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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 36-43

Social and clinical correlates of stimulant use disorder (mephedrone) in a tertiary mental health setting in Mumbai: A pilot exploratory study


1 Departments of Psychiatry, Grant Government Medical College, Mumbai, Maharashtra, India
2 Departments of Community Medicine, Grant Government Medical College, Mumbai, Maharashtra, India
3 Department of Psychiatry, Foundation for Research and Advocacy in Mental Health (FRAMe), Mysore, Karnataka, India
4 Department of Mental Health, Post Graduate Medical School, University of Chester, Chester, England
5 Department of Community Medicine, Mysore Medical College and Research Institute, Mysore, Karnataka, India

Date of Web Publication4-Jun-2020

Correspondence Address:
Poornima S Rao
Grant Government Medical College, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_40_19

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  Abstract 


Introduction: Increasing mephedrone use is a major public health concern in India. There are limited data on sociodemographic determinants and psychiatric comorbidity associated with stimulant use disorder (mephedrone) (SUD-M) from India. Aim: The primary objective of this study was to report the clinical and social correlates of SUD-M among those presenting to specialist mental health services in Mumbai, India. Methods: Patients with SUD-M were recruited from a clinical setting. Standardized culturally validated assessments were carried out to obtain information about sociodemographics and mental health: comorbid psychopathology Brief Psychiatric Rating Scale, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Minnesota Multiphasic Personality Inventory-2 for personality traits and a clinical assessment for diagnosis of mental disorder using DSM-5. Results: SUD-M was more common among young men from the low socioeconomic position. The most common reasons for choosing mephedrone over other substances were better high from the drug and peer pressure. There were no associations between sociodemographic factors with the severity of SUD-M. Around 40% of the patients with SUD-M had psychiatric comorbidity. Psychotic disorders and anxiety symptoms were most common. Family history of substance use, comorbid substance use, and comorbid psychiatric disorders were directly related to the severity of SUD-M. Conclusions: This was a cross-sectional study with a relatively smaller sample size of self-nominating participants limiting the generalizability of findings to a wider population. Therapeutic implication of this finding is that prompt attention and treatment of the comorbid psychiatric disorder is essential while treating patients with SUD-M. Further population-based studies are recommended for a better understanding of the burden of SUD-M.

Keywords: Legal high, mephedrone, pattern of use, psychiatric co-morbidity, synthetic cathinone


How to cite this article:
Bharath D U, Rao PS, Kale VP, Panigrahi SK, Krishna M, Jones S, Majgi SM. Social and clinical correlates of stimulant use disorder (mephedrone) in a tertiary mental health setting in Mumbai: A pilot exploratory study. J Mental Health Hum Behav 2019;24:36-43

How to cite this URL:
Bharath D U, Rao PS, Kale VP, Panigrahi SK, Krishna M, Jones S, Majgi SM. Social and clinical correlates of stimulant use disorder (mephedrone) in a tertiary mental health setting in Mumbai: A pilot exploratory study. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Jul 10];24:36-43. Available from: http://www.jmhhb.org/text.asp?2019/24/1/36/285991




  Introduction Top


Mephedrone is a novel synthetic stimulant drug classed into a group of β-ketone-amphetamine compounds derived from cathinone, the active stimulant found in the khat plant, and mimics the effects of other controlled stimulant drugs such as cocaine, 3,4-methylenedioxy-methamphetamine (MDMA), and methamphetamine.[1] Reported mephedrone use is on the increase causing serious individual, societal, and health consequences, making it a global health concern.[2],[3]

Mephedrone was first reported on the India drug scene in 2013,[4] and soon, there was a sudden surge in mephedrone-related cases presenting to hospitals in Mumbai, with an estimate of at least 30,000 residents of Mumbai with harmful use and or dependence to mephedrone in 2014. Drug suppliers reportedly sell around 600 kg of mephedrone each day in Mumbai under street names such as meow meow, M-cat, Meth, Crystal, MD for Rs 150–300 per gram (2–5 USD equivalent). Mephedrone is substantially cheaper (by at least 20 times) compared to the street value of cocaine.[5],[6] Emerging evidence, although limited, from the Indian subcontinent indicate that the prevalence of mephedrone use among those with a history of any substance users in Mumbai was alarmingly high (8 out of 10) and the attributing factors were multiple: wider availability, affordability (in comparison to other substances), and high purity (not adulterated like some other drugs of abuse).[7] The long-term harmful effect of mephedrone is still not fully evaluated but is thought to be broadly similar to that of other stimulants.[1],[2]

Considering its widespread reports of use and complications, it was criminalized under Section 3 of the Narcotic Drugs and Psychotropic Substances (NDPS 1985) Act in February 2015.[8] It was reported that 54% of all narcotics seized in Mumbai between January and June 2017 was mephedrone,[9] indicating that it was well embedded in the recreational drug market and was a serious public concern in Mumbai.[9] Despite this, there are limited data on sociodemographic determinants and psychiatric comorbidity associated with stimulant use disorder (mephedrone) (SUD-M) from low- and middle-income countries settings including India. The primary objective of this study was to report the clinical and social correlates of SUD-M in Mumbai, India.


