The current authors have conducted exploratory sessions with consumers of mental health services interested in the topic of high energy drink (HED) use, with and without alcohol, and with and without prescribed drugs. The genesis of these sessions originated with the first author (S.A.S.) who has worked for decades with individuals in various stages of recovery from mental illness as a clinician in private practice and a faculty member at the Rutgers College of Nursing. Most of her clinical was work was performed in New Jersey or surrounding states, but sessions were also held with consumers of mental health services attending conferences in the United Kingdom.
The current article describes how a research instrument was developed to collect data on HED and the knowledge, attitudes, and practices of individuals with mental illness regarding HED use. The process to develop this instrument included consumers of mental health services in New Jersey, as well as e-mail suggestions from members of the U.K. Service User and Carer Group Advising on Research (SUGAR). The findings and analysis are presented, along with concerns and implications for future clinical practice and research.
Rationale for the Current Study
The first author (S.A.S.) presented a paper about HED at the Network for Psychiatric Nursing Researchers (NPNR) in Oxford, England several years ago. Members of SUGAR asked what was known about individuals with mental illness and their use of HED products. The answer was “I don't know,” which generated considerable discussion in the group, and the outcome was that the advice given was to fix that deficit. The other outcome was that this group became the authors of a special issue of the Journal of Psychosocial Nursing and Mental Health Services (Vol. 52, No. 1; Humm & Simpson, 2014), featuring topics such as their involvement with researchers, peer support workers, and wellness coaching.
For the current study, the authors contacted the Collaborative Support Programs of New Jersey (CSP-NJ). Members of CSP-NJ community wellness centers advertised, using their contacts and networks, that the study was being developed and solicited members to participate in its development, including the design and identification of respondents. CSP-NJ, founded in 1984, is a private, not-for-profit organization directed, managed, and staffed through collaborative efforts of mental health consumers/survivors and non-consumers. CSP-NJ strives to provide individualized, flexible, community-based services that promote responsibility, recovery, and wellness (Swarbrick, 2009; Swarbrick & Ellis, 2009).
Peer and non-peer staff from CSP-NJ collaborated via planning meetings, which took place every other month in 2014 and 2015. Undergraduate Rutgers nurse students, engaged as research assistants (RAs) for the first author, attended these sessions. At each meeting, which was approximately 1.5 hours long, two or three RAs, approximately eight to 10 consumers of mental health services, and several staff were present. More intense sessions produced a pilot version of the existing survey on the knowledge, attitudes, and practices concerning HED. This pilot instrument was tested and revised twice before being made available to the CSP-NJ network of community wellness centers.
In the current article, when referring to individuals who have (or had) a mental illness, and who enlist professional providers of health care services, the term consumers of mental health services is used. In the United Kingdom and Europe, these individuals are referred to as users, or patients, or former patients. As background to designing the study, the first author presented short information sessions on caffeine and HED. The content of these sessions was repeated in statewide groups as part of their regular education conferences. Some of this information on caffeine and HED was incorporated as knowledge items in the questionnaire.
The Institutional Review Boards of Rutgers University approved the study, including the methods for soliciting participants and assuring their anonymity.
The final version of the instrument was designed to be used via SurveyMonkey®. The instrument was divided into Practice, Opinions and Attitudes, and Knowledge sections; demographic data were solicited at the end of the survey. The Practice area comprised 12 questions, with items such as consumption of caffeine in various types of drinks, having been prescribed psychoactive drugs and how they were taken, and whether HED and drugs were used in a combined way. The Opinions and Attitudes section had seven questions. Inquiries included what the respondents thought was safe use, and what actions they believed should be taken by health care providers and pharmacists if they knew their patients were consuming HED. The Knowledge section had seven items, and asked about how much caffeine was in each type of drink and the regulatory powers of the U.S. Food and Drug Administration (FDA).
After the questions about demographic variables, the respondents were asked if they would like to learn more. Five paragraphs followed, summarizing the knowledge items; these were also made available in print form at all community wellness centers.
Caffeine is the most widely used drug throughout the world. It is commonly found in a variety of foods, such as coffee, tea, cocoa, guarana, some nuts, and more than 60 plants (Bailey, Saldanha, & Dwyer, 2014; MedlinePlus, 2013). Caffeine is most commonly consumed in coffee; there are approximately 150 million Americans who consume coffee every day (E-Imports, 2016). Another major source of caffeine intake can be found within sodas and energy drinks. HED consumption has been on the rise among many populations; in 2006, annual worldwide consumption was estimated at 906 million gallons (Reissig, Strain, & Griffiths, 2009). In North America, HED are the fastest growing segment of the multi-billion-dollar beverage industry, comprising 63% of the market (Spierer, Blanding, & Santella, 2014). Caffeine is also found as an additive to many other products, such as gum, jellybeans, marshmallows, and sunflower seeds (FDA, 2013).
