Friday, 29 July 2011

Amy Winehouse dies. Is the stigma about alcoholism partly to blame?

Today's verdict (26th October) on Amy Winehouse's death was shocking, but few had expected the post-mortem to tell them anything that they didn’t already know.  Recording a verdict of misadventure, St Pancras Coroner Suzanne Greenway said the singer had 416mg of alcohol per 100ml of blood. As The Sun reported, 'the pathologist who conducted the post-mortem said at 200mg per decilitre (of blood), someone would lose control of their reflexes and 350mg was considered a fatal level'.

The Guardian summed it up at the time of her death: ‘the 27-year-old singer, who fought a well-documented battle with drugs and alcohol, was found dead at her home‘.  Singer, drink, drugs and early death.  The stories write themselves, or as Hadley Freeman more cynically wrote in The Guardian ‘Winehouse at last gave the media a collective orgasm of prurient crocodile tears by dying. At last we can wheel out those pre-written columns as we photograph her body being wheeled out of her house!’



Dad Mitch and Amy Winehouse at the 2008 Grammy Awards

And some trite stuff has been written.  Freeman warned journalists not to talk of 'inevitable death' and getting song lyrics into the title. But they did.  'The New York Post's "They Tried to Make Her Go To Rehab, She Said No No No" was as predictable as it was stupid'.  But overall the predictable prize goes, as Mary Anne Hourihan writes in the Irish Times, to 'the faintly damning phrases such as “tortured soul” and “poor creature”, and the stupid prize goes to the umpteen articles pretending that you only die of alcohol abuse if you are a druggie, 27 and a rock star.

Thankfully Amy Winehouse's friend Russell Brand, an actor and a recovered addict himself, has been there and done it.  Amy Winehouse is not the exception, he writes.  Very publicly she lived the up and down life of every addict, but in a moving tribute to his friend, Brand writes ‘When you love someone who suffers from the disease of addiction you await the phone call.  There will be a phone call.  The sincere hope is that the call will be from the addict themselves, telling you they’ve had enough, that they’re ready to stop, ready to try something new.  Of course though, you fear the other call, the sad nocturnal chime from a friend or relative telling you it’s too late, she’s gone’.

What happened?  The Priory clinic had reportedly been warned by doctors earlier this year that Winehouse ‘won't have long to live if she doesn't dramatically change her lifestyle’. A source said: "It's the last chance saloon for Amy.  Doctors have come down hard on her because of the severity of her situation. It's a harsh reality but she had to hear it."  So Amy’s disastrous concert in June was a big clue that things weren't going well.  ‘When I saw Amy perform live’ says the Guardian’s Barbara Ellen, ‘she was shambolic, slurring and quite rightly booed offstage’.


Ironically Winehouse had apparently pretty well beaten her drug problem. As reported in Celebrity Now, her dad Mitch 'admitted Amy, 27, still struggled with her dependence on alcohol but had given up drugs 3 years ago. 'The doctors said it was impossible but she really did it,' said Mitch, 60. 'She was trying hard to deal with her drinking and had just completed 3 weeks of abstinence’.

It's an ordinary story about booze
Taking up the point that booze is really to blame, Anne Marie Hourihan in the IrishTimes wrote ‘In fact, alcohol is probably much more of a key player in this tragedy than we, the faintly respectable, would like to admit.  On her recent, abandoned, comeback tour, it was alcohol that her handlers were trying to keep her away from.’ And well they might.  The Health Research Board told us this week that 56% of Irish people now 'drink to dangerous levels'.  One in five people in western countries drink to excess, and more than 10% are alcoholics. Amy Winehouse is by no means the exception, she's becoming the rule.

Her struggle with alcohol was of course part of her art: the tortured chronicler of our own appetite for self-destruction.  Her best songs were the most honest,  including the self-written hits Rehab and Alcohol Logic. Which is why they meant so much to us. As alcohol blogger Eoin Cannon writes ‘What really places her at the center of the addict-artist discussion, is how explicitly her lyrics included the subject matter of escapist intoxication, destructive behavior, and regret.'.

