Health effects of binge drinking

In Canada, a "drink" or a "standard drink", as a unit of alcohol consumption, refers to a drink containing 13.6 grams of ethanol.  This amount is present in a 12-ounce (355 mL) beer, or a 5-ounce (146 mL) glass of wine, or a 1.5 ounce (44 mL) shot of hard liquor such as whiskey or vodka.  Reference: *

Binge drinking is defined as having 5 or more drinks on one occasion for men; or 4 or more drinks on one occasion for women.  This pattern of consuming alcohol is a common cultural habit, with historic roots going back thousands of years.

There are various sources of epidemiologic evidence that light drinking may have health benefits.  My review of the evidence suggests that the cut-off point for this would be no more than 2 drinks per 24 hours, with any episodes of greater alcohol consumption conferring a substantial health risk (both physical and psychiatric).

When it comes to binge drinking, I believe the health risks are very high.  The immediate risks have to do with accidents & injuries, which are much more likely during a binge drinking episode.  This risk also affects other people, such as passengers in a car or other drivers on the road.

In my opinion, the psychiatric risks of binge drinking can be divided into several categories:

1) Simple addiction.  If heavy intoxication is associated with pleasure or relief, this may easily become an addictive process, such that relief or pleasure may only come with intoxication.  As a result, other activities not involving intoxication become more subjectively boring and more prone to induce dysphoria rather than pleasure.   I call this the "greying of the sky" phenomenon.  The sky becomes less and less blue--figuratively speaking-- the more one repeats an addictive behaviour.  It is so gradual as to often be unnoticable, until years later one may have the realization that the simple pleasure of gazing at the blue sky is no longer available. 

2) Subcultural effect.  In conjunction with simple addiction, binge drinking is likely to affect one's social network, such that one's friends will more likely also be binge drinkers.  This makes it more difficult to leave the behaviour behind, since it would involve leaving one's social network.  Also the subcultural effect tends to cause a subjective normalization of the behaviour, such that people could actually feel abnormal if they cut back or stopped binge drinking.  Heavy drinking and its associated behaviour are a regular source of humour in our culture, which unfortunately may be another normalizing influence for those who are addicted. 

3) Direct pharmacological effects during intoxication and withdrawal.  Aside from the obvious effects during intoxication, I observe that binge drinking often leads to "mini-withdrawals" afterwards.  While many people may normalize their once-weekly alcohol binge, they may not realize that the withdrawal effects during the rest of the week cause impaired sleep quality and heightened anxiety.  Many young people are very resilient, so this may not be a problem, but if there is already a progressing problem with anxiety, depression, or other causes for insomnia, then binge drinking will make these problems much more difficult to treat.   I believe that the presence of binge-drinking behaviour makes antidepressant treatment much less likely to be successful.

My recommendation is never to binge drink.  More than 2 drinks per 24 hours is harmful, causing adverse short-term and long-term health effects in all cases.  If binge drinking is a significant part of recreational culture for any individual, then therapeutic work needs to be done not only to cut back on alcohol consumption, but to build a healthier cultural life, and probably a healthier social network.   

Here is a review of some of the research literature on the subject:


http://www.ncbi.nlm.nih.gov/pubmed/21345624
binge drinkers have double the rates of depression; reductions of drinking subsequently associated with reduced depressive symptoms.


http://www.ncbi.nlm.nih.gov/pubmed/20858964
This is a very strong 2010 prospective twin study, showing that binge drinkers have double the risk of cognitive impairment (dementia); light drinkers have the lowest risk; abstainers in the middle.   High alcohol intake is clearly a strong risk factor for dementia; binge drinking is a risk factor independent of total alcohol intake. That is, even if you don't drink a large volume of alcohol in a month, if you ever binge drink you will still be in a high risk group. 

http://www.ncbi.nlm.nih.gov/pubmed/19556525
prospective study showing increased strokes and overall mortality in binge drinkers

http://www.ncbi.nlm.nih.gov/pubmed/19438420
Current binge drinking associated with increased depression 5 years later. This was strong data with a good effort to control for confounding factors. Heavy intoxications at least once a month, especially with associated phenomena (e.g. blackouts, hangovers), were associated with double to fourfold increases in hospitalizations due to depression. 


http://www.ncbi.nlm.nih.gov/pubmed/19144978
binge drinking a stronger predictor of social harms (e.g. violence, loss of relationships) than total alcohol volume


http://www.ncbi.nlm.nih.gov/pubmed/21294995
2011, large epidemiologic study.  16% of men over 50 met criteria for binge drinking, 6% of women over 50.   Binge drinking behaviour strongly correlated with alcohol dependence (alcoholism). 


