Incidence and predictors of mental health disorder diagnoses among people who inject drugs in a Canadian setting

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.

Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine

INTRODUCTION

Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months.

METHODS

A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months.

PRELIMINARY RESULTS

For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months.

CONCLUSION

This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.

Making community pharmacies psychologically informed environments (PIE): a feasibility study to improve engagement with people using drug services in Scotland

AIM

This developmental study tested the feasibility of training pharmacy staff on the psychologically informed environments (PIE) approach to improve the delivery of care.

BACKGROUND

Community pharmacies provide key services to people who use drugs (PWUD) through needle exchange services, medication-assisted treatment and naloxone distribution. PWUD often have trauma backgrounds, and an approach that has been demonstrated to work well in the homeless sector is PIEs.

METHODS

Bespoke training was provided by clinical psychologists and assessed by questionnaire. Staff interviews explored changes made following PIE training to adapt the delivery of care. Changes in attitude of staff following training were assessed by questionnaire. Peer researchers interviewed patient/client on observed changes and experiences in participating pharmacies. Staff interviews were conducted six months after training to determine what changes, if any, staff had implemented. Normalisation process theory (NPT) provided a framework for assessing change.

FINDINGS

Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rated training structure and delivery as 'very good' or 'excellent'. There was no statistically significant change in attitudes. COVID-19 lockdowns restricted follow-up data collection. Staff interviews revealed training had encouraged staff to reflect on their practice and communication and consider potentially discriminatory practice. PIE informed communication skills were applied to manage COVID-19 changes. Staff across pharmacies noted mental health challenges for patients. Five patients were interviewed but COVID-19 delays in data collection meant changes in delivery of care were difficult to recall. However, they did reflect on interactions with pharmacy staff generally. Across staff and patient interviews, there was possible conflation of practice changes due to COVID-19 and the training. However, the study found that training pharmacy teams in PIE was feasible, well received, and further development is recommended. There was evidence of the four NPT domains to support change (coherence, cognitive participation, collective action and reflexive monitoring).

Medical Complications of Injection Drug Use - Part II

Medical Complications of Injection Drug Use - Part IIDuring the past 2 decades, the risk of death, as well as the prevalence of hospitalizations in the United States, has increased substantially among people who inject drugs, mainly because of the opioid epidemic. In Part Two of this two-part review, the authors review complications observed in people who inject drugs and strategies to reduce harm.

Improving Harm Reduction Services: A Qualitative Study on the Perspectives of Highly Marginalized Persons Who Inject Drugs in Montreal

Harm reduction (HR) is an alternative to the moralization of drug use and a pragmatic public health approach aimed at minimizing harms associated with use. This study sought to gain the perspectives of persons who inject drugs (PWID) on the adequacy of services provided by HR organizations in Montreal. Twenty-two semi-structured interviews and two focus groups were conducted with 30 participants. Some of the key advantages of HR perceived by participants include access to injection equipment, psychosocial support, and reduced social isolation. However, many wanted more opportunities for social insertion and greater value to be placed on their knowledge and life experiences (e.g., experiential knowledge of the street scene, drug use, sex work, or homelessness). This study suggests that PWID who access HR services in Montreal are interested in paid work opportunities in environments that promote power sharing, and activities that are conducted and managed by and for them.

Periods of Homelessness Linked to Higher VACS Index Among HIV-Positive People Who Use Drugs

We sought to evaluate the impact of homelessness on HIV disease progression among people who use unregulated drugs (PWUD) living with HIV and test if this association was mediated by adherence to antiretroviral therapy (ART). We applied general linear mixed-effects modeling to estimate the longitudinal relationship between homelessness and the Veterans Aging Cohort Study (VACS) Index, a validated measure of HIV disease progression that predicts all-cause mortality, among a prospective cohort of PWUD. In a longitudinal model adjusted for ART adherence, homelessness was significantly associated with increased VACS Index scores and 16% of the association was mediated by ART adherence. These findings indicate that homelessness was a significant risk factor for HIV disease progression and this association was marginally mediated by ART adherence. Future studies are needed to quantify the other mechanisms (e.g., food insecurity, mental health) by which homelessness increases mortality risk among PWUD living with HIV.

