Abstract to symposium
Title: Psychiatric Disorders in Methadone Patients
Shelly Iskandar1,2, Arifah Nur Istiqomah1, Lucky Saputra1, Ike M. P. Siregar1, Teddy Hidayat1
1
Department of Psychiatry, Faculty of Medicine, Padjajaran University/ Hasan Sadikin Hospital, Bandung, Indonesia
2
Health Research Unit, Faculty of Medicine, Padjadjaran University/ Hasan Sadikin Hospital, Bandung, Indonesia
Background:
Psychiatric co-morbidities are common among patients with substance use disorders. Psychiatric disorders influence effectiveness of treatment programs and quality of life of the patients. However, data regarding co-occurrence of psychiatric disorders are lacking in low-middle income countries. We therefore determined the prevalence of psychiatric disorders among methadone patients in Indonesia and how this affected their quality of life.
Methods:
Data on psychiatric disorders and quality of life were collected in 112 injecting drug users attending methadone maintenance program in Bandung, West Java, Indonesia using Mini International Neuropsychiatric Interview (MINI) and the EuroQol-5D (EQ-5D). Results:
Psychiatric disorders in methadone patients were high. Therefore those who deliver addiction care also have to address psychiatric co-morbidity in order to have a better outcome.
Psychiatric Disorders in Methadone Patients
Background
In 2007, between 11.0 million and 21.2 million people worldwide were estimated to be injecting drug users (IDUs) and HIV prevalence among this group is high in many countries especially in Eastern Europe, South America, and East and Southeast Asia (Mathers, et al., 2010; UNAIDS, 2009).
One of the most used injecting substances is heroin. Heroin and other opioids are powerful drugs that can induce a sense of well-being, deliver a boost to self-esteem and increase tolerance to pain. People taking opioids, whether for recreational use or for a medical condition, may become dependent on these drugs (Connock, et al., 2007).
Drug substitution therapy, such as methadone or buprenorphine has shown its effectiveness in reducing injecting drug use, unsafe injection practices, unsafe sexual practices, and seroconversion rates for HIV (Berkman & Wechsberg, 2007; Mattick, Kimber, Breen, & Davoli, 2003, 2008) and systematic reviews show that methadone maintenance treatment is the most effective treatment in retaining patients in treatment and suppressing heroin use (Amato, et al., 2005).
psychiatric care have been found to be associated with improved treatment retention and lower relapse rates (Berkman & Wechsberg, 2007). On the other hand, treatment for addictive and mental disorders will lead to increase adherence to medical regimes, thus reducing the risk of the early emergence of treatment-resistant AIDS and tuberculosis (Willenbring, 2005).
It is hoped that improving integration of those different services will increase patient and provider satisfaction, improve access, engagement, retention, and adherence to treatment, and thus improve both proximal and distal outcomes. However, some researches and reviews showed that the integration of the services was not always effective. The integration of the program will be more effective if the problems are carefully define on the basis of information about patient population characteristics (Willenbring, 2005).
Methadone was established first in Indonesia in 2003 by WHO and the Ministry of Health in two pilot projects. The expansion of methadone really started in 2006. National Aids Committee plan to increase the number of drug users treated (Mesquita, et al., 2007). However, the coverage of the intervention programs remains very low: only 1% of the IDUs are covered by Methadone Maintenance Treatment (MMT) programs; and only 6% of the HIV-infected IDUs have received anti retroviral treatment (ART) (Mathers, et al., 2010).
Specific programs addressing the correlating problems will increase the
identify what supplementary services are the most needed. We therefore determined the prevalence of psychiatric disorders among methadone patients in Indonesia and how this affected their quality of life.
Methods
Participants
All IDUs enrolled in a hospital-based methadone maintenance treatment (MMT) program in Bandung, Indonesia from January 2008 until December 2010 were offered to participate in this study. Participation was voluntary, but the patients were repeatedly encouraged to take part. Each patient was informed that the personal results of the study would be included in further treatment planning. Participants who were agree to participate giving their informed consent before interview. Follow-up interview was conducted 6 months after the first interview.
The study was approved by the regional medical-ethical committee (The Health Research Ethics Committee Faculty of Medicine UNPAD- Dr. Hasan Sadikin General Hospital Bandung) and conducted within a program on prevention and treatment of HIV in the context of injecting drug use in Indonesia (Alisjahbana, et al., 2009).
