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Published in final edited form as: Int J Prison Health. 2015;11(3):183–192. doi: 10.1108/IJPH-03-2015-0007

Community reentry challenges after release from prison among people who inject drugs in St. Petersburg, Russia

Javier A Cepeda 1, Marina V Vetrova 2, Alexandra I Lyubimova 3, Olga S Levina 4, Robert Heimer 5, Linda M Niccolai 6
PMCID: PMC4753565  NIHMSID: NIHMS754718  PMID: 26277925

Abstract

Purpose

Little is known about the context of the post-release risk environment among formerly incarcerated people who inject drugs (PWID) in Russia. The purpose of this paper is to explore these challenges as they relate to reentry, relapse to injection opioid use, and overdose.

Design/methodology/approach

The authors conducted 25 in-depth semi-structured interviews among PWID living in St Petersburg, Russia who had been incarcerated within the past two years. Participants were recruited from street outreach (n = 20) and a drug treatment center (n = 5).

Findings

Emergent themes related to the post-release environment included financial instability, negative interactions with police, return to a drug using community, and reuniting with drug using peers. Many respondents relapsed to opioid use immediately after release. Those whose relapse occurred weeks or months after their release expressed more motivation to resist. Alcohol or stimulant use often preceded the opioid relapse episode. Among those who overdosed, alcohol use was often reported prior to overdosing on opioids.

Practical implications

Future post-release interventions in Russia should effectively link PWID to social, medical, and harm reduction services. Particular attention should be focussed on helping former inmates find employment and overdose prevention training prior to leaving prison that should also cover the heightened risk of concomitant alcohol use.

Originality/value

In addition to describing a syndemic involving the intersection of incarceration, injection drug use, poverty, and alcohol abuse, the findings can inform future interventions to address these interrelated public health challenges within the Russian setting.

Keywords: Keywords Russia, Incarceration, Relapse, Risk environment, Injection drugs, Overdose, Opioid

Introduction

Since the fall of the Soviet Union, Russia has become a major destination of Afghan heroin, consuming approximately 20 percent of the total supply (Demirbüken et al., 2012). The Russian criminal justice system has instituted and implemented laws that target drug users (Bureau for International Narcotics Control and Law Enforcmeent, 2005; Butler, 2003; Paoli, 2002) and this policy of mass incarceration of drug users is evidenced by the fact that more than half of all cases involve drug possession with no intent to distribute (Merkinaite, 2012). Indeed, the prevalence of injection drug use in the adult population in Russia is approximately 1.8 percent (or 1.8 million individuals), one of the highest in the world (Mathers et al., 2008). Given the lack of effective substance abuse treatment (Rhodes and Sarang, 2012), illegality of opioid substitution therapy such as methadone in Russia (Mathers et al., 2010), and weak or non-existent linkage to health care and social services, the majority of the incarcerated people who inject drugs (PWID) will eventually relapse to drug use shortly after release (Cepeda et al., 2014).

This immediate period after release is particularly perilous since many PWID are at high risk of overdose and death (Binswanger et al., 2007; Seaman et al., 1998; Merrall et al., 2010). Reduced tolerance after a long period of abstinence during incarceration may in part explain the elevated risk of opioid overdose after release (Warner-Smith et al., 2001; Bird and Hutchinson, 2003; Seaman et al., 1998). Lifetime experience of overdose is exceedingly common among PWID in Russia, with approximately 75 percent of PWID in St Petersburg reporting ever having an overdose (Walley et al., 2014; Grau et al., 2009). Despite the high risk of overdose shortly after release from prison and the high prevalence of PWID who have circulated through the criminal justice system in Russia, the context of relapse to injection drug use and experiencing an overdose after release has not been thoroughly examined.

The dearth of experiential data related to reentry, relapse, and overdose among recently released Russian PWID was the impetus for conducting this qualitative study. Because much attention has been drawn on how one’s physical, social, economic, and political environment (collectively known as the risk environment) influence drug-related harm, we used the risk environment framework as the basis for our interview guide (Strathdee et al., 2010; Rhodes, 2002). The objectives of this study were to qualitatively explore: first, the context of the risk environment that presented challenges to reentry; second, the attitudes and behaviors related to the injection opioid relapse episode; and third, the experience of opioid overdose among recently released PWID.

