co-morbidity among idus

Co-morbidity among Co-morbidity among IDUsIDUs

What is co-morbidity?What is co-morbidity?

Presence of two or more conditions Presence of two or more conditions together in an individual (co-together in an individual (co-occurrence)occurrence)– The conditions can occur simultaneouslyThe conditions can occur simultaneously– One condition can precede another oneOne condition can precede another one

Co-occurrence of mental illness along Co-occurrence of mental illness along with drug use problem is called as with drug use problem is called as dual diagnosisdual diagnosis

Co-morbidity among drug Co-morbidity among drug usersusers

Physical illnessPhysical illness– TuberculosisTuberculosis– HIVHIV– Hepatitis B & CHepatitis B & C– AbscessesAbscesses– COPD and other COPD and other

respiratory illnessrespiratory illness– Systemic Systemic

infectionsinfections

Mental IllnessMental Illness– DepressionDepression– Anxiety Anxiety

disordersdisorders– Schizophrenia Schizophrenia

and other and other psychotic psychotic disordersdisorders

– Personality Personality disordersdisorders

Physical illnessesPhysical illnesses

Physical illnessPhysical illness

Physical illness among Physical illness among IDUs is more common as IDUs is more common as compared to the general compared to the general populationpopulation– A Study from Chennai A Study from Chennai

conducted in 2005 – 06 conducted in 2005 – 06 showed increased rates of showed increased rates of physical illnessphysical illness

(Solomon et al, (Solomon et al, 2008)2008)

– The same group also The same group also showed that mortality is showed that mortality is more in comparison with more in comparison with the following causes: the following causes: Overdose, AIDS, Overdose, AIDS, tuberculosis, accident tuberculosis, accident

(Solomon et al, (Solomon et al, 2009)2009)

IllnessIllness PrevalencPrevalence / rate e / rate

(%)(%)

TuberculosisTuberculosis 33.933.9

Lower respiratory Lower respiratory tract infectionstract infections

16.116.1

AnaemiaAnaemia 22.922.9

Hepatitis BHepatitis B 11.911.9

Hepatitis CHepatitis C 94.194.1

CellulitisCellulitis 6.86.8

Herpes simplexHerpes simplex 9.39.3

Herpes zosterHerpes zoster 9.39.3

Oral candidiasisOral candidiasis 43.243.2

Physical illness – reasons Physical illness – reasons

Three main factors for increased rates of Three main factors for increased rates of physical illnessphysical illness– Drug use itself may lead to increased ratesDrug use itself may lead to increased rates

E.g. smoking may lead to respiratory problems; E.g. smoking may lead to respiratory problems; nicotine and alcohol may lead to cancer; nicotine and alcohol may lead to cancer; injecting may lead to abscesses, HIV, hepatitisinjecting may lead to abscesses, HIV, hepatitis

– Individual may use drugs due to existing Individual may use drugs due to existing physical illnessphysical illness E.g. person with pain condition may initiate drug E.g. person with pain condition may initiate drug

use and then become ‘addicted’ to the druguse and then become ‘addicted’ to the drug Some addictive drugs banned today were used Some addictive drugs banned today were used

earlier to treat physical illnessearlier to treat physical illness

Cocaine used in coca-cola as energy drink

Cocaine used to relieve toothache

Heroin used for relief of cough

Physical illness – reasons Physical illness – reasons

Both drug use and Both drug use and physical illness may physical illness may be caused by be caused by overlapping factors overlapping factors leading to both leading to both illnessesillnesses– E.g. genetic factors, E.g. genetic factors,

stress related factorsstress related factors– Drug use and TB may Drug use and TB may

be caused by the be caused by the individual living in poor individual living in poor socio-economic socio-economic conditionsconditions

Common vulnerability factors

Drug usePhysical illness

Physical illness – Hepatitis CPhysical illness – Hepatitis C

Hepatitis C infection is a Hepatitis C infection is a major concern among major concern among IDUsIDUs– 80 – 90% IDUs infected 80 – 90% IDUs infected

with Hepatitis C in some with Hepatitis C in some parts of Indiaparts of India

Hepatitis is inflammation Hepatitis is inflammation of liverof liver– Liver can be inflamed by Liver can be inflamed by

toxins, infection, alcohol, toxins, infection, alcohol, etc. etc.

