Prevalence Rates And Related Factors Of Co-occurring Mental Disorders And Other Substance Use Disorders Among Heroin-dependent Patients

BackgroundCo-occurring disorders (COD) are both common and highly complex phenomena that are very widespread. Considerable researches have established the high prevalence of co-occurring mental disorders among individuals who have substance use disorders. Although the phenomena of co-occurring disorders have aroused more attention, current research literatures are mainly concentrated in the United States of America and Europe. Substances commonly used in the western and eastern countries usually vary, with heroin as the most dominative illicit drug used in China. Hence, understanding the status of co-occurring disorders in heroin-dependent patients in China should be of important concern in the field of psychiatry. Unfortunately, so far, in China, studies addressing this issue were only limited to few small scale surveys. On this background, the need for large sample investigation on COD among heroin-dependent patients in China has urgently arisen. On the other hand, dual or multiple substance abuse or dependences are prevalent among substance users. Dual or multiple substance use disorders also present a range of problems for diagnoses and interventions, and increase the risks of fatal drug overdose and suicide. Hence, concurrent investigation on co-occurring substance use disorders among heroin-dependent patients in China is also highly recommended.ObjectiveTo conduct large sample (N=1002) survey on co-occurring mental disorders and other substance use disorders among heroin-dependent patients and provide prevalence rates of co-occurring mental disorders and other substance use disorders among patients with heroin dependence in China. MethodsCross-sectional study and face-to-face individual interview were conducted. Subjects were1,002heroin-dependent patients who were consecutively admitted into a voluntary drug rehabilitation center and two compulsory drug rehabilitation centers in Hunan province of China, from March10,2008to October30,2008. A questionnaire was developed to get demographic and drug use-related information of the subjects. Structured Clinical Interview for DSM-IV-TR Axis Ⅰ Disorders-Patient Edition (SCID-I/P) and Structured Clinical Interview for DSM-Ⅳ-TR Axis Ⅱ personality Disorders (SCID-Ⅱ) were used for DSM-Ⅳ axis Ⅰ and axis Ⅱdiagnoses.ResultsAccording to DSM-Ⅳ axis Ⅰ and axis Ⅱ diagnoses,67.2%of the sample had lifetime co-occurring mental disorders.29.6%of the subjects had suffered from DSM-IV axis Ⅰmental disorders in their lifetimes, among which, mood disorder was the most common co-occurring diagnosis with a prevalence rate of19.1%, followed by anxiety disorder with a prevalence rate of12.8%. Major depression was the most common diagnosis among co-occurring mood disorders, whereas post-traumatic stress disorder (PTSD) was the most common diagnosis among co-occurring anxiety disorders.59.3%of the subjects co-occurred with DSM-Ⅳ axis Ⅱ personality disorders, among which, Cluster B personality disorder was the most frequent, reaching a percentage of51.2%. In the diagnoses of co-occurring personality disorders, antisocial personality disorder was the most common one with prevalence rate of40.7%, followed by borderline personality disorder with a prevalence rate of22.6%. With respect to co-occurring disorders, gender differences existed among the subjects to the extent that female heroin-dependent patients were more vulnerable to axis Ⅰ mental disorders especially PTSD, whilst male heroin-dependent patients were more apt to suffer from axis Ⅱ personality disorders especially antisocial personality disorder.57.8%subjects had other substance (non-opioid, other than tobacco) use disorder diagnoses. The most frequent diagnoses of other substance use disorders were sedative-hypnotic use disorder and alcohol use disorder, with lifetime prevalence rates of around32.2%and28.8%respectively, followed by stimulant and hallucinogen use disorder with lifetime prevalence rates of above10%respectively. There were also some differences with respect to other substance use disorder diagnoses between male and female heroin-dependent patients. Male heroin-dependent patients were more likely to co-occur with sedative-hypnotic use disorders, while female heroin-dependent patients were more likely to co-occur with stimulant use disorders in their lifetimes.In heroin-dependent patients, it was usual situation that one individual co-occurred with multiple mental disorders and/or substance use disorders.Of the total sample,6.0%had co-occurred with two or more diagnostic classes of axis I mental disorders other than substance use disorders during their lifetime.29.9%got two or more personality disorder diagnoses. And25.4%had two or more lifetime diagnoses of non-opioid substance use disorders.ConclusionsCo-occurring mental disorders and other substance use disorders among heroin-dependent patients in China are highly prevalent, to which great importance should be attached in the process of diagnosis and treatment. BackgroundMood disorders and cluster B personality disorders are the most prevalent axis Ⅰ and axis Ⅱ comorbidities among individuals with heroin-dependence, respectively. While polydrug use—the consecutive or simultaneous use of two or more substances—is also common in heroin users, and may complicate their clinical course. From findings of Part Ⅰ in our research of