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RESEARCH REPORT
doi:10.1111/add.12780
Factors associated with depression and anxiety among patients attending community-based methadone maintenance treatment in China Wenyuan Yin1, Lin Pang1, Xiaobin Cao1, Jennifer M. McGoogan1, Michael Liu1, Congbin Zhang2, Zhijun Li3, Jianhua Li2 & Keming Rou1 National Center for AIDS/STD Control and Prevention, China CDC, Beijing, China,1 Yunnan Institute of Drug Abuse, Kunming, Yunnan, China2 and US CDC Global AIDS Program (GAP), Beijing, China3
ABSTRACT Aim To estimate the prevalence of, and identify factors associated with, depression and anxiety among communitybased methadone maintenance treatment (MMT) clients in China. Design A cross-sectional survey. Setting Nine MMT clinics, three each from three Chinese provinces (Yunnan, Anhui and Jiangsu) between October 2008 and February 2009. Participants A total of 1301 MMT clients. Measurements A questionnaire, including the Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS), and on-site urine drug testing. Findings The prevalence of depression (SDS score ≥ 53) and anxiety (SAS score ≥ 50) in our sample was 38.3% [95% confidence interval (CI) = 35.7, 40.9] and 18.4% (95% CI = 16.3, 20.5), respectively, with 14.2% (95% CI = 12.3, 16.1) displaying symptoms of both. Sample prevalence rates for depression [mean = 49.69, standard deviation (SD) = 10.34] and anxiety (mean = 40.98, SD = 10.66) were higher than the national average for each (t(0.05/2, 1300) = 19.2, P < 0.001 and t(0.05/2, 1300) = 8.0, P < 0.001, respectively). Employing multi-level modelling techniques, gender (P = 0.03) and employment status (P < 0.001) were found to be associated significantly with depression in a single-level model; however, in a multi-level mixed model, only employment status (P < 0.001) was associated with depression. Gender (P = 0.03), education level (P = 0.02), marital status (P = 0.04), employment status (P < 0.001), positive urine drug test results (P = 0.02) and daily methadone dose (P < 0.001) were found to be associated significantly with anxiety in a single-level model, while only employment status (P < 0.01) and positive results for the urine drug test (P = 0.04) were associated with anxiety in a multi-level mixed model. Conclusions A considerable proportion of methadone maintenance treatment clients in China have experienced depression and anxiety during treatment. There is a need to provide tailored mental health interventions for this high-risk population. Keywords
Anxiety, depression, drug user, methadone maintenance treatment, Zung’s Self-Rating.
Correspondence to: Wenyuan Yin, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China. E-mail: [email protected] Submitted April 2012; initial review completed 16 Oct 2012; final version accepted 27 Aug 2014
INTRODUCTION In 2001, up to 66.5% of newly diagnosed HIV infections were related to drug use in China [1]. In recognition of the need for a harm reduction strategy, China’s methadone maintenance treatment (MMT) programme was initiated in 2004 as a small, successful pilot and since 2006 has been operating as a nation-wide programme. So far, China has developed an extensive network of 758 community-based MMT clinics in 28 provinces, which has treated more than 384 500 heroin users cumula© 2014 Society for the Study of Addiction
tively with 208 450 clients still receiving treatment by the end of 2012 [1]. Increasing evidence demonstrates that the MMT programme has resulted in a reduction of heroin use, risky injection practices and criminal behaviours among clients. The MMT programme has also decreased drug-related consumption and trade nationwide and improved the reconciliation of family and social functions [2–4]. Importantly, the MMT programme has effectively curbed the spread of HIV among drug users. Assessment shows that the new HIV infection rate among MMT clients decreased from 0.95% in 2006 to 0.20% in Addiction, 110 (Suppl. 1), 51–60
52
Wenyuan Yin et al.
