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Wei Hao, MD.
Mental Health Institute
WHO Collaborating Center for Drug Abuse and Health
Central South University
Prevalence Rates and Related Factors of Co-occurring Mental Disorders in Heroin-dependent Patients
Outline
• Background and introduction • Co-occurring mental disorders in
1002 heroin-dependent patients• Impact factors of co-occurring
mental disorders in heroin-dependent patients
Addictive Disorders
Mental Disorders
Addictive Disordersoften Co-Exist withMental Disorders
Background
Co-occurring Disorders (COD)
• COD is a more accurate term– A substance use disorder and an independent
mental disorder co-occurring in one person.
• What are independent disorders– In DSM-IV, independent mental disorders requires
that psychiatric symptoms of these disorders are not direct result of substance use or general medical conditions.
CSAT, A Treatment improvement protocol-42: 2005.
Background
5
COD among clinical populations
• Estimates of psychiatric co-morbidity rates among clinical populations in substance abuse treatment settings are 25 -70%.
• Estimates of substance use co-morbidity rates among clinical populations in mental health treatment settings are 20-50%.
* Differences in incidence due to: nature of population served (e.g.: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).
CSAT, DHHS, TIP 42, 2005.
Background
BackgroundHigh prevalence of drug use disorder among individuals with
mood and anxiety disorders, in the NESARC
Conway KP et al., J Clin Psychiatry, 2006.
Any Drug Opioids Amphetamines Cocaine Marijuana
Any anxiety disorder
Any mood disorder
All respondents
7
Higher prevalence of mental disorders among patients with drug use disorders, in the NESARC
Conway KP et al., J Clin Psychiatry, 2006.
Anxiety DisordersMood Disorders
Background
8
Impact of COD
• Impaired treatment success, more relapse, higher cost.
• Increased likelihood of committing offence and suicide.
• Increased rates of homelessness and insecure housing.
• Increased risk of HIV infection.
• Family problems or problems with intimate relationships
• Isolation and social withdrawal.
• Greater levels of unemployment.
• Increased risk of poverty.
Drake et al., 1989; Kamail et al., 2000 Linazen et al.,1994; Mc Crone et al., 2000; Scott et al,1998.
Background
What’s the problem?
• Most of the evidence concerning COD comes from the United States and European countries.
• Big disparities exist in region, race/ethnicity, social environment and drug variety.
• Information in the field of COD in Asian populations is astonishingly rare.
• Heroin is the most dominative drug used in China.
Background
• Design Cross-sectional study, face-to-face individual interview.
• Setting Voluntary and compulsory drug rehabilitation centers.
• Participants 1,002 heroin-dependent patients, consecutively.
• Instruments Self-designed questionnaire; SCID-I; SCID-II.
Method
Method
Demographic characteristics
0.64 ± 0.56Daily dose of heroin use before admission (g·d-1) , M ± SD
840 (83.8) Intravenous injection, n (%)
6 ( 0.6) Intramuscular injection, n (%)
156 (15.6) Inhalation, n (%)
Heroin use route
10.1 ± 4.8Years of chronic heroin use, M ± SD
33.0 ± 6.8 *Age , M ± SD
301 (30.0) Female, n (%)
701 (70.0) Male, n (%)
Gender
Subjects (N=1002)Variable
* P < 0.05, male-female comparison
Results
Lifetime prevalent rates of axis I mental
disorders
* P < 0.05, ** P < 0.01, male-female comparison
27.4
18.8
12.9
4.6
10.6
5.1
34.9
19.6
14.6
4.0
17.9
15.0
29.6
19.1
13.5
4.4
12.8
8.1
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Any axisⅠmental
Any mood Majordepression
Dysthymia Any anxiety PTSD
Male Female Total
** With 6.0% having two or more lifetime comorbidities.
** **
Results
Present prevalent rates of axis I mental
disorders
12.6
7.8
4.6
7.0
1.4
19.9
13.3
9.0
4.04.7
1.7
19.5
12.8
8.2
4.4
6.3
1.5
19.3
0.0
5.0
10.0
15.0
20.0
25.0
Any axisⅠmental
Any mood Majordepression
Dysthymia Any anxiety PTSD
Male Female Total
With 3.6% having two or more present comorbidities.