That artistic connection with drink and Winehouse's refusal to hide her problem made it far too easy for the press to stereotype Winehouse as 'the real alcoholic'- a lie which lets the rest of us off the hook.  As Russell Brand put it, ‘not all addicts have Amy’s incredible talent. Or Kurt’s or Jimi’s or Janis’s, some people just get the affliction. All we can do is adapt the way we view this condition, not as a crime or a romantic affectation but as a disease that will kill. We need to review the way society treats addicts, not as criminals but as sick people in need of care’. And more to the point  'We need to look at the way our government funds rehabilitation'.

Hiding the problem
Another artistic recovered alcoholic, Wonderwoman actress Lynda Carter talked about her years of addiction to alcohol describing it as "like staring into a deep, dark hole that I thought no one would understand or still love me if I ever admitted it – or (if) the public ever knew about this very shameful part of my life.  My family suffered... and I was very good at hiding my problem."

Lynda Carter

So rather than distance ourselves from Amy Winehouse,  we, ‘the faintly respectable’, need to own up to the problem of our alcohol culture and above all end the stigma about alcoholism that prevents people getting help.  Scott Basinger, who heads an employee assistance program in Houston, Texas, talks about the stereotypes of addicted people that stand in the way of help: "What we know statistically is that 70 percent of people on alcohol and drugs are employed. The old concept of 'if you're an alcohol- or drug-dependent person, you're living under a bridge' is a horrible stereotype and prevents people from getting help."

One in five don't seek help because of the stigma
A big wake up was the first study to address the under-use of alcohol services, published in the American Journal of Epidemiology only last December, which found that ‘less than a quarter of people who are diagnosed actually seek treatment’.  This is chiefly because ‘people diagnosed with alcoholism at some point in their lifetime were more than 60% less likely to seek treatment if they believed they would be stigmatized once their status is known’.  And they do feel stigmatised.  Of 733 at-risk drinkers surveyed for a Journal of Behaviour study  86.1% felt that they had been stigmatised about their drinking by the community at large, and 48.9% even felt the stigma if they talked to a doctor about their drinking.

The collective hypocrisy of hiding the shame and burying the problem clearly isn't working.  Liver disease is now affecting more and more young people, alcohol-related hospital days are taking up 15% of the health budget and alcohol related cancer deaths are also rising.   As Anne Marie Hourihan concludes: ‘The death of Amy Winehouse was ...in some quarters greeted with a sort of weary contempt.  The poor child, so full of talent, has become a rock and roll cliché’.  Cliche or not, the problem is not going away.

Tuesday, 19 July 2011

Liver disease in young people rises: Health Minister James Reilly sits on the fence

Ireland has ‘dogs on the street’ who know stuff.  Its politicians meanwhile avoid knowing the same things, and when those things become unavoidable they buy themselves a little more time by commissioning a report. Many of the dogs, sadly unelected to the Dail, are now tweeting and the news is that alcohol and Ireland are becoming synonymous.  To take some recent examples of tweets from around the world (there are a dozen every day) - 'When can I move to ireland? I was just told how impressive drinking abilities are and I'd fit right in' says one. 'Binge drinking didn't ruin Ireland, binge drinking built Ireland hahaha' says another, or 'of course ireland doesn't have a drinking age...only a buying age that apparently is only loosely enforced'.

