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p class="Default"> Introduction: Women with ADS may have psychiatric comorbidites along with physical comorbidities. Societal attitudes towards women and alcohol are barriers to the detection and treatment of their alcohol related problems. Objective: To explore the magnitude of co-morbidity among women with ADS in Eastern Nepal. Method: This is a hospital based cross-sectional study of women with ADS. Those who scored two or more than two in T-ACE questionnaire were enrolled. The diagnosis was made according to ICD-10 criteria. Consultation with concerned physician was done to assess physical condition. Result: Fifty one patients with ADS were enrolled. Among them, 21.6% had no comorbidity, 52.9% had single co-morbidity (psychiatric or physical) and 25.5% had both psychiatric and physical co-morbidity. In psychiatric comorbidity, mood disorder in 35.29% was the commonest followed by nicotine use in 26.47%. Among mood disorders 83.3% had depression. In physical comorbidity, disease of gastrointestinal tract and hepatobiliary system in 50.9% was the commonest followed by hypertension in 11.5%. Conclusion: : Psychiatric as well as physical co-morbidities are common in women with ADS. The finding points to the importance of exploring comorbidities and their optimal treatment.</p
J Psychiatrists’ Association of Nepal Vol .5, No.1, 2016
Joshi RG et. al. Comorbidity in Women with Alcohol..
Co-morbidity in women with alcohol dependence syndrome
(ADS) in Eastern Nepal
Joshi RG1, Shakya DR2, Shyangwa PM3, Pradhan B4
1.Associate Professor, Department of Psychiatry, BPKIHS, Dharan, Nepal 2. Additional
Professor, Department of Psychiatry, BPKIHS, Dharan Nepal 3. Professor, Department of
Psychiatry, BPKIHS, Dharan, Nepal 4. Professor, Department of Internal Medicine, BPKIHS,
Dharan, Nepal
E-mail *Corresponding author: rinkugautam@hotmail.com
Abstract
Introduction: Women with ADS may have psychiatric comorbidites along with physical comorbidities. Societal
attitudes towards women and alcohol are barriers to the detection and treatment of their alcohol related problems.
Objective: To explore the magnitude of co-morbidity among women with ADS in Eastern Nepal.
Method: This is a hospital based cross-sectional study of women with ADS. Those who scored two or more than
two in T-ACE questionnaire were enrolled. The diagnosis was made according to ICD-10 criteria. Consultation
with concerned physician was done to assess physical condition.
Result: Fifty one patients with ADS were enrolled. Among them, 21.6% had no comorbidity, 52.9% had single co-
morbidity (psychiatric or physical) and 25.5% had both psychiatric and physical co-morbidity. In psychiatric
comorbidity, mood disorder in 35.29% was the commonest followed by nicotine use in 26.47%. Among mood
disorders 83.3% had depression. In physical comorbidity, disease of gastrointestinal tract and hepatobiliary system
in 50.9% was the commonest followed by hypertension in 11.5%.
Conclusion: : Psychiatric as well as physical co-morbidities are common in women with ADS. The finding points
to the importance of exploring comorbidities and their optimal treatment.
Keywords: Alcohol, Comorbidity, Nepal, Women
INTRODUCTION
Comorbidity refers to the presence of more than
one illness in a person. These illnesses can be
medical or psychiatric, as well as drug /
substance use disorders. Comorbid illnesses
may occur simultaneously or sequentially, but it
does not necessarily imply that one is the cause
of the other, even if one occurs first. An
understanding of comorbidity is essential in
developing effective treatment and prevention
strategy. Similarly, in alcohol dependence
syndrome (ADS), identification and
management of the comorbid conditions are of
great importance.1
The toxic effects of alcohol can have adverse
effects on different system of the body. In
women along with those systemic effects, the
alcohol use may result in breast cancer,
amenorrhoea, anovulation, early menopause
and Fetal Alcohol Syndrome (FAS) of the infant
if consumed during pregnancy.2,3 Women with
alcohol-use disorders may have co-occurring
psychiatric disorders such as major depression,
anxiety, panic disorder, bulimia, post traumatic
stress disorder (PTSD), or borderline personality
disorder. They are more likely to have physical
or sexual abuse and domestic violence. This
trauma can lead to higher instances of PTSD,
depression, anxiety, and alcohol dependence.4
Even with the evidence that alcohol use has a
devastating effect on women, societal attitudes
stigmatize women with alcohol drinking habit
ORIGINAL ARTICLE
18
J Psychiatrists’ Association of Nepal Vol .5, No.1, 2016
Joshi RG et. al. Comorbidity in Women with Alcohol..
