ORIGINAL ARTICLE
Year : 2021 | Volume
: 3 | Issue : 3 | Page : 195--202
Psychiatric and Substance Use Comorbidities among People who Inject Drugs in India: A Cross-Sectional, Community-Based Study
Romil Saini1, Arpit Parmar2, Ravindra Rao1, Ashwani Kumar Mishra1, Atul Ambekar1, Alok Agrawal1,
1 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Drug De-Addiction and Treatment Centre, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Correspondence Address:
Dr. Ravindra Rao
Department of Psychiatry, National Drug Dependence Treatment Centre, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
India
Abstract
Background: People who Inject Drugs (PWID) show higher rates of comorbid psychiatric illnesses than the general population. We aimed to assess the rates of different psychiatric disorders and substance dependence among PWID in the state of Delhi, India. Methods: We conducted a community-based, cross-sectional study interviewing 104 adult male participants receiving various harm reduction and HIV prevention services. A semi-structured questionnaire assessed socio-demographics, drug use and injecting patterns, and opioid overdose experience. Mini-International Neuropsychiatric Interview Version 7.0.2 (for screening and diagnosing major psychiatric disorders), World Health Organization-Alcohol, Smoking, and Substance Involvement Screening Test for the pattern of other psychoactive substance use were used. Results: The mean age of participants was 27.9 years. The predominant opioid injected in the last 1 year was heroin. About 52% of participants had at least one psychiatric illness during their lifetime. Antisocial personality disorder (25%) was the most common psychiatric illness followed by suicidality (23.1%). About 23.1% had more than one psychiatric comorbidity other than substance use disorder. Being unskilled (χ2 = 11.39; P = 0.03), having early mean age of tobacco onset (t = −2.416; P = 0.02), longer duration of tobacco (t = 2.033; P = 0.04), alcohol (t = 2.204; P = 0.03) use, less abstinent attempts for opioid use (χ2 = 5.003; P = 0.03), longer duration of injecting drug use (t-test = 2.437; P = 0.02), higher vein-related complications (χ2 = 9.27; P = 0.02), high HIV positivity rate (χ2 = 8.54; P = 0.01), and high rates of nonfatal opioid overdose over lifetime (χ2 = 4.87; P = 0.03) were significantly associated with having lifetime psychiatric illness. Conclusion: Our study found high rates of psychiatric illnesses and the use of other psychoactive substances among PWID from India. There is an urgent need to incorporate mental health services into the existing HIV prevention services directed at PWID in India.
How to cite this article:
Saini R, Parmar A, Rao R, Mishra AK, Ambekar A, Agrawal A. Psychiatric and Substance Use Comorbidities among People who Inject Drugs in India: A Cross-Sectional, Community-Based Study.World Soc Psychiatry 2021;3:195-202
|
How to cite this URL:
Saini R, Parmar A, Rao R, Mishra AK, Ambekar A, Agrawal A. Psychiatric and Substance Use Comorbidities among People who Inject Drugs in India: A Cross-Sectional, Community-Based Study. World Soc Psychiatry [serial online] 2021 [cited 2023 Mar 23 ];3:195-202
Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/3/195/333422 |
Full Text
Introduction
Psychiatric illnesses are a major source of morbidity and mortality globally.[1],[2] Many factors such as difficult childhood, traumatic experiences in the past, unemployment, unstable housing, homelessness, legal problems, and the presence of other chronic health problems are commonly associated with injecting drug use and can act as risk factors for psychiatric illnesses development in People Who Inject Drugs (PWID).[3] Many studies, including systematic reviews and meta-analysis, have reported high comorbidity of psychiatric illnesses among PWID. A recent systematic review and meta-analysis reported that 28.7% of PWID had a diagnosable depressive disorder, while 42% reported current severe depressive symptomatology.[4] Similarly, suicide attempts were also high, with almost 29% PWID reporting at least one suicide attempt in their lifetime. Apart from depression and suicide, anxiety disorders, personality disorders, and other substance use disorders (SUDs) are also highly prevalent in PWID.[5]
India has a large population of PWID. As per the recent national survey, there are almost 850,000 PWID in India.[6] Most PWID in India use opioids and are dependent on opioids.[7] Despite this, little is known about psychiatric illnesses among PWID in India. Some studies have been conducted on psychiatric illnesses among PWID in India. However, these studies have focused on some psychiatric disorders or have used screening questionnaires such as Patient Health Questionnaire-9 and Generalized Anxiety Disorder (GAD-2) for psychiatric assessment.[8],[9],[10],[11] Only one study from the North-Eastern region of India has used a structured instrument (Mini-International Neuropsychiatric Interview, MINI) to assess psychiatric illnesses among PWID. The study reported antisocial personality disorder to be the most common comorbidity (85.7%), followed by depression (61.9%).[12]
Co-morbid psychiatric illnesses in PWID are associated with poorer behavioral, substance use, and psychiatric outcomes. For example, psychiatric illness, especially depression, is a known risk factor for fatal and nonfatal opioid overdose among PWID.[13],[14],[15] Depression is also associated with HIV risk behaviors such as needle and syringe sharing among PWID.[11] Thus, it is important to assess psychiatric disorders in PWID in a systematic manner to address their specific needs. Keeping this background in mind, we aimed to determine rates of different psychiatric disorders and psychoactive substance use among PWID in the state of Delhi, North India.
