Synopsis for PhD Program

Title: Psychiatric Morbidity in Drug addiction: prevalence of mental disorders and

role of illicit drugs

Proponent: Kazi Jahangir Hossain ssistant !egistrar Department of Psychiatry Sir Salimullah Medical "ollege Mitford Hospital Dha#a$%%&&

Supervisor: Professor ' H' Mohammad (iroz Director )ational *nstitute of Mental Health Sher$e$+angla )agar, Dha#a$%-&.

)ational *nstitute of Mental Health, Dha#a January -&&/

"hec# documents submitted here0ith

1thical issues 2page: 34 Summary of the study 2page: 54 Time schedule of the study 2page: %/4 *nformation to participants 2page: -34 *nformed consent form 2page: -54 6uestionnaire 2page: -74 "urriculum 8itae of the proponent 2page: -/4 9ist of publications 2page: -:4 ""!+ certificates 2page: 5-4

Title: Psychiatric Morbidity in Drug addiction: prevalence of mental disorders and

role of illicit drugs

1thical issues

total of %-&& drug abusers 0ill be investigated' as updated in -&&-'

s drug abusers are vulnerable, the procedures

0ill be follo0ed for this study 0ill in accordance 0ith the "*;MS guidelines for biomedical research

Trained personnel, not in hospital employee, 0ill brief ob<ectives, perspectives, benefits, ris#s and burdens of this study to the drug abusers and their close relatives' ;nly positive respondent, consistent 0ith selection criteria, 0ill be recruited, as research participants' The trained personnel 0ill ta#e 0ritten informed consent from each of the participant 0ith maintaining full autonomy' He 0ill also collect general information follo0ing the =uestionnaire' The proponent, under supervision of !esident Psychiatrist, 0ill collect socioeconomic$family profile and drug habit' (inally, the proponent 0ill e>amine mental state using standard diagnostic criteria follo0ing guidelines' 1ach of the participants 0ill be intervie0ed and e>amined in a room separately to maintain their privacy and confidentiality strictly' Drug abusers usually see# deto>ification therapy and 0ill attain at ;utpatient Department of "T" for treatment voluntarily' They 0ill be selected at the time of registration and re=uired time for intervie0 and e>amination 0ill be 3&$5& minutes appro>imately' )o e>tra 0edge$compensation 0ill be given to the participants' ;utcomes of this study 0ill be of public interest and 0ill be of immense helpful to the medical practitioners' *t 0ill also contribute in the preparation of national policy for effective treatment and prevention policy against drug addiction and traffic#ing' ll documents including =uestionnaire 0ill #eep under control of the proponent' article 0ill be published in national or international reputed <ournals' )o individual

information 0ill be given' !esults 0ill be used in partial fulfillment of PhD degree' ;riginal research

Title: Psychiatric Morbidity in Drug addiction: prevalence of mental disorders and

role of illicit drugs

SMM !? Drug addiction is a human catastrophe@ no nation in the globe is immune to its fatal conse=uences' The primary aim of this study is to investigate psychiatric morbidity among the drug abusers' *t is anticipated that about 5'A million young adults have been using illicit drugs in +angladesh and this number is increasing 0ith time' "onse=uence of drug addiction severely inflicts family and societal life' *n addition, they are also topmost high$ris# sub population for H*8B *DS in +angladesh' Demand reduction is an integral part of preventive strategy' +ehavioral therapies and medical management, family and social participation <ointly can tailored the individual need of illicit drugs, can learn to control their crisis and be trained to maintain their normal and productive life in family or 0or# place or in community' rehabilitation' Cpdate management in drug addiction is still remaining in embryonic state in +angladesh' Drug abusers are haphazardly and indiscriminately treated there and every0here in an unhealthy environment' *t has, thus, been creating increased demand of services in public healthcare system' *n addition, it 0ipes out the gain made by developments' This study is important, because once their assessment data 0ill be collected, a national policy for effective treatment and prevention modality 0ill be established 0hich 0ill be of public interest, and 0ill be of immense helpful to the medical practitioners' total of %-&& drug abusers 0ill be investigated' "entral Drug ll of the research participants 0ill be drug Scientific information about drug abuse related mental illnesses and mental disorders is of vital important for effective behavioral therapies and medical management and

dependent population' They 0ill see# deto>ification therapy voluntarily at ;utpatient Department of ddiction Treatment "enter 2"T"4, Te<gaon, Dha#aD' They 0ill be selected on the basis of defined criteria' !esearch instrument 0ill be intervie0er$administered =uestionnaire and mental state e>amination criteria' Trained personnel 0ill brief the ob<ectives and perspective of this study to the drug abusers and their close relatives in detail' ;nly positive respondent and consistent 0ith selection criteria 0ill be included in this study' Trained personnel 0ill collect general information follo0ing the =uestionnaire' The proponent 0ill document socioeconomic$family profile and drug habit follo0ing the =uestionnaire' =uestionnaire' Data 0ill be compiled and analyzed using SPSS soft0are pac#age program 2version %-'&4' ;ne$0ay analysis of variance 2descriptive, );8 4 and nonparametric analysis - 0ill use to evaluate (inally, proponent 0ill also e>amine mental state using standard diagnostic criteria follo0ing the

influence of illicit drugs and socioeconomic$family profile on mental illnesses and mental disorders' 4

"ontents
%'& *ntroduction
%'% %'%'3 %'5 %'7 %'A %'. %'/ %': ;vervie0 *llicit drugs and its category Production and traffic#ing of illicit drugs (actors influencing drug addiction 9ife style of drug abusers "onse=uence of drug abuse Drug addiction and +angladesh +ac#ground of the study !ationale of the study A . . / : : %% %%3 %5

%'%& ;b<ectives

-'& Materials and Methods

-'% -'-'3 -'5 -'7 -'A -'. -'/ -': !esearch =uestion Hypothesis Study design Study population Sample size Selection criteria !esearch instruments Plan of action Time schedule %7 %7 %7 %7 %A %A %. %. %/ %/ %/ %: -3 -5 -7 -A -/ -: 3& 37 3A

-'%& Statistical analysis 3'& 5'& 7'& A'& .'& /'& :'& %%'& %3'& Ctilization of results !eferences *nformation to participants *nformed consent form 6uestionnaire ;perational guidelines "urriculum 8itae bstract of publications cademic certificates

