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The Royal College of Psychiatrists Improving the lives of people with mental illness

$3.3 billion worth of alcohol sale

$3.3 billion worth of alcohol sale in one state in India!

Chennai is the capital of the Tamil Nadu state which is one of the 28 states in India. The population of Tamil Nadu (72.1 million)1 is slightly higher than that of the UK (62.2 million)2, but the total area of Tamil Nadu (50,216 sq miles) is nearly half the size of the UK (94,060 sq miles)!

India is traditionally viewed as a ‘dry’ or ‘abstaining culture’3. Those who drink alcohol are looked upon as ‘outcasts’ in society. In 2004, the per capita alcohol consumption for the UK was 10.39 compared with 0.82 for India4. The National Household Survey of Drug and Alcohol Abuse (India) showed in 2001 that the prevalence of men using alcohol was about 21% and it was only between 2% and 5% among women5, 6.


"...alcohol consumption is still considered a taboo in Tamil Nadu. The society does not accept any form of drinking...".


But in recent years things have changed. The change is visible especially in major cities like Mumbai, Delhi, Pune, Chandigarh, and Bangalore. Women-only Alcohol Anonymous (AA) meetings held in these areas have found an increase in the number of women who drink in India7. Also the average age of first time alcohol use in general has reduced from 28 in 1980s to 18 years in 20108.

However, alcohol consumption is still considered a taboo in Tamil Nadu. The society does not accept any form of drinking (either ‘social drinking’ or ‘binge drinking’). Local magazines reported that bar workers lack social dignity9 and hence many of them remain unmarried as the parents are hesitant to give their daughter in marriage to them10.

The Indian government has given rights to individual states to develop their own rules in terms of alcohol production, sale and taxation. Historically, consumption of alcohol was totally banned in Tamil Nadu state between 1937 to 1991 and the ban was lifted only 3 times during those periods11. The whole production and sale of alcohol is controlled by the Government company called TASMAC (Tamil Nadu State Marketing Corporation) which has nearly 7000 sale outlets and about 30,000 employees11. There has been a steady profit over the years. Reports suggest that in 2005-06, the annual revenue was about 7,335 crores of Indian rupees (73.35 billion rupees, equivalent to $1336 million). The most recent data (2011-12) showed annual revenue of an astonishing 18,018 crores of Indian rupees12 (180.18 billion rupees, roughly equivalent to $3.3 billion)!

With the sale of alcoholic beverages soaring high over the last decade, I believe that alcohol-related morbidity and mortality have been on the rise. Hence there is a great demand for alcohol treatment services. Let me give a brief account on the treatment model at the CSI Rainy Hospital, Chennai, Tamil Nadu. There are some striking contrasts from the western world:

First, the referral system is entirely different. Anyone can self refer to the psychiatric out-patient clinic. There are no waiting lists and the patients are seen on the same day of referral. Frequently, those who are already undergoing treatment bring their friends or relatives who have alcohol or mental health problems.

Assessment of a patient (with alcohol history) with his carers at CSI Rainy Hospital, Chennai



Secondly, the patients are always seen with their family members (mother, spouse etc), and counselling forms an inevitable part of the treatment process. Thirdly, there is striking gender difference - only male patients access the service! As for the possible reasons, a local report suggests female drinkers are less in number13. But apart from this, I believe it is due to the stigma attached to drinking. The initial assessment consists of history taking, administration of questionnaires (such as Addiction Severity Index) and alcohol withdrawal scale (CIWA-AR) and blood tests. If the patient presents with severe withdrawal symptoms, he would be admitted to the medical ward for detoxification. However, those with minimal or no withdrawal symptoms are assessed for the suitability of initiating disulfiram (about 12 to 24 hours after their last drink). If there are no contraindications, the patient is started on disulfiram after giving information about the medication and obtaining consent. This process constantly involved the participation from the family. As a rule of thumb disulfiram would not be commenced if there are no carers available at the time of the assessment.
A family counselling session at CSI Rainy Hospital, Chennai

"The patients (and the carers) are then given weekly appointments for up to a month – during which time an intense short term (both individual and family) counselling sessions takes place."


