Psychiatric comorbidity in alcohol dependence: a cross-sectional study in a tertiary care setting

Abstract

Background
Alcohol dependence is a very important public health issue in Kerala. Though alcohol dependence is demonstrated to be associated with psychiatric comorbidities, no attempts have been made to analyze the magnitude and pattern of comorbid psychiatric disorders in the state.
Methods
We assessed 88 inpatients with ICD 10 diagnosis of alcohol dependence syndrome for the presence of comorbid psychiatric disorders, using ICD 10 Diagnostic Criteria for Research,
after two weeks of inpatient care. Patients with delirium tremens, alcohol-induced psychosis or
organic illnesses were excluded.
Results
66.59% of our subjects had a comorbid psychiatric disorder. Bipolar affective disorder was the most common one (20.4%). Prevalences of other disorders were: unipolar depression (17%), phobia (9%), antisocial personality disorder (6.8%), generalized anxiety disorder (6.8%), schizophrenia (3.4%), obsessive compulsive disorder (1.1%) and delusional disorder (1.1%).
Conclusion
Comorbid psychiatric disorders are highly prevalent in alcohol dependence. There is a need for further large-sample studies on the comorbidities and on integrated strategies for the identification and management of both alcohol dependence and comorbid psychiatric disorders.

Full text

Kerala Journal of Psychiatry // 28(2) July – December 2015 // www.kjponline.com
1
Research Report
PSYCHIATRIC COMORBIDITY IN ALCOHOL
DEPENDENCE: A CROSS-SECTIONAL STUDY IN A
TERTIARY CARE SETTING
Shihab Kattukulathil1*, Roy Abraham Kallivayalil2, Rachna George3, Firoz Kazhungil4
1Senior Resident, Dept. of Psychiatry, Government Medical College, Manjeri.
2Professor and Head, Dept. of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre,
Thiruvalla.
3Junior Resident, Dept. of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre,
Thiruvalla.
4Assistant Professor, Dept. of Psychiatry, Government Medical College, Manjeri.
*
Correspondence
: Dept. of Psychiatry, Government Medical College, Manjeri, Kerala. PIN 676121
Email
: shihab001@gmail.com
ABSTRACT
Background:
Alcohol dependence is a very important public health issue in Kerala. Though
alcohol dependence is demonstrated to be associated with psychiatric comorbidities, no attempts
have been made to analyze the magnitude and pattern of comorbid psychiatric disorders in the
state.
Methods:
We assessed 88 inpatients with ICD 10 diagnosis of alcohol dependence syndrome for
the presence of comorbid psychiatric disorders, using ICD10 Diagnostic Criteria for Research,
after two weeks of inpatient care. Patients with delirium tremens, alcohol-induced psychosis or
organic illnesses were excluded.
Results:
66.59% of our subjects had a comorbid psychiatric disorder. Bipolar affective disorder
was the most common one (20.4%). Prevalences of other disorders were: unipolar depression
(17%), phobia (9%), antisocial personality disorder (6.8%), generalized anxiety disorder (6.8%),
schizophrenia (3.4%), obsessive compulsive disorder (1.1%) and delusional disorder (1.1%).
Conclusion:
Comorbid psychiatric disorders are highly prevalent in alcohol dependence. There
is a need for further large-sample studies on the comorbidities and on integrated strategies for
the identification and management of both alcohol dependence and comorbid psychiatric
disorders.
Keywords: Alcohol dependence, comorbidity, psychiatric disorder
Please cite this article as:
Kattukulathil S, Kallivayalil RA, George R, Kazhungil F. Psychiatric comorbidity in alcohol
dependence: a cross-sectional study in a tertiary care setting. Kerala Journal of Psychiatry 2015; 28(2). Available at
http://kjponline.com/index.php/kjp/article/view/23/pdf

