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 Table of Contents  
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 43-50

Proportion of subjects remaining abstinent following alcohol de-addiction treatment and factors associated with abstinence - A 3 months prospective cohort study

1 Junior Resident, Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Associate Professor, Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 Professor and HOD, Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission25-Oct-2020
Date of Acceptance15-Mar-2021
Date of Web Publication20-Apr-2021

Correspondence Address:
Dr. Praveen Arathil
Department of Psychiatry, Amrita Institute of Medical Sciences, Ponnekara Po, Kochi - 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_49_20

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Aims: The aim is to study prevalence of abstinence rates for 3 months follow-up in individuals of alcohol dependence undergoing de-addiction treatment. Also to assess for possible co-relation between sociodemographic, clinical, personality, cognitive functioning and laboratory variables of relapsed and abstinent individuals.
Subjects and Methods: Eighty-six individuals who were admitted for alcohol deaddiction treatment were taken for the study after taking consent. Sociodemographic and clinical variables were assessed using a pro forma. The Mini-International Neuropsychiatric Interview was administered to rule out other disorders. Clinical Institute Withdrawal Assessment of Alcohol, revised scale to assess the severity of withdrawal. Personality was assessed using 16PF. The Tower of London (ToL) test was used to assess executive function. Individuals were followed up after discharge till 3 months from the admission date to assess for the maintenance of abstinence.
Results: Out of 86 individuals, only 24 individuals maintained abstinence at 3 months. About 72.08% of those who had previous deaddiction treatment did not maintain abstinence or were lost to follow-up. Duration of hospitalization was significantly more in abstinent individuals (15.63 ± 6.31, P = 0.001). On 16PF individuals who did not maintain abstinence had higher perfectionism scores (5.97 ± 1.9, P = 0.027) similarly on the ToL test they had lower scores on the total number of problems solved on the minimum number of moves (7.02 ± 1.76, P = 0.001).
Conclusion: There is the low rate of abstinence among individuals having undergone deaddiction treatment at the end of 3 months. Modifying treatment for individuals who have past relapses, personality disturbances, and avoiding early discharge may help in increasing the abstinence rate.

Keywords: Alcohol dependence, abstinence, personality

How to cite this article:
Nair A, Arathil P, Narayanan D. Proportion of subjects remaining abstinent following alcohol de-addiction treatment and factors associated with abstinence - A 3 months prospective cohort study. Arch Ment Health 2021;22:43-50

How to cite this URL:
Nair A, Arathil P, Narayanan D. Proportion of subjects remaining abstinent following alcohol de-addiction treatment and factors associated with abstinence - A 3 months prospective cohort study. Arch Ment Health [serial online] 2021 [cited 2021 Nov 28];22:43-50. Available from: https://www.amhonline.org/text.asp?2021/22/1/43/314185

  Introduction Top

Alcohol dependence syndrome is one of the leading causes of death and disability in the world.[1] How a person using alcohol becomes dependent is a complicated process to understand. Many neurobiological and environmental factors are involved in relation to the adverse effects of alcohol, the reasons and compulsion to continue drinking despite knowing that it is harmful, and the motivation needed to quit it.[2] Addiction cannot be considered as a single entity as it leads to long-term functional and structural changes in the brain, resulting in persistent changes in behavior, reasoning capacity, and ultimately, dysfunction in all aspects of a person's life.[3]

Studies have found that personality traits such as high reward-seeking, disinhibited behaviors, and being prone to anxiety are predictive risk factors associated with chronic alcohol consumption.[4] Recent studies have shown that in addition there is imbalance between various neural systems and this results in poor decision-making leading to more risk of addiction.[5] The biochemical markers for chronic alcohol consumption which have been most commonly researched for, are serum Gamma-glutamyl transferase (GGT), aspartate aminotransferase, alanine aminotransferase, mean corpuscular volume (MCV), and carbohydrate-deficient transferrin (CDT). However, most studies have not been able to find a reliable marker to be used as a tool for abstinence compliance due to their low specificity.[6] Elevated GGT alone has got both low sensitivity and specificity for alcohol abuse, but studies have found that using a combination of these markers together has been more effective in detecting individuals having alcohol dependence.[7]

The primary objective of the study was to understand the prevalence of abstinence rate for 3 months of follow-up in individuals with alcohol dependence undergoing de-addiction treatment. The secondary objectives were to assess for possible co-relation between sociodemographic variables of relapsed and abstinent individuals, assess clinical co-relates between relapsed and abstinent individuals, assess personality parameters between relapsed and abstinent individuals, assess laboratory values that can co-relate between abstinent and relapsed individuals and to assess the correlation in cognitive functioning among relapsed and abstinent individuals with alcohol dependence syndrome.

