|Year : 2022 | Volume
| Issue : 1 | Page : 67-72
Impact of Covid-19 pandemic on quality of life in persons with alcohol use disorder - A cross-sectional study
Sindhu Ponnusamy, Suvarna Jyothi Kantipudi
Department of Psychiatry, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
|Date of Submission||23-Jul-2021|
|Date of Decision||06-Sep-2021|
|Date of Acceptance||24-Nov-2021|
|Date of Web Publication||15-Mar-2022|
Dr. Suvarna Jyothi Kantipudi
Department of Psychiatry, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Alcohol use disorder has a chronic relapsing course. Various biological, psychological, environmental, and psychosocial factors play a major role in maintaining abstinence and determining relapse in patients. The COVID-19 pandemic has caused significant changes in every person's life. It is important to assess how this situation has determined alcohol use in the patients who had utilized deaddiction services in the past. Aim: The aim of this study is to assess the pattern of alcohol use, perceived stress, and quality of life (QOL) during COVID-19 in patients who had utilized deaddiction services for alcohol use disorder in the preceding 1 year. Materials and Methods: A cross-sectional design was employed in the study. After obtaining consent, telephonic interviewing of patients who had utilized deaddiction services during January–December 2019 was done, and questionnaires including sociodemographic details, Severity of Alcohol Dependence Questionnaire, Brief Substance Craving Scale, Perceived Stress Scale-10, and WHOQOL-BREF scale were administered to assess the pattern of alcohol use, stress levels, and QOL. Comparisons were carried out on different variables using SPSS version 20. Results: A total of 122 patients were inducted into the study. About 70.5% of the relapsed individuals belonged to joint families. There was a significant association between the poor QOL and relapse status of the individuals. High levels of stress were reported among the individuals who have relapsed compared to nonrelapsed individuals. Conclusion: High rates of relapse and higher stress levels were found in our study. This study has helped us to understand the pattern of alcohol use in individuals during this pandemic. It is important to address the factors contributing to relapse in individuals so as to focus on developing and implementing feasible and accessible interventions to help the individuals.
Keywords: Alcohol dependence, COVID, quality of life, relapse, stress
|How to cite this article:|
Ponnusamy S, Kantipudi SJ. Impact of Covid-19 pandemic on quality of life in persons with alcohol use disorder - A cross-sectional study. Ann Indian Psychiatry 2022;6:67-72
|How to cite this URL:|
Ponnusamy S, Kantipudi SJ. Impact of Covid-19 pandemic on quality of life in persons with alcohol use disorder - A cross-sectional study. Ann Indian Psychiatry [serial online] 2022 [cited 2022 May 22];6:67-72. Available from: https://www.anip.co.in/text.asp?2022/6/1/67/339665
| Introduction|| |
The COVID-19 pandemic has caused tremendous changes in all our lives. It has brought significant challenges in delivery of health-care system and more difficulties in the management of psychiatric illnesses, especially substance use disorders (SUDs). There is already an existing huge treatment gap for alcohol problems (86%), which is the highest amongst all mental and SUDs. Studies done in the United States show that the lifetime risk of alcohol-use disorders for men is more than 20%, with a risk of about 15% for alcohol abuse and 10% for alcohol dependence., Alcohol use disorder contributes to more than 3 million deaths globally every year.
Relapse is an inherent attribute in the course of any SUD. Relapse is the recurrence or resumption of drinking after a period of reduced substance use or after a period of abstinence., Treating alcohol use disorder can be effective in the short term, but ensuring long-term abstinence is the ultimate difficult goal to reach in any SUD. Many factors such as reduced sleep, sedentary lifestyle, behavioral addiction, social pressure, interpersonal conflicts and negative emotional states like anger, anxiety, depression, frustration, loneliness and boredom can trigger a person to consume alcohol at any point of time after deaddiction treatment. Even individuals can consume alcohol post deaddiction treatment to experience positive emotional states. Duration of abstinence varies from person to person based on these factors.
