When a Man Loves a Woman - The true story anbout the Green family

(See also what the International Movie Database says about When a Man Loves a Woman)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

"When a Man Loves a Woman" is about a an airline pilot, Andy Garcia, and his wife, Mey Ryan and how they are forced to face the consequences of her alcoholism when her addictions threaten her life and their daughter's safety. While the wife enters detox, her husband must face the truth of his enabling behavior.

By Dr Göran Nordström, Senior Physician

When a man loves a woman

The true story about the Green family

There are scenes in Luis Mandoki’s film "When a Man Loves a Woman" which, to put it mildly, are not that convincing. Yet, it would be a pity if some of the scenes made some people switch off. The film is better than that! As it turns out, this is not so much a sickly-sweet film, but one based on an essentially tragic theme. But go and see the film first and then read this article afterwards. The film is not full of thrills, but gives us more material for us to research its various underlying themes for ourselves.

So why a Hollywood film about alcoholism? If you look through the list of films made by director Mandoki before and since "When a Man Loves a Woman", there is nothing to suggest an interest in questions of alcohol abuse or social problems in general. The fact that the film company signed up Meg Ryan (who had previously starred in the blockbuster "Sleepless in Seattle") and Andy Garcia ("The Godfather") and was also able to afford Ellen Burstyn in an important supporting role suggests this was a major venture.

This usually means that the film company is expecting a box-office hit. And this is usually tantamount to a film with a message that is neither too complicated, nor too controversial. With a dutifully charming Meg Ryan and a stylish Andy Garcia, it should of course be reasonable to produce a film with a sufficiently shocking and yet sufficiently sweet story.
Add, too, an uplifting end and it ought to be wholly in line with the standard Hollywood genre. Even if the subject matter is alcoholism.

So you should go and see the film. It is about Alice Green (Meg Ryan), who is married to the handsome and reliable pilot, Michael (Andy Garcia). She has two sweet children and lives in a beautiful house in San Francisco. Nevertheless, she drinks too much. Why? The emptiness behind the idyllic facade? Far too many lonely evenings when her pilot husband is away working? Problems she has been wrestling with dating back to her past?

Her mum's attitude towards her has never been good for her self-esteem. Her father drank. And there are other problems. Alice’s oldest daughter is from a previous relationship, and the girl’s father only gets in touch with her now and again.

The film about Alice’s path out of abuse deals with a young woman who, deeply unsure of her worth, ends up using alcohol as a means of escape. This is how alcoholics manage to keep a grip. However, there is a big risk that the alcohol will take over and that they will lose their grip. And so it was for Alice. Her husband, Michael, is possibly co-dependent – he fixes everything and, more often than not, smoothes everything out with his pleasant behaviour.

It is possible that he somehow condones her reckless behaviour when she is intoxicated. But, gradually, the problem becomes impossible to manage with the occasional extra efforts of the nanny. Alice is admitted to a rehab centre. She confronts her relationship with alcohol on the basis of the twelve-step model.

She and Michael attend counselling as a couple. Things don't go well at all. Michael has difficulty finding his role when Alice abandons her alcoholic behaviour. With the help of AA and the support of other alcoholics, Alice manages to regain her self-respect.

"The film about Alice's path out of abuse deals with a young woman who, deeply unsure of her worth, ends up using alcohol as a means of escape"

Central to the change in Alice is the fact that she becomes more serious. More competent. She stops dealing with difficult situations with a joke or her attractive smile. The final scene shows how Alice, in a humble and balanced way, talks about herself and her alcoholism in front of other AA members and their relatives. And, in actual fact, Michael, who as a result of problems in the couple's relationship temporarily moves out of the home, is also there in attendance, listening. The film ends more or less as it starts, with a tender kiss between Alice and Michael, right in the midst of the people around them.

It has a classic comedy-drama ending. Our heroes have been tested, they have changed, and are now able to embark on their future life stronger, thanks to the insights they have gained.

During their journey, we have been able to witness a lot of what the everyday reality of alcohol dependence looks like. Heavy drinking. The highs. Shame. Emotional outbursts. Relations that break down. One deception after another. And, at the same time, the alcohol abuser may come across as someone who is normal, well presented and nice. Look through the list of symptoms of dependence in ICD or DSM. Most symptoms are neatly and realistically personified in "When a Man Loves a Woman”.