  Subjects and Methods Top

Based on the percentage of patients with alcohol dependence syndrome maintaining abstinence as reported in a previous study conducted by Abraham et al. with a 95% confidence interval and 20% allowable error minimum sample size required is 80.[8] A total of 86 individuals were included in the study.

The study was conducted in Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi which is a 1450-bedded tertiary care center in Kerala, Southern India. The study was done over 2 years from September 2017 to September 2019 in the inpatient wards of the Department of Psychiatry.

The individuals for the study were selected if they satisfied the inclusion criteria of being at least 18 years of age diagnosed with alcohol dependence as per ICD-10 by a consultant psychiatrist. Having the ability to understand informed consent and giving written informed consent. Individuals were excluded if they were not completing all the baseline tests. If they were admitted for the management of other comorbid psychiatric disorders primarily except for tobacco dependence syndrome.

A semi-structured pro forma was used to record information regarding the socio-demographic profile and clinical details of the participants. Other tools used included the Mini-International Neuropsychiatric Interview (MINI). The MINI 5.0 is a short, structured interview developed in 1990 by David. V. Sheehan. It maps onto diagnostic criteria of DSM V and ICD-10.[9] MINI.5 focuses both on current and lifetime diagnosis. It has been used reliably for multicentre clinical trials, epidemiological studies, outcomes research as well as in nonresearch clinical settings. Clinical Institute Withdrawal Assessment of Alcohol revised (CIWA-Ar) was also used. Sullivan et al. developed this scale which has been referred to as CIWA-Ar. It is a ten-item scale used in the assessment and management of alcohol withdrawal.[10] 16PF was also used as a tool. The Sixteen Personality Factor Questionnaire as described by Raymond Bernard Cattell measures personality on two hierarchical levels, primary and secondary traits, and has been developed as a result of extensive factor analyses of the large assortment of behavioral items.[11] From the hierarchical analysis of the 16 factors, came the Five-Factor Model of Personality Traits that is: extraversion, anxiety, tough-mindedness, independence, and self-control, which would later be updated as extraversion, neuroticism, openness to experience, agreeableness and consciousness, through reanalysis of Cattell's data by others.[12] The Tower of London (ToL) test was also used. ToL is an executive function task utilized primarily to assess planning ability and was originally developed by Shallice as a modification of the Tower of Hanoi. The scoring systems evaluate planning ability according to the time needed for a correct solution, trials needed for a correct solution or a combination of both.[13]

This study was conducted after obtaining the approval of the ethical committee and their guidelines were followed. It is a prospective cohort study of 86 individuals. Individuals admitted under the department of psychiatry, diagnosed with Alcohol dependence Syndrome, by a consultant psychiatrist as per the ICD-10 criteria, were included in the study. Convenience sampling technique was used to select the individuals. Written informed consent was taken from the subject or from the appropriate relative or caretaker after explaining the details of the study. Sociodemographic data were recorded using the structured pro forma. Clinical variables were also noted from individuals MINI.5 was administered to confirm the diagnosis as well as to rule out other major psychiatric disorders. In these individuals, the severity of withdrawal symptoms was assessed using CIWA-Ar scoring. The sixteen personality factor questionnaire and the ToL were administered once the de-toxification was completed. From the primary factors of 16 PF, secondary factors were analyzed using the formulae. The treatment to each subject was decided by individual consultants, according to the general health condition and stage of motivation. After discharge, subject were then followed up on outpatient basis every 2 weeks regularly for 3 months. Those individuals who regularly visited the outpatient clinic regularly and were reported to be abstinent from alcohol were considered as abstinent from alcohol in this study.

