Authors: CS Bharath, Kaushik Chatterjee, Arun S. Yadav, Ankit Dangi, Pookala Shivaram Bhat
Categories: Original Article, Alcohol dependence syndrome, alcoholic liver disease, prevalence, severity
Source: Industrial Psychiatry Journal
Excessive alcohol use leads to a spectrum of liver disease. While physicians treat liver disease, the cause, i.e. alcohol, often remains untreated. This portends a poor overall outcome as such patients may continue to consume alcohol for the want of appropriate treatment directed at alcohol dependence or abuse.
To assess the prevalence and severity of alcohol dependence among patients with Alcoholic Liver Disease (ALD).
A cross-sectional observational study was conducted among patients with varying severity of ALD (steatosis, hepatitis, and cirrhosis) where 75 were included. They were evaluated for alcohol dependence using clinical interview and M.I.N.I 6.0. The severity of dependence was rated using the SADQ (Severity of Alcohol Dependence Questionnaire). Appropriate statistical tests were applied to identify correlations.
All the patients of ALD met the criteria of Alcohol Dependence Syndrome (Clinical interview and ICD 10 criteria). Among them, 40% were severely dependent (SADQ >30). Among those with ALD, 57.3% had alcoholic hepatitis, 18.7% had steatosis, and 24% suffered cirrhosis. Patients with cirrhosis had higher median SADQ scores compared to those with steatosis or hepatitis.
All the patients with ALD suffered from Alcohol Dependence Syndrome. Those with the most severe ALD had a higher severity of dependence. To ensure effective treatment and lasting outcomes, there is a need for greater awareness of this fact among physicians. Psychiatric referral of those suffering from ALD will ensure concurrent treatment of Alcohol Dependence Syndrome.
Keywords: Alcohol dependence syndrome, alcoholic liver disease, prevalence, severity
Excessive alcohol use produces a spectrum of liver disease from milder steatosis to reversible hepatitis and most severe fibrosis or cirrhosis.[1,2] These disorders together constitute Alcoholic Liver Disease (ALD), a major component of liver afflictions the world over.[3] Patterns of alcohol use leading to liver damage can range from binge drinking to Harmful use and the more severe Alcohol Dependence Syndrome (ADS).[4] Medical care for ALD is usually provided by physicians or gastroenterologists. Physicians diagnose and treat ALD, but sometimes the root cause, excessive alcohol use, remains unaddressed. This portends a poor prognosis since they may continue to consume alcohol as the Alcohol Use Disorder remains untreated.[5]
Very few studies have explored the prevalence of ADS in patients with ALD. Most studies have focused on the dose of alcohol consumed and the consequent risk of ALD.[6] While such an approach acknowledges the impact of alcohol, it neglects the patterns of alcohol consumption and Alcohol Use Disorders. A recent study (N = 155) reported that among patients with ALD, 40% were binge drinkers while 60% met the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for ADS.[7] An Indian study (1986) reported that 76% of patients with ALD suffered from Alcohol Dependence, with 30% being severely dependent.[8] Other studies have tried to identify patterns of drinking and severity in patients of alcohol dependence with and without cirrhosis. In one such study, ADS patients with cirrhosis had higher rates of severe dependence and higher mean alcohol consumed per day.[9] However, another study found that among patients attending a detoxification unit, those without evidence of liver disease had higher rates of severe dependence compared to those with cirrhosis.[10] Overall, literature directly addressing the question of the prevalence of ADS in patients with ALD is scarce. Also, there is much variation among the results of published studies.
Our study was designed to evaluate the prevalence of ADS among those with ALD and to rate its severity. We also intended to study the relationship between the severity of dependence on alcohol and the severity of ALD. Further, we attempted to identify socio-demographic factors associated with severe dependence among these individuals. We hope that findings from this study will create greater awareness among physicians and help them make appropriate treatment decisions, thereby improving outcomes.[11]
This was a hospital-based, cross-sectional, and observational study conducted among inpatients and outpatients at a tertiary care multi-specialty hospital. The Data were collected from November 2015 to June 2017. The study population included adults diagnosed with ALD as per defined criteria in the background of alcohol use [Table 1].[12,13]
The sample size for the study was calculated to be 69 based on 76.7% prevalence of ADS in patients with ALD considering a 10% absolute margin of error and 95% CI.[8] Ethical Committee approval was taken from IEC, AFMC Pune on 15 Nov 2015.
Patients suffering from chronic liver disease due to causes other than alcohol (e.g. viral hepatitis, non-alcoholic steatohepatitis, hemochromatosis, autoimmune etiology, Wilson’s disease), and those with concurrent major medical illness were excluded from this study.