The shame is even greater if you are an alcoholic and a woman. It can often be the case that specially formulated approaches are required to help women suffering from alcohol problems. Read Agneta Österling’s highly informative contribution further down! If treatment for alcohol abuse is initiated in time, there are grounds for optimism. There are good, validated methods out there - both pharmacological and psychosocial – read more about this in Lars Schultz and Bengt Sternebring’s articles!

But let’s get back to the film. The similarity between the closing scene, after Alice's speech at the meeting, and the opening scene, where they are having lunch in a café, opens up another perspective, different to the one I gave at the outset. In the opening scene, Alice and Michael are engaged in some kind of role play before a public audience. They appear as if they do not know one another. Michael strikes up a conversation with Alice and manages (so it seems to the amazed clientele in the café) to enchant Alice with his words, so much so that she instantly flings herself into his arms. And, again, in the closing scene, Michael does exactly the same thing! He has listened to Alice. He goes up to her. And then he starts to talk about his wife who is an alcoholic, but who has 600 ways of smiling which make him melt …

"The shame is even greater if you are an alcoholic and a woman"

So he talks to Alice about his wife – as if she were not one and the same person! This is the same trick used at the café where they have lunch. Like a teenage game, a secret that just the two of them share.

As the film progresses, Michael goes through various phases. As enabler, as failed family father, as potentially supplanted spouse (Alice has close contact with a man from the treatment centre, played by a young Philip Seymor Hoffman), as separated father of his children. But does he learn anything? Or is his verbal magic in the closing scene a sign that he is back where the film started?

He draws a veritable smokescreen over reality and we are led to believe that everything is well again. If you see the film from this perspective it is less clear whether Alice's and Michael's tender kiss in the closing scene is a happy ending. Does Michael actually want to have a wife who has left all her delusory antics behind her? Or is it the case that the enabler is laying the ground for a relapse?

I should think that there are many of you who will recognise aspects of Michael's behaviour in relatives or in one or more patients suffering lifestyle problems that you have come across. It is easy to feel sympathetic and to have understanding, but sometimes you nevertheless wonder whether there is anything attractive about being the stronger party.

The film about Michael shows, among other things, that the desire for change – so clearly expressed, so visibly obvious – does not always manifest itself in the way people really act. His is a more disturbing tale than the one about Alice, and a story which highlights why it is sometimes the case that the whole "family unit" – patterns of communication, the balance of power – must be included in the treatment if you really want to get anywhere.

Yet the really dark dimension to the film revolves around the daughter, Jessica. Jessica knows what to do when bottles of alcohol are thrown into the dustbin. She has seen her mum do it many a time. She has been given clips round the ear and has seen her drunken mother collapse in a mess at home.

She has had to contend with emotional outbursts out of all proportion. She has been involved in all attempts to keep the fabric of the family unit together, with overtime for the nanny. When the family does split, she receives some acid comments about her biological father from Michael. Her attempt to talk in earnest with her mother, Alice, is met virtually every time with jokes or evasion.

At an "AlAnon" meeting (an offshoot of AA, for relatives) Michael hears a woman talk about her situation as someone who is emotionally abused by her alcoholic husband. If there is someone in this film who is emotionally abused, it is Jessica. Her story is a story of a long series of deceptions and abandonment, of various kinds.

Alcohol dependence and alcohol abuse are common. Many children grow up with more or less Jessica's experiences. We may not all agree on theories about the significance of past traumas on later life. However, if and when we see children whose life is like Jessica's, then there is actually no room for theoretical niceties. Children in this situation are not doing well. Maybe there are no stock answers, no simple ways to help. Those who see what happens must, morally speaking, try to do something. As physicians, as we know, it may even be the case that we have a duty.

The strength of "When a man loves a woman" lies in the fact that it binds together the various different strands in such a convoluted way that, just as in reality in our clinics, we can end up seeing just one of the many films that are being played out at the same time.

By Dr Bengt Sternebring, Senior Physician

Brief Intervention

– treatment for patients with dangerous levels of alcohol consumption

Brief Intervention means offering therapeutic and preventative counselling for a short and limited period of time to two groups of patient in particular: those who drink too much but cannot be identified /diagnosed as alcohol abusers, and those who have established abuse, but to a low degree. This method of brief intervention can also be used as an initial approach in alcohol-dependence patients in order to gain a more in-depth insight into their problems and, if appropriate, to continue and implement the treatment started at a specialist centre (alcohol-dependence unit or similar).

