STUDY OF PSYCHIATRIC COMORBIDITY OF ALCOHOL USE DISORDER Dr.C P Sedain Department of Psychiatry Chitwan Medical College Bharatpur ,Chitwan,Nepal

Abstract

Introduction:

The Problem of alcohol consuming is increasing in the world.  The subjects for this study comprised of all consecutive patients who are consumping alcohol regularly, attending psychiatric  department of CMC  Teaching Hospital, Bharatpur, Nepal .

Method:

This is a retrospective study on the data recorded in the psychiatric department of  CMC Teaching Hospital,  263 concutive patients of  alcohol use disorder with or without   psychiatric comorbidity    were analyzed. The ratios and proportions were used for statistical analysis.The study was conducted from 1st January 2009 to 30 th December 2009.

Result:

This study  shows that  alcohol use disorder without comorbidity is  (71.04%).    Psychosis is  (alcoholic hallucinosis)  (12.36 %) followed by anxiety disorder ( 7.33 %) and  depressive disorder ( 6.56 %). Data shows highest number of cases were age group 40-49 ( 33.46%) followed by 50-59 ( 24.71%).Highest  number of  cases were of  lower caste,  Baisya  ( 52.85%) followed by Sudra (21.671%).

 Conclusion:

The current study shows  28.95% patients consuming alcohol have  psychiatric comorbidity including psychosis, anxiety disorder, depressive disorder and bipolar disorder etc.

Key words: comorbidity, bipolar disorder ,alcoholic hallucinosis

Correspondence

Dr.C P Sedain

Chitwan Medical College Bharatpur ,Chitwan,Nepal

Email-drcpsedai@yahoo.com

phone-9779855056666

Introduction

      The Problems of alcohol consuming is increasing in the world. The patients with alcohol dependent may be comorbid with other psychiatric disorder. If it is comorbidity   with psychiatric disorder  it is consider poor outcome. Many alcohol  dependent person treated in the hospital found to be relapse in many occasion. So it is essential to identify the co morbid psychiatric disorders . If we treat comorbid  psychiatric disorder  the relapse can be decrease significantly. Patients with alcohol use disorder can be presented with  different ways including  abuse, dependent, intoxication, withdrawl state.The objective of this study is identify different types of psychiatric disorders that is related with alcohol consumption.

      Alcohol-dependent patients often present with symptoms of anxiety or depression. Alcoholism can be a consequence of anxiety and mood disorders . It can develop independently after anxiety and depression, or it can precede anxiety and depressive symptoms. Almost every alcoholic will report  having mood swings. It is very important to distinguish these alcohol–induced symptoms from actual bipolar disorder. However, diagnosing bipolar disorder in the face of alcohol abuse can be difficult because  chronic use, can mimic nearly any psychiatric disorder. Alcohol intoxication can produce a syndrome indistinguishable from mania or hypomania, characterized by euphoria, increased energy, decreased appetite, grandiosity, and sometimes paranoia. However, these alcohol–induced manic symptoms generally occur only during active alcohol intoxication, which makes them fairly easy to differentiate from mania associated with bipolar I disorder. Bipolar disorder and alcoholism commonly co–occur. Multiple explanations for the relationship between these conditions have been proposed, but this relationship remains poorly understood. Some evidence suggests a genetic link. This comorbidity also has implications for diagnosis and treatment. Alcohol use may worsen the clinical course of bipolar disorder, making it harder to treat.. There are a number of disorders in the bipolar spectrum, including bipolar I disorder, bipolar II disorder, and cyclothymia. Bipolar disorder and alcoholism co–occur at higher than expected rates.

Alcohol is a central nervous system depressant.  In the stage of alcohol dependence, up to 80 per cent of people report depressive symptoms at some time in their life. About one-third of male patients and up to 50 per cent of female patients have experienced longer periods of severe depression.¹ These high prevalence rates are noteworthy, since more than 20 per cent of alcoholics have attempted suicide once or more and about 15 per cent die in their attempt. Besides depressive features, alcohol-induced mood disorders may also comprise manic symptoms or mixed features.

                                                                                                                               

Methods

The subjects for this study comprised of all consecutive patients associated with alcohol consumption  which were attended psychiatric Department of CMC Teaching Hospital Bharatpur Chitwan, Nepal. The study was performed over 1 year (1st January 2009 to 30 th December 2009)..A brief explanation about the study was offered to the subjects and written or verbal consent was obtained either from them or guardians and all the subjects   were included in the study. The diagnosis was made on the basis of ICD-10 DCR .2 The patients were follow up  after one month and in one month follow up the diagnosis  was revised.

