Psychiatric comorbidity in injecting drug users in Asia and Africa

Psychiatric comorbidities and concurrent substance use among people who inject drugs: a single-centre hospital-based study

The management of people who inject drugs (PWID) is compounded by the presence of psychiatric comorbidities leading to frequent relapses and poor treatment outcomes. Early identification and treatment of psychiatric comorbidities should be included in the management to enhance treatment outcomes. The objective of this study was to estimate the prevalence of psychiatric comorbidities and concurrent substance use among opioid injectors. This hospital-based, cross-sectional study was conducted from March 2021 to August 2022. This study included opioid injectors of all ages and both sexes. The Mini International Neuropsychiatric Interview-7 (MINI-7) and WHO-ASSIST were used to determine psychiatric comorbidities and concurrent substance use, respectively. Both crude and adjusted odds ratios were calculated to assess associations among demographic variables, concurrent substance use and psychiatric comorbidities. Among the 328 opioid injectors, the overall prevalence of psychiatric comorbidities was 88.1%, with the majority (68.6%) having more than one comorbidity. The most common psychiatric comorbidities were panic disorder (41.2%), social anxiety disorder (40.5%), and antisocial personality disorder (39.3%). Concurrent use of alcoholic beverages doubled the risk of ASPD (odds ratio 2.14 (1.24-3.72)). Cocaine (odds ratio 2.36 (1.10-5.03)) and amphetamines (odds ratio 7.68 (2.21-26.65)) increased the risk of OCD. Daily heroin injections were negatively associated (odds ratio 0.18 (0.03-0.94)) with psychotic disorders. Younger age (adjusted odds ratio 0.20 (0.79-0.53)) and never married status (adjusted odds ratio 2.62 (1.06-6.47)) were the only significant variables in the regression analysis. In conclusion, opioid injectors had a higher prevalence of numerous psychiatric comorbidities. The most common comorbidity was anxiety disorders. Concurrent use of tobacco, cannabis, cocaine, inhalants, etc., greatly increased the risk of psychiatric comorbidities.

Gender, homelessness, hospitalization and methamphetamine use fuel depression among people who inject drugs: implications for innovative prevention and care strategies

Background

The co-occurrence of substance use disorder and mental disorder, known as dual diagnosis, has a distressingly high prevalence among individuals grappling with either of these conditions. Mood disorders, especially depression, constitute a substantial burden for People Who Inject Drugs (PWID) and a significant public health concern in Vietnam. Identifying risk factors for depression in PWID is imperative for the development of targeted interventions.

Methods

We enrolled PWID into a cohort using the respondent-driven sampling method. Over a 36-month period, we systematically tracked the emergence of depression and employed multiple imputation in conjunction with a mixed nonlinear model to pinpoint risk factors for depression in this demographic. At inclusion, depression was screened using the PHQ-2 questionnaire, and subsequent episodes of depression were assessed semi-annually using the CES-D8.

Results

Three hundred and ninety-one PWID (26.6%) were depressed. Major risk factors for depression included being female, not having a permanent residency, having been hospitalized and using methamphetamine more than weekly. Other risk factors included age, being single, not having a health insurance card and not being on methadone.

Limitations

The exclusion of missing visits and social desirability could have led to selection and information biases. In this observational study, confusion biases are possible despite our best efforts.

Conclusion

Depression is alarmingly frequent in PWID. In this study taking in account the chronological relationship between sociodemographic and clinical factors and depression, risk factors were identified in this specific setting of low-to-middle income country. The findings highlight the need to develop innovative targeted psychiatric interventions with the help of supporting peers.

Quality-adjusted life years among people who inject drugs in a needle syringe program in Sweden

PURPOSE

Needle syringe programs (NSP) significantly reduce risk behavior and HIV and hepatitis transmission in people who inject drugs (PWID). However, PWID are underrepresented in studies on health-related quality of life (HRQoL), representing a barrier to evaluate effects of public health and preventive measures related to injecting drug use. In this study, we investigate how well the two questionnaires EQ-5D-3L and SF-6D measure health in PWID. We also estimate HRQoL in the PWID population.

METHOD

Data on demographics, injection drug use, HIV, hepatitis status, and self-reported HRQoL were collected from 550 PWID enrolled in the Stockholm NSP at enrollment and at 6-, 12-, and 24-month follow-up. Self-rated HRQoL was measured as QALY, using EQ-5D-3L and the SF-6D. Item response theory (IRT) was used to evaluate which of the two instruments that measure health most accurately in this population. Regression analysis was used to estimate population-specific QALYs.