Brief Intervention (BI) is a method of treatment that has been studied closely, with very good results. The scientific evaluations are clear: the method is effective for the intended patient groups. Add to this the fact that BI is simple to apply and requires relatively little time.

BI can be used to reduce the level of alcohol consumption and thereby increase what we normally call "quality of life". This means less frequent illness and fewer trips to the doctor or hospital, as well as a reduced risk of ending up with advanced abuse and dependence.

Despite the fact that this method, which is both cost and time effective, was established twenty years ago, it has been difficult (not to say impossible) for it to become accepted in Sweden.
The background to this indecision probably lies in the fact that there is resistance to the implementation of a new method for a condition which no one, apart from specialists (doctors treating dependence) sees as a priority or knows enough about.

British alcohol researcher Jonathan Chick from Edinburgh carried out the pioneering work and presented the first scientific assessments of BI. Shortly afterwards, the method began to be adopted by GPs throughout Scotland, before spreading throughout the UK and, over the years, it has been accepted across large parts of the world.

BI is thought to be a suitable method in general healthcare, especially within local integrated healthcare services and corporate healthcare, but it is of course also possible to apply it within all areas of healthcare where dangerously high levels of alcohol consumption are to be found.

The Method

BI means a structured approach on a limited scale: from one to four treatment sessions,
although this number can be increased if required. The meetings should not last for less than 15 minutes and not more than one hour. The normal length of a meeting is between 15 and 30 minutes.

The meeting and the treatment are managed by doctors who do not need to be specialists in dependence illnesses. Each member or team must agree on the structure, and this must be followed throughout the treatment period, which should span a year.

"Jonathan Chick from Edinburgh carried out the pioneering work and presented the first scientific assessments of Brief Intervention"

The basis for treatment and follow-up is formed by six key concepts, known by the acronym FRAMES:

Feed-back of Personal Risk – what are the risks of continued high levels of alcohol consumption? The patient discusses the obvious risks, which are confirmed by the therapist.

Responsibility of the Patient – to ensure that the aim of the treatment can be achieved, the patient needs to take on responsibility.

Advice to change – the therapist offers advice on how low-risk alcohol consumption might look and be achieved; alternative to complete sobriety.

Menu of Ways to reduce drinking – discuss together options and strategies for reducing alcohol consumption.

Empathic Counselling Style – therapist must have a warm, considerate and understanding attitude.

Self-efficacy or Optimism of the Patient – the patient’s self-respect needs to be boosted the whole time, and positive thinking accentuated.

As well as going through FRAMES in the four sessions, it is important to establish the target for continued alcohol consumption from the outset, everything from no alcohol at all to certain "safe" or acceptable consumption levels. This target may be set out in writing and signed or may be used as a basis for continued work.

If the target cannot be reached by adopting this approach, the patient probably has more difficult alcohol problems requiring different treatment.

Proposed diagnostics and treatment model in Brief Intervention

Visit 1: Diagnosis in accordance with ICD or DSM with the help of AUDIT
Alcohol case history
Laboratory tests (CDT, GGT, PEth)
The goal of the treatment

Visit 2: Treatment : FRAMES

Visit 3: Treatment : FRAMES

Visit 4: Treatment : FRAMES

Visit 5: Laboratory check-ups in accordance with the above (nurse)

Visit 6: Treatment (FRAMES) and conclusion with liaison if goal achieved.

A good alternative to Brief Intervention

MOTIVATIONAL INTERVIEWING

A treatment method which has its origins in England (Miller) and Norway (Rollnick) at the start of the 1990s is Motivational Interviewing (MI). This method has also proven effective in a number of scientific evaluations. MI is based on the current situation of the individual, with all that this means in terms of both positive aspects and problematic elements. Treatment, however, focuses not on the whole but draws on the ambivalence (”I want to stop, so why don’t I...”) and the inner motivation to change. The patient is supposed to achieve this themselves by using their own position in life as a starting point to help them understand the problems they have and what it is that preserves this ambivalence.

