Review and Evaluation of Current Drug Therapies in Alcoholism

KEITH S. DITMAN

This article reviews the current status of psychotropic drugs in the treatment of alcoholism and discusses the difficulties in assessing any treatment in light of the poor understanding of the condition. Phenothiazine tranquilizers, antidepressants, anorexiants, sedatives, antidipsotropics, and hallucinogens are discussed through a review of the literature and in reporting present clinical and experimental studies.

RUGS are frequently used in the treat- there is a single entity that should be D ment of alcoholism. Hayman and labeled "alcoholism." Here, where we are Ditman (in press) surveyed the psychiatrists considering drugs in the treatment of the of southern California on their use of drugs alcoholic, alcoholism would best be viewed and found that alcoholism was the second as chronic excessive drinking symptomatic most frequent condition in which psycho- of an underlying disorder in the individual, analysts use drugs, and the third most fre- be it psychological, emotional, or physio- quent in which general psychiatrists use logical. Most psychiatrists and therapists see them. Drugs were used more frequently emotional problems in the alcoholic, view for schizophrenia and depression. Of the these as chronic, even lifelong, and see the psychoanalysts responding, 57% said they drinking behavior as not only stemming used drugs in the treatment of alcoholism from these problems but as adding to them. by classical psychoanalysis, and 85% said The relationship between the drinking and they used them in psychoanalytic psycho- the underlying problems is admittedly therapy. The numbers for the general poorly understood. However, many alco- psychiatrists were higher: 81% used drugs holics report that they feel anxious, tense, with intensive and 87% with supportive lonely, irritable, frustrated, hopeless, in- psychotherapy of alcoholism. Family phy- ferior, depressed, etc., and that they drink sicians use drugs even more frequently. when they become more upset as alcohol Why are drugs used so often? First, let relieves them temporarily, although they us consider what alcoholism is. Various generally feel better when they are "not assessments have been made of the causes drinking." Thus, it makes sense to view underlying chronic excessive drinking but alcoholic bouts as possibly precipitated by there is no certainty of the correct answer emotional upsets in emotionally disturbed and certainly in our present state of knowl- individuals, and to attempt to treat these edge there is no reason to conclude that underlying disturbances. The assumption KF.lrH s. DITMAN,M.D.: Alcoholism Research that drugs could contribute significantly to Clinic, Department of Psychiatry, University of the treatment of the alcoholic is based on California. Los Angeles, Health Science Center, Los Angeles, Calif. the above view of underlying problems and the fact that psychotropic drugs affect Reprinted from Psychosomatic Medicine, Vol. XXVIII, moods, thought processes, perception, and , o. 4. Part II, j uly-August 1966 :N~ CURRENT DRUG THf.RAPIES IN ALCOHOLISM 249 behavior. They are reported effective in treatment of such symptoms as anxiety and depression, as well as many symptoms com- "... the behavior of the alcoholic mon to the psychoses. is frequently unreliable. His The question is, how warranted is the accounts of his own conduct are belief that drugs are effective in treating alcoholics? It is well known that, when often grossly distorted and treating psychiatric conditions, it is diffi- frequently he fails to follow cult to differentiate between effects of drugs through with treatment." and those of the doctor-patient relationship. Also, the behavior of the alcoholic is frequently unreliable. His accounts of his own blind procedure and other controls in simi- conduct are often grossly distorted and fre- lar treatment settings. quently he fails to follow through with treatment. Most physicians, including psy- The Phenothiazines chiatrists, as Hayman (1956) has shown, view alcoholics as poor treatment risks. The phenothiazine tranquilizers have One aspect of this unreliabiIity, however been established as the most important -a notorious tendency of alcoholics to drugs in the treatment of the psychoses. drop out of treatment, regardless of type Cole et al. (1965) reviewed the controlled -can be used for treatment evaluation. studies of these drugs in the treatment More will be said on this later. of psychosis.Many of the studies they re- Most drugs given to alcoholics by physi- viewed reported significant drug effects on cians are given in the office setting. A most of the rated symptoms of schizo- doctor-patient relationship is established phrenia, except for those of anxiety-ten- and the patient presents his complaints for sion-agitation and depression, which were treatment. Almost always these include relatively unresponsive. The effect of these complaints about how he feels. In our drugs on drinking in the schizophrenic was studies we have attempted to determine not determined.Although such findings do the value of giving various mood-changing not necessarily support the idea that these drugs, and their effects upon the alcoholic's drugs would be helpful to the alcoholic, behavior and complaints, by the use of one would consider what value they might weekly evaluational interviews and forms, have as a treatment in maintaining sobriety one filled out by the patient and one filled and decreasing mood systems. Other less- out jointly by a research assistant and the well-controlled studies have reported that psychiatrist. A description of this proce- the phenothiazines have decreased anxiety dure, and forms in facsimile, have been in neurotics and alcoholics and might thus published previously. (Ditman 1961, Dit- help the alcoholic. However, Heilizer (1960) man & Cohen 1959) These forms or rating reviews five studies that had some measure scales were attempts to quantify certain of acceptable design where neurotics were aspects of the patient's behavior and feel- treated with chlorpromazine. He states: ings and to determine any changes follow- "No significant differences were found being drug or placebo treatment. We studied tween chlorpromazine and placebo on a a number of drugs in this fashion and variety of evaluative procedures ... there what follows is an over-view of our findings, is no evidence of a chlorpromazine effect plus those of others, using the double- with neurotic patients." 250 KEITH S. DITMAN