Association of co-occurring mental health problems with hepatitis C status among young people who inject drugs in rural New Mexico, 2016-2018

BACKGROUND

Injection drug use (IDU) remains the strongest risk factor for hepatitis C virus (HCV) in the United States. HCV rates are increasing in rural areas among young adult people who inject drugs (PWID). People with HCV and PWID have disproportionate rates of mental health problems; however, it is unclear whether risky injection behaviors mediate the association between mental health problems and HCV. We examined the association between mental health problems and HCV in a rural cohort of young adult PWID, with the goal of informing rural service delivery.

METHODS

We conducted a secondary analysis of cross-sectional data from a convenience sample of young adult PWID in 2 rural counties in New Mexico. Participants were recruited from 2 community venues between September 2016 and May 2018. Associations between mental health problems and HCV were examined using bivariate (Fisher's exact) and multivariable modified Poisson regression analyses (with robust standard errors). Using structural equation modeling (SEM), we assessed duration of IDU and receptive syringe sharing (RSS) as mediators of this relationship.

RESULTS

A total of 263 patients were enrolled, with a median age of 26.1 years. The majority were male (66.3%) and Hispanic/Latino (a) (87.6%). The median age first injected was 19 years, and over half reported having ever engaged in RSS (53.4%). At least one mental health problem was reported by 60.1% of participants, with post-traumatic stress disorder (PTSD) being the most prevalent condition (42.2%). A majority (60.9%) tested positive for HCV antibody, and just under half (45.7%) of all participants tested positive for HCV ribonucleic acid. In SEM, PTSD had a significant total effect on HCV (τ = 0.230, P = 0.05), and this relationship was partially mediated by duration of IDU (αβ = 0.077, P = 0.03). The association between mental health problems and HCV was partially mediated by duration of IDU and the sequential mediation of duration of IDU and RSS (αβ + αββ = 0.091, P = 0.05).

CONCLUSIONS

High HCV rates among young adult PWID in rural New Mexico may be partly explained by mental health problems, duration of IDU and RSS. Mental health services for young adult PWID in rural areas may help decrease HCV transmission in rural areas. Trial Registration N/A.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

Prevalence and predictors of recent temporary psychiatric hold among a cohort of people who inject drugs in Los Angeles and San Francisco, California

California's Welfare and Institutions code 5150 allows for a temporary psychiatric hold (TPH) of individuals who present a danger to themselves or others and/or may be gravely disabled due to mental illness. Little is known about the frequency and predictors of involuntary holds among people who inject drugs (PWID).

METHODS

We sought to identify the prevalence and predictors of recent TPHs (within the past 12 months) among a community-recruited sample of PWID in Los Angeles and San Francisco, California during 2017-2018 (N = 531). Multivariable logistic regression modeling was used to evaluate demographic (e.g., age), economic (e.g., homelessness), drug use (e.g., types of drugs used), incarceration (e.g., recent arrest history) and mental health (e.g., lifetime mental health diagnosis) variables associated with recent TPH.

RESULTS

Age (40-49 years old vs age 50 or older: AOR = 5.85; 95 % CI = 2.18, 15.67), current homelessness (AOR = 3.75; 95 % CI = 1.28, 11.0), lifetime mental health history (AOR = 6.23; 95 % CI = 2.08, 18.66), and frequency of methamphetamine use (AOR = 1.01; 95 % CI = 1.00, 1.01) were statistically associated with increased odds of having experienced a TPH, while frequency of past month heroin/opioid use was associated with decreased odds of reporting a TPH (AOR = 0.99; 95 % CI = 0.99, 1.00) in multivariable analysis.

CONCLUSIONS

Diverse factors were associated with TPH among PWID. Our analysis underscores the need for research on PWID with co-occurring substance-use and mental illness disorders and homelessness. There is urgent need for expanding access to lower barrier publicly funded mental health treatment from a harm-reduction approach.

Healthcare stigma and HIV risk among rural people who inject drugs

INTRODUCTION

The HIV epidemic is increasingly penetrating rural areas of the U.S. due to evolving epidemics of injection drug use. Many rural areas experience deficits in availability of HIV prevention, testing and harm reduction services, and confront significant stigma that inhibits care seeking. This paper examines enacted stigma in healthcare settings among rural people who inject drugs (PWID) and explores associations of stigma with continuing high-risk behaviors for HIV.

