WHO South-East Asia Journal of Public Health
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ORIGINAL RESEARCH
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 186-189

Psychoactive substance use by psychiatric patients in the National Referral Hospital, Bhutan: a retrospective analysis


Psychiatric Ward, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

Date of Web Publication22-May-2017

Correspondence Address:
Sonam Choki
Nurse Manager, Psychiatric Ward, Jigme Dorji Wangchuck National Referral Hospital, Thimpu
Bhutan
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DOI: 10.4103/2224-3151.206735

PMID: 28607305

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  Abstract 


Background: The costs to the individual and to society of psychoactive substance use is of growing concern in Bhutan. This study aimed to assess the relation between the demographic variables of patients admitted to the National Referral Hospital for first-time detoxification and the psychoactive substances used.
Methods: The demographic variables and types of psychoactive substance used by 284 substance users were reviewed. Data were collected through patients’ history sheets and admission registers, and analysed through descriptive statistics, one-way analysis of variance and independent t test.
Results: The commonest psychoactive substance used was alcohol, followed by cannabis, nitrazepam, dextropropoxyphene, glue (inhaled) and chlorphenamine/ pseudoephedrine/codeine-containing cough syrup. Only 14% of participants were aged 45 years or older. Most patients used more than one substance; the mean number of psychoactive substances used was highest among males, individuals aged 15–24 years and those who were unemployed.
Conclusion: Among patients admitted for first-time detoxification, harmful use of alcohol is the most common, followed by cannabis and illicit prescription drugs. Preventive measures should be prioritized on a need-based strategy. The findings of this study indicate that some of these preventive measures should be focused on males, unemployed groups and youth, and should involve raising awareness of harmful use of substances and the services available to treat substance use disorders.

Keywords: Bhutan, employed, men, psychiatric ward, psychoactive substance, unemployed, women


How to cite this article:
Choki S, Dorji T, Choden T. Psychoactive substance use by psychiatric patients in the National Referral Hospital, Bhutan: a retrospective analysis. WHO South-East Asia J Public Health 2014;3:186-9

How to cite this URL:
Choki S, Dorji T, Choden T. Psychoactive substance use by psychiatric patients in the National Referral Hospital, Bhutan: a retrospective analysis. WHO South-East Asia J Public Health [serial online] 2014 [cited 2019 Jul 19];3:186-9. Available from: http://www.who-seajph.org/text.asp?2014/3/2/186/206735




  Introduction Top


Alcohol use is common and deeply rooted Bhutan’s customs and culture. Drinking alcohol is widely accepted by Bhutanese society. Its use is a part of almost all social occasions, including childbirth, religious ceremonies, festivals, social gatherings and funerals.

Alcohol prevalence studies for Member States of the World Health Organization (WHO) South-East Asia Region show that 35% of Bhutanese men use alcohol and, at 25%, women’s alcohol use is the highest among the Member States of the Region.[1] In the Region in 2004, an estimated 350 000 people died of alcohol-related causes.[1] Alcohol-use disorder was the most common psychiatric diagnosis among admissions to the psychiatric ward of the National Referral Hospital of Bhutan during 2004–2011.[2]

Bhutan has seen an increase in the number of cases of substance use reaching the police.[3] A recent study indicated that the majority of those engaging in harmful drug use were students, with a mean age of onset at 16 years of age.[1] Alcohol and drug use also give rise to antisocial behaviour. In 2010, the Narcotic Drugs Law Enforcement Unit of Bhutan had 72 people arrested for illegal transaction of psychoactive substances.[4] The problem of addiction is becoming increasingly complex in Bhutan. This complexity is evidenced by the shift from licit drugs to illicit drugs; the associated social problems; the repeated admissions for substance use disorders; and the soaring costs of detoxification.

Therefore, this study was conducted to determine the types of psychoactive substance used by the patients admitted to the ward for detoxification in the National Referral Hospital, and to investigate associations with the socio demographic characteristics of these individuals. The study also aimed to generate evidence that will facilitate the development of evidenced-based approaches to reducing repeated admissions, which will impact in reduction of the costs of detoxification.


  Methods Top


Ethical approval for the study was obtained from the Research Ethics Board of Health, Ministry of Health, Thimphu, Bhutan.

This retrospective analysis study was carried out in patients admitted to the psychiatric ward of Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan for the first time (i.e. non-relapse) for detoxification, in 2011. Admission records and patients’ case sheets were used to collect data. Data captured were the types of psychoactive substance used and the sociodemographic characteristics of patients admitted for first-time detoxification in the year 2011.

Data were analysed using SPSS version 19.0 and descriptive statistical tests were performed to determine the types of psychoactive substances used. Independent t tests were used to determine the relationship between sex, employment status and the use of psychoactive substances; one-way analysis of variance and post-hoc tests were used to determine the relationship between the use of psychoactive substances and different age groups.