Since little acceptable evidence is avail- with the use of these drugs in treating de- able on the use of phenothiazines in chronic pression, there are a number of non con- alcoholism, one might hold the opinion trolled studies claiming they have value for from the evidence on the use of these drugs the chronic alcoholic. However, these in neurotics, as summarized by Heilizer, claims are not supported by well-controlled, that they would be of no help. We have double-blind studies. In fact, Kimbell et al., looked at a number of phenothiazines in (1965) reviewing their studies of the use of chronic alcoholics and our views of their antidepressant drugs in depressed patients, value can be summarized by the results of have raised questions regarding the drugs' the following two studies. efficacy and specificity. In one double-blind study,Cohen et at. Shaffer and co-workers (1962) at the (1954) treated 158 outpatient skid-row al- Spring Grove State Hospital undertook a coholics with trifluoperazine, (2-8 mg. per double-blind study of nialamide or placebo day) or a placebo. As compared to the in the treatment of 85 alcoholics. After 30 placebo-treated group, the drug-treated days, the over-all improvement was the group reported an increase in physical en- same in both groups. Thus no clear bene- ergy, a decrease in mental alertness, and no ficial effect from nialamide could be dem- improvement in drinking pattern. On all onstrated. other symptoms rated, no drug or placebo In Alberta, Canada,Ramsay and co-work- differences were found. ers (1964) treated in a controlled study 211 In a double-blind, placebo-controlled outpatient alcoholics with the combination study with thioridazine, Ditman (1961) of I mg. of trifluoperazine and 10 mg. of found the drug no more effective than the tranylcypromine, a placebo, or no drug. placebo in influencing the return rate of The number of returns in a month for alcoholic outpatients.Although thiorida- group or individual therapy was the cri- zine did not show any significant advan- terion of benefit. There was no significant tage over the placebo, patients with more difference in the attendance of the groups, severe complaints who received the placebo and the idea that an antidepressant drug were less likely to return than were those would help to decrease the drop-out rate who received the drug. In addition, pa- or would help a patient to increase atten- tients who rated themselves as hostile, ir- dance at therapy sessions was not substan- ritable, unsociable, and lonely were less tiated. likely to return if given the placebo. - In a double-blind study, Ditman (1961) From this and other studies using tran- treated 116 alcoholic outpatients with imi- quilizers of the phenothiazine group, it is pramine and 79 with a placebo. The two our impression that this type of drug has groups were apparently adequately matched some value in the treatment of symptoms since comparison of items on a form filled due to acute alcohol withdrawal, but is of out at the initial interviews revealed no little or no value in the treatment of the significant differences between them. No usual alcoholic who does not have with- significant differences were found between drawal symptoms or, in addition to his the drop-out rates of the drug and placebo alcoholism, symptoms of a psychosis. groups. Only 60% of the entire sample re- turned for the second week of treatment. The Antidepressants However, when the drug and placebo What is the value of the antidepressant groups were split into two further groups drugs in treating the chronic alcoholic? As -those who showed signs of alcohol with- CURRENT DRUG THERAPIES IN ALCOHOLISM 251 drawal and those who had not been drinking at the time of the initial visit-there was a difference in return rates between "Wequestion that the those given imipramine and those given antidepressants are of any value placebos.Those who had been drinking for treatment unless the alcoholic were more likely to return if given the is in withdrawal or suffering an drug, while those who had not been drink- acute depression with ing were more likely to return if given the placebo. Using the two-sample Kolmogorov- psychomotor slowing and Smirnov test, the significance of this differ- morbid feelings .. ." ence was .001. Nondrinking patients who expressed a craving for alcohol were even less likely to return if given the drug. the physicians as having more morbid ex- These data indicate that imipramine pressions, deeper depressions, less energy, may have some adverse effect on the al- and greater impairment of thinking. While coholic unless he has withdrawal symptoms. none of the alcoholics showed any evidence This adverse effect may be the atropine- of psychomotor slowing, many of the other like side effects of the drug, which were depressed patients did. The nonalcoholics frequent in this group. At the end of one generally responded to imipramine treat- week of treatment, 43% of drug-treated ment after 3 to 4 weeks. The differences be- patients, but only 15% of placebo-treated tween these patients on questionnaire items patients, reported side effects. Analysis of and in results of imipramine treatment sug- the items on the questionnaires did not re- gest that there were quantitative and quali- veal any other basis for this difference in tative differences between the depressions response. of the alcoholic and nonalcoholic patients. The above study was based on the hy- The depression of the alcoholics seems mild pothesis that the depressed mood that al- and chronic, that of the others more severe coholics frequently report might respond and acute. to an antidepressant drug. The results of Although we are impressed that many this brief study, however, do not support alcoholics are depressed, we question that this hypothesis. The reason for the favor- the antidepressants are of any value for able effect of imipramine on the return rate treatment unless the alcoholic is in with- of alcoholics showing withdrawal symptoms drawal or suffering an acute depression has not been determined. However, de- with psychomotor slowing and morbid feel- pression has been reported as a prominent ings and expression in addition to his al- symptom in alcohol withdrawal. coholism. A group of nonalcoholic depressed pa- The Anorexigenics tients was also treated with imipramine and compared with the alcoholics who re- Diethylpropion was studied (Ditman ceived the drug. These two groups were 1961) to determine whether an anorexigenic difficult to distinguish when just the patient- agent might have some damping effect on rated questionnaires were compared, al- the alcoholic's drinking, craving for although there was a tendency for the non- cohol, smoking, or eating. There were no alcoholic patients to feel more unsociable significant differences in the drug- and and complain of a more unsatisfactory sex placebo-treated groups in the first three life. The non alcoholics were described by areas mentioned, but patients taking the 252 KEITH S. ntTM AN

