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