Reward vouchers are an incentive for drug addicts to remain drug-free.

Reinforcement therapy helps patients achieve and maintain abstinence from illegal drugs by providing them with a voucher each time they provide a drug-free urine sample. The voucher has monetary value and can be exchanged for goods and services consistent with the goals of treatment. Initially, the voucher values are low, but their value increases with the number of consecutive drug-free urine specimens the individual provides. Cocaine- or heroin-positive urine specimens reset the value of the vouchers to the initial low value. The contingency of escalating incentives is designed specifically to reinforce periods of sustained drug abstinence.

Studies show that patients receiving vouchers for drug-free urine samples achieved significantly more weeks of abstinence and significantly more weeks of sustained abstinence than patients who were given vouchers independent of urinalysis results. In another study, urinalyses positive for heroin decreased significantly when the voucher program was started and increased significantly when the program was stopped.

References:

Silverman, K.; Higgins, S.; Brooner, R.; Montoya, I.; Cone, E.; Schuster, C.; and Preston, K. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53: 409-415, 1996.

Silverman, K.; Wong, C.; Higgins, S.; Brooner, R.; Montoya, I.; Contoreggi, C.; Umbricht-Schneiter, A.; Schuster, C.; and Preston, K. Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence 41: 157-165, 1996.

Source: National Institute of Drug Abuse, "Principles of Drug Addiction Treatment: A Research Based Guide."
Last updated September 27, 2006.

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American Journal of Public Health, 83:803-810, 1993.

Morristown, NJ

Abstract

Objectives. The prevailing view today is that alcohol consumption is unambiguously a social and public health problem. This paper presents evidence to balance this view.

Methods. Evidence of beneficial effects of alcohol against coronary artery disease is examined, together with cultural reasons for resistance in the United States to the implications of this evidence.

Results. Alcohol use reduces the risk of coronary artery disease — the major cause of heart disease, America's leading killer — even for those at risk for such disease. Moreover, recent research indicates that alcohol continues to reduce risk at the higher levels of drinking measured in general populations. However, with consumption of more than two drinks daily, these gains are increasingly offset by greater mortality from other causes.

Conclusions. Educators, public health commentators, and medical investigators are uneasy about findings of healthful effects of drinking. A cultural preoccupation with alcoholism and the negative effects of drinking works against frank scientific discussions in the United States of the advantages for the cardiovascular system of alcohol consumption. This set has deep roots in American history but is inconsistent with public health goals.

Epigram

Clashing Drinking Cultures (not published with article)

Nilgul and James F. Taylor lost the restaurant they ran for 14 years after a sizable segment of their clientele, mostly fundamentalist Christians, stopped coming when the Taylors added wine to the menu. "I'm not believing this," said Mrs. Taylor [who came to the United States from Turkey in 1967].... "I wish someone had told us that serving wine would ruin our lives"....

Few subjects are as likely to stir the emotions of people in this region as alcohol, as seen in the array of letters to the editors of local newspapers.... Several of them discussed whether the wine Jesus drank was fermented.... Like half of the 100 counties in North Carolina, Transylvania County never repealed the 18th Amendment, which prohibited the manufacture, sale or transportation of liquor....

"As wine is served, business sours." The New York Times; p. A.14, January 7, 1993.

[Sections of the article that follows were not italicized in published version.]

Introduction

Today there is a public health debate in America over how to deal with beverage alcohol. The dominant approach, the disease model of alcoholism, emphasizes the biological — probably inherited — nature of problem drinking.¹ This model is challenged by the public health model, which strives to limit alcohol consumption for everyone in order to reduce individual and social problems.² The first approach is medical and treatment-oriented and the second is epidemiologic and policy-oriented; however, both present alcohol in fundamentally negative terms.

We hear little from those who hold the view that alcohol consumption satisfies an ordinary human appetite and that alcohol has important social and nutritional benefits. Yet at one time, the official position of the National Institute on Alcohol Abuse and Alcoholism under its founding director Morris Chafetz was that moderation in drinking should be encouraged and that young people should be taught how to consume alcohol moderately. This attitude has been completely expunged from the American scene. National and local antidrug campaigns produce banners to be displayed at schools throughout the United States declaring "ALCOHOL IS A LIQUID DRUG." Educational curricula are completely negative towards alcohol. Indeed, one of their thrusts is to attack the concept of moderate drinking as indefinable and dangerous. The logically inconsistent ideas that youthful drinking creates lifetime problem drinking and that alcoholism is inherited are merged into implausible, alarmist messages, such as this one in a school newsletter sent to one high school's entering freshman:

• Alcoholism is a primary chronic disease.
• A person who begins to drink at 13 years of age has an 80% risk of alcoholism and an extremely high risk of using other drugs.
• The average age at which kids begin to drink is 11.7 for boys and 12.2 for girls.³

Selden Bacon, a founder and long-time director of the Rutgers (formerly Yale) Center for Alcohol Studies, criticized this set of attitudes. Bacon's position is intriguing, because the Yale Center played an integral role in the National Council on Alcoholism's successful campaign to convince Americans that alcoholism was a rampant and unrecognized American epidemic. Bacon ruefully commented on what this effort had wrought:

Current organized knowledge about alcohol use can be likened to...knowledge about automobiles and their use if the latter were limited to facts and theories about accidents and crashes.... [What is missing are] the positive functions and positive attitudes about alcohol uses in our as well as in other societies.... If educating youth about drinking starts from the assumed basis that such drinking is bad...full of risk for life and property, at best considered as an escape, clearly useless per se, and/or frequently the precursor of disease, and the subject matter is taught by nondrinkers and antidrinkers, this is a particular indoctrination. Further, if 75-80% of the surrounding peers and elders are or are going to become drinkers, there [is] ... an inconsistency between the message and the reality.⁴

Drinking in America

The level of alcohol consumption in colonial America was many times its contemporary level, but alcohol was not considered a social problem, regulation of antisocial drinking behavior was strictly enforced in the tavern by informal social groups, and alcohol was widely considered a benign and healthful beverage. The temperance movement was launched in 1826, and for another century America warred over the prohibition of alcohol. Throughout the last century and the current one, alcohol consumption fluctuated, drinking was at different times associated with personal freedom and a modern lifestyle, and temperance attitudes always remained central to large groups of Americans while periodically surfacing as a core part of the American psyche.⁵

These crossing currents have left a patchwork of drinking attitudes and behavior in the United States, to wit:

1. America has a high percentage of abstainers (the Gallup Poll⁶ put this figure at 35 percent in 1992).
2. Abstinence and attitudes towards alcohol vary widely by region of the country, social class, and ethnic group. For example, those with less than a high-school degree are highly likely to abstain (51%). Few Italian, Chinese, Greek, and Jewish Americans abstain, but few have drinking problems (Glassner and Berg⁷ calculated that 0.1% of the Jews in an upstate New York city were alcoholic; this figure is a fraction of the alcoholism rate for all Americans), and the idea of alcohol as a social problem is alien to these cultural groups.
3. High abstinence and problem drinking rates are associated in some groups. Those with high income and education levels are more likely than other Americans both to drink (about 80% of college graduates drink), and to drink without problems.⁸ George Vaillant⁹ found that Irish Americans had a much higher abstinence rate than Italian Americans, but were nonetheless seven times as likely as Italians to become alcoholic.
4. Superimposed on these conflicting patterns of drinking behavior has been a steady overall decline in drinking in the United States for over a decade and the appearance of what some term a "new temperance movement."¹⁰
5. American adolescents continue to drink at high rates, not only bucking larger American drinking trends, but contravening their own reduction in illicit drug use over the last decade. Almost 90 percent of high school seniors say they have begun to drink, and 40 percent of senior boys binge-drink regularly.¹¹
6. Nonetheless, a majority of Americans continue to drink without problems; this majority is sandwiched between the minority with drinking problems and the somewhat larger minority of abstainers.⁸
7. Many of these moderate drinkers are former problem drinkers, "75% [of whom] will likely 'mature out' of their excessive drinking, often without any formal intervention."¹² The percentage of high school and college students who moderate their excessive drinking is even higher.

Drinking in Different Western Societies

As alcoholism has come to be conceived as a biological, medical disease, cross-cultural analysis of patterns of drinking has almost disappeared and we rarely hear today of massive cross-cultural differences in drinking styles. Yet these differences persist as strongly as ever, influencing even diagnostic categories and conceptions of alcoholism in different societies. When an American clinician, William Miller, ventured to Europe, he observed "huge national differences in what is recognized to be a harmful amount of alcohol consumption":

The American samples that I have defined as "problem drinkers" in my treatment studies have reported, at intake, an average consumption of approximately 50 drinks per week. In Norway and Sweden, the audiences tended to be shocked by this amount of drinking and argued that my samples must consist of chronic addicted alcoholics. In Scotland and Germany, on the other hand, the skepticism tended to be aimed at whether these individuals had a real problem at all because this level was regarded as quite ordinary drinking.¹³

One insightful conception of cultural differences in drinking attitudes and behavior has been put forward by Harry G. Levine,¹⁴ who classified as "temperance cultures" nine Western societies which have generated large-scale, sustained temperance movements in the 19th or 20th centuries. All are predominantly Protestant, English-speaking (United States, Great Britain, Australia, New Zealand) or Northern Scandinavian/Nordic (Finland, Sweden, Norway, Iceland).

There are several differences between the temperance cultures and 11 "nontemperance" European countries identified by Levine (Table 1):

1. Temperance cultures are much more acutely concerned with the dangers of alcohol, as demonstrated not only by the temperance movements they have sustained, but by their high Alcoholics Anonymous memberships. The number of Alcoholics Anonymous groups per capita in the temperance countries is, on average, more than four times that in nontemperance countries. (The United States continues to have a large majority of the Alcoholics Anonymous groups in the Western industrial world.)
2. Temperance societies drink considerably less alcohol than nontemperance societies. They do consume a higher percentage of their alcohol in the form of distilled spirits, which leads to more of the staggering, public drunkenness related to the classical loss-of-control model of alcoholism which has been Alcoholics Anonymous's focus.
3. Nontemperance Western cultures consume a much higher percentage of their alcohol as wine, which is associated with the kind of domesticated drinking patterns in which alcohol is drunk as a beverage at meals and at family, social, and religious gatherings that unite those of different ages and both sexes.
4. Levine's analysis¹⁴ demonstrates that, despite reference to supposedly scientific and medically objective bases for alcohol policies, societies rely on historical, cultural, and religious attitudes for their stances towards beverage alcohol.
5. LaPorte et al.¹⁵ found a strong inverse relationship cross-culturally between consumption of alcohol (primarily represented by wine) and death rates from atherosclerotic heart disease. LaPorte et al.'s and Levine's analysis overlapped for 20 countries (LaPorte et al. included Japan but not Iceland). Table 1 shows the large and significant difference in heart disease death rates between temperance and nontemperance countries.

Indeed, the "red wine paradox" — noted in France, where much red wine is drunk and French men have a substantially lower death rate from heart disease than do American men — has been the most popular version of the positive effects of alcohol, particularly since 60 Minutes featured a segment on this phenomenon in 1991. However, Protestant-Catholic, Northern-Southern European, dietary and other differences correspond with red wine consumption and confuse efforts to account for specific differences in disease rates. Furthermore, epidemiological studies have not found that the form of alcoholic beverage affects heart disease rates.

Does Alcohol Prevent Cardiovascular Disease? If So, at What Levels of Drinking?

The depth of American antialcohol feeling is expressed in the controversy over alcohol's protective effect against coronary artery and heart disease (both terms, which have the same meaning, are used by the authors discussed in this article). In a comprehensive 1986 review, Moore and Pearson¹⁶ concluded, "The strength of existing evidence makes new and expensive population-based studies of the association of alcohol consumption and CAD [coronary artery disease] unnecessary." Nonetheless, in a 1990 article on the negative effects of alcohol for the cardiovascular system based primarily on alcoholic drinking, Regan¹⁷ declared "a preventive effect of mild to moderate drinking on coronary artery disease is, at present, equivocal, largely due to the question of appropriate controls." The primary justification for this doubt has been the British Regional Heart study, in which Shaper et al.¹⁸ found that non-drinkers were at minimal risk for coronary artery disease (as opposed to ex-drinkers, who were older and who may have quit drinking due to health problems).