%&'& 9ist of publications %-'& ""!+ certificate

%'& *ntroduction %'% ;vervie0

Drug abuse is a human catastrophe@ no nation in the globe is immune to its fatal conse=uences 2C)D"P, %::.a@ + S , %::A4' *t is a to0ering sociopolitical, health and economic problem in the 0orld 2Soyibo and 9ee, %:::4' *t inflicts every sphere of human life destroying innumerable lives and undermining civic societies' *t is a life challenge to the international community' lthough, drug abuse has been a fact of life for centuries, it has been mushroomed over the last fe0 decades 2 nnan, %::.4' (ollo0ing the end of Eorld Ear **, young adults are being afflicted relentlessly 0ith drug addiction' *t is because of outnumbered young adults, change in familial living arrangement, change in beliefs and values, and change in drug mar#ets 2Johnson and Ferstein, %::/4' ?ouths are in a state of ruination' Firls and boys are soaring 0ith illicit drugs and 0ading into the sea of drug e>perimentation' They are at high ris# for H*8 infection 2* S, -&&5@ *slam et al, -&&3@ Feddes et al, %::A4' Ho0ever, in spite of a focus on its fatal conse=uences, until recently research on substance abuse has received a little attention in +angladesh' *n the %::&s, the annual global prevalence rate of drug abuse 0as .'.G of the 0orld population' ;f them, about -'7G 2H%5% million people4 used cannabis, &'-3G 2%3'3 million people4 abused cocaine and &'%5G 2/ million people4 too# heroin and other opiate derivatives' *n the recent years, synthetic drugs TS 2amphetamine$type stimulants4 have been abused by a large section of the 0orld drug t abusers 2H3& million people4, 0hich 0as above cocaine and heroin users' More than -7 million people too# hallucinogens 2lysergic acid diethylamide 9SD, phencyclidine piperidine P"P etc4' present 2the -&&/4, global prevalence rate of illicit drug use is tremendously high' Cse of illicit drugs induces affective alterations@ change in behaviors and cognitions@ change in neurovegetative functions such as insomnia, se>ual dysfunctions and altered food habit and also induces perceptual or thought disturbances 2DSM$*8, -&&7@ Khando=or et al, -&&-@ C)D"P, %::.e@ Felder, -&&%@ "ummings, -&&-4' Eatts and Eright, %::5@ C), %://4' Most of the illicit drugs are immunosuppressive 2Miyagi, -&&&4' Drug abusers have poor nutritional status and multiple nutrient deficiencies are prevalent among them, 0hich is the leading cause of immunodeficiency 2*slam et al, -&&-@ "handra, %::., -&&%4' "hronic use of illicit drugs also impairs immunoglobulin and 0hite cell profile 2*slam et al, -&&54' Se>ual behaviors of the drug abusers are highly vulnerable in shape, ma<ority of them have multiple se> partners 2most of them are se> sellers4 and unprotected ris#y se> practices 0ith them 2*slam et al, -&&&4' Thus, use of illicit drugs produces ntisocial activities such as home or street violence, crimes, illegal gambling, snatching, mugging, stealing etc are highly prevalent among drug abusers 2Millar, %::5@

immunonutritional deficiencies, and influences susceptibility to infectious agents including H*8, hepatic and 1pstein$+ar 21+84 viruses, ST* etc 28arela, %::.a, %::.b@ Eang, %::%@ +rugura, %:/54' 9i#e other sian country, drug abuse has become a national problem in +angladesh' *t is increasing 0ith time' *t has invaded every fabrics of community in both urban and rural life 2*slam et al, -&&&@ !abbani, %::-4' Productive young adults are being soared 0ith illicit drug use' Drug addiction has also flared up difficulties in societal, health, economic and even political sectors in +angladesh' *t has been addressed nationally to control its further fatal e>plosion' lthough, several researches on drug addiction and illicit drug use are being carried out 0orld0ide, a very fe0 scientific study has, so far, been conducted in +angladesh' The proposed study 0ill, therefore, attempted to investigate psychiatric morbidity 2mental illnesses and mental disorders4 of the drug dependent population'

%'- *llicit drugs and its category

The illicit drugs are psychoactive or mood altering substances, 0hich is defined as Iany substance that, 0hen ta#en by human or any living beings, may modify their perception, mood, cognition and behaviour or motor function'J The Cnited )ation ;ffice of the Drugs and "rimes 2C);D"4 does not recognize a distinction bet0een licit and illicit substance, but does describe only use to be licit or illicit' The term illicit drug refers to describe the substances, 0hich are under international control and may or may not have therapeutic or medical uses, but are being produced, traffic#ed andBor consumed illicitly' C);D" and *nternational )arcotic "ontrol +oard 2*)"+4 categorized illicit drugs as follo0s %' ;piates -' ")S depressants 3' ")S stimulants 5' Hallucinogens 7' *nhalants A' "annabis : ;pium, morphine, codeine, heroin, pethedine, buprenorphine etc' : +arbiturates: anesthetics, benzodiazepines 2diazepam4 etc' : "ocaine, amphetamines etc' : Mushroom, lysergic acid diethylamide 29SD4, phencylidine 2P"P4 etc' : (uels, aerosols, gum$glue etc' : Fan<a, charash, mari<uana, nosshi, siddhi etc'

%'3 Production and traffic#ing of illicit drugs

The largest shares of illicit substances are plant$based products' The opioids are derived from Opium poppy plant, cocaine is from Coca bush and cannabis is from Cannabis sativa' *t is evident that almost :&G of the 0orldDs illicit opioids are being produced in the three main regions of sia: the Folden Triangle 29aos, Mayanmar and Thailand4, the Folden "rescent 2 fghanistan, *ran and Pa#istan4 and the Folden Eadge 2)epal and part of *ndia4' To some e>tent, the illicit cultivation of 7

Opium poppy ta#es place in 8iet )am, "hina, HongKong, Tazi#istan, Tur#menistan, and the Middle 1ast and in other central sian countries 2*)"+, %:::@ C)D"P, %::.b4' To a limited scale, it is also cultivated in 9atin merica 2Me>ico, Fuatemala4, nden region 2"olombia4 and in 1urope 2!ussian (ederation, C#raine, 9ithuania, 9atvia and Poland4 2*)"+, %:::4' "ocaine is only produce in the mericas' More than :/G of Coca bush is being cultivated in Peru, +olivia and "olombia 2C)D"P, %::.b4 and the remaining is cultivated in +razil, 1cuador and 8enezuela' s cannabis gro0s naturally throughout the 0orld, the largest number of 0orld drug addicts uses it' Potent strains of Cannabis sativa 2that contains higher tetra$hydro cannabinol, TH"4 are largely cultivated in the CS , South frica, Morocco, "entral sia, "ommon0ealth of independent states 2"*S4, fghanistan, Pa#istan, "olombia, Me>ico and Jamaica 2C)D"P, %::.c4' Synthetic illicit substances are

manufactured in clandestine laboratories as per demand of the drug abusers throughout the 0orld' *llicit drug traffic#ing is an organized crime' The international crime syndicates that almost entirely control the illicit drug traffic#ing are$ "ocaine "artels 2Medellin "artels and "ali "artels in "olombia4, Fulf cartels 2Me>ico4, Triads 2Hon#ong, Myanmar4, ?a#uza 2Japan4, "osa )ostra 2*taly4, 9a "osa )ostra 2)e0 ?or#4 and Mafia 2!ussia4 2C)D"P, %::.c4' The aim of drug traffic#ing syndicates is to e>pand po0er and influence, develop ne0 capabilities and to establish ne0 bases of support' They influence diversification of drug abuse into ne0 mar#ets and in many cases of legitimate financial operations' They have 0orld0ide net0or# and maintain 0ell interrelationship 2C), %://4' The crime groups finance and supervise the cultivation, production and smuggling of illicit drugs through a chain of command in the 0orld' Depending on la0$enforcement, they use all of the international routes 2such as seaports, airports, road transport truc#s, e>press mail parcels4 as trans$ shipment or transit points or corridors for traffic#ing of the illicit drugs throughout the 0orld' The codeine based cough medicine 2phensedyl4, cannabis, heroin, buprenorphine and pethedine are the ma<or illicit drugs used in South sia 2+angladesh, *ndia, )epal and Sri 9an#a4, all of 0hich are sian countries, and are traffic#ing into the manufactured clandestinely in *ndia and other

neighboring countries' +angladesh for its uni=ue geographical location bet0een the largest opium producing zones, has become an important trans$shipment traffic#ing zone for transporting illicit drugs to 1urope and the mericas through its sea and air routes' This has, thus, turned +angladesh into a high drug abusing country in the 0orld 2C)D"P, %::54'

%'5 (actors influencing drug addiction

Since the very beginning of human life, psychoactive substances have been used in social practice of medicine, religion and ceremony' This traditional use of the substances has been replaced and regulated by profit$see#ing criminal organizations, 0hich has influenced certain groups or individuals to use psychoactive substances illicitly' There are many factors that influence or motivate individuals 8

to be illicit drug users' Ho0ever, the predominant factors are 2i4 interpersonal 2family, peers and others4, 2ii4 sociopolitical 2socioeconomic, cultural, environmental and political4, 2iii4 personal and 2iv4 constitutional 2anatomic and genetic4 factors'

