Open Access

Mental health among clients of the Sydney Medically Supervised Injecting Centre (MSIC)

Harm Reduction Journal201613:29

DOI: 10.1186/s12954-016-0117-y

Received: 3 June 2016

Accepted: 24 September 2016

Published: 12 October 2016

Abstract

The Sydney Medically Supervised Injecting Centre (MSIC) is a supervised injecting facility (SIF) where people who inject drugs (PWID) can do so legally, under health professional supervision. The majority of clients have low levels of education and employment, high rates of incarceration and unstable housing and poor social networks, and 70 % do not access local health services. These factors increase the risk of poor mental health, and it has been documented that PWID have elevated rates of mood, anxiety, personality and psychotic disorders; post-traumatic stress disorder (PTSD); and higher rates of trauma exposure, suicidality and self-harm. The current study is the first to investigate the mental health among clients of a SIF. Validated instruments to examine clients’ mental health, social networks and trauma histories were administered to 50 frequently attending clients by a mental health nurse. The majority of respondents were unemployed, homeless and had a history of incarceration, and 82 % report they had been diagnosed with a mental health problem, but only 24 % report they were receiving treatment. Respondents had poor social networks, had poorer mental health symptoms compared to US inpatients and had experienced multiple traumatic events, and a high number of respondents had scores indicative of PTSD. These results highlight the need for mental health clinicians to be employed in SIFs and other drug consumption rooms (DCRs) to assist clients to address their mental health and psychosocial needs, particularly in light of the fact that these services are often the only places these PWID engage with in an ongoing way.

Keywords

Mental health Mental disorders Supervised injecting centres, supervised injecting facilities, illicit drugs

Background

The Sydney Medically Supervised Injecting Centre (MSIC) is a supervised injecting facility (SIF) where people who inject drugs (PWID) do so legally, under health professional supervision. Operational since May 2001, MSIC aims to reduce death and injury from drug overdose and reduce harm associated with injecting drug use. As in May 2015, MSIC had supervised more than 930,000 injections and managed over 5925 overdoses without a fatality. MSIC has more than 15,000 registered clients, of which approximately 600 clients attend in a typical month and 70 % of whom had not accessed local health services prior to MSIC registration [1, 2]. Engaging this “hard-to-reach” population, staff aim to enhance access to drug treatment and psychosocial and health services, including mental health, with over 11,500 referrals provided as in May 2015.

The broad population of PWID is characterised by low educational attainment and employment rates [3] and high rates of incarceration and unstable housing [4]. Such attributes are exaggerated among MSIC’s clients [2], of whom 92 % report unemployment and 65 % report unstable housing [4]. Additionally, PWID commonly have limited social networks, as rejection by non-using friends [5] often leads to social isolation [6], a well-documented risk factor for poor mental health [7]. Such social determinants of health are associated with mental health problems [8, 9], and consistent with these associations, PWID have documented elevated rates of mood, anxiety, personality and psychotic disorders [10, 11]; post-traumatic stress disorder (PTSD) [12]; and suicidality and self-harm [10, 12]. Trauma exposures such as being witness to serious injury or death, being involved in a life-threatening accident, being threatened with a weapon, being held captive or kidnapped [13] and being sexually abused as a child [14] are commonly experienced by people with substance dependence. These traumas usually occur before the onset of substance abuse disorders [13] and increase the risk of later mental health problems [14].

Despite high rates of mental health problems, PWID often encounter multiple barriers to accessing relevant services, ranging from clinician attitudes to the systems within which they work [15, 16]. Early evaluation of MSIC found that of those PWID registered to use the service, only 42 % were clients of local services targeted to their needs [2]. Likewise, qualitative research suggests substantial barriers to accessing treatment among MSIC clients, including unwillingness precipitated by stigma and discrimination [17]. MSIC clients are a hard-to-reach, and sometimes invisible, population who are unlikely to be captured by previous investigations of the mental health of people who use drugs.