Nearly one of two people in the United States dies of cardiac causes. Two thirds of these deaths are due to coronary artery disease, which is caused by the fatty deposits in the blood vessels characteristic of atherosclerosis. The less common forms of cardiovascular disease include cardiomyopathy and ischemic (or occlusive) stroke and hemorrhagic stroke. Ischemic (occlusive) stroke behaves like coronary artery disease in response to drinking.^19,20 Nonetheless, all other sources of cardiovascular mortality taken together increase at lower levels of drinking than does coronary artery disease.²⁰ The most likely mechanism in alcohol's positive effect on coronary artery disease is that it increases high-density lipoprotein (HDL) levels.²¹

Following are the conclusions of research on the relationship of drinking to coronary artery disease:

1. Alcohol reduces CAD substantially and consistently, including incidence, acute events, and mortality. The large population multivariate prospective studies on alcohol and coronary artery disease reported since the 1986 Moore and Pearson review¹⁶ include those shown in Tables 2 and 3,^19-23 along with the American Cancer Society study.²⁴ These six studies had populations in the tens and even hundreds of thousands; taken together, they numbered about a half million subjects of varying ages, both genders, and different economic and racial backgrounds — including groups at high risk for coronary artery disease. The studies were able to adjust for concurrent risk factors — including diet, smoking, age, high blood pressure, and other medical conditions — and to allow for separate analyses of lifetime abstainers and ex-drinkers,^20,23 drinkers who reduced their consumption for health reasons,¹⁹ all nondrinkers,²² and coronary artery disease risk candidates.^20,21 The studies consistently found coronary artery disease risk is reduced by drinking. Taken together, they make the risk-reduction link between alcohol and coronary artery disease close to irrefutable.
2. An inverse linear relationship between drinking and coronary artery disease risk through the highest levels of drinking has been observed in large-scale multivariate studies. Studies adjusting risk of coronary artery disease for concurrent risk factors correlated with drinking level, such as high-fat diets^19,22 and smoking, indicate that risk is reduced at higher levels of drinking than previously thought. Relative to abstinence, more than two drinks daily optimally reduced risk for coronary artery disease (by 40% to 60%) (Table 2). This protective effect is robust even at the level of six drinks or more, although the Kaiser²⁰ and American Cancer Society²⁴ mortality studies showed an upturn in coronary disease risk at higher levels of drinking (see Table 3 for the Kaiser²⁰ findings). Although the American Cancer Society study of 276,802 men reported a lesser degree of risk reduction from drinking, the study is anomalous in its remarkably high abstinence rate of 55% (twice the rate for men reported by the Gallup survey⁶).
3. Overall mortality risk levels off at three and four drinks daily, owing to the rise in other causes of death, such as cirrhosis, accidents, cancer, and cardiovascular diseases other than coronary artery disease such as cardiomyopathy^20,24 (see Table 3 for Kaiser²⁰ findings). However, some major sources of alcohol-related death in the United States — such as accident, suicide, and murder — vary from society to society and are not inevitable consequences of high levels of drinking. For example, different policies towards drinkers can reduce drinking accidents,²⁵ and violence towards oneself and others cannot be shown to be a result simply of a chemical reaction called "alcoholic disinhibition."²⁶
4. Style, mood, and setting elements of drinking can affect the health consequences of drinking as much as the amount of alcohol consumed. Little epidemiologic attention has been given to patterns of drinking, although one study found that binge drinking led to more coronary occlusions than regular daily drinking.²⁷ Harburg and associates have shown that mood and setting when drinking are better predictors of hangover symptoms than is the amount of alcohol consumed,²⁸ and that hypertension can be better predicted from a drinking measure including psychosocial variables than solely from amount of alcohol consumed.²⁹
5. The beneficial effects of drinking extend to all population and risk categories, including those who are at risk for and those who have symptoms of coronary artery disease. Suh et al.²¹ found a reduction of coronary artery disease mortality in asymptomatic men at risk for coronary artery disease. Klatsky et al.²⁰ found even greater than average reduction of risk of coronary artery disease mortality from drinking for women and elderly subjects. For patients who were either at risk or symptomatic for coronary artery disease, coronary artery disease mortality was reduced by consumption of up to six drinks daily and optimal risk reduction was achieved at three to five drinks per day (Table 3). These results indicate a powerful secondary prevention benefit from drinking for coronary artery disease patients.

Table 3. Relative Risk of Death from Coronary Artery Disease (CAD), All Cardiovascular Disease, and All Causes

Talking to People about Drinking

The fear of discussing benefits from drinking extends far beyond nervous secondary school educators.

1. Most prominent medical and public health authorities damn alcohol at every turn. According to Klatsky, "consideration of the harmful effects [of alcohol] almost completely dominates discussions in scientific and medical meetings, even when ... consider[ing] light to moderate drinking."³⁰ A 1990 government pamphlet, Dietary Guidelines for Americans, declared "Drinking them (alcoholic beverages) has no net health benefit, is linked with many health problems, is the cause of many accidents, and can lead to addiction. Their consumption is not recommended.³¹
2. Even researchers who find benefits from alcohol seem reluctant to describe them. A Wall Street Journal article³² about Rimm et al.²¹ noted: "Some researchers have played down alcohol's beneficial effects for fear of encouraging inappropriate drinking
   — 'We have to be very cautious in presenting this type of information,' says Eric B. Rimm." This report of the study's results — "men who consume from one-half to two drinks a day reduce their risk of heart disease by 26% compared with men who abstain" — failed to mention the 43% reduction in risk from more than two and up to four drinks a day and the 60% reduction from more than four drinks daily.
3. No American medical body will recommend drinking as healthful. The benefits of alcohol in reducing coronary artery disease are similar to those of the low-fat diets recommended by nearly all health and medical organizations, but no medical organization will recommend drinking. Typically, a conference of prominent researchers and clinicians convened in January 1990 declared, "Until we know more about metabolic and behavioral effects of alcohol and about its linkage to atherosclerosis, we have no basis for recommending either that patients increase their alcohol intake or that they start to drink if they do not already."³³ Perhaps additional research published since then would convince such a group to make this recommendation, but it is highly unlikely.
4. This attitude is, paradoxically, related to American clinicians' refusal to tell excessive drinkers to drink less. The United States has systematically eliminated efforts to help people reduce alcohol consumption in favor of instructing all problem drinkers to abstain.³⁴ We are not deterred by the finding that the abstinence prescription fails for a sizable majority of such drinkers, or that 80% of problem drinkers are not clinically dependent on alcohol.¹² Even other temperance cultures accept drinking reduction programs. In Britain, significant reductions in consumption have resulted from programs in which primary care physicians conduct drinking assessments and advise excessive, but nondependent, drinkers to lower their alcohol intake.³⁵
5. According to the data, alcohol has a role as a therapy for coronary artery disease, a role that scares American clinicians. Alcohol could be recommended as a therapy for coronary artery disease, just as patients with coronary artery disease are instructed to follow cholesterol-reducing diets. Cardiomyopathy and concurrent medications, among other things, would need to be considered in consultations with individual patients. One would think that findings that alcohol reduces coronary artery disease deaths for those at risk for coronary artery disease could not be ignored, but they are. Suh et al.,²¹ who reported such a relationship, nonetheless concluded, "alcohol consumption cannot be recommended because of the known adverse effects of excess alcohol use."
6. Americans would not drink more even if we told them to. Health professionals seem to live in fear that, on hearing it is good to drink, people will rush out and become alcoholics. They may be reassured to know that according to the Gallup poll,⁶ "fifty-eight percent of Americans are aware of recent research linking moderate drinking to lower rates of heart disease," but "only 5% of all respondents say the studies are more likely to make them drink moderately." Meanwhile, although only 2% of respondents said they averaged three or more drinks daily, more than a quarter of all drinkers planned to cut back or quit drinking altogether in the coming year.
7. Those we tell not to drink also do not listen to us. Young people, who are the primary targets of the abstinence message, blithely ignore it. Almost 90% of high school senior boys and girls have drunk alcohol (usually illegally obtained), and 30% (40% of boys) have drunk five or more drinks at one sitting in the 2 prior weeks, as have 43% of college students (over half of college men).¹¹
8. Advice about healthy drinking should not differ for children of alcoholics. The American medical preoccupation with alcoholism has led to the view that some children may be genetically destined to be alcoholics. Although positive evidence has been presented (along with negative) about the heritability of alcoholism, the model that people inherit loss of control — that is, alcoholism per se — has been soundly refuted.³⁶ Whatever people may inherit that heightens susceptibility to alcoholism operates over years as a part of the long-term development of alcohol dependence. Moreover, a large majority of children of alcoholics do not become alcoholic, and the majority of alcoholics do not have alcoholic parents.³⁷

