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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 63-66

Psychiatric comorbidity in patients with substance use disorder: A hospital-based study


1 Department of Psychiatry, SKIMS Medical College and Hospital, Srinagar, Jammu and Kashmir, India
2 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Ab Majid Gania
Department of Psychiatry, SKIMS Medical College and Hospital, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.200093

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  Abstract 

Background: Pattern of substance use, profile of substance users, and treatment-seeking differ across cultures and continents. These differences could potentially affect the pattern and perhaps prevalence of dual diagnosis. However, the study of dual diagnosis from de-addiction clinics in India is limited in number and methodology. In this study, we report the prevalence and patterns of psychiatric disorders in subjects attending a de-addiction clinic in a teaching hospital in Srinagar, Kashmir. Methodology: In this cross-sectional study, 300 subjects (>18 years of age) seeking treatment for substance use disorders were screened with Mini International Neuropsychiatric Interview Plus for the presence of psychiatric comorbidity. Subjects were assessed after 4 weeks of complete abstinence from psychoactive substances. Results: Cannabis (26%) was the most common single-use substance. It was followed by polysubstance use (22.3%) and opioids (21.3%). Among the 300 subjects assessed for the purpose of the study, 174 (58%) were found to have dual diagnosis. Psychotic disorders (34%) were the most common psychiatric comorbidity, and it was followed by major depressive disorder (16%) and bipolar affective disorder (16%). Posttraumatic stress disorder (PTSD) was present in 20 (11.5%) subjects. When the groups with or without dual diagnosis were compared, cannabis and benzodiazepine dependence was found to be significantly common in the dual diagnosis group. Conclusions: A high prevalence of dual diagnoses, especially psychotic disorders and also PTSD, in our predominantly cannabis-using subjects attending hospital located in a distinct sociocultural setting in India, highlights the importance of taking into consideration the sociocultural context in which substance use as well as dual diagnoses should be understood.

Keywords: Cannabis, dual diagnosis, psychotic disorders


How to cite this article:
Gania AM, Margoob MA, Shah HU, Khan A W, Ghosh A, Basu D. Psychiatric comorbidity in patients with substance use disorder: A hospital-based study. Indian J Soc Psychiatry 2017;33:63-6

How to cite this URL:
Gania AM, Margoob MA, Shah HU, Khan A W, Ghosh A, Basu D. Psychiatric comorbidity in patients with substance use disorder: A hospital-based study. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Dec 5];33:63-6. Available from: https://www.indjsp.org/text.asp?2017/33/1/63/200093


  Introduction Top


In general, dual diagnosis is the co-occurrence of substance use disorder(s) and other psychiatric disorder(s) when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder.[1] Dual diagnosis of substance use and psychiatric illness is associated with more frequent relapses and hospitalization, higher risk of suicidality and violence, higher rates of comorbid medical illnesses, and higher risk of nonadherence to treatment.[2]

In India, research exploring the prevalence and pattern of dual diagnosis has been primarily clinic-based studies conducted either in addiction or in psychiatry treatment settings. Among the earliest Psychiatry clinic-based studies, the prevalence of substance use was 16.4% and alcohol was most commonly abused.[3] Research from de-addiction centers showed an occurrence of psychiatric disorder in the range of 60–75% among patients with substance use disorders.[4],[5] European studies demonstrated a wide range of variation across various countries ranging from 19% to 35%.[6] In a retrospective chart-based study from India where the data were collected over 11 years from a de-addiction center, the occurrence of psychiatric comorbidity was 13.2%.[7] The authors explained in unusually low rate by treatment-seeking pattern and methodological issues. Across the studies, mood disorders are the most common diagnostic category and this is followed by anxiety or psychotic disorders.

Pattern of substance use and profile of substance users differ across culture and continent.[8] Treatment-seeking pattern either for substance use or for psychiatric illness also varies.[8] These differences could potentially affect the pattern and perhaps prevalence of dual diagnosis. However, the study of dual diagnosis from de-addiction clinics in India is sparse at its best. Existing literature consists of studies which had used Diagnostic and Statistical Manual (DSM-III) diagnostic criteria and did not make adequate attempt to establish independent psychiatric disorder. They were underpowered or had retrospective design.[4],[5],[7]

Recognizing these caveats, we conducted this study to capture the prevalence and pattern of psychiatric disorders in treatment-seeking, substance-dependent subjects who were abstinent from substances for at least a month and attending a teaching hospital in Srinagar, Kashmir. We have also compared the substance use and the sociodemographic profile of subjects with or without dual diagnosis.