Caffeine, or 1,3,7-trimethylxanthine, derives from a methylxanthine group and includes theophylline and theobromine. Methylxanthines inhibit the neurotransmitter adenosine, which acts as a central nervous system depressant, thus creating effects such as increased alertness and less fatigue (Pohler, 2010). Caffeine of different levels affects individuals differently. Not all individuals who consume 100 mg of caffeine will feel the effects that caffeine can cause, whereas others may be very sensitive to its effects. This tolerance can develop over time through regular caffeine consumption or genetics (Attwood, Higgs, & Terry, 2007). However, for many individuals, clinical manifestations will usually begin with one cup of coffee or tea, or approximately 80 mg to 120 mg of caffeine consumption, producing effects such as enhanced alertness and reduced lethargy (Hoey, 2015). Higher doses of caffeine can cause headaches, diuresis, tachycardia, rapid breathing, tremors, and insomnia, while also increasing anxiety (Mayo Clinic Staff, 2014).
Although caffeine affects individuals uniquely, clinical manifestations are common among consumers and affect almost every organ system. Adverse effects of caffeine on the central nervous system generally include agitation, irritability, headache, restlessness, insomnia, delirium, and hallucinations (Higgins, Tuttle, & Higgins, 2010). Neuromuscular deficits caused by caffeine consumption include problems with fine motor movement, seizures, trembling, and twitching (Pohler, 2010). Cardiac effects include vasodilation, increased cardiac output, angina, flushing, palpitations, and tachycardia (Pohler, 2010). Studies of caffeine consumption have suggested it can lead to decreased bone density (Pohler, 2010). Caffeine also affects the gastrointestinal tract by causing abdominal pain, nausea, and vomiting, possibly with blood (Pohler, 2010). The half-life of caffeine for adults ranges from 3 to 6 hours, with circulation in the body beginning in as little as 5 to 30 minutes (Hoey, 2015). Mild side effects of caffeine, such as insomnia and gastritis, can begin with caffeine doses as low as 50 mg (Hoey, 2015).
Regulation of Caffeine
Regulatory status of caffeine in the United States has been a complex issue because of how prevalent and natural it has been in many individual's diets. Currently, the FDA (2011, 2016b) declares that caffeine is generally recognized as safe up to a level of 0.02% or 200 parts per million, which is approximately 71 mg of caffeine per 12 oz (Reissig et al., 2009). The FDA also adds that overall consumption of caffeine is said to be safe up to 400 mg per day (FDA, 2013; Rosenfeld, Mihalov, Carlson, & Mattia, 2014). Average cups of coffee and soda beverages fit well within these suggested limitations; however, the energy drink marketplace has changed dramatically with excessive caffeine concentrations. Although there are approximately 3 mg to 16 mg of caffeine per 16 oz in decaffeinated coffee, 2.9 mg/oz to 4.5 mg/oz in soda, and 12.8 mg/oz to 25 mg/oz in coffee, the concentration of caffeine in energy drinks is much greater, easily surpassing the limitations set by the FDA. The concentration of caffeine found in HED and energy shots is up to 90 mg/oz to 171 mg/oz (Arria & O'Brien, 2011; “Decaf that's often not,” 2007).
The FDA requires dietary information of nutrients in food and beverages to be labeled on the Nutrition Facts Panel. Yet, because of caffeine's natural chemical makeup found within a variety of plants, coffee beans, and cacao, its listing is not necessarily required. An example of this includes the ingredients for a granola bar containing chocolate. Although the ingredients include chocolate, the ingredients do not have to state there is caffeine in chocolate. If caffeine is found as an additive to a beverage, it is required to have it listed as an ingredient (FDA, 2016a). Although caffeine may be listed as an ingredient, the FDA does not require labeling of the defined amount unless it is labeled as a dietary supplement, such as an over-the-counter supplement (Mattia, 2013). Because only the labeling of caffeine in a dietary supplement is required, the total amount of caffeine and other stimulating properties is often underrepresented in products such as HED. This underrepresentation is true because it is not totaled with other ingredients with stimulating effects, such as guarana (Moustakas et al., 2015). For dietary supplements, the amount of caffeine used as an ingredient must be listed (Rosenfeld et al., 2014), but the quantity does not need to be listed. If the added caffeine is part of a proprietary blend, then the total amount of the blend must be listed, but not necessarily the amount of caffeine itself (Kole & Barnhill, 2013). Nonetheless, voluntary labeling and cautionary statements regarding the amount of caffeine have been made (Mattia, 2013). There is no definitive research that defines how much caffeine may be harmful, although there are recommendations from various medical organizations (Seifert, Schaechter, Hershorin, & Lipschultz, 2011).
