Prevalence of depressive symptoms among the clients maintained in methadone maintenance treatment programme at Tribhuvan University Teaching Hospital

Introduction: Depression is widely prevalent among the former opioid addicts in Methadone Maintenance Treatment (MMT). It is important to be aware of its severity as it plays a crucial role in methadone dosage, length of time in treatment and the relapse rate. The co-existence of depression is seen to worsen the prognosis in outcome of MMT. Objective: This study aimed to study the prevalence of the symptoms of depression among MMT clients. Method: This is a descriptive and Cross-Sectional study done in 60 MMT clients attending the out patients clinic in Tribhuwan University Teaching Hospital, Nepal. A structured proforma was constructed obtaining the data regarding age, sex, religion, occupation, marital status, literacy rate and socio-economical status. Depressive symptoms were evaluated using 21-item BDI scale. Result: Depressive symptoms were found in 63.3 % of the patients. 38.3% had mild to moderate depression, 15% had moderate to severe, and 11.7% had severe level of depressive symptoms. The depressive symptoms were most prevalent among females (90%) and age group 40-50 years. The prevalence of depressive symptoms were more in unmarried (82%), unemployed(65%), lower socio-economic class(71%) and completing only secondary level in education(73%). Conclusion: The major risk factors for depression among former opioid users were female gender, unmarried, low education level, unemployment and low socio-economic status.


INTRODUCTION
Substance users are the individuals who abuse opioids, alcohol, cocaine, benzodiazepines, caffeine, nicotine etc. Methadone is a long acting opioids which is used as the treatment for opioid users.Patients taking methadone remains physically dependent on methadone and withdrawal from methadone is much slower than opioids avoiding serious side effects.Methadone has cross tolerance with other opioids as well establishing itself as a well-tested safe treatment for all opioids withdrawals.Substance users are seen to have various psychiatric and personality disorders.These disorders can be anxiety, depression, psychosis, neurosis, antisocial or personality disorders. 1,2,3ubstance users are also found to have higher criminal record and higher prevalence of HIV infection.Some psychiatric disorders preceded the onset of drug dependence while others are precipitated by the chronic drug use. 4,5Clinical studies have shown that half of the opioid dependent individuals report lifetime depression, whereas one-third have depressed mood during drug abuse to addiction therapy. 3,4,5The prevalence of psychiatric comorbidity among opioid users is relevant to treatment provider as client respond poorly to treatment.It has also been found that severity of psychiatric co-morbidity is inversely proportionate to the degree of treatment success.

MATERIAL AND METHOD
This was a cross sectional and descriptive study conducted in Methadone clinic of Tribhuwan University Teaching Hospital which is operated by Psychiatric Department.60 former opioid user Clients attending the Methadone clinic for a period of 4 months were taken into study.Every case was explained about the purpose of the study and the verbal consent was taken.Data were collected regarding the patient's age, gender, marital status, occupation, education and socio economic status.A semi-structured pro-forma was filled up containing questionnaire of Beck Depression Inventory (BDI).The collected data was profiled using Microsoft Excel worksheet and analyzed using SPSS software version 11.5.Inclusion criteria were clients on regular Methadone maintenance treatment program for at least four months and methadone Clients who gave written consents for participating in the study.Methadone clients using other psychoactive substances like alcohol, cannabis, brown sugar etc. besides methadone were excluded from the study.Methadone maintenance clients diagnosed with medical illness like HIV, chronic hepatitis with B or C virus, diabetes mellitus, Hypertension, stroke, cardiac disease etc. or surgical illness like cellulitis, abscess, deep vein thrombosis etc. were also excluded from the study.

RESULT
Majority of the clients in MMTP belonged to age group 30-39 (50%) years.Most of the patients 96.7% of cases were male and only 3.3% were female.About 46.7 % of the methadone maintenance clients were unmarried and 18% were separated.In this study majority of cases were Newars (56%) followed by Mongolians, Chhetris and Brahmins with 16.7%, 16.7% and 10% respectively.Around 75% of cases were Hindus, 6.7% were Buddhists and 18.3% were Muslims.38.3% of cases had finished their secondary level education with 33.3% completing higher level ( graduates and post graduates).Majority of cases in our study attending MMTP were unemployed (65%), 17% were in business, 13% were clerks and 5% were students.81% of patients belonged to middle class group and 11.7% belonged to lower class group.(

DISCUSSION:
In our study there were very few females (3.3%) in comparison to males.Weissman et al, in 1976 had 79% of Methadone Maintenance clients as males 6 .Karki et al in Nepal also found only 4 females using illicit drug in 1108 clients in Nepal in 1999. 7The majority of our clients in MMTP were of age group 30-39 years (50%).These could be because most people start using opioids in early teens and adolescence period and are dependence by the time they are in thirties and forties.The dominance of Newars (56.7%) in our study is because this study was conducted in Kathmandu valley where majority of people are Newars.
Figure 2: Distribution according to different levels of weighted score of Beck depression inventory (BDI).
Till date no studies has been conducted in Nepal to see the prevalence of depression among Methadone Maintenance Treatment Program (MMTP) patients.Thus this study was carried out to see the prevalence of Depressive symptoms among MMTP clients in Methadone Clinic in Tribhuwan University Teaching Hospital, Nepal which is one of the only two Methadone Clinics in Nepal.

Table 1 )
In this study, 63.3% of the cases had symptoms of depression with varying severity.According to different level of weighted score of Beck