Alcohol: Use and Abuse in America

The objectives of this monograph are to put contemporary American drinking practices and problems within a historical context and to integrate recent alcohol-related research in medicine, biology, psychology, and the social sciences. American Colonial society did not oppose drinking, but drunkenness was severely punished. Alcohol remained a central feature of American life after independence. At the end of the eighteenth century the estimated alcohol consumption reached nearly six gallons of absolute alcohol per adult, more than twice the current American usage. In the early nineteenth century, the United States became known as a nation of drunkards. Benjamin Rush was one of the first to consider intemperance a disease; he became the father of the American temperance movement. Although he died in 1813, Rush’s scientific authority was cited in the advice to abandon the widespread practice of providing free liquor to laborers. By the 1830s, drunkenness was the largest category of criminal offense in Boston, New York, and Philadelphia, and at Pennsylvania Hospital and McLean Hospital, alcoholrelated mental illness accounted for more admissions than any other type of mental disorder. By that time, temperance organizations, with strong participation by the nation’s Protestant churches, were claiming that any kind of involvement in the liquor business was incompatible with Christian morality. As the temperance movement broadened its base, liquor consumption dropped 75% by mid-century. Local option laws were passed in towns and cities prohibiting the sale of alcoholic beverages. Those who advocated total abstinence became known as “teetotalers.” By 1855, 13 states forbade the manufacture and sale of intoxicating liquors. By 1863, however, only five did so. The temperance movement splintered as social interest turned to the slavery question and the war. It was not until the 1870s that temperance reform regained its vigor. Women’s crusades against alcohol led to the formation of the Women’s Christian Temperance Union, the first mass movement of women in American history. Mendelson and Mello describe all of this and the growing social march toward the Eighteenth Amendment in 1919 and Prohibition in an easy yet detailed style. The entire first third of their book is devoted to the historical review. They go on to describe contemporary drinking patterns and the fact that a concern for health rather than sin is the conceptual basis of those who combat alcoholism today. The last chapter of part one deals with regulation of the alcoholic beverage industry from the local to the federal level. Extensive statistics on production, tax revenues, and consumption are included, as well as an in-depth state-bystate summary of drinking laws. Part two, entitled Alcohol: Biology and Behavior, assumes no medical expertise on the part of the reader but is nonetheless instructive to the physician who does not specialize in the treatment of alcoholism. The discussion of alcohol metabolism follows the molecule from its passage through the pylorus to the complicated processes involved in its inactivation and excretion. The depth of the new evidence about alcohol’s effect on luteinizing hormone, testosterone, and male feminization is disappointing, largely because of the paucity of research. Research on alcohol’s effects has tended to ignore women almost totally until recently. Especially unstudied is alcohol’s effect on sexual arousal in both men and women. Mendelson and Mello challenge the common belief that alcohol intoxication regularly produces even a transient state of happiness. Research conducted while subjects were intoxicated has repeatedly demonstrated that alcohol often produces dysphoria, depression, and anxiety. Subjects, however, remember the anticipated pleasure, not the actual displeasure. To explain continued drinking despite the pain, the authors suggest the concept of “stimulus self-administration” with the goal of state change. “At least it’s different,” and “different,” they claim, may be the reinforcer of the drinking. Part three deals with the role of alcohol in sickness and health. Cancer and disorders of the heart, the gastrointestinal system, the brain, and the reproductive system are discussed. Seen as a hypnotic for millennia, alcohol changes sleep patterns so that they resemble those of an elderly person. Even a single drink in the evening can decrease REM sleep to a subnormal level. Many depressed people find that abandoning the alcohol they use to self-medicate paradoxically causes improvement in depression and/or insomnia. Chapter 14, which deals with the search for origins of alcoholism, is based on a previously published monograph by Mello. Little is really known other than the fact that alcoholism in a biological parent is a better predictor of alcoholism than any social or environmental factors. More prospective studies are needed. Until recently, physicians argued against alcohol as the agent responsible for withdrawal syndromes, favoring poor nutrition and other extraneous factors. The demonstration that alcoholism is an addiction manifested by withdrawal and tolerance was dccisive in supporting the disease concept of alcoholism. The book’s section on treatment and prevention are thin, however, again because of the paucity of scientific fact. Mendelson and Mello see multimodality treatment as preferable to any single therapy. Recent assessment of the prevalence of mental disorders in the United States found alcohol abuse and dependence to be the most common form of mental disorder among men. This book by Mendelson and Mello is much needed. I hope that it will be recommended by psychiatrists to other mental health professionals and appropriate laypersons. They are the readership for whom it is primarily intended.