Abstract
Background
Early age at first drink (AFD) has been linked to early onset and increased severity of alcohol dependence in various studies. Few Indian studies on AFD have shown a negative correlation between AFD and severity of alcohol dependence. Our study aimed to explore this relationship in patients with alcohol dependence syndrome (ADS) diagnosed using ICD-10 criteria.
Methods
One hundred fifty-one consecutive patients freshly diagnosed with ADS were included in the study, which was conducted at the psychiatry unit of a tertiary care, multispecialty hospital. The Addiction Severity Index (ASI) was used to assess severity of alcohol dependence.
Results
Mean AFD was 24.85 years (range = 13–40 years). Median ASI score was 36 (range = 21 to 57). The study yielded a weak negative correlation (ρ = −.105) between AFD and ASI, which was statistically not significant.
Conclusions
We found no correlation between AFD and severity of alcohol dependence at detection in Indian Armed Forces personnel, which is contrary to what has been reported worldwide and in previous Indian studies. Delayed initiation of alcohol use among those enrolling in the Indian Armed Forces and early detection of alcohol dependence within the military environment are possible explanations.
Keywords: Alcohol dependence, Age at onset, Addiction severity
Introduction
Alcohol dependence syndrome (ADS) is a public health problem across the world and in India as well (World health Organization [WHO], 2014).1 Etiology of alcohol dependence has been linked to genetic and environmental factors. Age at first drink (AFD), family history, occupation, social milieu, socioeconomic status, cultural practices, and negative childhood experiences are some of the factors that impact occurrence and severity of alcohol dependence. AFD has been linked to early onset and increased severity of alcohol dependence in studies across the world.2, 3, 4 An early age at onset of alcohol consumption has been linked to social maladaptation, behavioral disinhibition, and criminality (indirect markers of severity of dependence).4 Very few Indian studies have assessed the effect of age at onset on the severity of dependence. Johnson et al5 studied AFD and severity of dependence using the “Severity of Alcohol Dependence Questionnaire” (SADQ) in cases of ADS and reported a significant negative correlation. However, they had excluded more than half of the cases from the study, that is, those who had medical complications. This is a cause of bias because those with alcohol-related physical harm were excluded. Prakash et al.6 in 2010 studied 54 consecutive patients in a military milieu and concluded that early-onset drinkers differ from late-onset drinkers, in that they consume greater amounts of alcohol and are diagnosed at an early age. The present study aims to explore the relationship of AFD with severity of dependence in patients with ADS.
Materials and methods
This cross-sectional analytical study was carried out in the psychiatry unit of a large tertiary care multispecialty hospital in Kolkata over 24 months (Aug 13 to Jul 15). Clearance from the institutional ethics committee was obtained before starting the study. Written informed consent was obtained from the patients before enrolling them. Sample size was calculated considering an expected correlation coefficient of .3 and a 95% confidence interval half width of .2 (power of the study = 80%, significance level = .05); the sample size required was 133. The sample size in the present study was 151.
All consecutive male inpatients diagnosed fresh with ADS (as per ICD-10 Diagnostic criteria for research) and able to communicate and cooperate were included in the study. Those patients who were unable to cooperate because of extreme severity of complications and those patients who were transferred to other wards/hospitals were excluded from the study. Patients were evaluated in detail (psychiatric interview and medical evaluation) during the first week of admission. The Addiction Severity Index (ASI) was administered by a trained resident in psychiatry during the third week of admission, after adequate rapport was established.
The ASI was used in the study to assess severity of alcohol dependence. It has been in clinical use since 1989 and has good reliability (interrater correlation coefficients >.85) and validity (correlation coefficients between .43 and .7).7, 8 The ASI has 7 items rated between 1 and 9. These are medical status, alcohol status, drugs, employment status, legal status, family/social status, and psychological status. In addition, demographic data were collected, and pattern of alcohol use was assessed for each patient. Lifetime alcohol use was calculated by estimating the amount of alcohol (in grams) from history, consumed over the years, added together. Family history of alcohol use, family history of mental illness, type of drink, other substance use, occupation, medical illnesses, marital status, socioeconomic status, and educational background were anticipated as potential confounders, and the data were collected in the demographic data sheet for analysis. Analysis was performed using Statistical Package for Social Sciences (SPSS-20, IBM). Spearman's correlation coefficient was calculated (for correlation between continuous data – age – and ordinal data – ASI scores), and an independent-sample t-test was used to find differences between groups.
