Year : 2015 | Volume
: 20 | Issue : 2 | Page : 82--84
Dependence on carbonated water: Clinical and policy implications
Sumit Kumar Gupta, Abhishek Pratap Singh
Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Dilshad Garden, New Delhi, India
Sumit Kumar Gupta
Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Dilshad Garden - 110 095, New Delhi
A case of caffeine dependence syndrome with preference for a specific brand of carbonated water (popularly known as soft drinks or colas) is discussed to highlight the clinical and policy implications.
|How to cite this article:|
Gupta SK, Singh AP. Dependence on carbonated water: Clinical and policy implications.J Mental Health Hum Behav 2015;20:82-84
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Gupta SK, Singh AP. Dependence on carbonated water: Clinical and policy implications. J Mental Health Hum Behav [serial online] 2015 [cited 2021 Aug 4 ];20:82-84
Available from: https://www.jmhhb.org/text.asp?2015/20/2/82/174601
Caffeine dependence syndrome has a controversial nosological status. It is considered a valid diagnosis as per International Classification of Disease-10 (ICD-10) but is not listed as a codable diagnosis in the diagnostic and statistical manual of mental disorders, in fifth edition (DSM-5). , A case of caffeine dependence with preference for a specific brand of carbonated water (CW also popularly known as soft drinks or colas) is probably being discussed for the first time in the Indian context. Implications for clinical practice and the need for disclosing actual caffeine content on package labels of CW are discussed.
A 24-year-old, unmarried, graduate female residing in Delhi visited Psychiatry OPD with her fiancé for follow-up with the complaints of frequent altercations among them. She had been earlier diagnosed with recurrent depressive disorder, tension-type headache, and three depressive episodes each lasting 2-3 months, over nine years total duration of illness. She had the last depressive episode around 2 years back and had attained remission on oral fluoxetine 40 mg/day and amitriptyline 25 mg/day along with supportive psychotherapy.
According to her fiancι; she had frequent anger outbursts on trivial issues for nearly last 1-year. He had known her for the last 4 years, and this was unlike her previous self. A detailed inquiry into the usual associations with her anger outbursts revealed that she would be quite irritable, if she had not consumed soft drink for few hours, or if there was lesser quantity available. There was no history of persistent or pervasive sadness, low energy levels, or pessimism about the future in last 2 years. She described that the current experience was "unlike" the experience of depressive episodes earlier.
She informed that since her early adolescence, she was fond of soft drinks. She used to take soft drinks once or twice in a month with friends or family members. However, for the last 2 years, she started taking it daily and gradually started increasing amount also. She would not feel fresh and alert with any lesser amount. At the time of presentation, she used to take approximately 1500 ml of soft drinks every day. She complained of facing embarrassment as she became known to everyone in her circle as a "cold drinker." One year back, she realized that intake of soft drinks by her was excessive and may have an adverse effect on her health. She also attempted to stop taking it. However, if she did not take soft drinks at an interval of 7-8 h, she started having craving, restlessness, irritability, lack of interest in work, and low energy levels. All these symptoms would get relieved on taking soft drinks. When she used to feel angry, she used to drink more to control anger. Initially, she used to take soft drinks of any brand and color. However, lately she started taking soft drinks of black color only. She reported feeling cheerful and energetic after taking black soft drinks, but not the same with soft drinks of any other color. She preferred taking soft drinks of a particular brand even among those with black color.
There was no history of consuming energy drinks as she was unaware of any such product (she was even not aware of caffeine in soft drinks). There was no history of use of any other psychoactive substance in the past. There was no history of similar symptoms when hungry, or symptoms being relieved by any other sugary drink or carbohydrate-rich food. She had not thought of trying low-calorie soft drinks or diet-colas, probably because of her thin built. There was no history of any significant medical or surgical illness. There was no family history of any psychiatric illness or any psychoactive substance use. Personal history was unremarkable. She was average in studies. She had impulsivity and was short tempered to some extent premorbidly, but it did not lead to any sociooccupational dysfunction.
