Prevalence and correlates of psychological distress among drug users in Phnom Penh, Cambodia

Abstract

Background

Compared to the general population, drug users are at increased risk of both poor mental health and HIV infection. The aim of this study was to determine the prevalence and correlates of high psychological distress among drug users in Cambodia.

Methods

In April 2014, a two-stage cluster sampling method was used to randomly select 169 drug users from hotspots in Phnom Penh. Psychological distress was measured using General Health Questionnaire (GHQ-12). Bivariate and multivariable analyses were conducted to identify factors associated with levels of psychological distress among this population.

Results

Our study found high prevalence of attempted suicide (15.3%), drug related arrests (46.2%), and incarceration (31.4%). Of the 169 participants, 42.0% were found to have high levels of psychological distress, indicating poor mental health. After adjustment, high levels of psychological distress were independently associated with suicidal ideation (p < 0.001), higher frequency of drug use (p = 0.02), sharing of needles or syringes (p = 0.005), and having been sent to a rehabilitation centre (p = 0.02). In addition, participants who perceived their overall health as being poor or very poor were more likely to have high levels of psychological distress (p = 0.002).

Conclusion

Integration of mental health within HIV and needle and syringe exchange programmes is required to address psychological distress among drug users in Cambodia. Health system interventions, such as screening, referral, and training of health providers, need to be strengthened. In addition, interventions addressing social determinants of mental health and mitigation of frequent arrests and improving conditions in rehabilitation centres are required.

Introduction

Poor mental health is a source of significant public health burden globally (Whiteford et al., 2013). In 2010, mental health was the 11th most important cause of morbidity and mortality globally (Murray et al., 2012). Mental health conditions are also among the most difficult to treat (Stein & Seedat, 2007). In many contexts, people with severe mental disorders are also the most vulnerable and socially excluded (Funk, Drew, Freeman, & Edwige, 2010). Although prevalence of poor mental health differs by contexts and sensitivity of screening methods (Charlson, Diminic, Lund, Degenhardt, & Whiteford, 2014), evidence suggests that, compared to the general population, drug users are more likely to have mental disorders (Armstrong et al., 2013b, Brienza et al., 2000, Conner et al., 2008, Knowlton et al., 2001).

Research has shown that the relationship between mental disorders and drug use is complex and either can proceed, reinforce, or be the consequence of the other (Buckingham, Schrage, & Cournos, 2013). Drug use is often a behavioural mechanism for coping with mental health symptoms (Loue, Sajatovic, & Mendez, 2011). While understanding the causation sequence remains relevant, evidence suggest that severity of poor mental health is often correlated with the extent of drug dependence, unmet service needs (Li et al., 2015), and in some cases, adverse childhood experiences (Kang, Deren, & Goldstein, 2002) of drug users. In addition, while the direction of the effect may differ, gender is also an important mediator of the way in which poor mental health is experienced or coped with among this population (Loue et al., 2011, Pettes et al., 2015, Shaw et al., 2015, Springer et al., 2009).

HIV is often overlaid within this complex situation: poor mental health, particularly depression, is often linked with an increased uptake of high-risk behaviours and ultimately, HIV infection among drug users. Various studies have shown that drug users with severe depressive symptoms and suicidal thoughts are more likely to share needles and syringes (Armstrong et al., 2013a, Mackesy-Amiti et al., 2014). Those with severe depression and suicidal thoughts have a greater frequency of unsafe drug injection (Li et al., 2013, Pilowsky et al., 2011), more sexual partners, and greater frequency of unprotected sex (Armstrong et al., 2013a, Pettes et al., 2015).

Once infected with HIV, poor mental health can lead to poor treatment outcomes among drug users, including poor adherence to antiretroviral therapy (Carrieri et al., 2003, Palmer et al., 2003), faster disease progression (Bouhnik et al., 2005), and increased hospitalisation (Marimoutou et al., 2003). In addition, improvement in mental health has been noted following initiation of antiretroviral therapy among drug users. Standard interventions in HIV treatment, such as motivational counselling, adherence counselling, peer-based support, and case management, often have a positive psychological impact, which in turn reduces substance use (Springer et al., 2009). These observations suggest that better linkages between mental health, HIV prevention and treatment, and needle-exchange programmes could be beneficial.

In particular, it is important to identify how the already defined packages of mental health services (Patel & Thornicroft, 2009) can be delivered to drug users in low- and middle-income countries. In countries such as Cambodia, limited progress has been made in the understanding patterns of mental health among this population. In response to this gap, this paper documents the prevalence and correlates of high psychological distress among drug users in Phnom Penh, Cambodia.