Alcohol Dependence syndrome (ADS) is a chronic, relapsing psychiatric disorder characterized by compulsive alcohol use, impaired control over drinking, physiological withdrawal symptoms, increased tolerance, and persistent drinking despite evidence of harmful consequences. Globally, ADS represents a serious public health concern due to its prevalence, associated comorbidities, and socio-economic impact. The World Health Organization (WHO) estimates nearly 3 million annual deaths attributable to harmful alcohol use, constituting 5.1% of the global disease burden.

The burden of ADS is disproportionately high in low- and middle-income countries such as India, where healthcare accessibility, awareness, and early intervention remain limited. The “Magnitude of Substance Use in India” (2019) reported that 14.6% of the Indian population aged 10–75 years consumed alcohol in the past year, with 5.2% meeting dependence criteria. Despite millions suffering from ADS, treatment engagement is hindered by stigma, poor service reach, and inadequate follow-up.

Treatment of ADS involves pharmacological agents, psychosocial therapies such as cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET), and support groups like Alcoholics Anonymous. However, relapse rates remain discouragingly high, often ranging between 60% and 70% within 6 months post-treatment.

Research highlights various biological, psychological, and social determinants of treatment outcome, including personality traits that predict vulnerability to relapse. Traits like impulsivity, neuroticism, and antisocial features have been associated with early drinking initiation, poor adherence, and repeated relapse. In India, studies also underscore family history and early drinking patterns as adverse prognostic indicators.

Stressful life events significantly affect ADS trajectory. Financial strain, familial discord, bereavements, and occupational challenges exacerbate relapse risk by diminishing coping efficacy.

Despite extensive isolated studies, there is a scarcity of ambispective research integrating retrospective and prospective data to examine multifactorial influences such as personality, stress, and treatment adherence on relapse in an Indian clinical setting.

This study aims to fill this gap by examining the treatment modalities, determinants of treatment outcome, and follow-up in patients with ADS admitted to a tertiary care center in South India. By tracking patients at multiple intervals over 6 months and integrating clinical, psychosocial, and personality assessments, it provides comprehensive insights to guide improved interventions.

This study is an ambispective observational study conducted at the Institute of Mental Health, Chennai, over 9 months from October 2024 to June 2025. A total of 116 patients diagnosed with ADS admitted for inpatient care were included using consecutive non-probability sampling. Patients with a diagnosis of ADS as per DSM-5 criteria, who were admitted for the first time for treatment and were willing to participate and provide follow-up data, were included in the study. And patients with severe medical or neurological illness were excluded from the study. Data collection combined retrospective review of records and prospective follow-ups at 1, 2, 3, and 6 months post-discharge. Clinical and demographic variables recorded included age, sex, education, occupation, marital status, socioeconomic status, family history of alcohol use, age at first drink, duration and frequency of alcohol use, severity of dependence (SADQ), presence of craving, pharmacological treatment used, and treatment compliance. Personality assessment was done using the 16PF personality questionnaire. Stressful life events were measured using the presumptive stressful life events scale (PSLES).

This ambispective study conducted at a tertiary care center in South India provides important insights into the clinical, psychosocial, and demographic determinants of relapse in patients with ADS. The findings reinforce the complexity of relapse risk and highlight areas for targeted intervention.

The exclusively male sample mirrors treatment-seeking trends in India, where women with alcohol use disorders are underrepresented due to socio-cultural stigma, gender roles, and limited access to care (1, 2). This gap necessitates gender-sensitive research and services.

The mean age of 37.7 years aligns with established dependence patterns but is younger than those reported in other Indian studies (3, 4). This suggests earlier initiation of alcohol use, which is further supported by the high proportion of participants who began drinking before age 21. Early onset has been linked with a higher risk of chronic dependence and poor outcomes (5).

Marital status was unexpectedly associated with increased relapse risk, with married individuals relapsing more frequently. While some literature suggests marriage may act as a protective factor against substance use (6), this study indicates that marital stress and relationship discord may instead serve as significant relapse triggers, as indicated by some studies (7). Thus, couple and family interventions may be considered in relapse prevention strategies.

Craving emerged as a prominent and statistically significant factor associated with relapse, in line with prior research that identifies craving as a key clinical target in preventing relapse (8, 9). This emphasizes the need for pharmacological agents such as naltrexone and acamprosate and psychosocial interventions including CBT to manage craving effectively (10).

In this study, treatment adherence was another major determinant of outcome. All patients with poor adherence experienced relapse, consistent with literature showing that non-adherence predicts poor long-term outcomes (11, 12). Factors such as socioeconomic burden, family support, motivation, and side effects often influence adherence in chronic conditions like ADS (13).

Pharmacologically, disulfiram was associated with better abstinence outcomes compared to other agents. While this may partly reflect selection bias—since disulfiram is often prescribed to motivated patients with strong supervision. The same results were replicated by existing evidence (14, 15). Careful patient selection remains key for optimal outcomes.

A positive family history of alcohol dependence significantly predicted relapse, in line with prior studies highlighting both genetic predispositions and familial modeling of substance use behavior (16, 17). This underscores the importance of taking family history into account during assessment and designing family-inclusive interventions.

Contrary to international studies that emphasize personality traits like impulsivity and neuroticism as predictors of relapse (18), this study found no significant association, except between the trait of “Liveliness” and increased stressful life events. Differences in sociocultural norms and assessment tools may account for this divergence (19).

The SADQ, as measured by the SADQ, was a strong predictor of relapse. This finding aligns with earlier studies that validate this (20). Greater severity often reflects higher tolerance, compulsivity, and associated psychosocial impairment, necessitating more intensive interventions.

The relapse rate in this study, which is lower when compared to a previous study (21) conducted in South India, is probably due to the severity of alcohol dependence of cases that visit the tertiary care center as most of the patients have severe alcohol dependence.

This study highlights the multifactorial nature of relapse in ADS in India, where craving, poor treatment adherence, family history, marital status, and SADQ dominate outcomes. Psychosocial factors and personality traits play a major role, necessitating personalized treatment approaches emphasizing craving management, family and marital support, and adherence-promoting strategies. This study provides insight on the determinants playing a significant role in the outcome for patients with alcohol dependence when followed up for 6 months.

Data available on reasonable request from the corresponding author.

Approved by the Institutional Ethics Committee, Madras Medical College. Written informed consent was obtained from all participants.

Not applicable.