Methods
This study was a part of a cross-sectional, observational study to assess the prevalence and knowledge of opioid overdose among PWID.[16] It was conducted over 6 months in 2017–2018 among PWID receiving various harm reduction and HIV prevention services at a nongovernmental organization (NGO) in New Delhi, India, supported through the National AIDS Control Programme (NACP) of India. The HIV prevention services provided through the NGOs include needle syringe exchange, distribution of abscess prevention materials, condom distribution, referral for HIV testing and treatment, regular medical check-ups, etc., The NGOs also maintain a Drop-in-centre which provides abscess management, treatment of sexually transmitted diseases, and counseling services to the PWID.
Male PWID aged 18 years or more, registered with the NGO and currently receiving HIV prevention services from the NGO, were considered for the study. Those on opioid agonist maintenance treatment (OAMT) and those who refused to provide written consent were excluded. OAMT is a known protective factor against opioid overdose; hence, those on OAMT were excluded in keeping with the primary objectives of the study. More than 850 PWID were found to be registered as active clients (i.e., having received HIV prevention services at least once in the last 6 months). To recruit about 100 PWID, a list of 150 potential participants was generated using a simple random table. Sixteen of these 150 PWID from the list could not be traced, 23 PWID were on OAMT, and another seven declined to participate in the study. Thus, we could include 104 PWID for our study. After written informed consent, each participant was interviewed in a single session of around 45 min using semi-structured and structured tools. The data was collected by the first author. The study was conducted after receiving approval from the Ethics Committee of the authors' institution (IECPG-14/16.02.2017, RT-24/22.03.2017 dated 29.03.2017). Those participants who were found to have psychiatric illnesses were provided with appropriate psychiatric consultations after the interview, especially for those with high-risk suicidality; family members were contacted and psycho-educated about the illness and need for continued supervision and urgent psychiatric intervention.
Measures
A semi-structured questionnaire was used to assess socio-demographic profile, the pattern of psychoactive substance use in terms of age of initiation of each drug, duration, abstinence, treatment-seeking, the pattern of injecting drug use, HIV-testing and status, the experience of opioid overdose ever in life or within the past year. To assess the comorbid psychiatric illnesses, MINI Version 7.0.2 was used. It is a brief structured interview for screening and diagnosing major psychiatric disorders in DSM-IV and ICD-10, and DSM-5 (latest version 7.0.2).[17] The other instruments used included the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for the assessment of lifetime use of substances and associated problems over the past 3 months. The scores represent lower, moderate, and high risks of problems associated with particular substance use.[18] The severity of opioid dependence was assessed using the Leeds Dependence Questionnaire (LDQ) which was translated (and back-translated) to the Hindi language before administration.[19]
Statistical analysis
Data were analyzed using licensed SPSS 21.0 version software (IBM Corp 2012, Armonk, NY, USA). Descriptive statistics for the continuous variables were expressed as mean (standard deviation [SD]) or median (interquartile range), while the categorical variables were expressed as frequencies (with percentages). To study the correlates of psychiatric comorbidity, two-group comparisons of quantitative variables among the group with “any psychiatric illness” versus those with “no psychiatric illness” (other than opioid use disorder), an independent sample t-test/Mann–Whitney U was used. The bivariate distribution was summarized through the contingency table (depending on frequency distribution), and its test of significance was tested by the Chi-square test or Fisher's exact test. The P < 0.05 was considered statistically significant.