When COVID pandemic struck the world, the policymakers are forced to make quarantine and lockdown regulations in most of the nations, including India. Under these social restrictions, people are forced to stay inside their houses without much social interaction. This could increase the risk of boredom, feelings of loneliness, troubled relationships, interpersonal conflicts, and domestic violence. These factors might, in turn, contribute to risk of individuals getting into initiating substance use, increasing use, or even causing relapse in individuals who are long-term abstainers.,
With the COVID pandemic, the individuals might have difficulties with the COVID infection and its consequences, coping with the loss of closed ones and accessing support service, which might cause significant disruption in their lives. Importantly, lockdown has resulted in temporary shutting of shops, hotels, and businesses resulting in financial insecurity., All these factors might result in making the vulnerable individuals experience more negative emotional states, all these factors might result in making the vulnerable individuals experience more negative emotional states, which in turn may increase their risk of relapse. Few studies showed that there has been an increase in alcohol use and even long-time abstainers have relapsed during this period.,
The uncertainty associated with the COVID pandemic has put a huge number of people in crisis, leading to physical, psychological, financial, and social consequences. Hence, it is of utmost importance to know how alcohol consumption has changed during this challenging period, the stress experienced by these individuals, and their quality of life (QOL) which can be accounted to plan for future services to improve health-care delivery in alcohol use disorders. The study was done with the aim to assess the pattern of alcohol use, perceived stress, and QOL during COVID-19 in patients who had utilized deaddiction services for alcohol use disorder in the preceding 1 year.
| Materials and Methods|| |
The study was done in the department of psychiatry in a tertiary care center. The research protocol was approved by the Institutional Ethics Committee.
A cross-sectional, observational design was used to determine the alcohol use pattern in previously treated patients.
Participants: Inclusion and exclusion criteria
In this study, patients who had been diagnosed with alcohol dependence syndrome based on International Classification of Diseases-10 criteria, had past deaddiction treatment, above the age of 18 years, and able to provide consent were inducted.
Patients who had co-existing SUDs (except tobacco), major mental illnesses, and unwilling to provide consent were excluded.
The details of the patients who were diagnosed with alcohol dependence syndrome and treated for deaddiction (both inpatients and outpatients) during the period of January–December 2019 in the Department of Psychiatry in SRIHER were obtained from the hospital records. The patients were contacted through their telephone numbers and explained about the study. After obtaining consent from the patients, they were recruited into the study and telephonic interviewing was done. Questionnaires were administered to assess their current alcohol use pattern, craving for alcohol, perceived stress, and the QOL and data were collected. The questionnaires used include sociodemographic details, Severity of Alcohol Dependence Questionnaire (SADQ), Brief Substance Craving Scale (BSCS), Perceived Stress Scale-10 (PSS-10) and WHOQOL-BREF scale. The spouse or the reliable family member was also be interviewed to corroborate the history and other details.
A semi-structured pro forma was used to collect sociodemographic details like age, marital status, education, occupation, family type, monthly income, socioeconomic status, and locality.
Severity of Alcohol Dependence Questionnaire
SADQ questionnaire helps to measure the severity of dependence. It covers to assess the (a) physical withdrawal symptoms, (b) affective withdrawal symptoms, (c) relief drinking, (d) frequency of alcohol consumption, and (e) speed of onset of withdrawal symptoms. SADQ score of ≥31 was severe dependence, 16–30 was moderate dependence, 8–15 was mild dependence, and 0–7 was nondependent.
Brief Substance Craving Scale
The BSCS is a 16 item self-report instrument that assesses craving for substances of abuse over a 24 h period.
Perceived Stress Scale-10
The PSS is the most widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one's life are appraised as stressful. Items were designed to tap how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress. The questions in the PSS ask about feelings and thoughts during the last month. In each case, respondents are asked how often they felt a certain way. PSS scoring 0–13 was low stress, 4–26 was moderate stress, and 27–40 was high stress.
