Impact of breathing and relaxation training (Sudarshan Kriya) on cases of alcohol dependence syndrome.

BACKGROUND: Alcohol abuse is a public health problem and the course of alcohol dependence syndrome (ADS) is known for its relapsing nature. Additional interventions with empirical evidence are worthy of consideration. Breathing and Relaxation Training, like Sudarshan Kriya (SK) is recommended for stress management, and have been shown to positively affect outcomes in stress-related disorders. The aim of this study was to assess the effect of an intervention of Breathing and Relaxation Training, on drinking behavior in patients of ADS.
METHODOLOGY: Eighty in-patients diagnosed with ADS were included after obtaining informed consent, in this prospective study and were randomized into two groups. They were administered Alcohol Use Disorder Identification Test (AUDIT) at admission and 6-months after discharge. The Study group (n = 40) underwent a 6-day intervention of Breathing and relaxation Training (SK) apart from the standard therapy. "WHO-5 Well-Being Index" was administered before and after the training. The Control group was exposed to the standard therapy for ADS. A follow-up on a monthly basis and finally at 6-month interval was done to assess alcohol consumption status.
RESULTS: Socio-demographically both the groups were comparable. The breathing and relaxation training (study) group had a significant rise in "WHO-5 Well-Being Index" (P < 0.001). There was a significant reduction in AUDIT scores after 6 months in both groups. AUDIT scores were significantly lower in the study group (11.20 ± 2.81) than the control group (15.30 ± 4.05) after 6 months (P < 0.001). The study group also reported fewer days of drinking (P = 0.004) and reduced overall drinking in the intervening period (P < 0.001).
CONCLUSION: The addition of Breathing and Relaxation Training (SK) in the management of ADS provided additional therapeutic benefits in the form of fewer days of drinking and reduced total alcohol consumption. Copyright:

Substance use, especially alcohol use, continues to be an important public health problem globally and in India. Studies from India have reported a prevalence of around 10% for Alcohol Use Disorders (AUD).[12] Alcohol is the second most common cause of disability globally, and about 5% of the global burden of disease can be attributed to its uses, being implicated in almost 3 million deaths every year.[3] Substance use disorders constitute large proportion of preventable causes of morbidity and mortality in India. The National Household Survey of Drug Abuse in India reported, that around 14.6% of population, in the 10–75-year age range, are current users of alcohol, amounting to around 160 million persons. Prevalence among men was 17 times higher than in women and around 5.2% of Indians (>57 million) are affected by harmful or dependent alcohol use.[4]

Excessive alcohol use impacts various organ systems of human body including the brain causing varied adverse effects. Acceptance and understanding of the problem, and being motivated for the process of change are the first step toward comprehensive treatment of AUD. Management includes detoxification, withdrawal treatment with benzodiazepines and long term treatment which includes anti-craving drugs, psychosocial interventions like motivational enhancement therapy (MET), motivational interviewing, relapse prevention,[5] cognitive behavioral coping skills training.[6] The course of the disorder is studded with relapses and abstinence rates are found to be superior with combination treatment.[7] Studies have highlighted the importance of Breathing and Relaxation training, Sudarshan kriya (SK) in patients with AUD.[8910] However, there are hardly any follow-up studies, providing evidence for improvement in drinking behavior in patients of Alcohol Dependence Syndrome (ADS).

SK (Su = proper, Darsha-na = vision, Kriya = purifying action) involves a set of repeated exercises to control and regulate the pattern of breathing. The training is imparted by a nonprofit organisation (Art of Living Foundation). It provides relaxation and an experience of calmness presumably through a regulatory effect on the sympathetic and parasympathetic system.[11]

This study was planned to evaluate the impact of Breathing and Relaxation Training (SK) offered as an adjunct therapy along with standard treatment followed at our centre to see if it altered drinking behavior in male patients of ADS, when compared with standard treatment alone. An additional objective was also to evaluate the effect on subjective well-being of these individuals.

METHODOLOGY

This was prospective, randomized case-control study in which the patients were followed up for 6 months. Clearance was obtained from the institutional ethics committee prior to start of the study and Informed Consent was obtained from each patient for enrollment. Treatment naïve male patients of ADS between 18 and 60 years of age, who met the ICD-10-Diagnostic Criteria for Research for ADS, admitted in tertiary care general hospital psychiatry unit were included. Patients with other substance abuse disorders (except nicotine and caffeine), any other psychiatric disorder, organic disorders or any chronic medical disorder, or persons with intellectual disability were excluded. Based on certain similar studies[1012] which had a total sample size of 60, a total of 80 male patients were enrolled and randomly distributed into two groups of 40 each. Initial detoxification was done with chlordiazepoxide and further pharmacotherapy (anti-craving medication) and psychosocial therapy like MET, group therapy was started for all patients during their stay in the hospital (as per the standard treatment protocol followed).