Results
Sociodemographics
The mean age of the participants was 27.9 (SD = 8.4) years. About 51.9% (n = 54) were in the age group of 18–25 years. Most participants were unmarried (53.8%, n = 56) and had schooling up to fifth grade (63.7%, n = 70). The majority of the participants were residing in an urban slum area (83.7%, n = 87). About half of the participants were not employed in any gainful work (51.9%, n = 54) and 43.3% (n = 45) were involved in unskilled work, and a large majority of them (91.3%, n = 95) had monthly income <10,000 rupees (USD 136 approximately) [Table 1].{Table 1}
Pattern of opioid use and injecting drug use
All participants had misused opioids in their lifetime. The mean age of onset of opioid use was 17.87 (SD = 3.74) years, with a mean duration of use of 10.17 (SD = 6.34) years. About 80.8% (n = 84) of participants had cut-off score ≥20 on LDQ suggesting severe dependence. The mean LDQ score for all participants was 21.12 (SD = 3.76). Almost all participants had used heroin in their lifetime (99%, n = 103), with the mean age of onset for heroin use at 17.39 (SD = 4.06). About 90.4% (n = 94) had used heroin within the past year. The mean age of initiation of injecting drug use was 20.86 (SD = 5.35) years. The median duration of injecting drug use was six (interquartile range [IQR]: 1,3) years. Most participants used heroin (71.2%, n = 74) as the predominant opioid for injecting in the last 1 year, followed by buprenorphine (28.8%, n = 30). The sharing and reuse of needles/syringes and injection paraphernalia present among 93.3% (n = 97) and 96.1% (n = 100) participants respectively, vein-related complications among 70.2% (n = 73) participants with a HIV positivity rate of 43.3% (n = 45) [Table 2]. The mean score of opioid use on World Health Organization (WHO)-ASSIST was 34.92 (SD = 3.05).{Table 2}
Pattern of other psychoactive substance use
All participants reported tobacco use in their lifetime. About 90.4% (n = 94) and 89.4% (n = 93) participants reported using alcohol and cannabis ever in their lifetime, respectively. Lifetime use of sedative/hypnotics and inhalants was reported by 61.5% (n = 64) and 46.2% (n = 48) participants, respectively. Cocaine, hallucinogen, or stimulants were used by a small proportion of participants (9.6%, 1.9%, and 1.0%, respectively). [Table 2] shows the mean age of onset and duration of other psychoactive substances among study participants. The mean WHO-ASSIST score for tobacco was 15.02 (SD = 4.6), with most participants in the moderate-risk category (99%, n = 103). About 90.4% (n = 94) and 89.4% (n = 93) of participants reported using alcohol and cannabis ever in their lifetime, respectively. More than half of the participants were in the moderate-risk category for cannabis use (n = 56; 53.8%), followed by the low-risk category (n = 42; 40.4%). The mean WHO-ASSIST scores for alcohol use was 2.55 (SD: 3.2), with no participant scoring in the high-risk category [Table 3].{Table 3}
Other clinical variables related to substance use
About 67.3% (n = 70) of participants reported a history of at least one significant abstinence attempt in the past. Only half (n = 53) of the participants had taken treatment for their opioid use disorder in the past in the form of either OAMT or naltrexone therapy as outpatient or admission at drug dependence treatment center. The median numbers of abstinent attempts were two (IQR: 1, 3).
A large majority of participants (94.2%, n = 98) participants had a family history of substance use. The common psychoactive substances reported to be used by the family member were tobacco (77.9%, n = 81), alcohol (25%, n = 26), heroin (15.4%, n = 16), and cannabis (14.4%, n = 15)., Most of them (67.3%, n = 70) had a brother who was using a psychoactive substance. Around 8.7% (n = 9) of participants reported having a history of injecting drug use in their brother.