Telling children they are born to be alcoholic on the basis of the available evidence is a double-edged sword. The broadest assertion yet made about the association of a genetic marker and alcoholism was Blum et al.'s³⁸ for the A1 allele of the dopamine D₂ receptor. Accepting at face value Blum et al.'s result (although it has been disputed by many and never fully matched by any other than the original research team³⁹), fewer than a fifth of those with the A1 allele would be alcoholic. This means that more than 80% of those with the gene variant would be misinformed if they were told they would become alcoholics. Because children readily ignore advice not to drink, we would be left with the self-fulfilling impact of our efforts to convince children with a putative genetic marker that drinking will lead them inevitably to alcoholism. Telling them this would only make it less likely that they would be able to control the drinking most will eventually initiate.

The goal of eliminating drinking for all Americans was abandoned in the United States in 1933. The failure of Prohibition implies that our public policy should be to encourage healthy drinking. Many people drink to relax and to enhance meals and social occasions. Indeed, human beings have discovered many health-related uses for alcohol over the centuries. Alcohol is used as a medicine to alleviate tension and stress, to promote sleep, to relieve pain in teething babies, and to assist in lactation. Perhaps public health policy should build on the healthy uses to which most people put alcohol. Short of this, perhaps we can simply tell the truth about alcohol.

Acknowledgements

The author thanks the following people for information and assistance they provided: Robin Room, Harry Levine, Archie Brodsky, Mary Arnold, Dana Peele, Arthur Klatsky, and Ernie Harburg.

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References

1. Peele S. Diseasing of America: Addiction Treatment Out of Control. Boston: Houghton Mifflin, 1991.
2. Room R. Alcohol control and public health. Annu Rev Public Health. 1984;5:293-317.
3. Parents Advisory Council. Summer 1992. Morristown, NJ: Morristown High School Booster Club; June 1992.
4. Bacon S. Alcohol issues and science. J Drug Issues. 1984;14:22-24.
5. Lender ME, Martin JK. Drinking in America: A Social-Historical Explanation, Rev. ed. New York: Free Press, 1987.
6. The Gallup Poll News Service. Princeton, NJ: Gallup, February 7, 1992.
7. Glassner B, Berg B. How Jews avoid alcohol problems. Am Soc Rev. 1980;45:647-664.
8. Hilton ME. Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcoholism: Clin Exp Res. 1987;11:167-175.
9. Vaillant GE. The Natural History of Alcoholism. Cambridge, MA: Harvard University Press, 1983.
10. Heath DB. The new temperance movement: Through the looking glass. Drugs Society. 1987;3:143-168.
11. Johnston LD, O'Malley PM, Bachman JG. Smoking, drinking, and illicit drug use among American secondary school students, college students, and young adults, 1975-1991. Rockville, MD: NIDA; 1992. DHHS publication 93-3480.
12. Skinner HA. Spectrum of drinkers and intervention opportunities. Can Med Assoc J. 1990;143:1054-1059.
13. Miller WR. Haunted by Zeitgeists: Reflections on contrasting treatment goals and concepts of alcoholism in Europe and America. Paper presented at the conference on Alcohol and Culture: Comparative Perspectives from Europe and America. May, 1983; Farmington, CT.
14. Levine HG. Temperance cultures: Alcohol as a problem in Nordic and English-speaking cultures. In Lader M, Edwards G, Drummond C, eds. The nature of alcohol and drug-related problems. New York: Oxford University Press, 1992:16-36.
15. LaPorte RE, Cresanta JL, Kuller LH. The relationship of alcohol consumption to atherosclerotic heart disease. Prev Med. 1980;9:22-40.
16. Moore RD, Pearson TA. Moderate alcohol consumption and coronary artery disease. Medicine. 1986;65:242-267.
17. Regan TJ. Alcohol and the cardiovascular system. JAMA. 1990;264:377-381.
18. Shaper AG, Wannamethee G, Walker M. Alcohol and mortality in British men: Explaining the U-shaped curve. Lancet. 1988;2:1267-1273.
19. Stampfer MJ, Colditz GA, Willett WC, Speizer FE, Hennekens CH. A prospective study of moderate alcohol consumption and the risk of coronary heart disease and stroke in women. N Engl J Med. 1988;319:267-273.
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22. Rimm EB, Giovannucci EL, Willett WC, Colditz GA, Ascherio A, Rosner B, Stampfer MJ. Prospective study of alcohol consumption and risk of coronary disease in men. Lancet. 1991;338:464-468.
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Read about complementary, non-drug treatment and prevention for anxiety and panic attacks.

In complementary or alternative treatments to psychotherapy and/or medication, your doctor may prescribe several natural methods to help treat and later prevent anxiety and panic attacks.

Naturopathic practitioner, Dr. James Rouse, lists these alternative treatments for anxiety and panic:

1. Natural medicine practitioners have used herbs including kava kava and St. John's Wort as effective treatment alternatives to prescription anxiety drugs. Kava is well known for its calming effects and holds great promise in easing the symptoms of nervousness; however, the FDA has recently issued warnings on kava due to its adverse effects on the liver. Valerian root is another herb that is often used for its calming effects. St. John's Wort is backed by more research on its safety and use as an anxiety treatment, and as a treatment for mild to moderate depression. Its effectiveness in treating anxiety is yet to be confirmed.