A continuous sequential number was given to each subject and available necessary information was kept confidential in a separate file.The socio demographic profile which contains name, age, sex, caste, , marital status, occupation, and other information was  also filled.

Results

Among 263 cases  male were 245 and female were only 18.Data shows highest number of cases were age group 40-49 (N-88, 33.46%) followed by 50-59 (N-65, 24.71%).HIghest number of cases were caste of Baisya  (N-139, 52.85%) followed by Sudra (N-57, 21.671%). Data shows most of cases were married (N-234, 88.97%). Data shows highest cases  were education up to SLC (N-114, 43.35%) followed by education up to primary level were (N-64, 24.33%). Data shows most of cases were farmer (N-125, 47.53 %) followed by businessman(N-62,23.57%).Four cases were dropped out after 1 month follow up period.

  Diagnosis at first day,most of cases were without any comorbidity (N-256,97.34%). Alcohol use disorder with depressive disorder   (N-4,1.52 %) followed by anxiety disorder (N-2, 0.76 %) and Bipolar disorder  (N-1,0.38%). However after  1 month follow up psychiatric comorbidity is  increased significantly.Highest comorbidity with alcohol use disorder is  psychosis (alcoholic  hallucinosis)  (N-32,12.36 %) followed by anxiety disorder (N-19, 7.33 %) and  depressive disorder (N-17, 6.56 %).Other comorbidity were  Bipolar disorder  (N-4,1.54%),dementia (N-1,0.39),obsessive compulsive disorder (N-1,0.39), and pathological jealousy (N-1,0.39).

Table-1

AGE	MALE	FEMALE	TOTAL	%
20-29	27	3	30	11.41
30-39	50	4	54	20.53
40-49	82	6	88	33.46
50-59	61	4	65	24.71
60-69	21	1	22	8.37
70 <	4	0	4	1.52
Total	245	18	263	100

Table-2

DISTRIBUTION ON THE BASIS OF CASTE

CASTE	MALE	FEMALE	TOTAL	%
BRAMIN	33	1	34	12.93
CHHETRI	32	1	33	12.55
BAISYA	129	10	139	52.85
SUDRA	51	6	57	21.67
TOTAL	245	18	263	100

Table -3

 DISTRIBUTION ON THE BASIS OF MARIETAL STATUS

MARIETAL STATUS	CASE
	NO	%
MARRIED	234	88.97
UNMARRIED	23	8.75
WIDOW	6	2.28
TOTAL	263	100%

Table 4

DISTRIBUTION ON THE BASIS OF EDUCATIONAL STATUS

EDUCATION	CASE
	NO	%
UNEDUCATED	25	9.50
PRIMARY	64	24.33
SLC	114	43.35
INTERMEDIATE	51	19.39
GRADUATE	9	3.42
TOTAL	263	100

Table-5

DISTURIBUTION ON THE BASIS OF OCCUPATION

OCCUPATION	N	%
FARMER	125	47.53
BUSINESSMAN	62	23.57
SERVICE HOLDER	25	9.50
UNEMPLOYED	33	12.55
STUDENT	7	2.66
HOUSEWIFE	11	4.18
TOTAL	263	100

Table-6

DISTURIBUTION ON THE BASIS OF DIAGNOSIS IN THE FIRST DAY OF TREATMENT

DIAGNODIS	MALE	FEMALE	TOTAL	%
ALCOHAL USE DISORDER ONLY	239	17	256	97.34
COMORBID  DEPRESSIVE DISORDER	3	1	4	1.52
COMORBID ANXIETY DISORDER	2	0	2	0.76
COMORBID BIPOLAR DISORDER ( I & ll)	1	0	1	0.38
TOTAL COMORBIDITY	6	1	7	2.66
TOTAL	245	18	263	1OO

Table-7

DISTURIBUTION ON THE BASIS OFRAVISED DIAGNOSIS AFTER ONE MONTH FOLLOW UP

DIAGNODIS	MALE	FEMALE	TOTAL	%
ALCOHAL USE DISORDER ONLY	172	12	184	71.04
COMORBID  DEPRESSIVE DISORDER	15	2	17	6.56
COMORBID PSYCHOSIS( (ALCOHOLIC HALUCINOSIS)	29	3	32	12.36
COMORBID ANXIETY DISORDER	18	1	19	7.33
COMORBID BIPOLAR DISORDER ( I & ll)	4	0	4	1.54
COMORBID OBSESSIVE COMPULSIVE DISORDER	1	0	1	0.39
COMORBID DEMENTIA	1	0	1	0.39
COMORBID PATHOLOGICAL JEALESY	1	0	1	0.39
TOTAL COMORBIDITY	69	6	75	28.95
TOTAL	241	18	259	1OO

