|Year : 2017 | Volume
| Issue : 4 | Page : 336-341
Psychiatric comorbidity and quality of life in patients with alcohol dependence syndrome
Sidharth Arya, Priti Singh, Rajiv Gupta
Institute of Mental Health, Pt BDS University of Health Sciences, Rohtak, Haryana, India
|Date of Web Publication||17-Nov-2017|
Institute of Mental Health, Pt BDS University of Health Sciences, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
Context: There is a lack of literature on the relation between psychiatric comorbidities and their influence on quality of life in patients with alcohol dependence syndrome in the Indian settings. Aims: To study the relation between psychiatric comorbidity with quality of life in patients with alcohol dependence. Settings and Design: The study was carried out in a de-addiction centre of a tertiary care hospital upon randomly selected inpatients of alcohol dependence syndrome. Patients with other substance abuse except tobacco or those with severe physical impairment were excluded. Materials and Methods: Hundred in-patients were assessed between the period of August 2013 to July 2014, using a number of instruments including specially designed proforma for clinical and drinking variables, CIWA-Ar, SADD, M.I.N.I 5.0 and WHO QoL Bref. Statistics used: SPSS 19.0 was used for analysis. Significance was calculated using t-test for continuous variables and chi-square test for categorical variables. Results: Prevalence of psychiatric disorder was found to be 32% across all the tested patients, with anxiety (n = 13) and depressive disorder (n = 12) being most common. Presence of psychiatric comorbidity lead to significant lowering in overall quality, perception of general health, physical (42.12 vs 57.78, P = 0.001), psychological (40.19 vs 53.29, P = 0.002), social (43.97 vs 66.90, P = 0.000), and environment (50.47 vs 62.71, P = 0.001) domains. Conclusion: Comorbid psychiatric disorders have a significant negative impact on the quality of life in patients with alcohol dependence syndrome.
Keywords: Alcohol dependence, dual diagnosis, psychiatric comorbidity, quality of life
Key messages: (a) Poor quality of life in patients with alcohol dependence disorder, (b) Comorbid psychiatric disorder tends to severely lower the quality of life in alcohol dependence syndrome
|How to cite this article:|
Arya S, Singh P, Gupta R. Psychiatric comorbidity and quality of life in patients with alcohol dependence syndrome. Indian J Soc Psychiatry 2017;33:336-41
|How to cite this URL:|
Arya S, Singh P, Gupta R. Psychiatric comorbidity and quality of life in patients with alcohol dependence syndrome. Indian J Soc Psychiatry [serial online] 2017 [cited 2018 Jul 17];33:336-41. Available from: http://www.indjsp.org/text.asp?2017/33/4/336/218595
| Introduction|| |
Alcohol abuse has been recognised as a major public health concern. It is directly or indirectly related to more than 200 diseases and contributed to 6% of global mortality in 2013. Apart from medical morbidity, impact of alcohol in society and individual's quality of life (QoL) are well marked. It has variably been ascribed as a contributing factor to physical accidents, violence, aggression, absenteeism, as well as high degree of deterioration in psychological wellbeing and social life.
Alcohol use has been found to have an elevated risk of comorbidity with other mental disorders (30–75%), which significantly exceeds the prevalence rate of mental diseases in the general population (15–20%)., A number of Indian studies conducted on inpatients have shown strong associations between alcohol dependence with other substance abuse, mood and anxiety disorders, personality disorders with prevalence ranging from 16% to as high as 90%.,,,
As alcohol dependence is being increasingly recognised as chronic relapsing illness, QoL assessment have been often used as secondary outcome measure as well as to measure individual's well being, contentment, and ability to function in different domains. WHO defines QoL as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. Three areas have been defined as relevant to QoL in connection with alcohol addiction: the 'clinical condition', where the amount of alcohol consumed and the level of addiction are the determining factors; 'addiction-specific problems', where the viewpoint of the addicted individual is fundamental; and the 'general functions' associated with social relations and environmental support.