Comorbid psychiatric illness
More than half (51.9%, n = 54) of the participants had at least one psychiatric illness during their lifetime as evaluated using MINI version 7.0.2, apart from the diagnosis of SUDs. Lifetime diagnosis of antisocial personality disorder was highest among the participants (n = 26; 25%), followed by suicidality, which was present among 24 participants (23.1%), of which three participants (2.8%) showed current suicidality, i.e., within past 1 month. The severity scores were high in two of these participants. The major depressive episode was found among 14 participants (13.5%), of which 10 participants (9.6%) met the criteria for a current episode. All the three participants who showed current suicidality also met the criteria for a current major depressive episode. Around 13.4% (n = 14) participants had been found to have various anxiety disorders over the last 1 month, of which seven participants met the criteria for panic disorder, six for agoraphobia, and one participant met the criteria for GAD. None of the participants met the criteria for current obsessive-compulsive disorder or posttraumatic stress disorder and any manic episode or psychotic disorder currently or in the past. About 23.1% (n = 24) of the participants were found to have more than one psychiatric comorbidity other than SUDs. [Table 4] shows the frequency of various psychiatric disorders in our study participants according to the MINI.{Table 4}
Association of psychiatric illness among people who inject drugs with other variables
Group comparison between two groups those having lifetime “any psychiatric illness” versus “no psychiatric illness” (other than opioid use disorder) showed a significantly higher proportion of unskilled individuals in the former group (χ2 = 11.39; P = 0.03). PWID with a history of any psychiatric illness had a significantly earlier mean age of onset for tobacco use (t = −2.416; P = 0.02), a significantly longer duration of tobacco (t = 2.033; P = 0.04) and alcohol use (t = 2.204; P = 0.03) compared to PWID with no psychiatric illness. The group with no psychiatric illness had a significantly higher proportion of participants with a history of past abstinence attempts from opioid use (χ2 = 5.003; P = 0.03). There were no significant differences between the two groups in terms of ASSIST scores of tobacco, alcohol, cannabis, sedative/hypnotics, and opioids use. A significantly longer duration of injecting drug use (t-test = 2.437; P = 0.02), higher vein-related complications (χ2 = 9.27; P = 0.02), and higher HIV positivity rates were found in the group with psychiatric illness (χ2 = 8.54; P = 0.01). The group with psychiatric illness had significantly high lifetime rates of nonfatal opioid overdose (χ2 = 4.87; P = 0.03) [Table 2].
Discussion
The present study is among a few studies that have focused on assessing rates of psychiatric illnesses and other substance use among PWID in a community setting. The study used a randomly selected sample of PWID receiving HIV prevention and other harm reduction services and assessed psychiatric illnesses using a structured, standard instrument commonly used to assess psychiatric illness.[20],[21] Our study reported high rates of co-morbid tobacco, alcohol, and cannabis use, antisocial personality disorder, and depression. Suicidality was also disconcertingly common in our sample of PWID.
Our participants' socio-demographic profile is similar to the previous studies on PWID in India.[7],[12] The rates of common mental disorders among PWIDs in our study were higher than the general population. The National Mental Health Survey of India (NMHS), 2015–2016, a general population-based survey, reported the lifetime prevalence of depressive disorders in the general population as 5.3%, which is almost three times lower than what has been found in our study. Similarly, the rates of current depressive disorder and anxiety disorder reported in NMHS were 2.7% and 3.5%, respectively, which are almost three-four times lower than our study rates. The risk of suicide in the general population had been reported to be 0.9% compared to 23.4% suicidality among PWID in our study.[20] Almost similarly high suicidality rates were found in another study among PWIDs in New Delhi, India.[22] A systematic review reported pooled estimates for current severe depressive symptomatology to be 42%, while depression diagnosis was found in 28.7% of PWID.[4] The review also reported the rate of suicide attempts to be 22.1%. On the other hand, a study from North-East India reported much higher estimates: antisocial personality disorder (85.7%), depression (61.9%), anxiety disorder (41%), and psychosis (23.8%).[12] Another study from Delhi reported 84% prevalence of depression and 71% prevalence of anxiety among male PWID.[8] The differences might be attributable to multiple factors, including differences in the methodology (e.g., the inclusion of only male participants, community sample, and use of more structured assessment using MINI), or differences in the overall profile of injecting drug use. Given the high prevalence of psychiatric illnesses among PWID, this study demonstrates the need for mental health screening in this population.
