Drug and Alcohol Dependence 207 (2020) 107793

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Drug and Alcohol Dependence

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Short communication

Depression, post-traumatic stress disorder, suicidality and self-harm among T

people who inject drugs: A systematic review and meta-analysis
Samantha Colledgea,*, Sarah Larneya, Amy Peacocka, Janni Leunga,b, Matt Hickmanc,
Jason Grebelyd, Michael Farrella, Louisa Degenhardta
a
National Drug and Alcohol Research Centre, UNSW Sydney, 22-32 King St, Randwick, NSW, 2031, Australia
b
School of Public Health, University of Queensland, 266 Herston Rd, Herston, Qld, 4006, Australia
c
Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Rd, Bristol, BS82PS, United Kingdom
d
Kirby Institute, UNSW Sydney, Wallace Wurth Building, High St, Kensington, NSW, 2052, Australia

ARTICLE INFO ABSTRACT

Keywords: Background: A range of negative experiences and circumstances that are common among people who inject
Mental health drugs (PWID) are risk factors for developing mental disorders. Despite this, there has been no systematic review
Depression of the prevalence of mental health indicators among PWID. Thus, we aimed to estimate the prevalence of de-
Suicide pression, post-traumatic stress disorder (PTSD), suicidality and self-harm among PWID.
People who inject drugs
Methods: We searched the peer-reviewed and grey literature for data on depression, PTSD, suicidality and non-
Injecting drug use
suicidal self-harm among PWID from sources published from 2008-2018. We pooled estimates of depression and
PTSD
Self-harm suicidality using random-effects meta-analysis and provided a narrative summary of estimates of PTSD and self-
harm.
Findings: We found 23 studies that reported on these mental health indicators among PWID. The pooled estimate
for current severe depressive symptomology was 42.0 % (95 % confidence interval [CI] = 21.3, 62.8 %), and for
a depression diagnosis was 28.7 % (95 % CI = 20.8, 36.6 %). With much variation, the pooled lifetime pre-
valence of a suicide attempt was 22.1 % (95 % CI = 19.3, 24.9 %). There were only two studies each that
reported on PTSD and non-suicidal self-harm among PWID.
Interpretation: Recent data investigating these mental health indicators among PWID was limited, particularly
from low- and middle-income countries. Even so, estimates were high and call for further research into the
epidemiology of such mental health disorders and self-harming behaviours, as well as the promotion of in-
tegrated mental health and substance dependence treatment. Finally, incorporating suicide prevention strategies
into services accessed by PWID must be considered as a harm reduction priority.

1. Introduction Although injecting drug use is not necessarily indicative of sub-

stance use disorders, their comorbidity with mental health problems
Mental disorders, including depression and self-harm, are a major can elevate the risk of poor mental, physical and behavioural outcomes
source of morbidity and mortality worldwide (Vigo et al., 2016; World in PWID (Bartoli et al., 2014; Darke and Torok, 2013; Lemstra et al.,
Health Organization (WHO, 2013, 2017). It is common for people who 2011; Mills et al., 2006; Plotzker et al., 2007; Teesson et al., 2015). For
inject drugs (PWID) to be exposed to distressing circumstances, such as example, depression is consistently associated with a higher prevalence
unstable housing, unemployment, legal problems, physical injury or of overdose, injecting-related injuries and diseases, and sharing in-
disease (Degenhardt et al., 2017; Havens et al., 2006; Larney et al., jecting equipment among PWID (Lemstra et al., 2011; Teesson et al.,
2017; Milloy et al., 2008; Richardson et al., 2014, 2010), as well as 2015). Considering this, better evidence is needed to inform integrated
having experienced traumatic events such as childhood maltreatment treatment services and address the mental health needs of PWID.
and stigma (Darke and Torok, 2013; Wilson et al., 2014). Such events, There has been no systematic review of the evidence of mental
particularly in combination, may increase the risk of mental disorders health indicators among PWID. This paper aimed to synthesise the
among this population. existing literature on the prevalence of mental health problems among