Physical illness – Hepatitis Physical illness – Hepatitis Liver is a vital organ of Liver is a vital organ of

the body. Functions the body. Functions include: include: – Processing food for energy Processing food for energy

conversionconversion– Neutralise toxins and other Neutralise toxins and other

drugsdrugs– Store iron and important Store iron and important

vitaminsvitamins– Process hormonesProcess hormones– Fight infectionsFight infections– Produce important proteins Produce important proteins

in the bodyin the body Liver can re-grow, if Liver can re-grow, if

injuredinjured

Physical illness – Hepatitis Physical illness – Hepatitis When liver is inflamed When liver is inflamed

chronically, it causes chronically, it causes scarring, called as fibrosisscarring, called as fibrosis– Extensive scarring and re-Extensive scarring and re-

growth of liver leads to growth of liver leads to cirrhosiscirrhosis

– The end-stage of cirrhosis The end-stage of cirrhosis is liver failure, which leads is liver failure, which leads to symptoms such as to symptoms such as jaundice, collection of fluid jaundice, collection of fluid in abdomen, easy bleeding, in abdomen, easy bleeding, toxins entering into blood toxins entering into blood stream and also brain stream and also brain (encephalopathy) which (encephalopathy) which can make the individual can make the individual comatosecomatose

Fluid collection in abdomen

Physical illness – Hepatitis Physical illness – Hepatitis

Viral hepatitisViral hepatitis– 5 types of viral 5 types of viral

hepatitis: A, B, C, hepatitis: A, B, C, D, ED, E

– Reaction in liver is Reaction in liver is samesame

– Degree of Degree of damage and damage and persistence of persistence of infection depends infection depends on the type on the type (summarised in (summarised in table)table)

Type Type of of virusvirus

Route of Route of transmissiontransmission

prognosisprognosis

AA Eating Eating unhygienic unhygienic foodfood

Transient; very Transient; very good prognosisgood prognosis

BB Injection, Injection, sexualsexual

Chronic infectionChronic infection

CC Injection, Injection, sexualsexual

Chronic infectionChronic infection

DD Occurs along Occurs along with hepatitis with hepatitis BB

Worsens prognosis Worsens prognosis of hepatitis Bof hepatitis B

EE Unhygienic Unhygienic foodfood

Poorer than Poorer than Hepatitis AHepatitis A

Transmission of Hepatitis CTransmission of Hepatitis C– Sharing of contaminated injecting equipments Sharing of contaminated injecting equipments

in majority of casesin majority of cases Other injecting equipments such as spoons, Other injecting equipments such as spoons,

tourniquet, swabs, water in addition to N/Stourniquet, swabs, water in addition to N/S Contamination of hands during mixing of drugContamination of hands during mixing of drug

– Transfusion of infected blood and blood Transfusion of infected blood and blood productsproducts

– Mother to baby (5% chances)Mother to baby (5% chances)– Very low risk through sexual route, (but still Very low risk through sexual route, (but still

chances exist)chances exist)

Physical illness – Hepatitis C Physical illness – Hepatitis C

Stages of infectionStages of infection– Acute: some infected individuals have Acute: some infected individuals have

symptoms during this stage: symptoms during this stage: Nausea, vomiting, jaundice – ‘Acute Nausea, vomiting, jaundice – ‘Acute

hepatitis’hepatitis’

– 25% of individuals clear the virus from 25% of individuals clear the virus from their body by 2 years of infectiontheir body by 2 years of infection

Physical illness – Hepatitis C Physical illness – Hepatitis C

Physical illness – Hepatitis CPhysical illness – Hepatitis C

– Chronic: 75% of infected individuals will have Chronic: 75% of infected individuals will have chronic hepatitis with presence of virus in body chronic hepatitis with presence of virus in body and ability to transmit it to othersand ability to transmit it to others About 45% do not develop liver damageAbout 45% do not develop liver damage About 30 – 40% develop mild liver damageAbout 30 – 40% develop mild liver damage About 10 – 20% develop liver cirrhosisAbout 10 – 20% develop liver cirrhosis About 1 – 5% develop liver failure or liver cancerAbout 1 – 5% develop liver failure or liver cancer

Treatment of Hepatitis CTreatment of Hepatitis C– Not everybody requires treatmentNot everybody requires treatment– Success rate is only 30 – 40%Success rate is only 30 – 40%– Treatment is currently very costly in IndiaTreatment is currently very costly in India

Hepatitis C – counselling issuesHepatitis C – counselling issues

For every IDU, the TI counsellor should: For every IDU, the TI counsellor should: – Educate about the transmission dynamics of Hepatitis CEducate about the transmission dynamics of Hepatitis C– Stress on using safe injecting equipment (not only N/S, Stress on using safe injecting equipment (not only N/S,

but also others)but also others)– Teach the clients on how to inject safelyTeach the clients on how to inject safely