RESULTS

The IRT analysis showed that SF-6D was better suited to measure health in PWID. More specifically, SF-6D to a larger extent discriminated between persons regardless of their health status, while EQ-5D was more suitable to detect persons with poorer health. Self-rated HRQoL showed that average QALY was lower among PWID compared to the general Swedish population. However, a general increase in self-reported health was noted over time among participants.

CONCLUSION

This study increase knowledge of what instruments are most suitable to measure health among PWID. This is of great importance when evaluating effects of public health and preventive measures in the PWID population.

Development and assessment of a community-based screening tool for mental health disorders among people who inject drugs

INTRODUCTION

The prevalence of mental health disorders among people who use drugs is high and well documented. This hard-to-reach population faces a very low awareness and access to mental health care, especially in developing countries. The objectives of this study were to design and assess a quick screening tool (QST) that community-based organisations (CBO) could routinely apply to a Vietnamese population of people who inject drugs (PWID), in order to refer them appropriately to mental health specialists.

METHODS

We devised a tool that included nine questions covering anxiety, depression, suicide risk and psychotic symptomatology. Its use required no specific background and 2 h training. Specificity and sensitivity of the QST were assessed in a population of 418 PWID recruited via respondent driven sampling, using the Mini International Neuropsychiatric Interview questionnaire plus clinical evaluation as a reference standard. Acceptability was assessed using a self-administered anonymous questionnaire submitted to all CBO members who used the QST.

RESULTS

CBO members considered the QST easy to use, relevant and helpful to deal with mental health issues. Area under the curve for detection of any symptom using the QST was 0.770. The maximum sensitivity and specificity were reached with a cut-off of 2 [sensitivity was 71.1% (95% confidence interval 62.4, 78.8), specificity was 75.9% (70.5, 80.7)].

DISCUSSION AND CONCLUSIONS

The QST appeared to be both efficient and well accepted. Given the burden of mental health problems among hard-to-reach PWID in developing countries, community-based screenings such as this one could be a particularly appropriate response.

Assessment of a psychiatric intervention at community level for people who inject drugs in a low-middle income country: the DRIVE-Mind cohort study in Hai Phong, Viet Nam

Background

Access to psychiatric care for people who inject drugs (PWID) is limited/absent and stigmatized in most low-middle-income countries (LMICs). Innovative interventions are needed. We aimed to describe and assess the impact of a community-based psychiatric intervention among PWID in Hai Phong, Vietnam

Methods

In a cohort study with one year psychiatric follow-up, PWID diagnosed with a psychotic disorder, a major depressive episode, or suicide risk, were recruited from the wider Drug-Related Infections in ViEtnam (DRIVE) project in the city of Hai Phong. The community-based psychiatric intervention included specialized follow-up (free consultations with psychiatrists, free medication, referral to mental health department for hospitalization when necessary) and support from community-based organisations (case management, harm reduction, administrative support, linkage to HIV care, methadone maintenance treatment and mental health support). The main outcome was reduction/remission of symptoms. Access to and retention in psychiatric care, quality-of-life and stigmatization were also measured pre and post-intervention.

Findings

Among the 1212 participants screened from March to May 2019, 271 met the inclusion criteria, 233 (86.3%) accepted the intervention and 170 completed the follow-up (72.9%). At inclusion, 80.6% were diagnosed with current depression, 44.7% with psychotic disorder and 42.4% with suicide risk. After a one-year follow-up, these proportions dropped to 15.9%, 21.8%, and 22.9% respectively. Quality-of-life and perceived stigma related to mental health were also significantly improved, while drug use decreased only marginally.

Interpretation

Community-based psychiatric interventions are both feasible and efficient in the Vietnamese context. Similar interventions should be implemented and evaluated in other, different LMICs.

Funding

: This work was supported by grants from NIDA (US) (#DA041978) and ANRS (France) (#13353). The funding agencies had no role in designing the research, data analyses, or preparation of the report.