Methods

Ethical approval, recruitment, and enrollment

The Yale University Human Investigation Committee and the local NGO Stellit Institutional Review Board approved the study protocol and consent forms. Participants were recruited from June 2013 – January 2014 in St Petersburg, Russia by outreach workers affiliated with NGO Stellit and from a clinic specializing in drug detoxification and treatment. We recruited a convenience sample of 25 PWID and given the higher propensity of incarceration among men, we purposely oversampled women. No one refused to participate among eligible respondents. At the end of the interview respondents received HIV prevention information and mobile phone cards worth 500 RUB (approximately 15 USD).

Outreach workers and an addiction psychiatrist with prior experience interviewing the target population conducted the in-depth semi-structured interviews. The former conducted the interviews (n = 20) on a bus that offered harm reduction and HIV prevention services while the latter conducted the interviews in the detoxification ward of a narcology clinic (n = 5). Participants were eligible if they met the following criteria: at least 18 years old, injected opioids at least once in the past month, and released from an incarcerated setting within the past two years. Participation was voluntary and anonymous.

Interview guide and text analysis

Data from this study were collected via interviews that contained a brief close-ended survey and a qualitative interview guide that consisted of in-depth questions designed to capture the main concerns facing PWID after release from prison. The interview guide was prepared in English and reviewed by experts in qualitative health research at Yale University and Stellit who were familiar with the study population. Questions were translated into Russian by a native speaker and then translated back into English to ensure no loss of original meaning. We piloted the first five interviews, included in the final sample, to ensure that the respondents properly understood all questions. We altered and added some follow-up probes to elicit more detailed responses as they pertained to certain topics. Questions were designed to create as much of a narrative as possible about individual experiences related to these topics after release. Example questions included:

  1. “Tell me about your most important concerns as soon as you were released from prison or jail. What was happening in your life?”

  2. “Tell me about the first time you started injecting drugs after being released from prison or jail […]. Just tell me what was happening in your life when you started using again.”

  3. “What was happening earlier in the day that you experienced an overdose?” (among those who reported experiencing an overdose after their most recent release).

Duration of interviews ranged between 30 and 60 minutes. All interviews were audio recorded and transcribed by native Russian speakers. To ensure accuracy of transcription, transcripts were read while simultaneously re-listening to audio files and revised if there were any inconsistencies.

Analysis

All transcripts were translated into English by a bilingual Russian/English speaker and verified by a native English speaker proficient in Russian and native Russian speakers fluent in English. Descriptive thematic coding was conducted independently by two coders (JC and MV) using ATLAS.ti qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) following established methods (Braun and Clarke, 2006). A codebook, initially drafted based on the research questions used in the study, was further refined based on salient information gleaned from reading the transcripts multiple times. The coders discussed on a weekly basis any discrepancies that arose in the application of the codes until high agreement was achieved. We then applied the finalized codes to all the transcripts. The data were organized according to the codes and emergent themes were identified.

Results

Sample characteristics

Characteristics of the sample are described in Table I. The average age was 33 years. Approximately 75 percent of the sample reported receiving income from sources other than employment. The median time to injecting drugs after release from prison was four days. Other opioid use was common, as 64 percent had injected methadone within the past 30 days. More than two-thirds of the sample (68 percent) reported being HIV positive.

Table I.

Characteristics of study participants

Months since release, mean, SD (range) 13, 7.1 (1-24)
Days between release and resumption of injection drug use, median (range) 4 (0a-180)
Age, mean, SD (range) 33, 5.4 (24-45)
Male, n (%) 15 (60)
Age first injected drugs, mean, SD (range) 17.7, 3.3 (12-25)
Main source of income, n (%)
Official employment 3 (12)
Unofficial employment 3 (12)
Spouse/partner or family member 6 (24)
Thievery or robbery 7 (28)
Other 6 (24)
Education, n (%)
Less than high school 9 (36)
High school or technical 13 (52)
Other 3 (6)
Injected methadone in past 30 days, n (%) 16 (64)
Number of times injected drugs in past 30 days, mean, SD (range) 21.6, 11.8 (1-50)
Overdose since release, n (%) 12 (48)
Days between release and overdose, median (range) 30 (0b-180)
Number of times in jail, mean, SD (range) 2.8, 2.0 (1-8)
Self-reported HIV status, n (%) 17 (68)
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Notes: n=25.

a

Relapsed the same day of release;

b

overdosed the same day of release

The risk environment and challenges to reentry

Financial instability associated with bureaucracy and stigma, interactions with law enforcement, returning to a physical drug using environment, and reuniting with drug using peers presented themselves as significant factors upon reentry that either directly or indirectly led to resumption of drug use.

