This was a cross sectional study to identify the factors related to first relapse in patients, following the treatment for Alcohol Dependence Syndrome (ADS). The study was conducted at the Department of Psychiatry at a tertiary care Army hospital in Delhi from January 2015 to December 2015. Ethical clearance was taken from the Hospital Ethics Review Committee. All consecutive patients who were earlier diagnosed with ADS (as per ICD -10: WHO 1992) and now admitted following first time relapse drinking of alcohol were included in the study.

Those patients with multiple relapses, multiple substance use or co-morbid medical or psychiatric illness were excluded. For the purpose of the study, remission was defined as complete abstinence from alcohol at least for a month and relapse as reinstatement of dependent pattern of drinking as per ICD-10 criteria. All patients were evaluated with: a) Semi structured interview questionnaire to enumerate demographic profile, support systems and other variables related to alcohol use like age of onset of drinking alcohol, duration of dependence, duration of inpatient de-addiction treatment, number of follow ups etc; b) CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-revised) [13] scoring immediately after admission then every six hours, as a routine protocol of the ward; c) Reasons For Drinking Again Questionnaire (RFDAQ). It is a 20 item self-report measure that was designed to identify reasons of relapse among relapse precipitants within three broad domains: negative emotions, social pressure and craving [14]; d) Relevant neuroimaging and laboratory tests were performed. After the completion of detoxification treatment, written informed consent from each patient was obtained. Information from the spouse/ family members if staying along with the patient and/or unit report was also collected for analysis.

The data was statistically analysed using Statistical Package for Social Sciences (SPSS) (version 22) computer software package. Appropriate parametric/non-parametric tests were used for continuous data. For categorical data, Chi-square test was used. A significance level of p <0.05 was accepted for all analysis.

100 patients of ADS relapse (first relapse) were admitted during study duration. Mean age of the subjects was 38.02 (SD 7.79). The most vulnerable age group in the study was 36-49 years; comprising 50% of the relapsed subjects followed by 40% in the 26-35 years age. Mean age of onset of drinking was 24.31(SD 3.642) years. 39 % cases were drinking for 11-15 years followed by 32% drinking alcohol for the last 6-10 years. 20% were sober for more than one year duration while 28% could be sober only till 2-3 months. A 33% patient had followed up monthly in addiction clinic following initial treatment while 19% never followed in person after initial treatment and discharge. 27% had just one time follow-up after initial treatment. While 5% patients could maintain a week-end pattern of drinking while 57% were drinking daily. Majority (88%) of the subjects were married, 37 % of respondents were 12th qualified followed by 31% as 10th Standard qualified, 15% were educated only till 8^th class and 11 % were degree holders [Table/Fig-1].

Support from significant others like superiors, colleagues, spouse and other family members was available in 79, 71, 73 and 85% patients respectively. The lack of support was perceived from religious groups, friends and after care services by 85, 79 and 74% of people respectively [Table/Fig-2].

The rank order of reasons for relapse was as following: 52% cited ‘feeling sad’ as reason (stated they felt sad and had to give in), 40 % reported that they felt like drinking due to good mood & an equal percentage agreed to that they drank again as someone offered them a drink [Table/Fig-3].

Alcohol Use Disorder is a chronic relapsing illness which is incompatible with military ethos and training. Earlier the reasons of the relapse are studied in soldiers, the better they could be mentored at cognitive behaviour level. Each relapse shall be viewed as an important step in the path of abstinence and hence this study focused on the background of soldier and first relapse following first treatment so that early active intervention could be formulated to improve outcome in light of knowledge gained.

Preventing relapse is a huge challenge for de-addiction specialist. During first three months post treatment relapse rate was reported as 58% by researches [15]. This increased to 90% by 4 years with at least one relapse [16]. Host, agent and environment interact in complex ways to produce relapse [17]. The correlates of relapse and its role as a predictor of long-term prognosis has not received its due attention and importance.

Mean age of patients were 37-38 years in current study is similar to results found in other studies [18-20]. Similar findings were reported in Armed Forces too [21]. The most vulnerable age group in our study has been 36-49 years; comprising 50 % of subjects [Table/Fig-1]. Another study stated that 64% of relapse participants were in age group 31-45 years [19]. Thus the intervention strategies focused on this age group can lead to significant reduction in alcohol related disorders as well as DALY’s lost. Educational qualification in our study was higher than the figures obtained by other Indian researchers [22,23]. Army has increased the minimum requirement for enrollment gradually to 12th standard. Poor educational achievement was reported with the increased risk of alcohol disorders [22]. The study on burden and impact of alcohol showed the greater use of alcohol among those who had less than 8^th grade of education [23].