2012, a decline of 78.9%, suggesting that approximately 11 000 drug users have avoided HIV infection [5]. The national sentinel surveillance data suggests that the HIV infection rate among drug users has declined continually in recent years [6]. This progress in curbing the incidence of HIV infection has provided the impetus for further expansion of the MMT programme in China. However, despite the extensive and successful implementation of the MMT programme in China, many challenges and obstacles remain. The most significant of these are relapse-related dropout and continued use of heroin or other illicit drugs while participating in MMT [2–8]. Notably, both higher dropout and relapse rates have been documented in a growing body of literature among MMT clients with psychiatric problems or disorders [9–13]. Furthermore, there is extensive evidence that psychiatric problems or disorders (i.e. depression, anxiety, post-traumatic stress disorder, schizophrenia, etc.) are more prevalent among drug users than the general population [9,14–17]. While there is continued debate as to whether psychiatric problems or disorders are a cause or a consequence of opiate addiction [10–15], it is clear that they have a close and complex relationship and probably influence each other in a variety of ways over time and across individuals [9–18]. Many studies have suggested that patients with comorbid psychiatric problems or disorders may require higher methadone doses and/or various types of psychosocial interventions to promote retention in MMT programmes, reduce heroin or other illicit drug use and improve overall health outcomes [11–16]. In China, while the issues of MMT drop-out and continued illicit drug abuse during MMT have been recognized and are suggested to be partly the result of a general lack of psychosocial support services [2–8], few studies have directly examined these problems, and present mixed results. For example, a recent study of 500 Chinese heroin users enrolled in MMT found 24 cases of depression (4.8%) and 32 cases of anxiety (6.4%) [19], while a previous study of 134 female Chinese MMT clients found that the estimated prevalence of depression and anxiety was 25 and 61%, respectively [20]. In another study of 300 MMT patients, all of whom had been diagnosed with depression, the severity of symptoms ranged from mild to extreme with roughly 10% identified as suicidal [21]. However, these studies are not directly comparable in terms of different kinds of subjects and measurement tools. In order to improve the quality of MMT services in China (and possibly MMT programmes in other parts of the world), a more thorough assessment of possible comorbid conditions in these clients, such as depression and anxiety, is needed. By understanding the extent of comorbid conditions such as these in MMT clients, researchers and treatment providers will be better posi© 2014 Society for the Study of Addiction
tioned to consider the role of adjunct therapies to complement MMT and improve service outcomes. The purpose of this study was thus to examine the prevalence of, and factors associated with, depression and anxiety among heroin users in community-based MMT programmes in China.
METHODS Study design and setting A cross-sectional survey was conducted between October 2008 and February 2009 among clients from selected MMT clinics through a self-administered questionnaire and on-site urine testing. As provinces in China experience different levels of HIV epidemic, which implies varied transmission modes, service status, social contexts and other social and economic conditions, we used a stratified random sampling method by province and HIV prevalence to control for the influence of these factors. By the end of September 2008 there were 531 clinics, including 16 clinics newly opened in August, and 21 mobile MMT vans in 23 of 31 provinces in China. The number of clinics in each of the provinces varied from one to 67. The number of clients per clinic in each of provinces varied from 57 to 369, with a national average of 162 clients/clinic. The national total number of clients attending MMT was 86 192, with the lowest 114 to the highest 9599, an average 3747 (86 192/23) clients in a province. The national average prevalence of HIV infection among MMT clients was 7.92%, with the lowest 0.3%, medium 1.63% and highest 36.3% in a province. Provinces with a total of fewer than 500 clients or fewer than five MMT clinics were removed from the sampling frame, and four provinces were excluded. The remaining 19 provinces were ranked by the total of clients attending MMT clinics, from the lowest 704 to the highest 9599 clients. Three provinces were selected randomly from the list: Anhui, with eight clinics, 858 clients and 0.71% HIV infection, Jiangsu, with 11 clinics, 3122 clients and 3.12% HIV infection and Yunnan, with 67 clinics, 7452 clients and 25.54% HIV infection, were selected. In each of the provinces, three clinics were selected randomly among those that had been open and operating for more than 1 year. Study participants A total of 1304 MMT clients met the inclusion criteria in this study, with 1301 (99.7%) participants consenting to and completing all aspects of the study, including 450 from Yunnan, 402 from Anhui and 449 from Jiangsu. Participants were included if they met the following eligibility criteria according to the ‘Chinese MMT Program Working Scheme’: Addiction, 110 (Suppl. 1), 51–60
Depression and anxiety among MMT clients
53
1 Dependence on opium drugs according to the third version of the Chinese Classification of Mental Disorder (CCMD-3) [22]. CCMD-3 has 10 categories, from 0 to 9, including: 0, organic mental disorders; 1, mental disorders due psychoactive substances or nonaddictive substances; 2, schizophrenia and other psychotic disorders; 3, mood (affective) disorders; 4, hysteria, stress-related disorders, neurosis; 5, physiological disorders related to psychological factors; 6, personality disorders, habit and impulse disorders, psychosexual disorders; 7, mental retardation and disorders of psychological development with onset usually occurring in childhood and adolescence; 8, hyperkinetic, conduct, and emotional disorders with onset usually occurring in childhood and adolescence; and 9, other mental disorders and psychological health conditions. Enrolled in a MMT programme in one of the nine selected study sites for at least 1 month and received a stable treatment course when the study started on site. 2 At least older than 18 years. 3 Provision of informed consent.
level of depression or anxiety symptoms. The higher the score, the more severe the depression or anxiety status, which is consistent with Zung’s method. Both Zung’s selfrating scales and the cutoff points described have been used extensively in studies of depression and anxiety in China, and the Chinese translations of these surveys have been validated previously [26,27].
