Comparing Family Burden in Alcohol Dependence Syndrome with Dual Diagnosis of Alcohol Dependence and Bipolar Affective Disorder: A Cross-sectional Study from South India

Comparing Family Burden in Alcohol Dependence Syndrome with Dual Diagnosis of Alcohol Dependence and Bipolar Affective Disorder: A Cross-sectional Study from South India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparing Family Burden in Alcohol Dependence Syndrome with Dual Diagnosis of Alcohol Dependence and Bipolar Affective Disorder: A Cross-sectional Study from South India Rohn Sam George, Neetu Kurian, Joseph P. Varghese This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7345424/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The burden on family is substantial for individuals diagnosed with Alcohol Dependence Syndrome (ADS), and it is hypothesized that caring for an individual with a dual diagnosis of ADS with Bipolar Affective Disorder (BPAD) can be more complex. This study compared the family burden of caregivers of individuals with ADS with and without comorbid BPAD. Methods: This cross-sectional comparative study was conducted in a tertiary care psychiatric centre in Kerala, India. A total of 160 primary caregivers were enrolled using purposive sampling divided equally between two groups: Family caregivers of patients with ADS (n=80) and those of patients with a dual diagnosis (n=80). Data on socio-demographic and clinical variables were collected using a structured proforma. The measurement tools used included Family Burden Interview Schedule (FBIS), Severity of Alcohol Dependence Questionnaire (SADQ), Young Mania Rating Scale (YMRS), and Hamilton Depression Scale (HAM-D). Statistical analyses involved chi-square test, Fisher’s exact test, and Mann-Whitney U test. Results: Among caregivers of patients with a dual diagnosis, 71.3% (n = 57) reported severe burden, compared with 61.3% (n = 49) of caregivers of patients with ADS alone; this difference was not statistically significant ( P = 0.181). The mean FBIS score was 27.24 in the dual diagnosis group and 26.18 in the ADS group. In the ADS group, severe caregiver burden was significantly associated with greater severity of alcohol dependence ( P < 0.001), history of tobacco use ( P = 0.002), and daily alcohol use frequency ( P = 0.021). In the dual diagnosis group, severe burden was significantly associated with the patient’s occupational status ( P < 0.0001), nuclear family structure ( P = 0.041), pattern of alcohol use ( P = 0.009), and frequency of alcohol use ( P = 0.032). Conclusions: Severe family burden was common in both groups, caregivers of individuals with ADS and those with ADS and BPAD associated with differing clinical factors in the two groups. These findings highlight the critical need for family-centered interventions for families of patients with alcohol use disorders, tailored to the unique challenges posed by a single diagnosis versus a dual diagnosis. Alcohol Dependence Bipolar Affective Disorder Dual Diagnosis Caregiver Burden Family Burden Family Burden Interview Schedule (FBIS) South India Figures Figure 1 Introduction Over recent decades, psychiatric care has moved steadily away from long-term institutionalization toward community-based management.(1) While this shift offers clear benefits for patients, it also places much of the responsibility for ongoing care onto families.(2) This effect is magnified because most individuals with chronic psychiatric disorders still live with relatives, and cultural expectations make caregiving a family duty rather than an optional choice.(3) Consequently, the family unit well-being is inextricably linked to patient outcomes. This immense responsibility often manifests as "family burden," a complex construct that includes both objective and distressing challenges, such as financial stress and disruptions to family routines and subjective, emotional distress. This burden is a major public health issue, with high rates across various mental health conditions and a clear link to negative physical and psychological health outcomes for caregivers.(4) Specific psychiatric conditions create unique burden patterns. Alcohol Dependence Syndrome (ADS), a global health priority in substance use disorders, significantly disrupts family life by causing challenges, including unpredictable behavior, interpersonal conflicts, and financial stress. Studies from India show that families of individuals with ADS consistently experience moderate to severe burden, especially in financial and family routine areas. Separately, Bipolar Affective Disorder (BPAD) presents its own challenges, such as the cyclical nature of mood episodes, considerable functional impairment even between episodes, and high levels of expressed emotion and distress among caregivers . (5) The clinical challenge intensifies with presence of comorbidities. Substance use disorders commonly co-occur in patients with severe mental illness, with prevalence rates as high as 42%.(6) The dual diagnosis (DD) of ADS and BPAD is associated with a more severe clinical course, poorer treatment response, and increased rates of hospitalization, logically suggesting a compounded or synergistic burden on caregivers. However, while the burden of each condition is well-documented, there is a scarcity of research that directly compares the burden between caregivers of patients with ADS alone versus those with this specific dual diagnosis, especially within non-Western sociocultural settings. This comparison is important in the Indian context, where close-knit family structures and societal stigma surrounding both mental illness and substance use may uniquely shape the caregiving experience. This study aimed to systematically compare the overall burden experienced by primary caregivers of individuals with ADS alone versus those with DD of ADS and BPAD. The secondary aim was to identify and compare the clinical and socio-demographic factors associated with a higher caregiver burden within each diagnostic group. Methods Study Design and Setting This descriptive, comparative cross-sectional study was conducted in the De-addiction Center of the Department of Psychiatry at Malankara Orthodox Syrian Church (MOSC) Medical College, a tertiary care teaching hospital in Kerala, South India. The study period was June 2020 to June 2022. The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. Participants A purposive, non-probability sampling method was used to recruit consecutive eligible participants. The final sample consisted of 160 patient-caregiver dyads, comprising 80 each in the ADS group and 80 in the DD group. Figure 1 illustrates the flow of the participant recruitment, screening, and group allocation. Inclusion criteria were as follows: Patients : Male patients aged 18–60 years with an ICD-10-DCR diagnosis of alcohol dependence syndrome (ADS) or a dual diagnosis of ADS and bipolar affective disorder (BPAD). Caregivers : Primary caregivers aged 18–60 years, residing with the patient and providing care for at least one year. Exclusion criteria were as follows: Caregivers : Paid caregivers or those with a clinically diagnosed psychiatric disorder or severe medical illness. Patients : Use of psychoactive substances other than alcohol or tobacco, presence of other comorbid psychiatric disorders (e.g., schizophrenia, dementia), or refusal to provide consent. Data Collection and Measures Data were collected through face-to-face interviews conducted by the first author following a standardized protocol. Participant confidentiality was maintained by the ethical guidelines throughout the study. Socio-demographic and clinical information, including patient and caregiver age, gender, education, occupation, family type, and clinical history (e.g, duration of illness and number of abstinence attempts) was obtained using a semi-structured proforma. The primary outcome was family burden, assessed using the Family Burden Interview Schedule (FBIS), a 24-item semi-structured interview developed by Pai and Kapur in 1981. The FBIS measures objective burden across six domains: financial burden, disruption of family routines, disruption of leisure, disruption of family interactions, and their effects on physical and mental health. Each item is scored on a 3-point scale (0 = no burden, 1 = some burden, 2 = severe burden), yielding a total score of 0–48, categorized as no burden (0–6), moderate burden (7–24), or severe burden (>24). The FBIS demonstrated good interrater reliability (r = 0.78) and concurrent validity (r = 0.72) in an Indian population.