%'7 9ife style of the drug abusers

9ife style of the drug abusers is detrimental to themselves as 0ell as to family and society' Most of time they remain in KhighD or sic# or euphoric or semi$stupors state 2(innegan, %::/4' They are pathological liar, restless, stubborn and manipulative in nature' They are unable to sustain education or profession and fail to conform to the social norms 0ith respect to la0ful behaviors' (re=uent lying, repeated promise brea#ing, avoiding family or social functions and loss of friendship are the predominant habit, highly prevalent, among the drug abusers' "raving for illicit drugs indulges them in robbery, mugging, snatching, forgery, street crimes, violence, even sale of blood and prostitution 2(innegan, %::/@ C)D"P, %::5a4' Cse of illicit drugs undermines the desire for ta#ing any food' +y neglecting sleep and basic hygiene, drug addicts severely compromise their physical health' "onse=uently they appear to be emaciated for most of the time 2*nciardi et al, %::3@ !atner, %::3@ Mc"oy and Miles, %::-4' Multiple drug abuse for longer period is of common habit and their se>ual life is virtually at vulnerable shape' Ma<ority of them have unprotected se> 0ith multiple partners, 0hich ultimately results in suffering from se>ually transmitted infections, even H*8 infection 2*slam et al, -&&&@ -&&3@ )!", %::.4' *mmunonutritinal deficiencies, chronic infections and other health ris#s are also fre=uently associated 0ith drug addiction 2*slam et al, -&&5@ 8arela et al, %::.a@ %::.b@ C)D"P, %::5a@ Eang et al, %::%4'

%'A "onse=uence of drug abuse

Cse of illicit drugs affects all of the components of health: physical, mental, social and spiritual health' *t induces numerous mental illnesses such as disturbed behaviors, altered food habit, malnutrition, neuro$vegetative dysfunctions, perceptualBthought disturbances etc 2 merican Psychiatric ssociation, -&&7@ C)D"P, %::.e@ Felder et al, -&&%@ "ummings and Trimble, -&&-4' *n addition, antisocial activities li#e home or street violence, illegal gambling, snatching, mugging, stealing etc are e>tremely 0idespread among the drug abusers 2Miller, %::5@ Eatts and Eright, %::5@ C), %://4' Studies sho0 that substance abuse is highly prevalent among the bipolar and mi>ed bipolar patients or bipolar episodes and mi>ed episodes are fre=uently common among the drug abusers 28ieta, -&&74' The horrendous effect of drug abuse shatters the civic life style of the 0orld community 2C)D"P, %::5a4' *ts impact on community is multi$dimensional' *t does, not only, affect the individuals, but also the societal life and public health' 9

Effect on social value: 1mergence of illicit substance uses results in an e>plosive social violence 0orld0ide' The illicit drug use causes a change in attitudes and values to0ards society, community, family and religion as 0ell as morality' *t also results in incomplete education, homelessness and loss of economic competitiveness 2Soyibo and 9ee, %:::4' The epidemic of drug abuse has over0helmed men, 0omen and children and it has resulted in an immense damage to an honoured structure in human civilization$ the family 2(innegan, %::/4' ;nce a single member of a family becomes addicted, the entire members of the family$spouse, parents, children or siblings face the conse=uences that ultimately disintegrate the family unit' Health consequence: Drug addiction is a life threatening challenge to the public health' *t does, not only, affect the drug addictDs life and hisBher family but also inflicts entire social community and nation' Depending on specific interaction bet0een illicit drug and userDs lifestyle, it results in fatal conse=uences for physical, mental and social health' *mmunosuppressive illicit drug ma#es the drug addicts susceptible to infectious agents including H*8, +$virus etc 28arela et al, %::.a@ %::.b@ Eang et al, %::%@ +ruguera, %:/54' Drug addicts are prone to developing chronic #iller diseases li#e *DS, cardiovascular diseases, #idney dysfunction etc 2C)D"P, %::.e@ 8arela et al, %::.b: EH; %::-@ +att<es et al %:/:4' *t is also associated 0ith other chronic diseases such as hepatitis, tuberculosis, ST* that further impairs immunity and influences susceptibility to any disease' H*8 and ST* are =uic#ly spreading by se>ual contact and by in<ection drug use 2+ooth et al, -&&&@ "hit0ood et al, -&&&@ DesJarlais et al, -&&&, +luthenthal et al, -&&&4' (re=uent use of high dose of opiates impair se>ual performance and fertility, resulting in impotence in men and severe irregularities in menstrual cycle in 0omen, and also produces mood instability, lethargy, anore>ia 2C)D"P, %::.e@ McFlothlin, %:.:4' Heroin alters muscle and #idney function and glucose metabolism 2Pearce and "o>, %:/&4' *t is reported that morphine use causes hypoglycemia by raising insulin level, but it may induce atherogeneis by its hypercholesterolemic effect' Diabetes decreases sensitivity and dependence on morphine' "entral nervous system depressants such as barbiturates and benzodiazepine abuse cause e>cessive dro0siness and respiratory problems@ even high dose can cause unconsciousness or death through respiratory failure' "ocaine, 0hich is a vasoconstrictor, can induce cardiac complications such as rise of blood pressure, heart attac# etc' "ocaine abuse may also cause spontaneous abortion, lo0 birth 0eight baby or neonatal complications' 9ong$term use of cocaine can damage liver, heart and brain 2C)D"P, %::.e@ *nciardi, %::54 and have mouth ulceration and burned lips and tongue from the hot steams of their pipes, and they seem to cough constantly 2*nciardi et al, %::3@ !atner, %::3@ Mc"oy and Miles, %::-4' Hallucinogens such as 9SD, P"P illicit uses may cause perceptual distortion, visual disturbance, disorientation, self$damaging behavior and belligerent paranoia 2C)D"P, %::.e4' "annabis such as gan<a, mari<uana, hashish, contains very slo0 metabolizing fat$soluble psychoactive ingredient $:$tetrahydrocannabinol' Since the brain tissue is highly fatty substance, abuse of cannabis may involve in neurogenic change of drug addicts resulting in impairment of motor 10

and sensory coordination functions' *n +angladesh, the ma<ority of drug addicts are suffering from infectious diseases li#e tuberculosis, hepatitis, respiratory infections, contagious s#in diseases 2"T", -&&&4@ some of them are also inflicted 0ith H*8 infection 2*slam et al, -&&3@ *"DD!D+, %:::4'

%'. Drug addiction and +angladesh

+angladesh still has not become an illicit drugs producing country' Feographically, it is in the middle of the KFolden TriangleD, KFolden "rescentD and Folden EadgeD drug producing zones' +ecause of its uni=ue position, +angladesh has become an important trans$shipment traffic#ing zone for transporting illicit substances to 1urope and the mericas, and other sian countries through its sea and air routes' 9ea#age during traffic#ing ma#es easy availability of illicit substances in +angladesh' This has, thus, turned +angladesh into a high illicit drug using country 2C)D"P, %::54' *t is anticipated that about 5'A million drug abusers in +angladesh and this number in increasing 0ith time 2Sharma et al, -&&A4

