Psychiatric Disorders in Methadone Patients.

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:
Sixty-four of the patients (57%) reported psychiatric disorders and 42% had current
psychiatric problems. The most diagnosed disorders were within anxiety disorder
category (32%). However, forty-nine patients (44%) had experienced a psychotic
disorder in their life time. Depression episode correlated significantly with quality of life.
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.

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).
However, because of the complex nature of opioid dependence, methadone alone
is not sufficient for treatment to be successful. AIDS-related medical care, and

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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
effectiveness and higher utilization of the services (Berkman & Wechsberg, 2007).
Particularly in an environment where MMT programs have limited resources available
like in Indonesia, specific identification of the most common problems are important to

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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.
MINI is a brief diagnostic interview based upon the ICD10 criteria was used to
screen

for

psychiatric

disorders.

It

assess

current

and

lifetime

psychiatric

4

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 sociodemographic characteristics with those who participated in this study.
Sixty-four of the patients (57%) reported psychiatric disorders and 42% had
current psychiatric problems. The most diagnosed disorders were within anxiety disorder

5

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).
Our result about drug use was also in line with other studies which showed that
drug use among methadone patients was common (Carpentier, et al., 2009; Gourevitch,
Chatterji, Deb, Schoenbaum, & Turner, 2007; Peles, et al., 2007). Some studies showed
that benzodiazepine use by methadone patients was linked to psychological distress and
negatively influenced treatment outcomes (Brands, et al., 2008). Furthermore, in general,
persisting co-morbid substance use disorder (SUD) has been associated with a negative
outcome, including more frequent and longer periods of hospitalization, higher
psychiatric disorder relapse rate, higher non-compliance, elevated extra pyramidal
syndrome rate, unemployment, homelessness, violence, incarceration, suicide, and HIV
infection (Wobrock, et al., 2007).

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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.

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