Common mental health problems

Substance Use Problems

We use the term "substance" to mean any drug, both legal (e.g. alcohol, tobacco) and illegal (e.g. cannabis) that can cause dependence. Psychoactive substances are substances which, when taken into the body, have a major effect on the brain and can alter physical and psychological functioning. Many people enjoy the psychological changes in mood and thoughts that psychoactive substances can bring about. As a result, people often develop a habit of taking the drugs more frequently. These substances are therefore also referred to as habit-forming substances.

Throughout history, human beings have used substances to alter their state of mind. Substances can alter thoughts, emotions, sleep, appetite and social interactions. They are also used to relieve pain and tension. There is a wide range of substances used, and the number of people using substances has increased alarmingly in recent years. In many countries, including Ethiopia, substance-related problems are a major public health concern. It is important that steps are taken at the community level to prevent the increasing problem of substance use.

Reasons to initiate substance use by the users:

There are many reasons why people start to use and continue to use substances. The substances may be taken to reduce stress and alleviate pain, or alternatively to stay alert, to stimulate the mind in order to study or to better perform some task, or simply to have fun with friends. People with mental health problems may take substances to "treat" symptoms although this is very unwise because it can aggravate symptoms and limit the effectiveness of antipsychotic medication. Some disadvantaged members of the community (for example, people who are unemployed or youth out of school) may use substances to occupy their time. Young people often initiate drug use out of curiosity or because of peer pressure. You may be wondering why people continue to use substances. After repeated drug use, "deciding" to use substances is no longer voluntary because the substances induce changes in brain function, which leads to addiction.

Addiction (also called dependence) is a complex illness characterised by compulsive behaviour (the person has a compelling need to use a substance), and uncontrollable cravings (having a strong desire to get the substance). People who are addicted to psychoactive substances persist in using the drug even in the face of extremely negative consequences (e.g. family or job problems, being jailed). Alcohol, cigarettes, khat and cannabis are all drugs that frequently lead to addiction in Ethiopia.

People with addiction typically need increasingly high doses of the drug to achieve the same effect (this is called tolerance), and when they try to stop or reduce the intake of the drug they develop adverse physical and/or psychological symptoms, called withdrawal effects.

Substance abuse is frequent use of a substance despite negative consequences. Not all drug use is bad. Many people have the occasional glass of alcohol and don't develop any negative effects. It is only when someone shows the harmful use of a substance (e.g. excessive drinking that is damaging to physical and mental health) that problems develop.

Classification of substances according to their effects.

Alcohol Use

Alcohol is a habit-forming substance that is present in varying amounts in beer, wine, and spirits. Examples of Ethiopian local drinks that contain alcohol are, "tella", "tej", and "areki". Moderate use of alcohol does not have major consequences for health; the substance use becomes problematic when someone uses a lot of alcohol, and/or consumes alcohol throughout the day, especially in the morning.

Maximum alcohol limits a person can drink:

• For men = 21 units per week (or on average three units per day)
• For women = 14 units per week (or on average two units per day)

(1 standard unit = 6-8 grams of alcohol: a shot of spirit or areki contains approximately 1 unit of alcohol, a bottle of beer contains about 1.5 units and a glass of wine about 2 units.)

Immediate effects of alcohol use:

The immediate effects of alcoholic drinks are seen soon after drinking excess amounts of alcohol. A typical effect on mental status is sedation (it makes people sleepy). There are also other effects on the body, e.g. a lower heart and respiration rate, a slower reaction time (speed of reaction of a person to an incident requiring a fast response), impaired coordination (e.g. difficulty in walking straight), and even loss of consciousness in the case of very heavy alcohol intake.

Long-term complications of alcohol use:

The long-term effects of alcohol are seen after drinking alcohol for years. Alcohol affects most organs of the body including the brain. Long-term heavy alcohol use can lead to brain damage, which may in turn, lead to loss of memory. People with alcohol abuse may, for instance, forget familiar places (e.g. they walk aimlessly, often missing their own houses) or may no longer recognise people who are familiar to them. The brain damage may also cause slurred speech and decreased motor coordination.

Alcohol abuse can also lead to deficiencies in nutrition. People with alcohol problems often eat poorly (limiting their supply of essential nutrients) and alcohol interferes with the nutritional process in the body, so that the nutrients are not fully absorbed. Alcohol may also affect the fetus if a pregnant woman consumes alcohol. The use of alcohol increases the risk of delivering a low birth weight baby and may increase the child's risk of developing learning difficulties later in life.

Withdrawal effects of alcohol use:

Withdrawal effects of alcohol use can occur when people with alcohol use problems suddenly decrease or stop using alcohol. The majority of people with alcohol use problems have mild to moderate withdrawal symptoms, including tremors (shaking hands), sweating, sleep disturbance, decreased appetite and nausea. These withdrawal symptoms usually disappear in less than seven days with or without treatment. Sometimes the withdrawal symptoms can be very severe, and lead to an emergency medical condition called delirium tremens. Delirium tremens is characterized by loss of consciousness, agitation, restlessness, tremor, disorientation (difficulty in knowing place and time or recognising familiar people), sweating and high fever, visual hallucinations, and paranoia. It commonly occurs three to seven days after drinking has stopped.

Identifying someone with a drinking problem:

Questions to ask the family or friends:

• Has the person been drinking recently?
• Are your worried about his or her drinking? Why?
• Has the person been drinking in the mornings?

Screening questions to ask the person (CAGE questionnaire):

• Have you ever felt you should cut your drinking?
• Have people annoyed you by criticising your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever taken a drink first thing in the morning (eye opener) to steady your nerves or get rid of a hangover? Yes to two or more questions suggests the person has a harmful drinking problem.

Management of people with alcohol-related problems:

The goal of treatment is to help the individual live a normal life without alcohol use. The first step is to help the individual and family to accept the problem. In the process, it is important that you understand the patient's perspective and attitude towards drinking. Successful treatment depends on the attitude and confidence of the patient. For patients willing to stop, advise them to set a definite date to quit. The preferred goal of treatment should be abstinence.

However, abrupt abstinence for a person with a heavy alcohol drinking habit may lead to severe withdrawal symptoms. When you deal with people with alcohol problems, you should explain the benefits of reducing or stopping drinking alcohol to them. Stopping using alcohol can save them money, reduce the risk of liver disease, depression, weight loss, brain damage, sleep disturbances and accidents. There is also the benefit of reducing problems at work with their employer or workmates, reducing criticism and insults from the family, and avoiding legal problems (e.g. being arrested for fighting and other criminal acts while under the influence of alcohol).

The second step for your client is to seek assistance from the nearest health facility. Advise the patient and refer them for medical treatment at the health centre or nearest hospital. Sudden withdrawal can result in severe symptoms, including delirium tremens. Such patients should be referred because medical supervision is important.

Ways to support a person with an alcohol use disorder and their family:

• Reassure the family and the affected person that an alcohol drinking problem is treatable, and is not due to a bad character.
• However, it is important that the affected person and everyone in the family accept that excessive regular consumption of alcohol is a serious health and social problem.
• Successful treatment depends on the attitude and confidence of the person to stop drinking alcohol and the willingness of family members to help him or her to succeed.
• Explain the benefits of stopping using alcohol, e.g. it saves money and reduces the risk of major physical and mental health problems, job loss, sleep disturbance, marriage breakdown, accidents or criminal acts while under the influence of alcohol.
• Pregnant women must be strongly advised not to drink alcohol because it can harm the baby in their womb.