Financial instability associated with bureaucracy and stigma

Many respondents mentioned employment, money, and/or problems “with documents” (internal passports) as their most pressing concern at release. These passports are used only within Russia serving as official residence registration entitling access to health care and lawful employment. The overly bureaucratic system in reinstating documents created an additional barrier toward any kind of successful reentry. Addressing these bureaucratic issues usually superseded addressing any health-related problems upon release:

Interviewer: What were the serious concerns you had after the last time you were released? What was going on in your life?

Respondent: Problems with documents […] it was hard to reinstate my documents, problems with housing, problems with employment. They tell you in prison that there is work when you are released but in reality they [employers] say “No, you are a convict. We do not need you.” […] I also had problems at the doctor’s regarding my documents of course. At the polyclinic they said “Where is your medical card, insurance, passport?” With HIV it turned out to be easier. Only your passport needs to be reinstated (ID4, 40-year old male).

Many respondents described experiences of not being able to find a job and the subsequent negative mental health effects. Stigma due to one’s criminal background contributed to additional isolation from society by not being able to secure a “normal job.” This isolation sometimes directly contributed to an escape via drugs. One respondent described his financial struggles after being released: “I didn’t feel like robbing […] it became clear to me that no one really needs you […] everywhere people can shit on you […] such total loneliness.” (ID10, 45-year old male):

Who is going to take me for a normal job? No one. If you happen to lie to them, you will work there for around 2 months. The security will find out and then they will kick you out. Then you keep on looking. Then you work for another 2 months. They find out and kick you out again. You can only do anything [find work] through your friends and that’s it. Otherwise you will be looking in a dumpster like a bum. I will not be a bum. I would rather drown myself somewhere. But honestly, what else can I say? How can I feed my own family? My kids will come up to me and say “feed us” and what do I tell them? “Sorry, there is no work, because your father was a prisoner” (ID 22, 32-year old male).

Indeed, financial security upon release was especially heightened among participants with dependent children. One respondent described, in her post-release struggle to avoid relapse, how she eventually had to succumb to drug dealing when she was unable to meet her financial needs to provide for herself and her son. In the end, the easy availability of drugs led her to using heroin again:

He [son] lives with his grandma. I see him every day […] but I was worried that one day they would take him away, that’s why it is safer if he lives with his grandma. And […] umm well, there was not a good handle on money because there were no jobs. Actually I did not start using drugs [after release] but after realizing that I was not able to find a job, I started to sell drugs because I didn’t have enough money […] So at the beginning being a drug dealer was a way to get money, but then later I again started using […] heroin (ID18, 24-year old female).

Negative interactions with law enforcement

Further complicating successful reentry was harassment and abuse from law enforcement. The frequency of harassment from police since release varied, but most reported a few occurrences while some even reported interacting with police “three to four times per month” (ID25, 42-year old male). Being previously incarcerated put respondents at greater risk of coming into contact with police who already knew them and their whereabouts. Types of negative interactions included being harassed on the street (sometimes involving physical violence), having drugs planted, being detained at the police station, and paying bribes.

Male participants in particular reported being detained by police and that simply “having that appearance (of a drug user) aroused suspicions” (ID5, 35-year old male). Some respondents “knew the law” (ID2, 28-year old male) and were aware that in principle they could not be detained for simply walking down the street with a syringe since carrying syringes is not illegal:

I had nothing on me, just walking down the street. But they came up to me, searched my clothes and eventually took me to the police station. Why should I sit there for no reason? Just because I had a syringe in my pocket? Is that enough of a reason to take me to the station? (ID13, 34-year old male).

