A CROSS-SECTIONAL COMPARISON OF ALCOHOL USE DISORDERS, DRINKING PATTERNS AND ALCOHOL RELATED MEDICAL MORBIDITIES IN PATIENTS ATTENDING A SECONDARY CARE (DISTRICT) HOSPITAL V/S TERTIARY CARE (UNIVERSITY) HOSPITAL Risal A., Tharoor H. 6th International Conference-South Asian federation of Psychiatric Associations

INTRODUCTION Alcohol is one of the most commonly used psychoactive drugs in the world South East Asian Region (SEAR) is a region with comparatively low, but increasing levels of drinking with a detrimental pattern, heavy episodic or “binge” drinking World Health Organization, 2004

CHANGING TRENDS OF ADS Early age-of-onset, ↑ usage among women, changes in drinking patterns and increasing problems Gururaj et al, 2006 An important percentage of the global burden of disease requiring a synchronized approach by everyone involved in the health services Rehm et al, 2007

MEDICAL MORBIDITY Alcoholic liver disease is a major source of alcohol related morbidity and mortality Schuckit et al, 2005 Hospital-based surveys indicate 1/3rd of men admitted to medical and surgical wards have alcohol-related problems Hearne et al, 2002 The amount of alcohol consumed and drinking patterns are independent risk factors for all-cause mortality for men Baglietto et al, 2006

EPIDEMIOLOGY In South East Asian Countries, 20–30% of hospital admissions are due to alcohol-related problems WHO, 2004 36% of the households in rural areas and 34% in semi-rural or transitional towns had at least one alcohol-user in the 15 to 60 year age group The Bangalore Study; Gururaj et al, 2006

AIM OF THE STUDY To study and compare between the alcohol use disorders (AUDs), drinking patterns and alcohol related medical morbidities in patients diagnosed with ADS and attending psychiatry services at Secondary care centre (Government District Hospital, Udupi) & Tertiary care centre ( Kasturba Hospital, Manipal)

STUDY DESIGN Study type: Cross-sectional, comparative Sampling type: Serial sampling No. of groups: Two District hospital (Group I) Kasturba hospital (Group II) Sample size: Group I- 50, Group II- 75, Total-125

Contd…. Sample: The patients diagnosed with ADS, attending psychiatry services at Government District Hospital, Udupi or Kasturba Hospital, Manipal. Study period: April 2008 to April 2009.

INSTRUMENTS USED Customized proforma for collecting socio-demographic and clinical data for the study Standardized physical examination proforma Proforma for entering laboratory data and physician/consultant’s medical diagnosis of the patient Severity of alcohol dependence questionnaire (SAD-Q) Alcohol intake database MINI-PLUS

DATA ANALYSIS SPSS version 13.0 Descriptive statistics were used Group comparison done using chi square test and Fisher’s exact test of probability

RESULTS: 1) Socio-demographic data Variables Tertiary level Hospital N1=75 (%) Secondary level Hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Mean Age (± SD) 44.73 (±10.60) 39.58 (±11.39) Sex Male Female 74 (98.7) 1 (1.3) 50 (100) 0 (0) 124 (99.2) 1 (0.8) 0.672 1 0.412

Variables Tertiary level Hospital N1=75 (%) Secondary level Hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Marital status Married Single, Separated or Divorced 70 (93.3) 5 (6.7) 38 (76) 12 (24) 108 (86.4) 17 (13.6) 8.488 2 0.008* Religion Hindu Others 65 (86.7) 10 (13.4) 44 (88) 6 (12) 109 (87.2) 16 (12.8) 0.395 0.821 Residence Urban Rural 54 (72) 21 (28) 31 (62) 19 (38) 85 (68) 40 (32) 6.098 0.047*

Variables Tertiary level Hospital N1=75 (%) Secondary level Hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Family type Nuclear Others 45 (60) 30 (40) 18 (36) 32 (64) 63 (50.4) 62 (49.6) 9.988 2 0.004** SES LSES MSES and above 40 (53.3) 35 (46.6) 34 (68) 16 (32) 74 (59.2) 51 (40.8) 3.090 0.160