  Methodology Top


The study was conducted in a Teaching Hospital of North India. This hospital caters to Kashmir Valley in addition to the Ladakh Division and some part of Jammu Division. It was a cross-sectional study of all consecutive subjects registered in the substance use treatment clinic of the hospital during the study period (January 2003–December 2003). All consecutive subjects seeking treatment for their substance use disorders were approached for the purpose of the study. Subjects with only tobacco dependence were excluded from the study. Subjects who had either organic brain disease or medical illness known to cause psychiatric disorders (such as thyroid disorders, epilepsy, and Cushing's disease) were excluded from the study. Those who fulfilled the inclusion criteria were approached for informed consent and consented subjects were recruited for the study. Three-hundred subjects (>18 years of age) seeking treatment for their substance use disorder were evaluated 4 weeks after complete abstinence from psychoactive substances to eliminate transient substance-induced disorders, which are not true dual diagnoses. Abstinence was based on subjective reporting and corroboration from the family members. Subjects were screened with Mini International Neuropsychiatric Interview-Plus (MINI-plus) 6.0 for the presence of psychiatric comorbidity.[9] English version of MINI was used and was applied by a trainee psychiatrist and supervised by a consultant psychiatrist. In case of discrepancy of information provided by the subject and the family members regarding the use of substance, urine thin layer chromatography was done. Subjects with or without dual diagnosis were compared by Chi-square test (or Fischer's exact test) with respect to the age, gender, marital status, duration, occupation, residential, family status, and type of substance abused.


  Results Top


Three-hundred subjects were assessed in the study, of which 290 (96.7%) were male and 10 (3.3%) were female. In our sample, cannabis (26%) was the most common single-use substance. It was followed by polysubstance (22.3%), opioid (21.3%), and benzodiazepine (7%) use. Polysubstance use was defined by three or more substance use (except tobacco) in a dependent pattern, where the dependence criteria were made as a group but not for specific substance. Polysubstance dependence commonly included cannabis and opioids along with other substances. Alcohol dependence was present in only 8 (3%) subjects. Only three subjects were dependent on inhalants. Age of onset of regular drug use in our study subjects ranged from 14 to 53 years with highest number of subjects (n = 173; 57.6%) between 14 and 21 years. This was followed by 22–29 years (28.3%), 30–37 years (9.3%), 38–43 years (3.3%), and >43 years (1.3%). Most of the subjects were using substance for 6 months to 2 years (25%) followed by 2–4 years (23.3%), 4–6 years (20%), 6–8 years (16%), and >8 years (12%). Only 3.6% of subjects had started using substance in last 6 months. The mean duration of substance use in our study was around 5 years (5.1, standard deviation: 3.7).

Among the 300 subjects assessed for the purpose of the study, 174 (58%) were found to have dual diagnosis. Psychotic disorders (n = 59; 34%) were the most common psychiatric comorbidity and it was followed by major depressive disorder (n = 28; 16%) and bipolar affective disorder (n = 28; 16%). A small proportion (n = 4; 2.3%) of subjects were suffering from dysthymia. Anxiety disorders were the next diagnostic group, which consisted of generalized anxiety disorder (n = 12; 6.8%), panic disorder (n = 5; 3%), and obsessive compulsive disorder (n = 6; 3.5%). Posttraumatic stress disorder (PTSD) was present in 20 (11.5%) subjects. Among the Axis II diagnosis, anti-social personality disorder was present in 12 (7%) subjects [Table 1].
Table 1: Profile of various nonsubstance psychiatric disorders in dual diagnosis

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When the groups with or without dual diagnosis were compared, cannabis (P < 0.0001) and benzodiazepine dependence (P = 0.005) was found to be significantly common in the dual diagnosis group [Table 2].
Table 2: Comparison of dual diagnosis and no-dual diagnosis group with respect to primary substance

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With respect to sociodemographic profile, the dual diagnosis group was significantly different from the single diagnosis (substance use disorder only) group in educational (χ2 = 26.5; P < 0.0001) and residential status (χ2 = 4.3; P = 0.03). However, both the groups were similar in terms of age, gender, occupation, and marital status.


  Discussion Top


Our study was an attempt to estimate the clinic-based prevalence of dual diagnosis from India. To reduce the possibility of including substance-induced psychiatric disorders, only subjects with at least a month of drug-free period were recruited for the study. The diagnosis of psychiatric disorders was determined by MINI-plus, which is compatible with both ICD 10 and DSM IV-TR.

