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ORIGINAL PAPER: RESEARCH ARTICLE

Psychiatric comorbidity and reason for relapse in patients with alcohol dependence syndrome

Lipika Malik, Vikas Punia, Preiti Modi

Department of Clinical Psychology, Institute of Mental Health, University of Health Sciences, Rohtak, Haryana, India

Abstract

Background: Relapse is quite common in patients with substance use disorders. Various studies have shown prominent role of various psychosocial factors in relapse like family environment, peer pressure, personality, and craving. Comorbidities of various psychiatric disorders like antisocial personality disorder, depression, and anxiety disorder among patients of substance use disorders are very common. However there seems to be dearth of literature which studies above variables in patients with alcohol dependence. Aim: Present study aims at bridging gaps in literature and studying the phenomenology of relapse and psychiatric comorbidity in patients with alcohol dependence. Method: Keeping this in view present study is designed with an aim of studying the psychiatric comorbidity and reason for relapse in patients with alcohol dependence. For this purpose, 30 patients with alcohol dependence were selected as sample. Sociodemographic and clinical datasheet was especially designed for the study to assess the reason for relapse and the Brief Psychiatric Rating Scale (BPRS) was used to assess the psychiatric comorbidities in patients with alcohol dependence. Descriptive statistics were used. Results: Results indicate that most of the patients had mild somatic concerns (76.6%) and anxiety (90%) as well as moderate tension (83.4%) and guilt feelings (90%). Majority of patients had both external as well as internal reasons for relapse. Conclusion: Present study has implications in providing valuable insights into the reasons for relapse and abstinence. It would also be helpful in identifying various risk and protective factors for relapse and other psychiatric disorders which can coexist in such patients and hence be helpful in their pharmacological and non-pharmacological management.

Keywords: Substance use disorders, psychosocial factors, abstinence

Correspondence: Preiti Modi, M. Phil Scholar, Department of Clinical Psychology, Institute of Mental Health, University of Health Sciences, Rohtak, Haryana, India. PIN - 124001. preitim.81@gmail.com

Received: 16 September 2019

Revised: 4 August 2022

Accepted: 11 August 2022

Epub: 18 August 2022

INTRODUCTION

Alcohol dependence is a debilitating and waning disease, and its treatment often involves multiple relapses. Relapse is often a critical element of recovery, as is prominent in the stages of motivation as described by Prochaska and DiClemente.[1] Relapse rates with respect to the area of addiction are assumed to be in the range of 50% to 90%.[2-4]

There are many factors involved with relapse such as individual and intrapersonal factors which comprise negative emotional states like stress, depression, and anxiety. Cummings et al.[5] conducted a study and found that negative emotional states accounted for 30% of all relapses. Mermelstein et al.[6] further highlighted that 43% of relapses occur under stress. Various other factors such as inadequate motivation to quit alcohol also plays a major role. However there seems to be scarcity of research in this area.

Other factors of prime importance are response to treatment and coping skills. Glasgow et al.[7] have reported that self-reported compliance was related to success in self-quitters. They further emphasized that patients who struggle to a moderate degree with adherence throughout a treatment programme may do well later because they can cope with temporary setbacks.

There seems to be substantiating evidence that points out towards high rates of psychiatric disorders in patients with alcohol dependence syndrome. The co-occurrence of substance abuse and mental illness has been reported since very long time. Patients with alcohol dependence syndrome are reported to be three times more likely to have another psychiatric disorder.[8]

Ross et al.[9] have reported in their study that 64.8% of patients with alcohol use disorders had a comorbid diagnosis. In another study,[10] it was found out that, out of 30 patients with alcohol dependence syndromes 23 were found to have comorbid psychiatric illness. It was seen that axis I and axis II comorbidity was found in 76.6% and 40% of the samples, respectively. Disorders such as other psychoactive substance abuse, mood disorder, anxiety disorder, and psychotic disorder were reported to have a high prevalence of comorbidity.[11-13] Another study using SCID, i.e., the Structured Clinical Interview for the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria found a 57% prevalence of personality disorders in substance abusers.[14] However there seems to be lacunas in the study of socio-clinical factors of relapse, considerably in patients with alcohol dependence syndrome. Hence it becomes of prime importance to investigate the socio-clinical correlates of relapse, which will be further helpful in management of such patients. Further present study also aims to investigate reason for relapse and psychiatric comorbidity in patients with alcohol dependence syndrome. Investigations of this nature have been scarce in literature; hence present study aims to bridge these gaps in literature.

METHOD

The main aim of the present study was to study psychiatric comorbidity and the reason for relapse in patients with alcohol dependence syndrome. The study was approved by the institutional ethics committee and it was ensured that the research would not harm the patients’ current treatment or functioning in any way.

Sample

In the present study, a sample of 30 patients with the diagnosis of mental and behavioural disorder due to use of alcohol, currently using the substance (active dependence) were included. The sample was collected by using purposive sampling method. For this purpose, patients who fulfilled the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) Diagnostic Criteria for Research (DCR)[15] criteria for alcohol dependence, aged between 18-50 years, formal education for at least eight years, and those who gave the informed consent were included in the present study.