  Results Top


Demographic profile of subjects

A total of 473 patients were admitted to the psychiatric ward in 2011, including those with psychiatric illnesses, of whom 304 were admitted for detoxification. Excluding those admitted for relapse, the final sample included 284 subjects; of these, 85% (N = 240) were male and 15% (N = 44) were female. Ages ranged from 15 years to 65 years, with a mean age of 32.7 years. Of the 284 subjects, 44% (N= 124) were employed, while 56% (N = 160) were unemployed. Of the employed subjects, 25% (N = 72) worked in government services, 15% (N = 43) private services and 3% (N = 9) business. Unemployed subjects consisted of students 11% (N = 32), farmers 11% (N = 30), housewives 8% (N=23) and dependents 26% (N= 75).

Most of the subjects used more than one psychoactive substance in combination with another (see [Table 1]). Alcohol was the most commonly used psychoactive substance in this study, followed by cannabis, dextropropoxyphene, nitrazepam, glue (inhaled) and chlorpheniramine/pseudoephedrine/ codeine-containing cough syrup. Correction fluid (inhaled), ketamine, pseudoephedrine-containing cough syrup, heroin and injectable drugs such as pentazocine and morphine were also used.
Table 1: Psychoactive substances used

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Independent t test showed a significant sex effect. The mean number of types of psychoactive substances was higher among men than among women (mean=1.84, standard deviation [SD] = 1.563 versus mean = 1.32, SD = 1.052, P<0.001). Independent t test also showed a significant employment effect. The mean number of types of psychoactive substances used was higher among unemployed people than among those with employed people (mean = 2.05, SD = 1.7331 versus mean = 1.38, SD = 1.036; P < 0.001).

Only 14% of participants were aged 45 years or older and those in the age group 15–24 years engaged in the harmful use of significantly more types of psychoactive substances than the older subjects (P <0.001) (see [Table 2]).
Table 2: Number of participants and mean psychoactive substances used harmfully by age group

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Follow-up post-hoc Scheffé comparisons showed that the mean number of substances used among the age group 15–24 years was higher than for all other age groups (P <0.01 for age groups between 25 and 54 years, and P = 0.031 for age group 55 years and above). For each of the other age groups, the differences were not statistically significant.


  Discussion Top


This study revealed that 88.7% of the subjects engaged in the harmful use of alcohol alone or in combination with other substances. One of the reasons could be attributed to the easy availability of alcohol in the country. It is a common sight in Bhutan to witness liquor shops in every nook and corner of a town. There were 3000 licensed liquor shops across the country in 2004, for a population of 700 000.[5] Likewise, cannabis was found to be the second most commonly used substance among the study participants. One plausible explanation could be the prevalence of freely available cannabis, which grows wild in the country. Although dextropropoxyphene and nitrazepam are not produced in Bhutan, they are imported and easily available.

In this study, 85% of the patients admitted for first-time detoxification were male. The finding that more men are engaging in the harmful use of psychoactive substances (or, at least, more likely to be admitted for detoxification) is consistent with the findings of studies carried out in the United States of America and Canada.[6],[7] In addition, the mean number of types of psychoactive substances used was higher among men than among women. These findings may reflect the differences in psychoactive drug use in the community – Bhutanese women are rarely seen using psychoactive substances publicly, while men are seen to do so. These findings may also reflect fewer women coming forward for detoxification, owing to stigma –alcohol use being seen as “unfeminine” – and discrimination against female users of harmful psychoactive substances.

More patients admitted for first-time detoxification were unemployed and the mean number of types of psychoactive substances used was higher among unemployed participants than among those with employed participants. This finding is in line with a study conducted in South Africa where unemployment was one of the factors that led to the use of illicit drugs.[8] Many factors may underlie this difference, since the social groups within the unemployed category are diverse. Anecdotally, farmers usually comment that they drink alcohol at the end of a day’s hard manual labour. By contrast, unemployed youths, who are mostly school drop-outs, cite frustration and low mood as the reasons for using psychoactive substances. A British Crime Survey reported a strong connection between unemployment and illicit drug use in 16–24–year–olds.[9]

It is unknown whether the lower number of employed persons admitted reflects the pattern of psychoactive substance use in the community, since these individuals may be less willing to seek detoxification for fear of losing employment.

The study found that subjects in the youngest age group engaged in harmful use of significantly more types of substances than older participants. A survey carried out in the United Kingdom of Great Britain and Northern Ireland found that 50% of young people between the ages of 16 and 24 years used illicit drags.[9] A British Crime Survey found that, while 49% of young people aged 16 to 29 years had tried prohibited drugs, their rates of use during the past year and month were much lower, at 25% and 16%, respectively.

The present study found that those who came for detoxification comprised mostly the younger age groups aged 15–24 and 25–34 years. It is likely that the level of awareness of harmful use of psychoactive substances has increased, through schools and the media. This may have been instrumental in encouraging younger age groups to come forward for detoxification.

