Co-ordinate addictions, mental health services

In 2009, the annual incidence of positive HIV test reports in the Saskatoon Health Region was 31.3 new cases per 100,000 population, at a time when the comparable national average was only 9.3.

The number of new cases goes up every year, with the 94 new cases reported in 2009 up from 16 in 2004.

A study published in the Canadian Journal of Psychiatry last week suggests that a reason for the increased incidence might be unresolved depression in injection drug users. In a study of 1,000 high-risk clients, of whom 603 were daily injection drug users, the study found that 81.4 per cent had depression while 57.7 per cent were severely depressed. In studies conducted elsewhere, the levels of depression, but not severe depression, among injection drug users ranged from 38 per cent to 52.6 per cent.

The public health problem with not identifying and resolving depression among injection drug users is that they are more likely to engage in even riskier behaviours.

Comparing depressed injection drug users to those who were not, the former were more likely to trade sex for money, trade sex for drugs, trade drugs for sex, and also more likely to share injecting equipment frequently, lend used needles to friends or acquaintances, inject with needles used by a sexual partner and more likely to inject with needles used by a friend or acquaintance.

As one example, injection drug users who are depressed were more than twice as likely to frequently share their injecting equipment compared to users who are not depressed.

Another example is that 81.5 per cent of injection drug users who are depressed traded drugs to receive sex, compared to only 3.6 per cent of those who are not depressed.

The first reaction might be to offer more medical treatment to address depression in injection drug users.

However, in this study, the risk indicators of depression was a history of being sexually assaulted as an adult or as a child, being forced to attend a residential school, and having an annual income of less than $10,000.

If complicated issues such as childhood sexual abuse and poverty are the actual causes of depression in this specific risk group, management will need be more co-ordinated.

For example, substance abuse prevention and cessation interventions will need to be integrated with both mental health and postvictimization services.

If sexual abuse is a cause of depression, victims will need additional resources to cope with this trauma.

However, given that most sexual assaults are committed by someone known to the victim, the assaults will only be prevented with a comprehensive strategy that includes low-income subsidized housing that is safe and secure.

If poverty predicts depression, and depression increases HIV-risk behaviour, then increased payments from Social Services are also required.

Even if a strictly medical model is suggested to treat depression, it is regrettable that the injection drug users surveyed in Saskatoon reported significant barriers to accessing care.

These included long distances to medical facilities, lack of transportation, medical personnel who refuse to provide direct care, shortages of mental health professionals, and the inability to access treatment programs.

For example, 57.3 per cent of injection drug users reported having experienced a medical professional who declined to provide care.

Perhaps ironically, 44 per cent were unable to access a drug treatment facility, with the most common concern being long waiting lists.

These barriers to care are counterproductive to the strategy of reducing HIV incidence in our community.

A prospective longitudinal study published in AIDS Care found that quitting drug use was associated with reduced depressive symptoms at followup.

The study's authors concluded facilitating drug treatment and preventive care to reduce depression in injection drug users was a public health priority.

As well, the finding that depression increases HIV risk behaviour is a conclusion that has been found in a number of other studies outside Saskatoon. For example, a study published in the International Journal of Addiction found that depression was a direct antecedent and predictor of increased frequency of intravenous drug use in urban populations.

As such, we must offer more co-ordinated mental health and addiction services where injection drug users live and these interventions need to be more responsive to the patients.