and these are barriers to the detection and the
treatment. Until this perception persists, women
will continue to suffer and fail to present
themselves for treatment. Fear of stigmatization
may lead women to deny their suffering, they
hide their drinking habit and drink alone.5 This
study was conducted to explore the co-
morbidity among the women with ADS.
MATERIAL AND METHOD
This was a hospital based cross sectional
descriptive study. The participants were
consecutive women with ADS seeking
psychiatry services of BPKIHS, Dharan. Those
who gave informed written consent to
participate in the study, who scored two or
more than two in T-ACE questionnaire6, 7 and
age group of 16 years and above were enrolled.
Patient with multiple substance dependence, or
who were severely ill and could not give
informed consent and did not have reliable care
taker to give consent were excluded. The aim of
the study was to explore the co-morbidity
among the women with ADS. The psychiatric
diagnosis was made according to ICD-10
criteria. Consultation with concerned physician
was done to assess physical condition. The
relevant investigations were done. The study
duration was from 2009 - 2010. The ethical
approval for the study was obtained from the
Institute’s Ethical Board. The data was analysed
using SPSS version 14.0.
RESULT
A total of 51 female patients with ADS
participated in the study.
Table no. 1: Distribution Of ADS according to
Presentation
Diagnosis
Frequenc
y (n)
Percent
(%)
ADS
Active use
16
31.37
Abstinence
6
11.76
Uncomplicated
WD
16
31.37
Complicated
WD
13
25.49
Complicated
WD
DT alone
9
69.23
Seizures alone
1
7.69
Both DT and
Seizure
3
23.08
Table no. 2: Distribution of Comorbidity
Frequency
(n)
Percent
(%)
Character
Category
ADS with
No comorbidity
11
21.6
Single (either
psychiatric or
physical)
Comorbidity
27
52.9
Both
(psychiatric and
physical)
Comorbidity
13
25.5
Psychiatric
Comorbdity
Present
29
56.9
Absent
22
43.1
Physical
Comorbidity
Present
24
47.1
Absent
27
52.9
Table no. 3: Distribution of Psychiatric
Comorbidity#
Character
Category
Frequency
(n)
Percent
(%)
Psychiatric
Comorbidity
Mood Disorders
12
35.29
Substance Use
9
26.47
DSH
2
5.88
Amnestic
Syndrome
3
8.82
Schizophrenia
2
5.88
Anxiety NOS
1
2.94
OCD
1
2.94
Post partum
psychosis
1
2.94
Panic Attacks
1
2.94
Persistent
Somatoform
Pain Disorder
1
2.94
Substance
Induced Mania
with Psychosis
1
2.94
Mood
Disorders
Depression
9
75
RDD
1
8.33
BPAD current
Mania
2
16.67
DSH
Hanging
1
50
OPC poisoning
1
50
Other
Substance
Nicotine
8
88.88
Cannabis
1
11.12
Total #
57
100
# Multiple response category one respondent may have
one or more responses
Majority (31.37%) ADS cases presented in active
use and uncomplicated withdrawal and 69.2%
had delirium tremens (Table 1).
19
J Psychiatrists’ Association of Nepal Vol .5, No.1, 2016
Joshi RG et. al. Comorbidity in Women with Alcohol..