Mental Disorders Are Associated With Leukocytes Telomere Shortening Among People Who Inject Drugs

Premature biological aging, assessed by shorter telomere length (TL) and mitochondrial DNA (mtDNA) alterations, has been reported among people with major depressive disorders or psychotic disorders. However, these markers have never been assessed together among people who inject drugs (PWIDs), although mental disorders are highly prevalent in this population, which, in addition, is subject to other aggravating exposures. Diagnosis of mental disorders was performed by a psychiatrist using the Mini International Neuropsychiatric Interview test among active PWIDs in Haiphong, Vietnam. mtDNA copy number (MCN), mtDNA deletion, and TL were assessed by quantitative PCR and compared to those without any mental disorder. We next performed a multivariate analysis to identify risk factors associated with being diagnosed with a major depressive episode (MDE) or a psychotic syndrome (PS). In total, 130 and 136 PWIDs with and without psychiatric conditions were analyzed. Among PWIDs with mental disorders, 110 and 74 were diagnosed with MDE and PS, respectively. TL attrition was significantly associated with hepatitis C virus-infected PWIDs with MDE or PS (adjusted odds ratio [OR]: 0.53 [0.36; 0.80] and 0.59 [0.39; 0.88], respectively). TL attrition was even stronger when PWIDs cumulated at least two episodes of major depressive disorders. On the other hand, no difference was observed in mtDNA alterations between groups. The telomeric age difference with drug users without a diagnosis of psychiatric condition was estimated during 4.2-12.8 years according to the number of MDEs, making this group more prone to age-related diseases.

Daily heroin injection and psychiatric disorders: A cross-sectional survey among People Who Inject Drugs (PWID) in Haiphong, Vietnam

BACKGROUND

Psychiatric comorbidities are frequent among people who inject drugs, they are associated with a poorer prognosis and need to be addressed. Their interaction with daily heroin injection requires clarification.

METHODS

A cross-sectional survey was conducted among PWID recruited in the city of Haiphong, Vietnam, by respondent-driven sampling. The inclusion criteria were age 18 or older and current injection drug use, verified by skin marks and positive urine tests for heroin or methamphetamine. Data on socio-demographic characteristics, drug use, sexual behaviour and access to treatment were collected using face-to-face questionnaires by trained interviewers. PWID were screened by trained psychiatrists for depression, psychotic disorder and suicidality, using the MINI questionnaire.

RESULTS

418 participants were included in the analyses. All were injected heroin users, 21 % were diagnosed with a current major depressive disorder, 15 % with a current psychotic disorder and 12 % presented a suicide risk. In the bivariate analyses, regular meth use, cannabis use and ketamine use were positively associated with presenting at least one psychiatric condition while daily heroin injection and being currently treated with methadone were negatively associated. In the multivariate model, poly-substance use was positively associated with depression (methamphetamine and drinking in addition to heroin) and psychotic disorder (methamphetamine and/or hazardous drinking in addition to heroin) while daily heroin injection and current methadone treatment were negatively and independently associated with depression and psychotic syndrome.

CONCLUSIONS

Our survey confirms the burden of methamphetamine use and the protective effect of methadone but also a possible protective effect of daily heroin injection.

Depression, injecting drug use, and risky sexual behavior syndemic among women who inject drugs in Kenya: a cross-sectional survey

BACKGROUND

Injecting drug use (IDU) is a key driver of the HIV epidemic particularly when individuals experience psychosocial conditions and risky sexual behavior in a syndemic manner. This study sets out to assess evidence of a syndemic pattern of psychosocial conditions (IDU, depression, intimate partner violence (IPV)) on one the hand and risky sexual behavior on the other while accounting for the socio-economic disadvantage among women who inject drugs (WWID) in low-income urban settings in Kenya.

METHODS

Using a cross-sectional study design, this study recruited 306 WWIDs from two sites in Nairobi between January 2017 and July 2017. Multiple methodologies including descriptive analyses of co-occurrences of psychosocial conditions at the individual level, standard logistic regression analyses to examine relationships and interactions within and between psychosocial conditions and risky sexual behavior, and classification trees algorithm for predictive modeling via machine learning were employed.

