A florist shop in Mladost, once run by a nice lady with a friendly smile, is now empty. It is still open but without staff. The woman now spends the day drinking prodigious quantities of cheap wine at a cafe opposite. If a customer comes in, she has to dash over.

I have never seen her eat anything at all. In the evening, when I go to the supermarket on the way home, she is often there with her equally befuddled partner, buying "dinner" – a loaf of bread and a bottle of the cheapest rakiya. She looks dreadful: emaciated, withered, ravaged and ruddy-complexioned with a swollen stomach. She would be – although I have not suggested it to her – the "perfect" candidate for admission to an alcohol treatment centre.

Alcoholism and drug addiction are not discriminatory illnesses. They do not respect geography, social class or profession. They are worldwide problems, although each country seems to have its own distinctive pattern. The crazed binge drinker who ends up in a pool of vomit in the street, an increasingly tiresome characteristic of British life, is perhaps less common in Bulgaria. On the other hand, the incidence of alcoholism is actually higher in France than in the UK, perhaps due to habitual wine consumption at meal times.

Yet times they are a-changing everywhere and so are old assumptions. Economic crisis is pushing more people to the bottle. And Christmas time gives them the perfect excuse to over-indulge.

So it is appropriate perhaps that on a foggy Sofia day in the run-up to the holidays I find myself in an austere building at the state psychiatric hospital of alcohol and drug addiction, a specific section within the Ministry of Health.

Hidden problem
Associated professor Sonya Toteva-Zhenkova is the director of the hospital. She treats problem drinkers but only as out-patients. The main hospital for residential patients – a last resort as beds are scarce – is in the mountains 20km outside Sofia.

The "out of sight" location of the residential hospital, is, she says, no accident. Rather, it is a relic of communism. "During totalitarian times, alcoholics were isolated far from the city because this kind of problem was hidden. The authorities did not want to recognise it," she says.

Toteva-Zhenkova estimates that in Bulgaria, 340 000 people are alcoholics, and about 40 000 are drug addicts. In Bulgaria, unlike in the UK where drinking with meals is perhaps rarer, alcohol use often begins at home. The classic example is, of course, the obligatory rakiya with salad.

Alcoholism progresses through "stages" familiar to those unfortunate enough to have experience of the illness. The problem drinker develops increased tolerance for alcohol. He or she tries to control it but ultimately fails because of painful withdrawal symptoms. Consumption increases until the final stage – dramatically reduced tolerance. By then sometimes just uncorking a whisky bottle and taking a good whiff can transform the person into a shambling wreck.

Treatment
If alcoholics seek help for their drinking, their first encounter is likely to be with a professional like professor Toteva-Zhenkova.

She adopts a multi-disciplinary approach, involving contact with relatives – not just the drinker – because she thinks the problem also concerns the patient's family. She works with 13 doctors and 10 psychologists who are skilled in behavioural therapy. She says that treatment over the past decade or so has been characterised by more of a psycho-therapeutic approach.

Unemployment and poverty, notes the professor, are pushing up rates of alcoholism.

"Sometime they (alcoholics) come from a broken home, or they are divorced. But, especially, if people watch TV all day and sit doing nothing – without children or family – it's common to drink to forget there is no money."

She has identified other drinking "types", without, of course, wishing to generalise. That is the bored expat. "People from countries like the UK, Norway and Sweden, who have relocated to Bulgaria, may drink because they have too much free time. Their problems are not typically Bulgarian ones (material concerns) but of a different nature."

She has also come across another type of addict, the Bulgarian emigre who has worked in the UK. Perhaps feeling disorientated and displaced, they have turned to booze to help them adjust to the faster pace of life. Totev-Zhenkova is familiar with this pattern through working for two years in the alcohol unit of London's Chelsea and Westminster hospital.

The professor admits that goiing cold turkey is hard. Medicines – such as benzedrine and sleeping tablets – sometimes have to be administered to drinkers to facilitate their withdrawal. She notes that 70 to 80 per cent of patients have depression, panic attacks and mood disorders. Occasionally, these are actually the primary problems which, if treated, can eliminate or lessen alcohol dependency.