By attracting a disengaged population, and offering services which facilitate sustained client contact, MSIC is uniquely placed to assess and engage with PWID regarding mental health. The present study builds on our formative research [17] by utilising validated instruments to examine clients’ mental health, social networks and trauma histories. There are now approximately 100 SIFs and drug consumption rooms (DCRs) around the world, and this study is the first to apply a structured, quantitative approach to mental health assessment among clients of these services.

Methods

The study was approved by the Human Research Ethics Committee of South Eastern Sydney Local Health District. MSIC’s mental health nurse (author MG) assessed the mental health of 50 frequent attendees, defined as the 100 clients visiting most often between October and December 2014 (visit count range 29–321). It should be noted that within a typical month approximately 600 individual clients make up the majority of all visits to the service [1]. The first 50 of these 100 clients to present all agreed to participate and were reimbursed with an AU$40 voucher.

Structured questionnaires assessed demographic characteristics. Unstable accommodation was defined as primary (“sleeping rough”), secondary (staying with friends/relatives or in specialist homelessness services) and tertiary (neither secure lease nor private facilities) homelessness [4]. A broad mental health history was collected, including suicide, self-harm, previous mental health diagnoses, treatment and prescription of psychiatric medication. Lubben’s Social Network Scale-6 (LSNS-6) was used to assess perceived social support from family and friends [18]. The Behavior and Symptom Identification Scale (BASIS-24) provided a measure of recent difficulty in the symptom and functioning domains that underlie the need for mental health services [19]. BASIS-24 scores range from 0 to 5, with 5 the highest score indicating severe mental health symptoms and functional difficulties [19]. Trauma exposure and PTSD were assessed with the Composite International Diagnostic Interview (CIDI) version 2.1 and the PTSD Checklist (PCL-C), respectively [20, 21]. The CIDI measures lifetime and childhood exposure to traumatic events [20], and the PCL-C 17 items are added to obtain a possible score range from 17 to 85, and a cut-off of 50 is a predictor of a PTSD diagnosis [21].

Results and discussion

Participants (N = 50) had a mean age of 42 years (SD 9.2); 70 % were male, 26 % female and 4 % transgender; and 92 % were unemployed. Sixteen percent of participants identified as Aboriginal and/or Torres Strait Islander; 62 % reported current unstable accommodation; and 70 % reported a history of incarceration.

Eighty-two percent reported that “a doctor had ever told (them) that (they) had a mental health problem” (Table 1). Self-reported diagnoses included the following: mood disorders including depression (48 %) and bipolar disorder (16 %); anxiety disorders including anxiety (36 %), panic disorder/attacks (4 %), obsessive-compulsive disorder (4 %) and generalised anxiety disorder (2 %); psychotic illnesses including schizophrenia (22 %), drug-induced psychosis (6 %) and schizoaffective disorder (4 %); PTSD (12 %); attention deficit hyperactivity disorder (10 %); and personality disorders including borderline personality disorder (4 %) and antisocial personality disorder (4 %). Among the 54 % of participants who reported a previous suicide attempt, a median of 2 attempts (range 1–12) had been made. One third of the sample reported a history of self-harm.
Table 1

Mental health indicators reported by MSIC frequently attending clients (N = 50)

Mental health indicator

% sample

Any mental health diagnosis by a doctor (lifetime)

82

Mood disorder (lifetime)

64

Anxiety disorder (lifetime)

46

Psychotic illness (lifetime)

32

Post-traumatic stress disorder (lifetime)

12

Attention deficit hyperactivity disorder (lifetime)

10

Personality disorder (lifetime)

8

History of suicide attempt/s

54

History of self-harm

44

Currently receiving support from mental health services

24

Just 24 % of participants reported currently receiving mental health treatment, including 8 % from a psychiatrist/psychiatric registrar and 2 % from a general practitioner. Forty-four percent reported current psychiatric medication prescription, including antipsychotics (20 %), antidepressants (20 %) and mood stabilisers (4 %). In this open-ended format (“Are you prescribed any psychiatric medications? Specify which”), no participants reported a current benzodiazepine prescription.