⁎
Corresponding author.
E-mail address: s.colledge@student.unsw.edu.au (S. Colledge).

https://doi.org/10.1016/j.drugalcdep.2019.107793
Received 22 October 2019; Received in revised form 27 November 2019; Accepted 30 November 2019
Available online 10 December 2019
0376-8716/ © 2020 Elsevier B.V. All rights reserved.
 Table 1
Study-level information for estimates of depression, post-traumatic stress disorder (PTSD), suicide attempts, and non-suicidal self-harm among people who inject drugs (PWID).
Country Geographical Study year Literature Method Sample description Measure Sample Case/Score Estimate (%) Reference
region grade grade size (N)
S. Colledge, et al.

Depression
Australia Sub-national 2014 A1 A Recruited people who tampered with PHQ-9 606 Moderate to severe (score ≥10) 61.0 (Larance et al.,
pharmaceutical opioids 2015)
Australia City 2004 A1 A People who inject drugs (PWID) recruited from MINI 103 Mood disorder diagnosis 49.5 (Gibbie et al.,
needle-syringe programs (NSPs) and a primary 2011)
health center
Canada City 2010 A2 B1 Set in Saskatoon, a region with a high CES-D 603 Mild to severe (score ≥16) 81.4 (Lemstra et al.,
prevalence of indigenous/First Nations people. Severe (score ≥23) 57.7 2011)
Nearly 90 % of the sample were Aboriginal
(First Nations, Metis or Inuit)
China City 2013 A1 B1 People who primarily inject heroin recruited CES-D 257 Mild to severe (score ≥16) 93.4 (Li et al., 2015)
from three different NSPs Moderate to severe (score ≥21) 86.4
Severe (score ≥25) 75.1
India National 2013 A1 B1 PWID recruited from 15 cities around India PHQ-9 6449 Moderate to severe (score ≥10) 33.5 (Sabri et al., 2017)
India City 2012 A1 B1 Men who inject drugs who are not enrolled in PHQ-9 450 Moderate to severe (score ≥15) 84.4 (Armstrong et al.,
treatment Severe (score ≥20) 17.4 2013b)
New Zealand National 2015 A1 A PWID recruited from NSPs and pharmacies DASS-21 225 Mild to severe (score ≥10) 68.4 (Hay et al., 2017)
Moderate to severe (score ≥ NR*) 54.2
Severe (score ≥ NR) 32.0
Tanzania City 2012 A1 C People who were enrolled in a methadone John Hopkins 400 Depression diagnosis 22.0 (Lambdin et al.,
program recruited from Muhimbili National Symptoms Checklist 2013)
Hospital for Depression -25
Tanzania City 2013 A1 C People who were enrolled in a methadone John Hopkins 629 Depression diagnosis 23.0 (Lambdin et al.,
program recruited from Muhimbili National Symptoms Checklist 2014)

2
Hospital for Depression -25
Ukraine Sub-national 2015 A1 A People who were diagnosed with ICD-10 opioid CES-D 1613 Moderate to severe (score ≥10) 53.2 (Marcus et al.,
use disorder 2017)
United States Sub-national 2012 A1 A PWID recruited through respondent driven CES-D 454 Mild to severe (score ≥ NR) 68.1 (Grau et al., 2016)
sampling (RDS) Moderate to severe (score ≥ NR) 45.4
Severe (score ≥ NR) 28.2
United States Sub-national 2010 A1 B1 PWID recruited from Appalachian, Kentucky MINI version 5.0 392 Severe: Major depressive disorder 28.1 (Havens et al.,
diagnosis 2013)

PTSD
Australia Sub-national 2014 A1 A People who tampered with pharmaceutical PC-PTSD 606 Possible presence of PTSD:Score 42.0 (Larance et al.,
opioids >3 2015)
United States Sub-national 2010 A1 B1 PWID recruited from Appalachian, Kentucky MINI version 5.0 392 DSM-IV PTSD diagnosis 14.8 (Havens et al.,
2013)