For Hepatitis C infected IDU clientsFor Hepatitis C infected IDU clients– Instil hope in the client that not every case is fatalInstil hope in the client that not every case is fatal– No special diet is required, but if the client is obese, fat No special diet is required, but if the client is obese, fat

foods should be avoidedfoods should be avoided– Alcohol IS STRICTLY prohibited: this message should be Alcohol IS STRICTLY prohibited: this message should be

strongly delivered to the clientstrongly delivered to the client If the client has problem alcohol use, he should be If the client has problem alcohol use, he should be

counselled accordingly, and if required, should be sent counselled accordingly, and if required, should be sent to a de-addiction centreto a de-addiction centre

Physical illness – Physical illness – Tuberculosis Tuberculosis

Tuberculosis (TB) is Tuberculosis (TB) is caused by a microscopic caused by a microscopic organism – bacteria – organism – bacteria – mycobacterium mycobacterium tuberculosistuberculosis

Can affect any body part Can affect any body part – Usually affect lungsUsually affect lungs– Other sites: lymph nodes, Other sites: lymph nodes,

bone, brain, spinal cord, bone, brain, spinal cord, genital-urinary system, genital-urinary system, etc. etc.

TB causing bacteria

Physical illness – Physical illness – TuberculosisTuberculosis

TB is contagious and spreads through airTB is contagious and spreads through air– Transmitted from one person to another Transmitted from one person to another

through droplets through droplets – When an infected person sneezes, coughs When an infected person sneezes, coughs

or talks, tiny droplets of saliva/mucus or talks, tiny droplets of saliva/mucus spread to another person, who can get spread to another person, who can get infectedinfected

If not treated, each infected person with If not treated, each infected person with active TB will infect 10 – 15 person every active TB will infect 10 – 15 person every year year

TB is not transmitted by touching clothes TB is not transmitted by touching clothes or shaking hands of an infected personor shaking hands of an infected person

Physical illness – TuberculosisPhysical illness – Tuberculosis

Inhaled by another Person

Entry into his lungs

Strong immune system

Low immune system

Tuberculosis disease

Fibre wall around the bacteria

If low immunity

Bacteria breaks the wall

Droplet

spread

Risk factors for tuberculosisRisk factors for tuberculosis


Injecting Drug UsersInjecting Drug Users DiabetesDiabetes Certain cancersCertain cancers HIV infectionHIV infection Health care Health care

workers, including workers, including doctors and nursesdoctors and nurses

Living with a person Living with a person who has an active who has an active TBTB

PovertyPoverty HomelessnessHomelessness Nursing home Nursing home

residentsresidents Prison inmatesPrison inmates AlcoholicsAlcoholics

Symptoms of active tuberculosisSymptoms of active tuberculosis


Coughing up of Coughing up of sputumsputum

Coughing bloodCoughing blood Shortness of breathShortness of breath If other systems If other systems

involved, symptoms involved, symptoms according to the according to the function of the function of the organorgan– E.g. Brain: fits, E.g. Brain: fits,

unconsciousnessunconsciousness

Generalised Generalised tiredness/weaknesstiredness/weakness

Weight lossWeight loss FeverFever Night sweatsNight sweats CoughCough Chest painChest pain

Diagnosis based onDiagnosis based on– Symptom profileSymptom profile– Chest X rayChest X ray– Sputum examinationSputum examination– Skin test (Monteux test)Skin test (Monteux test)

TreatmentTreatment– Nearest TB centre under RNTCP Nearest TB centre under RNTCP – Directly Observed treatment (DOT)Directly Observed treatment (DOT)– Duration 9 – 12 months for complete cureDuration 9 – 12 months for complete cure– Person becomes non-infectious within 3 weeks Person becomes non-infectious within 3 weeks

of initiating treatmentof initiating treatment


Other important considerationsOther important considerations– TB is the leading killer of people with HIVTB is the leading killer of people with HIV

HIV infected people are 20 – 40 times more likely to HIV infected people are 20 – 40 times more likely to develop active TBdevelop active TB

TB has resurfaced in the global epidemic because of TB has resurfaced in the global epidemic because of the onset of HIV infectionthe onset of HIV infection

– Multi drug resistant TB (MDR-TB): form of TB Multi drug resistant TB (MDR-TB): form of TB that is difficult and expensive to treat which that is difficult and expensive to treat which fails to respond to standard treatmentfails to respond to standard treatment