heroin-dependent sample, major depression and dysthymia were the dominating diagnoses of co-occurring mood disorders, which are featured by depressed emotions. Individuals co-occurred with antisocial and/or borderline personality disorders, both of which are characterized by instability, impulsivity and aggressivity, occupied the majority of those with a cluster B personality disorder. However, researches involved their related factors were scarce. To our knowledge, the relationship of the comorbid mood disorders, cluster B personality disorders, and other substance use disorders with the characteristics and backgrounds variables in a heroin dependent sample has not been tested in a comprehensive model.ObjectiveTo explore related factors of co-occurring mood disorders, cluster B personality disorders, and other substance use disorders among heroin-dependent patients, particularly focusing on variables of environmental and psychosocial backgrounds, clinical characteristics of drug use, and relationship between these co-occurring disorder classes.MethodsChi-squared tests or Student’s t-tests were conducted to determine whether an association existed between variables and the comorbid mood disorders, B cluster personality disorders, or other substance use disorders among our heroin dependent sample of1002individuals. Bivariate Logistic regression was used to report odds ratios. Not all variables reported by bivariate analyses were included in the multi-variate analyses. Multi-variate Logistic regression was used to test for associations between the dependent variable and the independent variables.Results1. Chronic somatic disease, other substance use disorders and cluster B personality disorders are main risk factors to predict co-occurring mood disorder among heroin-dependent patients. Compared with heroin-dependent patients without mood disorders, those who co-occurred with mood disorders are more likely to use heroin for the first time to cope with depression or worry, more likely to felt bad in the first time of heroin use, and receive more times of compulsive rehabilitation.2. Male gender, a family history of DSM-IV axis I mental disorders, childhood adversity, without a legal employment, mood disorders and other substance use disorders are main risk factors predicting co-occurring cluster B personality disorders among heroin-dependent patients. Compared with heroin-dependent patients without cluster B personality disorders, those co-occurred with a cluster B personality disorder tend to use heroin for the first time on an earlier age, use heroin with a larger maximum day dose, experience more severe withdrawal symptoms, and receive more times of compulsive rehabilitation.3. A family history of substance (not including nicotine) use disorders, any traumatic event in adulthood, mood disorders and cluster B personality disorders are main risk factors predicting co-occurring other substance (other than opioids, not including nicotine) use disorder. Compared with heroin-dependent patients without any other substance use disorders, those co-occurred with other substance use disorders tend to be younger, use heroin with a larger maximum day dose, experience more severe withdrawal symptoms, and more likely to use heroin by introvenus injection.ConclusionsAmong heroin-dependent patients, mood disorders, cluster B personality disorders, and other substance use disorders are main risk factors for each other. Chronic somatic disease is main risk factor for co-occurring mood disorders. Family history of mental disorders, childhood adversity, and adverse social status are main risk factors for co-occurring cluster B personality disorders. Family history of substance (not including nicotine) use disorders and experiences of traumatic event in adulthood are main risk factors for co-occurring other substance use disorders. Among heroin-dependent patients, individuals with cluster B personality disorders and individuals with other substance use disorders may be more addicted to heroin. BackgroundAvailable studies in the area of related factors of COD and poly drug use are rarely involved with genetic factors. We have already discussed some related factors of co-occurring mood disorders, cluster B personality disorders, and other substance use disorders among the sample of heroin-dependent patients. In the Part Ⅲ, we would further discuss any genetic factors for the sake of providing a theoretical basis for risk individual interventions. By reviewing literatures, we selected5-HTR2A-1438A/G (rs6311), COMTVal158Met (rs4680), MAOA-LPR, DATVNTR and5-HTTVNTR polymorphisms into this part of study.ObjectiveThe aim of this study was to investigate the possible relationship of the genetic variants of rs6311, rs4680, MAOA-LPR, DATVNTR and5-HTTVNTR with the comorbid mood disorders, cluster B personality disorders, and other substance use disorders in heroin-dependent patients.MethodsIn case control study, we compared the polymorphic distributions of5-HTR2A-1438A/G, COMTVal158Met, MAOA-LPR, DATVNTR and5-HTTVNTR in884heroin-dependent patients and295normal volunteers by genotypes, alleles, and interaction between genes.Results1. Rs4680, MAOA-LPR,5-HTTVNTR and DATVNTR are associated with the co-occurrence of mood disorders and heroin dependence in females. Compared to normal females, heroin-dependent females with mood disorders have a higher frequency of5-HTTVNTR10R/10R genotype. Heroin-dependent females with major depression have a higher frequency of