Social networks, isolation and mental health symptoms

Mean score on the LSNS-6 was 9 (SD 6.2); 70 % received a score <12 indicative of social isolation. Mean total score on the BASIS-24 was 2.59 (SD 0.79), and Table 2 outlines the subscale means, which are compared to a US mental health inpatient population.
Table 2

BASIS-24 (mental health symptoms over the past week) (N = 50)

 

MSIC

US inpatient

 

Mean

SD

Mean

SD

Total

2.59

0.79

1.85

0.83

Depression/functioning

2.64

1.00

2.22

1.13

Interpersonal problems

2.78

0.87

1.76

1.06

Self-harm

1.62

0.89

1.15

1.25

Emotional labiality

2.78

1.01

1.96

1.13

Psychosis

2.01

1.05

1.11

1.15

Substance abuse

3.03

0.62

1.85

0.83

Trauma

Ninety-six percent of the sample had experienced a traumatic event in their lives (M 4.54, SD 2.45), including a mean of 3.04 traumatic exposures before the age of 16 (SD 2.50) (Table 2). Mean PCL-C score was 44.54 (SD 17.33), with 36 % scoring above 50, indicative of current PTSD.

This study, the first to apply a structured, quantitative approach to the assessment of mental health among clients of SIFs and DCRs, documented elevated lifetime rates of mental health disorders among Sydney MSIC clients. Over 80 % reported having ever received a mental health diagnosis from a doctor, most commonly mood (64 %), anxiety (46 %) and psychotic disorders (32 %). More than one half (54 %) reported attempted suicide and 34 % history of self-harm. These estimates are considerably higher than those in the Australian general population (46 % lifetime prevalence) [22] and at the upper end of lifetime prevalence estimates reported for Australians in substance use treatment (46–100 %) [23]. Further highlighting MSIC clients’ poor mental health were BASIS-24 scores, a measure of symptom and functioning difficulties in the preceding week. The mean BASIS-24 score for MSIC clients (2.59) was substantially higher than the benchmark figure for patients admitted to US mental health facilities (1.85), as were a number of the mean subscale scores including psychosis (2.01 vs 1.11) and substance use (3.03 vs 1.85) [19]. These scores highlight that MSIC clients have more severe mental health symptoms and functioning than patients within a mental health facility [19].

Results clearly suggest substantial mental health needs, yet 76 % of participants were not currently accessing mental health treatment. There was also substantial disconnect between MSIC clients reporting prescription of psychiatric medication (44 %) and having a qualified prescriber (10 %). Given the high rates of anxiety disorders among participants, the absence of prescription benzodiazepine use was unexpected. This result may reflect recent changes to benzodiazepine scheduling by Australia’s Therapeutic Goods Administration [24] and/or the normalisation of benzodiazepine use among MSIC clients and their ready illicit access to this class of drugs.

Given the robust relationships between mental health and social determinants including education, employment and housing [8, 9], and in light of the demographic characteristics of MSIC clients [2] and in this study, elevated prevalence of untreated mental health disorders among this group is unsurprising. Seventy percent of this sample was deemed socially isolated by the LSNS-6 [18]. As an integral component of health and well-being, MSIC clients’ lack of social connectedness is undoubtedly inextricably linked to their poor mental health [7]. Consistent with the literature, trauma exposure and PTSD as assessed by the PCL-C were highly prevalent [12]. Given that past trauma is strongly associated with mental health problems [14], the high rates of exposure of participants to traumatic events such as death, violence, sexual violence and natural disasters, including during childhood, are also consistent with the patterns of poor mental health among MSIC clients (Table 3). However, the discrepancy between the proportion of clients having ever received a diagnosis of PTSD (12 %) and the proportion screening positive for current PTSD on the PCL-C (50 %) indicates that there may be marked underdiagnosis of this disorder, and possibly other disorders, among clients of SIFs and DCRs.
Table 3

Lifetime and childhood exposure to traumatic events among MSIC frequently attending clients