(7) The Severity of Alcohol Dependence Questionnaire (SADQ) was administered to evaluate alcohol dependence severity, and the Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HAM-D) were used to assess the current mood state of patients with dual diagnoses. Statistical Analysis All statistical analyses were performed using the SPSS statistical software (version 28; IBM Corp). Descriptive statistics were used to summarize the study variables: frequencies and percentages for categorical data; means and standard deviations (SDs) for normally distributed continuous data; and medians with interquartile ranges (IQRs) for non–normally distributed continuous data. Group comparisons were performed using the χ² test or Fisher’s exact test for categorical variables and the Mann-Whitney U test for non–normally distributed continuous variables. Associations between caregiver burden (FBIS score categorized as moderate [≤24] vs severe [>24]) and other variables were examined with χ² tests, and results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as a 2-sided P < 0.05, with interpretation emphasizing 95% CIs in addition to p values. Results Participant Characteristics A total of 160 patient–caregiver dyads were included in the final analysis, with 80 in the alcohol dependence syndrome (ADS) group and 80 in the dual diagnosis (DD) group. As shown in Table 1, caregiver groups were similar in age, sex (predominantly female [80.6%]), marital status, education, occupation, family type (nuclear vs joint), relationship to the patient (spouse, parents, siblings, other) and rural or urban residence, with no statistically significant differences between groups in these variables (all P > 0.05). The patient groups were comparable in age, marital status, and education. Table 1 : Sociodemographic Characteristics of Caregivers, by Patient Diagnostic Group Characteristic ADS Group (n = 80) DD Group (n = 80) Total (N = 160) P value Caregiver Age Group, No. (%) 0.091 55 y 17 (21.2) 20 (25.0) 37 (23.1) Gender, No. (%) 0.161 Female 61 (76.3) 68 (85.0) 129 (80.6) Male 19 (23.8) 12 (15.0) 31 (19.4) Family Type, No. (%) 0.118 Nuclear 61 (76.3) 52 (65.0) 113 (70.6) Joint 19 (23.8) 28 (35.0) 47 (29.4) Relationship to Patient, No. (%) 0.878 Spouse 47 (58.8) 45 (56.3) 92 (57.5) Parent 22 (27.5) 25 (31.3) 47 (29.4) Sibling 7 (8.8) 5 (6.3) 12 (7.5) Other 4 (5.0) 5 (6.3) 9 (5.6) Abbreviations: ADS, alcohol dependence syndrome; DD, dual diagnosis; ADS group = patients with alcohol dependence syndrome only; DD group = patients with alcohol dependence syndrome and bipolar affective disorder; P values derived from χ² test or Fisher exact test, as appropriate. Comparison of Overall Caregiver Burden In the primary outcome analysis, overall caregiver burden did not differ significantly between groups. The mean (SD) FBIS score was 26.18 (6.24) for caregivers in the ADS group and 27.24 (6.56) for those in the DD group ( P = 0.32). In both groups, a substantial proportion of caregivers reported severe burden (FBIS score > 24): 49 of 80 (61.3%) in the ADS group and 57 of 80 (71.3%) in the DD group. As shown in Table 2 , the odds of severe burden were not significantly different between the DD and ADS groups (OR, 1.56; 95% CI, 0.81–3.03; p = 0.18). Table 2 Comparison of Caregiver Burden (FBIS) Between ADS and Dual Diagnosis Groups Burden Measure ADS Group (n = 80) DD Group (n = 80) Odds Ratio (95% CI) P Value FBIS Burden Category, No. (%) 0.18 Moderate (score 7–24) 31 (38.8) 23 (28.7) Reference Severe (score >24) 49 (61.3) 57 (71.3) 1.56 (0.81–3.03) Abbreviations: ADS= Alcohol dependence syndrome; DD=dual diagnosis; FBIS,=Family Burden Interview Schedule; ADS group = Patients with Alcohol Dependence Syndrome only; DD group = Patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder; P value derived from χ² test. Factors associated with severe caregiver burden in the Alcohol Dependence Syndrome (ADS) Group In the ADS group, caregiver burden was significantly associated with clinical characteristics of the patient’s alcohol use ( Table 3 ). Greater severity of alcohol dependence showed a strong, dose-dependent association with severe caregiver burden: compared with mild dependence, moderate dependence had an OR of 4.39 (95% CI, 1.06–18.17; p < 0.05) and severe dependence had an OR of 35.00 (95% CI, 5.02–243.85; p < 0.001). Daily alcohol use frequency was also significantly associated with severe burden compared with <1 day/week use (OR, 3.92; 95% CI, 0.40–38.64; p = 0.021). A history of tobacco use was a significant predictor (OR, 4.94; 95% CI, 1.71–14.28; p = 0.002). Caregivers reporting moderate burden indicated that patients had a higher number of prior abstinence attempts compared with those reporting severe burden (median, 3 [IQR, 1–4.5] vs 1 [IQR, 0–3]; p = 0.035), indicating that repeated quit attempts were more common among families experiencing lower burden. Table 3 Factors associated with severe Caregiver Burden (FBIS >24) in the Alcohol Dependence (ADS) Group Factor Burden ≤24 (n = 31) Burden >24 (n = 49) Odds Ratio (95% CI) P Value Patient Severity of Dependence, No. (%) <.001 Mild 10 (76.9) 3 (23.1) Reference Moderate 19 (43.2) 25 (56.8) 4.39 (1.06–18.17) Severe 2 (8.7) 21 (91.3) 35.00 (5.02–243.85) Patient Frequency of Alcohol Use, No. (%) .021 3 d/wk 13 (65.0) 7 (35.0) 0.27 (0.02–3.42) Daily 17 (29.8) 40 (70.2) 3.92 (0.40–38.64) Patient History of Tobacco Use, No. (%) .002 No 14 (66.7) 7 (33.3) Reference Yes 17 (28.8) 42 (71.2) 4.94 (1.71–14.28) Factors associated with Burden in the Dual Diagnosis (DD) Group In the DD group, caregiver burden was significantly associated with patient functional status and family structure ( Table 4 ). Severe burden was significantly more likely among caregivers of unemployed patients compared with those in semi-professional or professional occupations (OR, 0.13; 95% CI, 0.02–0.94; p < 0.05). Caregivers from nuclear families had higher rates of severe burden compared with those from joint families (OR, 2.80; 95% CI, 1.03–7.63; p = 0.041). The pattern of alcohol use was also significant: compared with continuous heavy use, episodic use was associated with lower odds of severe burden (OR, 0.10; 95% CI, 0.01–0.80; p = 0.028), as was frequent heavy use (OR, 0.06; 95% CI, 0.01–0.52; p = 0.009). Frequency of alcohol use was also significant ( p = 0.032), with daily use having the highest proportion of severe burden. Table 4 : Factors Associated with Severe Caregiver Burden (FBIS >24) in the Dual Diagnosis (DD) Group Factor Burden ≤24 (n = 23) Burden >24 (n = 57) Odds Ratio (95% CI) P Value Patient Occupation, No. (%) <.001 Unemployed 1 (20.0) 4 (80.0) Reference Unskilled/clerical/skilled 7 (13.7) 44 (86.3) 1.59 (0.17–14.80) Semi-professional/ professional 15 (65.2) 8 (34.8) 0.13 (0.02–0.94) Caregiver Family Type, No. (%) .041 Joint 12 (42.9) 16 (57.1) Reference Nuclear 11 (21.2) 41 (78.8) 2.80 (1.03–7.63) Patient Pattern of Alcohol Use, No. (%) .009 Continuous heavy 1 (4.5) 21 (95.5) Reference Episodic 11 (33.3) 22 (66.7) 0.10 (0.01–0.80) Frequent heavy 11 (44.0) 14 (56.0) 0.06 (0.01–0.52) Abbreviations: CI, Confidence interval; DD, Dual diagnosis; FBIS, Family Burden Interview Schedule; Moderate burden category: FBIS score ≤24; Severe burden category: FBIS score >24; P values derived from χ² or Fisher exact test, as appropriate. Occupation categories were collapsed for analysis due to small cell sizes. Comparison of Clinical Profiles Between Patient Groups Analysis of the patients’ clinical histories revealed significant differences between the two groups ( Table 5 ). Patients in the DD group had a higher number of past abstinence attempts lasting over one month (median, 3 [IQR, 2–6] vs 2 [IQR, 0.75–4.0]; p = 0.002). In contrast, the median duration of illness was significantly longer in the ADS group (15.0 years [IQR, 7.75–20.0]) compared with the DD group (5.0 years [IQR, 3.0–10.0]; p < 0.001). Table 5 Comparison of Clinical History Variables Between Patient Groups Variable ADS Group (n = 80), Median (IQR) DD Group (n = 80), Median (IQR) P Value Number of abstinence attempts 2.0 (0.75–4.0) 3.0 (2.0–6.0) .002 Duration of illness, y 15.0 (7.75–20.0) 5.0 (3.0–10.0) <.001 Abbreviations: ADS, Alcohol dependence syndrome; DD, Dual diagnosis; IQR, Interquartile range; ADS group = Patients with alcohol dependence syndrome only; DD group = patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder; P values derived from Mann-Whitney U test. Discussion This study compared the family burden experienced by caregivers of patients with ADS alone versus those with a dual diagnosis of ADS and BPAD in a South Indian setting. Both groups reported a profoundly severe level of burden. However, contrary to clinical expectation, there was no statistically significant difference in the overall magnitude of this burden between the two groups. Although the magnitude of burden was similar, it does not imply an identical caregiving experience, and the reasons behind it appeared to differ between the groups. Among caregivers in the ADS-only group, the burden seemed closely related to the core features of the addiction itself: its severity and frequency. The strong correlation between the SADQ score and the FBIS score suggests that as addiction worsens, the objective strain on the family worsens. Even moderate severity was linked to higher odds of severe burden compared with mild dependence, showing that burden rises early in the disorder course and not only at extreme severity. This is consistent with the literature that describes ADS as a "family disease" where financial pressures and disruptions to daily life are significant consequences.