http://www.ncbi.nlm.nih.gov/pubmed/20930706?dopt=Abstract
another major prevalence study

http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a22.htm
a concise review from the Centers for Disease Control and Prevention.  Prevalence of binge drinking at least 20% for men, 10% for women; rates were higher still for young adults. 


http://www.ncbi.nlm.nih.gov/pubmed/19538908
this study shows even higher binge drinking prevalences for college students; 40% of this population engaging in binge drinking in a one month period.

http://www.ncbi.nlm.nih.gov/pubmed/20407040
This is a very nice 2010 review article and discussion from JAMA , about the health impacts of alcohol consumption, particularly the question of whether light drinking might protect against cardiovascular disease.  In the particular case discussion, it is concluded that light drinking could have a small but insignificant positive health impact, and it would be more a lifestyle choice than one rationally motivated by health variables.  For other individuals, any drinking at all could confer substantial health risks (e.g. those with severe addictive disorders, high sensitivity to negative side-effects of alcohol, various medical diseases).  Reasonable warnings are included, such as never to drink while pregnant, before driving, etc.

Vitamin B12

A reader recently sent in a comment wondering about the possible role of vitamin B12 supplementation in psychiatry.

Here's a brief review of the literature:
http://www.ncbi.nlm.nih.gov/pubmed/21191533     --a small case report of b12-deficient individuals responding better to antidepressants after b12 supplementation.

http://www.ncbi.nlm.nih.gov/pubmed/20976769
--survivors of stroke who took folic acid 2mg/d, b6 25 mg/d, and b12 0.5 mg/d had slightly lower rates of depression; there was an impressive 7 year follow-up period


http://www.ncbi.nlm.nih.gov/pubmed/20716710
this cross-sectional study using a diet questionnaire found an association between dietary folate & b6 and lower rates of depression in a sample of over 6000 adolescents; no association was found regarding b12.  

http://www.ncbi.nlm.nih.gov/pubmed/20519557
a study from the American Journal of Clinical Nutrition, which showed a relationship between higher folate and b12 levels, and lower rates of depression, over 7 years of follow-up.

http://www.ncbi.nlm.nih.gov/pubmed/19175490 
another study finding an association between low b12 & folate levels and higher rates of depression.  Here, the b12 association was specifically for women. Looking more closely at the data, I find that the results are not overwhelmingly strong or convincing; I suspect there could be many confounding factors influencing the association.

http://www.ncbi.nlm.nih.gov/pubmed/18854539
this is an important study from JAMA showing that high dose folate, b6, and b12 supplements did not improve the course of dementia.  Furthermore, 28% of the vitamin group experienced depression, compared to  18% of the placebo group.

http://www.ncbi.nlm.nih.gov/pubmed/18557664this study from the Journal of Clinical Psychiatry showed very little protective effect of vitamin b6, b12, and folate supplementation to prevent depression in older men.  However, I see the vitamin group did slightly better than the placebo group, but not well enough to meet criteria for statistical significance.


In summary, there is a little bit of evidence of benefits from b12 in psychiatry, but the results are not overwhelmingly strong unless there is evidence of deficiency.  It is worthwhile to have B12 levels checked.  It appears not to be dangerous to take supplements; I suppose it is reasonable to aim for the higher part of the recommended serum levels, and to adjust any supplementation accordingly.  Having said that, I acknowledge the possibility that some individuals may have a more beneficial effect from b12 supplementation, perhaps there could be selected cases in which this could act synergistically or as an augmentation with other treatments for depression, or perhaps there could be cases of subtle deficiency.

B12 deficiency is not uncommon; this can occur due to malabsorption (as in pernicious anemia or bowel disease), or due to dietary deficiency (e.g. in vegans).  If the cause of low b12 is malabsorption, is may be necessary to have b12 injections.  Once again, it is important to have b12 levels checked, and make decisions about supplementation if the level is low.

Looking at affected body parts reduces pain

Here's an interesting little study showing that acute physical pain is diminished in intensity when one is looking at the affected body part;   if this body part is artificially made to look larger, then the subjective pain is reduced even further. 
http://www.ncbi.nlm.nih.gov/pubmed/21303990

 In applying this type of idea to psychological pain, I guess one could say that "looking at the affected body part" could translate to discussing the problem in a therapeutic dialog. 