A standard proforma was used to collect data socio-demographic and disease-related data on factors like age, sex, education, occupation, income, residence, marital status, domestic status (living alone/with family), age of onset of alcohol use, most commonly consumed beverage, average daily alcohol intake, other substance use, family history of alcohol use, and ALD diagnosis. Mini International Neuropsychiatric Interview (M.I.N.I 6.0) (Alcohol Dependence module) which is a short-structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders was used along with a clinical interview to establish the diagnosis of ADS. This clinician-rated tool has good sensitivity (0.80) and specificity (0.95), in concordance with SCID-P (Structured Clinical Interview for DSM disorders—Patient edition) diagnosis of current Alcohol Dependence Syndrome. Concordance with CIDI (Composite International Diagnostic Interview) diagnosis of Alcohol Dependence Syndrome is also good, with a sensitivity of 0.83 and specificity of 0.97. Reliability evaluation of the tool has inter-rater kappa of 1.00 and test-retest kappa of 0.86 for current Alcohol Dependence Syndrome.[14]
The Severity of Alcohol Dependence Questionnaire (SADQ), which evolved from the SADQ, is a questionnaire designed to measure the severity of alcohol dependence.[15] It contains 20 items, each of which is rated on a four-point Likert scale, ranging from “never or almost never” (score zero) to “nearly always” (score three). The minimum and maximum possible scores are 0 and 60, respectively. A score of up to 15 usually indicates only mild dependence, over 15 up to 30 is taken to indicate moderate dependence and a score of 31 or more as severe dependence.[15] Internal consistency is strong for the SADQ (Cronbach’s alpha = 0.98).[16] It has a high test–retest reliability (0.85) and good construct and concurrent validity.[15]
To examine the socio-demographic and clinical characteristics of ALD, descriptive analyses were conducted. Categorical variables were described using percentages and quantitative variables (SADQ scores) using medians and range. The prevalence of ADS in ALD was described using the percentage of patients meeting diagnostic criteria of ADS using M.I.N.I. 6.0. For the objective of correlation between the severity of ALD and ADS, assessments were done using the SADQ score as both categorical (mild/moderate/severe) and continuous variable. Kruskal–Wallis test and Mann–Whitney U test were applied for the comparison of medians. Chi-square test was used to test for association between categorical variables. Data analysis was done by using SPSS (Statistical Package for Social Sciences) Version 20.0. A P value < 0.05 was considered statistically significant.
A total of 75 patients freshly diagnosed with ALD were included in this study. One-third was younger than 35 years of age. The mean age of the sample was 40.7 years. 92% were married. More than 90% had an educational achievement of up to 12 years. Skilled and unskilled workers constituted 76% of the study population. 68% were urban dwellers. The age at onset of alcohol consumption was 25 years or less in 49.3% of the patients. 48% consumed more than 300 mL of distilled spirit/day (100 gm/day alcohol). Detailed demographic and clinical characteristics of the study population are shown in Table 2.
Of the patients with ALD, 57.3% were diagnosed with Alcoholic Hepatitis, 18.7% with steatosis, and 24% suffered from Cirrhosis of liver. Those with Cirrhosis had higher SADQ scores indicating that those with severe liver disease had more severe dependence [Table 3].
All the patients of ALD met the criteria of Alcohol Dependence Syndrome (M.I.N.I. 6.0 and clinical interview). The severity of dependence on alcohol based on SADQ scores in the patients is shown in Table 4. Severe dependence was detected in 40%. Correlation between different forms of ALD and the severity of alcohol dependence revealed that 66% of patients with Cirrhosis had severe dependence, compared to 41% with Alcoholic Hepatitis. No patient with steatosis suffered severe dependence. This difference was statistically significant indicating again that those with higher severity of dependence had more severe Alcoholic Liver Disease [Table 5].
A significant association was detected between various socio-demographic variables and SADQ scores. Younger individuals, unemployed, urban dwellers, drinking more than 300 mL of distilled spirits daily, family history of alcohol use, and age of onset of alcohol after 25 years of age, were associated with higher SADQ scores.
The primary aim of this study was to estimate the prevalence of Alcohol Dependence Syndrome in patients with Alcoholic Liver disease. While it may seem axiomatic, published literature on the prevalence of ADS in ALD is scarce. The only available Indian study by Sarin et al.[8] studied 56 male patients with ALD. They reported that 76.7% suffered ADS. This was lower than the 100% prevalence of ADS among patients of ALD, identified in our study. The difference may be because, unlike in our study which used the alcohol dependence diagnostic module of the M.I.N.I 6.0 instrument, along with a clinical interview to diagnose ADS; that study utilized only the SADQ score to recognize alcohol dependence. That study considered those in the moderate and severe range according to SADQ as “Alcohol Dependent.” In this regard, the findings of our study were similar, where a total of 74.7% of those ALD patients were found to be in the combined moderate (34.7%) to severe (40%) range of SADQ scores.
Another aim was to study the severity of dependence on alcohol in patients with ALD. A few studies have assessed the severity of alcohol dependence in patients with ALD using a severity of dependence scale.[10,17] These studies did not use a standard diagnostic interview schedule or clinical assessment for the diagnosis of ADS, indicating an assumption by researchers that all patients with ALD have ADS. This clinical axiom was corroborated in our study, where the prevalence of ADS in patients with ALD was 100%.