(8) The ongoing nature of severe, daily alcohol use appears to saturate the family's coping capacity, leading to high levels of measurable, objective strain.(9) In addition, history of tobacco use emerged as a significant predictor of severe burden, suggesting that broader patterns of substance use may compound caregiving demands through cumulative health, financial, and interpersonal strains.(10) Interestingly, caregivers reporting moderate burden indicated that patients had a higher number of prior abstinence attempts than those reporting severe burden, possibly reflecting greater treatment engagement or more successful coping strategies in these families. In contrast, in the Dual diagnosis ( DD) group, caregiver burden appeared to arise from a more complex mix of psychosocial and functional factors. The most salient predictor was patient's occupational status rather than addiction severity. This functional impairment particularly the inability to sustain employment, due to mood fluctuations appeared to be primary driver of family distress. This is a finding consistent with existing research highlighting occupational dysfunction as a major source of family burden in BPAD.(11,12)Conversely, employment in semi-professional or professional roles exerted a protective effect, potentially mitigating financial stress and preserving a sense of social functioning. This is compounded by the finding that caregivers in nuclear families experienced significantly higher burden. In the Indian sociocultural context, the traditional joint family system offer shared responsibilities for caregiving, along with other challenges of instrumental assistance and emotional support.(13) Absence of such support system in caregivers of nuclear family, concentrates the immense responsibility of managing both mood instability and addiction onto fewer individuals. (14) Drinking patterns were also associated with differential burden. Both episodic heavy drinking and frequent heavy consumption were linked to elevated burden levels similar to continuous heavy drinking, although intermittent drinking allows for temporary relief in caregiving intensity. This may indicate that the broader social and instrumental support network available in a traditional joint family is a critical buffer against the volatility and multifaceted challenges of caring for someone with DD.(15) The sources of burden in this group appear to be less about the direct effects of alcohol consumption and more about the secondary consequences of living with a severe, disabling mental illness. The lack of a significant difference in overall burden, although unexpected, can be explained by the maximum measure of the measurement tool in this specific context. The FBIS mainly assesses objective aspects of burden. Severe ADS alone might be enough to push these objective measures to their maximum or near-maximum levels for many families, especially in settings with inadequate social safety nets(16). As a result, the additional psychiatric symptoms linked to BPAD, while undoubtedly distressing, may not produce a significantly higher score on the FBIS, since families could already be experiencing a maximum level of objective disruption.(17) The difference in the DD caregiving experience may be primarily qualitative, seen in increased subjective distress, emotional turmoil, and the difficulties of managing mood unpredictability—areas that the FBIS may not fully capture but are recognized as crucial aspects of BPAD caregiving.(5) The paradoxical finding reinforces this interpretation that patients in the DD group had a shorter duration of illness but a significantly higher number of past abstinence attempts. This clinical profile indicates a more volatile and chaotic illness course, a cycle of repetition of crises that lead to quit attempts, followed by relapse often triggered by mood instability. This cycle of hope and despair is a powerful, unmeasured source of caregiver burnout and emotional exhaustion, a hallmark of the DD experience.(17) The constant vigilance needed to manage both manic/hypomanic episodes and alcohol-related behaviors creates a unique and relentless form of subjective stress that is not adequately captured in a simple burden score. Strengths and Limitations A key strength of this study is its direct, head-to-head comparison of these two clinically significant groups within the same sociocultural setting, using standardized and validated instruments. However, several limitations must be acknowledged. First, the cross-sectional design prevents any inference of causality. For example, it is impossible to determine whether patient unemployment causes higher caregiver burden or if severe family stress contributes to the patient’s inability to work. Second, the study was conducted at a single tertiary care center with an all-male patient sample, which may limit the generalizability of the findings to community settings, other regions, or female patients. Third, the use of purposive sampling may have introduced selection bias, as patients presenting to a tertiary hospital may represent more severe or complex cases. Fourth, reliance on self-reported information for substance use and caregiving burden introduces potential recall and social desirability biases. Fifth, unmeasured clinical variables—such as medication adherence, comorbid medical conditions, and severity of psychiatric symptoms—may confound the observed associations. Sixth, reliance on the FBIS may have limited our ability to capture the full spectrum of subjective burden, potentially masking qualitative differences between the groups, and temporal changes in burden could not be assessed in this single time-point study. Finally, the influence of sociocultural factors such as stigma and family structure is likely context-dependent, and these findings may not fully apply to settings with different social support systems.(18) Implications for Clinical Practice and Policy The findings have significant implications for the design of caregiver support services. The primary message is that a generic, one-size-fits-all approach to caregiver support is insufficient. Interventions must be tailored to the specific drivers of burden for each condition. For caregivers of individuals with ADS, support should focus on psychoeducation about the progressive nature of addiction, practical strategies for managing intoxication and withdrawal, and assistance in navigating the direct financial and behavioral consequences of severe alcohol use. For caregivers of individuals with DD, support must be more comprehensive. In addition to addiction-focused interventions, programs must address the challenges of managing mood unpredictability, coping with the patient's long-term functional disability and unemployment, and mobilizing broader social support networks, particularly for those in nuclear families. Integrated treatment models that address both the psychiatric and substance use disorders concurrently are essential for improving outcomes for both the patient and the family. Finally, these results underscore the importance of routine screening for caregiver burden in all de-addiction and psychiatric services. Family members are a critical but often neglected component of the care system, and their well-being is paramount to the long-term recovery of the patient. Conclusions In this South Indian cohort, caregivers of patients with ADS alone and those with a