– Extensively drug resistant TB (XDR-TB): form of Extensively drug resistant TB (XDR-TB): form of TB which is resistant to drugs used in MDR-TBTB which is resistant to drugs used in MDR-TB


IDU related issues for TBIDU related issues for TB– IDUs have a very high rate of TB IDUs have a very high rate of TB

Reasons are many – poverty, homelessness, poor living Reasons are many – poverty, homelessness, poor living conditions, low immunity, poor nutrition, high HIV ratesconditions, low immunity, poor nutrition, high HIV rates

Early symptoms of TB may be mistaken for Early symptoms of TB may be mistaken for other conditions. For e.g. other conditions. For e.g. – Weight loss, weakness or tiredness Weight loss, weakness or tiredness general general

debilitydebility– Cough, chest pain Cough, chest pain chronic bronchitis associated chronic bronchitis associated

with co-morbid smokingwith co-morbid smoking


During every follow up, symptoms of TB During every follow up, symptoms of TB must be positively ruled outmust be positively ruled out

Baseline screening must be ensured by Baseline screening must be ensured by the counsellor by referral to the physicianthe counsellor by referral to the physician

Clients should be educated on Clients should be educated on signs/symptoms of TBsigns/symptoms of TB

Clients with symptoms resembling TB Clients with symptoms resembling TB must be referred to nearby DOTS centremust be referred to nearby DOTS centre

For those on treatment for TB: counselling For those on treatment for TB: counselling for adherence, physically verify whether for adherence, physically verify whether the client is taking TB medicines or notthe client is taking TB medicines or not


Mental illnessesMental illnesses

Mental illnessMental illness

Mental illness rates more common in Mental illness rates more common in Drug using population – dual diagnosisDrug using population – dual diagnosis

Mental IllnessMental Illness Rates (%)Rates (%)

Anti-social personality Anti-social personality disorderdisorder

15.515.5

ManiaMania 14.514.5

SchizophreniaSchizophrenia 10.110.1

DepressionDepression 4.14.1

Obsessive compulsive Obsessive compulsive disorderdisorder

3.43.4

PhobiaPhobia 2.12.1National Co-morbidity Study, USA

Mental illnessMental illness

Reasons for increased rates of mental Reasons for increased rates of mental illness: illness: – Drug use itself may cause mental illnessDrug use itself may cause mental illness

E.g. cannabis use for a long time seen to cause E.g. cannabis use for a long time seen to cause psychosis in somepsychosis in some

– Individuals suffering from mental illness may Individuals suffering from mental illness may initiate drug use – self medication hypothesisinitiate drug use – self medication hypothesis E.g. individuals suffering from schizophrenia increase E.g. individuals suffering from schizophrenia increase

tobacco/cigarette consumption to reverse the tobacco/cigarette consumption to reverse the slowness in thinking due to their illness or due to the slowness in thinking due to their illness or due to the medicines used to treat schizophreniamedicines used to treat schizophrenia

– Both drug use and mental illness may be Both drug use and mental illness may be caused by the same underlying factorscaused by the same underlying factors E.g. genetic vulnerability, stress related factors, etc. E.g. genetic vulnerability, stress related factors, etc.

Mental illness – Depression Mental illness – Depression

Depression is a very Depression is a very commonly occurring mental commonly occurring mental illness, with great morbidityillness, with great morbidity

Everyone feels sad at some Everyone feels sad at some point of timepoint of time

Depression is morbid state Depression is morbid state of sadnessof sadness– Affects the productivity and Affects the productivity and

normal functioning of an normal functioning of an individualindividual

Depression – symptoms Depression – symptoms Symptoms in an individual for at least two weeks period Symptoms in an individual for at least two weeks period

leading to difficulty in work OR personal sufferingleading to difficulty in work OR personal suffering

Low mood /sadness Low mood /sadness – Varies little from day to Varies little from day to

dayday– Unresponsive to Unresponsive to

external situationsexternal situations Reduced energy Reduced energy

– Marked tiredness even Marked tiredness even after minimal effortafter minimal effort

Decreased activityDecreased activity– Psychic (thought level)Psychic (thought level)– Motor (physical level)Motor (physical level)