Statistical analysis was performed using IBM SPSS Statistics 20 Windows (SPSS Inc., Chicago, USA). The results are given in mean ± standard deviation or in median (minimum to maximum) for continuous variables and in frequency (percentage) for categorical variables. Independent sample t-test was applied to compare the mean of continuous parameters such as age, personality factors, ToL test for assessing cognitive functioning and CIWA score between relapsed and abstinent individuals. Mann–Whitney U-test was applied to compare the median level of laboratory parameters between the two categories. Pearson's Chi-square test with continuity correction was applied to find the association between relapsed and abstinent groups for categorical demographic.

  Results Top

Eighty-six individuals with an ICD-10 diagnosis of Alcohol Dependence Syndrome were included in this study. All the individuals were male. During 3 months follow-up period following de-addiction treatment, a total of 62 individuals were considered as not being abstinent. This included 25 individuals who actually came to the outpatient clinic following relapse which means they went back to earlier pattern of use of alcohol, 13 individuals who visited other departments and were marked as not abstinent and 24 individuals who did not come for follow-up at all in our hospital. Twenty-four individuals remained completely abstinent for 3 months. The prevalence of abstinence rate for 3 months follow-up in individuals with alcohol dependence undergoing de-addiction is found to be 27.91%.

In [Table 1], their mean age was 48.48 ± 10.56 and there was no statistically significant difference between the mean age of the individuals in the two groups. With regard to educational level, primary school, secondary school, and 12th standard pass were clubbed together as up to 12th standard. Graduates and postgraduates were clubbed together as college and above. No statistically significant difference on Pearson square test.
Table 1: Association of sociodemographic variables between relapsed and abstinent individualswith alcohol dependence

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Fifty-six individuals lived in the nuclear family, and among them, 40 (71.4%) had a relapse. Using Pearson's Chi-square test with continuity correction, significant statistical difference was seen between the groups (P = 0.001).

In [Table 2], out of the 62 relapsed individuals, the mean age at the time of first drink was 22.79 ± 8.254 on independent t-test there was no statistical difference with abstinent groups. Out of the 21 individuals who had chronic liver disease 15 (71.4%) had relapse. Among the 65 individuals with other comorbidities like type 2 Diabetes mellitus, systemic hypertension, 47 (72.3%) relapsed. No statistically significant difference among the two groups based on medical comorbidities. Among the 34 individuals who have taken previous de-addiction treatment, 31 (91.2%). Using Pearson's Chi-square test, there is a statistically significant difference with the abstinent group based on past de-addiction treatment (P = 0.001). Out of the 62 relapsed individuals, the mean duration of hospital stay was 10 ± 6.142. Independent t-test was done and there is a statistically significant difference with the abstinent group who had a longer duration of stay (P = 0.001). The severity of withdrawal symptoms as assessed using CIWA score at admission in the two groups using independent t-test was not statistically significant. Among the various laboratory parameters assessed, using Mann–Whitney U-test, there was no statistically significant difference in the average serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), GGT, and MCV values between the two groups as the P > 0.05.
Table 2: Association of psychosocial variables and clinical variables between relapsed and abstinent individualswith alcohol dependence

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In [Table 3], out of the 16 primary personality factors, perfectionism among the relapsed individuals was 5.97 ± 1.907, and 4.88 ± 2.271 among the abstinent groups. Independent t-test was applied and there was statistical significance as P = 0.027.
Table 3: Association of personality factors between relapsed and abstinent individuals with alcohol dependence using independent t-test

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In [Table 4], among the secondary factors of 16 PF, using independent sample t-test, there was no statistically significant difference observed between the two groups.
Table 4: Association between secondary factors of 16 personality factor between relapsed and abstinent individuals with alcohol dependence using independent t-test

