|A 35 year old male agriculturist residing in rural area, married and has family with two children, living in a extended nuclear family presented to the emergency in the night with complaints of shaking of hands and body, and hearing voices since 1 day, fatigue since 4 days consumption of alcohol since 8 days, sadness for the last 10-12 weeks.|
The patient and the spouse reported that he has incurred a loss of approximately Rs 100,000 (INR) as he was not able to sell his harvest due to the COVID19 lockdown which had increased his prior financial burden. The patient already had a loan of Rs 4,00,000 (INR).
The patient reported that he will have to take loan again to buy seeds and materials for the new harvest. He reported feeling helpless and worried with loss of interest in various day to day activities.
He also reported that he takes alcohol periodically once in 2-3 months but drinks for a few days continuously, from morning till night and then remains abstinent for many weeks.
He was abstinent during the entire lockdown but on the day of resumption of alcohol sale on 4th May 2020, patient started alcohol and drank in a binge pattern (560 ml -720 ml, from morning till night) neglecting all other activities. He was able to buy alcohol on credit and binge.
The patient reported that he got into a verbal altercation with his relative on a trivial issue which made him consume alcohol citing sadness and frustration as the reason.
A day before admission he started to hear many voices of people related to the altercation even though there was no one around him.
The patient had two previous episodes of binge drinking in the past few years which were also accompanied by similar depressive episodes. He also had history of one suicide attempt two months back during one of his binge drinking episodes. He did not have any history suggestive of mania or hypomania.
The patient had a family history of alcohol dependence syndrome in his father and his elder brother. The elder brother had committed suicide.
General Physical Examination –
Moderately built and adequately nourished. Withdrawal tremors were present.
On palpation, the liver was non tender and with no signs of enlargement.
Mental Status Examination –
The patient was poorly kempt and groomed. He was oriented to time, place and person. Rapport was established with difficulty during the interview. On the second day. He reported sadness, objectively appeared depressed.
Auditory hallucination “of voices shouting at him” were present. The voices were perceived by him to be in the external environment.
He also expressed ideas of hopelessness and sadness.
Following investigations were sent: Complete blood picture, Serum Electrolytes and Serum Ammonia levels, Liver function tests, Serum Gamma Glutamyl Transferase (GGT) levels and HIV, HBsAg, HCV tests. All were within normal range except GGT.
GGT was raised 760 (Normal 0-60IU/L) indicating recent consumption.
HAMD– A score of 24 was obtained, indicating severe depression.
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) was applied to assess for the risk of suicide. Results were interpreted as the patient having Suicidal ideation of low intensity
Based on WHO ICD – 10 criteria
- 1) Mental and behavioral disorders due to use of alcohol: Alcohol (Substance) Induced Psychotic disorder
- 2) Severe depression without psychotic symptoms (F32.2)
- Sadness, easy fatigability and loss of interest along with diminished appetite, disturbed sleep, low self-confidence, ideas of self -harm, bleak views about the future (3 major and >4 minor criteria present)
- Symptoms should be ideally present for 2 weeks, but if the intensity is sufficiently severe, it can be diagnosed even before 2 weeks
Pharmacological Management –
Detoxification was done with tapering dose of Benzodiazepines (Lorazepam 4-8mg/d) with Multivitamin (including Thiamine 100mg/d) supplementation.
For symptomatic treatment of psychotic symptoms:
Atypical antipsychotic Tab. Risperidone 2 mg for brief period 1-2 week and re-evaluate the need.
For depression (SSRI) Tab. Sertraline 50 mg once day, to be optimized and continued for 3-6months
Non-Pharmacological Management –
●Psychoeducation was provided and patient was educated about the risks and the consequences of continued alcohol use and its impact on his life and his family
●Patient was involved in Motivational enhancement therapy for alcohol abstinence. Or harm reduction.
●In view of prior suicide attempt, suicide risk assessment was done, and a suicide contract was taken from the patient
|Out of all the mental health disorders, depression and substance abuse constitute major components in the overall burden of disease. In 2017, 197·3 million people had mental disorders in India, including 45·7 million (with depressive disorders and 44·9 million with anxiety disorders.|
The weighted percentage of prevalence of alcohol use disorder was 4.6% according to the national mental health survey in 2015-2016. Substance use disorders (SUDs), including alcohol use disorder, moderate to severe use of tobacco and use of other drugs (illicit and prescription drugs) was prevalent in 22.4 % of the population.
COVID19 crisis in India has significantly impaired all aspects of people’s lives.
Adding to risk is that people with mood disorders are much more likely to develop substance use disorders as presented in this case.Depression in turn has various etiological factors which may also include various environmental factors.
In the present case it was due to increased financial burden and occupational impairment.Evidence from a recent meta-analysis suggests there is a strong association between alcohol use or dependence and development of suicidal ideations, suicide attempts, and completed suicide.
This possibility has to be adequately addressed while planning treatment for this patient.
● Murthy R. National mental health survey of India 2015–2016. Indian Journal of Psychiatry. 2017;59(1):21.
● Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-Related Risk of Suicidal Ideation, Suicide Attempt, and Completed Suicide: A Meta-Analysis. PLOS ONE. 2015;10(5):e0126870.
●Sagar R, Dandona R, Gururaj G, Dhaliwal R, Singh A, Ferrari A et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020;7(2):148-161.