RESULTS

The prevalence of the psychosocial conditions was as follows: IDU, 88%; depression, 77.1%; and IPV, 84%. The prevalence of risky sexual behavior was 69.3%. IDU and depression were related to each other (P < 0.05) and each of them with risky sexual behavior (P < 0.05). The highest 2-way and 3-way co-occurrence of conditions were reported in IDU and depression (72%) and in IDU, depression, and risky sexual behavior (62%), respectively, indicating clustering of the conditions at the individual level. Further, each additional psychosocial condition (IDU and depression) was associated with sixfold odds (P = 0.000) of having risky sexual behavior suggesting a dose-response relationship. Logistic regression analyses incorporating multiplicative interactive effects returned three significant variables (P < 0.05): IDU*depression interaction effect, "Age when delivered the first child," and "Income." Classification tree modeling represented a 5-level interaction analysis with IDU and depression predicted to have the highest influence on risky sexual behavior.

CONCLUSION

Findings provide possible evidence of a syndemic pattern involving IDU, depression, and risky sexual behavior suggesting the need for an integrated approach to the implementation of harm reduction interventions among WWID in low-income urban settings in Kenya. This work highlights the need for further studies to authenticate the findings and to characterize pathways in the syndemic development in WWID.

Hepatitis C: clinical and biological features related to different forms of cocaine use

INTRODUCTION

Hepatitis C virus (HCV) infection is related with several liver diseases such as cirrhosis and hepatocellular carcinomas, leading to more than 0.5 million deaths every year and to a great global burden. It is known that injection drug users show a high prevalence of HCV infection, being considered a risk group for this disease. Cocaine users seem to be in greater risk than other drug users, and several hypotheses for this association are being studied.

AIM

To review data on HCV infection in cocaine users, taking into consideration the relevance of the different routes of drug administration and other risk behaviors.

METHODS

This was a narrative review performed in the main scientific databases.

RESULTS AND CONCLUSION

Data suggest that cocaine use could be associated with HCV infection due to the specificities of cocaine consumption pattern, even in those subjects who do not inject drugs, in addition to other risky behaviors, such as tattooing and unprotected sex. Injectable cocaine users seem to be more susceptible to contamination than users who do not inject drugs. However, evidence is pointing to the possibility of infection by sharing drug paraphernalia other than syringes. Moreover, specific immune system impairments caused by cocaine use are also being linked with HCV infection susceptibility, persistence and increased pathological effects.

Psychiatric Comorbidities among People Who Inject Drugs in Hai Phong, Vietnam: The Need for Screening and Innovative Interventions

The objective of this study is to describe psychiatric comorbidities, associated factors, and access to psychiatric assessment and care in a cohort of people who inject drugs (PWID) in Hai Phong, Vietnam. Mental health was assessed after 12 months' follow-up using the Mini International Neuropsychiatric Interview questionnaire (MINI 5.0.0). PWID medical history, drug use, and sociodemographic and clinical characteristics were also collected. Among 188 PWID who participated in the assessment, 48 (25.5%) had at least one psychiatric disorder and 19 (10.1%) had 2 or more psychiatric disorders. The most common current psychiatric disorders were major depressive episode (12.2%) and psychotic disorder (4.8%), reaching 10.1% for the latter when lifetime prevalence was considered. Females were more likely than males to have at least one psychiatric disorder, a major depressive disorder, or an anxiety disorder. Methamphetamine use was associated with an increased risk of presenting a lifetime psychotic syndrome. Problematic alcohol consumption was associated with an increased risk of having at least one psychiatric disorder. Psychiatric comorbidities are frequent among PWID in Vietnam. These results highlight the need for routine assessment and innovative interventions to address mental health needs among PWID. Community-based interventions targeting mental health prevention and care should be strongly supported.

Intravenous heroin use in Haiphong, Vietnam: Need for comprehensive care including methamphetamine use-related interventions

BACKGROUND

The aim of this study was to describe patterns among people who inject drugs (PWID), risk-related behaviours and access to methadone treatment, in order to design a large-scale intervention aiming to end the HIV epidemic in Haiphong, Vietnam.

METHODS

A respondent-driven sampling (RDS) survey was first conducted to identify profiles of drug use and HIV risk-related behaviour among PWID. A sample of PWID was then included in a one-year cohort study to describe access to methadone treatment and associated factors.

RESULTS

Among the 603 patients enrolled in the RDS survey, 10% were female, all were injecting heroin and 24% were using methamphetamine, including 3 (0.5%) through injection. Different profiles of risk-related behaviours were identified, including one entailing high-risk sexual behaviour (n=37) and another involving drug-related high-risk practices (n=22). High-risk sexual activity was related to binge drinking and methamphetamine use. Among subjects with low sexual risk, sexual intercourse with a main partner with unknown serostatus was often unprotected. Among the 250 PWID included in the cohort, 55.2% initiated methadone treatment during the follow-up (versus 4.4% at RDS); methamphetamine use significantly increased. The factors associated with not being treated with methadone after 52 weeks were fewer injections per month and being a methamphetamine user at RDS.