Suicide Timeframe Definition

Taiwan Sub-national 2008 A1 B1 People who had recently used heroin and were Month 523 Attempted suicide 32.7 (Lee et al., 2011)
on methadone maintenance therapy, recruited
from four different clinics
Canada City 2011 A1 B1 Street-recruited PWID 6 months 1240 Attempted suicide 5.7 (Artenie et al.,
2015)
India Sub-national 2006 A1 C Male PWID who were mostly unstably housed 6 months 449 Attempted to take your own life 4.2 (Sarin et al., 2013)
(89.0 %)
Australia City 2012 A1 B1 PWID recruited through NSPs who were 12 months 300 Deliberate self-harm with the 3.0 (Darke and Torok,
injecting weekly or more frequently Lifetime intention of causing death 25.7 2013)
Canada City 2013 A1 B1 PWID recruited using RDS 12 months 272 Attempted suicide 7.7 (Shaw et al., 2015)
India City 2012 A1 B1 Men who inject drugs who are not enrolled in 12 months 450 Attempted suicide 36.3 (Armstrong et al.,
treatment 2013b)
(continued on next page)
Drug and Alcohol Dependence 207 (2020) 107793
S. Colledge, et al. Drug and Alcohol Dependence 207 (2020) 107793

Note: CES-D: Center for Epidemiologic Studies Depression Scale; DASS-21: Depression Anxiety Stress Scale 21; DSM: Diagnostic and Statistical Manual of Mental Disorders; ICD-10: 10th revision of the International
Statistical Classification of Diseases and Related Health Problems; MINI: Mini International Neuropsychiatric Interview; NR: Not reported; NSP: Needle-syringe exchange programs; PHQ-9: Patient Health Questionnaire;
PWID, specifically: depression, post-traumatic stress disorder (PTSD),

(Ojha et al., 2014)

Focal Point, 2010)

(Darke and Torok,

(Hakansson et al.,
(Backmund et al.,
suicidal thoughts, plans and attempts, and non-suicidal self-harm.

(Reitox National

(KPMG, 2010)
(Zerden et al.,
2. Methods
Reference

2010)

2011)

2012)

2013)
This systematic review uses data gathered for a previous review
(PROSPERO registration numbers CRD42016052858 and
Estimate (%)

CRD42016052853) investigating sociodemographic and risk char-

acteristics of PWID. Details of the methodology have been described
27.4

11.2

20.0

23.0
22.1

23.7

12.9
13.9
elsewhere (Degenhardt et al., 2017). Adhering PRISMA and GATHER

8.0

9.8
guidelines (Appendix 1–2 (in Supplementary material)) we searched

as the deliberate destruction of body

Non-suicidal self-harm was defined
peer-reviewed (Medline, Embase, and PsycINFO) and grey literature,

tissue without conscious suicidal

and online databases for data published from January 2008-June 2018
Deliberate self-harm with the

(see Appendix 3-4(in Supplementary material)). We then circulated

intention of causing death
Tried to commit suicide

data requests to international experts and agencies.

Deliberate self-harm
Two researchers provided independent screening, and conflicts
Attempted suicide

Attempted suicide

were resolved by a third reviewer. We included all studies providing

Suicide attempt

sociodemographic or risk characteristics, or reporting on blood borne

Case/Score

viruses, overdose, mental health, or injecting related injuries and dis-

intent

eases among PWID, and did not limit the search results by language.
Studies were excluded if they:
size (N)

a) had fewer than 40 participants;

Sample

1049
124

107

300

300

687
813
784

b) limited participants on key outcomes except for treatment status

68

(e.g. gender, age, HIV status, prison status etc.); or

c) were a follow-up study of a previously recruited sample (e.g. cohort
studies).
12 months

12 months

12 months

Suicide, self-harm, depression and PTSD data were included in this

Measure

Lifetime

Lifetime
Lifetime

Lifetime

Lifetime

review. Where two studies provided data on the same sample, the study
with the most complete reporting on the variables of interest was re-
tained. Study quality was assessed using previously developed grading
PWID requiring heroin detoxification recruited

systems of methodology and literature type (Mathers et al., 2008) (see

Data collected from PWID through 10 low-

New entrants to the Medically Supervised

Appendix 5(in Supplementary material)).