DATVNTR allele9R and9R/10R genotype. Heroin-dependent females with dysthymia have a higher frequency of rs4680A allele and MAOA-LPR L/H genotype. Among female heroin-dependent subjects, DATVNTR10R/10R genotype is lesser distributed in those co-occurred with major depression, and MAOA-LPR L/H genotype is more distributed in those co-occurred with dysthymia.2. Among male heroin-dependent patients, the interactions between rs6311, rs4680and MAOA-LPR are associated with co-occurring major depression, and a strong synergy was found in the interaction between rs6311and MAOA-LPR.3.5-HTTVNTR and DATVNTR are associated with the co-occurrence of cluster B disorders and heroin dependence. Compared to normal controls, heroin-dependent individuals co-occurred with any cluster B personality disorder, to be more specific, with antisocial and borderline personality disorders, are less frequently carrying the homozygous of5-HTTVNTR12R/12R, and more frequently carrying5-HTTVNTR10R allele. Moreover, heroin-dependent subjects with borderline personality disorder have a higher frequency of the9R allele of DATVNTR. Among heroin-dependent subjects,5-HTTVNTR allele10R is more frequent in individuals co-occurred with cluster B personality disorders, and the9R allele of DATVNTR is more frequently distributed in the individuals with borderline personality disorder. The above associations have not found to correlate with gender. Compared to the normal controls, heroin-dependent subjects with borderline personality disorder have a higher frequency of the10R/1OR genotype of5-HTTVNTR, however, the significance of difference vanished between male groups when comparisons were divided by gender. Among heroin-dependent patients,5-HTTVNTR12R/12R genotype is less likely and10R allele is more likely to predict the risk of co-occurrence of antisocial personality disorder, however, the significance of difference vanished between female groups when comparisons were divided by gender.4. Rs6311, MAOA-LPR, and the interaction of MAOA-LPR and5-HTTVNTR are associated with the co-occurrence of cluster B personality disorder and heroin dependence in females. Compared to the normal females, the female heroin-dependent individuals with antisocial personality disorder have a higher frequency of rs6311T allele, while the female heroin-dependent individuals with borderline personality disorder have a lower frequency of MAOA-LPR H/H genotype. When set the normal females as controls, the interaction between MAOA-LPR and5-HTTVNTR was associated with the risk of the comorbidity of any cluster B personality disorder, and was associated with the risk of comorbid borderline personality disorder, in female heroin-dependent subjects respectively. To be specific, when the individual’s5-HTTVNTR genotype is homozygous12R/12R, the L/H genotype of MAOA-LPR predicts higher comorbidity risks, whereas while the individual’s5-HTTVNTR genotype is heterozygous10R/12R, the L/H genotype of MAOA-LPR predicts lower comorbidity risks. Furthermore, among female heroin-dependent patients, MAOA-LPR H/H genotype is less, while the L allele of MAOA-LPR is more frequent in those co-occurred with borderline personality disorder.5. All polymorphisms of rs6311, rs4680, MAOA-LPR,5-HTTVNTR and DATVNTR may be associated with the co-occurring other substance use disorders in heroin-dependent individuals, whereas, genetic heterogeneity may exist between gender. To be specific:Compared to the normal males, as well as among the male heroin-dependent subjects, male individuals with the co-occurrence of other substance use disorders and heroin dependence are more frequent to carry the10R allele while less frequent to carry the12R/12R genotype of5-HTTVNTR, with those who co-occurred with sedative-hypnotic use disorder having a higher frequency of the10R allele and a lower frequency of the12R/12R genotype of5-HTTVNTR respectively. Furthermore, among the male heroin-dependent subjects, the10R allele and the10R/10R genotype of DATVNTR are predictive of the co-occurrence of other substance use disorders, and the G/G genotype of rs4680is predictive of the occurrence of alcohol use disorder.On the other side, compared to the normal females, heroin-dependent females with alcohol use disorder have a higher frequency of the A allele of rs4680, indicating a positively association between the A allele and the co-occurrence of alcohol use disorder and heroin dependence, which shows some contrary finding contrasted to that found among the male heroin-dependent subjects.Among heroin-dependent patients, individuals with other substance use disorders are more likely to be carriers of homozygous C/C of rs6311, and this association is not correlated to gender.ConclusionsRs4680, MAOA-LPR,5-HTTVNTR and DATVNTR may be associated with the co-occurrence of mood disorders and heroin dependence in females. Interactions between rs6311, rs4680and MAOA-LPR may be associated with the comorbidity of major depression in male heroin-dependent subjects.5-HTTVNTR and DATVNTR may be associated with the co-occurrence of cluster B personality disorders and heroin dependence. Rs6311, MAOA-LPR and the interaction between MAOA-LPR and5-HTTVNTR may be associated with the co-occurrence of cluster B personality disorders and heroin dependence in females.Rs6311, rs4680, MAOA-LPR,5-HTTVNTR, DATVNTR may be associated with the co-occurrence of other substance use disorders and heroin dependence, and genetic heterogeneity exists between males and females.