On the other hand, there were few older people admitted for detoxification. It is possible that the older people understood the ill effects of psychoactive substance use and thus stopped their harmful use on their own. In Bhutan, most of the older generation takes religious vows to stop drinking alcohol and this is a commonly practised tradition. Therefore, it could be interpreted that they were stopping the use on their own as a result of conforming to the vows. The other possible explanation could be the fact that harmful substance use is a recent phenomenon, particularly in Bhutan. In addition, some older people will have died from substance-related problems. Deaths from alcohol liver disease and alcohol-related problems are among the highest in the country.[10]

Finally, the recent availability of detoxification services in the psychiatric ward, unlike in the past, will have contributed to the difference between the older and younger age groups. The capital of Bhutan has the country’s only detoxification centre, which became operational in 2004, and hence awareness of substance use and harmful use may not have reached the older population.


  Conclusion Top


Preventive measures should be prioritized on a need-based strategy. The findings of this study indicate that some of these preventive measures should be focused on males, unemployed groups and youth, and should involve raising awareness on harmful use of substances and the services available to treat substance use disorders. More job opportunities, especially for the youth, would help to keep them engaged and offer an improved quality of life. An increased level of awareness of the harmful effects of psychoactive substances would help potential users and harmful users to refrain from their use. Concerted effort through an evidence-based approach by the relevant stakeholders would help overcome the dilemma of the growing drug and alcohol problem in Bhutan.

This study had some limitations related to the procedure for sample selection and the method of data collection. The participants were not randomly selected, were from one centre alone and had presented for detoxification. The extent to which the findings of this study can be generalized to all people in Bhutan undergoing treatment for psychoactive substance use, or to the community, is not known.

Source of Support: Nil.

Conflict of Interest: None declared.

Contributorship: sc: research conception and design, proposal write up, ethical submission, research supervision, manuscript writing, final submission for publication; TD: research conception, proposal write up, literature review, data collection and analysis, manuscript writing; TC: proposal write-up, data collection, proof reading.



 
  References Top

1.
Panda S, Wangdi C, Mukherjee D, Chowdhury L, Wangdi S, Pahari S. National baseline assessment of drugs and controlled substance use in Bhutan-2009. New Delhi: United Nations Office on Drug and Crime, 2009. http://www.unodc.org/documents/southasia/reports/ National_ Baseline_Assessment_of_Drugs_and_Controlled_Substance_use_in_ Bhutan_2009.pdf - accessed 23 September 2014.  Back to cited text no. 1
    
2.
World Health Organization, Regional Office for South-East Asia. Noncommunicable diseases in the South-East Asia Region. New Delhi: WHO-SEARO, 2011. http://www.searo.who.int/ LinkFiles/SDE Rep-2011-Dec.pdf - accessed 23 September 2014.  Back to cited text no. 2
    
3.
Pelzang R. The pattern of psychiatric admissions in a referral hospital, Bhutan. WHO South-East Asia Journal of Public Health. 2012; 1(1):52-58. http://www.searo.who.int/publications/journals/seajph/media/2012/ seajph_vlnl/whoseajphvlilp52.pdf?ua=1 - accessed 23 September 2014.  Back to cited text no. 3
    
4.
Gyelmo D. Amost 1,000 drug users in Bhutan. News Paper. Kuensel, 2011.  Back to cited text no. 4
    
5.
Dorji C The myth behind alcohol happiness. In: Proceedings of the Second International Conference on Gross National Happiness. Centre for Bhutan Studies, Thimphu 2005. pp. 64-77.  Back to cited text no. 5
    
6.
Cormier RA, Dell CA, Poole N. Women and substance abuse problems. BMC Women’s Health. 2004 August;4(Suppl 1):S8. doi: 10.1186/1472-6874-4-S1-S8. http://www.biomedcentral.com/1472-6874/4/S1/S8 -accessed 23 September 2014.  Back to cited text no. 6
    
7.
Robbins c, Frey R. Women and substance abuse: encylopedia of drugs, alcohol, and addictive behaviour. Encyclopedia.com, 2001. http://www. encyclopedia.com/doc/lG2–3403100476.html - accessed 23 September 2014.  Back to cited text no. 7
    
8.
Peltzer K, Ramlagan S, Johnson BD, Phaswana-Mafuya P. Illicit drug use and treatment in South Africa: a review. Substance Use Misuse. 2010 Nov;45(13):2221–43. http://www.ncbi.nlm.nih. gov/pmc/articles/ PMC3010753/ – accessed 23 September 2014.  Back to cited text no. 8
    
9.
Ramsay M, Partridge S. Drug misuse declared in 1998: results from the British crime survey: a research, development and statistics directorate report. London: British Criime Survey, 1998.  Back to cited text no. 9
    
10.
Royal Government of Bhutan, Ministry of Health. Inpatient cases in Bhutan. Annual Health Bulletin. Thimphu: Policy and Planning Department, 2011.  Back to cited text no. 10
    



 
 
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  [Table 1], [Table 2]



 

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