After detoxification, the Study group (n = 40) were trained SK by a qualified teacher in a 6-day course. They were given additional training material on CDs, which they practised on their own daily. During the next 3 weeks as in-patients, SK practise was supervised and after discharge, they continued on their own. This was reviewed during monthly follow-up. The control group (n = 40) were administered standard therapy as mentioned above.

All patients were initially evaluated on a semi-structured proforma to assess their socio-demographic and alcohol consumption profiles. AUD Identification Test (AUDIT)[13] was administered to both the groups at the time of admission and after 6 months. “WHO-5 Well-Being Index”[14] was additionally administered to the Study group before and after SK training. Follow up assessment was recorded on a semi-structured proforma, by interviewing the patient and a significant family member. The interview included assessment of drinking behaviour in terms of frequency and amount of alcohol consumed during the previous months, treatment adherence, general health and functioning in occupational, social and domestic spheres. Outcome measures were a comparison of AUDIT scores, frequency of alcohol consumption and number of drinks per sitting at end of 6 months. The WHO-5 Well-Being Index score at the end of the course in the Study group.

AUDIT[13] is a ten-item tool developed by the World Health Organization (WHO) to assess and screen alcohol consumption, and alcohol-related problems. Score ranges between 0 and 40. Scores of 0–7 indicate low risk of addiction, 8–15 medium risk, 16–19 high and the scores of 20–40 indicates likely addiction. Cronbach's alpha is 0.80.

WHO-5 Well-Being Index[14] is a short self-reported measure of current mental wellbeing. Total score, ranges from 0 to 25, with zero representing the worst imaginable well-being and 25, the best imaginable well-being.

Data were analyzed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Continuous variables are presented as mean ± standard deviation, and categorical variables presented as absolute numbers and percentage. Nominal categorical data between the groups were compared using Chi-square test or Fisher's exact test, as appropriate. The comparison of continuous variables between the two groups was performed using Mann–Whitney U test. For intra-group comparisons, Wilcoxon Signed-Rank Test was used. P < 0.05 was considered statistically significant.

RESULTS

The two groups were comparable with respect to the socio-demographic profile, alcohol consumption status and AUDIT scores admission [Table 1]. All were male, married, with the similar job profile and pay structure.

Table 1

Demographic profile, alcohol consumption status and Alcohol Use Disorder Identification Test scores at admission

	Cases (n=40)	Controls (n=40)	P
Age, mean±SD	37.70±7.60	38.88±8.95	0.528
Education
≤10th	22	19	0.464
>10th	8	11
Quantity of alcohol (ml) in one sitting
120-180	12	11	0.914
180-240	16	19
240-300	10	8
300-360	2	2
Frequency (days/week), mean±SD	4.30±1.11	4.45±1.11	0.548
Episodes of delirium^
1	6	7	0.543
2	1	3
Nil	33	30
Episodes of seizure^
1	5	6	0.809
2	2	1
Nil	33	33
AUDIT (at admission), mean±SD	18.35±3.19	19.25±3.61	0.241

^Fisher’s exact test. Chi-square test unless specified otherwise. AUDIT Alcohol Use Disorder Identification Test; SD – Standard deviation

After 6 months of treatment, there was reduction in the AUDIT scores, frequency and quantity of alcohol use in both the groups. The Study group, exposed to the SK, reported fewer days of drinking (P = 0.004) and reduced overall drinking (P < 0.001) over 6 months and a significantly lower score on AUDIT [Tables 2-4]. The WHO-5 Well-Being Index scores in Study group after the 6-day intervention [Table 5] showed significant improvement.

Table 2

Frequency of alcohol consumption (days/week) during 6 months’ follow-up

Frequency (days/week)	Cases (n=40), n (%)	Controls (n=40), n (%)	P
0	9 (22.5)	4 (10)	0.004
1	10 (25)	2 (5)
2	16 (40)	15 (37.5)
3	5 (12.5)	18 (45)
4	0	1 (2.5)

Chi-square test

Table 4

Average amount (mL) consumed in one sitting in each groups during the 6 month follow-up

Amount	Cases (n=40), n (%)	Controls (n=40), n (%)	P
Nil	9 (22.5)	4 (10)	0.001
<60	8 (20)	1 (2.5)
60-120	16 (40)	7 (17.5)
120-180	2 (5)	12 (30)
180-240	3 (7.5)	10 (25)
240-300	2 (5)	6 (15)