Results
Prevalent rates of personality disorders
* P < 0.05, ** P < 0.01, male-female comparison
Any axis
II
Any B
Antisocia
l
Borderli
ne
Any C
Avoidant
Any A
Paranoid
Passive
Depressio
n0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
67.6
60.2
51.8
23.3
16.312.4 11.7
9.812.0
7.3
39.9
30.2
15.0
20.9
10.37.3 6.3 5.6
7.35.6
59.3
51.2
40.7
22.6
14.510.9 10.1 8.6
10.66.8
Male Female Total
****
**
* * ** * *
With 29.9% having two or more present comorbidities.
Results
15
Bivariate analyses for related factors of mood disorder
0.96 (0.40-2.30) ≥46
0.85 (0.42-1.71) 41-45
1.02 (0.59-1.76) 36-40
1.03 (0.61-1.74) 31-35
1.20 (0.71-2.03) 26-30
1 ≤ 25
Age, %
0.95 (0.68-1.34)Male
1Female
OR (95%CI)Variables
Gender, %
Results
16
Bivariate analyses for related factors of mood disorder (cont.)
Childhood adversity, %
Chronic physicaldisease, %
Marital state, %
1.58 (1.11-2.25) * With
1 Without
1.90 (1.36-2.66) *** With
1 Without
1.37 (0.93-2.01) Unmarried
1.65 (1.06-2.59)* Divorced or widowed
1 Married or cohabit
OR (95%CI)Variables
* P < 0.05, ** P < 0.01, *** P < 0.001
Results
17
Being depressed, worried, or in pain, %
No1.88 (1.26-2.82)*** Yes
1
OR (95%CI)Variables
Bivariate analyses for related factors of mood disorder (Cont.)
Motivation for first time use of heroin
Being curious, or fashion pursuit, %
0.62 (0.44-0.87)**1
Feeling bad, %
Yes
No
Feeling for heroin first use
1.61 (1.16-2.24) **
1
Yes
No
* P < 0.05, ** P < 0.01, *** P < 0.001
Results
18
OR (95%CI)Variables
Bivariate analyses for related factors of mood disorder (Cont.)
Severity of withdrawal§, M ± SD 1.35 (1.08-1.68) **
Compulsive rehab times, %
3.17 (1.27-7.88)* ≥6 2.33 (1.02-5.28)* 3-5 1.82 (0.80-4.12) 1-2
1 0
2.03 (1.17-3.55)* With
1 Without
Family history of mental disorders, %
Other substance use dis., %
Cluster B personality dis., %
2.21 (1.56-3.12)***
2.31 (1.66-3.22)***
* P < 0.05, ** P < 0.01, *** P < 0.001
Results
19
2.17 (1.50-3.12)3.37E-51 0.781=without 2=with Cluster B personality dis.
1.82 (1.27-2.62)0.0011 0.601=wihout 2=withOther substance use disorders
1.26 (1.01-1.58)0.04210.231=‘0’ 2=‘1-2’ 3=‘3-5’ 4=‘≥6’
Compulsive rehab times
1.99 (1.38-2.85)1.93E-410.691=no 2=yesChronic physical disease
1.57 (1.12-2.21)0.00910.451=no 2=yesFeeling bad from first heroin use
2.96 (1.73-5.08)7.87E-511.091=no 2=yesBeing depressed, worried, or in pain &
Adjusted OR(95%CI)
PdfB Value Variables
Multi-variate analysis for co-occurring mood disorder
Pin=0.05 , Pout=0.10 & Motivation for first time use of heroin
Results
20
Bivariate analyses for related factors of Cluster B personality disorder
0.41 (0.17-0.96) * ≥University
0.61 (0.42-0.90) * high school
0.87 (0.63-1.21) Junior high school
1 ≤Primary school
Education, %
0.27 (0.13-0.54) *** ≥46
0.35 (0.21-0.60) *** 41-45
0.52 (0.33-0.80) ** 36-40
0.59 (0.39-0.90) * 31-35
0.55 (0.36-0.84) ** 26-30
1 ≤ 25
Age, %
3.49 (2.62-4.66) ***Male
1Female
Gender, %
OR (95%CI) Variables
Results
211.69 (1.25-2.28) *** Without
1 With
Childhood adversity, %
1.12 (0.75-1.65) ≥100000
0.78 (0.57-1.07) 30000-99999
0.69 (0.48-0.98) * 10000-29999
1 0-9999
Personal annual income ( ¥ ), %
1.96 (1.52-2.55) *** Unemployed or in illegal work
1 Employed
Employment
1.73 (1.30-2.31) *** Never married
0.92 (0.65-1.31) Divorced or widowed
1 Married or cohabit
Marriage, %
Bivariate analyses for related factors of Cluster B personality disorder (Cont.)