Brief training is required to be able to implement MI treatment professionally. MI can be said to contain five main strands: expression of empathy for the patient, clarification of patient discrepancies, avoidance of argumentation, rolling with resistance (ambivalence) and support for patient self efficacy.

By Lars Schultz, Senior Physician

Pharmacological treatment of alcohol dependence

Detoxification and aversion therapy

Benzodiazepines (oxazepam, diazepam and so on) are helpful in combating sweating, tremors and heart palpitations, to give but three examples. They also help prevent seizures and delirium tremens. Some benzodiazepines also affect the heart in the same way that alcohol does, so they must be used very carefully and under controlled conditions. Otherwise, there is a high risk that patients will still end up dependent.

A second drug which is commonly used in this field is chlormethiazole (Heminevrin®), a tranquiliser and sleep-inducing drug that can give rise to dependence. Both groups should be reserved for detoxification under highly controlled conditions, normally in inpatient care.

In detoxification as part of outpatient care, non-dependence-inducing, anxiety-suppressing drugs are primarily used such as alimemazine (Theralen®), hydroxyzine (Atarax®) and propiomazine (Propavan®) or, alternatively, zopiclone. The most common drugs to prevent seizures in abstinence epilepsy are various drugs containing carbamazepine.

Disulfiram (Antabus®) still has its place in the treatment of alcohol dependence, even though scientific documentation dates back a while. However, the drug has proven itself very well in clinical trials. Antabus® should never be administered without patient knowledge. The patient should also be informed of the mechanism of effect and the risks of concomitant alcohol consumption.

Treatment works best if the patient takes medicine from the care giver or another third party. It can even be started during abstinence as soon as a “nought per mille” alcohol level has been established.

Treating craving
Acamprosat (Campral®) can, in combination with other treatment measures, severely reduce the risk of relapse into alcohol dependence. The drug is administered three times a day (2+2+2), but can be stretched to twice a day just like that (3+0+3), based on the drug metabolism.

Another drug, naltrexone (ReVia®), is an opioid antagonist which also affects craving for alcohol in alcohol-dependence individuals. ReVia® is used mainly for patients where the initial “high” soon after alcohol intake is a dominant cause of abuse and loss of control. ReVia® is administered once a day.

Both drugs work best if combined with underlying cognitive psychosocial measures, but can also work with simple, limited support and motivation approaches available at care centres, for example. It is more beneficial to combine both drugs concomitantly.

Treatment with ReVia® and Campral® can also be given if the patient is not free of abuse, but it is initiated appropriately in a phase during which the patient is abstaining from alcohol intake, e.g. in conjunction with detoxification. Documentation about the effect cites a period of duration of 6 months, and any attempt at treatment should ideally span several months before the strategy is given up.

Given the scale of alcohol dependence and the documented effects of the drugs, Campral® and ReVia® are highly underused clinically. This is probably due to a combination of weak marketing by the manufacturer, inadequate training of dispensing chemists and an unwarranted negative attitude to the medical treatment of alcohol dependence in general.

Vitamin supplements
Vitamins should always be considered in the abstinence phase because alcohol-induced absorption impairments and poor nutritional status is very common. Often, Oralovite®, a multivitamin substance (B-complex + vitamin C) with a high thiamine content but without folic acid and B12, is used. It has hitherto been difficult to specify exactly which vitamins and doses are needed in the detoxification phase by referring to existing documentation. It has become more common also to give folic acid supplement in the abstinence phase.

Antidepressants and alcohol dependence
There is no clear evidence that treatment with antidepressants can prevent a relapse into alcohol abuse.
Where depression or anxiety disorders are present at the same time as alcohol dependence this should be treated with a prevalent selection of drugs and can, if effective, even improve the abuse picture indirectly. Since the clinical picture in the acute alcohol abstinence phase can highly resemble depression or anxiety disorders, doctors should - where possible - refrain from initiating drug treatment until at least one drug-free week has elapsed.

By Dr Göran Nordström, Senior Physician

Alcohol dependence and depression

In recent years, the problems of comorbidity have been observed more and more. Many studies have shown that abuse is more common among patients in primary care or in somatic healthcare than is average for the population. This is, of course, due to the fact that alcohol is a cause of sickness and ill health – everything from accidents and fractures, to liver damage, hypertension, gastritis and pancreatitis.