  Methods Top


This single-phase cross-sectional study was conducted at a state-run tertiary care general hospital in Mumbai, India, with general psychiatry clinic services and a separate de-addiction clinic and ward, providing pharmacological and psychotherapeutic interventions. Participants were recruited from inpatient and outpatient services between 2016 and 2017. The study was approved by the Institution Ethics committee. Participants who were able to provide fully informed consent and those above 18 years of age and meeting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criterion for SUD-M were recruited. Those with current or previous diagnoses for any chronic medical, surgical, neuropsychiatric, or any other substance use disorders were excluded following a structured clinical evaluation.

Instruments

  1. Sociodemographic data were obtained by administering a standardized validated structured questionnaire developed for the purpose of this study
  2. The diagnosis of SUD-M and other comorbid psychiatric disorders was established by a structured mental state examination by a consultant psychiatrist according to the DSM-5 criterion. The severity of SUD-M was categorized as mild, moderate, or severe as per DSM-5 criteria[10]
  3. Comorbid psychopathology was evaluated by administering: a Brief Psychiatric Rating Scale (BPRS) for general psychopathology,[11],[12] Hamilton Anxiety Rating Scale (HAM-A) for anxiety,[13],[14],[15] Hamilton Depression Rating Scale (HAM-D) for depression,[16],[17] and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) for personality traits.[18]


Statistical analysis

Data were analyzed using SPSS version 22 (IBM, SPSS Statistics, Mumbai, Maharastra, India). Categorical data were cross-tabulated and Chi-square test was conducted to examine the difference between the groups; similarly, numerical data were tested for normal distribution, and then, independent t-test and one-way ANOVA were applied if the grouping variables were 2 and >2, respectively. P < 0.05 was considered statistically significant.


  Results Top


Of the 84 of potentially eligible participants (64 from outpatients and 20 from inpatients), 70 (58 men and 12 women) were recruited. The reasons for exclusion included comorbid chronic medical, surgical, and neurological illness and diagnoses of concomitant other substance use disorders.

Sociodemographic characteristics of the study sample are provided in [Table 1]. Three-fourth (n = 53) of the study participants were single, 80 percent of them had completed at least 10 years of formal schooling, nearly three-quarters of them were from lower and middle socioeconomic classes, and nearly a quarter of the study participants were students. Around half of the participants were either part-time employees (n = 22) or unemployed (n = 12), and only less than a fifth had a full-time job (n = 13).
Table 1: All the sociodemographic variables

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Clinical correlates of mephedrone users in the study sample are shown in [Table 2]. In nearly half of the participants, a major source of mephedrone was through drug dealers (n = 40, 57%), mephedrone was the only substance of misuse (n = 30, 43%), and the gateway drug was commonly absent. Insufflation (snorting) (n = 41, 59%) and oral (n = 29, 41%) were the only modes of intake of mephedrone. Majority (n = 39) of those with SUD-M were not diagnosed with any comorbid psychiatric disorders; however, 10 (14%) of them were diagnosed with psychoses. Nearly 60% of them had higher scores (>50) on the psychopathology checklist (BPRS) and mild-to-moderate levels of anxiety as determined by the HAMA scale, while a fewer (10%) had mild levels of depression.
Table 2: Clinical correlates of stimulant use disorder (mephedrone)

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[Table 3] shows the correlation between sociodemographic and clinical determinants with severity of SUD-M. History of comorbid substance use (P < 0.001) and family history of substance use (P <0.01) showed strong correlation with severity of SUD-M.
Table 3: Correlation between various sociodemographic and clinical determinants with the severity of stimulant use disorder (mephedrone)

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[Table 4] provides correlation between psychiatric comorbidity and severity of SUD-M. The mean BPRS scores (P < 0.001), mean scores of subscales for psychoses (P = 0.001), Pd (P = 0.03), and HAM-A scores (P = 0.03) were significantly and directly related to the severity of SUD-M.
Table 4: Correlation between the mean scores of Brief Psychiatric Rating scale, Hamilton Anxiety Rating Scale, Hamilton Anxiety Rating Scale, and Minnesota Multiphasic Personality Inventory-2 scales with the severity of stimulant use disorder (mephedrone)

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  Discussion Top


A majority of the total participants in our study were men (n = 58), with half of them aged between 21 and 30 years providing some evidence of drug use prevalence in this subset of the population, supporting two other studies conducted in the UK and US. The UK survey was conducted on a dance music population of 943 mephedrone users who were typically younger (mean age of 25 years, standard deviation – 6.7 years) and males (n = 656) (5). While the respondents in the US survey of 112 mephedrone users were often men (n = 57) aged 18–24 years.[19]