Assessment
The interview was conducted by trained interviewers who assured all participants that their anonymity would be strictly maintained. Data was collected using Mini International Neuropsychiatric Interview (MINI), and EuroQol-5D (EQ-5D). Besides, laboratory results were retrieved from medical record.
symptomatology (Sheehan, et al., 1998). The questions are precise and carefully worded, requiring only ‘yes’ or ‘no’ answers, so reducing error in the interpretation of responses during the research interview. The MINI diagnostic framework allows for multiple mental disorders, and distinguishes current mental disorders from those arising at an earlier stage of the subject’s life (Bhui, et al., 2006). It is currently available in over 40 languages, including in Bahasa Indonesia.
The EuroQol-5D (EQ-5D) is a simple self-report instrument developed by an international and interdisciplinary group of researchers (EuroQol Group) to evaluate quality of life and applicable to a wide range of health conditions and treatments. The EQ-5D VAS (also known as EQ-5D Thermometer) is a visual scale, calibrated from 0 (worst imaginable health state) to 100 (best imaginable health state) (Carpentier, et al., 2009; Dolan, 1997; Inotai, et al., 2011).
characteristics, perceived severity, perceived treatment needs, interviewer severity rating scale of, and define the drug use, physical, and psychiatric co-morbidities among methadone patients.
Results
At methadone clinic, during the study period, a total of 188 patients were enrolled in the methadone maintenance treatment program and 108 patients (57%) voluntary enrolled in this study. The group of 80 non-participants had comparable socio-demographic characteristics with those who participated in this study.
category (32%). However, forty-nine patients (44%) had experienced a psychotic disorder in their life time. Depression episode correlated significantly with quality of life.
Discussion
The findings about current and life time psychiatric problems were comparable with other studies but the prevalence of psychotic disorder was higher (Carpentier, et al., 2009; Chiang, et al., 2007; Gelkopf, Weizman, Melamed, Adelson, & Bleich, 2006; Peles, Schreiber, Naumovsky, & Adelson, 2007; Tegger, et al., 2008; Trafton, Minkel, & Humphreys, 2006). High psychotic disorder can possibly be explained by high substance abuse in individuals with schizophrenia (Wobrock, et al., 2007); and cannabis, alcohol, amphetamine, stressful life events, and neurotic symptoms which can induce psychosis (Broome, et al., 2005; van Os, Kenis, & Rutten, 2010).
Conclusion:
Psychiatric disorders in methadone patients were high. Therefore those who deliver addiction care also have to address psychiatric co-morbidity in order to have a better outcome.
References
Alisjahbana, B., Susanto, H., Roesli, R., Yusuf, H., Hinduan, Z., Mose, J. C., et al. (2009). Prevention, Control, and Treatment of HIV-AIDS among Injecting Drug User in Bandung, Indonesia.Acta Med Indones, 41(Supplement 1), 65-69. Amato, L., Davoli, M., Perucci, C. A., Ferri, M., Faggiano, F., & Mattick, R. P. (2005).
An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat, 28(4), 321-329. doi: S0740-5472(05)00049-8 [pii]
10.1016/j.jsat.2005.02.007
Berkman, N. D., & Wechsberg, W. M. (2007). Access to treatment-related and support services in methadone treatment programs.J Subst Abuse Treat, 32(1), 97-104. doi: S0740-5472(06)00217-0 [pii]
10.1016/j.jsat.2006.07.004
Bhui, K., Craig, T., Mohamud, S., Warfa, N., Stansfeld, S. A., Thornicroft, G., et al. (2006). Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors.Soc Psychiatry Psychiatr Epidemiol, 41(5), 400-408. doi: 10.1007/s00127-006-0043-5 Brands, B., Blake, J., Marsh, D. C., Sproule, B., Jeyapalan, R., & Li, S. (2008). The
impact of benzodiazepine use on methadone maintenance treatment outcomes. J Addict Dis, 27(3), 37-48.