Chi-square test

Table 5

World Health Organization-5 Well-being Index before and after the Sudarshan Kriya course

	Cases, mean±SD	P
Before the course	19.10±1.61	<0.001
After the course	21.72±1.01

Wilcoxon signed-rank test. SD – Standard deviation

DISCUSSION

In ADS, symptoms of withdrawal, perceived stress and negative affect have shown to increase risk of relapse. This occurs through a constellation of interrelated cognitive, emotional, physiological, and behavioural mechanisms[1112] including attention bias toward alcohol-related cues, poor emotion regulation and reactivity, leading to habitual alcohol-seeking.[15] SK and other breathing techniques have been recommended for relaxation, stress management and control of psychophysiological states. It has been shown to positively affect autonomic nervous system imbalance in stress and related disorders,[8] probably by increasing vagal tone and decreasing sympathetic discharge and also dealing with negative emotions effectively.[1617]

After follow-up for 6 months, we found a significant reduction in the number of drinks per sitting, in the study group, with almost half consuming <60 mL of alcohol (whiskey or rum) in one sitting, while in the Control group the majority consumed >180 mL [Table 4]. The numbers of such sittings, per week, were also significantly less in the Study group, with almost half of the sample consuming less than twice a week [Table 2]. We thus had a significant proportion who showed considerable improvement in overall drinking habit when followed up for 6 months, emphasising that learning such exercises had contributed to the improvement in the study group. A Swedish study exploring role of yoga as an adjunct treatment for alcohol dependence found reduction in the number of drinks per day in the intervention group, although not significant (limitation of small sample size).[18] A study conducted in India showed that rhythmic breathing helped to control the tobacco habit in 21% of individuals who were followed up for 6 months.[19] Similar practices like Yoga or meditation or controlled breathing exercises have been shown to improve craving for alcohol[2021] and SK has shown reduced craving for tobacco.[22]

All the patients (both groups) were followed at regular intervals after discharge for 6 months and family members or colleagues were involved to improve treatment adherence. The improvement was seen in both groups, in all the parameters such as AUDIT scores, frequency and quantity of alcohol intake, which shows that the basic intervention followed in the institution is helping the patients. The training in SK and adherence to it further improves on the existing management schedule.

For analyzing immediate impact, WHO-5 Well-Being Index was administered before and after the intervention which showed a significant improvement [Table 5]. Studies analyzing the impact of SK on stress levels found that regular practice improved levels of well-being, happiness, focus, and reduced anger and frustration and concluded that the life appeared “eased out.”[923] Other studies have shown SK to have an antidepressant like affect and also reported stabilized cortisol levels and normalization of BDNF levels.[8] Another study[10] which evaluated an improvement of depressive symptoms in ADS patients found similar results, lowering of Cortisol and ACTH levels and improvement of depressive symptoms. Thus a lowering of stress hormones, improvement in the feeling of general well-being as demonstrated in this study and others as above, could be one of the reason, which kept the subjects motivated enough to continue practicing SK even after discharge and adding onto the improvement in final outcome measure after 6 months.

The strengths are that with significant results this follow-up study shows evidence in improving the outcome in ADS patients. There also evidence that the general well-being increases after this training and practice, although another well-being score at the end of 6-months would have given additional information. Limitations of the study being, a relatively small sample size and follow-up for only 6 months, having only male, inpatients from a tertiary care setting which could limit the generalization of the study to general population. In addition, the information of alcohol intake was based on a comprehensive history and inputs from a significant family member, no objective tests for assessment were applied.

CONCLUSION

De-addiction therapy has uncertain success rates, and relapses are common. Various reasons for relapses have been outlined in literature. Breathing and Relaxation Training can be used to break the cycle of stress, negative emotions and addictive behavior by creating a sense of self-control. Breathing and Relaxation training (SK) makes those entering treatment for ADS feel better (improves well-being). Over a period of the next 6 months, it reduces the number of drinking days and the total amount of alcohol consumed. Further follow-up studies with a longer observation period will add to the evidence and classify the role of such interventions can be utilized for better outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 3

Alcohol Use Disorder Identification Test score of case and control groups at admission and after 6 months

	Median (IQR)		P
	At admission	After 6 months
	Cases	18 (16-21)		11 (10-13)	<0.0001*
Control	19 (16-22)	15 (13-18)	<0.0001*
P	0.201**	<0.0001**

*Wilcoxon signed-rank test; **MannWhitney U-test. IQR – Interquartile range