1. 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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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.

9. 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

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

11. 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

12. 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*

13. 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

14. 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**

15. 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**

16. 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)

17. 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)

18. 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)

19. 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)

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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)

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. “First man takes a drink, then the drink takes a drink and then the drink takes the man.”
A Japanese proverb
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