WHO Quality of Life-BREF scale
The WHOQOL-BREF instrument is a self-administered questionnaire, comprised 26 items, to assess the four major QOL domains defined by the WHO; physical health, psychological health, social relations, and environment. The first two items separately assess the overall perception of QOL and health. The tool follows a scoring system, where each question is rated on a 5-point Likert scale, ranging from 1 (very poor/very dissatisfied/none/never) to 5 (very good/very satisfied/extremely/always), and then, the scores of all four domains are summed and scaled in a positive direction, with higher scores indicating better QLL.
Statistical analysis was done using computer software. Descriptive statistics was used to describe the sample. Mean, standard deviation, and frequency were employed to describe continuous variables, while frequency distributions were obtained for categorical variables. The Chi-squared test was used to assess the significance of associations between categorical variables. P < 0.05 was considered statistically significant.
| Results|| |
A total of 183 patients' records were accessed and contacted through their telephone numbers given in the hospital records. Out of which 21 patients were unreachable, four patients had died, 13 patients were unwilling to provide consent for the study, and 23 were excluded. The response rate is 66.67%.
A total of 122 patients were inducted into the study. They were interviewed and questionnaires were administered through telephonic interviewing. After the analysis, the patients were categorized as nonrelpased and relapsed depending on their scores on SADQ (nondependence and mild dependence taken as nonrelapsed status and moderate and severe dependence taken as relapsed status).
Sociodemographic variables are presented in [Table 1]. The mean age of the patients who have nonrelapsed was 39.08 years and relapsed was 41.12 years, and all of the patients were males. The Chi-square test was used to test the significance of association between demographic variables and severity of alcohol use. There was no significant association between age and relapse status. There was no statistical association found with marital status, employment, education, locality, and relapse. About 70.5% of the patients who relapsed were in joint families compared to patients who lived in nuclear families and this was found to be statistically significant (P = 0.02).
|Table 1: Demographic characteristics of patients with AUD who have relapsed versus nonrelapsed|
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The association between severity of alcohol dependence and QOL was assessed [Table 2]. The mean value of physical QOL in nonrelapsed patients was 68.75 (11.81) and relapsed patients was 66.65 (10.22), and it was not statistically significant. The mean value of psychological QOL in nonrelpased patients was 56.09 (12.29) and relapsed patients was 53.12 (12.16). The mean value of social relationships QOL in nonrelapsed patients was 53.08 (14.91) and relapsed was 49.61 (14.95), and this was statistically significant (P = 0.02). Similarly, the mean value of environmental QOL in nonrelapsed was 65.91 (10.49) and relapsed was 62.06 (10.73), and this was also statistically significant with P value of 0.050. The association between the QOL and severity of alcohol dependence is given in [Table 3]. The patients have reported significant distress relating to physical pain, bodily appearance, safety, financial needs, and their satisfaction with health and sexual life.
|Table 2: Quality of life, perceived stress, and craving of patients who are in nonrelapse versus in relapse|
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The PSS-10 was administered to determine the stress levels in these patients and results shown in [Table 4]. Patient-reported high levels of stress were related to their confidence to handle their personal problems and inability to control irritations. About 62.8% of the relapsed patients reported moderate-to- high stress. There was a statistical significance found between PSS scores and severity of alcohol dependence (P = 0.03). It was also found to have a significant association between moderate-high stress and poor QOL (P = 0.009) [Table 5]. Furthermore patients 69.2% of the patients with moderate-high stress reported that they were dissatisfied with health (P = 0.01).