It has become the responsibility of the carer to supervise this medication and it is done meticulously. The patients (and the carers) are then given weekly appointments for up to a month – during which time an intense short term (both individual and family) counselling sessions takes place. Emphasis is given to restoration of marital relationship during recovery. It is interesting to note that these sessions are based on ‘Steps to Freedom’, a faith-based intervention in resolving personal issues such as anger, ego defences, dysfunctional coping, pseudo self-esteem, sexuality and genetic traits.

This was tried by Hurst et al14 and found to produce positive results for depression, anxiety and other mental disturbances. The same version is currently applied for patients with alcohol dependence. One of the remarkable differences I noted is that there are no set time limits for these sessions. They are so flexible and each session could carry on for few hours!

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital:

 

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital



Of those 33 patients with history of alcohol use 11 attended for the first time for assessment.The rest of the 22 patients are currently abstinent and attending regular follow ups.Their case notes were analysed to check how long they were in treatment and abstinent.

 

The table is as follows:

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital


In conclusion, the sale and consumption of alcohol in Tamil Nadu is escalating day by day and it raises alarm bells. This has become a major public health concern. The available alcohol treatment services are too few in number and the country is ill equipped with resources to address the issues. However, there are pockets of excellence where a tiny unit such as the CSI Rainy hospital in Chennai shines like a lode star in the dark!

CSI Rainy hospital in Chennai

References:
  1. Census India 2011 www.census.tn.nic.in/whatsnew/ppt_total2011.pdf
  2. The World Bank data
  3. Bennet et al, 1993.
  4. WHO Global status report on alcohol 2004. Page 17-18.
  5. Prasad R. Alcohol use on the rise in India. The Lancet, Volume 373, Issue 9657, Pages 17 - 18, 3 January 2009.
  6. Benegal V, Nayak M, Murthy P, Gururaj G et al. Alcohol, gender and drinking problems – perspectives from the low and middle income countries. Chapter 5: Women and alcohol use in India. World Health organization. 2005.
  7. Suryanarayan D. A dubious high for ‘spirited’ women in India’s cities. Daily News and Analysis. Published: Wednesday, May 26, 2010.
  8. Gururaj G, Murthy P, Rao G N, Benegal V et al. Alcohol related harm: Implications for public health and policy in India. Publication No. 73, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India. ISBN No: 81-86428-00-X.
  9. The Hindu: TASMAC staff request CM to make them full-fledged government employees. 18 July 2012.
  10. D.L.Sanjeevi Kumar. Junior Vikadan article: Mayakkam Enna. 24 June 2012.
  11. Wikipedia, the free encyclopedia: TASMAC.
  12. The Times of India. Tamil Nadu's liquor revenue rises to Rs 18K cr. 27 April 2012.
  13. Linda A. Bennett, Carlos Campillo, C.R. Chandrashekar and Oye Gureje. Alcoholic beverage consumption beverage in India, Mexico and Nigeria – a cross cultural comparison.
  14. George A. Hurst, Marion G. Williams, Judith E. King and Richard Viken. Faith-based intervention in depression, anxiety and other mental disturbances. Southern Medical Journal: - Volume 101 - Issue 4 - pp 388-392 April 2008 doi:10.1097/SMJ.0b013e318167a97a

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About this blog

Dr Jeshoor Jebadurai


Dr Jeshoor Jebadurai is a Consultant Psychiatrist working in Wales. He is interested in International Psychiatry.

Prior to his move to the UK, he was trained at the Institute of Mental Health, Chennai, India.

He has been travelling to India over the last few years conducting health screening camps in rural parts of South India and raising the awareness about mental health. He is in the process of setting up a mental health unit in India.