Kerala Journal of Psychiatry // 28(2) July – December 2015 // www.kjponline.com
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INTRODUCTION
“Comorbidity” denotes the presence of a
distinct clinical entity that has existed or may
occur during the clinical course of a patient
having the index disease.1 Psychiatric
comorbidities have a high prevalence among
patients of alcohol dependence,2,3,4 and often
pose challenges in their diagnosis and
treatment. Comorbid psychiatric illnesses
have been found to be a major contributor to
relapses.5 Comorbidities commonly reported
in this population include unipolar depression,
bipolar disorder, panic disorder, generalized
anxiety disorder (GAD), antisocial
personality disorder (ASPD), obsessive
compulsive disorder (OCD) and
schizophrenia.2,6,7,8 Unfortunately, often only
the symptoms of dependence get sufficient
clinical attention.
Comorbid psychiatric disorders in patients of
alcohol dependence is a crucial area of
research due to various reasons: First is the
already reported very high prevalence of such
comorbidity. In National Comorbidity
Survey (NCS), the largest household
psychiatric disorder survey, about one-third
of respondents with alcohol dependence had a
comorbid mood disorder.9 Prevalence of
comorbid major depressive disorder (27.9%)
and anxiety disorder (36.9%) were very high
in the NCS. Studies have shown that
comorbidity in alcohol dependence would
lead to more chronic alcohol use, treatment
resistance of the comorbid disorder, and high
suicide rates and disability.10 Moreover,
presence of psychiatric comorbidities is
associated with poor treatment seeking for
alcohol dependence.11 Comorbid disorders
also raise a challenging question of how to
provide the best integrated treatment to
address both the alcohol dependence and the
comorbidities.
Among the Indian states, Kerala has the
highest per capita consumption of alcohol —
nearly three times the national rate.11 A
WHO-funded study conducted by Indian
Council of Medical Research found that, in
Kerala, 11% of the respondents had consumed
alcohol over the past 30 days, and, of the total
number of drinkers, the average consumption
was three drinks per day.12 Such a severe
alcohol dependence will be associated with
high prevalence of psychiatric disorders too.
But, to the best of our knowledge, no studies
have looked into the pattern of psychiatric
comorbidity in alcohol dependence in the
state.
Our study aimed to find the prevalence of
psychiatric comorbidities among alcohol
dependence patients attending a de-addiction
facility.
METHODOLOGY
The study followed a cross-sectional design.
It was conducted in the De-addiction unit of
the Dept. of Psychiatry at Pushpagiri Institute
of Medical Sciences and Research Centre,
Thiruvalla, which is a tertiary care hospital.
Study population included patients admitted
for de-addiction who fulfilled the ICD-10
criteria for alcohol dependence syndrome.
The assessment for psychiatric comorbidities
was done by a qualified psychiatrist,
according to ICD-10 Diagnostic Criteria for
Research, through clinical assessment, after
two weeks of inpatient treatment. Assessment
of sociodemographic profile and other
characteristics of patients in terms of age of
initiation of alcohol use and duration of
dependence was also done.
Patients who remained in delirium even after
two weeks, those with alcohol-induced
psychosis, and those with organic illnesses
were excluded. Duration of the study was six

Kerala Journal of Psychiatry // 28(2) July – December 2015 // www.kjponline.com
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Table 1: Distribution of study participants by
demographic variables
months — from July 2013 to December 2013.
The study was approved by the Institutional
Ethics Committee. Informed consent was
obtained from the patients.
Continuous variables, such as age, were
summarized in the form of means and
standard deviations; while categorical
variables like marital status were summarized
in percentages.
Variable
Number (n= 88)
Percent
AGE AT INITIATION (in years)
Mean=28.9 SD= 1. 63
<20
3
3
21-30
52
59
31-40
33
38
DURATION OF DEPENDENCE (in
years)
Mean= 5.8 SD= 1. 6
1-5
48
54
6-10
30
34
11-15
8
9
16-20
2
3
Table 2: Characteristics of alcohol use
RESULTS
A total of 88 patients were included. All the
participants were male. Majority were in the
age group of 31-40 years (n=42, 47%),
married (n=75, 85%), had completed
secondary school education (n=33, 38%),
unskilled workers (n=40, 45%), and earning
in the range of 10000-20000 INR per month
(n=45, 52%) (Table 1). Age at initiation was
between 21-30 years in 52 (59%) subjects,
while the duration of alcohol dependence was
in 1-5 year range in 48 (54%) of them (Table
2).
Overall prevalence of any psychiatric
comorbidity was 66.59%. Rates of specific
comorbidities are depicted in Figure 1.
DISCUSSION
Our sample contained relatively elderly
patients (mean age 40.39 years, SD 2.38) and
age of onset of alcohol use too was relatively
late (mean 28.9 years, SD 1.63), compared to
another Indian study by Singh et al.2 The
mean duration of dependence was 5.8 (SD 1.6)
years, which is shorter compared to the
finding by Singh et al.2 Similar to some other
Indian studies on comorbidities in alcohol
Variable
No: (n= 88)
Percent
AGE (IN YEARS)
Mean= 40.39 years SD= 2.38 years
21-30
5
6
31-40
42
47
41-50
34
39
>50
7
8
MARITAL STATUS
Married
75
85
Unmarried
10
11
Separated
3
4
EDUCATION
Primary
30
34
SSLC
33
38
PDC/+2
18
20
Degree
7
8
OCCUPATION
Unemployed
8
9
Unskilled
40
45
Skilled
22
25
Professional
18
21
FAMILY INCOME PER MONTH (in
rupees)
5000 -10,000
34
39
10,000-20,000
46
52
>20,000
8
9
Total
88
100