Results
One hundred sixty-five patients with ADS were enrolled in the study. Ten patients were lost to follow-up, 2 patients died due to complications, and 2 patients were excluded from the study. Analysis was carried out on 151 subjects. Thirty patients presented with pancreatitis (19.8%), 26 with hepatitis (17.2%), 23 with seizures (15.2%), and 72 were referred for various social and behavioral consequences of drinking (47.68%). Other parameters studied are summarized in Table 1. To compare our findings with those of Johnson et al5, the subjects were divided into two groups – based on the presence or absence of “medical complications.” Seventy-nine subjects (52.31%) had medical complications, while the 72 subjects (47.68%) were referred for “only” social/behavioral consequences of alcohol use (no medical complications). These two groups did not differ from each other in any parameters (Table 2).
Table 1.
An overview of various parameters studied – Age characteristics, years of alcohol use, and lifetime alcohol use (n = 151).
| Parameters | Mean | Standard deviation | Variance |
|---|---|---|---|
| Age at first drink (years) | 24.85 | 5.50 | 30.29 |
| Age at dependence (years) | 33.59 | 7.28 | 52.86 |
| Age at detection (years) | 36.39 | 7.77 | 60.36 |
| Mean years of drinking | 11.69 | 7.18 | 51.50 |
| Years of dependence before diagnosis | 2.97 | 2.42 | 5.84 |
| Lifetime alcohol use (kg) | 148.73 | 102.90 | 10,588.82 |
Table 2.
Differences between “medical complication” and “no complication” groups on various parameters (independent-samples t-test).
| Parameters | Groups | N | Mean | Standard deviation | Standard error mean | T | P value |
|---|---|---|---|---|---|---|---|
| Age | Medical complications | 76 | 35.71 | 6.68 | .76 | −1.08 | .280 |
| No complications | 75 | 37.08 | 8.72 | 1.00 | |||
| GGT | Medical complications | 76 | 157.71 | 258.66 | 29.67 | 1.78 | .076 |
| No complications | 75 | 91.11 | 195.26 | 22.54 | |||
| MCV | Medical complications | 76 | 93.29 | 9.11 | 1.04 | 1.66 | .099 |
| No complications | 75 | 90.78 | 9.49 | 1.09 | |||
| AST | Medical complications | 76 | 93.19 | 119.10 | 13.66 | 1.91 | .057 |
| No complications | 75 | 63.33 | 64.01 | 7.39 | |||
| ALT | Medical complications | 76 | 82.28 | 88.43 | 10.14 | 2.25 | .026 |
| No complications | 75 | 56.68 | 43.30 | 5.00 | |||
| BMI | Medical complications | 76 | 22.95 | 3.32 | .38 | -.29 | .775 |
| No complications | 75 | 23.08 | 2.49 | .28 | |||
| Addiction Severity Index | Medical complications | 76 | 35.64 | 4.38 | .50 | -.85 | .394 |
| No complications | 75 | 36.52 | 7.76 | .89 | |||
| Lifetime alcohol use | Medical complications | 76 | 151.83 | 112.30 | 12.88 | .37 | .710 |
| No complications | 75 | 145.58 | 93.06 | 10.74 | |||
| Years of drinking | Medical complications | 74 | 11.14 | 6.92 | .80 | -.93 | .352 |
| No complications | 75 | 12.24 | 7.42 | .85 | |||
| Age at dependence | Medical complications | 76 | 32.84 | 6.28 | .72 | −1.27 | .205 |
| No complications | 75 | 34.34 | 8.12 | .93 | |||
| Age at onset | Medical complications | 76 | 24.86 | 5.68 | .65 | .024 | .981 |
| No complications | 75 | 24.84 | 5.35 | .61 |
GGT, gamma glutamyl-transferase; MCV, mean corpuscular volume; AST, aspartate aminotransferase; ALT, alanine aminotransferase; BMI, body mass index.
The mean age at presentation (detection/diagnosis of alcohol dependence) was 36.4 years. The mean age at first drink was 24.85 years (range = 13–40 years). The median ASI score was 36 (range = 21 to 57). The mean duration of alcohol use before diagnosis was 11.9 years. The mean age at dependence (Three ICD-10 criteria met) was 33.58 years, and the mean duration of dependence before diagnosis was 2.9 years.
Three patients (1.98%) reported family history of mental illness in first-degree relatives, and 69 patients (49.6%) reported family history of regular alcohol consumption in first-degree relatives. However, they were not significantly different with respect to severity of alcohol dependence. Tobacco use was reported in 31 (20.52%) patients, and 01 patient reported Cannabis use. These patients were not significantly different from those who did not use any other psychoactive substance, with respect to severity of dependence. Statistical analysis was undertaken to evaluate relationship of the aforementioned potential confounders with severity of dependence, but no such relationship was found.