Trauma

% ever experienced

% experienced prior to age 16 years

Witnessed someone badly injured or killed

78

42

Seriously physically attacked or assaulted

72

56

Threatened with a weapon, held captive or kidnapped

68

32

Involved in a life-threatening accident

58

30

Molested

52

46

Raped

42

40

Involved in a fire, flood or natural disaster

34

24

Tortured or victim of terrorist

34

26

Direct combat experience in a war

12

6

Events listed in the table are verbatim from the CIDI version 2.1 [20]

This cross-sectional study is unable to delineate the extent to which mental health problems among MSIC clients are a cause or a consequence of drug use. Another limitation of this study is its sample size of 50. In a previous study of street-based injectors in Kings Cross (MSIC’s location), indicators of social marginalisation, including unstable housing, unemployment and public injecting, were significantly associated with psychological distress, while indicators of drug use were not [25]. Regardless of the temporal sequencing of trauma, social isolation, mental health disorders and drug use, the fact remains that despite their reluctance to engage with other health services, clients suffer poor mental health. As a service that facilitates sustained, ongoing contact with clients, MSIC is uniquely placed to assess and engage with PWID around mental health issues. Indeed, this potential is reflected both in the visit numbers of the frequent attendees described here (up to 321 within a 3-month period) and in the 100 % response rate of clients invited to participate in this study.

Conclusions

Specialised mental health services should be essential partners in the establishment of SIFs, and the ever-increasing number of DCRs, due to the high levels of mental distress among PWID and the multiple traumatic events they experience. Based on our findings, we recommend that, where possible, SIFs and DCRs implement multiple strategies to enhance mental health outcomes, including the following:
  • Fostering good working relationships with local mental health services to create effective referral pathways

  • Employment of a specialised mental health clinician

  • Ongoing staff training in mental health, risk assessments and trauma informed care

  • Establishing regular onsite psychiatric clinics for clients unwilling to access mainstream health services

Abbreviations

BASIS-24: 

Behavior and Symptom Identification Scale

CIDI: 

Composite International Diagnostic Interview

DCRs: 

Drug consumption rooms

LSNS-6: 

Lubben’s Social Network Scale-6

MSIC: 

Sydney Medically Supervised Injecting Centre

PCL-C: 

PTSD Checklist

PTSD: 

Post-traumatic stress disorder

PWID: 

People who inject drugs

SIF: 

Supervised injecting facility

Declarations

Acknowledgements

Mark Goodhew is funded by the Commonwealth Government of Australia’s Substance Misuse Grant scheme. Katherine Mills is funded by the NHMRC Centre of Research Excellence in Mental Health and Substance Use. Christina Marel is funded by a Society of Mental Health Research Early Career Researcher Fellowship. Dr. Libby Topp provided direction on this paper and editing at an early stage.

Funding

This study has not been funded.

Availability of data and materials

The data will not be shared given the sensitive nature of the data. Ethics approval for this project did not include provision for the sharing of data.

Authors’ contributions

MG interviewed the participants. MG, CM, KM and MJ helped with the design of the study. All authors were involved in the analysis of the data and the draft of the manuscript and read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval

The study was approved by the Human Research Ethics Committee of South Eastern Sydney Local Health District, 12/277 (HREC/12/POWH/521).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Sydney Medically Supervised Injecting Centre
(2)
Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre (NDARC), University of New South Wales