PWID who experience negative affect may develop maladaptive thoughts compromising their motivation to take self-care and avoid the negative consequences of high-risk behaviors.[23],[24],[25] This was reflected in our study as well, where PWID with a psychiatric illness were different in many clinical parameters compared to those with no such history. There were differences in the pattern of use of other substances, specifically tobacco, alcohol, and sedative/hypnotics, and duration of injecting drug use between those with and without a history of psychiatric illness. Furthermore, the PWID with psychiatric illnesses tried to abstain from opioids significantly less compared to PWID without psychiatric illness. The rates of HIV were also considerably higher among this group of PWID. A study from Delhi reported that PWID with depressive symptoms and suicidal thoughts are more likely to share needles and syringes. Similarly, those with suicidal ideations were five times more likely to have unprotected sex with a female paid sex partner.[9] The rates of nonfatal opioid overdose were also higher among those with a history of psychiatric illness, which is also reported in many previous studies.[15] Thus, the findings show that PWID with psychiatric illnesses have higher high-risk behaviors that can put them at risk for blood-borne infections and overdose episodes.
The high rates of psychiatric illnesses and other substance use have important implications for PWID treatment and care. A growing literature has shown the association of mental disorders like depression with injecting drug use among PWIDs with more involvement in HIV-related risk behaviors, failure to access HIV care and treatment, poor adherence to antiretroviral therapy, and also increase in morbidity and mortality.[26],[27] In India, two distinct entities provide harm reduction services under the NACP. The NGOs supported through NACP largely provide needle syringe programs and other HIV prevention services.[28] The Opioid substitution therapy (OST) is mostly provided in Government hospitals by a nonspecialist medical officer. In both these settings, mental health issues are neither diagnosed nor addressed. The present study shows that it is important to address mental health issues to reduce potential HIV-related burden as well as other potentially life-threatening conditions such as opioid overdose. Unfortunately, there is a dearth of psychiatrists and psychologists in India.[29] In such conditions, it is important to train the existing staff on diagnosing and primary-care level management of mental health problems.
Our study has some limitations as well. The study was conducted in a single-center, and hence the findings might not be generalizable. The study employed a cross-sectional design, and hence causality cannot be inferred. The use of the harm reduction site for participant recruitment means that we have recruited those PWID who are availing services. The study's findings may not apply to those PWID who are not in receipt of some services; they may have different rates of psychiatric illness as the sample selected.
Conclusion
The present study documents high rates of psychiatric illnesses and the use of other psychoactive substances among PWID from India. Further, our study also reports higher HIV and opioid overdose rates among PWID with a history of psychiatric illness. Our study, thus, highlights the need for incorporating mental health services into the existing harm reduction and OST services directed at PWID in India.
Acknowledgment
The authors acknowledge the support of the National AIDS Control Organization and the Delhi AIDS Control Society. The authors also acknowledge NGO “Bhartiya Parivartan Sansthan” from where the recruitment of participants was done.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
| 1 | Rehm J, Shield KD. Global burden of disease and the impact of mental and addictive disorders. Curr Psychiatry Rep 2019;21:10. |
| 2 | Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry 2015;72:334-41. |
| 3 | Minh KP, Vallo R, Thi HD, Hai OK, Des Jarlais DC, Peries M, et al. Psychiatric comorbidities among people who inject drugs in Hai Phong, Vietnam: The need for screening and innovative interventions. Biomed Res Int 2018;2018:8346195. |
| 4 | Colledge S, Larney S, Peacock A, Leung J, Hickman M, Grebely J, et al. Depression, post-traumatic stress disorder, suicidality and self-harm among people who inject drugs: A systematic review and meta-analysis. Drug Alcohol Depend 2020;207:107793. |
| 5 | Mackesy-Amiti ME, Donenberg GR, Ouellet LJ. Prevalence of psychiatric disorders among young injection drug users. Drug Alcohol Depend 2012;124:70-8. |