Earliest studies assessing QoL in alcohol dependence reported a lower QoL in those who used alcohol, more so in those with high frequency and binge drinking pattern. Romeis et al., in their study on twins concluded that differences in health-related QoL between alcohol and non-alcohol consuming groups were due to co-variation from physical and psychiatric problems, drug and nicotine dependence, marital status, income, and severity. Apart from certain socio-demographic factors, presence of psychiatric comorbidity have been found to contribute significantly to lowering QoL in alcohol dependence. There have been few studies from India highlighting the poor QoL in alcohol dependence,, however, there is lack of literature on the relation between comorbidities and their influence on QoL in alcohol dependence syndrome in Indian settings. This study was undertaken with following objectives: (a) to study the prevalence of psychiatric comorbidity in patients with alcohol dependence syndrome, (b) to study QOL in patients with alcohol dependence syndrome, (c) to study the relation between psychiatric comorbidity with QoL in patients with alcohol dependence syndrome.
| Patients and Methods|| |
The study sample comprised inpatient males aged 18–60 years admitted with a diagnosis of alcohol dependence syndrome according to ICD-10 criteria. The in-patient stay in ward varies from few days to four weeks depending upon patient and clinical profile; however, the average stay for subjects in this study was 3 weeks. Those patients who abused other substances except tobacco or those with severe physical impairment were excluded from the study. The study was carried out at a deaddiction centre of a tertiary care hospital in North India between the period of August 2013 to July 2014.
All the patients who were requested to participate in the given study, agreed. They were informed about the aims of the study and a written informed consent was taken. The study did not interfere in their treatment and management was carried out as usual. The study was approved by the institutional ethical board.
The study sample was assessed using following instruments:
- Sociodemographic proforma: A special semi-structured proforma was used to gather the information about socio demographic, clinical, and drinking variables.
- Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar): It is a 10-item scale widely used in the assessment and management of alcohol withdrawal. Patients were taken for assessment only when their CIWA score was less than 10 (no or mild withdrawal symptoms).
- Mini International Neuropsychiatric Interview 5.0 (MINI): It is a short, structured diagnostic interview to diagnose ICD-10 psychiatric disorders. It was used to establish the diagnosis of alcohol dependence syndrome as well as other comorbid psychiatric disorders.
- Severity of Alcohol Dependence Data (SADD): It is a 15-item self-report used the measure the severity of dependence. Each question has four possible responses, scored as 0, 1, 2, and 3. The maximum score on the scale is 45 and dependence is categorized, based on scores, into low (0–9), moderate (10–19), and high (>19) dependence.
- WHO Quality of Life (WHOQOL): BREF Hindi Version-it consists of 26 items: two benchmark items measuring overall QoL and perception of health and 24 items measuring four domains of QoL: physical, psychological, social, and environment. The instrument makes use of 5-point Likert scales with higher scores denoting a better QoL. Hindi version have been developed by Saxena et al., which has been found to have satisfactory psychometric properties with the original version.
| Methodology|| |
The patients taken in study were admitted for management of alcohol dependence syndrome. They were assessed only after completion of detoxification phase, at the end of 3 weeks when they were nearing the completion of inpatient management. Those meeting inclusion criteria were assessed for residual withdrawal symptoms using CIWA-Ar and only those scoring less than 10 (no or mild withdrawal symptoms) were further evaluated. Sociodemographic details and drinking variables were assessed using special proforma, following which their dependence severity was assessed by SADD. Psychiatric comorbidity was assessed using MINI, following which they were assessed for their QoL.
Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 19.0 (SPSS Inc., Chicago, IL). Frequency, mean, and range were calculated for sociodemographic and clinical variables. Chi-square test was used as test of significance for association between psychiatric comorbidity and QoL in sample population.
| Results|| |
The sample comprised 100 inpatient males. Mean age of the study group was 38.93 ± 8.57 years (mean ± SD). Ninety three (93%) of the patients had attended school at some point, while remaining 7% were illiterate. Majority of the patients were married (84%) and belonged to nuclear families (54%). Only 16% were currently unemployed and more than half of the sample (58%) was from rural background [Table 1].