Analysis yielded a weak negative correlation (Spearman's correlation coefficient ρ = −.105, p = 0.205) between AFD and ASI, which was not statistically significant. In the “no complications” group, there was a negative correlation between AFD and ASI (Spearman's ρ = −.215, p = 0.062). This correlation was not significant even in the medical complications group (Spearman's ρ = .008, p = 0.473). AFD was found to be negatively correlated with duration of drinking before diagnosis (Pearson's r = − .256, p = 0.002) (Table 3).
Table 3.
Correlation of age at first drink (AFD) with various parameters.
| Parameter | Correlation coefficient | Significance |
|---|---|---|
| Duration of drinking | r = −.256 | p = 0.002a |
| Lifetime alcohol use | r = .239 | p = 0.003a |
| Addiction Severity Index | ρ = - .105 | p = 0.201 |
Pearson's correlation coefficient “r” calculated for continuous variables.
Spearman's correlation coefficient “ρ” calculated for a continuous and an ordinal data set.
Significant values.
Discussion
In this study, we found no correlation between AFD and severity of addiction (measured using the ASI). This implies that lower AFD is not related to greater severity of dependence at detection. This is contrary to what has been reported in the published literature.5 According to studies in the past, early AFD has predicted more severe dependence,2 than delayed age at onset of drinking. It is likely that the population with early onset of alcohol use is not enrolling in the Indian Armed Forces. Other reason may be early detection and treatment of medical and behavioral consequences of alcohol use, which is a norm in our military milieu. This also explains a lesser average duration of drinking in the present study than in other studies worldwide (Table 4). Early detection and lesser average duration of drinking in turn might be leading to a less severe dependence at detection, which in turn also explains lack of correlation between AFD and ASI in the present study.
Table 4.
Comparison of study parameters between various studies (Indian, other countries, and Indian Armed Forces’ past studies).
| Study parameters | Saldanha et al (1992)12 | Chaudhury et al (2002)11 | Prakash et al (2013)6 | Schuckit et al (1998)14 | Johnson et al (2010)5 | Nair et al (2016)10 | Present study |
|---|---|---|---|---|---|---|---|
| Age at first drink (yrs) | 27 | 24 | 25.4 | 17 | 21.4 | 20.86 | 24.8 |
| Age at dependence (yrs) | – | – | – | 24.2 | 27.8 | 34.05 | 33.5 |
| Age at detection (yrs) | 37.2 | 38.0 | 38.2 | 31.7 | – | 41.39 | 36.4 |
| Mean years of drinking (yrs) | 10 | 14.7 | 12.8 | 22 | – | 20.53 | 11.9 |
Note: The studies by Saldanha et al., Chaudhury et al., and Prakash et al. are Indian Armed Forces' studies; the study by Schuckit et al. is a Western study; and the studies by Johnson et al., Nair et al. are Indian civilian studies.
A recent study on recruits of US Marine Corps found that about 21% of the risky drinkers had reported onset of alcohol use before 13 years of age.9 In the present study (comprising alcohol-dependent subjects), only two patients (1.3%) had started drinking at 13 years and six (3.9%) by 16 years of age. Pitkanen et al.,3 in a longitudinal study in the US, reported average age at onset of alcohol use as 15 years which is much lower than our finding (24.85 years).
In the Indian context, Johnson et al.5 have reported the mean age of onset of initiation of alcohol use as 21.39 years and mean age at dependence as 27.8 years. Nair et al.10 in a recent study reported the mean age at onset of alcohol use as 20.86 years. Prakash et al.6 reported the mean age at onset of alcohol use of 25.42 years and mean age at presentation of 38.29 years, which are similar to the present study (Table 4). Chaudhury et al.11 and Saldanha and Goel12 have reported findings from the Indian Armed Forces similar to the present study. Mean years of drinking before diagnosis in our study was 11.6 years which is similar to the 13-year findings of the study by Prakash et al.6 Other studies in India reported later detection, resulting in mean duration of drinking of 17 years before presentation.13 A longer duration of drinking would give rise to greater alcohol-related problems and more severe dependence. Shorter duration of drinking before diagnosis observed in the present study along with a later AFD might explain the lack of correlation between AFD and severity of dependence.
However, the same correlation (between ASI and AFD) in the “no complications” group was found to be (Spearman's ρ = −.215, p = 0.062) almost similar to the correlation coefficient found in the study by Johnson et al.5 (r = −.250, P < 0.001). It may be noted that Johnson et al.5 excluded a large number of cases (378 out of 673) presenting with medical complications. In effect, the cases included are likely to be those with no complications, and hence, similar correlation was observed. Thus, severity of alcohol dependence possibly correlates with AFD in the group presenting with social/behavioral consequences. Mortality and morbidity associated with medical complications may be preventing the development of a more “severe” alcoholism as measured using the available instruments.
