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  RESEARCH Open Access Multi-level predictors of psychologicalproblems among methadone maintenancetreatment patients in difference types of settings in Vietnam  Tuan Anh Le 1,2 , Mai Quynh Thi Le 1 , Anh Duc Dang 1 , Anh Kim Dang 3 , Cuong Tat Nguyen 3* , Hai Quang Pham 3 ,Giang Thu Vu 4 , Chi Linh Hoang 5 , Tung Thanh Tran 4 , Quan-Hoang Vuong 6,7 , Tung Hoang Tran 8 , Bach Xuan Tran 2,9 ,Carl A. Latkin 9 , Cyrus S. H. Ho 10 and Roger C. M. Ho 5,11,12 Abstract Background:  Methadone, a long-acting opioid agonist maintenance treatment (MMT) is used to treat opioidaddiction by preventing opioid withdrawal and reducing cravings. However, it is important to note that mentalconditions may persist, or even remain undetected while methadone maintenance treatment is ongoing. This studyaimed to examine the level of psychological problems among MMT patients at public and private health facilitiesand identify associated factors. Method:  From January to September 2018, a cross-sectional study was performed in Nam Dinh province, one of the largest epicenters providing HIV/AIDS surveillance and treatment services in the North of Vietnam. 395 malerespondents currently receiving MMT agreed to participate in a face-to-face interview. Depression, Anxiety andStress Scale-21 (DASS-21) were used to assess psychological problems among patients. Results:  The percentage of patients suffering from mild to extremely severe anxiety was the highest amongpsychological problems (18%). 2.8% of participants had mild depressive symptoms and the percentage of thosehaving mild or moderate stress was approximately 4%. In addition, the longer treatment duration, the lower mentalhealth scores regarding three types of psychological problems. Respondents who received MMT services in publichealth facilities were more likely to have a higher score of all psychological problems. Participants who lived withpartners or spouse, having higher monthly family income had a lower likelihood of having severe depression andstress status. Freelancers or blue-collars/farmers had lower score of depression and anxiety compared to peoplebeing unemployed. Conclusion:  This study suggests that among our sample, MMT patients receiving treatment in public healthfacilities might have higher rate of psychological problems, including depression, anxiety, and stress than that of those in the private health facility. These results highlight the necessity of taking psychological counselingadequately for MMT patients and psychological assessment should be prioritized in the early stage of treatment. Keywords:  Psychological, Depression, Anxiety, Stress, Methadone, Vietnam © The Author(s). 2019  Open Access  This article is distributed under the terms of the Creative Commons Attribution 4.0International License ( ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the srcinal author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver( ) applies to the data made available in this article, unless otherwise stated. * Correspondence: 3 Institute for Global Health Innovations, Duy Tan University, Postal address:No. 73 Hoang Cau street, Hanoi, Da Nang, VietnamFull list of author information is available at the end of the article Le  et al. Substance Abuse Treatment, Prevention, and Policy   (2019) 14:39  Background Methadone Maintenance Treatment (MMT) is along-term or permanent treatment, which replacesopioids by other substitutes to mitigate physical andpsychosocial hardships for patients [1]. Psychiatricdisorders have been cited as a significant barrier forindividuals to optimally adhere to opioid-dependenttreatments. Drug users suffering from psychologicalhealth issues have a higher risk of having lowerquality of life [2, 3], suicide attempts [4, 5] and an even higher rate of mortality [6]. Mental healthproblems can be considered as driving force indiminishing MMT treatment outcomes such ashigher rate of involving in HIV-related risk behaviors[7], interfering with therapeutic compliance withMMT and increasing retention in methadone treat-ment [8]. Thus, identifying and giving treatments of psychiatric co-morbidities for opioid-addicted pa-tients is crucial to enhance the efficacy of MMTprograms.Evidence in the literature shows that there is aconsiderable prevalence of MMT patients experien-cing psychological problems in which depression andanxiety are overwhelming disorders [9, 10]. A study  conducted in China revealed that 57.5% of MMTusers