More than half (52.9%) had single comorbidity
and one fourth (25.5%) had both psychiatric and
physical comorbidity. Psychiatric comorbidity
was in 56.9% and physical comorbidity was
47.1%. (Table 2)
In psychiatric comorbidity, mood disorder was
common 35.29% where depression was in
83.33%. (Table 3)
In the physical comorbibity, the diseases of
gastro-intestinal tract and hepatobiliary system
were the most common(50%). (Table 4)
Table no. 3: Distribution of Physical
Comorbidity#
# Multiple response category one respondent may have
one or more responses
DISCUSSION:
In this study, more than half had psychiatric
comorbidity (56.9%) which is similar to the
finding of 60% in Sweden8 and in USA9, but
higher in India10 (75.3%) and previous study in
Nepal11 (70%). In a study by Shakya DR12 which
enrolled both male and female ADS cases, 80.4%
psychiatric comorbidity inclusive of axis I
(62.7%) and axis II disorders (51%) were found.
In psychiatric comorbidities, mood disorder was
common (35.3%). Among mood disorders,
depression was seen in 83.3%. Depression was
17.5% of the total psychiatric comorbidities
which is similar to Korean13 (18.61%) and
American study9 (15%). But it was higher in
Sweden8 (50%) and in India10 (32.8%).
Substance use disorder was the second most
common psychiatric comorbidity (26.4%). The
nicotine use was found in 88.8% and cannabis
use in 12.2%. This is similar to finding of 80-
90% smoker found by Kennedy, JA14 but more
than the findings of Shakya DR12 (69%).
Alcohol use has been associated with high
suicidal risk. There were two cases (5.8%) of
deliberate self harm; one each of hanging and
organo-phosphorus poisoning. In a meta-
analysis, Stack S found the greater the per capita
alcohol consumption, the greater the suicide
rate.15 Robert J. Tait, found no association
between gender and suicide, though the female
deaths were 52% in the study.16 A study from
Thailand showed majority (73.6%) who
attempted suicide were female.17
In this study, physical comorbidity was present
in 24 cases (47.1%). There were variable
findings of prevalence of physical comorbidity
in different countries like, 70% in Nepal11 ,
Ireland18 (14.1%) and 68.7% in India10. The
disesease of hepatobiliary system was most
common (21.1%), which is similar to the findings
from India10 (30.3%), and United States9 (26%),
but lesser than previous studies in Nepal by
Shakya DR19 et al (70%) and Sharma A et al11
(92.48%). The second most common physical
comorbidity was diseases of cardiovascular
system (17.3%) of which hypertension was
11.5%, anaemia 3.8% and angina 1.9%. The
second most common was anaemia (26.5%) In
India10 and genitourinary problem (6%) in
USA20. But, in Ireland18, hypertension was the
most common 5.9%. Among the individual
Character
Category
Frequency
(n)
Percent
(%)
GIT /
Hepato-
biliary
Total
26
50
Cholelithiasis
7
13.46
UGI bleed
5
9.62
Alcoholic Liver
Disease
4
7.69
Fatty liver
4
7.69
Chronic Liver
Disease
3
5.77
PUD
3
5.77
CVS
Total
9
17.31
Hypertension
6
11.54
Anemia
2
3.85
Angina
1
1.92
CNS
Total
3
5.77
Hepatic
Encephalopathy
2
3.85
CVA
1
1.92
Respiratory
Total
3
5.77
Aspiration
Pneumonia
1
1.92
CAP
2
3.85
ENT
Total
2
3.85
CSOM
1
1.92
Otitis Externa
1
1.92
Urinary
System
Total
5
9.61
Nephrolithiasis
1
1.92
UTI
4
7.69
Others
Total
4
7.69
DM
2
3.85
Aphthous Ulcer
1
1.92
Tendoachillis
Injury
1
1.92
Grand Total #
52
100
20
J Psychiatrists’ Association of Nepal Vol .5, No.1, 2016
Joshi RG et. al. Comorbidity in Women with Alcohol..
diseases in this study, the most common was
cholelithiasis (13.4%) as the incidence of
cholelithiasis is high in ‘fat, fertile, flatulent and
female of fifty’.
CONCLUSION:
Psychiatric as well as physical co-morbidities are
common in women with alcohol dependence.
The finding points to the importance of
exploring comorbities and their optimal
treatment. Fear of stigmatization may lead
women to deny their suffering. A prompt
identification, intervention and treatment of
underlying co-morbidities are essential in the
management of ADS in women.
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