Reduced capacity to Reduced capacity to enjoyenjoy

Reduced interest in work Reduced interest in work and pleasureand pleasure

Reduced concentrationReduced concentration Thinking becomes Thinking becomes

muddled and hazymuddled and hazy Sleep disturbedSleep disturbed

– Early morning Early morning awakeningawakening

– Frequent awakening Frequent awakening from sleepfrom sleep

– Does not feel refreshedDoes not feel refreshed

Depression – symptoms Depression – symptoms

Loss of appetiteLoss of appetite Reduced self esteem Reduced self esteem

and confidenceand confidence Ideas of guiltIdeas of guilt

– feeling that he has feeling that he has committed wrongcommitted wrong

Ideas of worthlessnessIdeas of worthlessness– Feeling that he does not Feeling that he does not

have any worth, which have any worth, which he deserves he deserves

Ideas of hopelessnessIdeas of hopelessness– Feeling that there is no Feeling that there is no

hope for him in this hope for him in this worldworld

Ideas of helplessnessIdeas of helplessness– Feeling that no body can Feeling that no body can

help him from his help him from his present conditionpresent condition

Wishes to dieWishes to die Suicidal acts/attemptsSuicidal acts/attempts

– Feeling that life is not Feeling that life is not worth living and attempt worth living and attempt to end lifeto end life

Mental illness – anxiety Mental illness – anxiety disorders disorders

Anxiety as a symptomAnxiety as a symptom– Anxiety is irrational fear, or fear out of Anxiety is irrational fear, or fear out of

proportion to what is expected in the proportion to what is expected in the given situationgiven situation

– Almost everyone experiences fear or Almost everyone experiences fear or nervousness one time or the othernervousness one time or the other

– The fear is usually in anticipation or The fear is usually in anticipation or presence of a stimulus (e.g. darkness, presence of a stimulus (e.g. darkness, animals, exams, etc.)animals, exams, etc.) Fear helps the person in responding to the Fear helps the person in responding to the

situation: either fight the situation or situation: either fight the situation or prepare to run away (flight)prepare to run away (flight)

Anxiety disordersAnxiety disorders

– The fear is labeled as disorder if it: The fear is labeled as disorder if it: occurs without any stimulus occurs without any stimulus

is out of proportionis out of proportion to what is expected in the to what is expected in the given situation by majority of individualsgiven situation by majority of individuals

Hampers or hinders the individual’s Hampers or hinders the individual’s performanceperformance

Anxiety disorder: group of disorders in Anxiety disorder: group of disorders in which the predominant symptom is which the predominant symptom is anxietyanxiety

Anxiety disorders – type Anxiety disorders – type

Common types:Common types:1.1. Specific phobia Specific phobia

Irrational fear of a specific object, animal or situationIrrational fear of a specific object, animal or situation E.g. phobia for heights, spiders, water, exams, E.g. phobia for heights, spiders, water, exams,

2.2. Social phobiaSocial phobia Irrational fear of being judged negatively or publically Irrational fear of being judged negatively or publically

embarrassed in societyembarrassed in society

3.3. Panic disorderPanic disorder Characterised by repeated panic attacksCharacterised by repeated panic attacks Panic attack: state of extreme anxiety and fear with Panic attack: state of extreme anxiety and fear with

sense of dying without any external stimulus sense of dying without any external stimulus (spontaneous attack)(spontaneous attack)

Anxiety disorders – type Anxiety disorders – type Common types:Common types:

4.4. Obsessive compulsive disorderObsessive compulsive disorder Characterised by obsessions and compulsionsCharacterised by obsessions and compulsions Obsessions: anxiety provoking thoughts which Obsessions: anxiety provoking thoughts which

intrude into the mind repeatedly, and are intrude into the mind repeatedly, and are irrationalirrational

Compulsions: irrational actions which the patient Compulsions: irrational actions which the patient is compelled to perform repeatedlyis compelled to perform repeatedly

E.g. repeated thoughts of being dirty/unclean: though the E.g. repeated thoughts of being dirty/unclean: though the patient knows that he is not unclean, he is not able to resist patient knows that he is not unclean, he is not able to resist these thoughts and resisting them provokes anxiety these thoughts and resisting them provokes anxiety obsessions; as a result of these obsessions, the person obsessions; as a result of these obsessions, the person repeatedly washes his hands repeatedly washes his hands compulsions compulsions

Anxiety disorders – Anxiety disorders – symptoms symptoms

Excessive unrealistic Excessive unrealistic worryingworrying

Trembling/shakinessTrembling/shakiness Churning stomachChurning stomach NauseaNausea DiarrheaDiarrhea HeadacheHeadache BackacheBackache Heart palpitationsHeart palpitations Sweating/flushingSweating/flushing