Discussion

 There have been two large epidemiological studies of psychiatric disorders: the National Institute of Mental Health's Epidemiologic Catchment Area (ECA) study. 3,4 The ECA study  revealed that 60.7 percent of people with bipolar I disorder had a lifetime diagnosis of a substance use disorder (i.e., an alcohol or other drug use disorder); 46.2 percent of those with bipolar I disorder had an alcohol use disorder; and 40.7 percent had a drug abuse or dependence diagnosis (the percentages of people with alcohol use disorders and drug abuse disorders do not add to 100 due to overlap). Forty–eight percent of people with bipolar II disorder had a substance use disorder, 39.2 percent had an alcohol use disorder, and 21 percent had a drug abuse or dependence diagnosis (these figures reflect overlap, as above.) Alcohol dependence was twice as likely to co–occur in people with bipolar spectrum disorders than in those with unipolar depression . As part of the ECA study found that mania (i.e., bipolar I disorder) and alcohol use disorders are far more likely to occur together (i.e., 6.2 times more likely) than would be expected by chance.5 It was also reported that antisocial personality disorder was more likely to be related to alcoholism .

In the current study, diagnosis at first day of contact most  of cases were  alcohol use disorder without anypsychiatric comorbidity (N-256,97.34%). However alcohol use disorder comorbid  with depressive disorder   (N-4,1.52 %) , anxiety disorder (N-2, 0.76 %) and bipolar disorder  (N-1,0.38%).The patients were  follow up after 1 month. Four cases were dropped out during  1 month follow up period. One month follow up data shows significantly increased psychiatric comorbidity.

Follow up data shows, alcohol use disorder without psychiatric comorbidity  (N-184,71.04%). Data shows highest psychiatric comorbidity is  psychosis ( hallucinosis)  (N-32,12.36 %) followed by anxiety disorder (N-19, 7.33 %) and  depressive disorder (N-17, 6.56 %) respectively.Other psychiatric  comorbidity were  Bipolar disorder  (N-4,1.54%),dementia (N-1,0.39%),obsessive compulsive disorder (N-1,0.39%), and pathological jealousy (N-1,0.39%).This means patients with alcohol use disorder are associated with more  psychiatric comorbidity after  1 month follow up period . In the other hand data of first day  has less  psychiatric comorbidity may be masked by alcoholic metabolite on the  bodyin first day .Probably when alcololic metabolite are  absent in the body may show full features of psychiatric comorbidity.

Alcoholic hallucinosis is a  condition in which auditory hallucinations are present in clear consciousness and without autonomic overactivity, usually in a person who has been drinking excessively for many years. The hallucinations often begin as simple noises, but are gradually replaced by voices which may threaten, abuse, or reproach the Symptoms that last for 6 months generally continue for years.⁶ Anxiety disorders are among the most common groups of psychiatric disorders in the general population, with prevalence rates of up to 25 per cent.⁷ In clinical studies between 20 and 70 per cent of patients with alcoholism also suffer from anxiety disorders.⁸ On the other hand, between 20 and 45 per cent of patients with anxiety disorders also have histories of alcoholism.⁹ However, it has been argued that the comorbidity figures are overestimated, because in some of the studies the focus was on drinking patterns rather than on alcohol dependence or they describe anxiety symptoms rather than disorders according to diagnostic criteria.¹⁰ Family studies analysing the comorbidity of alcoholism and anxiety disorders might be a means of clarifying this controversy. For instance, in the Yale study the presence of anxiety disorders in the probands slightly increased the risk for alcohol dependence in their relatives, whereas alcohol dependence in the proband did not increase their relative's risk for anxiety disorders.¹¹ Similarly, Maier et al.¹² demonstrated an increased risk of alcoholism in probands with panic disorders, but not the reverse. Kendler et al.¹³ in a study of female twins, found evidence that common genetic factors may underlie both alcoholism and panic disorder.Indian study in rural area reported problem drinking in 1%. Physical complications possibly due to alcohol were seen in 4.1% and psychiatric co-morbidity in 1%. Pregnancy drinking was recorded in 4.4%. Only 0.2% came for follow-up.14
Problem alcohol drinking in rural women of Telangana region, Andhra Pradesh

 Conclusion:

The Problem of alcohol consuming is increasing in the world. One month follow up data shows  28.95% patients consuming alcohol have other psychiatric  diagnosis including psychosis, anxiety disorder, depressive disorder and bipolar disorder which couldn’t identify initial days of alcohol consumption.

CONFLICT OF INTREST

There is no conflict of interest in this article.

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