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 Table of Contents    
LETTERS TO EDITOR  
Year : 2020  |  Volume : 62  |  Issue : 3  |  Page : 333-335
Alcohol-related self-harm due to COVID-19 pandemic: Might be an emerging crisis in the near future: A case report


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission17-Apr-2020
Date of Decision19-Apr-2020
Date of Acceptance20-Apr-2020
Date of Web Publication15-May-2020
 

How to cite this article:
Rani S, Sahoo S, Parveen S, Mehra A, Subodh B N, Grover S. Alcohol-related self-harm due to COVID-19 pandemic: Might be an emerging crisis in the near future: A case report. Indian J Psychiatry 2020;62:333-5

How to cite this URL:
Rani S, Sahoo S, Parveen S, Mehra A, Subodh B N, Grover S. Alcohol-related self-harm due to COVID-19 pandemic: Might be an emerging crisis in the near future: A case report. Indian J Psychiatry [serial online] 2020 [cited 2020 Sep 28];62:333-5. Available from: http://www.indianjpsychiatry.org/text.asp?2020/62/3/333/284455




Sir,

COVID-19 was declared as pandemic on March 11, 2020, by the World Health Organization, and all countries had been subjected to high alert due to its rising infection rate and mortality rate. Considering the risk of rapid spread, which can overwhelm the health-care services, most of the countries entered into a “Lockdown” mode which basically means preventing public from moving from one area to the other, mostly practiced to protect people in a locality/area.

Complete lockdown further means that persons should stay where they are currently and no entry/exit movements would be allowed further. This strategy had been adopted as an emergency measure to tackle the growing number of cases in the community along with the principles of social distancing. In this scenario, only essential services such as hospitals, police stations, fire stations, petrol pumps, and grocery stores are allowed to be opened for limited time of the day with scheduled visits by the public. This “Lockdown” strategy was adopted by India on March 25, 2020, when the Prime Minister of India declared “Lockdown” mode in the whole country starting from the midnight of March 25, 2020, for the next 21 days with assurance that the basic needs of the general public will be taken care of.[1]

With potential benefits to the public to curb or tackle the COVID-19 pandemic in India, the “Lockdown” might prove to be a beneficial strategy; however, there can be many negative psychological consequences of sudden lockdown. Apart from having range of possible psychological issues such as anger, frustration, depressive symptoms, anxiety symptoms, irritability, insomnia, fear/apprehension, having a prevailing sense of being imprisoned in one's own house or “being in-house arrest,” etc., the lockdown has created a major crisis for people with substance dependence. As the liquor shops and local breweries were shut down by the government, it has led to the lack of availability of alcohol to many of the persons dependent on the same. Many patients are experiencing withdrawal symptoms. Similar problems are also expected to occur in subjects dependent on other illegal drugs such as heroin, cocaine, and cannabis. Some of the newspaper reports from the Western countries suggest rise in relapses and problems with drug recovery. (”Coronavirus is causing a rise in drug and alcohol relapses,” n.d.; “How the coronavirus is hurting drug and alcohol recovery,” n.d.). In this case report, we present the case of a 60-year-old male who presented to our emergency services with a suicide attempt due to alcohol-related withdrawal subsequent to “lockdown.”

A 60-year-old farmer was brought to emergency after attempting suicide by hanging himself. He had no past history of any other psychiatric disorder or any family history of mental illness. Exploration of history revealed that he had been taking alcohol for the past 40 years, with a dependence pattern for the past 20 years, characterized by craving, tolerance, and withdrawal symptoms. Prior to presentation, he was taking about 700 ml of Indian-made foreign liquor per day. In addition, he was also smoking 12 cigarettes per day, since the early 20's in a dependent pattern characterized by craving, tolerance, and withdrawal symptoms. He was consuming alcohol and tobacco in his usual pattern, till the lockdown was declared (i.e., March 25, 2020) in view of the COVID-19 pandemic. He could manage his alcohol intake for 1 week, but later ran out of the stock. Due to the lack of availability of alcohol, developed withdrawal symptoms in the form sleep disturbances, anxiety, sweating, restlessness, tremors, and decreased appetite. After 2–3 days, became abusive and started to verbally and physically abuse the family members. He also went out of the house to procure alcohol, but could not get the same. He started to remain irritable and would voice that how would he spend the remaining days and would keep on thinking when the “lockdown” will end. He was unable to relax and sleep at night. In view of lack of availability of alcohol and unable to tolerate the withdrawal symptoms after 3 days of last intake of alcohol, he tried to hang himself from the ceiling fan. Later was found by the family members and rescued.

After medical stabilization and management of withdrawal symptoms in the emergency, upon suicide assessment, the patient described that he hanged himself, because he thought that he is going to die anyway, either because of COVID-19/corona virus infection or due to severe withdrawal symptoms. Considering the act of hanging to be a less painful death, he hanged himself. On mental state examination, he was oriented to time, place, and person and had no gross impairment in cognitive symptoms. A diagnosis of alcohol-dependence syndrome currently in withdrawal, Tobacco Dependence Syndrome, currently using substance (active dependence), along with acute stress reaction and intentional self-harm was considered. Alcohol withdrawal was managed adequately with benzodiazepines along with the supplementation of thiamine. Brief intervention was done, and he was followed up telephonically.