A possible reason for the diverging results in this study could be lesser severity dependence because of early detection. In a large community-based study in the US, the average delay between the onset of alcohol dependence and the initiation of help from a health professional was 6.4 years for men.14 In our study, this delay is only 2.96 years, indicating a more sensitive environment where individuals are referred at an early stage. Mean years of drinking before detection is lower in Indian Armed Forces personnel than in general Indian population, indicating a greater sensitivity of detecting alcohol-related harm (Table 4).
Another explanation for this result might be related to the ASI, the tool chosen for assessing severity. The ASI has 7 items rated between 1 and 9. These are medical status, alcohol status, drugs, employment status, legal status, family/social status, and psychological status. There is a disproportionate representation of social and behavioral consequences of alcohol use in this study. An individual who is severely ill with only medical complications might still score less on the ASI.
Age correlates of alcohol dependence in the present study are similar to those in other studies conducted earlier in the Indian Armed Forces. However, they are markedly different from those reported in other countries, both civilian and military. There are methodological differences because most recent studies in the West are community-based surveys, whereas the present study and earlier Indian Armed forces studies have been hospital-based studies. Nevertheless, certain inferences may be drawn.
Family history of alcohol use disorders, in the present study, was found to be associated with greater severity alcohol dependence, earlier AFD, and a higher total lifetime alcohol consumed. This is similar to other studies in India and in the West.
The differing age correlates of alcohol dependence in this study might be due to cultural influences. Exposure to alcohol and drugs in general community in India is still low, compared with the Western world. Adolescent drinking is fairly common in the West, whereas it is still low in India. A higher AFD found in the present study and a previous study6 might reflect differences in culture and societal norms of drinking behavior. In many cultures, especially in the West (wet cultures), alcohol is accepted as a tradition within families and children grow up seeing family members drink, thus starting to drink early. In India, however, drinking is still considered a taboo and regular alcohol use does not constitute a part of culture (dry culture).15, 16 Hence, drinking is largely forbidden, especially for the adolescents, until they attain reasonable maturity. These adolescents might take to drinking later. Hence, their AFD is delayed. In a large population-based study in the UK, 25% of ever-drinkers had started consuming alcohol before 16 years of age.2 In our study, only 6 individuals (3.9%) had started drinking before 16 years of age. This may explain the lack of significant correlation between AFD and severity scores at detection.
Alcohol dependence among military personnel differs markedly from the general population. Easy availability of alcohol in the military has been cited as a reason for heavy alcohol use and increased severity of alcohol dependence. A study by Moore et al.17 found that 63% of underage personnel (younger than 21 years) reported easy availability of alcohol on military base, as well as off base. The factors cited for increased physical availability and social acceptances of alcohol in the armed forces include low alcohol prices in military stores, frequent barrack parties, drink promotions in bars surrounding bases, and multiple opportunities for underage drinking.17 Spera et al.18 reported on the effectiveness of certain interventions to reduce drinking among young Air Force personnel such as enforcement of legal purchase/drinking age, related compliance checks at local, off-base outlets, community education, and peer intervention (monitoring by peers and colleagues). Similar checks and balances exist in the Indian Military. In units of Indian Armed Forces, alcohol is not permitted to young recruits until a minimum number of years of service, thus providing for a minimum age for purchase/procurement of alcohol. In addition, there are several other checks in the unit, for example, the officers, junior leaders, and peers keep sensitizing the “at-risk” individuals about the consequences of risky drinking whenever it is observed that the soldier is indulging in high-risk drinking. This study highlights the effectiveness of these measures among the Indian Armed forces personnel, reflected in relatively lower severity of alcohol dependence, possibly consequent to early detection of alcohol-related problems and later onset of drinking.
We have attempted to correlate age at onset of alcohol use with severity of alcohol dependence at detection, which has been studied by very few studies in the past. This is both a strength and a limitation because it is difficult to compare the data directly. The possibility of bias in the present study exists because of the nature of referrals. Another source of possible bias is the patient's recollection of AFD. Hence, the results need to be replicated in more studies.
Conclusions
We found no correlation between AFD and severity of alcohol dependence at detection. In addition, we found that AFD among Indian Armed Forces population is markedly delayed, compared with that among the general population and other countries. This is a novel finding. Indian Armed Forces appear to have a higher age at onset of drinking and earlier detection of dependence, which may be the cause of lower severity scores, and lack of correlation of age at onset with severity. This calls for further research to elucidate this relation with greater clarity and to assess protective factors.
Conflicts of interest
All authors have none to declare.
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