The Misuse of Alcohol Steering Group

The word on the street is now even better informed, thanks to a new Health Research Board report published on the 12th July, confirming what we had suspected all along: the alcohol problem is bad and getting worse.  It tells us that most Irish people now drink to excess, that liver disease especially among the young has increased and that alcohol related deaths are on the rise. Of the 3,336 alcohol related deaths recorded between 2004 and 2008, 672 were as a result of alcohol poisoning.  Of the rest, one in four who died were killed by liver disease.   As Dr Lyons who co-authored the report says in explanation of the figures, "per capita consumption of alcohol in Ireland is among the highest in Europe’ and now ‘the majority (56%) of Irish people drink in a harmful manner".  How long can the country continue to function if we go on like this? And these are cautious figures. The deaths do not record cases where victims were binge drinking or cases where alcohol was a factor but not identified.  Add to this the economic cost - 9% of hospital bed days and 15% of the HSE budget spent on alcohol-related illnesses, and a rising suicide rate with 60% alcohol-related, and there is little to be happy about.

But the good news is that at least the press are beginning to acknowledge the issue rather than to bury it.  On the back of the HRB report The Irish Times has two articles this week, one identifying the failure of school programmes to get to grips with the problem, entitled 'deaths involving alcohol on the rise'  and the other in the Irish Times  on Saturday highlights that 'more of this country's young people are dying from alcohol than anything else' setting the facts against a moving interview with the distraught mother of a young liver disease sufferer who died as a consequence of his drinking.  “It’s quite frightening the amount of damage one can do to one’s liver in a relatively short time of drinking excessively….Five pints per day will lead you to severe liver disease and sudden death at any time. You can do this damage in four years of consistent heavy drinking.”

The Irish Independent also covers the HRB report with an article telling its readers that ‘The majority of Irish people "drink in a harmful manner”.  And while giving the story space under the reluctant headline ‘Alcohol a factor in poisoning deaths’ The Examiner writes that ‘more than one-third of people who died of alcohol-related liver disease were below 34 years of age, new figures reveal’.

So if the dogs on the street, the HRB and the press are lined up calling for something to be done, our TD’s must surely be listening.  Sure enough the Herald.ie even has a few words from a politician. ‘Fine Gael TD Jerry Buttimer has expressed alarm at the findings. "It clearly shows that as a society we need to look at our lifestyle habits," he said’.  Lifestyle habits?  Yes sure, but what about the recommendations in the HRB report itself which very clearly re-iterate the World Health Organisation’s evidence and advice that taxation, minimum-pricing and regulation of sales and advertising are the minimum requirements of any government to get to grips with the alcohol problem.  ‘In Ireland’ The Irish Times reports, ‘alcohol-control policies are relatively weak and have remained a low priority for successive governments’. Consequently it has one of the greatest problems of drinking in Europe.  Did the people of Cork elect Deputy Buttimer to address this legislative gap or to lecture them about lifestyle habits?

Back in 2008 Vincent Browne wrote on politico.ie about a similar inaction on the part of the previous government.  'They laboured mightily and came up with lots of recommendations. They were against binge drinking, in favour of more moderate alcohol consumption, protecting children from alcohol, against alcohol-related harm.... The new task force will be or should be a carbon copy of the report of four years ago. And the likelihood is that the recommendations of the new task force will meet the same fate'.  And so it proved to be.  As the Irish Times puts it:  ‘There has been plenty of talk about tackling alcohol abuse but little meaningful action.  There have been two strategic task force reports on alcohol, but the key recommendations to increase prices, reduce the number of places it can be bought and tighten controls on advertising remain largely unimplemented. For example, plans to strictly regulate the marketing of alcohol by the Fianna Fáil-Progressive Democrats government were ditched in favour of allowing the industry to regulate itself’.

Can this be happening again?

In the Dail on 14th July Deputy Jerry Buttimer brought the sad issues raised by the HRB to ministerial attention.  Like a man pitching the Titanic story wthout mentioning the iceberg, Deputy Buttimer's carefully worded speech leans heavily on the word 'habits' and 'choices' while avoiding the words advertising, marketing, sponsorship, policy or regulation altogether .  And in the shocked tones of a newcomer to the whole alcohol issue the Deputy tells us that he is 'worrying' about the 'extent of the impact of alcohol' that has been 'revealed' to him by the 'first national report' to come his way.