dual diagnosis of ADS and BPAD experienced equally high levels of severe overall burden, but for markedly different reasons. In the ADS group, burden was driven primarily by the intensity and persistence of alcohol use, whereas in the dual diagnosis group, it stemmed from the compounded challenges of patient functional disability, unemployment, and the reduced support of nuclear family structures. These distinct burden profiles underscore an urgent need for condition-specific, targeted caregiver interventions that address the unique stressors of each group, rather than relying on generic support models. Abbreviations ADS=Alcohol Dependence Syndrome; DD=Dual Diagnosis; FBIS=Family Burden Interview Schedule; ADS group = Patients with Alcohol Dependence Syndrome only; DD group = Patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder, CI, Confidence interval, OR-Odds Ratio, ; IQR, Interquartile range Declarations Ethics approval and consent to participate Approved by the Institutional Ethics Committee of MOSC Medical College, Kolenchery, Kerala, India (IEC Approval No.: MOSC/IEC/392/2019). Written informed consent was obtained from all participants and their caregivers. Consent for publication Not applicable – no individual person’s data are included in this manuscript. Availability of data and materials Available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding No specific funding was received. Authors’ contributions • RSG (Dr. Rohn Sam George): Conceptualised the study,data collection, data analysis and was the primary manuscript writer. • NK (Dr. Neetu Kurian): Contributed to methodology, supervised clinical ratings, and assisted in manuscript revisions. • JPV (Dr. Joseph P. Varghese): Guided the overall research design, interpretation, and provided final manuscript approval. All authors have read and approved the final manuscript. Acknowledgements We thank the Department of Psychiatry, MOSC Medical College, and the participating caregivers. References Thornicroft G, Bebbington P. 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Comparative analysis of caregiver burden in substance dependence and dual diagnosis. Indian J Psychiatry. 2022;64(4):359–65. Weiss RD, Jaffee WB. Bipolar disorder and substance abuse: Clinical considerations. J Clin Psychiatry. 2007;68(3):e09. Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16–20. PMID: 16946807; PMCID: PMC1489832. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7345424","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503331334,"identity":"74a91dab-595e-4eb3-955e-ca58033d4ce1","order_by":0,"name":"Rohn Sam George","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYFACHmROBRAzMzeQouUMSAsjKVoY28Akfi3m7b3HHv6o2WbXz977+MXHebXR/O1ALT8qtuHUInPmXLoxz7HbyTN7jptZztx2PHfGYcYGxp4zt3FqkZDIMZNmYLudbHAjjc2Yd9ux3AagFmbGNvxaJH/8u51sD9Lyd86x3PnEaJHgbbttZyCRxvyYsaEmdwNBLTxnzKR5+24nSJw5xsbYc+xA7kagloN4/cLeA3TYt9v2/O1tzB9+1NTlzjt/+OCDHxW4tcBAYgMDA5sEA8NhMO8AQfVAYA/EzB8YGOqIUTwKRsEoGAUjDAAAFhpbcBMcdOIAAAAASUVORK5CYII=","orcid":"","institution":"Christian Medical College","correspondingAuthor":true,"prefix":"","firstName":"Rohn","middleName":"Sam","lastName":"George","suffix":""},{"id":503331337,"identity":"aad54400-242c-4059-be61-6da1081ad7c0","order_by":1,"name":"Neetu Kurian","email":"","orcid":"","institution":"MOSC Medical College","correspondingAuthor":false,"prefix":"","firstName":"Neetu","middleName":"","lastName":"Kurian","suffix":""},{"id":503331340,"identity":"7ad5a802-ca64-4c24-8229-f7b028da4fb7","order_by":2,"name":"Joseph P. Varghese","email":"","orcid":"","institution":"MOSC Medical College","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"P.","lastName":"Varghese","suffix":""}],"badges":[],"createdAt":"2025-08-11 10:38:22","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7345424/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7345424/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89839891,"identity":"15503e46-b674-4595-af96-06c471350b1b","added_by":"auto","created_at":"2025-08-25 15:10:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18582,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7345424/v1/e80fd46611d9bd2668aa4b9e.png"},{"id":90991650,"identity":"5c0151d0-1aef-483d-8554-0a733669119a","added_by":"auto","created_at":"2025-09-10 11:23:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1336866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7345424/v1/6fcd15bc-053f-4dcf-ab53-c70b50a05e99.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparing Family Burden in Alcohol Dependence Syndrome with Dual Diagnosis of Alcohol Dependence and Bipolar Affective Disorder: A Cross-sectional Study from South India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver recent decades, psychiatric care has moved steadily away from long-term institutionalization toward community-based management.(1) While this shift offers clear benefits for patients, it also places much of the responsibility for ongoing care onto families.(2)\u0026nbsp;This effect is magnified because most individuals with chronic psychiatric disorders still live with relatives, and cultural expectations make caregiving a family duty rather than an optional choice.(3)\u0026nbsp;Consequently, the family unit well-being is inextricably linked to patient outcomes.\u003c/p\u003e\n\u003cp\u003eThis immense responsibility often manifests as \u0026quot;family burden,\u0026quot; a complex construct that includes both objective and distressing challenges, such as financial stress and disruptions to family routines and subjective, emotional distress. This burden is a major public health issue, with high rates across various mental health conditions and a clear link to negative physical and psychological health outcomes for caregivers.(4)\u003c/p\u003e\n\u003cp\u003eSpecific psychiatric conditions create unique burden patterns. Alcohol Dependence Syndrome (ADS), a global health priority in substance use disorders, significantly disrupts family life by causing challenges, including unpredictable behavior, interpersonal conflicts, and financial stress. Studies from India show that families of individuals with ADS consistently experience moderate to severe burden, especially in financial and family routine areas. Separately, Bipolar Affective Disorder (BPAD) presents its own challenges, such as the cyclical nature of mood episodes, considerable functional impairment even between episodes, and high levels of expressed emotion and distress among caregivers\u003csup\u003e.\u003c/sup\u003e(5)\u003c/p\u003e\n\u003cp\u003eThe clinical challenge intensifies with presence of comorbidities. Substance use disorders commonly co-occur in patients with severe mental illness, with prevalence rates as high as 42%.(6)\u0026nbsp;The dual diagnosis (DD) of ADS and BPAD is associated with a more severe clinical course, poorer treatment response, and increased rates of hospitalization, logically suggesting a compounded or synergistic burden on caregivers. However, while the burden of each condition is well-documented, there is a scarcity of research that directly compares the burden between caregivers of patients with ADS alone versus those with this specific dual diagnosis, especially within non-Western sociocultural settings. This comparison is important in the Indian context, where close-knit family structures and societal stigma surrounding both mental illness and substance use may uniquely shape the caregiving experience.\u003c/p\u003e\n\u003cp\u003eThis study aimed to systematically compare the overall burden experienced by primary caregivers of individuals with ADS alone versus those with DD of ADS and BPAD. The secondary aim was to identify and compare the clinical and socio-demographic factors associated with a higher caregiver burden within each diagnostic group.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis descriptive, comparative cross-sectional study was conducted in the De-addiction Center of the Department of Psychiatry at Malankara Orthodox Syrian Church (MOSC) Medical College, a tertiary care teaching hospital in Kerala, South India. The study period was June 2020 to June 2022. The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA purposive, non-probability sampling method was used to recruit consecutive eligible participants. The final sample consisted of 160 patient-caregiver dyads, comprising 80 each in the ADS group and 80 in the DD group. Figure 1 illustrates the flow of the participant recruitment, screening, and group allocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e were as follows:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003ePatients\u003c/strong\u003e: Male patients aged 18\u0026ndash;60 years with an ICD-10-DCR diagnosis of alcohol dependence syndrome (ADS) or a dual diagnosis of ADS and bipolar affective disorder (BPAD).