CONCLUSION

Heroin is still the main drug injected in Haiphong. Methamphetamine use is increasing markedly and is associated with delay in methadone initiation. Drug-related risks are low but sexual risk behaviours are still present. Comprehensive approaches are needed in the short term.

Mental health care providers' perceptions of the barriers to suicide prevention amongst people with substance use disorders in South Africa: a qualitative study

Background

Substance use is a well-established, and potentially modifiable, risk factor for suicide. Suicide prevention interventions are typically framed within the biomedical paradigm and focus on addressing individual risk factors, improving access to psychiatric care, and improving the skills of medical personnel to recognise at-risk individuals. Few studies have focused on contextual factors that hinder suicide prevention in people with substance use disorders, particularly in low-resource settings. The aim of this qualitative study was to explore mental health care providers’ perceptions of barriers to suicide prevention in people with substance use disorders in South Africa.

Methods

Semi-structured interviews were conducted with 18 mental health care providers who worked with suicidal people with substance use disorders in Cape Town, South Africa. Data were analysed using thematic analysis and Atlas.ti software was used to code the data inductively.

Results

Two superordinate themes were identified: structural issues in service provision and broad contextual issues that pose barriers to suicide prevention. Participants thought that inadequate resources and insufficient training hindered them from preventing suicide. Fragmented service provision was perceived to lead to patients not receiving the psychiatric, psychological, and social care that they needed. Contextual problems such as poverty and inequality, the breakdown of family, and stigma made participants think that preventing suicide in people with substance use disorders was almost impossible.

Conclusions

These findings suggest that structural, social, and economic issues serve as barriers to suicide prevention. This challenges individual risk-factor models of suicide prevention and highlights the need to consider a broad range of contextual and socio-cultural factors when planning suicide prevention interventions. Findings suggest that the responsibility for suicide prevention may need to be distributed between multiple stakeholders, necessitating intersectoral collaboration, more integrated health services, cautious use of task shifting, and addressing contextual factors in order to effectively prevent suicide in people with substance use disorders.

The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: A cross-sectional study

Background

Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen.

Methods

The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container).

Results

Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02).

Conclusions

Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3125-7) contains supplementary material, which is available to authorized users.

Effects of a Randomized Comprehensive Psychosocial Intervention Based on Cognitive Behavioral Therapy Theory and Motivational Interviewing Techniques for Community Rehabilitation of Patients With Opioid Use Disorders in Shanghai, China

OBJECTIVES

China is faced with the challenge of community rehabilitation of persons with opioid use disorders. A 1-year comprehensive psychosocial intervention (CPI) was developed, and its effectiveness was assessed in terms of its ability to improve community rehabilitation of persons with opioid use disorders after their release from detention in compulsory treatment centers in Shanghai, China.

METHODS

Participants were randomized to the CPI (n = 90) condition or the usual community care (UCC, n = 90) as a control condition. The Addiction Severity Index, Symptom Checklist-90, and Medical Outcomes Study 36-Item Short Form Health Survey were administered at baseline and at the end of the intervention. Urine screens were used to increase the validity of self-reported drug use.

RESULTS

Compared with the UCC group at follow-up, the CPI group showed lower scores in 6 dimensions of the Symptom Checklist-90: somatization, obsessive-compulsive, anxiety, phobia-anxiety, paranoia, and psychoticism. Members of the CPI group had higher scores in 2 dimensions of the 36-Item Short Form Health Survey—physical role limitation and emotional role limitation—compared with the UCC group (P < 0.05). A logistic regression analysis revealed that phobia-anxiety, lifetime heroin or amphetamine use, and injection drug use were risk factors of relapse, but differences were not found in drug urine test or self-report drug use between the 2 groups (P > 0.05).

CONCLUSIONS

The CPI condition improved participants' mental health and quality of life, and it could be a promising community rehabilitation approach for patients with opioid use disorders in recovery.

Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam

BACKGROUND

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate).