2. SAMe is another dietary supplement that has been used in treatment of anxiety.

3. Eliminating caffeine and alcohol, reducing your intake of sugar, sugary food products, refined carbohydrates and foods with additives and chemicals may help lessen anxiety symptoms. To minimize headaches and other withdrawal symptoms, make reduction of caffeine intake gradual. Instead of caffeinated beverages, try drinking tea made from chamomile (or passionflower, skullcap or lemon balm), which can relax you without causing drowsiness or addiction.

1. Calcium, magnesium, and vitamin B complex all contribute to the health and proper functioning of the nervous system. They also support the production of neurotransmitters, chemicals that help relay messages between nerve cells.

2. Exercising regularly and practice relaxation techniques such as meditation, yoga, t'ai chi or progressive relaxation are all nondrug remedies that can help relieve anxiety disorders. Your routine should include cardiovascular exercise, which burns lactic acid, produces mood-enhancing chemicals called endorphins, and causes the body to use oxygen more efficiently.

3. Controlled breathing techniques can help ease a panic attack. When an attack strikes, try this breathing exercise: Inhale slowly to a count of four, wait four counts, exhale slowly to a count of four, wait another four counts, then repeat the cycle until the attack passes.

Ed. Note: Dr. Rouse completed a four-year doctorate naturopathic medicine program at National College, in Portland, Oregon, the oldest naturopathic medical school in the country. He also studied Oriental medicine at Oregon College.

next: Non-Medication Treatments for Anxiety and Panic

Chapter 121 of the book Self-Help Stuff That Works

by Adam Khan:

METTLE IS A WORD you don't hear much these days. It means a strength of mind that gives you the ability to withstand pain or difficulties with bravery and resolution. Mettle is a quality we all admire. But it isn't something you are born with. It must be developed. It is strengthened by the way you conduct your everyday life. Specifically, mettle is created by daily making the decision to:

Remain loyal to your comrades. We are social creatures, and when you violate this cannon, you wound yourself at the core. If you are married and find yourself flirting with someone at work, make the decision to remain loyal to your spouse, even if it means not getting the admiring eyes of another. If someone is bad-mouthing a friend of yours behind their back, defend them in their absence. When you have committed yourself to someone, whoever they are, remain true to them. This is one of the deepest principles of integrity.

Speak honestly and directly. We live in a world of appearances and game-playing. It is one of the things that makes the world a crazy place and produces so much stress. More honesty in the world is needed and wanted, from the smallest level all the way up. Honesty requires courage, and it exacts a price. And although you will never be perfectly honest, you can always improve. It is the effort to increase your integrity that forges mettle.

Keep your word. Be careful about what you promise or what promises you imply. Be very clear with others about what they can expect from you and clear and careful with yourself about what you can expect from yourself. And then do everything you can to never disappoint. Keep your word. Think of your word as sacred and treat it so. It produces one of the finest experiences known to humankind: trust. People will learn they can count on you, and you will learn you can count on yourself.

These are the Three Commandments of Mettle. Courage may seem like an ancient and unneeded quality in our pampered modern era, but now we need it more than ever. The human race is controlling the destiny of all living things on earth, and what is needed is human integrity. The place to start is your own. The time to start is now. Give your spouse and children an example to emulate and you will be doing the most concrete good you can for the future of the planet.

Remain loyal to your comrades, speak honestly and directly, and keep your word.

Being honest with the people you're close to is a difficult business. Learn more about how to deal with the conflict honesty inevitably creates:
The Conflict of Honesty

next: Parting Shot

how to have good sex

While sex drive is natural, how we express our sexuality varies from instinctual mating just to get off or have children, to expressing caring intimacy and loving sensuality with our partners. Mating sex is natural. Caring, intimate sexuality is learned.

People view sexuality in different ways depending on their culture, personal attitudes and expectations, which are often based on past experiences. Sadly, many are exposed to negative sexual experience in childhood, which greatly inhibits positive, other-centered sexual sharing. But we often become defensive and resistant to learning new sexual attitudes.

The loving couple is willing to constantly learn and relearn about each other's sexual pleasures by experimentation and sincerely wanting to sensually please the other. But few couples take the time to have honest discussions about their sexuality. The result is years of repeating a sexual routine which often becomes boring. Our sex drive is natural, but we must learn as couples to keep it exciting, creative and fulfilling.

Problems in sex may turn into much broader relationship issues. The women with a low sex desire may have to deal with a sexually deprived man or vice versa. One partner may harp on the other for more sex and this drives them further apart. Often the partner with the lower sex drive recognizes the problem but is unable to acknowledge or discuss it without feeling inadequate. Sometimes just discussing honestly the problem can relieve a lot of tension, bring them closer together emotionally, and start the process of resolution.

Sometimes self-pleasuring is one partial solution. Kinsey data (1990) reveals that 94% of men and 70% of women admit they masturbate to orgasm. Another study shows that 66% of men and 46% of women in their fifties masturbate on a regular basis.

Most married couples masturbate to lessen tension, to decrease sexual demands on a lower sex desire partner and it can relieve sexual tension if one's partner is unavailable. Masturbation can also give you a feeling of being in control of your own sexual satisfaction without having to always rely on your partner.

next: Are Sexual Fantasies Good For Us?

Chapter 48 of the book Self-Help Stuff That Works

by Adam Khan:

HERE'S A RULE WE all know we ought to follow: Do the important things first. You and I know if we're doing something of secondary importance while we still have something of primary importance to do, we're essentially wasting our time -even if what we're doing is constructive, productive, positive, loving, or any other worthwhile description. If it isn't one of the few things that are important to us, then it's a waste of time.

Of course that's a rather extreme and absolute thing to say, and there are always mitigating circumstances and perfectly valid reasons why the rule can't be followed all the time, but doing important things first is rule few would argue with.

Important tasks are usually more difficult than unimportant tasks, so we tend to put them off. But listen: That's because we're thinking about what it will be like to do the task. And that's where we go wrong. Don't think about that. Think about what it will be like to have the task done. There's a big difference -a difference that can make a difference. It takes your attention off the part you don't like and puts your focus on something you really want: the result. That subtle difference will make the task more appealing, so you'll be less likely to put it off.

Instead of looking at the bills to be paid and thinking about all the time and frustration and neck-hurting hassle, imagine the feeling you'll get when you finish, when all the bills are stacked up there, paid, stamped and ready to mail. What a great feeling! Keep that image in mind when you look at the stack of bills. You'll get to it sooner.

And when you get to something sooner, you suffer less because you spend less psychological effort avoiding the task. You get to spend more of your time on the other side - satisfied that the job is finished.