The prevalence of dual diagnosis in our clinic was found to be 58%. This figure is in line with the finding of another study from India, which demonstrated dual diagnosis prevalence of 60.5%.[5] However, that study was conducted in 43 inpatients using DSM-III criteria for the diagnosis of psychiatric disorders and did not attempt to exclude the substance-induced psychiatric disorder. Another Indian study from a different de-addiction clinic had shown 13.2% prevalence of dual diagnosis.[7] Nonetheless, the methodology followed in this study was significantly different than the present study. This could explain the discrepancy between the two. The prevalence figure of dual diagnosis in our study was similar to the literature from the US and was more than that of the European countries.[6]

The most common psychiatric disorder in the present study was psychotic illness, and most of them were diagnosed to be schizophrenia. However, mood disorder as a group which includes major depressive disorder, bipolar affective disorder, and dysthymia outnumbered psychotic disorders marginally. This result is in contrast to the available literature from India and other parts of the world where mood disorders were by far the most common diagnostic category.[5],[6],[7] The high occurrence of psychotic disorders in the index study perhaps could be explained by the fact that cannabis was most commonly used substance in our study and available evidence has shown that it is more significantly associated with psychosis as compared to other substance use.[7],[10]

Another notable finding in our study was the occurrence of PTSD (11.5%) in a substantial minority of subjects. None of the Indian studies mentioned above had reported the prevalence of PTSD. Our finding may be due to the strife-torn nature of the local population because of political reasons, causing trauma, bereavement, and discontent in many.

Our study has a distinctive substance use profile as alcohol use, which is usually the commonest substance of abuse in the treatment-seeking population, was present in only a minority of subjects. This could be because of the religious proscription against use of alcohol in the Muslim predominant patient population studied. On the other hand, cannabis use was by far the most common in our population, which reflects local sociocultural pattern of use based on norms, availability, and accessibility. These factors are important as they might have influenced the results of our study.

Limitations of our study include a hospital-based sample (which might have inflated the prevalence of dual diagnoses), lack of drug testing in each subject and for all substances, and lack of a more detailed structured interview. Sample size has not been calculated formally. MINI-Plus can only screen for anti-social personality disorder amongst all Axis-II disorders. Hence, other personality disorders could not be explored. Nonetheless, the strengths of this study are prospective testing by a valid and structured instrument, and detection of psychiatric disorders 1 month after abstinence to eliminate the possibility of counting substance-induced transient psychiatric symptoms or syndromes.


  Conclusion Top


A high prevalence of dual diagnoses, especially psychotic disorders and also PTSD, in our predominantly cannabis-using subjects attending hospital located in a distinct sociocultural setting in India, highlights the importance of taking into consideration the sociocultural context in which substance use as well as dual diagnoses should be understood. This finding has important potential implications for clinical as well as social psychiatry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Basu D, Sarkar S. Clinical practice guidelines for management of dual diagnosis. In: Basu D, Dalal PK, editors. Clinical Practice Guidelines for Assessment and Management of Substance Use Disorder. New Delhi: Indian Psychiatric Society; 2014. p. 469-513.  Back to cited text no. 1
    
2.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with Co-occurring Disorders. Treatment Improvement Protocol (TIP) Series, No. 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.  Back to cited text no. 2
    
3.
Trivedi JK, Sethi BB. Drug abuse in psychiatric patients. Indian J Psychiatry 1978;20:345-8.  Back to cited text no. 3
  Medknow Journal  
4.
Goswami S, Singh G, Mattoo SK, Basu D. Courses of substance use and schizophrenia in the dual-diagnosis patients: Is there a relationship? Indian J Med Sci 2003;57:338-46.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Kisore P, Lal N, Trivedi JK, Dalal PK, Aga VM. A study of comorbidity in psychoactive substance dependence patients. Indian J Psychiatry 1994;36:133-7.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Carrà G, Johnson S, Bebbington P, Angermeyer MC, Heider D, Brugha T, et al. The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: Findings from the European Schizophrenia Cohort (EuroSC). Eur Arch Psychiatry Clin Neurosci 2012;262:607-16.  Back to cited text no. 6
    
7.
Basu D, Sarkar S, Mattoo SK. Psychiatric comorbidity in patients with substance use disorders attending an addiction treatment center in India over 11 years: Case for a specialized “dual diagnosis clinic”. J Dual Diagn 2013;9:23-9.  Back to cited text no. 7
    
8.
Ray R, editor. The Extent, Pattern and Trends of Drug Abuse in India-National Survey. New Delhi: Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime; 2004.  Back to cited text no. 8
    
9.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. 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 1998;59 Suppl 20:22-33.  Back to cited text no. 9
    
10.
Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry 2006;67 Suppl 7:5-9.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]


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