The effect of different types of migration on symptoms of anxiety or depression and experience of violence among people who use or inject drugs in Kachin State, Myanmar

**Background:** Evidence on the social determinants of mental health and violence among people who use or inject drugs (PWUD) is limited, especially in conflict-affected settings. Myanmar has high drug production and use, particularly in Kachin State, which also has a large internally displaced population due to decades of armed conflict. This study aimed to estimate the prevalence of anxiety/depression symptoms and violence among PWUD in Kachin State and examine associations with different types of migration.

**Methods:** A clinic-based cross-sectional survey was conducted at the Asian Harm Reduction Network (AHRN) Waingmaw service centre between July and November 2021. PWUD aged ≥14 years who had used heroin or amphetamines at least once in the prior 3 months were eligible. Of 1,237 unique attendees, 417 were screened and 406 (97.1%) consented. Structured questionnaires were administered in Burmese by trained interviewers. The primary outcome was symptoms of anxiety or depression measured by the Patient Health Questionnaire-4 (PHQ-4; score ≥6). The secondary outcome was experience of physical or emotional violence in the last 12 months. Three key explanatory variables were: migration for any reason (28.3%), economic migration (77.9%), and forced displacement (19.5%). Logistic regression models were used, adjusting for age, housing, main income from farming, and type of drug used.

**Key Results:** The median age was 30 years (IQR 25–37); 96.8% were male; 69.7% were Kachin ethnicity; 81.5% had ever injected drugs; 85.0% used opioid substances. Symptoms of anxiety or depression (PHQ-4 ≥6) were present in 32.8% (133/406). Physical or emotional violence in the last 12 months was reported by 61.8% (251/406); emotional violence alone was 61.0% and physical violence alone was 9.2%. Food insecurity (went hungry in last 12 months) was reported by 27.7%, and 30.1% had unstable housing. HIV seroprevalence was 64.4% and HCV 78.7%. Only forced displacement was significantly associated with symptoms of anxiety or depression (aOR 2.33; 95% CI 1.32–4.11) and with recent physical or emotional violence (aOR 2.18; 95% CI 1.15–4.15). Neither migration for any reason nor economic migration showed significant associations with either outcome. Higher stigma within families (average score ≥2) was associated with both anxiety/depression (aOR 1.73; 95% CI 1.05–2.83) and violence (aOR 3.09; 95% CI 1.94–4.94). Food insecurity was consistently associated with anxiety/depression across all models (aOR ~2.8). Being on methadone treatment was associated with reduced odds of violence (aOR 0.38; 95% CI 0.18–0.80).

**Clinical Implications:** The high prevalence of anxiety/depression symptoms (32.8%) and violence (61.8%) among PWUD in this conflict-affected region underscores the need to integrate mental health screening and services into existing harm reduction programmes, particularly for internally displaced persons. The strong association between forced displacement and both outcomes suggests that displacement creates additional vulnerabilities beyond those of economic migration. The protective association of methadone with reduced violence warrants further investigation but suggests potential broader benefits of opioid agonist therapy. Addressing family-level stigma, food insecurity, and unstable housing are critical structural interventions. Limitations include the cross-sectional design (cannot establish causality), convenience sampling (limits generalisability), reliance on self-report, low recruitment of women, and use of symptom scales rather than diagnostic instruments.