| 6 | Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK. Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019. Available from: http://socialjustice.nic.in/writereaddata/UploadFile/Magnitude_Substance_Use_India_REPORT.pdf. [Last accessed on 2019 Sep 20]. |
| 7 | Ambekar A, Rao R, Mishra AK, Agrawal A. Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs. Drug Alcohol Rev 2015;34:97-104. |
| 8 | Armstrong G, Nuken A, Samson L, Singh S, Jorm AF, Kermode M. Quality of life, depression, anxiety and suicidal ideation among men who inject drugs in Delhi, India. BMC Psychiatry 2013;13:151. |
| 9 | Armstrong G, Jorm AF, Samson L, Joubert L, Nuken A, Singh S, et al. Association of depression, anxiety, and suicidal ideation with high-risk behaviors among men who inject drugs in Delhi, India. J Acquir Immune Defic Syndr 2013;64:502-10. |
| 10 | Armstrong G, Jorm AF, Samson L, Joubert L, Singh S, Kermode M. Suicidal ideation and attempts among men who inject drugs in Delhi, India: Psychological and social risk factors. Soc Psychiatry Psychiatr Epidemiol 2014;49:1367-77. |
| 11 | Sabri B, McFall A, Solomon S, Srikrishnan AK, Vasudevan CK, Anand S, et al. Gender differences in factors related to HIV risk behaviors among people who inject drugs in North-East India. PLoS One 2017;12:e0169482. |
| 12 | Mawiong AM, Senjam GS, Haobam M, Singh NH, Khongji P. A. A study of psychiatric comorbidities among treatment seeking opioid injectors attending tertiary care teaching hospital, Imphal for a period of 2 years. J Med Soc 2018;32:174-7. |
| 13 | Chahua M, Sordo L, Barrio G, Domingo-Salvany A, Brugal MT, Molist G, et al. Non-fatal opioid overdose and major depression among street-recruited young heroin users. Eur Addict Res 2014;20:1-7. |
| 14 | Pabayo R, Alcantara C, Kawachi I, Wood E, Kerr T. The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting. Drug Alcohol Depend 2013;132:603-9. |
| 15 | Warfield SC. Characteristics and Patterns of Opioid-related Overdoses among Veterans; 2019. Available from: https://researchrepository.wvu.edu/etd/3902 [Last accessed on 2020 Jul 13]. |
| 16 | Saini R, Rao R, Parmar A, Mishra AK, Ambekar A, Agrawal A, et al. Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study. Drug Alcohol Rev 2020;39:93-7. |
| 17 | Sheehan DV, Lecrubier Y, Harnett K, 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. |
| 18 | WHO ASSIST Woeking Group. The alcohol, smoking and substance involvement screening test (ASSIST): Development, reliability and feasibility. Addiction 2002;97:1183-94. |
| 19 | Raistrick D, Bradshaw J, Tober G, Weiner J, Allison J, Healey C. Development of the Leeds Dependence Questionnaire (LDQ): A questionnaire to measure alcohol and opiate dependence in the context of a treatment evaluation package. Addiction 1994;89:563-72. |
| 20 | Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-16: Prevalence, patterns and outcomes. Bengaluru, National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129; 2016. Available from: http://indianmhs.nimhans.ac.in/Docs/Report2.pdf. [Last accessed on 2020 Jul 22]. |
| 21 | Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The global burden of mental disorders: An update from the WHO world mental health (WMH) surveys. Epidemiol Psichiatr Soc 2009;18:23-33. |
| 22 | Sarin E, Singh B, Samson L, Sweat M. Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India. Subst Abuse Treat Prev Policy 2013;8:2. |
| 23 | Ajzen I. Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. J Appl Soc Psychol 2002;32:665-83. |
| 24 | Fisher WA, Fisher JD, Harman J. The information-motivation-behavioraI skills model: A general social psychological approach to understanding and promoting health behavior. In: Social Psychological Foundations of Health and Illness. Malden: Blackwell Publishing; 2003. p. 82-106. |
| 25 | Mackesy-Amiti ME, Donenberg GR, Ouellet LJ. Psychiatric correlates of injection risk behavior among young people who inject drugs. Psychol Addict Behav J Soc Psychol Addict Behav 2014;28:1089-95. |
| 26 | Buckingham E, Schrage E, Cournos F. Why the treatment of mental disorders is an important component of HIV prevention among people who inject drugs. Adv Prev Med 2013;2013:690386. |
| 27 | Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: A systematic review and meta-analysis. Curr HIV/AIDS Rep 2014;11:291-307. |
| 28 | NACO (National AIDS Control Organisation) Annual Report: 2018-19. Available from: http://naco.gov.in/sites/default/files/Annual%20Report%20NACO-2018-19%20%281%29.pdf. [Last accessed on 2020 Jul 22]. |
| 29 | World Health Organization, editor. Mental Health Atlas 2014. Geneva, Switzerland: World Health Organization; 2015. |
|