The picture is the same if you look at comorbidity with psychiatric symptoms. A series of studies has shown that the simultaneous presentation of depression, bipolar disorder, anxiety or schizophrenia on the one hand and abuse/dependence on the other is common. On the other hand, comorbidity has long been observed in every day life in the clinic.

A current examination (1) of general psychiatric admissions in Lund and Uppsala revealed that consumption of alcohol at risk levels was significantly more common among mental patients than among the population in general. This applied first and foremost to younger patients. In this study, it was also possible to demonstrate that brief intervention by telephone in accordance with the Motivational Interviewing method (see Bengt Sternebring’s article) could reduce drinking.

Both abuse and depression are common conditions. In general medical practice it is, therefore, not uncommon to see problems linked to the simultaneous incidence of abuse or alcohol dependence and depression.

So is it the case that the one state is the cause of the other, or should they be considered independently of one another? High levels of alcohol consumption can give rise to symptoms of depression, which normally recede spontaneously after several weeks’ sobriety or reduced consumption. However, it is also the case that the increased incidence of depression among alcohol-dependent individuals reflects an increased risk of alcohol abuse in people with primary depression disorders.

In animal models it has been possible to show that SSRIs can reduce the intake of alcohol. Today, there is no strong evidence to support the argument that this would be the position among clinical populations. Treatment with antidepressants per se has thus not been shown to correlate with reduced alcohol consumption (2, 3).

Clinical experience suggests that comorbidity can explain some of the failed treatments in patients with depression or anxiety disorders. If the abuse is not noticed and treated, there is a risk that they will not otherwise progress in the treatment of their depression. And without adequate treatment of the depression there is a risk that it becomes difficult to help patients with their drinking habits (4-8).

Competent diagnosis is important in finding the right treatment. This may mean that some patients may not be allowed to drink for several weeks, or their level of consumption must be drastically reduced. It is probably not such a good idea to give antidepressants to patients who only present symptoms of depression in the abstinence phase.

On the other hand, it is important to give adequate antidepressant treatment to patients with symptoms of actual depression, regardless of whether or not alcohol-dependence presents simultaneously. The situation is altogether too common where the case is not examined and the depression is seen as being secondary to the drinking, with the result that the patient is denied important pharmacological help against depression.

Just as with the treatment of all depression, the aim of the treatment is remission. In order to achieve this in practice, simultaneous help to combat dependence is also required, which is treated pharmacologically (acamprosat, naltrexone) and with customised psychosocial support for patients.

Possibly, the most important study into comorbidity in alcohol dependence and mental illness, not least depression, is the “NESARC study” (9). The study confirms earlier results relating to high rates of
comorbidity, but on the basis of much more comprehensive material than that used in previous studies. In their summary, the authors also drew clinically relevant conclusions that are worth citing.

"The result underlines the fact that patients whose abuse or dependence is in stable remission should not be denied treatment of affective disorders or anxiety syndromes based on the incorrect view that such conditions are often due to intoxication or abstinence. Affective disorders left untreated can lead to relapses into abuse and dependence and can also be fatal because many former abusers suffering from depression which is difficult to treat commit suicide. Regardless of the risk of such tragic consequences, affective disorders and anxiety syndromes are hugely debilitating conditions, especially among people also suffering alcohol abuse/dependence."

References

1. Öjehagen A, Persson C, Nordström G: Sekundärprevention av riskabel alkoholkonsumtion bland patienter inom psykiatrisk öppen vård. En randomiserad kontrollerad studie. Abstract presented at the Svenska Läkaresällskapets riksstämma meeting, 2005
2. Pettinati HM: Antidepressant treatment of co-occurring depression and alcohol dependence. Biol Psychiatry. 2004 Nov 15; 56 (10): 785-92
3. Torrens M, Fonseca F, Mateu G, Farre M: Efficacy of antidepressants in substance use disorders with and without comorbid depression. A systematic review and meta-analysis. Drug Alcohol Depend. 2005 Apr 4; 78 (1): 1-22
4. Moak DH, Anton RF, Latham PK, Voronin KE, Waid RL, Durazo-Arvizu R: Sertraline and cognitive behavioral therapy for depressed alcoholics: results of a placebo-controlled trial. J Clin Psychopharmacol. 2003 Dec;23(6): 553-
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5. Nunes EV, Levin FR: Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA. 2004 Apr 21;291(15): 1887-96
6. Oslin DW: Treaatment [sic] of late-life depression complicated by alcohol dependence. Am J Geriatr Psychiatry. 2005 Jun;13(6):491-500
7. Dongier M: Psychopharmacology for the clinician, What are the treatment options for comorbid alcohol abuse and depressive disorders? Rev Psychiatr Neurosci. 2005;30(3):224
8. Sullivan LE, Fiellin DA, O’Connor PG: The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med. 2005 Apr; 118(4):330-41
9. Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, Pickering RP, Kaplan K: Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. Results from the National
   Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004 Aug;61: 807-816