METHODS

PWID participants (n = 324) were recruited into the study in three county health department syringe service programs (SSPs), as well as in local community-based organizations. Trained interviewers completed a standardized baseline interview lasting approximately 40 min. Bivariate logistic regression models examined the associations between enacted healthcare stigma, health conditions, and injection risk behaviors, and a mediation analysis was conducted.

RESULTS

Stigmatizing health conditions were common in this sample of PWID, and 201 (62.0 %) reported experiencing stigma from healthcare providers. Injection risk behaviors were uniformly associated with higher odds of enacted healthcare stigma, including sharing injection equipment at most recent injection (OR = 2.76; CI 1.55, 4.91), and lifetime receptive needle sharing (OR = 2.27; CI 1.42, 3.63). Enacted healthcare stigma partially mediated the relationship between having a stigmatizing health condition and engagement in high-risk injection behaviors.

DISCUSSION

Rural PWID are vulnerable to stigma in healthcare settings, which contributes to high-risk injection behaviors for HIV. These findings have critical public health implications, including the importance of tailored interventions to decrease enacted stigma in care settings, and structural changes to expand the provision of healthcare services within SSP settings.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use

BACKGROUND

Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI).

METHODS

People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years.

RESULTS

Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI.

CONCLUSIONS

Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

Frequent Cannabis Use Is Negatively Associated with Frequency of Injection Drug Use Among People Who Inject Drugs in a Canadian Setting

Objectives: High levels of morbidity and mortality associated with injection drug use continue to represent a significant public health challenge in many settings worldwide. Previous studies have shown an association between cannabis use and decreased risk of some drug-related harms. We sought to evaluate the association between high-intensity cannabis use and the frequency of injection drug use among people who inject drugs (PWID). Methods: The data for this analysis were collected from three prospective cohorts of PWID in Vancouver, Canada, between September 2005 and May 2018. Generalized linear mixed-effects models were used to analyze the association between daily cannabis use and the frequency of injecting illegal drugs (i.e., self-reported average number of injections per month). Results: Among the 2,619 active PWID, the frequency of injection drug use was significantly lower among people who use cannabis daily compared with people who use it less than daily (adjusted odds ratio [AOR]=0.84, 95% confidence interval [CI]: 0.73-0.95). Sub-analyses indicated that this effect was restricted to the frequency of illegal opioid injection (AOR=0.78, 95% CI: 0.68-0.90); the association between daily cannabis use and the frequency of illegal stimulant injection was not significant (AOR=1.08, 95% CI 0.93-1.25). Discussion: The findings from these prospective cohorts suggest that people who use cannabis daily were less likely to report daily injection of illegal drugs compared with people who use it less than daily. These results suggest the potential value of conducting experimental research to test whether controlled administration of cannabinoids impacts the frequency of illegal opioid injection among PWID.

Toxic Nightlife Relationships, Substance Abuse, and Mental Health: Is There a Link? A Qualitative Case Study of Two Patients

Introduction and Aims: This article explores the role of toxic close relationships in night life on substance use disorders and mental health conditions. We also contrast the quality and effects of social relationships when doing drugs with those produced by a mental health program that fosters quality relationships between patients. Design and Methods: This qualitative case study was carried out at a mental health day care center of a hospital in Malaga (Spain). The cases of two patients with severe mental disorders and a history of drug addiction were analyzed. Data were collected through in-depth interviews with every patient, semi-structured interviews about each patient with the psychologist of the medical team of the program, and medical documentation. The analysis involved a combination of inductive and deductive approaches. Results: The analysis of the data revealed, on the one hand, the influence of toxic relationships in nightlife, including violent sporadic sexual relationships, in the initiation and persistence of substance use that took part of the mental health disorder in these patients. On the other hand, the findings show that these participants' current involvement in a mental health program, which fosters quality relationships between patients, has brought emotional benefits to both of them. Discussion and Conclusion: This paper points out the relevance of considering quality of social relationships when examining substance use disorders and related mental health problems. Additionally, the findings indicate the importance of fostering quality peer relationships in mental health rehabilitation programs addressed to patients with histories of drug addiction to improve treatment outcome.

Brief Report: Reduced Use of Illicit Substances, Even Without Abstinence, Is Associated With Improved Depressive Symptoms Among People Living With HIV

PURPOSE

Substance use is linked with poor outcomes among people living with HIV (PLWH) and is associated with mental health disorders. This analysis examines the impact of decreasing substance use, even without abstinence, on depressive symptoms among PLWH.