drug were less likely to gain weight than chosen for study because it was reported ef- those taking the placebo. This difference fective against anxiety, fear, tension, and was particularly true of those who were symptoms of alcohol withdrawal. It was the told that the drug might cause loss of ap- most effective drug of any studied in getting petite. Patients given the drug were less patients to return for treatment. It was likely to return than those given the equally effective with both skid-row and placebo. The results indicate little promise white-collar subjects, regardless of whether in treating alcoholics with anorexigenic they showed signs of alcohol withdrawal agents. at the initial interview. Analysis of the various items on the patients' question- The Sedatives naires gave no indication of why this was so. The physicians' ratings, however, Much has been written on the use and showed more improvement in drug-treated dangers of the various sedatives in treat- than in placebo-treated patients. It is not ing the alcoholic. Many reports in the lit- known how the physicians were able to erature from non controlled studies indi- discriminate between the drug and the cate that sedatives have value in decreasing placebo treatments. They may have been anxiety and the likelihood of the alcoho- guided by frequent statements by patients lic's drinking. The opinion is common also about having a feeling of well-being from that they may be misused by the alcoholic the drug. These statements, however, did and that he may become addicted to them. not find their way into the self-ratings on The view that it is unlikely that a sedative the patients' questionnaires. On the other would help the alcoholic is based on the hand, the physicians may have been influ- following: these drugs may impair but not enced in their ratings by the fact that there enhance intellectual functioning, there is were more side effects from the drug than no evidence to support the belief that the from the placebo. drugs treat the underlying problem of alcoholism, and the use of the sedative-drug When drug-treated patients whom the alcohol has set a poor precedent. Certainly, physicians rated as improved were com- there are no well-controlled studies to sup- pared with drug-treated patients rated as port their use other than in temporary not improved, it was found that the im- symptomatic treatment. proved patients had rated themselves as In the past few years a new chemical more unsociable, shaky, worried, shy, and group of sedatives, the benzodiazepines, has fearful at the start of treatment. It was also reportedly been very useful in treating the noted that skid-row alcoholics who were alcoholic. The claims for these drugs are given the drug rated themselves more im- based on the reports that they decrease proved after the first week of treatment anxiety and aggression without impairing than did those who received the placebo. intellectual or motor functioning and, even This initial advantage over the placebo was in high dosages, do not impair respiration. lost in subsequent weeks, however. This study seems to indicate that chlordiazepoxide may have some usefulness ini- Chlordiazepoxide tially in brief symptomatic treatment of Mooney et al. (1961) did a controlled the alcoholic and in getting him to return double-blind study of chlordiazepoxide for further treatment. Also, the clinical with 214 outpatient alcoholics, half of impression drawn from a number of in- whom received a placebo. This drug was terviews with patients taking chlordiaze- CURRENTDRtJG THFRAPIES II ALCOHOLISM 253 