COVID-19 pandemic and subsequent lockdown has created an unprecedented crisis worldwide. Lockdown is an essential step for the prevention of spread of infection from the health-care point of view. As every possible strategy can have any pitfall, similarly, the lockdown strategy has few pitfalls too. One such pitfall of the immediate lockdown strategy is the development of withdrawal symptoms in patients with substance dependence. Substance more particularly alcohol has not been included under “essential services” category to be made available during “lockdown” period in many countries and the same is the case with India.[2]

While this essential services list can be debated upon from psychiatrists' point of view, it has many beneficial effects too. There can be stock piling and black marketing of liquor, increase in antisocial activities during lockdown under intoxication and possibility of increase in violence too. Further, there can be increase in the rates of alcohol use to overcome boredom and anxiety-related symptoms due to COVID-19 pandemic or some individuals may take substances/alcohol to overcome feelings of hopelessness. (”Tough Problems—Substance Abuse in the Time of Coronavirus,” n.d.). In this regard, alcohol not being included under the essential services list is justifiable.

However, if one visualizes from a broader humanitarian point of view, then the plight of sufferings and severe withdrawal symptoms which can lead to delirium tremens cannot be neglected. Therefore, several issues needs to be weighed upon and opinions of potential stake holders should be taken into view in the execution of lockdown strategy. Moreover, persons with substance use disorders (smoking, opioid users, methamphetamine users, and cannabis users) are at increased risk of COVID-19 and its serious consequences for multiple physiological and socioenvironmental reasons.[3]

In this regard, our case report illustrates the plight of an elderly subject dependent on alcohol for the past 20 years who due to abrupt stoppage of alcohol intake due to “lockdown” and subsequent development of severe withdrawal symptoms led to a lethal suicide attempt. So far, there has been newspaper reports of seven patients committing suicide from Kerala[4] and one each from Telangana (”As COVID-19 turns Telangana dry, alcoholic commits suicide- The New Indian Express,” 2020)[5] and Karnataka,[6] due to lack of availability of alcohol due to lockdown. As evident from a recent metaanalysis (n = 31 studies; 420,732 participants), there is a strong association between alcohol use/dependence and development of suicidal ideations (odds ratio: 1.86), suicide attempts (odds ratio: 3.13), and completed suicide (odds ratio: 2.59).[7] Therefore, there is sufficient evidence to suggest that alcohol dependence is a potential predictor of suicide and this can be an imminent health hazard to the mental health of people dependent on the same. Our case report highlights this very aspect of effect of lockdown on persons with problematic alcohol use disorders and similar issues might be occurring in persons with other types of substance use disorders too, which requires humanitarian approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
India Lockdown Live Updates: PM Modi Announces 21-Day Complete Lockdown from Midnight Tonight. N.D. Times India. Available from: https://timesofindia.indiatimes.com/india/corona virus-in-india-live-upd ates-pm-modi-to-address-the-nati on/liveblog/74783769.cms. [Last accessed on 2020 Mar 24].  Back to cited text no. 1
    
2.
Government of India, Ministry of Home Affairs; 2020. Guidelines on the Measures to be taken by Ministers/Departments of Government of India, State/Union Territory Governments and State/Union Territiry Authorities for Containment of COVID-19 Epidemic in the Country dated; 24 March, 2020.  Back to cited text no. 2
    
3.
National Institute on Drug Abuse. COVID-19: Potential Implications for Individuals with Substance Use Disorders; 2020. Available from: https://www.drugabuse.gov/about-nida/noras-bl og/2020/03/covid-19-potential-impli cations-individuals-subs tance-use-disorders. [Last accessed on 2020 Apr 07].  Back to cited text no. 3
    
4.
Nidheesh MK. In God's Own Country, 1 Died of Covid-19 but 7 Commit Suicide after Alcohol Ban. Live mint; 2020. Available from: https://www.livemint.com/news/in dia/in-god-s-own-country-1-died-of-co vid-19-but-7-commit-suicide-after-a lcohol-ban-11585483376504.html. [Last accessed on 2020 Apr 07].  Back to cited text no. 4
    
5.
As COVID-19 Turns Telangana Dry, Alcoholic Commits Suicide – The New Indian Express. Indian Express; 2020.  Back to cited text no. 5
    
6.
Pathak A. Lockdown Side Effect: Frustrated at not Getting Alcohol, Karnataka Man Attempts Suicide; 2020. Available from: https://www.indiatvnews.com/news/in dia/karnataka-man-attempts-sui cide-on-not-getting-alcohol-coron avirus-lockdown-side-effects-602841. [Last accessed on 2020 Apr 07].  Back to cited text no. 6
    
7.
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:e0126870.  Back to cited text no. 7
    

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Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_356_20

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