PWID recruited through NSPs who were
PWID recruited from treatment settings

Injecting Centre in Kings Cross, Sydney

The studies that met inclusion criteria for this paper were those that
injecting weekly or more frequently

reported on experience of suicide attempt, suicide plan, suicidal

thoughts, and non-suicidal self-harm (past month/current, 6 months, 12
PWID recruited using RDS

PWID recruited using RDS

months and lifetime). Self-report measures were used as there were no

from a tertiary hospital

studies that reported on suicide or self-harm using a validated scale.

threshold programs
Sample description

Studies that assessed current depression, or depressive symptomology,

Literature and method grading systems are in Appendix 3(in Supplementary material).

and PTSD using validated screening scales or diagnostic interviews (i.e.

any peer-reviewed scales/inventories with publications supporting
their validity and reliability) were included. We did not limit the vali-
dated screening scales in the extraction phase, although studies that
PC-PTSD: Primary Care PTSD screen; RDS: Respondent-driven sampling.

reported self-report depression or PTSD (i.e. answering yes to “have you

been diagnosed with depression/PTSD”) were excluded due to low
Method

validity. Although definitions of current or active PWID differ between

grade

B1

B1

B1

studies, we define PWID as those who have injected drugs within the
A
C

previous 12 months for this review.

To generate a pooled estimate of the prevalence of depression, and
Literature

the proportion who had attempted suicide, we ran a random-effects

grade

meta-analysis in STATA 15 using the ‘metan’ command. For studies that

A1

A1

A1
A1

A1
B2

B3

reported depressive symptomology by severity, we categorised esti-

Study year

mates to reflect mild to severe, moderate to severe, and severe symp-

tomology. Estimates from studies that used measures to diagnose par-
2007

2008

1997

2013
2009

2012

2010
2009
2008

ticipants with major depressive disorder (MDD) were pooled separately.

Studies providing estimates of suicide attempts among PWID were
pooled by timeframe (12 months and lifetime).
Geographical

Sub-national
National

National

3. Results
region

City

City

City

City
Table 1 (continued)

Of 61,077 studies and reports, screened for eligibility for the ori-
ginal review, information on characteristics and harms among PWID
Puerto Rico

Self-harm
Germany

Australia

Australia

was extracted from 1381 sources. Among those, there were 22 eligible
Slovenia
Country

Sweden
Nepal

studies of depression, PTSD, suicidality or non-suicidal self-harm (see

flowchart in Appendix 6(in Supplementary material)). Nearly all

3
S. Colledge, et al. Drug and Alcohol Dependence 207 (2020) 107793

Fig. 1. Prevalence of depression and depressive symptomology, and estimates of suicide attempts among people who inject drugs (PWID) by severity and timeframe.

(n = 20) included studies were peer-reviewed journal articles (Table 1). Neuropsychiatric Interview (MINI; n = 2), the John Hopkins symptoms
There were 39 estimates, and most were from samples recruited in one checklist for anxiety and depression (n = 2), and the Depression
city (n = 20), while six were recruited from multiple geographical sites Anxiety Stress Scale 21 (DASS-21; n = 1).
across a country. Among PWID, 28.7 % (95 % confidence intervals [CI] = 20.8, 36.6
%; I2 = 91.5 %) met diagnostic criteria for MDD (Fig. 1). Four estimates
representing PWID sampled from Tanzania, the United States, and
3.1. Depression Australia were pooled to generate this estimate (see study details in
Table 1). An estimated 42.0 % (95 %CI = 21.3, 62.8 %; I2 = 99.1 %) of
From 12 studies, there were five different inventories used to PWID screened as having ‘severe’ depressive symptomology. Estimates
measure depression or depressive symptomology: the Center for ranged from 17.3 % (95 %CI = 13.9, 21.2 %) (Armstrong et al., 2013b)
Epidemiologic Studies Depression scale (CES-D; n = 4), the Patient to 75.1 % (95 %CI = 69.3, 80.3 %) (Li et al., 2015) from five different
Health Questionnaire (PHQ-9; n = 3), the Mini International

