Substance Abuse and Comorbid Depression: A Cross-SectionalSurvey-Based Study Exploring Comorbidities and DepressionSeverity Using PHQ-9 among Female Substance Users in PakistanPost-COVID-19

Introduction: In Pakistan, females with substance use (FSU) remain critically neglected despite an estimated 1.5 million users. Post-COVID-19, the drug use patterns among FSU remain largely elusive. Depression, though common among users, is rarely addressed in primary care. This study used PHQ-9 to assess depression among treatmentseeking female substance users. It explored the prevalent types of substances misused, the underlying motivations for use, and the potential consequences of substance misuse on the general health of women. Method: A cross-sectional survey was carried out among 200 female substance users and 200 controls from rehabilitation centers in Rawalpindi/Islamabad. Results: Misuse of nicotine (62%), cannabis (18%), opioids (alcohol and morphine) (10%), and methamphetamine (8%) was prevalent, while prescription drugs and LSD misuse remained low (2%). A considerable number of participants were consumers of nicotine pouches (12%), vapes (23%), and cigarettes (27%). Binge drinking was reported by 20% of alcohol users. PHQ-9 scores were significantly higher in substance users (11.42 ± 0.86) than non-users (8.68 ± 0.73) (p<0.05). Vape users had the highest depression scores (16.5 ± 1.37), followed by cigarette (13.6 ± 1.10) and pouch users (12.4 ± 1.10). Substance users had nearly twice the odds of elevated PHQ-9 scores (OR = 1.982, 95% CI 0.261–4.22, p < 0.05). Nicotine users also had significantly lower BMI (21.62 ± 0.96) than other substance users (28.11 ± 2.27) (p<0.0001). Menstrual irregularities and PCOS were more common among users. Discussion: The findings underscore a critical gap in the recognition and treatment of mental health issues among female substance users (FSU) in Pakistan. The significantly higher PHQ-9 scores among substance users, particularly those using vapes, cigarettes, and nicotine pouches, point to a strong association between nicotine use and comorbid depression. This is particularly alarming given nicotine’s widespread availability and perception as a less harmful substance. The study also highlights post-COVID shifts in drug use patterns, with an increase in nicotine-based products and binge drinking behaviors. The health implications are considerable, with users exhibiting lower BMI, higher rates of menstrual irregularities, and PCOS, suggesting the compounding physiological burden of substance misuse in women. The study demonstrates the utility of the PHQ-9 as a practical screening tool for identifying depression among FSU in resource-limited clinical settings. This study calls for urgent policy-level interventions to address the dual burden of addiction and psychiatric illness in women, a historically neglected area in Pakistan’s healthcare system. Conclusion: The findings of this study highlight the urgent need for gender-sensitive rehabilitation policies for FSU with routine PHQ-9 screening.