That's it. It's a simple change that makes things better. Vividly anticipate the completion of important tasks and you will get more of them done.

Vividly imagine the completion of important tasks.

Here's an entirely different angle on how to face difficult situations or tasks and handle it without struggle or difficulty:
Refuse to Flinch

So now you know how to help yourself get more of the hard things done, but what about your kids or the people that work for you? Certainly you can share with them the technique you just learned, but what else can you do? Check it out:
An Island of Order in a Sea of Chaos

next: Use What You Get

teenage sex

Does thinking about gay sex make you gay? What about experimenting with same-sex sex?

Your sexual orientation is a reflection of your sexual and emotional feelings toward people of the same or opposite gender. Although some people know early on that they are homosexual, others go through a confusing period where they wonder: Am I different? Could I be gay? Are my feelings just a passing phase?

The answer is there is no single answer. Your sexual orientation will emerge over time, probably little by little. You shouldn't label yourself as gay just because you've had homosexual feelings or even homosexual encounters. These experiences are very common among people your age. Or, you may realize over time that you're only attracted to people of your own gender. Or maybe you'll find that you're into both guys and girls - that you're bisexual.

Right now the best thing you can do is give it time and explore and experience your sexual feelings with an open mind. If it turns out you're gay, you'll probably face some unique challenges but you'll also get a lot of support along the way. The world's come a long way. It's still not perfect, but these days most people know that it's okay to be gay, and homosexuals have more social freedoms and legal protections than ever before.

You may have wondered what causes homosexuality. Why are some people gay and some people aren't? Truth is, nobody really knows for sure. Researchers used to believe that homosexuality stemmed from improper parenting (some people still believe this), but this just isn't the case. As best we know, what "causes" homosexuality is the same as what causes heterosexuality: the roll of the biological dice.

Today, sex researchers and doctors view homosexuality not as a sexual problem but as a normal sexual difference, much like green is a normal - if fairly unusual - eye color.

What all this means is that homosexuals are no more responsible for their homosexuality than heterosexuals are for their heterosexuality. It is not a "lifestyle" you choose for yourself as much as something you discover in yourself. Which is not to say it's an easy discovery. Even if you know that homosexuality isn't a disorder or a flaw, you may fear that your family and friends won't accept you if you come out to them.

Visit HealthyPlace.com Gender Community for comprehensive GLBT information.

continue story below

next: Causes of Erection Problems Help for Erectile Dysfunction

Describing Depression Among African-Amarican Women by Nikki Giovanni, Introspection

because she didn't know any better
she stayed alive
among the tired and lonely
not waiting always wanting
needing a good night's rest

Defining the Roots of Depression Among African-American Women

Clinical depression is often a vague disorder for African- American women. It may produce an abundance of "depressions" in the lives of the women who experience its ongoing, relentless symptoms. The old adage of "being sick and tired of being sick and tired" is quite relevant for these women, since they often suffer from persistent, untreated physical and emotional symptoms. If these women consult health professionals, they are frequently told that they are hypertensive, run down, or tense and nervous. They may be prescribed antihypertensives, vitamins, or mood elevating pills; or they may be informed to lose weight, learn to relax, get a change of scenery, or get more exercise. The root of their symptoms frequently is not explored; and these women continue to complain of being tired, weary, empty, lonely, sad. Other women friends and family members may say, "We all feel this way sometimes, it's just the way it is for us Black women."

I remember one of my clients, a woman who had been brought into the emergency mental health center because she had slashed her wrists while at work. During my assessment of her, she told me she felt like she was "dragging a weight around all the time." She said, "I've had all these tests done and they tell me physically everything is fine but I know it's not. Maybe I'm going crazy! Something is terribly wrong with me, but I don't have time for it. I've got a family who depends on me to be strong. I'm the one that everyone turns to." This woman, more conerned about her family than herself, said she "[felt] guilty spending so much time on [her]self." When I asked her if she had anyone she could talk to, she responded, "I don't want to bother my family and my closest friend is having her own problems right now." Her comments reflect and mirror the sentiments of other depressed African-American women I have seen in my practice: They're alive, but barely, and are continually tired, lonely, and wanting.

Statistics regarding depression in African-American women are either non-existent or uncertain. Part of this confusion is because past published clinical research on depression in African-American women has been scarce (Barbee, 1992; Carrington, 1980; McGrath et al., 1992; Oakley, 1986; Tomes et al., 1990). This scarcity is, in part, due to the fact that African-American women may not seek treatment for their depression, may be misdiagnosed, or may withdraw from treatment because their ethnic, cultural, and/or gender needs have not been met (Cannon, Higginbotham, Guy, 1989; Warren, 1994a). I also have found that African-American women may be reticent to participate in research studies because they are uncertain as to how research data will be disseminated or are afraid that data will be misinterpreted. In addition, there are few available culturally competent researchers who are knowledgeable regarding the phenomenon of depression in African-American women. Subsequently, African-American women may not be available to participate in depression research studies. Available published statistics concur with what I have seen in my practice: that African-American women report more depressive symptoms than African-American men or European-American women or men, and that these women have a depression rate twice that of European-American women (Brown, 1990; Kessler et al., 1994).

African-American women have a triple jeopardy status which places us at risk for developing depression (Boykin, 1985; Carrington, 1980; Taylor, 1992). We live in a majority-dominated society that frequently devalues our ethnicity, culture, and gender. In addition, we may find ourselves at the lower spectrum of the American political and economic continuum. Often we are involved in multiple roles as we attempt to survive economically and advance ourselves and our families through mainstream society. All of these factors intensify the amount of stress within our lives which can erode our self-esteem, social support systems, and health (Warren, 1994b).

Clinically, depression is described as a mood disorder with a collection of symptoms persisting over a two-week time. These symptoms must not be attributed to the direct physical effects of alcohol or drug abuse or other medication usage. However, clinical depression may occur in conjunction with these conditions as well as other emotional and physical disorders such as hormonal, blood pressure, kidney, or heart conditions (American Psychiatric Association [APA], 1994). To be diagnosed with clinical depression, an African-American woman must have either depressed mood or loss of interest or pleasure as well as four of the following symptoms:

1. Depressed or irritable mood throughout the day (often everyday)
2. Lack of pleasure in life activities
3. Significant (more than 5%) weight loss or gain over a month
4. Sleep disruptions (increased or decreased sleeping)
5. Unusual, increased, agitated or decreased physical activity (generally everyday)
6. Daily fatigue or lack of energy
7. Daily feelings of worthlessness or guilt
8. Inability to concentrate or make decisions
9. Recurring thoughts of death or suicidal thoughts (APA, 1994).