METHODS

Data are from PLWH enrolled in the Centers for AIDS Research Network of Integrated Clinical Sites cohort. Participants completed longitudinal assessments of substance use (modified ASSIST) and depressive symptoms (PHQ-9). Changes in substance use frequency were categorized as abstinence, reduced use, and nondecreasing use. Adjusted linear mixed models with time-updated change in substance use frequency and depressive symptom scores were used to examine associations between changes in the use of individual substances and depressive symptoms. Analyses were repeated using joint longitudinal survival models to examine associations with a high (PHQ-9 ≥10) score.

RESULTS

Among 9905 PLWH, 728 used cocaine/crack, 1016 used amphetamine-type substances (ATS), 290 used illicit opiates, and 3277 used marijuana at baseline. Changes in ATS use were associated with the greatest improvements in depressive symptoms: stopping ATS led to a mean decrease of PHQ-9 by 2.2 points (95% CI: 1.8 to 2.7) and a 61% lower odds of PHQ-9 score ≥10 (95% CI: 0.30 to 0.52), and decreasing ATS use led to a mean decrease of 1.7 points (95% CI: 1.2 to 2.3) and a 62% lower odds of PHQ-9 score ≥10 (95% CI: 0.25 to 0.56). Stopping and reducing marijuana and stopping cocaine/crack use were also associated with improvement in depressive symptoms.

CONCLUSIONS

We demonstrated that both substance use reduction and abstinence are associated with improvements in depressive symptoms over time.

Association between mental health service utilisation and sharing of injection material among people who inject drugs in Montreal, Canada

BACKGROUND

High-risk injection behaviors are associated with high prevalence of mental health problems among people who inject drugs (PWID). However, whether the use of mental health services is associated with lower risk of sharing injection material remains undetermined. This study aims to examine the association between mental health service utilisation and receptive sharing risk, and determine the potential modifying effect of psychological distress on this association.

METHODS

Participants answered an interviewer-administered questionnaire at 3-month intervals gathering information on sociodemographic characteristics, substance use and related behaviors, services utilisation and significant mental health markers. Relationship between the use of mental health services and receptive sharing was modeled using the generalized estimating equation (GEE), controlling for age at baseline, gender, and other potential confounders. Psychological distress was estimated using the Kessler Psychological Distress Scale (K10). Effect modification was investigated by adding an interaction term in the univariate GEE analysis.

RESULTS

358 participants contributed to 2537 visits (median age 40.3, 82% male). Mental health service utilisation was reported in 631 visits (25%), receptive sharing in 321 visits (13%) and severe psychological distress in 359 visits (14%). In multivariate GEE analyses, a significant association was identified between receptive sharing and the use of mental health services (aOR = 0.69; 95% CI = 0.50-0.94). We found no evidence of effect modification by psychological distress.

CONCLUSION

Among PWID, mental health service utilisation was associated with lower likelihood of receptive sharing, regardless of level of psychological distress. These findings should be taken into account when designing harm reduction strategies for this population.

Role of Patient Sex in Early Recovery from Alcohol-Related Cognitive Impairment: Women Penalized

BACKGROUND

The objective was to explore the role of patient sex in cognitive recovery and to identify predictive factors for non-recovery in alcohol use disorder (AUD).

METHODS

All patients with AUD admitted to a residential addictions treatment center were systematically assessed at admission and after 6 weeks of abstinence in a controlled environment. The inclusion criteria were that patients were admitted for AUD with baseline alcohol-related cognitive impairment (baseline total Montreal Cognitive Assessment (MoCA) score < 26) and reassessed at 6 weeks (n = 395). A logistic regression model was built to determine the influence of sex on recovery status (MoCA < or ≥ 26) taking into account the interaction effect of sex with alcohol consumption on cognitive function.

RESULTS

The mean age was 50.10 years (SD = 9.79), and 27.41% were women. At baseline, the mean MoCA scores were 21.36 (SD = 3.04). Participants who did not achieve recovery (59.3% of women vs 53.8% of men) had lower total MoCA scores at baseline. The 2 factors that was significantly and independently associated with non-recovery and with a non-zero coefficient was being a woman and initial MoCA score (respective adjusted odds ratios (AOR) = 1.5 and 0.96, p-values < 0.05).

CONCLUSIONS

These results could influence the time required in a controlled environment to maintain abstinence and the duration of in-care for women.