Co-morbidity in women with alcohol dependence syndrome (ADS) in Eastern Nepal

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 comorbidity (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.


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. 2,3Women 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. 4ven with the evidence that alcohol use has a devastating effect on women, societal attitudes stigmatize women with alcohol drinking habit 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. 5This study was conducted to explore the comorbidity 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 questionnaire 6,7 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.1).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)

DISCUSSION:
In this study, more than half had psychiatric comorbidity (56.9%) which is similar to the finding of 60% in Sweden 8 and in USA 9 , but higher in India 10 (75.3%) and previous study in Nepal 11 (70%).In a study by Shakya DR 12 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 Korean 13 (18.61%)and American study 9 (15%).But it was higher in Sweden 8 (50%) and in India 10 (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, JA 14 but more than the findings of Shakya DR 12 (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 metaanalysis, Stack S found the greater the per capita alcohol consumption, the greater the suicide rate. 15obert J. Tait, found no association between gender and suicide, though the female deaths were 52% in the study. 16A study from Thailand showed majority (73.6%) who attempted suicide were female. 17n 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 Nepal 11 , Ireland 18 (14.1%)and 68.7% in India 10 .The disesease of hepatobiliary system was most common (21.1%), which is similar to the findings from India 10 (30.3%), and United States 9 (26%), but lesser than previous studies in Nepal by Shakya DR 19 et al (70%) and Sharma A et al 11 (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 India 10 and genitourinary problem (6%) in USA 20 .But, in Ireland 18 , hypertension was the most common 5.9%.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.

Table no . 3: Distribution of Psychiatric Comorbidity #
Among the individual