Measurement of depression and anxiety
Urine collection and testing
For the purposes of this study, Zung’s depression selfrating scale (SDS) and Zung’s anxiety self-rating scale (SAS) [23,24] served as assessment tools reflecting the possible severity of symptoms of depression and anxiety reported by participants, rather than as diagnostic criteria for psychiatric disorder. The SDS and SAS examine the severity of depression and anxiety symptoms for individuals, respectively, during the 7 days prior to completing the measure. Both measures contain 20 self-report items scored on a Likert-type scale of 1–4, with a total score range of 20–80. SDS scores of 20–44 are ‘normal’, while scores of 45–59 indicate mild depression symptoms, scores of 60–69 indicate moderate depression symptoms and 70+ suggests severe depression symptoms. Similarly, SAS scores of 20–44 are ‘normal’, while scores of 45–59 indicate mild anxiety symptoms, scores of 60–75 indicate moderate anxiety symptoms and scores of 75+ suggest severe anxiety symptoms. As the aim of the current study is to determine the prevalence of significant self-reported depression and anxiety symptoms, cutoff points were used to determine ‘high’ scores to contribute to prevalence estimates. Based on Zung’s classification criteria of levels of severity, psychiatry professionals in China have adapted SDS scores greater than 53 and SAS scores greater than 50 as the cutoff points for symptom severity associated with depression and anxiety disorders, respectively, when conducting assessment, screening or large-scale investigations in terms of Chinese National Normative Scores [25]. These cutoff scores indicate at least a middle–mild
Following completion of the questionnaire, participants also provided an on-site urine sample for testing, which was strictly supervised to ensure authenticity. All urine samples were tested immediately on-site using a rapid urine testing kit (Acon Biotech Co., Ltd, Hangzhou, China), which was validated for the accurate detection of five drugs, namely heroin/morphine, diazepam, ‘crystal’ methamphetamine hydrochloride, 3,4-methylenedioxyN-methylamphetamine (MDMA, also known as ecstasy) and buprenorphine. Detection of any one of these five substances was defined as fulfilling the criteria for positive drug test results. A positive drug test result, but not the presence of each individual drug type, was included as an independent predictor of depression or anxiety in analyses.
© 2014 Society for the Study of Addiction
Interviews SDS and SAS assessments were administered with the assistance of interviewers, due to the relatively low level of literacy among our participants of MMT clients. Prior to the commencement of this study, clinic staff members were trained as interviewers to follow a set of protocols to ensure consistent interviewing as well as to help participants understand the questions so that they could answer truthfully. Participants, assisted by trained interviewers, completed the confidential questionnaire in private. In addition to the SDS and SAS measures, the questionnaire also collected information on participants’ demographic characteristics, self-reported recent drug use and most recent MMT programme participation.
Statistical analysis Study data were collected and organized in a database created using EpiData software version 3.02 (EpiData Association, Odense, Denmark)) and double-entry was performed to check for and correct any errors. A series of one-way analyses of variance (ANOVA) were performed to examine group differences between SDS, as well as SAS, scores by demographics (e.g. gender, age, education), recency of drug use and MMT programme participation characteristics; t-tests were also performed to compare the average SDS and SAS scores for the total sample with the Chinese National Normative Scores for Addiction, 110 (Suppl. 1), 51–60
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Wenyuan Yin et al.
these measures [25]. Finally, single- and multi-level mixed-model analyses were employed simultaneously and compared to identify the factors associated with depression and anxiety. SDS and SAS scores were employed as dependent variables, while gender, employment status, education level, urine drug test results and MMT programme participation characteristics (including daily methadone dose) were employed as independent variables for both singleand multi-level mixed-model analyses (α < 0.05 level). Single-level statistical analyses were performed using SAS software version 9.1 (SAS Institute, Cary, NC, USA), while multi-level mixed-model analyses were performed using the SAS version 9.3 mixed module. Ethical approval This study was reviewed and approved by the Institutional Review Board (IRB) of the National Center for AIDS/STD Control and Prevention (NCAIDS) of the Chinese Center for Disease Control and Prevention (Chinese CDC). All participants provided informed consent for both the questionnaire and urine sample collection.