Drinking and clinical characteristics of the sample
The mean age at alcohol initiation was 21.40 years, while age at developing dependence was 32.32 years with 6.74 years as mean duration of alcohol dependence. The sample had severe (48%) and moderate (51%) level of dependence using SADD scale, with mean alcohol intake being 284.85 grams/day. Thirty two (32%) patients suffered from psychiatric comorbidity, with generalized anxiety (n = 13, 40%) and depression (n = 12, 37%) being the most common disorders [Table 2].
Psychiatric comorbidity and quality of life
The mean of the component assessing the overall QoL was 2.73 ± 1.26, while for the general health, the mean was 2.62 ± 1.02. In the physical health domain, the mean score was 52.77 ± 20.72 (range 4.00–94.00), while for psychological domain, the mean score was 49.10 ± 19.91 (range 6.00–94.00). In the social relationship domain, the mean score was 59.56 ± 24.63 (range 0.00–100.00), and in environment domain, the mean was 58.79 ± 17.07 (range 6.00–100.00).
A comparison of responses to overall QoL and perception of general health between total sample, subjects with or without psychiatric comorbidity has been shown in [Figure 1] and [Figure 2], respectively.
|Figure 1: Comparison of the perception of General Health in total sample, in subjects with and without Psychiatric Co-morbidity|
Click here to view
|Figure 2: Comparison of the perception of Overall QOL in total sample, in subjects with and without Psychiatric Co-morbidity|
Click here to view
When QoL domains were compared between subjects with or without psychiatric comorbidity, significant differences were found in all domains [Table 3], with maximum difference in social relationship domains (t = 4.80, P < 0.001) and least in psychological domain (t = 3.22, P = 0.002).
|Table 3: Psychiatric comorbidity and quality of life domains in alcohol dependence|
Click here to view
| Discussion|| |
The patient profile of the current study consisted of all male inpatients with majority of subjects being middle aged, married, employed, and educated upto middle school, findings which were similar to the previous studies carried out in India on alcohol-dependent patients.,, The mean age of initiation of drinking was 21.40 years and dependence was 32.32 years with 6.75 years as mean duration of dependence. A total of 75% of subjects had started drinking before they turned 25. All the subjects had moderate to severe dependence as measured by SADD.
The prevalence of psychiatric disorder in our sample was 32%, the most common disorders being Generalised Anxiety Disorder (n = 13, 40%) and depressive disorder (n = 12, 37%). The type of comorbid psychiatric diagnosis in alcohol dependence vary from study to study, with some indicating mood disorders to be the most common, while other studies reporting anti-social personality or anxiety to be the most common disorders.,, A number of factors have been proposed explaining the high rate of comorbid psychiatric disorders in alcoholic patients, including: (a) Use of alcohol as a self medication for insomnia, dysphoria, anxiety, (b) Inherited genetic vulnerability for both alcohol and psychiatric disorders, (c) Acute and chronic brain damage due to effect on central nervous system, (d) Excessive and chronic alcohol consumption can adversely affect a person's health, finances, and relations with resulting psychological stress making them vulnerable to psychiatric disorders.
A total of 38% of the subjects perceived their overall QoL as poor or very poor, while 44% expressed dissatisfaction with their general health. In comparison to psychiatric comorbidity, 17 (53%) subjects expressed having poor overall perception of QoL, while 18 (56%) were dissatisfied with their general health. This was quite similar to the study conducted by Coalpert et al., where 1/3rd subjects reported overall quality as poor, and 40% expressed dissatisfaction with their general health. In all the four domains of QoL, those with psychiatric comorbidity when compared with those without psychiatric comorbidity had significantly lower scores on physical domain (42.12 vs 57.78, P = 0.001), psychological domain (40.19 vs 53.29, P = 0.002), social domain (43.97 vs 66.90, P < 0.001), and environment (50.47 vs 62.71, P = 0.001) domain. Apart from occasional study, majority of literature supports the negative correlation of psychiatric comorbidity with a poor QoL. Studies comparing the specific groups with alcohol dependence, psychiatric illness, and patients with dual diagnosis, have found the lowest QoL in later group.,, Possible explanations for this negative relationship could be: (a) the attributes of both the illnesses may contribute to QoL in additive fashion, (b) these patients have a more complicated and recurrent course resulting in more relapses, which leads to impaired QoL, (c) another reason could be difficulty in the management of patients with dual diagnosis since they require a special approach. Alternatively, combination of all these factors would contribute to various extent, resulting in a poor QoL with psychiatric comorbidity in alcohol dependence syndrome.