A limitation of the study, and with pain studies in general, is that a brief intervention for an acute pain may not necessarily be equivalently helpful as a prolonged intervention for a chronic pain.  In fact, some effective physical treatments for acute pain potentially exacerbate a chronic or recurrent pain disorder (e.g. using opiates to treat mechanical back pain or migraine). 

However, I believe that studies of this type do illustrate that simple, brief psychological techniques can be surprisingly powerful in modulating perceptions or sensation.  

Working memory exercises for treating addictions?

Here's a link to an interesting article from Biological Psychiatry this month:
http://www.ncbi.nlm.nih.gov/pubmed/20965498

It is based on the notion that the decision to engage in an addiction is often made based on a short-term, possibly impulsive, analysis of benefits and risks; consequently, longer-term risks or benefits associated with the behaviour are undervalued.  This phenomenon is termed "delay discounting."   Resistance to delay discounting could be considered a cognitive faculty that would help, on an intellectual level, with making a healthy decision in the face of strong impulses in the moment.

The authors note a relationship between addictive disorders and increased delay discounting.  They also note a previously described relationship between delay discounting and reduced working memory function. 

Based on these relationships, they did a controlled study of persons with stimulant addiction, in which the active group did a set of memory training exercises for 1-2 months. They found that the memory exercises led to improved (reduced) delay discounting.


This study does not show that memory exercises directly improve the course of addictive disorders; but it does present a promising therapeutic idea which I think is currently underutilized in the therapeutic community, not only for addictions but for other types of problems.

Cognitive exercises could have a variety of benefits for various psychological problems:
1) the improvement one would see with practice could help with self-esteem
2) arguably, the exercises would favourably alter the balance between executive function and visceral, limbic emotional drives (which could often be turbulent or disruptive)
3) the exercises could be an introduction to the various mental and physical disciplines required to effect psychological or behavioural change

In terms of the specific exercises used in this study, I do think that the number of practice sessions was far too small.  I believe that most psychologically beneficial activities start to show substantial results after 50-100 hours of practice.  This study  used only a maximum of 15 training sessions.  The memory practice itself could have been organized in a more engaging, game-like manner.  I think of some quite unique working memory games from the lumosity.com website, which tap into a type of activity most people would rarely work on directly, but yet are quite entertaining and allow gradual progress.

In summary, this was an interesting article looking at the promising theme of using cognitive training exercises as part of the  treatment of  a psychological problem.  This is a relatively new idea, showing up only a few other times so far in the research literature.

Omega-3 deficiency and low dietary omega-3 to omega-6 ratio may exacerbate depression and reduce neuroplasticity

Here's an interesting update on the dietary fatty acid issue, as it pertains to mood disorders and neuroplasticity:
http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2736.html

This article, published in Nature Neuroscience (January 30, 2011), is an example of some good research being done by a group at the University of Bordeaux in France.  They demonstrate substantial negative neurophysiological changes in mice as a result of an omega-3 deficient diet.  It is interesting to note that the brain's endocanniboid system is specifically affected by omega-3 deficiency, according to this research.

This is further evidence supporting the importance of attending to a healthy diet, in maintaining optimal mental health.  Omega-3 fatty acids are one element of a healthy diet.  While omega-6 fatty acids are also needed in the diet, these lipids behave to some degree competitively with omega-3.  Therefore,  the ratio of dietary omega-3 to omega-6 is is very important.  Western diets tend to have an unhealthy ratio of these lipids, due to excessive omega-6. 

An ongoing issue of debate has to do with whether plant sources of omega-3 (primarily ALA) are as useful as fish sources (DHA and EPA).  Existing evidence shows that DHA and EPA are more important.  ALA can be converted in the body to DHA and EPA, but the efficiency of this may vary from person to person.

Wikipedia has a nice review of this subject: http://en.wikipedia.org/wiki/Omega-3_fatty_acid
but some of the sources are less than ideal.

It is interesting to consider that the DHA/EPA issue is not a "micronutrient" issue.  They could be considered  "macronutrients."  The solid mass of the brain consists mostly of lipids (60-80 % of the non-aqueous mass); DHA and EPA  make up over 10% of this lipid mass, which is a very high concentration.


Here's a link to a paper which quantifies the  high fractions of omega-3 lipids in brain mass:
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=921064   --this paper also showed that dietary changes substantially altered the proportion of omega-3 lipids in brain tissue