Health Minister James Reilly waits for news of a report

Questioned twice recently on the issue of the previous alcohol report (number three in the queue), incoming Minister for Health James Reilly had already learned the jargon.   Ducking a direct question on 'widespread sponsorship of major sporting events by alcohol companies' from Deputy Graham Nash, theMinister said that the report (commissioned in 2009) ‘showed that there were two different views represented in the Working Group; but it was not charged with finding a means of reconciling these opposing views or to assess the relative merits of the arguments made’.  Let's get this straight.  A 'Working Group' took two years to discover that they should have been told to make a decision.  What sort of work are they doing?  But nothing lost, apparently.  Their report has now been 'referred to the Steering Group that is developing the National Substance Misuse Strategy to assist it in its deliberations’ and  ‘is under consideration and…will be finalised in the coming months’.  Another long finger job then?

In April the Minister told us ‘I expect to receive the Report of the Steering Group later this year’ and in the Dail this week it was again mentioned in a reply to Deputy Buttimer, ‘The report of the national substance misuse strategy will be finalised at the end of September 2011.  Following this, the Minister for Health will bring proposals to the Government which will address the broad range of measures required to prevent and tackle the harms caused by alcohol use and misuse’.

So the third report in ten years into the bleeding obvious, again delayed, and again promising a broad sweep of nothing in particular. Are there any grounds for hope? 

Sunday, 10 July 2011

While suicide and alcohlism rise, politics is played with the figures

Tragically linked in many cases, suicide and alcohol have three things in common: an unhelpful stigma, an increase in times of hardship and a corresponding tendency to be under-reported. Underplaying the 'national shame' of suicide may also be about saving resources as a report on a 'cluster of suicides' in Cork found.  A new report by a British team identified a link between 21 suicide cases in one small area of Cork City alone since August 2010.  But as The Irish Examiner reports 'no new interviews are being carried out with families of the deceased and the report warns that "no commitments can be given to bereaved families that ongoing support in the medium to long-term can be provided".  This is because 'the work of the pioneering project has all but ceased in recent months, due to a discontinuation of €75,000 in HSE funding.'  Against this background national statistics published in June for 2010 are claiming a fall in suicides which is at odds with charities' experiences, and with both a Northern Ireland study and a European study published this month.  Gargle Nation reports.

What are the suicide figures for Ireland?
As Taoiseach Bertie Ahern infamously said at a 2007 trade union conference in Donegal "Sitting on the sideline or the fence, cribbing and moaning is a lost opportunity. In fact I don't know how people who engage in that don't commit suicide." Reported by the Independent on Sunday 'the sense of shock caused by his televised words to anti-suicide campaigners was heightened by the fact that some delegates greeted them with laughter'.

Turn the Tide on Suicide vigil, Dublin

The truth is that suicide is an increasing challenge in Ireland which politicians have yet to rise to. The official statistics show that there were 527 suicides in the Republic in 2009, a 24 per cent increase year on year. But another 200 deaths that year were of an undetermined nature. It is believed that the true suicide figure for 2009 was actually between 600 and 700 and of those 80% were men. 

Suicide, like alcoholism, is known to increase at times of unemployment and even anticipation of unemployment. A letter by specialists in public health led by David Stuckler of the University of Cambridge, published in the Lancet this July, notes a recorded annual increase in suicides in Ireland of 13% and comments that this is 'consistent with historical studies that show immediate rises in suicides associated with 'early indicators' of crisis, such as turmoil in the banking sector, which precipitates later unemployment'. The data are still preliminary which is a reminder, as Stuckler says, 'of the contrast between the substantial efforts expended by governments to collect up-to-the-minute financial data while health data lag by several years'.