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCaregivers\u003c/strong\u003e: Primary caregivers aged 18\u0026ndash;60 years, residing with the patient and providing care for at least one year.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e were as follows:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCaregivers\u003c/strong\u003e: Paid caregivers or those with a clinically diagnosed psychiatric disorder or severe medical illness.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePatients\u003c/strong\u003e: Use of psychoactive substances other than alcohol or tobacco, presence of other comorbid psychiatric disorders (e.g., schizophrenia, dementia), or refusal to provide consent.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face interviews conducted by the first author following a standardized protocol. Participant confidentiality was maintained by the ethical guidelines throughout the study. Socio-demographic and clinical information, including patient and caregiver age, gender, education, occupation, family type, and clinical history (e.g, duration of illness and number of abstinence attempts) was obtained using a semi-structured proforma.\u003c/p\u003e\n\u003cp\u003eThe primary outcome was family burden, assessed using the Family Burden Interview Schedule (FBIS), a 24-item semi-structured interview developed by Pai and Kapur in 1981. The FBIS measures objective burden across six domains: financial burden, disruption of family routines, disruption of leisure, disruption of family interactions, and their effects on physical and mental health. Each item is scored on a 3-point scale (0 = no burden, 1 = some burden, 2 = severe burden), yielding a total score of 0\u0026ndash;48, categorized as no burden (0\u0026ndash;6), moderate burden (7\u0026ndash;24), or severe burden (\u0026gt;24). The FBIS demonstrated good interrater reliability (r = 0.78) and concurrent validity (r = 0.72) in an Indian population.(7)\u003c/p\u003e\n\u003cp\u003eThe Severity of Alcohol Dependence Questionnaire (SADQ) was administered to evaluate alcohol dependence severity, and the Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HAM-D) were used to assess the current mood state of patients with dual diagnoses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using the SPSS statistical software\u0026nbsp;(version 28; IBM Corp). Descriptive statistics were used to summarize the study variables: frequencies and percentages for categorical data; means and standard deviations (SDs) for normally distributed continuous data; and medians with interquartile ranges (IQRs) for non\u0026ndash;normally distributed continuous data.\u003c/p\u003e\n\u003cp\u003eGroup comparisons were performed using the \u0026chi;\u0026sup2; test or Fisher\u0026rsquo;s exact test for categorical variables and the Mann-Whitney U test for non\u0026ndash;normally distributed continuous variables. Associations between caregiver burden (FBIS score categorized as moderate [\u0026le;24] vs severe [\u0026gt;24]) and other variables were examined with \u0026chi;\u0026sup2; tests, and results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as a 2-sided \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05, with interpretation emphasizing 95% CIs in addition to p values.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 160 patient\u0026ndash;caregiver dyads were included in the final analysis, with 80 in the alcohol dependence syndrome (ADS) group and 80 in the dual diagnosis (DD) group. As shown in Table 1, caregiver groups were similar in age, sex (predominantly female [80.6%]), marital status, education, occupation, family type (nuclear vs joint), relationship to the patient (spouse, parents, siblings, other) and rural or urban residence, with no statistically significant differences between groups in these variables (all \u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). The patient groups were comparable in age, marital status, and education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Sociodemographic Characteristics of Caregivers, by Patient Diagnostic Group\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eADS Group (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDD Group (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (N = 160)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Age Group, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;25 y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e26\u0026ndash;35 y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e36\u0026ndash;45 y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e46\u0026ndash;55 y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;55 y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (76.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68 (85.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e129 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Type, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNuclear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (76.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e113 (70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJoint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47 (29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship to Patient, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.878\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpouse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47 (58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92 (57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47 (29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSibling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ADS, alcohol dependence syndrome; DD, dual diagnosis; ADS group = patients with alcohol dependence syndrome only; DD group = patients with alcohol dependence syndrome and bipolar affective disorder; \u003cem\u003eP\u003c/em\u003e values derived from \u0026chi;\u0026sup2; test or Fisher exact test, as appropriate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Overall Caregiver Burden\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the primary outcome analysis, overall caregiver burden did not differ significantly between groups. The mean (SD) FBIS score was 26.18 (6.24) for caregivers in the ADS group and 27.24 (6.56) for those in the DD group (\u003cem\u003eP\u003c/em\u003e = 0.32). In both groups, a substantial proportion of caregivers reported severe burden (FBIS score \u0026gt; 24): 49 of 80 (61.3%) in the ADS group and 57 of 80 (71.3%) in the DD group. As shown in \u003cstrong\u003eTable 2\u003c/strong\u003e, the odds of severe burden were not significantly different between the DD and ADS groups (OR, 1.56; 95% CI, 0.81\u0026ndash;3.03; \u003cem\u003ep\u003c/em\u003e = 0.18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Comparison of Caregiver Burden (FBIS) Between ADS and Dual Diagnosis Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurden Measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eADS Group (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDD Group (n = 80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFBIS Burden Category, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerate (score 7\u0026ndash;24)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere (score \u0026gt;24)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (71.