Variables Tertiary level Hospital N1=75 (%) Secondary level Hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Occupation Farmer Laborer Professional Homemaker / Others 23 (30.7) 22 (29.3) 7 (9.2) 10 (20) 29 (58) 3 (6) 8 (16) 33 (26.4) 51(40.8) 26 (20.8) 15 (12) 24.560 8 0.000*** Education No formal <10 years 10 years and above 2 (2.6) 33 (44) 40 (53.3) 28 (56) 12 (24) 12 (9.6) 61 (48.8) 52 (41.6) 23.602C 7 0.001**

2) Drinking related variables Tertiary level hospital N1=75 (%) Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Onset of drinking Below 18 yrs 19-40 yrs 41-60 yrs 18 (24) 55(73.3) 2 (2.7) 28 (56) 21 (42) 1 (2) 46 (36.8) 76 (60.8) 3 (2.4) 13.248 2 0.001 ** Last drink Within 24 hrs 1 day-2 wks 2wks-1month >1 month 12 (16) 42 (56) 16(21.3) 5 (6.7) 44 (88) 5 (10) 0(0) 13 (10.4) 86 (68.8) 21 (16.8) 5 (4) 15.746 3 0.001**

3) Drinking patterns Drinking patterns Tertiary level hospital Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Low risk drinkers 51 (68) 25 (50) 76 (60.8) 7.827 2 0.020* Problem drinkers 17 (22.7) 11 (22) 28 (22.4) Binge drinkers 7 (9.3) 14 (28) 21 (16.8)

4) Severity of Alcohol Dependence SAD-Q Total score Tertiary level hospital N1=75 (%) Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value <35 28 (37.3) 8 (16) 36 (28.8) 6.658 1 0.015* >35 47 (62.7) 42 (84) 89 (71.2)

5) Medical morbidities Medical morbidities Tertiary level hospital N1=75 (%) Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Yes 67 (89.3) 35 (70) 102 (81.6) 7.468 1 0.006* No 8 (10.7) 15 (30) 23 (18.4)

6) Varieties of medical morbidities Medical morbidity Tertiary level hospital N1=75 (%) Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Nil 8 (10.7) 15 (30) 23 (18.4) 17.183 6 0.003** Gastrointestinal (GI) 37 (49.3) 28 (56) 65 (52) Others 9 (12) 4 (8) 13 (10.4) Combined 21 (28) 3 (6) 24 (19.2)

7) Gastro-Intestinal morbidities Alcohol related GI morbidities Tertiary level hospital N1=75 (%) Secondary level hospital N2 =50 (%) Total N=125 (%) Statistics X2 df p-value Alcoholic Liver Disease (ALD ) 28 (37.3) 26 (52) 54 (43.2) 18.791 6 0.005** Cirrhosis 8 (10.7) 3 (6) 11 (8.8) ALD with Cirrhosis 0 (0) 8 (6.4) Pancreatitis 3 (4) 0(0) 3 (2.4) Portal hypertension 4 (5.3) 1 (2) 5 (4) Others 16 (21.3) 5 (10) 21 (16.8) Nil 15 (30) 23 (18.4)

Relation with Drinking patterns Variables (Samples of TH) Relation with Drinking patterns Statistics X2 df p-value Low risk drinkers (%) Problem drinkers Binge drinkers Past Hospitalization No Yes 33 (64.7) 18 (35.3) 2 (11.8) 2 (28.6) 2(28.6) 5 (71.4) 15.628 2 0.000*** Medical morbidities Gastrointestinal Others Combined 6 (11.8) 28 (54.9) 8(15.8) 9 (17.6) 0 (0) 7 (41.2) 4 (23.6) 6(35.3) 1 (14.3) 8.923 10 0.539 SAD-Q(Total score) <35 >35 23 (45.1) 3 (17.6) 14 (82.4) 4.360 0.113