The mean age of onset of alcohol use 24.31 years and mean age of relapsed subjects 38.03 years suggests a significant time of around 14 years elapsed when they progress from onset of drinking to fully dependent drinking to face first relapse. Military researchers reported lag period of about four years between onset of drinking and its regular consumption [24]. Earlier the intervention better is the prevention. Hence during the training period in Regimental centers adequate emphasis on hazards of alcohol should be taught to recruits before induction in operational areas. Zonal combat training schools should also deglamorize drinking and remove myth about expectancy of positive outcome observed to be leading to onset of drinking [25]. Western researchers have reported that individuals who began drinking at younger ages were more likely to experience relapses and requiring prolonged treatment. A 28% had reported drinking onset at age 13 years [26]. This is may be due to cultural permissiveness in western world as compared to India. During younger days, soldiers spend more time in hard and harsh terrains and in operational areas to meet national priorities. During this period, both first responders (administrators) and second responders (health care givers) need to be more vigilant in identifying drinking behaviours.

Often, a soldier in Indian Army, is sent for de-addiction, after he has been adequately counseled by his unit authorities and sufficiently warned/cautioned to reform himself. This could increase the lag period for medical attention. Hence referral for evaluation and management of substance use disorders should be done at the earliest rather than at later stage for healthy and productive outcome of treatment.

Maintaining sobriety, post treatment for ADS is a big challenge due to multiple factors. In our study there was increased rate of abstinence. After a year, around 20% were abstinent as compared to 2.1% reported around 13-18 months by others in civilian population [19]. This can be explained by the fact that, in military setting, once a mental illness is diagnosed; there are defined and well-structured protocols for regular follow up of cases post discharge e.g., monthly review, 06 monthly reviews at the dependent psychiatric center for mandatory two years. Hence there is better monitoring of relapse or drug default. Other factors which possibly contributes to better rate of alcohol abstinence After treatment in Indian army soldiers, are fear of loss of job and loss of promotion to higher ranks. However, at six month, abstinence rates were better in civilian population (56% vs 36%).

Support received after the de-addiction treatment is important factor to delay relapse. Social support in soldiers is primarily in reference to two categories: support from within the military (e.g., perceived unit cohesion and support from military leaders and fellow personnel) and support from outside of the military (e.g., social support from family and friends). Alcoholics post discharge & treatment face range of challenges and stressors. Direct advice from pro-abstaining leaders, partners and co-workers, informal sharing with other junior colleagues may help in remaining abstinent [27]. The lack of critical comments, hostility and empathy expression towards the treated individuals does augment the recovery process. It was not surprising that from superior colleagues, spouse and other family members support was perceived before relapse. However despite the army being a large community the network therapy is not well established. Alcohol Anonymous group are scanty and sparse across the Armed Forces. Professional counselors and social workers are rare precious commodities in service hospitals due to acute shortage. Thus additional source of support when individual is in post treatment setting in community is hardly available to tackle the negative emotions and solving conflicts between the ill and their families or the environment. Hence army needs to invest more resources and men. Army requires the presence of psychologists in various centers of detoxification. They could be an additional source of support, constructively assisting in recovering within the community. The other solution is organizing groups of self-help where people affected by similar problems try to combat adversities. They provide support understanding and share experiences in solving of common problems or show and receive acceptance which helps alcoholic to maintain their self-esteem.

When reasons for relapse were analysed our results were consistent with earlier research [17] where it was indicated that the predominant factor was negative emotions from both the intrapersonal and interpersonal domains, followed by social pressure and lastly wanting to get high, testing control, substance cues and urges to drink. In a study of 30 male patients of ADS when precipitating factors of relapse were noted authors reported reduced cognitive vigilance being first ranked antecedent for relapse followed by external situations and euphoric states as well as unpleasant mood states as reasons for relapse [28]. Another study reported craving as an antecedent factor preceding relapse in Armed Forces [29] but multiple relapse cases and different instrument to assess the reason for relapse were taken. They however reported negative motions like feeling sad, then being happy and consumption due peer pressure as next commonest antecedent factors for relapse.

In our study, we looked into first relapse in the Indian soldiers who were healthier people drawn from civilian population. After tough training they underwent health check up every year. This was reflected in the current finding that majority of the subjects did not report health reasons or change in the environment/stressful environment as a reason for relapse. The results were different from earlier studies [3] which were not done in army environment. Similarly, majority of subjects in this study were not having frustration in relationships as causative factor for relapse in contrast to earlier study [30]. Based on the findings of our study, during psychoeducation and Cognitive Behaviour Therapy (CBT), handling positive and negative mood states and dealing with social pressures during therapeutic sessions and CBT should be focus of clinical attention. Self-help techniques like assertiveness training will go long way in improving positive coping skills to deal with relapse.

It was a cross sectional study; hence no causality can be drawn. A follow up study would have provided us with more valuable knowledge about the longitudinal course of the illness. The study focused on soldiers who relapsed post treatment for Alcohol Dependence. A prospective case control study would yield more relevant information on the subject.

The reasons for first relapse after achieving a period of abstinence were mostly intrapersonal factors like feeling of sadness and good mood followed by interpersonal issues like someone offering a drink. Careful consideration is required in evaluating the reasons for 1st relapse after successful de-addiction treatment. Improving the handling of positive and negative mood states and addressing these reasons in therapeutic regimen will enable us to have a good intervention progrramme.