1. 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

2. Outline Background and introduction Co-occurring mental disorders in 1002 heroin-dependent patients Impact factors of co-occurring mental disorders in heroin-dependent patients

3. Addictive Disorders Mental Disorders Addictive Disorders often Co-Exist with Mental Disorders Background

4. 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. 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

6. High 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. 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. 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

9. 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

10. 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

11. 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

12. Lifetime prevalent rates of axis I mental disorders * P < 0.05, ** P < 0.01, male-female comparison ** With 6.0% having two or more lifetime comorbidities. ** Results

13. Present prevalent rates of axis I mental disorders With 3.6% having two or more present comorbidities. Results

14. Prevalent rates of personality disorders * P < 0.05, ** P < 0.01, male-female comparison ** * * * * With 29.9% having two or more present comorbidities. Results

15. 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. 16 Bivariate analyses for related factors of mood disorder (cont.) Childhood adversity, % Chronic physical disease, % 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. 17 Being depressed, worried, or in pain, % No 1.88 (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. 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. 19 2.17 (1.50-3.12) 3.37E-51 0.781=without 2=withCluster 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=yes Being 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. 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 1 Female Gender, % OR (95%CI) Variables Results

21. 21 1.69 (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. 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. 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 -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. 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. 25 Multi-variate analysis for co-occurring Cluster B personality disorder Pin=0.05 ， Pout=0.10 Other substance use disorder A family history of mental disorders 2.40 (1.60-3.60)2.20E-51 0.881=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-410.56 1=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 use 1=‘≤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 0.0012.25 (1.42-3.57) Compulsive times 0.25 0.0181.28 (1.04-1.57) 1 0.022 2.16 (1.12-4.19) 1=without 2=with 0.59 1.44E-41.80 (1.33-2.43) 1 Results

26. 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. 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