By Agneta Österling, Specialist in General Psychiatry

From a woman’s point of view

Consumption
Total alcohol consumption has increased by a good 30% since the end of the 1990s. Among younger people, alcohol consumption in boys has fallen in the past five years, whilst consumption among girls has increased successively since the end of the 1980s. The gap between boys and girls is less than it was in the past, and the trend towards binge-drinking has been noted.

The latter is a risk factor in the development of alcohol dependence.
Young women drink less than young men and a consumption peak is observed in the 20-25 year age group, when consumption among men is twice that of women. Thereafter, consumption gradually tails off with age in men, but the drop for women is significantly less pronounced and does not become clear until the 50s age bracket.

In parallel with the increased alcohol consumption, an increased rate of alcohol-related traffic accidents and mortality in both men and women is observed. However, the number of incidents of people being found drunk in charge, suspected breaches of drink-driving laws and the level of hospitalisation/ medical care for alcohol abuse in institutions/ as inpatients has, along with alcohol-related deaths, increased by a relatively higher rate among women in the 2000s, meaning that the gap between the sexes has narrowed.

Alcohol abuse/dependence

In a study of all 42-year olds in Malmö who took part in a health survey in
1981, alcohol problems were observed in 4.6% of women and 15.5% of men at some time in their life (men: women; 3.3). Roughly half had suffered alcohol abuse/ dependence. In an American population study in 2001- 2002, a 12-month prevalence of alcohol abuse/ dependence was observed in 12.25% of men and 4.87% of women (men: women 2.5). Serious alcohol problems are thus still more common in men, but the gap has narrowed.

Mental comorbidity

Women with alcohol dependence have a lifetime prevalence of other mental disorders, in particular depression and anxiety syndrome. Mental comorbidity (lifetime prevalence) occurs in 66% of women and 45% of men with alcohol dependence. It is more common among women for other mental disorders to begin prior to alcohol dependence. Anxiety and symptoms of depression can be seen as risk factors and warrant an in-depth "alcohol case history" in patients suffering such complaints.

In both international and Swedish studies, a link between sexual violations (in children or in later life) and the subsequent development of alcohol abuse, depression and anxiety syndromes in women has been successfully substantiated.

”It is more common among women for other mental disorders to begin prior to alcohol dependence.”

Somatic complications of high-level alcohol consumption are different in men and in women in terms of certain organ damage. The reasons behind this are not entirely clear. The distribution of fat/muscle mass in women leads to relatively less water in the body (in which alcohol is released) compared with men.

Women, therefore, will have a higher alcohol content in their blood if they consume the same volume of alcohol as men. A lower content of alcohol dehydrogenase in the stomach (especially in female abusers), differences in the rate of elimination of alcohol in the liver and fluctuations in female sex hormones have been studied and judged to be significant.

However, even if you take account of physiological differences between the sexes (different levels of high consumption between the sexes, where that of women is 33% lower than that of men) it is thought that women are more prone to alcohol-related liver and cardiovascular disease and to CNS influences compared with men. Women suffering alcohol abuse are more likely to develop chronic alcohol-related liver disease and myopathy (both of skeletal muscles and heart muscle) than male alcohol abusers.

This even happens after a shorter consumption period where smaller quantities than those consumed by men are drunk. This is known as the "telescope effect". It is also thought that women with alcohol abuse are more easily affected by structural and functional defects in the heart (measured by CT, MR and neuropsychological test methods) compared with male alcohol abusers presenting a similar telescope effect.

Alcohol and health

Extensive longitudinal studies from the USA have shown that alcohol in moderate quantities has a cardioprotective effect compared with people who are teetotal. It should, however, be pointed out that the reduced risk of cardio-vascular incidents applied above all to post menopausal (55+) women. In the same studies, however, it was also observed that this same alcohol consumption is associated with an increased risk of breast cancer.