Whereas patient with serious physical problem and complicated withdrawal (seizure, delirium), physical illness and organic brain disorder, and history of harmful use or dependence on any other substance (except nicotine and caffeine), and mental retardation were excluded.

Tools used

Brief Psychiatric Rating Scale (BPRS)

This is one of the most widely used scales to measure psychotic symptoms and it was first published in 1962.[16] The Brief Psychiatric Rating Scale (BPRS) is a rating scale which is used to measure psychiatric symptoms such as depression, anxiety, hallucinations, and unusual behaviour. Each symptom is rated on a six-point rating scale and the scores can range from 18 to 126.

Procedure

Patients with the diagnosis of alcohol dependence as per ICD-10 DCR criteria and fulfilling the inclusion criteria were chosen for the study. At first informed consent was taken from each patient. After that necessary sociodemographic and clinical information was collected by using structured sociodemographic sheet. After that all the patients were assessed on BPRS. Descriptive statistics in the forms of frequency and percentage were used.

RESULTS

It was found that most of the patients had mild somatic concerns (76.6%) and mild anxiety (90%) as well as moderate tension (83.4%) and moderate guilt feelings (90%). Whereas, 33% had emotional withdrawn, motor retardation (ten per cent) and depression (93.3%) patients. Whereas hostility (6.7%) and conceptual disorganization (ten per cent) was found in very few patients (Table 1). Rest of the domains like mannerism and posturing, grandiosity, suspiciousness, hallucinatory behaviour, uncooperativeness, unusual thought content, blunted affect, excitement, and disorientation were not present in patients with alcohol dependence. It was seen that 63% of the patients had both external as well as internal reasons for relapse. Thirty per cent of the patients had external reasons for relapse and seven per cent of the patients had internal reasons for relapse (Table 2).

DISCUSSION

The main aim of the present study was to see the reason for relapse and psychiatric comorbidity in patients with alcohol dependence. The results of present study showed elevated scores and high percentages were found on the symptoms such as somatic concerns, guilt feelings, and depressive mood. These collectively can be categorized as symptoms of depression. The results found in the present study seem to be in accordance with findings from previous studies, where Ross et al.,[9] have found higher comorbidity of depressive disorders with alcohol dependence. Several other studies have also found findings similar to present study. Midha et al.[17] have reported high prevalence (66.6%) of depressive disorders in their respective alcoholic sample. Similarly, Dixit and Crum[18] have found that alcohol use increases the chances of onset of depressive illness by 2.6 times. In contrast, few Indian studies have pointed to low prevalence of depressive symptoms in patients with alcohol dependence syndrome.[19] However present study has found that depressive symptoms are quite prevalent in patients with alcohol dependence syndrome.

Elevated scores and high percentages were also found on symptoms of anxiety and tension. Collectively they can be categorized as symptoms of anxiety. Present study has found that such symptoms are prevalent in patients with alcohol dependence. This finding is also found to be in accordance with findings from previous studies. Schuckit[20] concluded that almost 80% of patients reported symptoms of anxiety and/or palpitations with shortness of breath. However, this discomfort tended to be self-limited and to disappear spontaneously with continued abstinence. Similarly, a recent study[11] has found that patients with alcohol dependence had higher state and trait anxiety than normal controls.

With respect to reasons for relapse, present study has found that most of the patients had both external and internal reasons for relapse. External factors were operationalized as factors in the patient’s environment such as stress, conflicts with family members, boredom, and peer pressure. Internal factors were subsumed as being craving, withdrawal, and body pains. Hence present study has found a prominent role of socio-cultural and familial factors as being crucial to relapse. This seems to be in accordance with results found by Cummings et al.,[5] where they have found that negative emotional states accounted for 30% of all relapses. However, based on findings from present study role of physiological factors cannot be ruled out and the authors do not have any intention to negate the role of physiological factors.

Conclusion

Present study was conducted to assess the reason for relapse and psychiatric comorbidity in patients with alcohol dependence syndrome. It was found that anxiety and depressive symptoms were found to be most prevalent in the sample. Both external and internal factors were found responsible for relapse in patients. Present study has implications in providing valuable insights into the reasons for relapse and abstinence. It would also be helpful in identifying various risk and protective factors for relapse and other psychiatric disorders which can coexist in such patients and hence be helpful in their pharmacological and non-pharmacological management.

Present study has its strength as it has been designed to cater to only patients with alcohol dependence syndrome, hence providing insights into the predictors of relapse of such patients. Findings from present study have emphasized the role of social and cultural factors as predictors of relapse. On the other hand, none of the research work cannot be complete without limitation. Due to less sample size, the study cannot be generalized to a bigger population and better insights could not be provided as the study did not contain any control group. Finally, use of standardized scale for reason for relapse could have given better insight.

AUTHOR CONTRIBUTIONS

LM: Definition of intellectual content, data acquisition, manuscript preparation, guarantor; VP: Design, clinical studies, statistical analysis, manuscript editing, guarantor; PM: Concepts, data analysis, manuscript review, guarantor.

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Malik L, Punia V, Modi P. Psychiatric comorbidity and reason for relapse in patients with alcohol dependence syndrome. Open J Psychiatry Allied Sci. 2022 Aug 18. Epub ahead of print.

Source of support: Nil. Declaration of interest: None.