*t has been observed that in most of the cases, the addicts started addiction 0ith cannabis follo0ed by phensedyl 2a cough syrup of codeine, promethazine and ephedrine4 or heroin 2di$acetyl morphine4' +ecause of lo0 price and easy availability cannabis is considered as first choice for addiction by the beginners and ultimately ended up 0ith heroin or phensedyl 2*slam et al, -&&&4' The drug addicts in +angladesh also abuse in<ection drugs such as buprenorphine, pethedine and benzodiazepine 2C)D"P, -&&&@ D)"D+, %:::4 and most of them share needles, 0hich is one of the ma<or ris# factors for spreading of H*8 infection 2* S, -&&5@ *slam et al, -&&34' ;nly fe0 addicts used single drugBsubstance, but most of them use multiple substances in lifetime 2*slam et al, -&&&4' Trend and pattern of illicit substance use, therefore, is same as it is in the other sian countries' small or insignificant amount of information on drug abuse is obtained from government and non$ government organizations' (e0 scientific studies published in national and international <ournals since %::%' *n addition, some postgraduate students 0ithin very limited scales carried out fe0 studies on drug abuse' Prevalence of drug abuse is not uniform throughout the country' *t is more in urban than rural +angladesh' The most prevalent areas are metropolitan cities and some district head=uarters, and border belt regions 2Ho0lader, -&&7a4' Prevention, rehabilitation and management system for drug addicts is in embryonic stage in +angladesh' t present, there is an only government treatment center for drug abusers and fe0 non$registered private centers' They are haphazardly and indiscriminately treated there and every0here in an unhealthy environment' Some centers follo0 medical approach and some centers follo0 non$medical approach or shrom approach' nd thus drug addiction is 0orsening day by day, 0hich conse=uently 0ipes out the gains made by development in +angladesh'

11

%'/ +ac#ground of the study

+angladesh is one of the least developed country 29D"4 thriving 0ith its multifarious problems including political instability, socioeconomic disparity, higher rate of unemployment, poverty, malnutrition, inade=uate heath care facilities and education services' *n addition to inflection of these difficulties, entire +angladesh is no0 being afflicted by drug abuse related problems such as crime, violence, family brea#do0n, snatching, mugging, <ob loss etc 2Hossain et al, -&&.p@ Ho0lader, -&&7b@ *slam et al, -&&&4' Most of the drug abusers are young adults of age %/$3& years 2*slam et al, -&&&4' ;f them, in<ection drug abusers 2*DCs4 are at topmost high$ris# sub$population getting H*8B *DS and other diseases li#e ST*, hepatitis etc 2Salim, -&&34' Surveillance has sho0n that H*8 prevalence increases from %'5 percent to 5'& percent to /': percent among *DCs in the past three years 2Kelly, -&&54' *t is an alarming signal to the nation for H*8B *DS epidemic in +angladesh' *n religious and social bac#ground, substance abuse is banned and illegal in +angladesh' s there is a strong religious and bac#0ard social tradition, drug$se>$H*8$related problems are not discussed freely or publicly in community' !epulsion, negligence or avoidance to0ards drug abusers is a social and cultural tradition in +angladesh' They are thus refraining from sympathy and cooperation from family as 0ell as society and even from relevant e>pert personnel' +ut, presently, it has been realized that drug abuse is not a curse rather it is a lifestyle disease' 1>ecutive head of +angladesh termed drug addiction as a man made physical, mental, economic and social problem hindering the process of human development' She said, J0e must 0or# out an effective plan immediately against drug abuse and drug traffic#ing to protect our present and future generationJ 2The Daily Star June -A, -&&A4' Drug addiction management still is in embryonic state in +angladesh' t present, there is only

government and fe0 private centers for their treatment but there is no national policy' They are haphazardly and indiscriminately treated there and every0here in an unhealthy environment' (e0 centers follo0 medical approach and some centre follo0s non$medical approach or approach' *t is, therefore, urgent need to develop update management policy for drug abusers' *n fact, there is a 0ide gap bet0een the scientific fact and public perceptions about drug abuse all over the 0orld 29eshner, %::.4' addiction, its *n +angladesh, general peoples are totally in dar# about drug small or insignificant amount of information on drug harmful$effect and drug related problems or conse=uences' Still, there is not even a shrom

report on the prevalence of drug addiction'

abuse is obtained from government 2Department of )arcotic "ontrol4 and non$government organizations' *nformation about H*8B *DS, 0hich directly targets the drug abusers, is reported to be scarce and inade=uate 2Salim, -&&34' fe0 scientific studies have, so far, been carried out on drug addiction 2+egum, %::%, !abbani, %::-, ra et al, %::/, *slam et al, -&&&, -&&%, -&&-, -&&3, -&&5@ Hossain et al, -&&%, -&&5, -&&A, -&&.4' There are many shortcomings of these studies, as for e>ample@ fe0 studies 0ere e>clusively cross$sectional emphasis on socioeconomic and drug abuse 12

behavior only'

Sample size 0as not conclusive 2nL./$-734 and using tools 0ere not appropriate@

selection of parameters 0as not uniform, represents only a particular period and confined 0ithin limited areas' Some studies 2*slam et al, -&&%, -&&-, -&&3, -&&54 are important but in these studies authors informed about basic physio$pathological status of immunoglobulins, immune cell profile, antio>idant vitamins, microminerals, hemoglobin, proteins etc of the drug abusers' Sample size 0as -73 but control 0as %&&, 0hich 0as inade=uate and using of laboratory investigations 0as also inade=uate' Postgraduate students 0ithin very limited scales carried out fe0 studies on drug addiction' Ho0ever, still there is not even a single scientific study on psychiatric morbidity of the drug abusers' Mental illnesses and mental disorders, 0hich have been suffering the drug abusers, are still remaining undiagnosed' *t is, therefore, urgent need to rigorous scientific studies on mental illnesses of the drug abusers' The proposed 0or# is a cross$sectional descriptive study' The specific ob<ective is to investigate drug abusers for screening of mental disorders and to analysis the influence of illicit drugs on the morbidity' Sample size 0ill be %-&& drug abusers' Data 0ill be collected for %- months to overcome seasonal variation' de=uate scientific standard clinical tools 2described detail in methodology4 0ill be used to diagnose mental illnesses' The proponent, 0ith the assistance of K!esident PsychiatristsD, 0ill be carried out mental state e>amination and 0ill ta#e drug history of the participant drug abusers' *n addition, socioeconomic$family profile 0ill also be investigated using appropriate scientific tools' *n fact, this 0or# 0ill not be a nation0ide study and 0ill not reflect national scenario of drug addiction' *n that case, this study 0ill provide conclusive scientific information about mental disorders of the drug abusers' *n addition, it 0ill also reveal the influence of illicit drugs on mental illnesses' outcomes 0ill be of public interest' ll of the

%': !ationale of the study

Drug abuse affects both health and nutrition 28arela et al, %::.a@ McDonough et al, %:/&4' They are prone to develop immunonutritional deficiency, 0hich influences susceptibility to infectious agents including H*8 2*slam et al, -&&3@ 8arela et al, %::.a@ %::.b4' Ma<ority of the drug abusers in +angladesh have poor nutritional status and multiple nutrient deficiencies are prevalent among them 2*slam et al, -&&-@ -&&%4' Their antibody status and 0hite cell profile is impaired 2*slam et al, -&&54' Cnprotected ris#y se> practice is common among them 2*slam et al, -&&&4' Ho0ever, their se>ual behavior related health ris# is significantly high 2 ra et al, %::/4' *n addition, drug abuse is associated 0ith ris# of ma<or #iller diseases li#e cardiovascular disease, #idney dysfunction, tuberculosis, hepatitis etc 2C)D"P, %::.e@ EH;, %::-@ +att<es et al, %:/:4' "hronic use of illicit drugs also induces mental illnesses and mental disorders 2Sadoc# and Sadoc#, -&&3b4'