The Meaning of Contextual Depression Theory

In the past, causal theories of depression have been used across all populations. These theories have utilized biological, psychosocial, and sociological weaknesses and changes to explain the occurrence and development of depression. However, I think that a contextual depression theory provides a more meaningful explanation for the occurrence of depression within African- American women. This contextual focus incorporates the neurochemical, genetic perspectives of biological theory; the impact of losses, stressors, and control/coping strategies of psychosocial theory; the conditioning patterns, social support systems, and social, political, and economic perspectives of sociological theory; and the ethnic and cultural influences which affect the physical and psychological development and health of African-American women (Abramson, Seligman, & Teasdale, 1978; Beck, Rush, Shaw, & Emery, 1979; Carrington, 1979, 1980; Cockerman, 1992; Collins, 1991; Coner-Edwards & Edwards, 1988; Freud, 1957; Klerman, 1989; Taylor, 1992; Warren, 1994b). Another important aspect of the contextual depression theory is that it incorporates an examination of the strengths of African- American women and the cultural competency of mental health professionals. Past depression theories traditionally have ignored these factors. Understanding these factors is important because depressed African-American women's assessment and treatment process is impacted not only by the women's attitudes but also by the attitudes of the health care professionals who provide services for them.

African-American women have strengths; we are survivors and innovators who historically have been involved in the development of family and group survival strategies (Giddings, 1992; Hooks, 1989). However, women may experience increased stress, guilt, and depressive symptoms when they have role conflicts between their family's survival and their own developmental needs (Carrington, 1980; Outlaw, 1993). It is this cumulative stress which takes a toll on the strengths of African-American women and can produce an erosion of emotional and physical health (Warren, 1994b).

Choosing a Treatment Path

Treatment strategies for depressed African-American women need to be based on contextual depression theory because it addresses women's total health status. African-American women's psychological and physiological health cannot be separated from their ethnic and cultural values. Mental health professionals, when culturally competent, acknowledge and understand African-American women's cultural strengths and values in order to successfully counsel them. Cultural competence involves a mental health professional's use of cultural awareness (sensitivity when interacting with other cultures), cultural knowledge (educational basis of other cultures' world views), cultural skill (the ability to conduct a cultural assessment), and cultural encounter (the ability to engage meaningfully in interactions with persons from different cultural arenas) (Campinha-Bacote, 1994; Capers, 1994).

Initially, I advise a woman to have a complete history and physical done to help determine the cause of her depression. I take a cultural assessment in conjunction with this history and physical. This assessment allows me to find out what is important for the woman in the areas of her ethnic, racial, and cultural background. I must complete this assessment before I can institute any interventions for the woman. Then I can spend time with her discussing her attitude toward her depression, what she thinks created her symptoms, and what the causes of depression are. This is important because depressed African-American women need to understand that depression is not a weakness, but an illness often resulting from a combination of causes. It is true that treating neurochemical imbalances or physical disorders may alleviate the depression; however, surgeries or certain heart, hormonal, blood pressure, or kidney medications actually may induce one. Consequently, it is important to provide a woman with information regarding this possibility and perhaps to alter or change any medications that she is taking.

I also like to screen women for their level of depression using either the Beck Depression Inventory or the Zung Self- Rating Scale. Both of these instruments are quick and easy to complete and have excellent reliability and validity. Antidepressants may provide relief for women by restoring neurochemical balances. However, African-American women may be more sensitive to certain antidepressants and may require smaller dosages than traditional treatment advises (McGrath et al., 1992). I like to provide women with information on the different types of antidepressant medications and their effects and to monitor their progress on medication(s). Women also should be given information regarding the symptoms of depression so they may recognize changes within their current condition and any future recurrence of depressive symptoms. Information regarding light, nutrition, exercise, and electroshock therapies may be included. An excellent booklet that I use, which is available for free through local mental health centers or agencies, is Depression Is a Treatable Illness: A Patient's Guide, Publication #AHCPR 93- 0553 (U.S. Department of Health and Human Services, 1993).

I also advise that women participate in some form of individual or group therapeutic discussion sessions with either myself or another trained therapist. These sessions can help them to understand their depression and their treatment choices, enhance their self-esteem, and develop alternative strategies in order to handle their stress and conflicting roles appropriately. I advise these women to learn relaxation techniques and develop alternative coping and crisis management strategies. Group sessions may be more supportive for some women and may facilitate the development of a wider selection of lifestyle choices and changes. Self-help groups, such as the National Black Women's Health Project, also may provide social support for depressed African-American women as well as enhance the work women accomplish with their therapeutic sessions. Finally, women need to monitor their ongoing emotional and physical health as they progress through life and "rise," as Maya Angelou writes, "into a day break that's wondrously clear . . . bringing the gifts that my ancestors gave" (1994, p. 164).

Barbara Jones Warren, R.N., M.S., Ph.D., is a psychiatric mental health nurse consultant. Formerly an American Nurses Foundation Ethnic/Racial Minority Fellow, she has joined the faculty of The Ohio State University.

References for article:

Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87, 49-74. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorder-IV [DSM-IV]. (4th ed.) Washington, DC: Author. Angelou, M. (1994). And still I rise. In M. Angelou (Ed.), The complete collected poems of Maya Angelou (pp. 163-164). New York: Random House. Barbee, E. L. (1992). African-American women and depression: A review and critique of the literature. Archives of Psychiatric Nursing, 6(5), 257-265. Beck, A. T., Rush, A. J., Shaw, B. E., and Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Brown, D. R. (1990). Depression among Blacks: An epidemiological perspective. In D. S. Ruiz and J. P. Comer (Eds.), Handbook of mental health and mental disorder among Black Americans (pp. 71-93). New York: Greenwood Press. Campinha-Bacote, J. (1994). Cultural competence in psychiatric mental health nursing: A conceptual model. Nursing Clinics of North America, 29(1), 1-8. Cannon, L. W., Higgenbotham, E., & Guy, R. F. (1989). Depression among women: Exploring the effects of race, class, and gender. Memphis, TN: Center for Research on Women, Memphis State University. Capers, C. F. (1994). Mental health issues and African-Americans. Nursing Clinics of North America, 29(1), 57-64. Carrington, C. H. (1979). A comparison of cognitive and analytically oriented brief treatment approaches to depression in Black women. Unpublished doctoral dissertation, University of Maryland, Baltimore. Carrington, C. H. (1980). Depression in Black women: A theoretical perspective. In L. Rodgers-Rose (Ed.), The Black woman (pp. 265-271). Beverly Hills, CA: Sage Publications. Cockerman, W. C. (1992). Sociology of mental disorder. (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall. Collins, P. H. (1991). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. (2nd ed.). New York: Routledge. Coner-Edwards, A. F., & Edwards, H. E. (1988). The Black middle class: Definition and demographics. In A.F. Coner-Edwards & J. Spurlock (Eds.), Black families in crisis: The middle class (pp. 1-13). New York: Brunner Mazel. Freud, S. (1957). Mourning and melancholia. (Standard ed., vol. 14). London: Hogarth Press. Giddings, P. (1992). The last taboo. In T. Morrison (Ed.), Race-ing justice, en-gendering power (pp. 441-465). New York: Pantheon Books. Giovanni, N. (1980). Poems by Nikki Giovanni: Cotton candy on a rainy day. New York: Morrow. Hooks, B. (1989). Talking back: Thinking feminist, thinking black. Boston, MA: South End Press. Kessler, R. C., McGongle, K. A., Zhao, S., Nelson, C. B., Hughes, H., Eshelman, S., Wittchen, H., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the U.S. Archives of General Psychiatry, 51, 8-19. Klerman, G. L. (1989). The interperson model. In J. J. Mann (Ed.), Models of depressive disorders (pp. 45-77). New York: Plenum. McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. F. (1992). Women and depression: Risk factors and treatment issues. (3rd printing). Washington, DC: American Psychological Association. Oakley, L. D. (1986). Marital status, gender role attitude, and women's report of depression. Journal of the National Black Nurses Association, 1(1), 41-51. Outlaw, F. H. (1993). Stress and coping: The influence of racism on the cognitive appraisal processing of African Americans. Issues in Mental Health Nursing, 14, 399-409. Taylor, S. E. (1992). The mental health status of Black Americans: An overview. In R. L. Braithwate & S. E. Taylor (Eds.), Health issues in the Black community (pp. 20-34). San Francisco, CA: Jossey-Bass Publishers. Tomes, E. K., Brown, A., Semenya, K., & Simpson, J. (1990). Depression in Black women of low socioeconomic status: Psychological factors and nursing diagnosis. The Journal of The National Black Nurses Association, 4(2), 37-46. Warren, B. J. (1994a). Depression in African-American women. Journal of Psychosocial Nursing, 32(3), 29-33. Warren, B. J. (1994b). The experience of depression for African-American women. In B. J. McElmurry & R. S. Parker (Eds.), Second annual review of women's health. New York:National League for Nursing Press. Woods, N. F., Lentz, M., Mitchell, E., & Oakley, L. D. (1994). Depressed mood and self-esteem in young Asian, Black, and White women in America. Health Care for Women International, 15, 243-262.

next: A Hidden Disease: In Older Blacks, Depression Often Goes Untreated
~ depression library articles
~ all articles on depression

The bipolar (also called the manic-depressive) illness, caused by as yet unknown imbalances of neurotransmitters in the brain, is know to wreak havoc with countless lives in this country and all over the world. My interest in the illness stems from the fact that my father (now deceased) had it (the illness first manifested itself when I was around fourteen or fifteen). Needless to say, it placed significant emotional burden on me and my family. In retrospect however, I realize that a lot of the pain and suffering (for us anyway) was due simply to misinformation and/or lack of information about the illness. Although things are improving, especially in the U.S. and in the western hemisphere at least, I feel that the bipolar illness (unfortunately) still remains taboo and a cause of much unnecessary suffering for the patient and for the family/caregivers involved. This website is my minuscule effort to correct this situation.

During graduate school in the late eighties, I had the privilege of meeting Dimitri Mihalas, then a distinguished professor of astronomy at the University of Illinois at Urbana-Champaign (and a member of the National Academy of Sciences). Though he suffers from the illness, he feels that he has actually "gained" instead of "losing" to it. He has also been a pioneer in attempts to increase public awareness of (and therefore decreasing the stigma associated with) the bipolar illness by the act of being completely open about it. Soon after a major, life-threatening episode of depression (which was treated successfully with medication), he set upon himself the task of composing a primer on manic-depression. Because of his openness, the primer is quite personal and many have thus found it to be useful in gauging their own experience with the illness. It also contains a great deal of useful information, particularly about the spiritual aspects of recovery, and contains a bibliography for those who want to learn more. Someone who read it described it as a "life saver" for her.

Anurag Shankar, Bloomington, Indiana, 2003

Contents in A Manic Depression Primer:

• Depression and Spiritual Growth: Introduction
• A Manic Depression Primer: Preface
• Mood Disorders as Physical Illnesses
• Treatment of Depression and Bipolar Disorder
• Suicide and Bipolar Disorder - Part II
• Impact of Mood Disorders on Victim, Family, and Friends
• Grace
• Purpose and Meaning
• Background and History: Anurag Shankar
• Love and Major Depression
• Mental Illness and Public Policy
• A Spiritual Model of Healing and Wellness
• Stigma of Having A Mental Illness
• The Role of Mystical Experience
• Why This Pamphlet?
• About the Author Dimitri Mihalas

next: Depression and Spiritual Growth: Introduction
~ bipolar disorder library
~ all bipolar disorder articles

Whites Are Far More Likely to Be Prescribed Antidepressant Drugs

Although depression is a common and troubling problem among the elderly, a July 2000 study suggests that its symptoms are being overlooked in many older black people. Elderly white people, the study found, are more than three times as likely to be prescribed anti-depressant drugs as elderly blacks.

In the July 2000 issue of the American Journal of Psychiatry, study author Dan Blazer, MD, PhD and colleagues from Duke University Medical Center in Durham, N.C., report the results of a 10 year survey of more than 4,000 people age 65 and older.

• One researcher says that part of the problem may be a reluctance on the part of black people to take antidepressants, to understand depressive symptoms, or to admit to having depression.
• Another expert says depression is often overlooked by patients and their doctors, and the symptoms are instead attributed to age-related medical conditions.

"Misconceptions of clinical depression as a weakness of character or a normal [part] of aging, rather than a treatable illness, are common," says George S. Zubenko, MD, PhD. Zubenko is a professor of psychiatry and biological sciences at the University of Pittsburgh School of Medicine.

A study that Zubenko conducted a few years ago suggested that older, depressed blacks responded better to antidepressants than whites. But further investigation found that, unlike whites with depression, the majority of blacks were never even treated for their depression until they required hospitalization.

Zubenko says that both patients and doctors may attribute signs of depression -- such as decreases in mood, interest, energy, sleep, and concentration -- to age-related medical conditions. "This contributes to the underdiagnosis of depression," he says.

next: Mental Illness and Minorities
~ depression library articles
~ all articles on depression