On the same theme Brendan Walsh wrote in May in his major report on unemployment and suicide in Ireland (see below) that 'there is some evidence that the suicide rate is being increasingly under‐reported in recent years'. Figures published by the Central Statistics Office this June for example record that '386 men and 100 women took their own lives in 2010', which the Irish Times reported emphatically under the title "Drop in number of suicides to 8% welcomed by research group". But after further emphasising these figures the same article acknowledges later on that 'researchers believe actual suicide rates are typically higher than official statistics as some people who take their own lives are classified as “deaths linked to undetermined intent” in official statistics'. The Times also reports that the office’s 'Vital Statistics Yearly Summary 2010 also shows the population increased to 4,470,700 last year... an increase of 11,400 people on the 4,459,300 population recorded in 2009'. With record emigration figures for the same period, you begin to wonder where these figures are coming from?

No doubt with similar thoughts in mind, The National Suicide Research Foundation welcomes this apparent “levelling off” in the number of deaths but cautions that 'the statistics were still provisional and could change'.

How or why official records of deaths can change is a mystery, but they may need to change in the light of European statistcs discussed by David Stuckler in The Lancet on 7th July which compares suicide statistics across ten European states since the recession kicked in.  Put neatly by RTE, 'Suicides rates rose sharply in Europe between 2007 and 2009 as the financial crisis drove unemployment up, with Greece and Ireland worst affected'. In 2008, according to the research, suicides among people aged younger than 65 in the other eight European states studied rose by 7% over 2007, but 'two of the worst hit economies' Ireland and Greece saw a rise of 13% and 17% respectively.

Suicide and Alcohol
The link between alcohol and suicide is unequivocal.  We already know from one Irish study of people who died as a result of suicide that more than half had alcohol in their blood, and in 2007 alcohol was a factor in 41% of all cases of deliberate self-harm.  Now a confidential report into suicide and mental illness in Northern Ireland by Professor Louis Appleby published in June has found that "Of all the patients who died by suicide, 60% were thought to be misusing alcohol by their doctors.  About half of these were alcohol dependent."  Dr Uzma Huda, Vice Chair of the Royal College of Psychiatrists in Northern Ireland, calling for a minimum pricing for alcohol, said: "We can no longer afford to ignore the growing trend linking alcohol and suicide, particularly in young people." For a full report see the Gargle Nation article here.

The Influence of Alcohol and Unemployment on Suicide
The link between suicide and alcohol is further explored in a study published in May by Professor Brendan Walsh of University College Dublin.  Tragically predicting that 2011 will be the worst year for suicides yet, Professor Walsh studied the relationship between unemployment and alcohol in Ireland and found that 'Alcohol consumption is a significant influence on the male suicide rate up to age 64'. Professor Walsh's findings suggest that higher alcohol consumption played a major role in the increase in suicide mortality among young Irish males between the late 1960s and the end of the century.  As Walsh concludes: 'the recent rise in the suicide rate may be attributed to the sharp increase in unemployment, especially among males'. His recommendations are clear:
"Increased taxation of alcoholic beverages is generally regarded as the most effective of the available policies to discourage heavy drinking .... The close association between the level of alcohol consumption and the suicide rates among young males suggest that a reduction in consumption due to heavier taxation of alcoholic beverages would lead to some reduction in the incidence of suicide. [The] relatively lenient tax treatment of alcoholic beverages over the last decade does not reflect the widely‐expressed concern about the high suicide rate among young people".
For information and contacts, and more on suicide and alcohol see the Gargle Nation suicide page. To read how NI Health Minister Edwin Poots has avoided mentioning alcohol after welcoming a report linking alcohol and suicide, see here

Tuesday, 5 July 2011

Suicide, murder and alcohol: Minister Poots fails to address issue in new report

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Northern Ireland was published by the University of Manchester in June, focussing on evidence of deaths by murder or suicide by people with mental illness in the British Isles, and Northern Ireland in particular.  It makes tragic reading, draws a clear link between alcohol and the deaths, and highlights (again) the need for government to heed the recommendations in their overall alcohol strategy. 