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.56 (0.81\u0026ndash;3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ADS= Alcohol dependence syndrome; DD=dual diagnosis; FBIS,=Family Burden Interview Schedule; ADS group = Patients with Alcohol Dependence Syndrome only; DD group = Patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder; \u003cem\u003eP\u003c/em\u003e value derived from \u0026chi;\u0026sup2; test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with severe caregiver burden in the Alcohol Dependence Syndrome (ADS) Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the ADS group, caregiver burden was significantly associated with clinical characteristics of the patient\u0026rsquo;s alcohol use (\u003cstrong\u003eTable 3\u003c/strong\u003e). Greater severity of alcohol dependence showed a strong, dose-dependent association with severe caregiver burden: compared with mild dependence, moderate dependence had an OR of 4.39 (95% CI, 1.06\u0026ndash;18.17; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) and severe dependence had an OR of 35.00 (95% CI, 5.02\u0026ndash;243.85; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Daily alcohol use frequency was also significantly associated with severe burden compared with \u0026lt;1 day/week use (OR, 3.92; 95% CI, 0.40\u0026ndash;38.64; \u003cem\u003ep\u003c/em\u003e = 0.021). A history of tobacco use was a significant predictor (OR, 4.94; 95% CI, 1.71\u0026ndash;14.28; \u003cem\u003ep\u003c/em\u003e = 0.002). Caregivers reporting moderate burden indicated that patients had a higher number of prior abstinence attempts compared with those reporting severe burden (median, 3 [IQR, 1\u0026ndash;4.5] vs 1 [IQR, 0\u0026ndash;3]; \u003cem\u003ep\u003c/em\u003e = 0.035), indicating that repeated quit attempts were more common among families experiencing lower burden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFactors associated with severe Caregiver Burden (FBIS \u0026gt;24) in the Alcohol Dependence (ADS) Group\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurden \u0026le;24 (n = 31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurden \u0026gt;24 (n = 49)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Severity of Dependence, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMild\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.39 (1.06\u0026ndash;18.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (91.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.00 (5.02\u0026ndash;243.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Frequency of Alcohol Use, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;1 d/wk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;3 d/wk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.27 (0.02\u0026ndash;3.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDaily\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.92 (0.40\u0026ndash;38.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient History of Tobacco Use, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42 (71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.94 (1.71\u0026ndash;14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with Burden in the Dual Diagnosis (DD) Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the DD group, caregiver burden was significantly associated with patient functional status and family structure (\u003cstrong\u003eTable 4\u003c/strong\u003e). Severe burden was significantly more likely among caregivers of unemployed patients compared with those in semi-professional or professional occupations (OR, 0.13; 95% CI, 0.02\u0026ndash;0.94; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). Caregivers from nuclear families had higher rates of severe burden compared with those from joint families (OR, 2.80; 95% CI, 1.03\u0026ndash;7.63; \u003cem\u003ep\u003c/em\u003e = 0.041). The pattern of alcohol use was also significant: compared with continuous heavy use, episodic use was associated with lower odds of severe burden (OR, 0.10; 95% CI, 0.01\u0026ndash;0.80; \u003cem\u003ep\u003c/em\u003e = 0.028), as was frequent heavy use (OR, 0.06; 95% CI, 0.01\u0026ndash;0.52; \u003cem\u003ep\u003c/em\u003e = 0.009). Frequency of alcohol use was also significant (\u003cem\u003ep\u003c/em\u003e = 0.032), with daily use having the highest proportion of severe burden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFactors Associated with Severe Caregiver Burden (FBIS \u0026gt;24) in the Dual Diagnosis (DD) Group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurden \u0026le;24 (n = 23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurden \u0026gt;24 (n = 57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 558px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Occupation, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnemployed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnskilled/clerical/skilled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e44 (86.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.59 (0.17\u0026ndash;14.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSemi-professional/ professional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.13 (0.02\u0026ndash;0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 558px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Family Type, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJoint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNuclear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e41 (78.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2.80 (1.03\u0026ndash;7.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 558px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Pattern of Alcohol Use, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuous heavy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21 (95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEpisodic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e22 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.10 (0.01\u0026ndash;0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequent heavy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.06 (0.01\u0026ndash;0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e CI, Confidence interval; DD, Dual diagnosis; FBIS, Family Burden Interview Schedule; Moderate burden category: FBIS score \u0026le;24; Severe burden category: FBIS score \u0026gt;24; \u003cem\u003eP\u003c/em\u003e values derived from \u0026chi;\u0026sup2; or Fisher exact test, as appropriate. Occupation categories were collapsed for analysis due to small cell sizes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Clinical Profiles Between Patient Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of the patients\u0026rsquo; clinical histories revealed significant differences between the two groups (\u003cstrong\u003eTable 5\u003c/strong\u003e). Patients in the DD group had a higher number of past abstinence attempts lasting over one month (median, 3 [IQR, 2\u0026ndash;6] vs 2 [IQR, 0.75\u0026ndash;4.0]; \u003cem\u003ep\u003c/em\u003e = 0.002). In contrast, the median duration of illness was significantly longer in the ADS group (15.0 years [IQR, 7.75\u0026ndash;20.0]) compared with the DD group (5.0 years [IQR, 3.0\u0026ndash;10.0]; \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Comparison of Clinical History Variables Between Patient Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eADS Group (n = 80), Median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDD Group (n = 80), \u0026nbsp; \u0026nbsp; \u0026nbsp;Median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of abstinence attempts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e2.0 (0.75\u0026ndash;4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e3.0 (2.0\u0026ndash;6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of illness, y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e15.0 (7.75\u0026ndash;20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e5.0 (3.0\u0026ndash;10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ADS, Alcohol dependence syndrome; DD, Dual diagnosis; IQR, Interquartile range; ADS group = Patients with alcohol dependence syndrome only; DD group = patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder; \u003cem\u003eP\u003c/em\u003e values derived from Mann-Whitney \u003cem\u003eU\u003c/em\u003e test.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study compared the family burden experienced by caregivers of patients with ADS alone versus those with a dual diagnosis of ADS and BPAD in a South Indian setting. Both groups reported a profoundly severe level of burden. However, contrary to clinical expectation, there was no statistically significant difference in the overall magnitude of this burden between the two groups. Although the magnitude of burden was similar, it does not imply an identical caregiving experience, and the reasons behind it appeared to differ between the groups.\u003c/p\u003e\n\u003cp\u003eAmong caregivers in the ADS-only group, the burden seemed closely related to the core features of the addiction itself: its severity and frequency. The strong correlation between the SADQ score and the FBIS score suggests that as addiction worsens, the objective strain on the family worsens. Even moderate severity was linked to higher odds of severe burden compared with mild dependence, showing that burden rises early in the disorder course and not only at extreme severity.