|Table 5: Association between perceived stress and relapse status, quality of life, and satisfaction with health|
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| Discussion|| |
In our study, out of 122 subjects interviewed, 56.5% of the individuals had relapsed, and 43.4% were in nonrelapse condition. Of the relapsed category, only 18% had severe dependence and 38.5% of them had moderate dependence. This showed that deaddiction treatment had helped the individuals in reducing their alcohol consumption. This might also be due to the unavailability of alcohol during lockdown period and financial restraints forcing them to cut down on expenditure for substance. Similar relapse rates of 50%–75% were found in other studies.,, However, lower relapse rates of around 30%–35% were observed in some studies., This difference between studies might be due to varied demographic settings, treatment protocols, and different follow-up methods. Furthermore, various studies show that there was a rise in alcohol use during the pandemic versus prior to it., However with our study, we were not able to differentiate the relapse rates prior and during the pandemic.
The sociodemographic variables did not vary much between the nonrelapsed and relapsed individuals except for the family types. However, few studies showed that there was a significant association with education, marital status, and relapse status.,,, Our study showed that individuals living in joint families had higher relapse rates (70.5%). This was comparable to a study done by Kharb et al. in India, which showed that 61.9% of the relapsed individuals belonged to joint families. This might be due to increased interpersonal conflicts present in joint families. Also due to the social restrictions in the current pandemic, there were high chances of all the family members getting isolated at their places altogether, leading to more conflicts.
The severity of alcohol use was compared with variable characteristics including perceived stress, craving, and QOL. There was significant distress perceived by the individuals in our study and had a significant association with the severity of alcohol dependence (P = 0.03). The individuals reported difficulty in controlling their irritations and felt less confident to handle their personal problems in our study. Negative emotional states experienced by the individuals such as anger, anxiety, depression, boredom, loneliness, sleep disturbances, Internet and gaming addiction, and social distance during this pandemic might be contributing to stress in the individuals.,,,,,,,,,, High levels of stress among alcohol-dependent patients were studied in various studies.,, The exacerbated anxiety and negative thinking that is inherent to the current experience of the pandemic and consequent lockdown can by itself be a significant trigger for relapse. One possibility might be that the individuals were unable to control their stress and cope with the life stressors which increased their vulnerability to alcohol use.
The WHOQOL-BREF scale was used to assess the QOL of the individuals. Our study found that the individuals had reported poor overall QOL and dissatisfaction with health. This was also found to be statistically significant with high levels of stress (P = 0.009 and 0.01). A study by Andersson and Nordfjærn reported that higher mental distress was associated with lower QOL. There was a significant association between physical pain and severity of alcohol dependence in our study. It has been known that individuals attribute their alcohol use as a form of self-medication for the physical pain, sleep, and exhaustion. A study done in Denmark showed that vital exhaustion is significantly associated with a 2- to 3-fold higher risk of alcohol use disorders in both men and women and 11% men and 21% women reported vital exhaustion.
The physical domain had the highest QOL domain scores in both relapsed and nonrelapsed patients and the social domain had the lowest scores. Severity of alcohol dependence was significantly associated with environmental QOL. This was comparable to the results of few studies that found the association between the QOL and alcohol use.,,, Also in our study, it was found that the patients had reported less satisfaction with their sex life and it was statistically significant (P = 0.03). There are possible chances of sexual dysfunction caused by alcohol use or might be secondary to marital discord in these patients.,
In our study, we have found the relapse rates of patients during this COVID pandemic period who had past deaddiction treatment in the tertiary care center which was high and compared with demographic variables. The high perceived stress and poorer QOL of the individuals could be the possible factors leading them into relapse which signifies the importance of addressing these factors and enabling the individuals to cope with them during the course of deaddiction treatment and planning for frequent and regular follow-ups after discharge to monitor them and to intervene earlier.
The study involved a cross-sectional design, and we do not have a sense of the longitudinal course. The individuals had their deaddiction treatment at different periods of time during the above-mentioned period which could have affected the relapse rates. The stress levels and the QOL were not assessed before deaddiction treatment to have comparative results.
| Conclusion|| |
High relapse rates had been found in the study population. Alcohol use is also associated with high stress and poor QOL. COVID-19 has caused significant changes in mental health services. Accessing treatment for alcohol use disorders has become more difficult during this pandemic. In order to address the high relapse of alcohol use disorders and to help cope better with the pandemic situation and improve the QOL, feasible and accessible psychological intervention strategies have to be adopted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64:830-42.