RESULTS

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

Challenges in managing HIV in people who use drugs

PURPOSE OF REVIEW

HIV management in people who use drugs (PWUD) is typically complex and challenging due to the presence of multiple medical and psychiatric comorbidities as well as social, physical, economic and legal factors that often disrupt the HIV continuum of care. In this review, we describe the individual, health systems and societal barriers to HIV treatment access and care retention for PWUD. In addition, the clinical management of HIV-infected PWUD is often complicated by the presence of multiple infectious and noninfectious comorbidities.

RECENT FINDINGS

Improved HIV treatment outcomes can be enhanced through improved testing and linkage strategies along with better treatment retention and antiretroviral (ART) adherence. Improved ART adherence can be achieved through the provision of opioid substitution therapy (OST), directly administered ART (DAART) and integration of ART with OST services. Recent advances with direct-acting antivirals (DAAs) for hepatitis C virus (HCV) have shown superior outcomes than interferon-based regimes in HIV-HCV coinfected patients. Newer diagnostic technologies for tuberculosis (TB) hold promise for earlier diagnosis for PWUD coinfected with TB, and TB treatment outcomes are improved through combination with OST.

SUMMARY

HIV-infected PWUDs are a key population who frequently experience suboptimal outcomes along the HIV continuum of care. A comprehensive strategy that encompasses evidence-based prevention and treatment interventions that target the individual, family, healthcare system, legal and societal structure is required to ensure greater participation and success in HIV treatment and care.

Profiles of psychiatric disorders among heroin dependent individuals in Changsha, China

BACKGROUND

The strong comorbidity of psychiatric and substance use disorders is well documented outside of China, however it has not been studied extensively among drug using individuals in China. This study evaluated patterns of co-occurring psychiatric and substance use disorders among heroin dependent individuals in Changsha, China.

METHODS

Participants were 1002 individuals consecutively admitted between March 10 and October 30, 2008 into two compulsory and one voluntary drug rehabilitation centers in Changsha. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) and the Structured Clinical Interview for DSM-IV-TR Axis II personality Disorders (SCID-II) were used.

RESULTS

Mental health disorders were highly prevalent among study participants: 29.6% had at least one lifetime DSM-IV Axis I and 19.5% had at least one current (past month) Axis I mental health disorder. Antisocial (40.7%) and Borderline (22.6%) Personality Disorders were most prevalent DSM-IV Axis II lifetime diagnoses and a mood disorder (19.1%) was the most prevalent Axis I lifetime disorder; 57.8% had other substance use disorder in addition to opioid dependence. Study results indicate that females in compulsory settings have lower socio-economic status than males in compulsory settings, and that males in compulsory settings have higher rates of co-morbidities, including personality, mood disorders, substance use co-morbidities, and lower socio-economic status than males in the voluntary setting.

CONCLUSIONS

The study findings suggest an urgent need to expand and improve diagnostic and treatment capabilities in compulsory rehabilitation settings in China and a need for additional services and interventions specific for female rehabilitants.

Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs

BACKGROUND

Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan.

METHODS

We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan.

RESULTS

Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon.

CONCLUSION

The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers' expenses and averting HIV infection rates among PWID.

Suicidal ideation and attempts among men who inject drugs in Delhi, India: psychological and social risk factors

OBJECTIVE

Suicide is major public health problem in India. The objective of the analyses presented in this paper is to examine depressive and anxiety symptoms and socio-demographic indicators as correlates of suicidal ideation and attempts among people who inject drugs (PWID), a high-risk group for suicide.

METHOD

We analysed data collected in April-May of 2012 from a community-based sample of 420 PWID in Delhi using time location sampling. Self-report symptom scales were used to measure the severity of symptoms of depression (PHQ-9) and anxiety (GAD-2) within the preceding 2 weeks. We assessed the presence of suicidal thoughts within the past 12 months.

RESULTS

Depressive and anxiety symptoms were associated with suicidal ideation, as were a range of social stressors including poor physical health, length of injecting drug use, housing insecurity, and experiences of violence and sexual abuse. However, depressive and anxiety symptoms were not associated with suicide attempts. Factors associated with suicide attempts among ideators were housing insecurity and relational dynamics including a poor relationship with family and, interestingly, being married.

CONCLUSION

Suicide prevention interventions among this population should address not only individual mental health and addiction support needs but also the overwhelmingly poor psychosocial circumstances of this group.

