perhaps more important at a time when the self-medication theory was still under attack, the
NCS survey provided a concrete and comprehensive answer to the chicken-and-egg question
about addiction and mental illness.
So Which Is It?
The NCS showed that when an alcohol disorder accompanied another mental disorder, the alcohol abuse began after the individual was suffering from symptoms of the other mental disorder, usually a year or more after. Not including other forms of substance abuse, the most common preexisting mental disorders reported among those interviewed were anxiety, depression, and, for men, conduct disorders.
When an updated NCS survey was done with a new group of ten thousand people in 2002
(called the NCS-R, for "replicated"), its findings were strikingly similar to the first. Faring
worst by age group in the 2002 numbers were 36- to 44-year-olds, among whom 37 percent
had anxiety disorders and 24 percent had mood disorders in addition to their alcohol abuse
issues. Depressed women in their 30s and 40s have a 2.6 greater risk for heavy drinking,
compared to those without major depression. It occurred to me as I read these numbers that
age 30 to 44, when comorbid disorders are highest, are also women's prime childbearing years.
A 2012 report by SAMHSA (U.S. Substance Abuse and Mental Health Services Administration) offers an eerie corollary in its finding that 10 percent of American kids today live with an alcoholic parent -- certainly a conservative estimate.
Too Late For So Many
My sister Rita died at 38; a year after an overdose of barbiturates and alcohol put her into a
three-week coma and, upon waking, left her unable to walk or talk. It was the end of a torturous 25 years for her and for those of us forced to helplessly stand by and watch. While packing for a move not long ago, I found a letter I'd received from Rita, written during her first stint in Rockland County Jail for robbery a decade earlier, dated March 1982:
I should have known I was heading for trouble again. I was having black outs from small amounts of liquor (small amounts for me). But I went on another drinking binge and now I'm back here again. I guess I've hit the pits this time. I just finished speaking to a woman from the jail ministry. She's quite sure that God brought me back here to save my life or try again. She may be right. I just feel really bad now that I won't be home for Easter when you come. So much for all that. Meanwhile pray for me, forgive me for letting you all down, try to talk to Mom for me and take care of my beautiful nephew. Love, Rita.
I didn't have any inkling of the unequal effect of alcohol and drugs on different people back in
the 60s when my friends and I started experimenting with whatever we could get our hands on. Back then, I suppose I went no farther than thinking that Rita and others like her were weaker than I was in some fundamental way. Science now illuminates the finer points of the unequal inheritance of predispositions to addiction even in the same family, as well as the debilitating effects on those who carry the heaviest genetic load, especially when they grow up as my sister and I did in a family and culture where, due to the continuing widespread stigma towards those with a mental disorder, self-medication is the preferred option to seeking mental health treatment.
In this broader and hopefully more enlightened context, simplifications like personal weakness
simply don't cut it anymore. It's time for the culture to catch up with the science and practice of treatment and recovery.
Victoria Costello is an Emmy Award winning science writer with articles in Scientific American MIND and Brain World. In addition to HuffPost, she blogs for PsychCentral.com and her own MentalHealthMomBlog. As an advocate for a prevention approach to mental health, she serves on the board of the Mental Health Association of San Francisco and leads workshops for parents and providers around the U.S. Her latest book, A Lethal Inheritance, A Mother Uncovers the Science Behind Three Generations of Mental Illness is available from Prometheus Books.
Follow Victoria Costello on Twitter: www.twitter.com/VCpsych