Further Evidence of Differences in Substance Use and Dependence between Australia and the United States. Available from: https://
. [Last accessed on 2021 Jul 08].
Global Status Report on Alcohol and Health; 2018. Available from: https://
. [Last accessed on 2021 Jul 05].
Andersson HW, Nordfjærn T. Factors associated with quality of life trajectories among inpatients treated for alcohol use disorders: A prospective cohort study. Addict Behav Rep 2020;12:100285.
Becker HC. Alcohol dependence, withdrawal, and relapse. Alcohol Res Health 2008;31:348-61.
Kharb R, Shekhawat LS, Beniwal RP, Bhatia T, Deshpande SN. Relationship between craving and early relapse in alcohol dependence: A short-term follow-up study. Indian J Psychol Med 2018;40:315-21.
] [Full text]
Kar SK, Arafat SM, Sharma P, Dixit A, Marthoenis M, Kabir R. COVID-19 pandemic and addiction: Current problems and future concerns. Asian J Psychiatr 2020;51:102064.
Marlatt GA, George WH. Relapse prevention: Introduction and overview of the model. Br J Addict 1984;79:261-73.
Banerjee D, Rai M. Social isolation in covid-19: The impact of loneliness. Int J Soc Psychiatry 2020;66:525-7.
Rehm J, Kilian C, Ferreira-Borges C, Jernigan D, Monteiro M, Parry CD, et al.
Alcohol use in times of the COVID 19: Implications for monitoring and policy. Drug Alcohol Rev 2020;39:301-4.
Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FH, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res 2020;289:113096.
Rao SR, Spruijt O, Sunder P, Daniel S, Chittazhathu RK, Nair S, et al.
Psychosocial aspects of COVID-19 in the context of palliative care – A quick review. Indian J Palliat Care 2020;26:S116-20.
Singh AK, Misra A. Impact of COVID-19 and comorbidities on health and economics: Focus on developing countries and India. Diabetes Metab Syndr 2020;14:1625-30.
Alpers SE, Skogen JC, Mæland S, Pallesen S, Rabben ÅK, Lunde LH, et al.
Alcohol consumption during a pandemic lockdown period and change in alcohol consumption related to worries and pandemic measures. Int J Environ Res Public Health 2021;18:1220.
Chodkiewicz J, Talarowska M, Miniszewska J, Nawrocka N, Bilinski P. Alcohol consumption reported during the COVID-19 pandemic: The initial stage. Int J Environ Res Public Health 2020;17:4677.
Suter M, Strik W, Moggi F. Depressive symptoms as a predictor of alcohol relapse after residential treatment programs for alcohol use disorder. J Subst Abuse Treat 2011;41:225-32.
Retention, Early Dropout and Treatment Completion among Therapeutic Community Admissions – DARKE-2012 – Drug and Alcohol Review – Wiley Online Library. Available from: https://
. [Last accessed on 2021 Jul 12].
Pasareanu AR, Vederhus JK, Opsal A, Kristensen Ø, Clausen T. Improved drug-use patterns at 6 months post-discharge from inpatient substance use disorder treatment: Results from compulsorily and voluntarily admitted patients. BMC Health Serv Res 2016;16:291.
Striley CW, Hoeflich CC. Converging public health crises: Substance use during the coronavirus disease 2019 pandemic. Curr Opin Psychiatry 2021;34:325-31.
Ramanan VV, Singh SK. A study on alcohol use and its related health and social problems in rural Puducherry, India. J Family Med Prim Care 2016;5:804-8.