Influence of psychiatric diagnosis on treatment uptake and interferon side effects in patients with hepatitis C

BACKGROUND AND AIM

Pegylated-interferon-α/ribavirin (PEG-IFN/RBV) treatment can cure hepatitis C virus (HCV) infection but has frequent neuropsychiatric side-effects. Patients with pre-existing psychiatric illness may not be offered therapy. We established prevalence of self-reported psychiatric comorbidity among HCV-infected patients in a hospital-liver clinic, and determined the impact of such diagnoses on uptake and tolerance to PEG-IFN/RBV.

METHODS

All HCV cases referred for assessment in Australian Capital Territory/surrounding regions April 2004-March 2012 were entered into a clinical database. We conducted univariate and multivariate analyses of variables correlating with uptake of antiviral therapy and frequency of treatment-related side-effects.

RESULTS

Of 773 referred patients, 235 (30%) described pre-existing psychiatric illness. Among these, 26% received antiviral therapy, compared with 30% of 538 without psychiatric comorbidity. History of depression (usually validated by liaison psychiatry) was associated with higher incidence of treatment-related neuropsychiatric side-effects (odds ratio 2.79 [1.35-5.70], P < 0.05) but did not affect treatment outcome. Twenty-seven patients reported schizophrenia: three (11%) received antiviral therapy, compared with 30% admitting depression and 20% with bipolar affective disorder (all assessed by psychiatrist). In most schizophrenia cases, the reason for not offering antiviral treatment was psychological illness, yet none of five treated (these three plus two others in a psychiatric rehabilitation facility) experienced worsening psychiatric symptoms.

CONCLUSIONS

A history of depression is common with hepatitis C but does not affect initiation of antiviral treatment, despite substantially increased risk of psychiatric side-effects. In contrast, pre-existing schizophrenia appears to influence treatment decisions, despite little evidence that PEG-IFN/RBV exacerbates the psychiatric condition, and well-supervised antiviral therapy can have good outcomes.

Association of depression, anxiety, and suicidal ideation with high-risk behaviors among men who inject drugs in Delhi, India

BACKGROUND

Sharing of needles and syringes and unprotected sex remain a common practice among people who inject drugs (PWID) in India and are important drivers of new HIV infections. Whether engagement in risk behaviors among PWID is associated with symptoms of common mental disorders in India is unknown.

METHODS

We analyzed the data collected in April and May of 2012 from a community-based sample of 420 PWID in Delhi using time location sampling. Self-report symptom scales were used to measure the severity of symptoms of depression (Patient Health Questionnaire 9) and anxiety (Generalized Anxiety Disorder scale 2) within the preceding 2 weeks. We assessed the presence of suicidal thoughts within the past 12 months.

RESULTS

PWID with severe depressive symptoms and those with suicidal thoughts were 4 and 2 times more likely to share needles/syringes, respectively. PWID experiencing suicidal thoughts had 82% more female sexual partners and were 5 times more likely to have had unprotected sex at last sex with a paid female partner. Conversely, symptoms of anxiety were associated with a 30% decrease in the likelihood of needle/syringe sharing and a 70% decrease in the likelihood of unprotected sex at last sex with a paid female partner.

CONCLUSIONS

We found a high prevalence of symptoms of depression, anxiety, and suicidal ideation among men who inject drugs in Delhi and that depression and suicidal ideation are independently positively associated with HIV risk behaviors, whereas anxiety is associated with a reduction in such behaviors. Ameliorating mental health problems among PWID in India may aid in reducing HIV infections.

Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers

Background

People who inject drugs (PWID) often encounter barriers when attempting to access health care and social services. In our previous study conducted to identify barriers to accessing care from the perspective of PWIDs in Saskatoon, Canada: poverty, lack of personal support, discrimination, and poor knowledge and coordination of service providers among other key barriers were identified. The purpose of the present investigation was to explore what service providers perceive to be the greatest barriers for PWIDs to receive optimal care. This study is an exploratory investigation with a purpose to enrich the literature and to guide community action.

Methods

Data were collected through focus groups with service providers in Saskatoon. Four focus groups were held with a total of 27 service providers. Data were transcribed and qualitative analysis was performed. As a result, concepts were identified and combined into major themes.

Results

Four barriers to care were identified by service providers: inefficient use of resources, stigma and discrimination, inadequate education and the unique and demanding nature of PWIDs. Participants also identified many successful services.