reported to suffer from depressive symptoms,and more than one in four (25.8%) had suicidal idea-tion [11]. In term of depression, a study of Weiss-man et al. showed that approximately one-third of MMT patients in the community had moderately toseverely depression [12], 50% of MMT patients werefound to experience depression based on study of Peles et al. [13], while the rate of lifetime depressionprevalence among opioid dependence patients en-gaging in treatment programs ranged from 20 to50% [14].Notably, the satisfaction of medical services is alsoconsidered as a factor related to the mental healthstatus of patients [15]. In order to meet the demandof patients and increase the accessibility of health-care services, private health facilities also provideMMT treatment for drug users. Public health facil-ity is referred to have a better quality of treatmentincluding licensed and certified medical staff [16],higher diagnostic accuracy [17], better adherence tomedical management standards [18] and higherrates of treatment success [19]. On the other hand,private health facility has succeeded in providing abetter quality of services, for example, reducing thewaiting time [20], improving hospitality from pro- viders [21] and lowering the proportion of patientsexperiencing stigma and discrimination [22].The expansion of the MMT program in Vietnamhas increased rapidly in recent years. Since the firstMMT clinic introduced in 2008, the government of Vietnam has made great commitment to expandingthe MMT program to cover a large number of drugusers nationwide [23, 24]. The Ministry of Health in Vietnam also emphasizes the need for psychologicalhealthcare when receiving MMT [25]. Prior studieshave assessed the prevalence of psychiatric problemsamong MMT patients, ranged from 26.8 to 43.1%.[6, 22]. However, there is little evidence taking ac- count of the impact of different types of MMT out-patient clinics. Therefore, this study aimed toexamine the level of psychological problems amongMMT patients at public and private health facilitiesand other factors contributing to a higher risk of suffering from these psychological problems. Methods Study setting and subjects We conducted a cross-sectional study from January 2018 to September 2018 in Nam Dinh province.Nam Dinh is one of the largest epicenters offeringMMT services in the North of Vietnam. The study settings took place in three MMT clinics (GiaoThuy district health center, Dai Dong private healthfacility and Giao Thuy center for social evilsprevention). We selected the clinics based on twoeligibility criteria [1] providing methadone treatmentservices following the official guidelines of the Min-istry of Health in Vietnam and [2] the period of of-fering Methadone treatment services was at least 12months.We used convenience sampling technique to re-cruit participants. Participants were chosen based onfour eligibility criteria, which were [1] being at least18 years old; [2] undergoing MMT services of set-tings mentioned above; [3] agreeing to participate inthe study and [4] being able to answer questionsfrom data collectors. A total of 395 respondentsagreed to take part in the study. The percentage of patients in each health facility was 49.4% (Dai Dongprivate health facility), 25.3% (Giao Thuy districthealth center) and 25.3% (Giao Thuy center for so-cial evils prevention). Measure and instruments 20-min face-to-face interviews were carried out tocollect data. The interviewers were well-trainedresearchers. Medical staffs in the clinics were notinvited to participate in data collection in order toavoid social desirability bias. Participants were askedto involve in the study when they attended theseclinics for treatment or counseling services. Eligiblerespondents were identified based on the feedbackfrom medical staffs. To secure participants ’ Le  et al. Substance Abuse Treatment, Prevention, and Policy   (2019) 14:39 Page 2 of 10  confidentiality, the interviews occurred in a smallprivate counseling room. Participants could take partin the study after being introduced the study objectives, benefits, drawbacks and provided verbalinformed consent.A pilot survey was conducted prior to the main study among 40 respondents with different social characteris-tics, including ages, employment and educational levelto test and refine the questionnaire. Minor changes re-garding wording were made based on the feedback of  Table 1  Socio-economic characteristics of respondents Characteristics Private facility