Drugs
Bulgaria is not, to the naked eye at least, a country of rampant drug use. Toteva-Zhenkova agrees with me that countries such as Portugal and the UK (I cite them only because of my familiarity with them) have more problems with hard drugs.

Professor Toteva-Zhenkov has just returned from Lisbon. Although a beautiful city, the Portuguese capital is conspicuously "druggie". Toothless addicts stand around on most street corners, waving cars into parking spaces. Certain sections of the city are given over to housing addicts. One of Sofia's (many) advantages is the relative lack of such cases, or at least they seem to be less visible.

"I was in Lisbon with my son and he must have been offered drugs at least 10 times as he walked through the streets," says Toteva-Zhenkov, noting that the "trade route" for drugs to Portugal comes from the ocean.

"A decade ago, the situation in Bulgaria was worse. Then there were too many people using heroin. Now the drugs of first choice are amphetamines and methadone."
She believes that drug dissemination routes to Bulgaria have been intercepted by "problems" in traditional countries that were suppliers. Such a case would be war-torn Afghanistan.

Diagnosis
Pinpointing alcoholism is not always straightforward and inevitably a matter of debate because of the stigma that is still attached. Such a diagnosis follows interviews, psychological tests and urine samples. Then professor Toteva-Zhenkova has to decide whether to treat the person as an outpatient or residential patient.

Diagnosis also depends on the makeup of the individual. The person who habitually drinks a bottle of wine a day is not necessarily an alcoholic, although they could be. It depends, she says, on individual metabolism – specifically the enzymes that burn alcohol – in the person concerned. She explains that were she to drink a bottle of wine she would feel bad the following day. Others could be unaffected.

Worldwide, between five and seven per cent of the population have alcohol problems; in Bulgaria the figure is close to the upper end of this range. She is particularly concerned that in Bulgaria – and perhaps in most countries – young people are drinking more. Whether this stems from emancipation or bravado is a different question. In Bulgaria, although it is technically against the law for those under the age of 18 to buy alcohol, rules are seldom enforced. Although it is hard to generalise, she says that certain professions – the military and law enforcement – are more prone to alcoholism. Ironically, she says that there is also a high incidence of alcoholism among surgeons.

Violence
One aspect of alcoholism particularly concerns her, and that is domestic violence and the lack of options open to her as a doctor. If a patient is persistently aggressive to their immediate family, verbally or physically, then Toteva-Zhenkova might recommend that they spend time as a residential patient. But if the drinker in question refuses to go, then she can do very little.

Unlike 20 years ago, when she could, for example, write a letter to the police recommending that the patient is separated from his/her family, forcing someone to accept treatment is not an option. She believes, however, that this is a failing in the law and that admission to a medical facility should be compulsory if the addict has been shown to be violent towards family members.

Another salient problem – and one that might mitigate against professionals diagnosing alcoholism – is the lack of beds for treatment, particularly in the Sofia region where, she says, incredibly, there are only 20 residential places for alcoholics, although there are more in other parts of the country, particularly near to Stara Zagora.

Another problem "facilitating" alcohol abuse in Bulgaria is that booze is cheap. There is one very good reason for this. Many families brew their own rakiya and the homemade variety is likely to be more potent than that found in shops.

Many alcoholics express a wish to return to "normal" consumption but, of course, the very loss of control that drove them to seek medical assistance in the first place makes that extremely unlikely. Rather than tell recovering alcoholics to face up to a life of abstinence – a pledge that is often hard to keep – Toteva-Zhenkova tells them that they should refrain from drinking for a year. At the end of that period, hopefully aware by now of the benefits of abstinence, they will be reluctant to fall off the wagon and revert back to old ways.

Toteva-Zhenkova says that recommended safe drinking limits are 50mm of spirits or two glasses of wine a day.