13

Treatment of the drug abusers is obligatory for Kdemand reductionD of the illicit drug use' Therefore, management of mental illnesses and mental disorders is of vital important for abstinence from illicit drug use' +angladesh' *t is so far #no0n@ still there is not even a scientific study on mental illnesses in *n addition, there is no national policy for management of drug abusers' *t has,

presently, been realized that drug abuse is not a curse, it is a lifestyle disease and health issue as 0ell as it is really a developmental issue closely related to poverty, unemployment, violence, lo0 level of literacy and poor #no0ledge about prevention' *t has, therefore, been recognized and considered as one of the most damaging national health and socioeconomic problems in +angladesh' *t needs rigorous scientific studies and so my present study'

%'%&

;b<ectives

a' Feneral ob<ectives

The primary aim of this study is to investigate psychiatric morbidity among the drug dependent population'

b' Specific ob<ectives

i' ii' To investigate mental illnesses as 0ell as mental disorders among the drug dependent population using standard diagnostic tools described in operational guidelines' To investigate drug habit and socio$economic$family profile of the drug abusers' illnesses or mental disorders' iii' To analysis influences of illicit drug use and socio$economic$family profile on mental

14

-'& Materials and Methods

-'% !esearch =uestion
a' Ehat proportion of the drug abusers have been suffering from mental illnesses and mental disordersM b' Ehat #ind of mental illnesses and mental disorders are found in drug dependent populationM c' Have any significance influence of illicit drug use on mental illnesses or mental disordersM d' Ehat are the characteristics of socio$economic$family profile of the drug abusersM

-'- Hypothesis
a' Ho L Cse of illicit drugs may not induce any mental illnesses in drug abusers' H L Cse of illicit drugs may induce many mental illnesses in drug abusers' b' Ho L Cse of illicit drugs may not influence mental illnesses of the drug abusers' H L Cse of illicit drugs may influence mental illnesses of the drug abusers' c' Ho L Socio$economic$family profile may not influence mental illnesses' H L Socio$economic$family profile may influence mental illnesses'

-'3 Study design

The proposed research 0or# is a cross sectional descriptive study' *t 0ill be conducted among the drug dependent population' *n light of the study aim, the protocol is designed as follo0s a' *nvestigation of mental illnesses and mental disorders of the drug abusers using standard diagnostic clinical tools described in IDiagnostic and Statistical Manual of Mental Disorders, DSM$*8T!J' b' *nvestigation of drug habit and socioeconomic$family profile of the drug abusers using a structured =uestionnaire'

-'5 Study population

Study sub<ects 0ill be drug dependent population' The place of study 0ill be )ational *nstitute of Mental Health, Ser$e$+angla )agar, Dha#a and data 0ill be collected from "entral Drug Treatment "enter 2"T"4, 55% Te<gaon *ndustrial ddiction rea, Dha#a$%-&/' "T" is the only government Csually, they 0ill see#

treatment centre solely for male drug abusers in +angladesh' The participant drug abusers 0ill voluntarily attained at ;utpatient Department 2;PD4 of this center' deto>ification therapy and other medical interventions 2counseling, group therapy etc4 at this centre'

15

-'7 Sample size

Estimation of sample size: The aim of this study is to determine 0hat proportions of drug abusers are suffering from mental illnesses and mental disorders' Statistically the follo0ing formula can be used to calculate sample size 2Daniel, %::%@ Kothair, %:/74''

nL

z- p2% $ p4 $$$$$$$$$$$$$$ d-

Ehere, n L as#ing sample size z L level of confidence or level of significance d L standard error p L the proportion in the population possessing the characteristic of interest ) L number of population The KpD is the proportion in the drug abusers possessing mental illnesses or mental disorders, 0hich is obviously un#no0n' Since p L &'7 in the formula yields the ma>imum value of KnD and the sample 0ill yield at least the designed precision 2Daniel, %::%@ Kothair, %:/74' follo0s 2%':A4- 2&'742&'74 n L $$$$$$$$$$$$$$$$$$$$$$$$$$ L %&A.'%% 2&'&34To overcome the inflation of sample size at any stage of data collection, it is decided to include at least %-&& drug abusers for this study' Mental illnesses and mental disorders 0ill be investigated The participant drug abusers 0ill be selected simultaneously for each of the drug abuser' for %- months' :7G confidence interval 2z L %':A4 0ith &'&3 standard error 2d L &'&34 is desired in this study' Hence, the sample size is as

consecutively on the basis of defined criteria' To overcome seasonal variation data 0ill be collected

-'A Selection criteria

a' Period of addiction more than one year' b' c' ge must be more than %7 years' Csing prescribe medications 0ill be e>cluded'

d' !e$registration 0ithin study period 0ill be e>cluded' e' Treatment from other private centers 0ithin one year 0ill not include' f' Positive respondent about the study 0ill be included only' g' )o se> differentiation'

16

-'. !esearch instruments

a' 6uestionnaire: structured =uestionnaire 0ill be developed for the collection of data from

research participants' *t 0ill be pre$tested among 7& drug addicts' *t includes i' ii' Feneral information: name, fatherDs name address etc' Socio$economic information: education, occupation, monthly income etc'

iii' Drug habit: present drug, starting drug, other drugs, choice of drugs, period etc' iv' SignBsymptoms of mental disorders: sleep, moodBaffect, food habit, an>iety, se>ual dysfunction, thought change, perceptual disturbance etc' b' Mental state e>amination criteria' c' *nformed consent form'

-'/ Plan of action

Trained personnel 0ill brief ob<ectives, perspectives, benefits, ris#s and burdens of this study to drug abusers and their close relatives in detail 0hen they 0ill attain at ;DP of "T" for treatment voluntarily' ;nly positive respondent, consistent 0ith selection criteria, 0ill be included as research participants' The trained personnel 0ill ta#e informed consent from each of the selected research participant and 0ill collect general information follo0ing the =uestionnaire' The proponent, under direct supervision of K!esident PsychiatristD, 0ill record socioeconomic$family profile, drug habit of the participant drug abusers' participants follo0ing the =uestionnaire' (inally, he 0ill e>amine mental state of the "lose relatives 0ill also be intervie0ed if necessary'

*ntervie0 and e>amination 0ill ta#e in a room separately to maintain their privacy and confidentiality' ll relevant documents including =uestionnaire 0ill #eep under control of the proponent investigator' This study 0ill not involve any societal, mental or physical ris# to the participants' Prior to conduct, institutional permission 0ill be ta#en from the director of "T"' s drug abusers are vulnerable, the procedures 0ill be follo0ed for this study 0ill in accordance 0ith the "*;MS guidelines or Helsin#i deceleration as updated in -&&- and -&&& respectively 2"*;MS, -&&-@ EM , -&&&4' )o 0edge$ compensation 0ill be given to the research participant'

17

-': Time schedule

?ears Months 6uestionnaire N training Study design N setup Data collection Seminar Data entry N analysis Seminar Thesis 0riting, submission 9iterature revie0s
%$3 5$A

(irst
.$: %&$%%$3

Second
5$A .$: %&$%%$3 5$A

Third
.$: %&$%-

-'%% Statistical analysis

SPSS soft0are pac#age 2version %-'&4 0ill be used to analyze data' Descriptive statistics 2fre=uencies, descriptive, crosstabes4 0ill be used to calculate all variables' 8alues 0ere e>pressed as percentage' ;ne 0ay analysis of variance 2descriptive, 0ill be performed if re=uired' );8 4 and - test 0ill be used to

analysis the influence of lifestyle factors on mental disorders and physical illnesses' ;ther analysis

3'& Ctilization of results

Medical management, behavioral therapies and family N social participation <ointly can tailored the individual need of illicit drugs, can learn to control their crisis and be trained to maintain their normal and productive life in family or in 0or# place or in community' *f this study 0ill be carried out successfully, outcomes 0ill be absolutely beneficial in medical management of the drug abusers' +ecause once their assessment data 0ill be collected, a treatment policy that includes medical deto>ification, behavioral therapies and rehabilitation programs 0ill be developed' preventive strategy against drug addiction and traffic#ing' *t 0ill be of immense helpful to the medical practitioners' *t 0ill also contribute in the preparation of national