Strengths and limitations
The measurement of QoL in patients with alcohol dependence just few weeks after detoxification pose a certain challenge. On one hand, patients are likely to report withdrawal symptoms and related anxiety and depressive features along with distress of admission might lead to reporting of poor QoL. On the other hand, treatment and non-pharmacological interventions may provide them support and a belief that they can quit alcohol, which might lead to better QoL. This study consisted of randomly selected alcohol dependent inpatients who were interviewed only after they had recovered from withdrawal symptoms, thus eliminating the bias due to intoxication or abstinence violation. The prevalence of psychiatric comorbidity was assessed using a standard diagnostic interview. However, this particular study was not free from limitations. First is the fact that it was a cross-sectional study and it was not possible to assess the direction of the relationship between different variables. Secondly, the sample size consisted of admitted patients, who are supposed to have severe dependence, and hence, more likely to report poor quality. Thirdly, it was not possible to measure the impact of economic status and other sociodemographic variables on QoL, which may have contributed to certain bias. Since the patients were assessed within three weeks of detoxification, the contribution of protracted withdrawal in over reporting of anxiety symptoms might have led to some bias. Lastly, the study did not measure the severity of anxiety and depression and its impact on QoL.
Interpretation and implications: Alcohol abuse leads to negative impact on social, occupational and economic aspects of an individual, leading to impairment of various role functions, ultimately contributing to poor QoL. Furthermore, psychiatric comorbidity in alcohol dependence leads to more impairment in QoL. The assessment of alcohol dependence with psychiatric co-morbidity must consider different aspects of QoL, which has been impaired and management strategies must aim to address this in certain way, only then a holistic approach to management of alcohol dependence could be put into practice.
Further research directions
Further studies with larger sample size and longitudinal follow-up would better help delineate the factors affecting the QoL as well impact of psychiatric comorbidity on QoL in alcohol dependence syndrome. On the same lines, QoL must be considered as an important measure of psychosocial burden in patients of alcohol dependence with psychiatric comorbidity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization 2014. World Health Organization. Global Status Report on Alcohol Health. Geneva Switzerland: WHO Press; 2011.
Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of diseases, injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373:2223-33.
Klimkiewicz A, Klimkiewicz J, Jacubczyk A, Kieres-Salomoński I, Wojnar M. Comorbidity of alcohol dependence with other psychiatric disorders. Part I. Epidemiology of dual diagnosis. psychiatr Pol 2015;49:265-75.
Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64:830-42.
Kattukulathil S, Kallivayalil RA, George R, Kazhungil F. Psychiatric comorbidity in alcohol dependence: A cross-sectional study in a tertiary care setting. Kerala J Psychiatry 2015;28:72-6.
Vohra AK, Yadav BS, Khurana H. A study of psychiatric comorbidity in alcohol dependence. Indian J Psychiatry 2003;45:247-50.
] [Full text]
Singh NH, Sharma SG, Pasweth AM. Psychiatric co-morbidity among alcohol dependants. Indian J Psychiatry 2005;47:222-4.
] [Full text]
Kaur R, Krishna PS, Ravinder E, Sahithi JK, Dattatrey M. Psychiatric disorders in adult males with alcohol dependence - A study in Telengana region of Andhra Pradesh. Int J Res Med 2013;2:80-6.
Ugochukwu C, Bagot KS, Delaloye S, Pi S, Vien L, Garvey T, et al.
The importance of quality of life in patients with alcohol abuse and dependence. Harv Rev Psychiatry 2013;21:1-17.
WHOQOL Group. Position paper from the World Health Organization. Soc Sci Med 1995;41:1403-9.