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In [Table 5], out of the 62 individuals relapsed, ToL test which assess the cognitive functioning and planning, the trial with the minimum number of moves (MNM) involved had a mean value with standard deviation of 1.87 ± 0.338 in trial 2, 2.27 ± 0.961 in trial 3, 1.95 ± 0.711 in trial 4 complex moves. Among the 24 abstinent individuals, the mean and standard deviation was 2.00 ± 0.000 in trial 2, 2.82 ± 0.664 in trial 3, and the complex trial 4 had 2.27 ± 0.550. Being a continuous variable independent t-test was applied. There is a statistically significant difference between the two groups with a P < 0.05. Among the relapsed individuals, the mean and standard deviation of the number of mean moves in trial 2 is 4.56 ± 2.266 and 3.45 ± 0.963. Independent t-test was applied and there is a statistically significant difference between the two groups (P = 0.002). The overall scores of the total number of problems solved with the minimum number of moves (TPMM) are 7.02 ± 1.760 among the relapsed and 8.36 ± 0.848 among the abstinent individuals. Independent t-test was applied and there is a statistically significant difference between the two groups (P = 0.001).
Table 5: Association tower of London test results of relapsed and abstinent individualswith alcohol dependence using t-test

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  Discussion Top

This study was conducted in an IP setting where individuals are assumed to present to medical attention with worsening of symptomatology or referred from other departments for de-addiction. A convenience sampling technique was hence adopted due to time constraints during the study.

In our study, it was observed that almost two-thirds of the individuals did have a relapse within 3 months period of follow-up. The prevalence of abstinence rate was found to be only 27.91%. This is in keeping with another study conducted by McLellan et al.[14] This high number is alarming and therefore warranted a thorough assessment at different modalities altogether, which can help a clinician aiming for ways to achieve a longer period of abstinence.

There was no statistically significant difference seen between the age of onset of relapsed and abstinent individuals. This is contrary to a study conducted by Hingson et al., in which it was found that individuals who began drinking at younger ages were more likely to experience recurrent relapses.[15] The failure to obtain any significant association in our study is probably due to the small sample size.

In our study, we were not able to demonstrate any significant association between the level of education among relapsed and abstinent individuals probably due to the prevailing high literacy rate in Kerala. However, studies have found that people with lower education tend to relapse. A study conducted by Crum et al. suggested that education can serve as a protective factor.[16] The present study did not show any association between the employment status of individuals who remained abstinent and relapsed. A study by Murthy et al. has demonstrated that the majority were self-employed or skilled workers among the people who relapsed rather than professionals.[17] This study did not find any significant association of monthly income among the abstinent and relapsed individuals. This is in keeping with the high standards of living in Kerala. A metanalysis by Collins has shown that low socio-economic status individuals have a higher risk of developing alcohol use disorders.[18]

In the present study, we were not able to demonstrate any association between the marital status of relapsed and abstinent individuals. This is contrary to another study done by Mattoo et al. where the majority of the married individuals had a relapse within 3 months.[19] A study by Kendler et al. reveal marriage as a protective factor for males from relapse, while it is a risk factor in females, our study did not show any such results, the probable reason being a small sample size.[20] In this study, among the 53 relapsed individuals, 40 of them lived in a nuclear family which is statistically significant. A similar finding was obtained by a study conducted by Ramanan and Singh that married people living in nuclear families tend to repeatedly drink as they have to manage more responsibilities and less bonding with family cause them to restart their drinking habit.[21] In this study, most of the population reside in an urban or suburban area. Those who relapsed also were from the above-mentioned areas. This could be due to the placement of the hospital within city limits and the existence of more urban and suburban areas within Kerala.

In this study, no statistically significant association was found between family histories of alcohol dependence among the two groups probably due to the small sample size. Positive family history has been proven to strongly predispose an individual to consume excess alcohol. In our study, there was a statistically significant higher number of individuals who had previously relapsed in the current group of subjects who could not stay abstinent. A study by Andersson et al. stated that the risk of relapse is high among people who have the previous relapse and also a positive history of alcohol use in the family.[22]

Craving being the most commonly studied as reason to relapse; our study population did not show a significant association on the types of craving between the relapsed and abstinent subjects. However, studies have shown high association with internal locus of control supporting the fact that addiction causes changes in the brain structure and long-term functioning. Our study could not obtain any such results probably due to the high attrition rate during follow-up. These subjects also were considered as relapsed with supporting evidence from a study conducted by O'Connor et al. having reported a higher dropout rate during alcohol withdrawal among outpatients with an increased craving.[23]