References

  1. KPMG. Further evaluation of the medically supervised injecting centre during its extended trial period (2001-2011): final report. Sydney: KPMG; 2010.Google Scholar
  2. National Centre in HIV Epidemiology and Clinical Research. Sydney Medically Supervised Injecting Centre interim evaluation report 3: evaluation of client referral and health issues. Sydney: National Centre in HIV Epidemiology and Clinical Research; 2007.Google Scholar
  3. Horyniak D, Higgs P, Jenkinson R, et al. Establishing the Melbourne Injecting Drug User Cohort Study (MIX): rationale, methods, and baseline and twelve-month follow-up results. Harm Reduction J. 2013;10:11.View ArticleGoogle Scholar
  4. Topp L, Iversen J, Baldry E, et al. Housing instability among people who inject drugs: results from the Australian needle and syringe program survey. J Urban Health. 2013;90(4):699–716.View ArticlePubMedGoogle Scholar
  5. Best D, Manning V, Strang J. Retrospective recall of heroin initiation and the impact on peer networks. Addiction Research & Theory. 2007;15(4):397–410.View ArticleGoogle Scholar
  6. Room R. Stigma, social inequality and alcohol and drug use. Drug and Alcohol Rev. 2005;24:143–55.View ArticleGoogle Scholar
  7. Cornwell EY, Waite LJ. Social disconnectedness, perceived isolation and health among older adults. J Health Soc Behav. 2009;50:31–48.View ArticlePubMedPubMed CentralGoogle Scholar
  8. World Health Organization & Calouste Gulbenkian Foundation. Social determinants of mental health. Geneva: World Health Organization; 2014.Google Scholar
  9. Martens W. A review of physical and mental health in homeless persons. PHR. 2001;29:13–33.Google Scholar
  10. Ross J, Teesson M, Darke S, et al. The characteristics of heroin users entering treatment: findings from the Australian Treatment Outcome Study (ATOS). Drug and Alcohol Rev. 2005;24(5):411–8.View ArticleGoogle Scholar
  11. Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012;379(9810):55–70.View ArticlePubMedGoogle Scholar
  12. Dore G, Mills K, Murray R, et al. Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug and Alcohol Rev. 2012;31(3):294–302.View ArticleGoogle Scholar
  13. Mills KL, Teesson M, Ross J, et al. Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being. Am J Psychiatry. 2006;163(4):652–8.View ArticlePubMedGoogle Scholar
  14. Farrugia PL, Mills KL, Barrett EA, et al. Childhood trauma among individuals with co-morbid substance use and post-traumatic stress disorder. Ment Health Subst Use. 2011;4:314–26.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Griffin S, Campbell A, McCaldin H. A ‘dual diagnosis’ community psychiatric nurse service in Lanarkshire: service innovation. Psychiatr Bull. 2008;32(4):139–42.View ArticleGoogle Scholar
  16. Todd FC, Sellman JD, Robertson PJ. Barriers to optimal care for patients with coexisting substance use and mental health disorders. Aust N Z J Psychiatry. 2002;36(6):792–9.View ArticlePubMedGoogle Scholar
  17. Goodhew M. Injecting drug users’ mental health issues and access to services: a case study. The MHS Annual Conference 2013. Melbourne.
  18. Lubben J, Blozik E, Gillmann G, et al. Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist. 2006;46(4):503–13.View ArticlePubMedGoogle Scholar
  19. McLean Hospital. Behavior and Symptom Identification Scale: BASIS-24 instruction guide. Belmont: McLean Hospital; 2006.Google Scholar
  20. World Health Organization. Composite International Diagnostic Interview (CIDI), version 2.1. Geneva: World Health Organization; 1997.Google Scholar
  21. Australian Centre for Posttraumatic Mental Health. The Posttraumatic Stress Disorder Checklist (PCL). Melbourne: The University of Melbourne; 2016. Available from: http://at-ease.dva.gov.au/professionals/files/2012/12/PCL.pdf.Google Scholar
  22. Slade T, McEvoy PM, Chapman C, et al. Onset and temporal sequencing of lifetime anxiety, mood and substance use disorders in the general population. Epidemiol Psychiatr Sci. 2015;24(1):45–53.View ArticlePubMedGoogle Scholar
  23. Kingston R, Marel C, Mills K. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug and Alcohol Rev. (in press).
  24. Therapeutic Goods Administration. Final decisions and reasons for decisions by delegates of the Secretary to the Department of Health and Ageing—notice under subsections 42ZCZS and 42ZCZX of the Therapeutic Goods Regulations 1990 (the Regulations) 2013.
  25. Topp L, Hudson S, Maher L. Mental health symptoms among street-based psychostimulant injectors in Sydney’s Kings Cross. Subst Use Misuse. 2010;45:1180–200.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2016

Advertisement