She was diagnosed with caffeine dependence syndrome and motivation enhancement therapy (MET) was initiated. It was suggested that she should discuss her problem with her family members to aid relapse prevention. Her family members supported her and helped in the management by stopping the storage of soft drinks at home, as part of environmental modification (nonavailability of substance leading to a lack of cues). She stopped taking cold drinks after the first session itself and has been maintaining abstinence for the last three months.
Caffeine, sugar, and flavoring agents are potential reinforcers that can induce dependence on CW (This designated food product category is popularly known as soft drinks or colas). No relief in symptoms with other sugary drinks and relief in symptoms with CW of different flavors before settling on a brand that has been found to have high caffeine content point toward caffeine as the culprit for inducing dependence on CW in this case. This case satisfies five (criteria a, b, c, d, and f) out of the six ICD-10 diagnostic criteria for Substance Dependence Syndrome due to caffeine (F15.2) and 7 out of nine criteria (criteria 1,2, 3, 4, 6, 7, and 9) of DSM-5 research diagnosis of caffeine use disorder. , She also required clinical help to overcome the personal distress and dysfunction associated with this diagnosis. The family members of the patient also helped her with environmental modification after learning the "diagnosis." The utility of diagnosis itself in the subsequent management is illustrative of need for the nosological entity of caffeine dependence. It was a mild dependence syndrome evidenced by being able to achieve complete abstinence after breaking denial in the first MET session, and nonpersistence of withdrawal or craving for long.
Caffeine is the most commonly consumed legal stimulant in the world.  In a study on university students who had consumed both illicit stimulants and coffee for cognitive enhancement, less than half perceived a "general difference" between the two.  Caffeine dependence has been found to be highly prevalent if the DSM diagnostic criteria for substance dependence are applied.  However, it is not recognized as a codable diagnosis in DSM.  Although the majority of addiction professionals believe that some people do develop caffeine dependence, only the minority of them agree to it being included in DSM.  The low clinical severity, infrequent severe dependence despite very common use, apprehension of diagnostic criteria being wrongly applied, and the fear that psychiatry and addiction may be criticized as a specialty for including such common disorders are few of the reasons for this hesitation in formally recognizing caffeine dependence. 
It may be recalled that historically, there had been some initial resistance to accept problems due to the use of tobacco.  However, dissemination of the scientific evidence changed the scenario to an extent that there are legislations and policies to control the use of tobacco.  Although the extent of potential harm because of persistent caffeine use may not be as high as tobacco, but there are many known harmful health effects. These include obesity, sleep disorders, anxiety disorders, increased risk for consuming other substances and risk-taking behavior, adverse effect on developing the brain in children, adolescents, and adverse pregnancy outcome. 
Although CW manufacturers argue that caffeine is only a flavoring agent, studies do not support this claim. , Caffeine is added to CW to produce a conditioned flavor response.  This case clearly illustrates the liability to produce dependence (even if the risk is very small) with CW. Use of only black colored CW and that too preferably of a specific brand in this index case because of that specific brand containing maximum caffeine content among nonenergy CW.  Behavioral phenomenon of shaping in the background of reinforcing properties of caffeine can easily explain this brand affinity. Although the case of caffeine dependence with preference for a specific brand of energy drinks that have a high caffeine content has been reported earlier, a case of caffeine dependence with preference for a specific brand of carbonated soft drink which contain lesser caffeine content as compared to energy drinks is probably being discussed for the first time in the Indian context. 
In India, the product label of CW is required to mention "Contains Caffeine" and exact caffeine content is not required to be disclosed with a maximum permissible limit of 145 part per million. , This regulatory loophole needs to be plugged, as CW manufacturing industry may resort to using the higher caffeine content (within the regulatory threshold) to boost demand.
Caffeine dependence syndrome is a valid diagnosis and some of these patients genuinely require clinical help. Nonpharmacological management in the form of MET and environmental manipulation can be of help. As various health hazards associated with consumption of CW are being recognized, authorities should seriously consider making it compulsory to disclose exact caffeine content of CW.
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Conflicts of interest
There are no conflicts of interest.
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