poxide was that the drug gave some al- Chlordiazepoxide Analogues coholic outpatients a sense of well-being Recently some analogues of chlordiaze- and freedom from tension, but this was of poxide, LA-I (Magadan), and diazepam short duration, a few weeks in most in- have been developed, which in animals ap- stances, The following brief case summary pear to be more potent tranquilizers. LA-I gives an example of one such patient. has the curious effect in animals of produc- LL, a 50-year-old white married sales- ing locomotor stimulation concomitant man, drank throughout the day and eve- ning because, he said,"It quieted an inner with muscle-relaxant, anticonvulsant, and restlessness and made me feel I was more aggression-inhibiting effects. It is reported out-going and functioning better." A num- that diazepam is more potent than chlor- ber of medications were tried and chlordiazepoxide was his preference. In various diazepoxide as a muscle relaxant, and as studies he had shown little indication of an anticonvulsant in tests with strychnine, being a "placebo reactor." He was switched pentamethylentetrazol, or electroshock con- back and forth five times from chlordiazepoxide to placebo, and always reported vulsions in mice and cats. feeling better, less restless, and more out- In a double-blind study a total of 379 going when taking the drug. After taking outpatient alcoholics were treated by Dit- 100 mg. of chlordiazepoxide daily for nearly 4 months, medication was stopped. man et al (1964).The treatment was as- He reacted to this by starting to drink signed randomly. After three weeks on the again on the same day. No withdrawal first treatment, each patient was then effects from the medication had had time to develop. A week after the drug was placed on a placebo-known to the phy- discontinued, he no longer had the sense sician only. One week later he was again of well-being and freedom from restlessness randomly assigned one of the three re- that he had had while taking the drug. maining treatments. In this fashion he was Shaffer et al. (1963) treated 199 hospital- carried through the three drugs and the ized postacute, chronic alcoholics over a matching placebo, with one week of phy- 3D-day period with chlordiazepoxide (10 sician-known placebo treatment inter- mg. or 20 mg., t.i.d.) or matching placebo posed between each of these four. Each pa- in a double-blind study. They found that tient was seen at weekly intervals and the the patients an the drug had fewer so- dosage was raised or lowered according to matic complaints and felt more friendly, clinical response. The range of dosage for but there was no evidence that the drug LA-I and diazepam was from 5 to 50 mg_ reduced anxiety or decreased the inci- daily, and for chlordiazepoxide, 10-100 mg. dence of drinking. Actually, trends were daily, with 15 or 30 mg., respectively, be- that the drug increased anxiety and the ing the usual total daily dose. incidence of drinking. This trend toward increased drinking was also noted in our studies at V.C.L.A. Shaffer and his group also reported that chlordiazepoxide (20 '',, , patients on [chlordiazepoxide] mg., t.i.d.) slightly impaired intellectual functioning and reduced serum albumin had fewer somatic complaints levels, which contrasts with findings from and felt more friendly, but, .. many previous studies reporting no blood- trends were that the drug chemistry alterations or intellectual dull- increased anxiety and the ing. Included in this report is a good review of the literature of chlordiazepoxide incidence of drinking," in the treatment of alcoholism.