Numbness/pins and Numbness/pins and needle sensation in needle sensation in arms, hands or legsarms, hands or legs

RestlessnessRestlessness Easily tiredEasily tired Poor concentrationPoor concentration Easy irritabilityEasy irritability Muscle tensionMuscle tension Frequent urinationFrequent urination Sleep difficultiesSleep difficulties Easy startleEasy startle

Apart from Anxiety as the main symptom, one or more of the following:

Mental illness – PsychosisMental illness – Psychosis

Group of mental illness characterised Group of mental illness characterised by a loss of realityby a loss of reality

Disorganisation in thoughts, perception Disorganisation in thoughts, perception and behaviourand behaviour

Psychotic Disorders : Psychotic Disorders : – SchizophreniaSchizophrenia– Delusional disorderDelusional disorder– Bipolar disorderBipolar disorder– Acute PsychosisAcute Psychosis

Psychosis – symptomsPsychosis – symptoms

DelusionsDelusions– False beliefs which are not part of the person’s False beliefs which are not part of the person’s

culture; these beliefs are not amenable to culture; these beliefs are not amenable to reasoning, and are held tightly by the person reasoning, and are held tightly by the person despite evidence to contrarydespite evidence to contrary

– Examples: Examples: Belief of being persecuted Belief of being persecuted persecutory delusions persecutory delusions Belief of being talked about Belief of being talked about referential delusions referential delusions Belief of having powers Belief of having powers grandiose delusions grandiose delusions

– Bizzare Delusions seen in schizophrenia Bizzare Delusions seen in schizophrenia E.g. patient may feel that neighbours are controlling E.g. patient may feel that neighbours are controlling

his mind and compelling him to perform actions by his mind and compelling him to perform actions by magnetic wavesmagnetic waves

Psychosis – symptomsPsychosis – symptoms

HallucinationHallucination– Sensory perception without any stimulusSensory perception without any stimulus– Any sense organ can be involvedAny sense organ can be involved

Most common is hearing – auditory Most common is hearing – auditory hallucinationshallucinations

– E.g. a person may hear voices talking bad E.g. a person may hear voices talking bad about him/ swearing at him when in reality about him/ swearing at him when in reality nobody is talking, and others around the nobody is talking, and others around the patient are not able to hear itpatient are not able to hear it

Psychosis – symptomsPsychosis – symptoms Thought disordersThought disorders

– Break in logical connection between one thought Break in logical connection between one thought chain to anotherchain to another

– Results in not understanding what the patient is Results in not understanding what the patient is sayingsaying

Negative symptomsNegative symptoms– Found in chronic psychotic disorders, e.g. Found in chronic psychotic disorders, e.g.

schizophreniaschizophrenia– Disruption of normal emotions and behaviour, Disruption of normal emotions and behaviour,

what is expected in a normal personwhat is expected in a normal person E.g. loss of emotions when a person speaks (loss of E.g. loss of emotions when a person speaks (loss of

affect), not speaking when required, loss of will power affect), not speaking when required, loss of will power to initiate, loss of goals in life, etc. to initiate, loss of goals in life, etc.

Mental illness – Mental illness – counselling issuescounselling issues

If the IDU presents with one of the symptoms If the IDU presents with one of the symptoms of mental illness, explore other symptoms of of mental illness, explore other symptoms of mental illnessmental illness– If suspicion of mental illness, refer to a psychiatristIf suspicion of mental illness, refer to a psychiatrist

Educate the client that Educate the client that – Mental illness are treatableMental illness are treatable– Having a mental illness does not mean that the Having a mental illness does not mean that the

person has some defect of will powerperson has some defect of will power– Instill hope that outcome of mental illness such as Instill hope that outcome of mental illness such as

depression and anxiety is good, if treated for depression and anxiety is good, if treated for adequate durationadequate duration

Mental illness – Mental illness – counselling issuescounselling issues

Reinforce risk reduction message, as the Reinforce risk reduction message, as the chances of sharing are increased due to chances of sharing are increased due to despairdespair

Emphasize on chances of overdoseEmphasize on chances of overdose– Due to suicidal ideationDue to suicidal ideation– To relieve symptoms of mental illnessTo relieve symptoms of mental illness

Seek support of family during this crisis of Seek support of family during this crisis of the IDUthe IDU

Regularly follow up with IDU and counsel Regularly follow up with IDU and counsel him during the follow up phasehim during the follow up phase

Thank youThank you

co-morbidity among idus

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