NI Health Minister Edwin Poots

As NI Minister for Health Edwin Poots describes it in his introduction,
"Covering a nine year period from January 2000 to December 2008 during which there were 1,865 suicides and probable suicides in Northern Ireland, (and 15% of homicides committed by people who have been in contact with mental health services) the report presents detailed data that looks behind the headline statistics. By presenting a better understanding of these deaths, the report will assist in fine tuning policy and practice for the care of people within mental health services and help to prevent deaths".
The report analyses data from mental health and criminal justice bodies and provides further evidence of the strong link between alcohol misuse and mental illness, strong evidence of a link between alcohol and homicide, and conclusive evidence of a link between alcohol use and suicide in particular.  Of those who killed an acquaintance in NI, for example, 67% had a history of mental illness, but 91% were alcohol abusers and 97% had a history of alcohol and/or drug dependence.  Amongst those receiving treatment for mental illness, alcohol misuse in particular was a common feature of patient suicides featuring in 60% of cases, and had become more common over the nine year period of the report.

The report gives clear recommendations.  Chief amongst them are the need for 'reducing alcohol misuse and dependence' which 'should be seen as a key step towards reducing the risk of suicide and homicide, requiring a broad public health approach including health education and alcohol pricing. Mental health services should ensure that they have full availability of services for alcohol and drug misuse, including dual diagnosis services'.

All very straight forward, but let down by the simple fact that Minister Poots' own introduction fails to mention the word alcohol at all, despite the 91% co-incidence between alcohol and homicide in the report. The reports author Professor Louis Appleby, interviewed by the BBC on 29th June said: "Of all the patients who died by suicide, 60% were thought to be misusing alcohol by their doctors. About half of these were alcohol dependent."  Dr Uzma Huda, Vice Chair of the Royal College of Psychiatrists in Northern Ireland, calling for a minimum pricing for alcohol, said: "We can no longer afford to ignore the growing trend linking alcohol and suicide, particularly in young people."  Yet on UTV the Minister discussed the report and focussed only on 'deprivation', which the report itself found to be co-related with suicide but only amongst young males in data from 2005.  Correspondingly Poots again neglected to mention the greater problem of alcohol at all .

Commenting on the issue David Keating of the Mental Health Nurses Association makes the same point, writing that:
"Edwin Poots has responded by confirming that funding for suicide prevention will be safeguarded.   This is a welcome reassurance but what is the position regarding alcohol services?  Currently, the Health and Social Care Board are consulting on Tier 4 in-patient addiction units. The indications from consultations are a closure of units or wards with only three in-patient residential facilities as the preferred option, covering all of Northern Ireland.  This will affect the addiction wards in Downshire, Holywell, St Luke’s, and the Tyrone and Fermanagh hospitals but also have implication for Cuan Mhuire in Newry, Carlisle House, Belfast, and Northlands in Derry".
This lack of joined up thinking is echoed by Order Grand Secretary Drew Nelson interviewd on BBC news yesterday (4th July).  Mr Nelson said he felt social policy regarding the regulation of the sale of alcohol in Northern Ireland had been a "massive failure over the last 20 years". "There are far more people obtaining their alcohol from supermarkets and the problem there is when it comes to consumption, there is no regulation," he added. "I hear stories in towns of taxis going to off-licences and getting alcohol and delivering it to teenagers and there must be older people going into the off-licences and getting it for them so this is a problem for society." Mr Nelson said the drinking problem was "absolutely massive", but the order wanted to play its part in tackling it.

The conclusion is simple, as David Keating writes.  '"The health minister in June 2010 estimated that alcohol abuse costs £240 million in health and social care alone, in Northern Ireland annually (population 1.2 million).  If the minister wants to reduce the rate of suicide, he must demonstrate commitment to develop alcohol services, both community and residential, and not close in-patient units''.


Government alcohol strategy takes off

Its not a lack of evidence or advice that is lacking, it is a lack of political will.