Caffeine and Psychiatric Medications
For consumers with psychiatric illnesses, the combination of caffeine and antipsychotic medications is especially of concern. Patients with schizophrenia, and possibly other mental illnesses, generally consume high quantities of caffeine (Thompson, Pennay, Zimmermann, Cox, & Lubman, 2014). This consumption is likely due to the desired stimulant properties of caffeine to negate the depressant effects of the medication (Thompson et al., 2014). One medication, for example, is clozapine. Clozapine is a common atypical antipsychotic agent used to treat positive and negative symptoms of schizophrenia (i.e., the presence of problematic thoughts, such as hallucinations, and absence of healthy behaviors, such as anhedonia and flat affect) (Horn & Hansten, 2013; Townsend, 2015). Clozapine can also be used for treatment-resistant cognitive deficits (Dickerson, Restieaux, & Bilkey, 2012).
In the body, clozapine and caffeine are largely metabolized by the same liver enzyme, CYP1A2. If the two are consumed, the concentration of clozapine has been shown to be dramatically increased due to the competition for elimination by the same enzyme. One study showed a 28.9% to 79.8% reduction in clozapine concentrations 5 days after concurrent consumption of caffeine and clozapine was discontinued (Lam, 2002). Elevated concentrations of clozapine can lead to clozapine toxicity, which has serious side effects of agranulocytosis, delirium, seizures, and neuromuscular deficits (Horn & Hansten, 2013; Townsend, 2015). Caffeine consumption should be monitored in patients who consume clozapine and other medications that are metabolized by CYP1A2.
High Energy Drinks
Relatively new products, HED contain significantly more caffeine than a cup of coffee. Anecdotally, psychiatric nurses believe caffeine interferes with the effectiveness of psychoactive drugs, and coffee and HED are forbidden in psychiatric hospitals and agencies. However, there is no literature regarding the interaction between HED and antipsychotic or antidepressive drugs or the knowledge, attitudes, and use patterns of consumers of mental health services. Nothing is currently known about whether individuals with mental illness use HED to offset their symptoms, or whether their use began after diagnosis or after psychoactive drugs were prescribed and taken as ordered. Individuals use HED to improve concentration, stay alert or awake, or intensify social experiences (Hoey, 2015). There are a few articles on caffeine and psychoactive drugs, but none on HED per se.
Beverages defined as HED contain high amounts of caffeine per fluid ounce (16 mg to 18 mg or more per ounce). Regular coffee, per fluid ounce, contains only 10 mg. Thus, a 12-oz can of HED has approximately 200 mg of caffeine, whereas a 6-oz cup of coffee has 60 mg. Another important difference is that coffee is usually consumed hot, and sipped slowly. HED are cold, and consumed quickly, often resulting in the consumer drinking greater quantities of caffeine in a shorter timeframe (Smoyak, Nowik, & Lee, 2015). HED also have stimulating additives, such as taurine or guarana.
Adding alcohol to HED became popular in the late 1980s. Alcohol is a suppressor of cognitive awareness, the opposite of caffeine; therefore, they have opposing effects on brain function. The dangerous aspect of adding alcohol to HED is that individuals consuming this mixture assume, because they are stimulated and cognitively aroused, that they are operating very well both physically and emotionally (Smoyak et al., 2015; Thombs et al., 2010). This is not the case because they may have consumed enough alcohol to be legally intoxicated.
HED are not regulated by any government body or agency in the United States. HED are considered “dietary supplements,” not food, drugs, or cosmetics, and therefore are not controlled by the FDA. The FDA, however, has a voluntary reporting system for adverse events recorded in emergency departments (EDs). The rise in HED-related incidents across the country is well documented in these reports. Although some countries, such as France, Denmark, and Canada, have initiated laws about HED, the United States has not to date (Reissig et al., 2009). Considering the excessively high content of caffeine found in HED, and the potential for serious adverse events, regulations are imperative to improve the safety of consumers.