[26]. Both the total mean SDS score (mean = 49.69, SD = 10.34) and the total mean SAS score (mean = 40.98, SD = 10.66) for the study sample were found to be significantly higher than the national standard (t(0.05/2,1300) = 19.2, P < 0.001 and t(0.05/2,1300y) = 8.0, P < 0.001, respectively). Similarly, the sample’s mean male SDS score (t(0.05/2,990) = 16.98, P < 0.001) and SAS score (t(0.05/2,990) = 6.69, P < 0.001), and the sample’s mean female SDS score (t(0.05/2,309) = 13.51, P < 0.001) and SAS score (t(0.05/2,309) = 6.30, P < 0.001), were each significantly higher than the total national standard. Table 3 shows that of the 1301 study participants, 498 had SDS scores higher than 53, suggesting high depression symptoms in 38.3% of individuals enrolled in the MMT programme [95% confidence interval (CI) = 35.7, 40.9]. Furthermore, 239 participants had SAS scores higher than 50, suggesting high anxiety symptoms in 18.4% of individuals enrolled in the MMT programme (95% CI = 16.3, 20.5). Co-occurring high symptoms of depression and anxiety were present in 185 participants (14.2%; 95% CI = 12.3, 16.1). Factors associated with depression and anxiety
RESULTS Participant demographics, self-reported recent drug use and MMT participation characteristics Overall, 1301 participants completed the study. The average age of participants was 34.6 years [standard deviation (SD) = 6.5 years, ranging from 19 to 58 years]. As shown in Table 1, most participants were male (76.2%), had a middle-school education-level (61.8%) and were unemployed (65.3%). Most participants had been receiving methadone doses of less than 60 mg/day (74.8%). A total of 306 participants (23.7%) selfreported recent drug use, among whom 61.1% (187 of 306) reported injecting drug use and 3.3% (10 of 306) reported sharing injecting equipment (Table 1). On-site urine test When urine samples were screened, a total of 462 participants (35.5%) tested positive for at least one drug and 137 participants tested positive for multiple drugs (10.5%) (Table 1). Positive results for heroin use were most common (27.8%), followed by diazepam (12.5%), ‘crystal’ methamphetamine hydrochloride (5.5%), buprenorphine (0.8%) and MDMA (0.5%). Prevalence of depression and anxiety As summarized in Table 2, mean SDS and SAS scores for the total sample and by gender were compared to the Chinese National Normative Scores for these measures © 2014 Society for the Study of Addiction
As summarized in Table 1, being female (F(1,1299) = 4.67, P = 0.03) and unemployed (F(1,1299) = 18.06, P < 0.001) were associated with higher SDS scores. Being female (F(1,1299) = 4.9, P = 0.03), having a primary school education or less (F(2,1298) = 3.98, P = 0.02), being married or cohabiting (F(2,1298) = 3.2, P = 0.04), being unemployed (F(1,1299) = 19.35, P < 0.001), having positive urine drug test results (F(1,1299) = 5.64, P = 0.02) and receiving methadone doses of greater than 80 mg/day (F(4,1296) = 6.16, P = < 0.001) were all associated with higher SAS scores. No other statistically significant associations were found. Single- and multi-level model analyses (see Tables 1, 4 and 5) were employed simultaneously to identify and compare factors associated with depression and anxiety. Specifically, multi-level mixed-model analyses were applied to control for intracluster correlation (ICC) and to account for cluster effect by clinic and province. In the single-level model, gender (P = 0.03) and employment status (P < 0.001) were associated with depressive symptoms, while in the multi-level model only employment status (P < 0.001) was associated with depressive symptoms. Single-level modelling also showed that gender (P = 0.03), education level (P = 0.02), marital status (P = 0.04), employment status (P < 0.001), positive results for the urine drug test (P = 0.02) and daily methadone dose (P < 0.001) were associated with anxiety symptoms, while in the multi-level model only employment status (P = 0.01) and positive results for the urine drug test (P = 0.04) were associated with anxiety symptoms. Addiction, 110 (Suppl. 1), 51–60
Depression and anxiety among MMT clients
55
Table 1 Comparison of Zung self-rating depression scale scores (SDS) and anxiety (SAS) with demographic, self-reported and on-site urine test of drug use and methadone maintenance treatment (MMT) programme participation characteristics in China.