\u0026nbsp;This is consistent with the literature that describes ADS as a \u0026quot;family disease\u0026quot; where financial pressures and disruptions to daily life are significant consequences.(8) The ongoing nature of severe, daily alcohol use appears to saturate the family\u0026apos;s coping capacity, leading to high levels of measurable, objective strain.(9) In addition, history of tobacco use emerged as a significant predictor of severe burden, suggesting that broader patterns of substance use may compound caregiving demands through cumulative health, financial, and interpersonal strains.(10) Interestingly, caregivers reporting moderate burden indicated that patients had a higher number of prior abstinence attempts than those reporting severe burden, possibly reflecting greater treatment engagement or more successful coping strategies in these families.\u003c/p\u003e\n\u003cp\u003eIn contrast, in the Dual diagnosis ( DD) group, caregiver burden appeared to arise from a more complex mix of psychosocial and functional factors. The most salient predictor was patient\u0026apos;s occupational status rather than addiction severity. This functional impairment particularly the inability to sustain employment, due to mood fluctuations appeared to be primary driver of family distress. This is a finding consistent with existing research highlighting occupational dysfunction as a major source of family burden in BPAD.(11,12)Conversely, employment in semi-professional or professional roles exerted a protective effect, potentially mitigating financial stress and preserving a sense of social functioning.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is compounded by the finding that caregivers in nuclear families experienced significantly higher burden. In the Indian sociocultural context, the traditional joint family system offer shared responsibilities for caregiving, along with other challenges of instrumental assistance and emotional support.(13)\u0026nbsp;Absence of such support system in caregivers of nuclear family, concentrates the immense responsibility of managing both mood instability and addiction onto fewer individuals.\u0026nbsp;(14)\u003c/p\u003e\n\u003cp\u003eDrinking patterns were also associated with differential burden. Both episodic heavy drinking and frequent heavy consumption were linked to elevated burden levels similar to continuous heavy drinking, although intermittent drinking allows for temporary relief in caregiving intensity. This may indicate that the broader social and instrumental support network available in a traditional joint family is a critical buffer against the volatility and multifaceted challenges of caring for someone with DD.(15)\u0026nbsp;The sources of burden in this group appear to be less about the direct effects of alcohol consumption and more about the secondary consequences of living with a severe, disabling mental illness.\u003c/p\u003e\n\u003cp\u003eThe lack of a significant difference in overall burden, although unexpected, can be explained by the maximum measure of the measurement tool in this specific context. The FBIS mainly assesses objective aspects of burden. Severe ADS alone might be enough to push these objective measures to their maximum or near-maximum levels for many families, especially in settings with inadequate social safety nets(16). As a result, the additional psychiatric symptoms linked to BPAD, while undoubtedly distressing, may not produce a significantly higher score on the FBIS, since families could already be experiencing a maximum level of objective disruption.(17)\u0026nbsp;The difference in the DD caregiving experience may be primarily qualitative, seen in increased subjective distress, emotional turmoil, and the difficulties of managing mood unpredictability\u0026mdash;areas that the FBIS may not fully capture but are recognized as crucial aspects of BPAD caregiving.(5)\u003c/p\u003e\n\u003cp\u003eThe paradoxical finding reinforces this interpretation that patients in the DD group had a shorter duration of illness but a significantly higher number of past abstinence attempts. This clinical profile indicates a more volatile and chaotic illness course, a cycle of repetition of crises that lead to quit attempts, followed by relapse often triggered by mood instability. This cycle of hope and despair is a powerful, unmeasured source of caregiver burnout and emotional exhaustion, a hallmark of the DD experience.(17)\u0026nbsp;The constant vigilance needed to manage both manic/hypomanic episodes and alcohol-related behaviors creates a unique and relentless form of subjective stress that is not adequately captured in a simple burden score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key strength of this study is its direct, head-to-head comparison of these two clinically significant groups within the same sociocultural setting, using standardized and validated instruments. However, several limitations must be acknowledged. First, the cross-sectional design prevents any inference of causality. For example, it is impossible to determine whether patient unemployment causes higher caregiver burden or if severe family stress contributes to the patient\u0026rsquo;s inability to work. Second, the study was conducted at a single tertiary care center with an all-male patient sample, which may limit the generalizability of the findings to community settings, other regions, or female patients. Third, the use of purposive sampling may have introduced selection bias, as patients presenting to a tertiary hospital may represent more severe or complex cases. Fourth, reliance on self-reported information for substance use and caregiving burden introduces potential recall and social desirability biases. Fifth, unmeasured clinical variables\u0026mdash;such as medication adherence, comorbid medical conditions, and severity of psychiatric symptoms\u0026mdash;may confound the observed associations. Sixth, reliance on the FBIS may have limited our ability to capture the full spectrum of subjective burden, potentially masking qualitative differences between the groups, and temporal changes in burden could not be assessed in this single time-point study. Finally, the influence of sociocultural factors such as stigma and family structure is likely context-dependent, and these findings may not fully apply to settings with different social support systems.(18)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Clinical Practice and Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings have significant implications for the design of caregiver support services. The primary message is that a generic, one-size-fits-all approach to caregiver support is insufficient. Interventions must be tailored to the specific drivers of burden for each condition. For caregivers of individuals with ADS, support should focus on psychoeducation about the progressive nature of addiction, practical strategies for managing intoxication and withdrawal, and assistance in navigating the direct financial and behavioral consequences of severe alcohol use.\u003c/p\u003e\n\u003cp\u003eFor caregivers of individuals with DD, support must be more comprehensive. In addition to addiction-focused interventions, programs must address the challenges of managing mood unpredictability, coping with the patient\u0026apos;s long-term functional disability and unemployment, and mobilizing broader social support networks, particularly for those in nuclear families. Integrated treatment models that address both the psychiatric and substance use disorders concurrently are essential for improving outcomes for both the patient and the family.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, these results underscore the importance of routine screening for caregiver burden in all de-addiction and psychiatric services. Family members are a critical but often neglected component of the care system, and their well-being is paramount to the long-term recovery of the patient.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this South Indian cohort, caregivers of patients with ADS alone and those with a dual diagnosis of ADS and BPAD experienced equally high levels of severe overall burden, but for markedly different reasons. In the ADS group, burden was driven primarily by the intensity and persistence of alcohol use, whereas in the dual diagnosis group, it stemmed from the compounded challenges of patient functional disability, unemployment, and the reduced support of nuclear family structures. These distinct burden profiles underscore an urgent need for condition-specific, targeted caregiver interventions that address the unique stressors of each group, rather than relying on generic support models.