Longabaugh R, Mattson RE, Connors GJ, Cooney NL. Quality of Life as an outcome variable in Alcoholism Treatment Research. J Stud Alcohol 1994;55:119-29.
Welsh JA, Buchsbaum DG, Kaplan CB. Quality of life of alcoholics and non-alcoholics: Does excessive drinking make a difference in the urban setting? Qual Life Res 1993;2:335-40.
Volk RJ, Cantor SB, Steinbauer JR, Cass AR. Alcohol use disorders, consumption patterns and health-related quality of life of primary care patients. Alcohol Clin Exp Res 1997;21:899-905.
Romeis JC, Waterman B, Scherrer JF, Goldberg J, Eisen SA, Heath AC, et al.
The impact of sociodemographics, comorbidity and symptom recency on health-related quality of life in alcoholics. J Stud Alcohol 1999;60:653-62.
Levola J, Aalto M, Holopainen A, Cieza A, Pitkänen T. Health-related quality of life in alcohol dependence: A systematic literature review with a specific focus on the role of depression and other psychopathology. Nord J Psychiatry 2014;68:369-84.
Srivastava S, Bhatia MS. Quality of life as an outcome measure in the treatment of alcohol dependence. Ind Psychiatry J 2013;22:41-6.
] [Full text]
Patra BN, Sarkar S, Basu D, Mattoo SK. Quality of life of opioid-and alcohol-dependent treatment seeking men in North India. J Substance Use 2015;9:1-6.
Singh S, Balhara YP. A Review of Indian Research on Co-occurring Psychiatric Disorders and Alcohol use Disorders. Indian J Psychol Med 2016;38:10-9.
] [Full text]
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders – Diagnostic Criteria for Research Geneva Switzerland: World Health Organization. 1992.
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: The revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84:1353-7.
Sheehan DV, Lecrubier Y, Harnett-Sheehan K, Amorim P, Janavs J, Weiller E, et al.
The M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.): The Development and Validation of a Structured Diagnostic Psychiatric Interview. J Clin Psychiatry 1998;5:22-33.
McMurran M, Hollins CR. The Short Alcohol Dependence Data (SADD) Questionnaire: Norms and reliability data for male young offenders. Br J Addict 1989;84:315-8.
The WHOQOL Group: Development of the WHOQOL-BREF Quality of Life Assessment. Psychol Med 1998;28:551-8.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. Natl Med J India 1998;11:160-5.
Sánchez-Peña JF, Álvarez-Cotoli P, Rodríguez-Solano JJ. Psychiatric disorders associated with alcoholism: 2 year follow-up of treatment. Actas Esp Psiquiatr 2012;40:129-35.
Kumar V, Dalal PK, Trivedi JK, Kumar P. A study of psychiatric comorbidity in alcohol dependence. Delhi Psychiatry J 2010;13:291-3.
Mueser KT, Drake RE, Wallach MA. Dual Diagnosis: A review of etiological theories. Addict Behav 1998;23:717-34.
Colpaert K, Maeyer JD, Broekaert E, Vanderplasschen W. Impact of Addiction Severity and Psychiatric Comorbidity on the Quality of Life of Alcohol, Drug and Dual Dependent Persons in Residential Treatment. Eur Addict Res 2013;19:173-83.
Garg N, Yates WR, Jones R, Zhou M, Williams S. Effect of gender, treatment site, and psychiatric comorbidity on quality of life outcome in substance dependence. Am J Addict 1999;8:44-54.
Singh J, Mattoo SK, Sharan P, Basu D. Quality of life and its correlates in patients with dual diagnosis of bipolar affective disorder and substance dependence. Bipolar Disord 2005;7:187-91.
Saatcioglu O, Yapici A, Cakmak D. Quality of life, depression and anxiety in alcohol dependence. Drug Alcohol Rev 2008;27:83-90.
Benaiges I, Prat G, Arden A. Health-related quality of life in patients with dual diagnosis: Clinical correlates. Health Qual Life Outcomes 2012;10:106.
Laudet AB. The case for considering quality of life in addiction research and clinical practice. Addict Sci Clin Pract 2011;6:44-55.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]