Charactaristics
n
Self-rating depression scale (SDS) scores
Self-rating anxiety scale (SAS) scores
Mean ± SD*
P
Mean ± SD
0.03
40.62 ± 10.61 42.15 ± 10.72
4.9
0.03
0.42
40.23 ± 10.56 41.20 ± 10.35 41.51 ± 11.71
1.32
0.27
0.97
43.08 ± 11.19 41.08 ± 10.82 40.04 ± 9.99
3.98
0.02
0.29
41.29 ± 10.16 42.49 ± 11.58 40.23 ± 10.86
3.2
0.04
RESEARCH REPORT
doi:10.1111/add.12780
Factors associated with depression and anxiety among patients attending community-based methadone maintenance treatment in China Wenyuan Yin1, Lin Pang1, Xiaobin Cao1, Jennifer M. McGoogan1, Michael Liu1, Congbin Zhang2, Zhijun Li3, Jianhua Li2 & Keming Rou1 National Center for AIDS/STD Control and Prevention, China CDC, Beijing, China,1 Yunnan Institute of Drug Abuse, Kunming, Yunnan, China2 and US CDC Global AIDS Program (GAP), Beijing, China3
ABSTRACT Aim To estimate the prevalence of, and identify factors associated with, depression and anxiety among communitybased methadone maintenance treatment (MMT) clients in China. Design A cross-sectional survey. Setting Nine MMT clinics, three each from three Chinese provinces (Yunnan, Anhui and Jiangsu) between October 2008 and February 2009. Participants A total of 1301 MMT clients. Measurements A questionnaire, including the Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS), and on-site urine drug testing. Findings The prevalence of depression (SDS score ≥ 53) and anxiety (SAS score ≥ 50) in our sample was 38.3% [95% confidence interval (CI) = 35.7, 40.9] and 18.4% (95% CI = 16.3, 20.5), respectively, with 14.2% (95% CI = 12.3, 16.1) displaying symptoms of both. Sample prevalence rates for depression [mean = 49.69, standard deviation (SD) = 10.34] and anxiety (mean = 40.98, SD = 10.66) were higher than the national average for each (t(0.05/2, 1300) = 19.2, P < 0.001 and t(0.05/2, 1300) = 8.0, P < 0.001, respectively). Employing multi-level modelling techniques, gender (P = 0.03) and employment status (P < 0.001) were found to be associated significantly with depression in a single-level model; however, in a multi-level mixed model, only employment status (P < 0.001) was associated with depression. Gender (P = 0.03), education level (P = 0.02), marital status (P = 0.04), employment status (P < 0.001), positive urine drug test results (P = 0.02) and daily methadone dose (P < 0.001) were found to be associated significantly with anxiety in a single-level model, while only employment status (P < 0.01) and positive results for the urine drug test (P = 0.04) were associated with anxiety in a multi-level mixed model. Conclusions A considerable proportion of methadone maintenance treatment clients in China have experienced depression and anxiety during treatment. There is a need to provide tailored mental health interventions for this high-risk population. Keywords
Anxiety, depression, drug user, methadone maintenance treatment, Zung’s Self-Rating.
Correspondence to: Wenyuan Yin, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China. E-mail: [email protected] Submitted April 2012; initial review completed 16 Oct 2012; final version accepted 27 Aug 2014
INTRODUCTION In 2001, up to 66.5% of newly diagnosed HIV infections were related to drug use in China [1]. In recognition of the need for a harm reduction strategy, China’s methadone maintenance treatment (MMT) programme was initiated in 2004 as a small, successful pilot and since 2006 has been operating as a nation-wide programme. So far, China has developed an extensive network of 758 community-based MMT clinics in 28 provinces, which has treated more than 384 500 heroin users cumula© 2014 Society for the Study of Addiction
tively with 208 450 clients still receiving treatment by the end of 2012 [1]. Increasing evidence demonstrates that the MMT programme has resulted in a reduction of heroin use, risky injection practices and criminal behaviours among clients. The MMT programme has also decreased drug-related consumption and trade nationwide and improved the reconciliation of family and social functions [2–4]. Importantly, the MMT programme has effectively curbed the spread of HIV among drug users. Assessment shows that the new HIV infection rate among MMT clients decreased from 0.95% in 2006 to 0.20% in Addiction, 110 (Suppl. 1), 51–60
52
Wenyuan Yin et al.