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/ 254 KEITH S. DITMAN

Of the 379 patients started on this study, chlordiazepoxide, with the placebo last. 85 completed two or more of the medica- LA-I ranked first 56% of the time; the tions and only 16 patients remained in other two drugs were first 19% of the time treatment 16 weeks to complete all three each, and the placebo was ranked first only drugs and a placebo. This dropping out of 6% of the time. Diazepam was ranked sec- treatment, for which the alcoholic is no- ond 44% of the time. torious, is used again for treatment evalu- When we enumerated our 46 patients' ation, as we have found it related to the favorable responses and side effects, we action of the drug. There was a trend, after found that LA-I had a slight edge with the first week of treatment, for LA-I, dia- more favorable responses and fewer side zepam, and chlordiazepoxide, in that or- effects. Actually, the incidence of side ef- der, to be more effective in getting the fects for the other two drugs was only patients to return. This delayed effect slightly greater than that for the placebo, might be due to the known accumulative and none of these was severe. For all three action of these drugs and suggests that the drugs they consisted principally of drowsi- initial dosages were too low. Previously we ness and lethargy. had reported that a higher dosage of chlor- With this patient population, and the diazepoxide (25 mg., b.i.d.) was significantly dosages used here, LA-I in particular, and more effective than the placebo in getting diazepam next, were found preferable to alcoholic outpatients to return. Conse- chlordiazepoxide or a placebo. quently, late in this study, with some pa- Oxazepam (Serax, Wyeth) is a recently tients we doubled the starting dose. The marketed drug in the benzodiazepine series. return rate after the first week was better Reportedly it is more water-soluble than for those placed on the higher initial dos- chlordiazepoxide or diazepam and elim- ages of drugs than for the placebo. This inated more quickly from the body. It has delayed effect of the drugs on return rate antianxiety and anticonvulsant activity and indicates that a high initial dosage would its manufacturer claims it to be safer and be desirable, followed by a lower, main- to have fewer side effects than the other tenance one. two benzodiazepines. As yet there have We analyzed the records of 46 of the been no studies evaluating it in alcoholics, patients in this study who completed two but one might expect it to be about equal or more of the drug or placebo treatments. to chlordiazepoxide as a short-term treat- All the drug treatments were rated better ment for the alcoholic. than the placebo. Chlordiazepoxide just missed being significantly better than the Meprohamate Analogues placebo. Diazepam and particularly LA-I Tybamate (Solacen), chemically related were both significantly better than the to meprobamate, reportedly has some seda- placebo. LA-I and particularly diazepam tive or antianxiety action and some stimu- were better than chlordiazepoxide but not lating effect in depressed patients. Conse- significantly so. LA-I and diazepam were quently, it is used in a variety of about equal. psychoneurotic disorders. It is claimed that For the 16 patients who completed the tybamate exerts its influence by acting on series of all three drugs and placebo, a the cerebral subcortex, thus presumably de- rank ordering for each of their four over- creasing emotional instability. all responses indicated that LA-I was the Tybamate interested Mooney and Dit- best treatment, followed by diazepam, then man (1965) for study in alcoholics because CURRENT DRUG THERAPIESINALCOHOLISM 255 of its curious effect of reversing LSD-induced electroencephalographic changes in rabbits and its combined antianxiety and "Thevalue of the massive [LSD] antidepressant effects. experience has been explained Starting with 102 outpatient alcoholics, as giving a transcendental or we did a double-blind controlled study mystical experience that ... is with tybamate (350-700 mg., q.i.d.), meprobamate (400-800 mg., q.i.d.), and a ... euphoric ... leading to a new matching placebo (q.i.d.). After one week awareness of self and the world." of treatment, we did not find tybamate superior to meprobamate or the placebo for relief of any of the symptoms of our Sweden." A repeat of this study now might alcoholic population. Analysis of the data not show disulfiram so effective. beyond the one-week time period was not A study from Russia by Yanuskevskii worthwhile because of the high drop-out (1959) reported only 25% remission in pa- rate from treatment. tients after six to twelve months of treatment and only 1.5% after two years. Disulfiram The value of disulfiram is that it ap- pears to be a good lest of the motivation Disulfiram was introduced in 1948 and, of the patient for sobriety, although it does although highly regarded by a number of little or nothing to maintain that motiva- experts in the field of alcoholism, the drug tion. As the motivation of the alcoholic has never been widely employed by phy- for sobriety wanes, so does the value of sicians for the treatment of alcoholism. disulfiram. Its value then will be deter- Part of this may have been due to the early mined by other factors in the doctor-patient warnings about the dangers of the disul- relationship that effect the patient's desire firam-alcohol reaction and the practice of for sobriety. testing the patient with alcohol after a period on the drug to show him what the The Hallucinogens reaction is like.