18

5'& !eferences
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Khando=or S*, !abbani F, Hamid M , !ahman MS' )europsychiatry assessment of drug abusers attending outpatient department of four selected psychiatric and drug addiction treatment centres in Dha#a city' +an J Psy -&&-@ %A2-4: 7$%.' Kothari "!' !esearch Methodology 2Method and Techni=ues4 - nd edition, Eish0a Pra#ashan, )e0 Delhi %:/7: %/.$---' 9eshner 9' ddiction is brain disease, and its matters' Science %::.@-./: 57$5.' Mc"oy H8 and Miles " ' gender comparison of health status among users of crac#$cocaine' J Psychoactive Drugs, %::-@ -5: 3/:$:.' McDonough !J, Madden JJ, (ale# ' lteration of T and null lymphocyte fre=uencies in the peripheral blood of human opiate addicts: *n 8ivo evidence for opiate receptor sites on T$lymphocytes' J *mmunol %:/&@ %-7: -73:$53' McFlithlin E' Drug use and assessment methodology in the Cnited States' *n: Eor#shop on reduction of demand for illicit drugs in Southeast sia' Penang, Malaysia, %5$-& May %:./' "olombo plans publication, Sri 9an#a, %:.:: %3:$7&' Miller + ' The interrelationship bet0een alcohol and drugs and family violence' *n: Drugs and violence: causes, correlates, and conse=uences, )*D research monograph seris$%&3, !osa MD9, 9ambert 1?, Fropper +' eds' )*H publication, !oc#ville, MD, CS , %::5: %..$-&.' Miyagi C, "huang T, 9am KM, Kung H(, Eang JM, ;sburn +*, "huang !?' ;pioids suppress chemo#ine$mediated migration of mon#ey neutrophils and monocytes$ an instant response' *mmunopharmacology -&&&@ 5.: 73$A-'

)ational H*8$ *DS' +ehavior change communication strategic implementation plan for +angladesh, first draft documents May %:::' )!" )ational !esearch "ouncil' *mproving reproductive health in developing countries' summary of the finding from )!" of the CS national academy of science, prepared by population reference bureau' )ational cademy Press, Eashington D" %::.: 3$%-' Pearce "? and "o> J"' Heroin and Hyper#alemia' 9ancet %:/&@ -: :-3' !abbani F' The conse=uence of drug abuse behaviour in addict, family and community' J +ang "oll Phy Sur %::-@ %&: .5$..' !atner MS' "rac# pipe as pimp: an ethnographic investigation of se> for crac#$cocaine e>change' 9e>ington +oo#s )e0 ?or# %::3' Sadoc# J+ and Sadoc# 8 ' Kaplang N Sadoc#Ds Synopsis of Psychiatry, :th edition, 9ippincott Eilliams N Eil#ins, Philadelphia, CS , -&&3a: -//$%:' Sadoc# J+ and Sadoc# 8 ' Kaplang N Sadoc#Ds Synopsis of Psychiatry, :th edition, 9ippincott Eilliams N Eil#ins, Philadelphia, CS , -&&3b: 3/&$.&' Sadoc# J+ and Sadoc# 8 ' Kaplang N Sadoc#Ds Synopsis of Psychiatry, :th edition, 9ippincott Eilliams N Eil#ins, Philadelphia, CS , -&&3c: .7A$ ./%' Sadoc# J+ and Sadoc# 8 ' Kaplang N Sadoc#Ds Synopsis of Psychiatry, :th edition, 9ippincott Eilliams N Eil#ins, Philadelphia, CS , -&&3d: /&&$ -%' Salim DM , program manager, )ational *DSBSTD programme, Directorate Feneral of Health Services' Treating the drug users' The Daily Star -&&3@ December %: 7 Sharma M, !ahman KO, Kelly !, ;DDay T' !educing the demand for drugs and preventing H*8 in +angladesh: a partnership bet0een la0 enforcement, the community and treatment agencies' *n: Drugs are not childrenDs play, souvenir, -&&A, Department of )arcotic "ontrol, Dha#a, +angladesh -&&A: A3$A/' Soyibo K and 9ee MF' Cse of illicit drugs among high$school students in Jamaica, +ulletin of the EH;, %:::@ ..: -7/$A-' C) Declaration of the international conference on drug abuse and illicit traffic#ing and comprehensive multidisciplinary outline of future activities in drug abuse control, C) publication, no' 1'//'P*'%, )e0 ?or#, %://: 7$.-' 21

C)D"P' Training pac#age on treatment and rehabilitation of drug addicts, Dha#a, %::5: %$3' C)D"P' Training pac#age on treatment and rehabilitation of drug addicts, Dha#a %::5a: 3-$A-' C)D"P' Eorld drug report, ;>ford Cniversity Press, )e0 ?or#, CS %::.a: :$%5' C)D"P' Eorld drug report, ;>ford Cniversity Press, )e0 ?or#, CS %::.b: %A$53' C)D"P' Eorld Drug !eport, ;>ford Cniversity Press, )e0 ?or#, CS %::.c: %--$73' C)D"P' Eorld drug report, ;>ford Cniversity Press, )e0 ?or#, CS %::.d: 55$A:' C)D"P' Eorld Drug !eport, ;>ford Cniversity Press, )e0 ?or#, CS %::.e: .&$%-%' C)D"P' 1pidemiology trends in drug abuse in sia@ advance report, +ang#o#, -&&&: %$:' 8arela P, Marcos , Santacruz *, !ipoll S, and !e=ue<o M' Human immunodeficiency virus infection and nutritional status in female drug addicts undergoing deto>ification: anthropometric and immunologic assessments' m J "lin )utr %::.a@ AA2suppl4: 7&5S$&/S' 8arela P, Marcos , !ipoll S, Santacruz *, !e=ue<o M' 1ffects of H*8 infection and deto>ification time on anthropometric measurements and dietary inta#e of male drug addicts' m J "lin )utr %::.b@ AA2suppl4: 7&:S$%5S' Eang 11, King S, Foldberg 1, +oc# +, Milner !, !ead S' Hepatitis + and H*8 infection in street youth in Toronto, "anada' Pediatr *nfect Dis J %::%@ %&2-4: %3&$33' Eatts ED and Eright 9S' The drug use$violent delin=uency lin# among adolescent Me>ican$ mericans' *n: Drugs and violence: causes, correlates, and conse=uences, )*D research monograph seris$%&3, !osa MD9, 9ambert 1?, Fropper +' eds' )*H publication, CS , %::5: %3A$%7:' EH;' Program on substance abuse, T9 S report %::-: %$.7' Eorld Medical ssociation 2EM 4' Declaration of Helsin#i: ethical principles for medical research involving human sub<ects' 7-nd edition 1dinburgh EM publication -&&&: %$AA'

22

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Psychiatric Morbidity in Drug addiction: prevalence of mental disorders and role of illicit drug use

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Psychiatric Morbidity in Drug addiction: prevalence of mental disorders and role of illicit drug use

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6uestionnaire
Serial no:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Feneral information
Hospital reg' no: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 1>amination date: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Patient name:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ (atherDs name: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Mailing address: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ nthropometry: age: $$$$$$$$$$$$$$y Height: $$$$$$$$$$$$$$$ cm Eeight:$$$$$$$$$$#g +M* $$$$$$$$$$$$$$$$$$$$$$