2012, a decline of 78.9%, suggesting that approximately 11 000 drug users have avoided HIV infection [5]. The national sentinel surveillance data suggests that the HIV infection rate among drug users has declined continually in recent years [6]. This progress in curbing the incidence of HIV infection has provided the impetus for further expansion of the MMT programme in China. However, despite the extensive and successful implementation of the MMT programme in China, many challenges and obstacles remain. The most significant of these are relapse-related dropout and continued use of heroin or other illicit drugs while participating in MMT [2–8]. Notably, both higher dropout and relapse rates have been documented in a growing body of literature among MMT clients with psychiatric problems or disorders [9–13]. Furthermore, there is extensive evidence that psychiatric problems or disorders (i.e. depression, anxiety, post-traumatic stress disorder, schizophrenia, etc.) are more prevalent among drug users than the general population [9,14–17]. While there is continued debate as to whether psychiatric problems or disorders are a cause or a consequence of opiate addiction [10–15], it is clear that they have a close and complex relationship and probably influence each other in a variety of ways over time and across individuals [9–18]. Many studies have suggested that patients with comorbid psychiatric problems or disorders may require higher methadone doses and/or various types of psychosocial interventions to promote retention in MMT programmes, reduce heroin or other illicit drug use and improve overall health outcomes [11–16]. In China, while the issues of MMT drop-out and continued illicit drug abuse during MMT have been recognized and are suggested to be partly the result of a general lack of psychosocial support services [2–8], few studies have directly examined these problems, and present mixed results. For example, a recent study of 500 Chinese heroin users enrolled in MMT found 24 cases of depression (4.8%) and 32 cases of anxiety (6.4%) [19], while a previous study of 134 female Chinese MMT clients found that the estimated prevalence of depression and anxiety was 25 and 61%, respectively [20]. In another study of 300 MMT patients, all of whom had been diagnosed with depression, the severity of symptoms ranged from mild to extreme with roughly 10% identified as suicidal [21]. However, these studies are not directly comparable in terms of different kinds of subjects and measurement tools. In order to improve the quality of MMT services in China (and possibly MMT programmes in other parts of the world), a more thorough assessment of possible comorbid conditions in these clients, such as depression and anxiety, is needed. By understanding the extent of comorbid conditions such as these in MMT clients, researchers and treatment providers will be better posi© 2014 Society for the Study of Addiction
tioned to consider the role of adjunct therapies to complement MMT and improve service outcomes. The purpose of this study was thus to examine the prevalence of, and factors associated with, depression and anxiety among heroin users in community-based MMT programmes in China.
METHODS Study design and setting A cross-sectional survey was conducted between October 2008 and February 2009 among clients from selected MMT clinics through a self-administered questionnaire and on-site urine testing. As provinces in China experience different levels of HIV epidemic, which implies varied transmission modes, service status, social contexts and other social and economic conditions, we used a stratified random sampling method by province and HIV prevalence to control for the influence of these factors. By the end of September 2008 there were 531 clinics, including 16 clinics newly opened in August, and 21 mobile MMT vans in 23 of 31 provinces in China. The number of clinics in each of the provinces varied from one to 67. The number of clients per clinic in each of provinces varied from 57 to 369, with a national average of 162 clients/clinic. The national total number of clients attending MMT was 86 192, with the lowest 114 to the highest 9599, an average 3747 (86 192/23) clients in a province. The national average prevalence of HIV infection among MMT clients was 7.92%, with the lowest 0.3%, medium 1.63% and highest 36.3% in a province. Provinces with a total of fewer than 500 clients or fewer than five MMT clinics were removed from the sampling frame, and four provinces were excluded. The remaining 19 provinces were ranked by the total of clients attending MMT clinics, from the lowest 704 to the highest 9599 clients. Three provinces were selected randomly from the list: Anhui, with eight clinics, 858 clients and 0.71% HIV infection, Jiangsu, with 11 clinics, 3122 clients and 3.12% HIV infection and Yunnan, with 67 clinics, 7452 clients and 25.54% HIV infection, were selected. In each of the provinces, three clinics were selected randomly among those that had been open and operating for more than 1 year. Study participants A total of 1304 MMT clients met the inclusion criteria in this study, with 1301 (99.7%) participants consenting to and completing all aspects of the study, including 450 from Yunnan, 402 from Anhui and 449 from Jiangsu. Participants were included if they met the following eligibility criteria according to the ‘Chinese MMT Program Working Scheme’: Addiction, 110 (Suppl. 1), 51–60
Depression and anxiety among MMT clients
53
1 Dependence on opium drugs according to the third version of the Chinese Classification of Mental Disorder (CCMD-3) [22]. CCMD-3 has 10 categories, from 0 to 9, including: 0, organic mental disorders; 1, mental disorders due psychoactive substances or nonaddictive substances; 2, schizophrenia and other psychotic disorders; 3, mood (affective) disorders; 4, hysteria, stress-related disorders, neurosis; 5, physiological disorders related to psychological factors; 6, personality disorders, habit and impulse disorders, psychosexual disorders; 7, mental retardation and disorders of psychological development with onset usually occurring in childhood and adolescence; 8, hyperkinetic, conduct, and emotional disorders with onset usually occurring in childhood and adolescence; and 9, other mental disorders and psychological health conditions. Enrolled in a MMT programme in one of the nine selected study sites for at least 1 month and received a stable treatment course when the study started on site. 2 At least older than 18 years. 3 Provision of informed consent.
level of depression or anxiety symptoms. The higher the score, the more severe the depression or anxiety status, which is consistent with Zung’s method. Both Zung’s selfrating scales and the cutoff points described have been used extensively in studies of depression and anxiety in China, and the Chinese translations of these surveys have been validated previously [26,27].