The FDA has attempted to regulate caffeine consumption in the past. In 1980, the FDA made movements to remove the added caffeine commonly found in soft drinks due to potential health concerns (FDA, 1980). However, the soft drink industry responded by declaring that caffeine acts only as a flavor enhancer (PepsiCo Inc., 1981). Yet, more recent research indicates otherwise. In 2007, Keast and Riddell from the School of Exercise and Nutrition Sciences at Deakin University challenged this idea, and found no significant detection of caffeine made through the tasting of a beverage. Many manufacturers of HED do not comply to these limitations suggested by the FDA because they claim their products apply to the 1994 Dietary Supplemental Health and Education Act, which classifies products deriving from herbs and natural sources, such as caffeine, as dietary supplements (FDA, 2009; Kapner, 2008). Products that fall under this act, such as caffeine, are not exempted from scrutiny. The FDA can take action to eliminate products from being sold, such as HED and energy shots, if the agency believes such products are unsafe or misbranded (FDA, 2016a).
The FDA's Center for Food Safety and Applied Nutrition recorded adverse health events related to HED such as 5-Hour Energy®, Monster Energy®, and Rockstar Energy Drink®. From 2004 to 2012, the FDA found many reports related to the consumption of caffeinated beverages. Outcomes ranged from mild symptoms of flushing, lethargy, dizziness, anxiety, and headache to symptoms as severe as palpitations, tachycardia, dyspnea, hemorrhage, convulsion, and death (FDA, 2012). Because caffeine has grown increasingly common in individuals' diets and poses such risks, the FDA announced that they will investigate the safety of caffeine in food products (FDA, 2013).
Sample and Instrument
The study sample comprised self-selected members of CSP-NJ community wellness centers. There are no data about how many members visit the wellness centers with any regularity. This lack of data is in keeping with their policy of assuring anonymity. SurveyMonkey was the manner by which the survey instruments were made available.
CSP-NJ community wellness center members could access the SurveyMonkey instrument by: (a) using a computer at the facility, onto which the instrument was loaded in a confidential format, or (b) using an iPad® provided by the Rutgers research team. Individual data from the computers and iPads were erased after each individual completed the instrument. The number of respondents who answered all questions was 184.
Participant age ranged from 29 to 72 years (median age = 50.5 years, mean age = 42 years). More men (58.2%) than women (41.8%) completed the survey, which from observation appeared to be the same proportion as those attending the wellness centers. The majority (52.3%) reported being diagnosed with a mental illness >6 years ago. Another 18.7% reported their diagnoses occurred in the past 2 to 5 years. More than one half (54%) had completed some or all of high school, 32% had some college experience, and 14.5% had earned a baccalaureate degree.
More than one half of respondents had some work experience; 31.5% were working part time and approximately 10% were working full time. In addition, 18% reported working as a volunteer, and 43% were not working. The question asking about a specific diagnosis yielded only 134 responses, which were distributed more toward acute psychosis than personality disorders.
Coffee, Tea, and High Energy Drink Use
Consumers of mental health services reported their use patterns for coffee, tea, and HED. More than one half (58.2%) reported drinking up to six cups of coffee daily, and less than one half (45.9%) reported drinking up to six cups of tea. Compared with coffee and/or tea, reported use of HED was considerably less, with 73.8% answering “never” and 17.5% answering “sometimes, but only rarely.” Sixteen (<10%) respondents reported using HED, consuming them from once per week to every day. Thus, the combined percentage of individuals who rarely used HED and those who consumed them regularly was 26.7%.
In some of the settings, where the computers or iPads were in close proximity, individuals answering the SurveyMonkey instrument sometimes asked the researchers to clarify a question or chatted among themselves, although chatting was asked to be kept to a minimum. The researchers stayed after the sessions to engage in dialogue with individuals attending the centers. For instance, there was a small debate about how “rare” should be interpreted. A few participants suggested that a response of “once per year,” or a specific time frame, would have been better. When asked about combining HED with coffee or tea, more than one half (56.8%) reported never using them together. Approximately 13% reported their pattern of use as coffee or tea in the morning, and HED later in the day.
More than one half (65.2%) of participants had prescriptions for antidepressant, antipsychotic, or anti-anxiety medications. Interestingly, approximately 90% reported that they took these medications exactly as prescribed. However, when listening to the informal chatting, the researchers concluded that this answer was the one that participants thought was the expected or desired response, rather than the actual one. Accurate answers were more likely “only when I can afford them,” “only to relieve troublesome symptoms,” or “only when I feel I need them.”