Around half of the participants were either part-time employees or unemployed and only less than a fifth had a full-time job. Unemployment and drug abuse have a bidirectional relationship and can worsen the prognosis of patients with drug abuse problems. Nearly a third of the samples were students who are the most vulnerable population in their formative years and drug abuse can have long-term deleterious impact on their education and health. Nearly two-third of the participants in our study belonged to lower socioeconomic status. The literature supports our finding of the higher preponderance of mephedrone use in the lower socioeconomic group.[10],[17],[20] However, this finding cannot be generalized to patients in the community, as the study was conducted in a state-run hospital which predominantly caters to low-income patients of the region.

More than half of the participants purchased mephedrone directly from the dealers and a third from their friends, indicating free access to dealers on the streets of Mumbai. Even though online vendors were easily accessible during the study period, in Mumbai, only one participant bought it through online. This could be due to fear of getting caught or lack of familiarity with online vending portals. Dargan et al. 2010 reported similar survey findings in Scotland, UK, where approximately 50% (n = 491) of 1006 participants obtained mephedrone from dealers.[21] Four of them self-manufactured mephedrone at home and sold it to dealers. This shows the relative ease with which mephedrone can be manufactured by individuals at their homes.

In our study, self-reported heightened drug efficacy (n = 22, 31%) compared to other drugs and peer pressure (n = 21, 30%) were common reasons for mephedrone preference over other drugs, followed by easy availability (n = 8, 12%), less chances of getting caught (n = 9, 13%), and lower cost (n = 10, 14%). This finding is similar to those reported by Winstock et al. where approximately half of their study respondents in the UK reported a better high with mephedrone when they were asked to compare effects with cocaine and MDMA and many considered mephedrone as better value for money.[22],[23],[24] With drug peddlers selling mephedrone for as little as INR 150 per gram and INR 15 per dose in Mumbai[5] plus self-reported heightened drug efficacy over other drugs add to the appeal of the drug for younger users.

Snorting (59%) and oral intake (41%) were the only two modes of consumption of mephedrone noted among the participants in our study. Similarly, multiple studies have found snorting to be the most common method of consumption and have been explained by the pharmacokinetic properties of higher bioavailability and faster onset of action by the intranasal route.[25],[26] Other modes of drug consumption mentioned in the literature such as intravenous, intramuscular, rectal, and gingival delivery were not seen in our participants.[25],[27]

An interesting observation was that around half of the participants had no prior self-reported drug use and initiated drug use with mephedrone and then became dependent. This shows high penetrance and popularity of mephedrone in the Mumbai drug scene at the time of the study.

More than half (n = 40) of the participants had comorbid substance use in nondependant pattern (those with other drug dependence were already excluded from the study). Alcohol and nicotine were the most common drugs used along with mephedrone aligning the findings of studies by Winstock et al. and Freeman et al. who proposed high prevalence rates of comorbid substance use in mephedrone users in the UK.[4],[22],[24]

Among the participants who had comorbid substance use, most had initiated drug use for the first time either with nicotine (27%) or alcohol (16%) which acted as gateway drug paving way for mephedrone. This could support the gateway hypothesis of drug use,[28],[29],[30] implying that measures for the prevention of drug dependence to be implemented for gateway drugs, and mere legal restrictions on mephedrone might not be effective.

Sixty percent of the participants scored >50 on the BPRS scale, indicative of the high prevalence of comorbid psychopathology; however, only 44% of the participants could be categorically diagnosed as per the DSM-5 criteria. This might be due to subclinical psychiatric syndromes and symptoms associated with SUD-M, which might progress to a diagnosable psychiatric disorder as per the DSM-5 or improve itself on the cessation of drug use. This is consistent with findings from other epidemiological studies and isolated drug studies which showed 38% comorbidity for all substance use in general,[17] 48% for alcohol use disorders,[31] 40%–70% for cocaine,[31],[32],[33] and 48% for methamphetamine.[34] The high prevalence of psychiatric comorbidity with SUD-M necessitates a detailed evaluation for identifying these comorbid disorders while treating patients with SUD-M. However, the causal relationship between mephedrone use and psychiatric comorbidity could not be established here.