4
S. Colledge, et al. Drug and Alcohol Dependence 207 (2020) 107793

studies in India, the United States, New Zealand, Canada and China. 4.2. Implications
The prevalence of moderate to severe depressive symptomology
among PWID was estimated to be 59.7 % (95 %CI = 42.7, 76.8 %; Studies among the general population have found that less than 1 %
I2 = 99.6 %), derived from seven estimates from six countries. Finally, had attempted suicide in the previous year and less than 3 % had ever
the pooled mild to severe depression estimate was 78.0 % (95 attempted suicide (Borges et al., 2010; Bromet et al., 2017). Our review
%CI = 66.1, 89.8 %; I2 = 97.4 %), which included samples of PWID found that estimates of recent attempts were as high as one third in
from the United States, New Zealand, Canada and China. Although the samples of PWID from Taiwan and India (Armstrong et al., 2013b; Lee
range in the estimates was notably smaller when pooling mild to severe et al., 2011). Considering previous suicide attempts are associated with
depression, with the lowest and highest point estimates being 25.3 future fatal and non-fatal attempts (Borges et al., 2000), as well as
percentage points apart (I2 = 97.4 %), there was less heterogeneity morbidity relating to the method used (Dunn and Lopez, Updated 2019
when pooling the MDD estimates (I2 = 91.5 %). Jul 3; Warner-Smith et al., 2002), there is substantial opportunity for
intervention within this group. The scale up of suicide prevention
3.2. Suicidality strategies targeting PWID must be considered in order to reduce the risk
of suicide fatalities.
There were 11 studies that included data on self-reported suicide Around 5 % and 0.3 % of the population are estimated to have
attempts among PWID across four different time frames, comprising current MDD and PTSD, respectively (Baxter et al., 2014a, b). We found
past month (n = 1), past 6 months (n = 2), past 12 months (n = 5) and that among PWID these estimates are many magnitudes higher. There is
lifetime (n = 4) (Fig. 1). Estimates of past year attempted suicide ample evidence that mental health and substance use comorbidities
among PWID ranging from 3.0 % (95 %CI = 1.4, 5.6 %) from an Aus- contribute to poorer prognosis on health outcomes and extensive
tralian sample (Darke and Torok, 2013) to 36.2 % (95 %CI = 31.8, 40.9 morbidity and mortality (Allsop, 2008). Integrating mental health and
%) among an Indian sample (Armstrong et al., 2013b). Estimates of substance dependence treatment with a multifaceted approach has been
lifetime suicide attempts were less heterogenous (I2 = 34.2 %), re- widely considered best practice (Roberts et al., 2015; Torrens et al.,
sulting in a pooled estimate of 22.1 % (95 %CI = 19.3, 24.9 %) and a 2012). Although there are several models that have been developed, a
range of 20.0 % (95 %CI = 17.6, 22.6 %; (Backmund et al., 2011)) to review found that including a harm reduction approach (e.g. dis-
25.7 % (95 %CI = 20.8, 31.0 %; (Darke and Torok, 2013)). couraging abstinence only conditions and providing access to sterile
Only five studies reported on suicidal thoughts (n = 5) or planning needles and syringes) was an important element to be considered in
(n = 2) (Appendix 7(in Supplementary material)). Estimates of suicidal integrated mental health and substance dependence treatment (Mueser
thoughts were high, with three studies reporting estimates of over 40 % and Gingerich, 2013).
within the previous year (Slovenia, past 12 months: 41.0 % (Reitox
National Focal Point, 2010); Puerto Rico, past 6 months: 43.8 % 4.3. Limitations
(Zerden et al., 2010); and India, past 12 months 53.1 % (Armstrong
et al., 2013b)). We noted several limitations. Firstly, there were few studies, par-
ticularly for non-suicidal self-harm and PTSD, that met our inclusion
3.3. Non-suicidal self-harm criteria. We know that data on mental health indicators has been re-
searched extensively in conjunction with substance use disorders;
Due to the small numbers of studies we were unable to pool the data however, compared to people with substance dependence that do not