Measurement of depression and anxiety
Urine collection and testing
For the purposes of this study, Zung’s depression selfrating scale (SDS) and Zung’s anxiety self-rating scale (SAS) [23,24] served as assessment tools reflecting the possible severity of symptoms of depression and anxiety reported by participants, rather than as diagnostic criteria for psychiatric disorder. The SDS and SAS examine the severity of depression and anxiety symptoms for individuals, respectively, during the 7 days prior to completing the measure. Both measures contain 20 self-report items scored on a Likert-type scale of 1–4, with a total score range of 20–80. SDS scores of 20–44 are ‘normal’, while scores of 45–59 indicate mild depression symptoms, scores of 60–69 indicate moderate depression symptoms and 70+ suggests severe depression symptoms. Similarly, SAS scores of 20–44 are ‘normal’, while scores of 45–59 indicate mild anxiety symptoms, scores of 60–75 indicate moderate anxiety symptoms and scores of 75+ suggest severe anxiety symptoms. As the aim of the current study is to determine the prevalence of significant self-reported depression and anxiety symptoms, cutoff points were used to determine ‘high’ scores to contribute to prevalence estimates. Based on Zung’s classification criteria of levels of severity, psychiatry professionals in China have adapted SDS scores greater than 53 and SAS scores greater than 50 as the cutoff points for symptom severity associated with depression and anxiety disorders, respectively, when conducting assessment, screening or large-scale investigations in terms of Chinese National Normative Scores [25]. These cutoff scores indicate at least a middle–mild
Following completion of the questionnaire, participants also provided an on-site urine sample for testing, which was strictly supervised to ensure authenticity. All urine samples were tested immediately on-site using a rapid urine testing kit (Acon Biotech Co., Ltd, Hangzhou, China), which was validated for the accurate detection of five drugs, namely heroin/morphine, diazepam, ‘crystal’ methamphetamine hydrochloride, 3,4-methylenedioxyN-methylamphetamine (MDMA, also known as ecstasy) and buprenorphine. Detection of any one of these five substances was defined as fulfilling the criteria for positive drug test results. A positive drug test result, but not the presence of each individual drug type, was included as an independent predictor of depression or anxiety in analyses.
© 2014 Society for the Study of Addiction
Interviews SDS and SAS assessments were administered with the assistance of interviewers, due to the relatively low level of literacy among our participants of MMT clients. Prior to the commencement of this study, clinic staff members were trained as interviewers to follow a set of protocols to ensure consistent interviewing as well as to help participants understand the questions so that they could answer truthfully. Participants, assisted by trained interviewers, completed the confidential questionnaire in private. In addition to the SDS and SAS measures, the questionnaire also collected information on participants’ demographic characteristics, self-reported recent drug use and most recent MMT programme participation.
Statistical analysis Study data were collected and organized in a database created using EpiData software version 3.02 (EpiData Association, Odense, Denmark)) and double-entry was performed to check for and correct any errors. A series of one-way analyses of variance (ANOVA) were performed to examine group differences between SDS, as well as SAS, scores by demographics (e.g. gender, age, education), recency of drug use and MMT programme participation characteristics; t-tests were also performed to compare the average SDS and SAS scores for the total sample with the Chinese National Normative Scores for Addiction, 110 (Suppl. 1), 51–60
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Wenyuan Yin et al.
these measures [25]. Finally, single- and multi-level mixed-model analyses were employed simultaneously and compared to identify the factors associated with depression and anxiety. SDS and SAS scores were employed as dependent variables, while gender, employment status, education level, urine drug test results and MMT programme participation characteristics (including daily methadone dose) were employed as independent variables for both singleand multi-level mixed-model analyses (α < 0.05 level). Single-level statistical analyses were performed using SAS software version 9.1 (SAS Institute, Cary, NC, USA), while multi-level mixed-model analyses were performed using the SAS version 9.3 mixed module. Ethical approval This study was reviewed and approved by the Institutional Review Board (IRB) of the National Center for AIDS/STD Control and Prevention (NCAIDS) of the Chinese Center for Disease Control and Prevention (Chinese CDC). All participants provided informed consent for both the questionnaire and urine sample collection.