Conclusion

The results from this investigation suggest poor utilization of resources, lack of continuing education of health care providers on addictions and coping skills with such demanding population, and social stigma and disparity. We recommend improvements in resource utilization through, for example, case management. In addition, sensitivity training and more comprehensive service centers designed to meet PWID’s complex needs may improve care. However, community-wide commitment to addressing injection drug issues will also be required for lasting solutions.

Opportunities, threats and limitations of neuroscience data in forensic psychiatric evaluation

PURPOSE OF REVIEW

In the last decade, a number of studies have been published to shed light on the interaction between neuroscience and the law, notably on the introduction of neuroscience data in forensic psychiatric evaluation (FPE). Even if there is a growing consensus on the relevance of neuroscience in clinical practice, the role of neuroscience in FPE is still controversial.

RECENT FINDINGS

The use of neuroscience data in FPE can support the detection of psychopathological disabilities (e.g. deficit of self-control, aggressiveness) that may be involved in criminal action. Traumatic brain injury-related clinical disorders that may lead to misconduct have a relevant role in the debate. Traditionally, literature refers also to rare and weird cases in which brain tumours, infections and morphological abnormalities were supposed to be significantly associated with disorders leading to criminal action.

SUMMARY

After reviewing recent literature from both legal and neuroscientific perspectives, we consider a broader range of clinical conditions (e.g. disorders of consciousness in sleepwalking, dopamine replacement therapy in Parkinson's disease, misattributions of self in delusional experience) that may have implications in legal settings. Obviously, it would be possible to consider also different clinical conditions. We conclude by suggesting further experimental and theoretical analysis.

Quality of life, depression, anxiety and suicidal ideation among men who inject drugs in Delhi, India

BACKGROUND

Mental disorders such as depression, anxiety and suicide represent an important public health problem in India. Elsewhere in the world a high prevalence of symptoms of common mental disorders have been found among people who inject drugs (PWID). Research in India has largely overlooked symptoms of common mental disorders among this high risk group. This paper reports on the results of a survey examining quality of life, depression, anxiety and suicidal ideation among adult males who inject drugs living in Delhi.

METHODS

Participants (n = 420) were recruited from needle and syringe programs using time location sampling and were interviewed using an interviewer-administered questionnaire. Self-report symptom scales were used to measure the severity of symptoms of depression (PHQ-9) and anxiety (GAD-2) within the preceding 2 weeks. We assessed the presence of suicidal thoughts and attempts within the past 12 months.

RESULTS

The mean length of injecting career was 20.9 years indicating a sample of chronic injecting drug users, of whom only one-third (38%) were born in Delhi. The level of illiteracy was very high (62%), and just 2% had completed class 12. Scavenging / rag picking was the main form of income for 48%, and many were homeless (69%). One-third (33%) had been beaten up at least twice during the preceding 6 months, and many either never (45%) or rarely (27%) attended family events. We found a high prevalence of depressive (84%, cut-off ≥10) and anxiety (71%, cut-off score of ≥3) symptoms. Fifty-three percent thought about killing themselves in the past 12 months, and 36% had attempted to kill themselves.

CONCLUSIONS

Our findings revealed a socially excluded population of PWID in Delhi who have minimal education and are often homeless, leaving them vulnerable to physical violence, poverty, poor health, imprisonment and disconnection from family. The high prevalence of psychological distress found in this study has implications for programmes seeking to engage, treat and rehabilitate PWID in India.

Why the Treatment of Mental Disorders Is an Important Component of HIV Prevention among People Who Inject Drugs

People who inject drugs are more likely to be HIV positive and to have a mental disorder than the general population. We explore how the detection and treatment of mental illness among people who are injecting drugs are essential to primary and secondary prevention of HIV infection in this population. Aside from opioid addiction, few studies have been conducted on the links between mental disorders and injection-drug use. However, independent of the injection-drug use literature, a growing number of studies demonstrate that untreated mental illness, especially depression and alcohol/substance use disorders, is associated with HIV-related risk behaviors, acquiring HIV infection, failure to access HIV care and treatment, failure to adhere to HIV care and treatment, and increased morbidity and mortality from HIV-related diseases and comorbidities. In our review of both the published literature and gray literature we found a dearth of information on models for providing care for both opioid addiction and other mental illnesses regardless of HIV status, particularly in low- and middle-income countries. We therefore make recommendations on how to address the mental health needs of HIV-positive people who inject drugs, which include the provision of opioid substitution therapy and integrated mental health, substance abuse, and HIV services.