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/ ~56 KEITH S. DITMAN

tical experience that for some is beautiful, low one to conclude that LSD is the effec- euphoric, and awe-inspiring, leading to a tive agent. new awareness of self and the world. Psy- If LSD is an effective agent for the alco- chological insights and new values are ob- holic, it may be so only when given en- tained. Often patients become more spiri- thusiastically and in a special setting-one tual, esthetic, and hopeful in their interests in which esthetic and spiritual values are and views. Dramatic improvements have suggested. Unfortunately, few controlled been reported for the neuroses, the char- studies are being carried out as the drug acter disorders, and alcoholism. These is being restricted to physicians who are claims have come for the most part from specialists and in research settings. Mean- uncontrolled studies and individual case while, there is a black market of LSD reports. The change in an individual fol- flourishing in the large metropolitan cen- lowing a massive LSD or mescaline experi- ters, particularly around universities. Many ence has many similarities to a religious individuals are treating themselves, unat- conversion, and, like a religious conver- tended by medical supervision. sion, may have to be believed in and en- All this is not only hazardous for many thusiastically endorsed to be obtained. Dit- people, but it has the effect of making man et al., (1962) in a questionnaire research with these potentially valuable follow-up study of 74 subjects who had had drugs less desirable and even suspect. It the LSD experience, found that 80% said is ironic that a possibly effective treatment the experience was beautiful, happy, bene- for the alcoholic can be put in disrepute ficial, and worth trying again. Those re- by virtue of its very allure and misuse. ligiously oriented claimed the most benefit from it. Of the alcoholics, 67% claimed Conclusion improvement and 36% claimed complete There are a number of difficulties in abstinence for three months or more fol- evaluating a treatment for alcoholism. The lowing the experience. Other studies using condition itself is not well understood and a similar questionnaire but studying pa- there are no reliable short-term criteria by tients where the LSD was administered in which to gauge improvement.Although al- a more enthusiastic environment obtained coholics apparently have more mood and an even higher percentage of abstainers. symptom complaints than normals, the re- O'Reilly (1964) studied 68 alcoholics and lationship of these complaints to alcoho- found that 38% were abstaining two to lism is poorly understood. Furthermore, thirty-four months after their LSD experi- the very nature of these complaints makes ence. Of those who had a transcendental- them difficult for the evaluation of symp- like experience from the drug, 46% be- tomatic treatment. They are subjective and came abstainers.Ramsay et al. (1963) at times ephemeral, and can be altered by treated 47 hospitalized alcoholics with many of the things that happen in the pa- LSD and found a resulting increase in their tient's life.Although an attempt to quan- religious values. titate aspects of the clinical approach for However, controlled studies are yet to statistical handling has many limitations, be done to substantiate the claims of those it seems likely that it can be refined and enthusiastic about the hallucinogens as that, with more careful application, some treatment. Smart (1964) reviewed the LSD of the changes not induced by drugs. which literature and pointed out that none of reduce the sensitivity of the method, can be the studies is well enough controlled to al- weeded out. CURRENT DRUG THERAPIES IN ALCOHOLISM 257