For those who reported HED use, more than one half said that they did not remember why, whereas 12.7% said they were used “to take the edge off my uncomfortable symptoms” and 7.3% said it was to “totally eliminate symptoms.” Of individuals who reported using HED, 10% said they always use them separately from psychoactive drugs; 11% said they use them together, but not often.
Approximately 60% of participants did not drink alcohol of any kind, and 26.6% reported “rare” use. During discussion, some participants said there should have been a question asking whether they had participated in Alcoholics Anonymous® or ever considered themselves to be an alcoholic or have a drinking problem.
An important finding was that 40.8% of consumers of mental health services thought that adding caffeine, particularly HED, to an alcoholic drink can act to keep one sober and alert. In other words, they believed that caffeine counteracts alcohol. A related finding, on being “wide-awake drunk,” follows.
The fact that 24 (13.9%) individuals reported being wide-awake drunk is cause for concern. However, no cross-tabulations were possible with questions such as diagnosis or medication use because the numbers were too small. The addition of the question “How many times?” was suggested. As discussion emerged, the speaker frequently started with “I'm not one of those ‘wide-awakers’, but…” Participants and others present in the community wellness center at any given time were provided 1-page handouts summarizing the fact questions that were in the survey. Several thought that the “wide-awake drunk” information should have been underlined. This item also resulted in many asking questions about the definition, per se, or stating that they had not realized that they fit the definition until taking the survey. One participant stated, “Friends always gave me coffee or a Red Bull® to make me safe.”
High Energy Drink Use by Adults and Children
More than 80% of respondents did not believe that HED are safe to drink for any adult. More than one half (56.4%) believed that children younger than 12 should not drink HED. The group was evenly divided on knowing whether there was current research that scientifically defines how much caffeine is safe to drink in any age group. Those who had children or adolescents offered comments about taking news of the survey home to their families.
Mental Health Professionals and Service Agencies
Approximately 80% of respondents thought that mental health professionals should always ask patients or consumers about their consumption of HED. Interestingly, less than one half of this group thought that physicians should not prescribe psychoactive drugs if a patient is using HED. However, their reported belief about what pharmacists should do differed, with 52.7% reporting that pharmacists should refuse to fill the prescriptions for psychoactive drugs if an individual is using HED.
Approximately 60% of respondents thought that inpatient or community agencies should not allow HED at their sites, whereas 55.9% thought that individuals attending any type of community agency should not be allowed to bring in HED. Those who had been in hospitals reminded others that nurses did not allow HED to be brought in, and they were not available on the wards.
FDA and Regulation
Approximately 70% of respondents knew that health care providers, particularly in EDs, may voluntarily report adverse events associated with consumption of HED. Adverse events are considered death or serious illness or injury. In approximately one half of the wellness centers where data were collected, discussion about the FDA, what it currently does, and what it should do included stories about friends or relatives who had experienced episodes of adverse events. Some of these individuals also encountered police in the ED who referred them to agencies for help, but who also threatened arrest for driving while intoxicated.
Information about caffeine and HED was used in the development and planning sessions. The intention had also been to use this material in education sessions, when the findings of the study were being communicated in the community wellness centers. However, extended and expanded dialogue with the members occurred in all wellness centers as data were collected. The process of collecting the data took between 1 and 1.5 hours, but the researchers stayed for an additional 1 hour or longer to allow more discussion and answer questions about not only caffeine and HED but other aspects of mental illnesses. Several wellness centers invited the researchers back to their regularly scheduled education sessions.
The current article explores the knowledge, attitudes, and practices about HED among middle-aged (mean age = 42 years) consumers of mental health services within the CSP-NJ community wellness centers, but what is known among younger adults, as well as teens, was limited by not having reached these populations. There are exponentially greater numbers of individuals with mental illness living in communities, working, going to school, and raising families. How to capture these younger individuals and determine their knowledge, attitudes, and practices about HED is important, especially given the fact that most HED consumers fall within the 18- to 24-year-old age range (34% of consumers of the current study), exclusive of psychiatric illness diagnosis (Gallimberti et al., 2013). A plethora of literature exists regarding HED in general, specifically among teenagers, college students, and bar patrons, but no articles were found that attempt to associate HED with any age population within consumers of mental health services.
As noted in the dialogue, within the statistical findings, the serendipitous happenings of extended and expanded discussions produced many useful ideas for follow up. The suggestions for asking better questions have been noted. No specific ideas were offered for finding younger individuals with mental illness and engaging them in networks and support groups. Many respondents, however, offered anecdotal suggestions about getting family members, particularly children and adolescents, involved in efforts such as the one just experienced by them.