State facility Total  P  -value n  %  n  %  n  % Total 195 49.4 200 50.6 395 100Age groupUnder 30 29 14.9 19 9.5 48 12.2 0.03*30 – 40 89 45.6 80 40.0 169 42.841 – 50 60 30.8 66 33.0 126 31.9Above 50 17 8.7 35 17.5 52 13.2EducationLess than secondary 33 16.9 33 16.5 66 16.7 0.94*Secondary school 118 60.5 119 59.5 237 60More than secondary 44 22.6 48 24 92 23.3Marital statusSingle 38 19.5 29 14.5 67 17 0.07*Live with partners/spouse 150 76.9 154 77 304 77Divorced/widow 7 3.6 17 8.5 24 6.1OccupationUnemployment 13 6.7 20 10 33 8.4 0.06*Freelancer 63 32.3 76 38 139 35.2Blue collar/farmer 45 23.1 47 23.5 92 23.3Business 11 5.6 17 8.5 28 7.1Others 63 32.3 40 20 103 26.1Quintile averagefamily incomeQuintile 1 39 20 41 20.5 80 20.3 0.89*Quintile 2 37 19 45 22.5 82 20.8Quintile 3 42 21.5 39 19.5 81 20.5Quintile 4 43 22.1 39 19.5 82 20.8Quintile 5 34 17.4 36 18 70 17.7Ever injected drugs 121 62.1 131 65.5 252 63.8 0.48*Alcohol drink 114 58.5 97 48.5 211 53.4 0.05*Smoke 163 83.6 157 78.5 320 81 0.20*Concurrent drug use 15 7.7 8 4 23 5.8 0.12*Median IQR Median IQR Median IQRAge 38 33 – 44 41 34 – 48 39 33 – 46 0.01 # Monthly family income (USD) 344 215 – 430 301 215 – 430 344 215 – 430 0.50 # Age of onset of drug use 25 20 – 30 25 21 – 31 25 20 – 31 0.05 # MMT duration (years) 2 1 – 5 3 2 – 6 3 1 – 5 0.02 # *Chi square test,  # Mann-Whitney rank sum test Le  et al. Substance Abuse Treatment, Prevention, and Policy   (2019) 14:39 Page 3 of 10  participants. A structured questionnaire was applied tothe following information: Socioeconomic characteristics Participants self-reported general information, includingage, marital status, occupation, educational level andmonthly income. Mental health status In order to assess the mental health status amongparticipants, we used the Depression, Anxiety, andStress Scale-21 (DASS-21). This tool consists of 21items, which measure three sub-scales of emotionalstates, including depression, anxiety, and stress. Eachsub-scale contains 7 questions and the answer foreach question ranges from 0 (Did not apply to me atall) to 3 (Applied to me very much, or most of thetime). Participants were asked to indicate the pres-ence of a symptom over the past week. Scores forthree emotional states were calculated by summingthe points for the relevant items (question 3, 5, 10,13, 16, 17, 21 for depression; question 1, 6, 8, 11,12, 14, 18 for stress; question 2, 4, 7, 9, 15, 19, 20for anxiety) and double up. There were 5 levels forthe cut-off point based on DASS-21 scoringcontaining: normal, mild, moderate, severe, extremely severe. The DASS can be a useful assessment of dis-turbance, either the level of severity of patients ’ symptoms or how the patient ’ s response to treat-ment [26]. Health risk behavior  Participants were asked about whether they currently drink alcohol, smoke tobacco or use drugs. In term of quality of life,  “ How your quality of life change betweenbefore and after having MMT service? ”  was also men-tioned in the questionnaire. Participants also reportedtheir HIV-infection status. Methadone maintenance treatment-related- characteristics Participants self-reported their overall assessmentregarding the quality of MMT service in the healthfacility where they attended and their satisfaction fortraveling to MMT facility to take pills. Level of adher-ence to MMT was self-assessed using a Likert scale,including 5 options from  “ Very good ”  to  “ Very bad ” .Moreover, a 100-point visual analog scale (VAS) wasalso employed to detect patients ’  adherence, with ascore range from 0  “ incompletely adherence ”  to 100 “ completely adherence ” . The threshold for optimaladherence was 95%. Table 2  MMT   –  related characteristic of participants Characteristics Private facility State facility Total  P  -value n  %  n  %  n  %Quality of life changeafter using MMT Better 185 94.9 192 96.0 377 95.4 0.59Unchanged 10 5.1 8 4.0 18 4.6HIV test resultsNegative 178 92.7 169 89.9 347 91.3 0.47Positive 7 3.7 7 3.7 14 3.7Unknown 7 3.7 12 6.4 19 5.0MMT adherence VASOptimal adherence 96 49.2 75 37.5 171 43.3 0.02Suboptimal adherence 99 50.8 125 62.5 224 56.7Receiving support for MMT Health workersat MMT facility97 49.7 66 33.0 163 41.3 < 0.01Relatives in family 167 85.6 140 70.0 307 77.7 < 0.01Peer in MMT 41 21.0 26 13.0 67 17.0 0.03Neighbors/other acquaintances 9 4.6 7 3.5 16 4.1 0.57 Le  et al. Substance Abuse Treatment, Prevention, and Policy   (2019) 14:39 Page 4 of 10

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