In this study, we observed that individuals who completed detoxification along with intensive appropriate pharmacotherapy and psychotherapy in the in-patient setting for a period of 2 weeks were able to stay abstinent for a longer period than the relapsed individuals. This is in keeping with other studies that patients who received intensive inpatient treatment within 30 days of completing detoxification were ten times less likely to relapse, while those completing detoxification alone are getting relapsed at the rate of 65%–80%.[24] It is expected to have a few days of some psychological problems such as anxiety/tension, depressive symptoms, and even suicidal thoughts after detoxification. It would be worth addressing these during in-patient treatment so that they would understand their own strengths through professional feedback and become self-sufficient in dealing with high-risk situations, increasing their self-efficacy.[16] Although statistically no association could be demonstrated, the CIWA score could generate clues in assessing whether a subject could relapse while experiencing such aversive and potentially life-threatening withdrawal symptoms like seizures.

In this study, we were unable to demonstrate any significant association between primary personality factors among relapsed and abstinent individuals. Literature says that with regard to alcohol dependence, the “novelty seeking” trait has been found to predict relapse in alcohol-dependent males and “harm avoidance” trait predicted early relapse in females.[25] Alcohol dependence has been associated with higher neuroticism scores and lesser conscientiousness scores.[26] In a study conducted by Gedam and Patil, most of the patients with alcohol dependence syndrome scored high on personality characteristics such as warmth (A), dominance (E), social boldness (H), sensitivity (I), vigilance (L), openness to change (Q1), and perfectionism (Q3) while they scored low on factors liveliness and privateness. Personality traits such as emotional stability and perfectionism were found to affect the severity of alcohol dependence in that study.[27] This is in keeping with our study in which relapsed individuals had more scores in perfectionism (Q3). Perfectionism can be characterized as a set of high standards of performance that is defined as negative self-evaluation, criticism, and self-blame.[28] Our study reveals that certain personality characteristics are seen more among people dependant on alcohol and also those very factors may hinder the desired outcome. Hence, this emphasizes the need to consider personality factors while treating alcohol dependence.

In this study, we were not able to demonstrate any significant association between laboratory parameters such as SGOT, SGPT, and GGT among the relapsed and abstinent groups. A study was conducted by Husemoen et al. and they also were not able to establish any association with a single biomarker for alcohol dependence.[29] MCV of relapsed and abstinent individuals were not having any statistically significant difference, but other studies have recognized its screening value in combination with other markers such as GGT and CDT.[30]

In the present study, the ToL test which assesses cognitive functioning showed that relapsed individuals had difficulty in planning to solve the problem with the minimum number of moves. They had to make more number of moves to achieve the solution. A similar finding was observed in a study conducted by Gould.[31] This could be interpreted as the failure of error-correcting ability, speed of processing, and mental flexibility which are core components of planning. A meta-analysis by Le Berre et al. has suggested that in individuals who relapse this may be due to poor decision-making ability in relation to alcohol use due to the executive dysfunction.[32]

There were various limitations of our study. The sample size was small so extrapolating the results for the general population would be difficult. Such as all the individuals in our study population were males, not all psychosocial and clinical variables were taken into consideration in this study, there was no standardization of the treatment regimen for the individuals in the study and individuals were followed up only for a short period.

  Conclusion Top

Abstinence in alcohol dependence is not an isolated process. Since emphasis cannot be narrowed to only one or two possible risk factors, the multi-dimensional assessment will certainly help to identify causes for relapse. Our study advocates the need for further research in combining the effect of deviant personality traits and cognitive deficits into clinical practise. The integration of neurocognitive parameters as well as genetic markers of relapse will prompt major challenges moving ahead, but emphasis on research will help develop strategies that are focused to enhance compliance and prevention of relapse in patients with alcohol dependence syndrome. The objective should be to make patients more aware of themselves, their boundaries and limitations, and how they can use their strengths to compensate for their weaknesses.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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