Relation with Drinking patterns Variables (Samples of SH) Relation with Drinking patterns Statistics X2 df p-value Low risk drinkers (%) Problem drinkers Binge drinkers Past Hospitalization No Yes 23 (92) 2 (8) 5 (45.5) 6 (54.5) 8 (57.1) 6 (42.9) 10.338 2 0.006 ** Medical morbidities Gastrointestinal Others Combined 7 (28) 17 (68) 1 (4) 0 (0) 3 (27.3) 4 (36.4) 2 (18.2) 5 (35.7) 7 (50) 1 (7.1) 13.831 10 0.181 SAD-Q (Total score) <35 >35 6(24) 19 (76) 11(100) 2(14.3) 12 (85.7) 3.316 0.085 0.317

SUMMARY OF THE RESULTS Total 125 patients, 75 from tertiary hospital (TH) & 50 from secondary hospital (SH), diagnosed with ADS were serially sampled SH group had more patients from LSES background, uneducated or below 10 yrs education and were working as laborers TH group had more patients who were from nuclear family, urban residence and married

Contd…. >50 % of SH patients had onset of drinking below 18 years and last drink within 2 weeks of hospitalization Both the study sample had irregular abstinence, frequent relapses and median duration of drinking above 15 years Maximum number of TH patients had low risk drinking pattern while SH patients had binge drinking patterns

Contd…. No significant difference was found in relation to the non-medical problems related to alcohol except in the financial problems, which was > 80 % in SH population > 80 % of SH patients were having SAD-Q score >35, showing severe alcohol dependence

Contd…. There was significant difference between the two groups in relation to the alcohol related medical morbidities Morbidities were found to be higher in TH population Both the groups had higher frequency of GI morbidity (Alcoholic liver disease, Cirrhosis, Pancreatitis and Portal Hypertension)

Contd…. There was no significant relationship between the patterns of drinking and alcohol related medical morbidities in both the hospital population Gastrointestinal morbidity was higher among the low risk drinker group in both the hospitals

DISCUSSION Majority of subjects were in the middle age group More patients from urban residence, nuclear family, MSES & above seen among the TH samples Maximum patients in SH were laborers & uneducated or below 10 years of education. Similar findings seen in the Bangalore study. Gururaj et al, 2006

Contd….. Median duration of drinking was found > 15 years in both the hospital samples, in keeping with the findings from the Bangalore study Gururaj et al, 2006 Majority of patients in both the hospital samples had irregular periods of abstinence and frequent relapses as has been seen in the earlier studies related to ADS Smith et al, 2006 ; Sampath et al, 2007

Contd… Maximum patients in SH (representative of patients from LSES, laborers, illiterate and rural population) had binge pattern of drinking. Similar findings seen in the Bangalore study Maximum population of rural sample had such pattern centered around pay-day or special occasions like festivals and marriages Gururaj et al, 2006

Contd… Interpretation of the findings in drinking patterns in relation to earlier studies may not show comparable statistics as the definition of drinking patterns has not been the same Distribution of different beverage types could not be studied as our sample population was small confined mostly to a particular locality who were using different types of beverages at different periods of time

Contd… Maximum patients in SH group were never hospitalized in the past SH has group of patients who may not be aware of the need for treatment as seen in the study among SEAR countries WHO, 2004 They may be either non-compliant to the treatment or attend hospital only with serious complications

Contd…. Almost 90 % of patients in TH had medical morbidities of some kind 50 % of these morbidities were related to GI system, ALD with or without cirrhosis, portal hypertension and pancreatitis being the predominant illnesses Similar results were obtained in earlier studies Wetterling et al, 1999; Rehm et al, 2003; Stokkeland et al, 2008

LIMITATIONS Small sample size Only the Hospital-based sample Major bulk of GI referrals

FUTURE DIRECTIONS Larger sample size To study the non-medical (social, legal and financial) aspects of AUDs Standardized definition of drinking patterns Exploration beyond the GEC samples to look for other alcohol related medical morbidities Comparison among the zonal, regional and specialty hospital samples

“First man takes a drink, then the drink takes a drink and then the drink takes the man.” A Japanese proverb THANK YOU!!!!!!