Smith et al.[10] in 2006 compared the severity of alcohol dependence in patients with liver disease and those without liver disease. They found that of 34 patients with alcoholic cirrhosis, only 9% had severe dependence. A majority of them reported mild/no dependence on SADQ. This is much lower than in our study, where severe dependence was detected among 40% of the patients with ALD. Another 34.7% had moderate and 25.3% had mild level of dependence. This difference could be because the researchers focused only on patients with liver cirrhosis (not other types of ALD) and did not specifically recruit freshly diagnosed patients (recall bias). This could have been a potential confounder as there is a likelihood that some of these patients had contact with healthcare providers thereafter and had reduced their alcohol consumption since. Possibly, a proportion of these patients had shifted to a non-dependent or less severe pattern of alcohol dependence. Hence, the number of patients with severe dependence may be higher than reported by Smith et al. Similar results were reported by Wodak et al.[17] in 1983 (18% patients of ALD found severely dependent). Gleeson et al.[18] used Short Alcohol Dependence Data (SADD) and reported that 26% of patients with decompensated liver disease had severe dependence. In India, Sarin et al.[8] found that among those with ALD, 30.3% had severe and, 46.4% had moderate alcohol dependence. These results compare with our findings.
We also studied the relationship between the severity of ALD and the level of alcohol dependence by using the SADQ score as both a categorical (mild, moderate and severe) and quantitative variable. Ewusi-Mensah et al.[19] reported that pre-cirrhotic SADQ scores were higher than cirrhotic SADQ scores, but this difference was not statistically significant. They did not find any correlation between the severity of alcohol dependence and the degree of liver damage. Wodak et al.[17] also reported that dependence scores tended to be lower in patients with cirrhosis than in those with pre-cirrhotic liver disease. In India, Sarin et al.[8] reported that the proportion of patients with moderate or severe dependence did not differ significantly between hepatitis and cirrhosis groups. We found that those with severe ALD (cirrhosis) had higher median SADQ scores. Among those with cirrhosis, 66% had severe dependence compared to 41% in those with alcoholic hepatitis and none among those with steatosis.
There could be many explanations for the differences observed. The sample studied by Ewusi-Mensah et al. had 41% females, while in our sample where all were males. The median SADQ scores in females studied by them were significantly lower than males, which possibly lowered the overall median SADQ scores. Literature suggests that women are more susceptible to alcohol-induced liver damage.[20] Hence, it is likely that they develop ALD at lesser severity of dependence. The mean age in this study was 40.7 years, which is younger than those studied by Wodak et al. (49.1+/- 1.4 years).[17] Studies report that of all those with alcohol dependence, two-thirds are dependent before the age of 25.[21] Such severely dependent patients possibly present early for treatment or spontaneously modify their drinking habits. There is a possibility that severely dependent patients are under-represented in this sample of older persons. A smaller sample size could have been the reason for non-significance of results in the study by Sarin et al. Our findings are significant in this regard, and challenge findings from most previous studies which have either found no correlation between the severity of dependence and ALD, or have reported less severe dependence in patients with ALD.
We found various socio-demographic correlates of the severity of alcohol dependence in this study. This study revealed higher median SADQ scores in individuals with a family history of alcohol use. Similar results have previously been reported by Gleeson et al.[18] and Johnson et al.[22] Association of higher mean daily alcohol intake with higher median SADQ scores in this study was in line with previous reports by Ewusi-Mensah et al.[19] We also found that younger age at onset of drinking was associated with more severe dependence, like Gleeson et al.[18] Patients who were unemployed and divorced also had higher severity of alcohol dependence in this study.
The strength of this study was that we used a structured, validated diagnostic schedule followed by a clinical assessment to arrive at a diagnosis of ADS which had not been done in earlier studies. Further, a validated scale was used to rate the severity of dependence in those diagnosed with ADS. This methodology tested the clinical axiom that all patients with ALD have ADS. We found this true, with a 100% prevalence of ADS among cases with ALD.
This study has a few limitations. First, it was a hospital-based study and thus does not reflect the prevalence in the community. Further, our study included only males, which limits the generalizability of results.
In the end, we can conclude from this study that all patients with ALD, irrespective of severity, suffer from ADS. Also, patients with more severe forms of ALD have comparatively severe dependence. Various socio-demographic factors like younger age at the onset of drinking, family history of alcohol use, higher mean daily drinking, and unemployment are associated with more severe dependence.
These conclusions have important implications. They will help in increasing awareness among primary care physicians and gastroenterologists regarding this issue. Many patients with ALD do not separately get referred for treatment of Alcohol Dependence. It is recommended that holistic treatment of patients with ALD should include referrals for the management of Alcohol Dependence. This is likely to substantially improve the overall outcome of Alcoholic Liver Disease.
Nil.
There are no conflicts of interest.