Socioeconomic information
1ducation: $$$$$$$$$$$$$$$$ occupation: $$$$$$$$$$$$$$$$$$$$$$$$$$$ self income 2T#4: $$$$$$$$$$$$$$$$$$$$$$$ 9ive in urban rural Marital status: unmarried married separated divorced *f married: period $$$$$$$$$$$$$$$y spouse education$$$$$$$$$$$$$$$ occupation$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ income T#$$$$$$$$$$$$$$$$ children M$$$$$$$$$ ($$$$$$$$ Habit of smo#ing: regular occasional no before addiction after addiction 0ith addiction (amily history (ather: alive dead education $$$$$$$$$$$$$$$$$$$$$$$$$$ occupation$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ income 2T#4$$$$$$$$$$$$$$$$$$$$$$$ Mother: alive dead education$$$$$$$$$$$$$$$$$$$$$$$$$ occupation$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ income 2T#4$$$$$$$$$$$$$$$$$$$$$$$ +rother:$$$$$$$$$$$$$$$$ Sister:$$$$$$$$$$$$$$$$$$$$ Present family member:$$$$$$$$$$$$$$$$$$$ (amily income T#'$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Tobacco habit in family: present absent Psychiatric illness in family: present absent ddict in family: present absent (amily disharmony: present absent Drug habit Present drug: regular$$$$$$$$$$$$$$$$$$$$$$$$$$$ occasional$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ duration$$$$$$$$$$$$$$y Starting drug$$$$$$$$$$$$$$$$$$$ ;ther drug in lifetime$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$"hoice of drug$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Total period$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$y *f in<ection: name$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ duration$$$$$$$$$$$$$$$$$y Sharing needle: regular occasional no sharing

Mental state e>amination

Mood: normal irritable elated Motor activity: normal hyperactive depressed an>ious other$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ retarded agitation others$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Speech: normal poverty pressure mute e>cessive fast self ta#ing muttering other $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Thought: normal 0orthless hopeless helpless flight of idea racing thought grandiosity guilty ris# ta#ing poor <udgment inability to concentrate impending doom other$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Sleep: increased normal insomnia hypersomnia altered sleep Appetite: normal decreased Sexual function: normal decrease desire early e<aculation hyper$se>uality no se> Energy: normal disturbed aggressive other$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ visual impaired present other $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ other $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ normal impaired absent "rientation: persecutory

delayed e<aculation decreased libido enhance fatigue Behavior: normal Hallucination: elusion: Memory: absent auditory normal #nsight: absent normal <ealousy impaired grandiose

Attention ! concentration:

"linical Diagnosis: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Signature of investigator 26

/'& ;perational guideline

Education: *nstitutional learning especially in schools, madrashas, colleges or universities' *t is denoted by digital numbers such as SS"L%&, HS"L%-, DegreeL%5, HonoursL%A, MastersL%.' "ccupation: The 0or# is doing regularly' #ncome: 1arning of a person from 0or#, from business, from investment etc' $amily mem%er: Those are living in the same shelter' $amily income: ll #ind of income other than self, father and motherDs income' 1>ample: rental income, income from crop cultivation, other family member income etc' Addict in family: any family member having uses illicit substances such as cannabis, heroin, phynsedyl, in<ections, tablets etc' &sychiatric illness in family: any family member has been suffering or history of suffering any mental problem' To%acco ha%it in family: any family member having uses tobacco products such as cigarettes, bidi, sadapata, <arda or gul' $amily disharmony: lac# of agreement about important family issues, 0hich causes bad feeling bet0een family members' The important family issues are education, occupation, marriage, sharing of properties, division of labor, business, illnesses, family rights etc'

Sleep
)ormal range of sleep is 3'7$ /'7 hours per night, usually A hours is ideal' Short or e>cess sleep is disorder' The ma<or symptoms of sleep disorders are insomnia and hypersomnia' *nsomnia: *t refers to the difficulty initiating or maintaining sleep' *t may be transient or persistent' The common cause of insomnia are any painful condition, ")S lesions, substance abuse, dietary factors, infections and other diseases, and aging' Transient insomnia is most often associated 0ith an>iety, either as a se=uel to an an>ious e>perience or in anticipation of an an>iety$provo#ing e>perience 2e>amination, intervie0 etc4' Persistent insomnia is a fairly common group of conditions in 0hich the problem is most often difficulty falling asleep rather than remaining asleep' Hypersomnia: *t manifest as e>cessive sleep, e>cessive daytime sleepiness or sometimes both' The most common cause of hypersomnia is sleep apnea and narcolepsy' ;ther common causes are metabolic or to>ic or encephalitic conditions, alcohol and depressant medications, 0ithdra0al from stimulants etc' (or the diagnosis of sleep disorders standard criteria described in Kaplan N Sadoc#Ds Synopsis of Psychiatry 0ill be used 2Sadoc# and Sadoc#, -&&3c4'

+ehaviors
+ehaviors or personality refers to the =uality of a personDs character that ma#es different from others' +ehaviors are grouped into three clusters' "luster 27 : persons in this group are often perceived as

odd and eccentric' "luster +: persons in this group are often seems dramatic, emotional, and erratic' "luster ": persons in this group are often seems an>ious or fearful' ntisocial, aggressive or dependent behaviors are highly prevalent among drug abusers' (or the diagnosis of behaviors standard criteria described in Kaplan N Sadoc#Ds Synopsis of Psychiatry 0ill be used 2Sadoc# and Sadoc#, -&&3d4'

(ood habits
The alter food habits are loss of appetite, loss of taste, e>cessive inta#e, and less inta#e' 9oss of appetite: *t refers to less or no physical desire for foods' The individual does not sho0 any eagerness to ta#e foods' *f any one re=uest to ta#e foods, the individuals fre=uently refuse it' 9oss of taste: *t refers to less or no flavors in foods' The individuals fre=uently e>press, the foods 0hich sBhe inta#e is not tasty or having no flavors' 1>cessive inta#e: The individual inta#es a bul# of foods several times daily result 0eight gain' 9ess inta#e: The individual inta#es minimum amount of foods daily result 0eight loss'

n>iety
The state of feeling nervous or 0orried that something bad is going to happen' ;r the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension' The focus of anticipated danger may be internal or e>ternal' (or the diagnosis of an>iety KHamilton an>iety rating scaleD 0ill be used 2Sadoc# and Sadoc#, -&&3a4' The ma<or an>iety symptoms are Panic attac#: *t is a discrete period of intense fear or discomfort, in 0hich at least four of the follo0ing symptoms developed abruptly and reached a pea# 0ithin %& minutes' 2a4 palpitation, pounding heart, or accelerated heart rate@ 2b4 s0eating@ 2c4 trembling or sha#ing@ 2d4 sensation of shortness of breath or smothering@ 2e4 feeling of cho#ing@ 2f4 chest pain or discomfort@ 2g4 nausea or abdominal distress@ 2h4 feeling dizzy, unsteady, lightheaded, or faint@ 2i4 feeling of unreality or being detached from oneself@ 2<4 fear of losing control or going crazy@ 2#4 fear of dying@ 2l4 numbness or tingling sensations and 2m4 chills or hot flushes' Phobia: *t may be e>cessive unreasonable an>iety or 0orry about an event or activity predominate in the clinical presentation particularly drug of abuse or social' Feneralized an>iety: 1>cessive an>iety or 0orry about a number events or activities predominates in the clinical presentation'

Mood
Mood is sustained affect or the 0ay of feeling at a particular time or a pervasive and sustained emotion that colors the perception of the 0orld' *t may be normal or abnormal' (or the diagnosis of 28

moodBaffects KHamilton rating scaleD 0ill be used 2Sadoc# and Sadoc#, -&&3a4' The symptoms of abnormal moodBaffects may be a' Depressive: an unpleasant mood, such as sadness or an>iety, b' 1lated: an e>aggerated feeling of 0ell$being, or euphoria' 1lated mood may describe as Ihigh,J Iecstatic,J Ion top the 0orld,J or Iup in the cloudsJ c' *rritable: easily annoyed and provo#ed to anger' significance or importance, d' 1>pansive: lac# of restraint in e>pressing oneDs feelings, fre=uently 0ith an overvaluation of oneDs