Kerala Journal of Psychiatry // 28(2) July – December 2015 // www.kjponline.com
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Figure1: Bar diagram showing the percentage of various psychiatric comorbidities.
BPAD: Bipolar
affective disorder GAD: Generalized anxiety disorder APSD: Antisocial personality disorder
OCD: Obsessive compulsive disorder
dependence, all our subjects were male.14,15
The reasons could be that, as per the
experience of psychiatrists working in the
state, alcohol consumption by women is less
socially accepted in Kerala, alcohol use is
more prevalent in men than women in this
region, and women are less likely to get
admitted for treatment of alcohol dependence.
Psychiatric comorbidity was found in
66.59% of our subjects. This is comparable to
the findings of other studies.4,14 One Indian
study had demonstrated a higher prevalence
of 81% in inpatients with alcohol
dependence.15 However, we should remember
that, as per existing literature, even in
outpatients with alcohol dependence the
reported prevalence range is from 76.6% to
92%2,4 — such wide range may be due to
factors like the context (whether the study is
conducted in outpatients, inpatients or
community sample), the tools used (whether a
structured interview schedule was used to
diagnose comorbidities or not) and stage of
illness (whether the evaluation was done
during active use or remission). NCS, which
was a community study, had found a
prevalence of 66.1% — a figure comparable to
our own finding.
Many Indian studies had revealed a very low
prevalence of bipolar disorder in alcohol
dependence, from 0% to 16%.2,4,9,15 But our
study found bipolar disorder to be the
commonest comorbidity (20.4%). This should
be viewed in light of the fact that comorbidity
of bipolar disorder and alcohol dependence
was the most common dual diagnosis detected
in NCS.9 Moreover, as the age onset of alcohol
dependence in our sample was later than the
usual age of onset for bipolar disorder, it is
possible that our patients with alcohol
dependence-bipolar comorbidity developed
bipolar disorder first and then only developed
alcohol dependence. But we did not look into
the temporal association of the two disorders
in our sample.
20.4(n=18)
17(n=15)
9(n=8)
6.8(n=6) 6.8(n=6)
3.4(n=3)
1.1(n=1) 1.1(n=1)
0
5
10
15
20
25

Kerala Journal of Psychiatry // 28(2) July – December 2015 // www.kjponline.com
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Unipolar depression was diagnosed in 17% of
our sample. Such a relatively lower
prevalence of unipolar depression has been
detected by another Indian study too.16
However, some other studies have also
documented higher prevalence of 26% and
33%.2,17 In our study, compared to other
studies, duration of dependence was short and
hence the less chronic nature of alcohol use
might have resulted in lower prevalence of
depression.2
In our sample, phobia was diagnosed in 9% of
subjects. (Different types of phobias, such as
social phobia, agoraphobia, specific phobia or
other phobic disorders, were grouped
together in this study.) GAD was diagnosed
in 6.8%, and this prevalence is similar to the
findings by Singh et al. (8%).2 ASPD was
diagnosed only in 6.6% of our cases, and this
is far less compared with the findings of Singh
et al. (21%).2 This may be due to our use of
unstructured interview and ICD-10 criteria to
diagnose personality disorders.
Surprisingly, our study showed a very low
prevalence of schizophrenia in alcohol
dependence (3.4%). In Epidemiologic
Catchment Area (ECA) study, the lifetime
rate of comorbid schizophrenia in the alcohol
dependence group was 24%.18 We included
only those patients who attended our de-
addiction unit — many patients with
schizophrenia- alcoholism comorbidity might
have been attending our general psychiatry
department for treatment of schizophrenia,
and hence could have got excluded from this
study. Another reason could be that many
patients with alcohol dependence-
schizophrenia comorbidity would have got
admitted to any of the rehabilitation centers
prevalent in the state, for life-long stay, due to
the higher severity or chronicity of their
illnesses. Prevalence of comorbid OCD we
found is comparable to the findings of Singh
et al.2
Limitations of our study include small sample
size, cross-sectional design, not using a
structured interview schedule, and including
only inpatients. We did not assess comorbid
use of other substances (including nicotine),
physical comorbidity, or treatment
parameters. Personality evaluation scales or
structured interview schedule for axis II
disorders could have been used to detect
personality disorders.
To conclude, our study highlights the fact that
psychiatric comorbidities are highly prevalent
in alcohol dependence. Studies with larger
sample size, studies that include patients with
remitted alcoholism, and studies on integrated
interventions to treat both alcoholism and the
comorbid psychiatric disorders are needed in
the future.
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Source of support:
None
Conflict of interest:
None declared.