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADS=Alcohol Dependence Syndrome; DD=Dual Diagnosis; FBIS=Family Burden Interview Schedule; ADS group = Patients with Alcohol Dependence Syndrome only; DD group = Patients with Alcohol Dependence Syndrome and Bipolar Affective Disorder, CI, Confidence interval, OR-Odds Ratio, ; IQR, Interquartile range\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eApproved by the Institutional Ethics Committee of MOSC Medical College, Kolenchery, Kerala, India (IEC Approval No.: MOSC/IEC/392/2019). Written informed consent was obtained from all participants and their caregivers.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable \u0026ndash; no individual person\u0026rsquo;s data are included in this manuscript.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAvailable from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo specific funding was received.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp;RSG (Dr. Rohn Sam George): Conceptualised the study,data collection, data analysis and was the primary manuscript writer.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp;NK (Dr. Neetu Kurian): Contributed to methodology, supervised clinical ratings, and assisted in manuscript revisions.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp;JPV (Dr. Joseph P. Varghese): Guided the overall research design, interpretation, and provided final manuscript approval.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe thank the Department of Psychiatry, MOSC Medical College, and the participating caregivers.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThornicroft G, Bebbington P. Deinstitutionalisation\u0026mdash;from hospital closure to service development. The British Journal of Psychiatry. 1989;155(6):739\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaul Liberman R, Corrigan PW. Designing new psychosocial treatments for schizophrenia. Psychiatry. 1993;56(3):238\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChadda RK. Caring for the family caregivers of persons with mental illness. 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Br J Psychiatry. 1981;138:332\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRehm J, Shield KD. Alcohol use and epidemiology of alcohol-attributable harm. Lancet. 2019;393(10167):2488\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMattoo S, Nebhinani N, Kumar B, Basu D, Kulhara P. Family burden with substance dependence: A study from India. The Indian journal of medical research. 2013;137:704\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaguib RM, El-Sheikh MM, Alqadi TG, El-awady SA. Impact of substance use patterns on caregivers\u0026rsquo; quality of life, mood and burden: a cross-sectional study in Egypt. Middle East Current Psychiatry. 2025;32(1):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption\u0026ndash;II. Addiction. 1993;88(6):791\u0026ndash;804. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1360-0443.1993.tb02093.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1360-0443.1993.tb02093.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 8329970.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh H, Singh R, Grover S, Avasthi A. Caregiver burden in patients with bipolar disorder and alcohol dependence: A comparative study. Indian J Psychol Med. 2015;37(1):43\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShankar R, Kumar S, Singh P. Family caregiving in India: Cultural and social dimensions. Soc Work Health Care. 2017;56(5):421\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar V, et al. Societal stigma and its impact on families of patients with mental illness. Asian J Psychiatr. 2020;50:101948.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePompili M, Harnic D, Gonda X, Forte A, Dominici G, Innamorati M, Fountoulakis KN, Serafini G, Sher L, Janiri L, Rihmer Z, Amore M, Girardi P. Impact of living with bipolar patients: Making sense of caregivers\u0026rsquo; burden. World J Psychiatr 2014; 4(1): 1\u0026ndash;12 DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5498/wjp.v4.i1.1\u003c/span\u003e\u003cspan address=\"10.5498/wjp.v4.i1.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNambi S, Varghese M, Chandra PS. Comparative analysis of caregiver burden in substance dependence and dual diagnosis. Indian J Psychiatry. 2022;64(4):359\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiss RD, Jaffee WB. Bipolar disorder and substance abuse: Clinical considerations. J Clin Psychiatry. 2007;68(3):e09.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16\u0026ndash;20. PMID: 16946807; PMCID: PMC1489832.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Alcohol Dependence, Bipolar Affective Disorder, Dual Diagnosis, Caregiver Burden, Family Burden, Family Burden Interview Schedule (FBIS), South India","lastPublishedDoi":"10.21203/rs.3.rs-7345424/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7345424/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The burden on family is substantial for individuals diagnosed with Alcohol Dependence Syndrome (ADS), and it is hypothesized that caring for an individual with a dual diagnosis of ADS with Bipolar Affective Disorder (BPAD) can be more complex. This study compared the family burden of caregivers of individuals with ADS with and without comorbid BPAD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This cross-sectional comparative study was conducted in a tertiary care psychiatric centre in Kerala, India. A total of 160 primary caregivers were enrolled using purposive sampling divided equally between two groups: Family caregivers of patients with ADS (n=80) and those of patients with a dual diagnosis (n=80). Data on socio-demographic and clinical variables were collected using a structured proforma. The measurement tools used included Family Burden Interview Schedule (FBIS), Severity of Alcohol Dependence Questionnaire (SADQ), Young Mania Rating Scale (YMRS), and Hamilton Depression Scale (HAM-D). Statistical analyses involved chi-square test, Fisher’s exact test, and Mann-Whitney U test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among caregivers of patients with a dual diagnosis, 71.3% (n = 57) reported severe burden, compared with 61.3% (n = 49) of caregivers of patients with ADS alone; this difference was not statistically significant (\u003cem\u003eP\u003c/em\u003e = 0.181). The mean FBIS score was 27.24 in the dual diagnosis group and 26.18 in the ADS group. In the ADS group, severe caregiver burden was significantly associated with greater severity of alcohol dependence (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), history of tobacco use (\u003cem\u003eP\u003c/em\u003e = 0.002), and daily alcohol use frequency (\u003cem\u003eP\u003c/em\u003e= 0.021). In the dual diagnosis group, severe burden was significantly associated with the patient’s occupational status (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.0001), nuclear family structure (\u003cem\u003eP\u003c/em\u003e= 0.041), pattern of alcohol use (\u003cem\u003eP\u003c/em\u003e= 0.009), and frequency of alcohol use (\u003cem\u003eP\u003c/em\u003e= 0.032).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Severe family burden was common in both groups, caregivers of individuals with ADS and those with ADS and BPAD associated with differing clinical factors in the two groups. These findings highlight the critical need for family-centered interventions for families of patients with alcohol use disorders, tailored to the unique challenges posed by a single diagnosis versus a dual diagnosis.\u003c/p\u003e","manuscriptTitle":"Comparing Family Burden in Alcohol Dependence Syndrome with Dual Diagnosis of Alcohol Dependence and Bipolar Affective Disorder: A Cross-sectional Study from South India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 15:10:32","doi":"10.21203/rs.3.rs-7345424/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63aba6f5-b77d-4677-8905-5c9adfe23853","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-10T11:23:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 15:10:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7345424","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7345424","identity":"rs-7345424","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}