It is important that the level of alcohol consumption designed to promote health is worked out on the basis of careful medical assessment, where any positive effects have to be weighed against risks.

Alcohol and pregnancy

when a women in her fertile years plans to have a family and become pregnant, her normal level of alcohol consumption can possibly no longer be seen as risk-free. Many women are now giving birth at the age of 28-30, by which time they have already established alcohol habits over many years, with many finding it difficult to change their ways.

In a study of maternity healthcare in Stockholm it was found that 30% of women continued to consume alcohol regularly during pregnancy. In the event of extensive alcohol consumption during the bulk of the pregnancy there is a high risk of the child developing foetal alcohol syndrome (FAS). This includes facial deformities, mental retardation and growth inhibition (pre- and post-natal) and is the most common cause of non-hereditary heart damage in children in the western world, but which is also entirely preventable.

Exposure to alcohol in the womb can also give rise to other physical deformities or neurodevelopment damage without the characteristic facial deformities. There are also studies which show that even regular, low-level consumption of approx. 10 g alcohol per day during pregnancy can mean an increased incidence of miscarriage, growth inhibition and damage to the growing brain, with cognitive and behavioural disorders.

Intensive consumption, where five or more drinks are consumed at every drinking session and a high ppm content is reached in a short period of time, have demonstrated damage to development of the brain in animal experiments.

"Alcohol and pregnancy"

So it is essential to map out not just consumption levels, but also drinking rates and drinking patterns. There is no good evidence to suggest that consumption during pregnancy is risk-free, which is why the message from the maternity care professionals in Sweden (as in the USA) is that pregnancy should be entirely alcohol-free. The same goes for drugs.

If alcohol is consumed during pregnancy, brief counselling or other preventive approaches (secondary intervention) can be applied in the first instance, with the aim of bringing about total abstinence for the remainder of the pregnancy. There is evidence of such measures, especially within primary care. Certain training in screening and Intervention methods is necessary, however.

If brief intervention is not successful or the pregnant women is suffering severe alcohol abuse/dependence then multidisciplinary treatment approaches should be selected to ensure adequate maternity healthcare, gynaecological/obstetrics follow-up, abuse treatment and social-services support. Inpatient or institutional care may be relevant as a continued form of support after childbirth.

Intervention and treatment

In the SBU report "Behandling av alkohol- och narkotikaproblem" from 2001 ("Treatment of drug and alcohol problems"), sex-related effects were discussed. It was noted in purely general terms in long-term follow-ups that women who undergo treatment have a better prognosis than men. In surveys into the natural course of alcohol dependence, there were no differences between the sexes, however.

Secondary intervention is effective for women with alcohol problems and, in certain studies, sometimes to a higher degree than for men. In a Swedish study into treatment for women with past alcohol problems, a specialist women’s unit was compared with a traditional mixed-sex treatment approach. The women's unit produced better results.

For women with complex mental disorders and experience of violations against them, complementary treatment /support beyond the actual treatment of the abuse per se is an issue which should ideally be dealt with within a single-sex treatment environment.

Useful reading

• Drogutvecklingen i Sverige Rapport 2005, Centralförbundet för alkohol- and narkotikaupplysning
• Behandling av alkohol- and narkotikaproblem. En evidensbaserad kunskapssammanställning. SBU 2001
• Gunzerath L et al . National Institute on Alcohol Abuse and Alcoholism Report on Moderate Drinking. Alcoholism Clin Exp Res 2004:28:829-847
• Österling, A. Gravid och missbrukare ss 95-107 i Antologi Könsperspektiv på missbruk. Leissner T, Hedin U-C (red) Bokförlaget Bjurner och Bruno AB 2001
• Heilig, M. Den värnlösa patienten: Alkohol som fosterskadande medel ss 53-57 i Beroendetillstånd (Studentlitteratur) 2004
• Göransson, M. Alcohol consumption during pregnancy: How do we separate myth from reality? Akademisk avhandling, Stockholm 2004. Karolinska University Press.

Web
www.niaaa.nih.gov/publications; Women and Alcohol: An Update Volume 26, Number 4, 2002
10th Special Report to the US Congress on Alcohol and Health