Psychotic disorders (14%) and anxiety symptoms (66% had mild-to-moderate anxiety symptoms on HAM-A and 10% fulfilled criteria for anxiety disorder as per the DSM-5) were the common psychiatric comorbidities in our study. Mackay et al. who published a case series with 20 cases of mephedrone use found that severe agitation was the most common presenting problem (70%), with 40% of individuals developing psychotic symptoms and 20% had depressive symptoms and suicidality.[35] Case reports have shown intoxication presenting as delirium and persistent psychosis, causing a confusing picture.[36] Psychotic symptoms were observed to last longer even after cessation of drug use, several days into treatment.[36],[37] The high incidence of comorbid psychosis and anxiety symptoms could be attributed to the transporter releasing action of mephedrone that causes efflux of dopamine, norepinephrine, and serotonin.[38],[39]

In our study, 14% of the participants had a psychotic disorder, 11% had a depressive disorder, 10% had an anxiety disorder, and 9% had personality disorders. There is abundant literature on comorbid mental health disorders of various substance use disorders with a wide range of results, but very less is written about SUD-Ms; hence, comparison of results could be made with similar drugs such as methamphetamine and cocaine. In a study of 526 methamphetamine users, mood disorders (34.2%) followed by anxiety disorders (26.2%), psychoses, (12.9%) and eating (2.5%) disorders were the most common comorbid diagnoses.[34] In similar stimulant comparative studies on cocaine users, mood and anxiety disorders were most common. Almost half (49.6%) of the participants were diagnosed with a personality disorder. Cocaine dependence was associated with a diagnosis of antisocial personality disorder, agoraphobia, and posttraumatic stress disorder.[31],[32],[33]

On the evaluation of personality traits on MMPI-2, we found higher mean scores on schizophrenia and psychopathic deviance (Pd) subscale.[40] Freeman et al. compared 20 controls with 20 mephedrone users and found that the users had generally higher scores in schizotypy and depression.[24] However, in our study, SUD-M was unrelated to depressive symptoms.

Sociodemographic factors such as age, sex, education, occupational status, socioeconomic status, and marital status were unrelated to the severity of mephedrone use, source, and route of administration. The most likely explanation is that this study may not have been sufficiently powered to show these differences.

Comorbid substance use directly related to the severity of SUD-M in our study, which may be explained as an innate characteristic of novelty seeking in these individuals. Fifty-nine percent of the sample had a family history of substance use, and it was positively and directly related to the severity of SUD-M. Tentatively, this could support familial predisposition and psychosocial factors together influencing the drug use behavior in the offspring. Permissive attitudes toward drug use or enabling behavior in family members and role modeling are known risk factors for severe drug dependence in the offspring.[10],[28]

The presence of a comorbid psychiatric disorder was significantly associated with the severity of SUD-M. The mean BPRS scores, mean scores of subscales for psychoses, Pd, and HAM-A scores (P = 0.03) were significantly and directly related to the severity of SUD-M. These findings suggest that those with the comorbid psychiatric disorder had a more severe form of SUD-M, though causality cannot be inferred due to the cross-sectional nature of this study. Several studies have found that psychiatric disorders associated with substance use disorders are associated with greater psychosocial impairment and poorer clinical course and treatment outcomes.[41],[42],[43] Similarly, a study on methamphetamine users found that those with a comorbid psychiatric disorder evidenced increased methamphetamine use and greater functional impairment.[34] The therapeutic implication of this finding is that prompt attention and treatment of the comorbid psychiatric disorder is essential while treating patients with SUD-M.

Strengths of our study

To the best of our knowledge, this is the first study in India to explore some sociodemographic and mental health determinants of patients with SUD-M. Patients were examined by a single psychiatrist for consistency using DSM-5 criteria, and the scales applied for the assessment of psychopathology were culturally validated for the study setting. Detailed personality assessment of all the participants was completed using MMPI-2. Patients were recruited against strict inclusion criteria to reduce confounding factors that minimize bias through provisional psychiatric comorbidity of SUD-M patients. This pilot exploratory study provides insights into the nature and extent of SUD-M in clinical settings that can inform future well-powered clinical- and community-based studies. Further strengths of the work are that it aims to communicate early evidence about the drug to users, clinicians, policymakers, and research audiences. The aim is to promote evidenced-based practice standards and protocols. We hope that this early clinical work generates further research and clinical understanding with an emerging evidence base.

Limitations

This was a cross-sectional study with a relatively smaller sample size of self-nominating participants with SUD-M limiting the generalizability of the study findings to a wider population. There is a possibility that the observed findings from this study may be confounded by polysubstance use and other adulterant agents in the drug consumed by the patients, as mephedrone use was not confirmed by a toxicology screen due to the lack of availability of test kits in Mumbai during the study period.


  Conclusions Top


In our study, SUD-M was more common among young men from the low socioeconomic position. The most common reasons for choosing mephedrone over other substances were better highs from the drug and peer pressure. There were no associations between sociodemographic factors such as age, sex, education, employment status, marital status, and socioeconomic status with the severity of SUD-M. Around 40% of the patients with SUD-M had comorbid psychiatric comorbidity: Psychotic disorders and anxiety symptoms were the most common. Family history of substance use, comorbid substance use, and comorbid psychiatric disorders were directly related to the severity of SUD-M.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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