Broome, M. R., Woolley, J. B., Tabraham, P., Johns, L. C., Bramon, E., Murray, G. K., et al. (2005). What causes the onset of psychosis?Schizophr Res, 79(1), 23-34. doi: S0920-9964(05)00072-1 [pii]
10.1016/j.schres.2005.02.007
methadone maintained patients.Am J Addict, 18(6), 470-480. doi: 10.3109/10550490903205652 [pii]
10.3109/10550490903205652
Chiang, S. C., Chan, H. Y., Chang, Y. Y., Sun, H. J., Chen, W. J., & Chen, C. K. (2007). Psychiatric comorbidity and gender difference among treatment-seeking heroin abusers in Taiwan.Psychiatry Clin Neurosci, 61(1), 105-111. doi: PCN1618 [pii] 10.1111/j.1440-1819.2007.01618.x
Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., et al. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation.Health Technol Assess, 11(9), 1-171, iii-iv. doi: 04/22/01 [pii]
Dolan, P. (1997). Modeling valuations for EuroQol health states.Med Care, 35(11), 1095-1108.
Gelkopf, M., Weizman, T., Melamed, Y., Adelson, M., & Bleich, A. (2006). Does psychiatric comorbidity affect drug abuse treatment outcome? A prospective assessment of drug abuse, treatment tenure and infectious diseases in an Israeli methadone maintenance clinic.Isr J Psychiatry Relat Sci, 43(2), 126-136.
Gourevitch, M. N., Chatterji, P., Deb, N., Schoenbaum, E. E., & Turner, B. J. (2007). On-site medical care in methadone maintenance: associations with health care use and expenditures.J Subst Abuse Treat, 32(2), 143-151. doi: S0740-5472(06)00244-3 [pii]
10.1016/j.jsat.2006.07.008
Inotai, A., Rojkovich, B., Fulop, A., Jaszay, E., Agh, T., & Meszaros, A. (2011). Health-related quality of life and utility in patients receiving biological and
non-biological treatments in rheumatoid arthritis.Rheumatol Int. doi: 10.1007/s00296-010-1721-x
Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., et al. (2010). HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.Lancet, 375(9719), 1014-1028. doi: S0140-6736(10)60232-2 [pii]
10.1016/S0140-6736(10)60232-2
Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2003). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.Cochrane Database Syst Rev(2), CD002207. doi: 10.1002/14651858.CD002207
Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2008). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.Cochrane Database Syst Rev(2), CD002207. doi: 10.1002/14651858.CD002207.pub3 Mesquita, F., Winarso, I., Atmosukarto, II, Eka, B., Nevendorff, L., Rahmah, A., et al.
HIV/AIDS crisis among people who inject drugs.Harm Reduct J, 4, 9. doi: 1477-7517-4-9 [pii]
10.1186/1477-7517-4-9
Peles, E., Schreiber, S., Naumovsky, Y., & Adelson, M. (2007). Depression in methadone maintenance treatment patients: rate and risk factors. J Affect Disord, 99(1-3), 213-220. doi: S0165-0327(06)00402-2 [pii]
10.1016/j.jad.2006.09.017
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.J Clin Psychiatry, 59 Suppl 20, 22-33;quiz 34-57.
Tegger, M. K., Crane, H. M., Tapia, K. A., Uldall, K. K., Holte, S. E., & Kitahata, M. M. (2008). The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals.AIDS Patient Care STDS, 22(3), 233-243. doi:
10.1089/apc.2007.0092
Trafton, J. A., Minkel, J., & Humphreys, K. (2006). Opioid substitution treatment reduces substance use equivalently in patients with and without posttraumatic stress disorder.J Stud Alcohol, 67(2), 228-235.
UNAIDS. (2009).HIV prevention among injecting drug users. Paper presented at the 24th Meeting of the UNAIDS Programme Coordinating Board, Geneva. van Os, J., Kenis, G., & Rutten, B. P. (2010). The environment and schizophrenia.
Nature, 468(7321), 203-212. doi: nature09563 [pii] 10.1038/nature09563
Willenbring, M. L. (2005). Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches.AIDS, 19 Suppl 3, S227-237. doi: 00002030-200510003-00033 [pii]
Wobrock, T., Sittinger, H., Behrendt, B., D’Amelio, R., Falkai, P., & Caspari, D. (2007). Comorbid substance abuse and neurocognitive function in recent-onset