[26]. Both the total mean SDS score (mean = 49.69, SD = 10.34) and the total mean SAS score (mean = 40.98, SD = 10.66) for the study sample were found to be significantly higher than the national standard (t(0.05/2,1300) = 19.2, P < 0.001 and t(0.05/2,1300y) = 8.0, P < 0.001, respectively). Similarly, the sample’s mean male SDS score (t(0.05/2,990) = 16.98, P < 0.001) and SAS score (t(0.05/2,990) = 6.69, P < 0.001), and the sample’s mean female SDS score (t(0.05/2,309) = 13.51, P < 0.001) and SAS score (t(0.05/2,309) = 6.30, P < 0.001), were each significantly higher than the total national standard. Table 3 shows that of the 1301 study participants, 498 had SDS scores higher than 53, suggesting high depression symptoms in 38.3% of individuals enrolled in the MMT programme [95% confidence interval (CI) = 35.7, 40.9]. Furthermore, 239 participants had SAS scores higher than 50, suggesting high anxiety symptoms in 18.4% of individuals enrolled in the MMT programme (95% CI = 16.3, 20.5). Co-occurring high symptoms of depression and anxiety were present in 185 participants (14.2%; 95% CI = 12.3, 16.1). Factors associated with depression and anxiety
RESULTS Participant demographics, self-reported recent drug use and MMT participation characteristics Overall, 1301 participants completed the study. The average age of participants was 34.6 years [standard deviation (SD) = 6.5 years, ranging from 19 to 58 years]. As shown in Table 1, most participants were male (76.2%), had a middle-school education-level (61.8%) and were unemployed (65.3%). Most participants had been receiving methadone doses of less than 60 mg/day (74.8%). A total of 306 participants (23.7%) selfreported recent drug use, among whom 61.1% (187 of 306) reported injecting drug use and 3.3% (10 of 306) reported sharing injecting equipment (Table 1). On-site urine test When urine samples were screened, a total of 462 participants (35.5%) tested positive for at least one drug and 137 participants tested positive for multiple drugs (10.5%) (Table 1). Positive results for heroin use were most common (27.8%), followed by diazepam (12.5%), ‘crystal’ methamphetamine hydrochloride (5.5%), buprenorphine (0.8%) and MDMA (0.5%). Prevalence of depression and anxiety As summarized in Table 2, mean SDS and SAS scores for the total sample and by gender were compared to the Chinese National Normative Scores for these measures © 2014 Society for the Study of Addiction
As summarized in Table 1, being female (F(1,1299) = 4.67, P = 0.03) and unemployed (F(1,1299) = 18.06, P < 0.001) were associated with higher SDS scores. Being female (F(1,1299) = 4.9, P = 0.03), having a primary school education or less (F(2,1298) = 3.98, P = 0.02), being married or cohabiting (F(2,1298) = 3.2, P = 0.04), being unemployed (F(1,1299) = 19.35, P < 0.001), having positive urine drug test results (F(1,1299) = 5.64, P = 0.02) and receiving methadone doses of greater than 80 mg/day (F(4,1296) = 6.16, P = < 0.001) were all associated with higher SAS scores. No other statistically significant associations were found. Single- and multi-level model analyses (see Tables 1, 4 and 5) were employed simultaneously to identify and compare factors associated with depression and anxiety. Specifically, multi-level mixed-model analyses were applied to control for intracluster correlation (ICC) and to account for cluster effect by clinic and province. In the single-level model, gender (P = 0.03) and employment status (P < 0.001) were associated with depressive symptoms, while in the multi-level model only employment status (P < 0.001) was associated with depressive symptoms. Single-level modelling also showed that gender (P = 0.03), education level (P = 0.02), marital status (P = 0.04), employment status (P < 0.001), positive results for the urine drug test (P = 0.02) and daily methadone dose (P < 0.001) were associated with anxiety symptoms, while in the multi-level model only employment status (P = 0.01) and positive results for the urine drug test (P = 0.04) were associated with anxiety symptoms. Addiction, 110 (Suppl. 1), 51–60
Depression and anxiety among MMT clients
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Table 1 Comparison of Zung self-rating depression scale scores (SDS) and anxiety (SAS) with demographic, self-reported and on-site urine test of drug use and methadone maintenance treatment (MMT) programme participation characteristics in China.
Charactaristics
n
Self-rating depression scale (SDS) scores
Self-rating anxiety scale (SAS) scores
Mean ± SD*
P
Mean ± SD
0.03
40.62 ± 10.61 42.15 ± 10.72
4.9
0.03
0.42
40.23 ± 10.56 41.20 ± 10.35 41.51 ± 11.71
1.32
0.27
0.97
43.08 ± 11.19 41.08 ± 10.82 40.04 ± 9.99
3.98
0.02
0.29
41.29 ± 10.16 42.49 ± 11.58 40.23 ± 10.86
3.2
0.04