At present, the evidence indicates that drugs of the antipsychotic or antidepressant type are of limited or no value in the "Since [drugs] are more widely treatment of alcoholics except in those used than evidence warrants, cases where there are also present symp- one can only conclude that toms of psychosis, acute depression, or al- they are used in ignorance cohol withdrawal. There is no evidence or desperation. which in effect to indicate that the drugs are of value in the treatment of alcoholism as an entity. is treating the doctor The sedatives pose problems of being and not the patient." abused and addictive, but have some ad- vantages over a placebo [or short-term treatment. Apparently they can give a sense experience they can produce in some peo- of well-being, but this is generally not last- ple. ing and apparently does not decrease the Enthusiasm for a treatment procedure likelihood of drinking. Of the sedatives, and concern and liking lor a patient will the newer ones of the benzodiazepine series favorably affect the patient's condition, have the advantage of longer action and do and skepticism and dislike will unfavor- not depress respiration. Disulfiram, a drug ably affect the patient's progress and sense that can be a deterrent for anyone who of well-being. Then, too, the success of a wishes to avoid drinking, has not been con- given therapy depends on the therapist's clusively shown to be an effective treat- ability to mobilize the patient's expecta- ment. Those who are motivated to take the tion of help. Thus, the giving of a placebo drug but do not get it maintain sobriety can produce a great deal of benefit, or as 'well as those who are given the drug. harm, depending on the doctor-patient re- The hallucinogens, such as mescaline and lationship. Drugs, to be of benefit for the LSD-25, are enthusiastically proclaimed by alcoholic, must be significantly better than some for the treatment of alcoholism. a placebo. Unfortunately, although drugs There are many anecdotal reports of re- are widely prescribed, there is little evi- markable recoveries from chronic, exces- dence to support the use of very many. sive drinking following treatment with Since they are more widely used than evi- these drugs-but as yet there are not dence warrants, one can only conclude that enough controlled studies to conclude they are used in ignorance or desperation, whether it is the effect of the drugs or the which in effect is treating the doctor and enthusiastic endorsement of the type of not the patient.

References

COllE', S., DUMAN, K. S., and MOO;>iEY, H.B., mcnt of alcoholics, (2.IWTt. l- Stud. Ale. (Sup. "Effect of Trifluoperazine on some symptoms Ko. 1), pp. 107-116, 1961. common among skid row alcoholics, in Trifluo- -- and COllEN, S., Evaluations of drugs in the perazine: Clinical and pharmacological aspects treatment of alcoholism, Quart. ]. Stud.Ale. (Philadelphia:Lea & Febiger, 1954). 20:573. 1959. COLE, J. 0., GOLDBERG, S. C., and DAVIS. J. 11., --, HAnlAN, M., and 'VHlTTLESEY, J. R. B., Drugs in the treatment of psychosis: Controlled Nature and frequency of claims following LSD, studies.Paper presented at the Amer, Psych. J. nerv. merit; Dis., 134:346, 1962 . .Assoc.Regional Conf., Boston, Mass., April 3-4, --, MOONEY, H. B., and COHEN,S., New drugs 1965. in the treatment of alcoholism, Neuropsycho- DnMAN, K. S., Evaluat ion of drugs in the treat- jJlw rinacoI., 3:352, 195'1.