Se>ual dysfunctions
The common se>ual dysfunctions are impaired desire, impotence and premature or delayed e<aculation' *mpaired desired: 9ac# of interest about se>ual activity' *mpotence: *t is the complete or partial failure of physiological changes in genital organs 0hen a man or a 0oman actively involves in se>ual pleasure' The ma<or changes in the male are penile erection, tumescence and secretion' The ma<or changes in the female are vaginal lubrication and s0elling of e>ternal genitalia' Premature e<aculation: 1<aculation of semen prior to penetration of penis into vagina, or if penetration occurs, e<aculation before the partner can achieve orgasm' ;rgasm is the pea#ing of se>ual pleasure 0ith the release se>ual tension of a female' *n orgasm there is a vaginal contraction' Delayed e<aculation: 1<aculation usually occur after the partner can achieve orgasm' ;rgasm is the pea#ing of se>ual pleasure 0ith the release se>ual tension of a female' *n orgasm there is a vaginal contraction'

Psychotic symptoms
The common psychotic disorders are hallucination and delusion' Hallucination: The fact of seeming somebody or something that is not really there' *n 0hich no actual e>ternal stimulus is present' Hallucination may be a' auditory: the perception of sound, most commonly of voice, b' gustatory: the perception of taste usually unpleasant, c' olfactory: the perception of odor usually burning rubber, d' somatic: the perception of a physical e>periences 0ithin the body eg' feeling of electricity, e' tactile: hallucination involving the perception of being touch or something under oneDs s#in, f' visual: the perception of sight' May see a group of people hovering over the bed 0hen no one is actually there'

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Delusion:

false belief about yourself' ;r the act of believing or ma#ing yourself believes something

that is not true' (alse belief to a stimulus, 0hich is, not shares by others' *t may be a' bizarre: delusion that involves a phenomenon that the personDs culture 0ill regard as totally implausible, b' delusional <ealousy: The delusion that oneDs se>ual partner is unfaithful, c' erotomanic: a delusion that another person, usually of higher status, is in love 0ith the individual, d' grandiose: a delusion of inflated 0orth, po0er, #no0ledge, identity, or special relationship to a deity or famous person, e' of being controlled: a delusion in 0hich feeling, impulses, thoughts, or actions are e>perienced as being under the control of some e>ternal force rather than being under oneDs o0n control, f' of reference: a delusion 0hose theme is that events, ob<ects, or other persons in oneDs immediate environment have a particular and unusual significance, g' persecutory: a delusion in 0hich the central theme is that one or someone to is being attac#ed, harassed, cheated, or conspired against, h' somatic: a delusion 0hose main content pertains to the appearance or functioning of oneDs body, i' through broadcasting: the delusion that oneDs thought are being broadcast out loud so that they can be perceived by others, and < thought insertion: The delusion that certain of oneDs thought are not oneDs o0n, but rather are inserted into oneDs mind'

"hanges in cognition
*t may include memory impairment, disorientation, or language disturbance' Memory impairment can be tested by as#ing the person to remember several unrelated ob<ects or a brief sentence, and then to repeat them after a fe0 minutes of distraction' Disorientation is usually manifested by the individual being disoriented to time 2thin#ing it is morning in the middle of night4, or being disoriented to place 2he is home rather than in a hospital4' 9anguage disturbance may be evident as dysnomia 22the impaired ability to name ob<ect4, or dysgraphia 2the impaired ability to 0rite4' *n some cases, speech is rambling and irrelevant or incoherent'

Professor Dr' H Mohammad (iroz Hossain Director !egistrar )ational *nstitute of Mental Health Psychiatry Sher$e$+nagla )agar, Dha#a$%-&. Dha#a

Dr' Kazi Jahangir ssistant Department of SSM" Mitford Hospital,

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"urriculum 8itae
)ame (atherDs name MotherDs name Position N *nstitution : Dr' Kazi Jahangir Hossain : Kazi )urul Ho=ue : 9ate Parul #ter : ssistant !egistrar Department of Psychiatry, SSM" Mitford Hospital, Dha#a Date of birth Mailing address : %% )ovember %:A& : /5Bi zimpur Fovernment 6uarter zimpur, Dha#a$%-&7, +angladesh Ph: /A3%%.3, Mob: &%/%/-%%//3 : Kacharighat, P;: )ilo#hi +andar Cpazilla: Shibchar, Dist: Madaripur : +angladeshi : Married, spouse house$0ife 2- children4

Permanent address )ationality Marital status

cademic Profile
Degree M++S HS" *nstitute Mymensingh Medical "ollege Dha#a "ollege, Dha#a Sub<ect Medical sciences Physics, chemistry, biology, mathematics, 1nglish and +engali Physics, chemistry, biology, mathematics, 1nglish and +engali !esult Passed (irst Division ?ear %:/7 %:..

SS"

)anda Kumar *nstitution, Madaripur

(irst Division

%:.5

1>periences
%' "ompleted K"ertificate "ourse on !esearch +ioethics 2""!+4D from +angladesh Medical !esearch "ouncil in collaboration of CS ' -' (amiliarity 0ith the use of 19*S 2enzyme lin#ed inmmunosorbent assay4 for the analysis of immunoglobulins, H*8$sepositivity etc' 3' (amiliarity 0ith the use of HP9" 2high performance li=uid chromatogram4 for the analysis of tocopherol 2vitamin 14 and retinal 2vitamin 4' 5' (amiliarity 0ith the use of S 2atomic absorption spectrophotometer4 for the analysis of micro minerals 2copper, zinc iron4' 7' %& years e>periences as a researcher, co$coordinator, and principal investigator' A' !esearch e>periences on immunity, nutrition, drug addiction, mental health and H*8B *DS' .' (amiliarity 0ith the use of computer particularly MS Eard, 1>cel, Po0er point and SPSS'

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9ist of publications

%'

Hossain '() !ahman MS, Ho=ue

HMM'

Management of drug addiction: importance of

naltre>one' Bangladesh Journal of Psychiatry -&&7@ %:2-4: AA$./ 2published: pril -&&.4' -' Hossian '(, Kamal MM, hsan M, *slam SK' Serum antio>idant micromineral 2"u, On, (e4

status of drug addicts: influence of illicit drugs and lifestyle factors' Substance Abuse Treatment Policy Journal 2CS 4 -&&.@ -: %-$%A' 3' Hossain '(, Kamal MM, #htaruzzaman M, *slam SK, hsam M' )utrient and immune profile of "1D$anemic substance abusers undergoing deto>ification' 372%4: 5$%&' 5' Siddi=ue MJ, Ho=ue HMM, Hossain '(, Sobhan M ' Psychosocial profiles of non$ulcer Bangladesh Medical Journal -&&A@

dyspepsia patients' Bangladesh Journal of Psychiatry -&&7@ %:2-4: 7/$A7' 7' Hossain '() Ho=ue HMM, !ahman MS' 1thical issues in mental health research' Sir

Salimullah Medical College Journal -&&.@ %72-4 : /A$/: 2in press4' A' Hossain '(, (raiduzzaman M, Kamal MM, Ho=ue Medicine -&&. 2 ccepted4' HMM, Mandal M", (iroz HM' Drug

ddiction and +angladesh: socio$demographic$family profile' Journal of Preventive & Social

Dr' Kazi Jahangir Hossain

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