] [Full text]
Pilowsky DJ, Keyes KM, Geier TJ, Grant BF, Hasin DS. Stressful life events and relapse among formerly alcohol dependent adults. Soc Work Ment Health 2013;11.
Arun AC, Ilangovan N, Rajma J. Risk factors for alcohol use relapse after abstinence in patients with alcoholic liver disease. J Family Med Prim Care 2020;9:5995-9. [Full text]
Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al.
Depression, anxiety and stress during COVID-19: Associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health 2020;17:4065.
Ramalho R. Alcohol consumption and alcohol-related problems during the COVID-19 pandemic: A narrative review. Australas Psychiatry 2020;28:524-6.
Calvey T, Scheibein F, Saad NA, Shirasaka T, Dannatt L, Stowe MJ, et al.
The changing landscape of alcohol use and alcohol use disorder during the COVID-19 pandemic – Perspectives of early career professionals in 16 countries. J Addict Med 2020;14:e284-6.
J JM, Kunjumon NC, Ruben JP, Devarbhavi H. Stressful life events, social support, and risk for relapse in relapsed harmful alcohol users in South India: A comparative study between psychiatry and gastroenterology patients. J Addict Dis 2021;39:125-32.
Menon J, Kandasamy A. Relapse prevention. Indian J Psychiatry 2018;60:S473-8.
Banerjee D, Vaishnav M, Rao TS, Raju M, Dalal PK, Javed A, et al.
Impact of the COVID-19 pandemic on psychosocial health and well-being in South-Asian (World Psychiatric Association zone 16) countries: A systematic and advocacy review from the Indian Psychiatric Society. Indian J Psychiatry 2020;62:S343-53.
Mattoo SK, Chakrabarti S, Anjaiah M. Psychosocial factors associated with relapse in men with alcohol or opioid dependence. Indian J Med Res 2009;130:702-8.
] [Full text]
Sinha R, Fox HC, Hong KA, Bergquist K, Bhagwagar Z, Siedlarz KM. Enhanced negative emotion and alcohol craving, and altered physiological responses following stress and cue exposure in alcohol dependent individuals. Neuropsychopharmacology 2009;34:1198-208.
Nadkarni A, Kapoor A, Pathare S. COVID-19 and forced alcohol abstinence in India: The dilemmas around ethics and rights. Int J Law Psychiatry. 2020;71:101579. Available from: https://
. [Last accessed on 2020 Sep 29].
Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health 2011;34:135-43.
Just-Østergaard E, Mortensen EL, Tolstrup JS, Flensborg-Madsen T. Vital exhaustion and risk of alcohol use disorders: A prospective cohort study. J Psychosom Res 2018;114:25-30.
Picci RL, Oliva F, Zuffranieri M, Vizzuso P, Ostacoli L, Sodano AJ, et al.
Quality of life, alcohol detoxification and relapse: Is quality of life a predictor of relapse or only a secondary outcome measure? Qual Life Res 2014;23:2757-67.
Olickal JJ, Saya GK, Selvaraj R, Chinnakali P. Association of alcohol use with quality of life (QoL): A community based study from Puducherry, India. Clin Epidemiol Global Health 2021;10:100697.
Foster JH, Marshall EJ, Hooper R, Peters TJ. Quality of life measures in alcohol dependent subjects and changes with abstinence and continued heavy drinking. Addict Biol 1998;3:321-32.
Macfarlane VF, Prentice DA, Walsh MS. The Auckland alcohol detoxification outcome study: Measuring changes in quality of life in individuals completing a medicated withdrawal from alcohol in a detoxification unit. Drug Alcohol Depend 2019;202:156-61.
Grover S, Mattoo SK, Pendharkar S, Kandappan V. Sexual dysfunction in patients with alcohol and opioid dependence. Indian J Psychol Med 2014;36:355-65.
] [Full text]
Pendharkar S, Mattoo SK, Grover S. Sexual dysfunctions in alcohol-dependent men: A study from north India. Indian J Med Res 2016;144:393-9.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]