OR (95%CI) Variables
Results
22
0.53 (0.32-0.83) * Yes
1 No
Being depressed, worried, or in pain, %
1.37 (1.03-1.83) * Yes
1 No
Being curious, or fashion pursuit, %
Motivation for first time use of heroin
0.16 (0.07-0.43) *** ≥36
0.16 (0.07-0.37) *** 31-35
0.28 (0.13-0.60) *** 26-30
0.35 (0.17-0.73) ** 21-25
0.62 (0.30-1.28) 16-20
1 ≤ 15
Age of first use of heroin, %
OR (95%CI)Variables
Bivariate analyses for related factors of Cluster B personality disorder (Cont.)
Results
23
Bivariate analyses for related factors of Cluster B personality disorder (Cont.)
2.32 (1.62-3.32) *** Intravenous injection
1.95 (0.38-9.96) Intramuscular injection
1 Chasing
Use route before admission, %
2.49 (1.68-3.69) *** >2.00
2.35 (1.54-3.59) *** -2.00
2.19 (1.39-3.43) ** -1.50
1.64 (1.17-2.29) ** -1.00
1 -0.50
The highest day dose ever (g·d - 1), %
1.78 (1.17-2.71) ** >15.00
1.72 (1.20-2.48) ** -15.00
1.65 (1.15-2.39) ** -10.00
1 -5.00
Years of chronic heroin use, %
OR (95%CI)Variables
Results
24
2.44 (1.88-3.15) *** Any other substance use disorder
2.31 (1.66-3.22) *** Any mood disorder
2.04 (1.19-3.49) ** A family history of mental disorders
1.37 (1.05-1.78) * A family history of alcohol use disorder
2.60 (1.36-4.95) ** ≥6
1.90 (1.13-3.21) * 3-5
1.19 (0.71-1.99) 1-2
1 0
Compulsive rehab times, %
3.49 (1.33-5.23) *** 3-4
1 0-2
Severity of withdrawal symptoms§, %
OR (95%CI)Variables
Bivariate analyses for related factors of Cluster B personality disorder (Cont.)
Results
25
Multi-variate analysis for co-occurring Cluster B personality disorder
Pin=0.05 , Pout=0.10
Other substance use disorder
A family history ofmental disorders
2.40 (1.60-3.60) 2.20E-51 0.88 1=without 2=with
1 0.77 1=wihout 2=with
1
1=‘0’ 2=‘1-2’ 3=‘3-5’ 4=‘≥6’
1.83 (1.26-2.67) 0.0021 0.611=without 2=with
1.75 (1.29-2.37) 3.14E-410.561=employed 2=unemployed..
5.28 (3.64-7.64) 1.27E-1811.661=female 2=male
Adjusted OR (95%CI)PdfBValue
Mood disorder
Severity of withdrawal symptoms
Childhood adversity
Employment
Gender
Variables
Age onset of use1=‘≤15’ 2=‘16-20’ 3=‘21-25’ 4=‘26-30’ 5=‘31-35’ 6=‘≥36’
-0.42 1 1.82E-9 0.67 (0.57-0.75)
1=‘0-2’ 2=‘3-4’ 0.81 0.001 2.25 (1.42-3.57)
Compulsive times0.25 0.018 1.28 (1.04-1.57) 1
0.022 2.16 (1.12-4.19)
1=without 2=with 0.59 1.44E-4 1.80 (1.33-2.43) 1
Results
26
Co-occurring mental disorders among heroin-dependent patients in China are highly prevalent, should be address in clinical practice.
The co-occurrence of mood disorders, Cluster B personality disorders are main co-occuring mental disorders..
Chronic physical diseases related to co-occuring mood disorders were often induced from chronic drug use.
A family history of mental disorders, childhood adversity, and an adverse social-economic status are independent predictors for co-occurring Cluster B personality disorders.
Patients co-occurred with Cluster B personality disorders are more severe in addiction and begin to use heroin on an earlier age.
27
Acknowledgements
2009CB522007 to Wei Hao
20111483 to Wei Hao
The Voluntary Drug Rehabilitation Center of Hunan Brain Hospital
Hunan Xinkaipu Compulsory Drug Rehabilitation Center
HunanBaimalong Compulsory Drug Rehabilitation Center
The STAFF