/ 258 KEITH S. DITMAN

HAYMAN,M., Current attitudes to alcoholism of alcoholics after LSD-25, Quart. J. Stud. Ale., psychiatrists in southern California, A mer, J. 24:443, 1963. Psychiat., 112:485, 1956. --, BAHREY,M" and ROBINSON,B.,Effect of an --- and DITMAN,K. 5., Age and orientation of antidepressant drug on clinic attendance of alco- psychiatrists and their prescription of drugs (In- holics, Quart. J. Stud. Ale., 25:544, 1964. stitute for Psychosomatic and Psychiatric Re- SCHAFFER,j. w., HANLON,T. E., "WOLF,S.,FOXWELL, search, in press). N. R., and KURLAND,A. A., Nialamide in the HElLIZER,F., A critical review of some published treatment of alcoholism, J. nero. ment. Dis., experiments with chlorpromazine in schizo- 135:222, 1962. phrenic, neurotic and normal humans, J. Chron. --, et al., A controlled evaluation of chlor- Dis., 11:102, 1960. diazepoxide (Librium) in the treatment of con- KIMBELL,I. JR., OVERALL,]. E., and HOLLISTER,L. E., valescing alcoholics, J. nero. merit. Dis., 137:'194, 1963. Antidepressant drugs: Myth or reality>, J. New S:\[ART,R. G. and STORM,T., The efficacy of LSD Drugs, 5:9, 1965. in the treatment of alcoholism, Quart. J. Stud. MOONEY,R. B. and DITMAN, K. S., Tybamate Ale., 25:333, 196'i, (Solacen), a meprobamate analog, in the treat- S,\HTH,]. A., The use of drugs in treating alco- ment of alcoholics, J. New Drugs, 5:233, 1965. holics, Consultant, pp. 40--42, 1965. ---, ---, and COHEN,S., Chlordiazepoxide in WALLERSTEIN,R. S., Hospital treatment of alco- the treatment of alcoholics, Dis. nero. Syst., (See. holism: A comparative experimental study (New 2, No.7) 22:44, 1961. York: Basic Books, 1957). O'REILLY, P. O. and FUNK, A., LSD in chronic YANUSKEVSKII,L.K., The effectiveness of antialcoho1 Alcoholism, Canad. psychiat. Ass. J., 9:258, 1964. treatment according to follow-up data, Zh. Neuro- RAMSAY,R., JEt>:SEt>:,S., and Soxrxrzn, R., Values in pat, 59:693, 1959.

CRITICAL EVALUATIONS

Do Psychotropic Drugs Help the Alcoholic?

Ruth Fox, M.D. Medical Director, The National Council on Alcoholism, Inc., New York.

Little reliance can be put on any drug except during the acute withdrawal stage, when some of the tranquilizers are of great utility. Dr. Ditman under- estimates the value of disulfiram as a means of helping the alcoholic to maintain sobriety while he works on his underlying difficulties.

HE complexity of the problem of alco- Most psychiatrists and therapists see emotional problems in the alcoholic, view these T holism is well described in one of the as chronic, even lifelong, and see the drink- early paragraphs of Dr. Ditman's excellent, ing behavior as not only stemming from comprehensive, and objective review of the these problems but as adding to them. The relationship between the drinking and the current drug therapies for this extremely underlying problems is admittedly poorly baffling condition. He states: understood. However, many alcoholics report that they feel anxious, tense, lonely, Alcoholism would best be viewed as chronic irritable, frustrated, hopeless, inferior, de- excessive drinking symptomatic of an un- pressed, etc., and that they drink when they derlying disorder in the individual, be it become more upset as alcohol relieves them psychological, emotional, or physiological. temporarily, although they generally feel