on PTSD or non-suicidal self-harm. There were two Australian studies inject, PWID have been found to have an elevated risk of depression and
that investigated non-suicidal self-harm among PWID. Among those suicidality (Cepeda et al., 2012; Darke and Kaye, 2004). Depression,
recruited from a supervised injecting facility in Sydney, Australia, the PTSD and suicidality are also associated with engaging in injecting risk
most recent estimate of lifetime engagement in non-suicidal self-harm behaviours, increasing the likelihood of contracting blood borne viruses
was 13.0 % (KPMG, 2010). In the second study, Darke and Torok (Armstrong et al., 2013a; Mackesy-Amiti et al., 2014; Plotzker et al.,
(2013) found nearly one in four PWID recruited from needle syringe 2007). Future research monitoring the prevalence of psychiatric co-
programs in Sydney, Australia had ever engaged in non-suicidal self- morbidities among PWID is important for informing harm reduction
harm (23.7 %) and nearly one in ten had done so in the previous year and treatment strategies that respond to major mental and physical
(8.0 %). health issues.
Much of the available data was from high-income countries. The
3.4. PTSD lack of data investigating self-harming behaviours among people who
use drugs in low- and middle-income countries, where 75 % of suicides
Two studies that met inclusion criteria reported clinically assessed occur (World Health Organization (WHO), 2014), has been highlighted
PTSD among PWID. Using the MINI inventory, a study in the United in a recent review (Breet et al., 2018). Updated epidemiological re-
States reported a prevalence of 14.8 % (Havens et al., 2013). The search investigating these harms, globally, remain important for mea-
second study from an Australian sample found that 42.0 % scored > 3 suring our progress in improving outreach of intervention strategies
on the Primary Care PTSD (PC-PTSD) screening tool, indicating “pos- and reducing self-harming behaviour.
sible presence” of PTSD (Larance et al., 2015). Several screening scales and inventories were used to measure de-
pression, and cut-off scores of severities were not always consistent.
4. Discussion Therefore, variability in our results might be explained by the differ-
ences in these inventories or the cut-off scores used. We found that most
4.1. Main findings inventories were measuring current depressive symptomology, com-
pared to diagnosing MDD. There were too few studies to undertake
To our knowledge, this is the first systematic review synthesising meta-regressions exploring associations between inventories and de-
the recent evidence of depression, PTSD, suicidality and non-suicidal pression prevalence; however, we found that among the few MDD es-
self-harm among PWID. We estimated that over half of PWID had timates there was less heterogeneity than the scales measuring severe
moderate to severe depressive symptomology, and one in six had at- depressive symptomology.
tempted suicide in the previous year. Our results call for further in- Finally, there is a lack of data that is representative of diverse
vestigation to expand our global understanding of the prevalence of geographical regions. Notably, two studies set in India using the same
mental health disorders and self-harming behaviours among PWID. scale to measure (moderate to severe) depression found a 51-percentage

5
S. Colledge, et al. Drug and Alcohol Dependence 207 (2020) 107793

point difference in estimates (Armstrong et al., 2013b; Sabri et al., and acknowledges NIHR School of Public Health Research.
2017). The higher estimate sampled male PWID from one city (Delhi),
while the lower estimate was a sample of both men and women re- Appendix A. Supplementary data
cruited from 15 cities. The latter is an example of incorporating mental
health screening in large-scale, routine surveillance data collection and Supplementary material related to this article can be found, in the
could be employed by more national-level research to better inform our online version, at doi:https://doi.org/10.1016/j.drugalcdep.2019.
global understanding of mental health in PWID (World Health 107793.
Organization (WHO, 2016).
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