Police often used the threat of planting drugs and detainment as a way to get the participants to cooperate with them by working as informants. Dire consequences were threatened for failing to comply with cooperating:

They start calling you and asking you to come to the police station. They asked me some questions, whether I am working or not. Then [they] began to recruit me to work for them. Who is doing what in the district and stuff like this […] After I was released a detective came by or someone from there and wanted to speak again – “Come to the station and let’s talk” and there they started to recruit me. (ID8, 27-year old male).

In addition to being visited by police to work as informants, participants also discussed the necessity of paying off corrupt police officers. This form of harassment involved the common occurrence of paying bribes to avoid detention. Failing to pay the bribes would provoke further harassment, disrupting their post-release adjustment to the community:

Respondent: And they [police] bug. Do you think they don’t? They do. If I didn’t pay one, another would come. If I did not pay the 3rd [officer], a 4th would come.

Interviewer: What did you have to pay them for?

Respondent: For living peacefully in my district. It probably sounds wild to you.

Interviewer: Did you always give them money? What happened if you did not?

Respondent: If I didn’t give them money? It would mean that I would have to stay at the station longer (ID 22, 32-year old male).

Returning to a physical drug using environment and reuniting with drug using peers

Unstable housing was generally not a concern in that most respondents returned to the same places where they living prior to incarceration. Some PWID mentioned that after being released they experienced certain triggers in their physical environment, such as living or walking in certain neighborhoods. These triggers reinforced the notion that drugs were omnipresent and that avoiding drugs would be a significant challenge:

Well basically (a region in southeastern St. Petersburg where homemade opioids were produced before the heroin market surged) is a huge swamp […] it sinks you in there […] damn. Everyone is boozing, everyone is shooting up […] it was all the same upon returning. People right there in front of you […] this has an impact on everything. The neighborhood, the people. Imagine – you don’t do drugs, you don’t drink and every day you’re constantly seeing people shooting up and drinking. Then the second day, the third day. And you are constantly seeing this. So then naturally you also feel like relaxing some too (ID15, 30-year old female).

In the vast majority of cases, respondents would reunite shortly after release with friends or other drug using peers and relapse often occurred. Respondents usually did not attribute their relapse to any kind of coercive peer pressure but rather a social environment where they could relax and celebrate their release. In several instances, respondents acknowledged that associating with drug using friends would inevitably bring them back to their drug addiction lifestyle. Reuniting with them after release did provide a sense of community. Thus, this reunion was characterized as a double-edged sword in that respondents often found comradeship in their company, while at the same time returning to their addiction:

I started talking to my friends again […] as a matter of fact, I started using again because of them. Because of like, this social circle […] they use and because of this you feel like breaking away with them accordingly […] it is impossible to be sober in society (ID17, 31-year old male).

Attitudes and behaviors associated with relapse to post-release injection drug use

Regarding individual-level factors, two main themes emerged: awareness and resignation to relapse and stimulants and alcohol use as precursors to heroin relapse.

Awareness and resignation to relapse

Overall, participants were generally aware of the fact that it was improbable that they would have been able to refrain from resuming opioid injecting. We characterized two types of individuals: first, “immediate relapsers” who were intent on injecting drugs again as soon as they were released and second, respondents who relapsed after a few weeks or months of sobriety out of a greater motivation to remain abstinent. The “immediate relapsers” usually reported thinking about using drugs again while still in prison or the moment they were released. They described how it was a conscious decision to resume injecting drugs. Further, pessimism about the future resulted in limited desires to avoid relapse or curb drug use after they were released:

Respondent: I was released and then went to go immediately shoot up. Interviewer: What do you mean “immediately”?

Respondent: I literally mean that as soon they let me go, by the evening I was ready […] When I was sitting [in prison] I was already thinking that when I get out I will inject once and will not use [drugs] again after that (ID5, 35-year old male).

What am I to do? I have been HIV infected since 2001, so what kind of special plans can I make now? Why make them? […] I have enough money. I am not an addict. I can use drugs for getting high twice per week. It has no impact on my life (ID8, 27-year old male).

On the other hand, motivation to restrain oneself from injecting drugs after release was expressed by a minority. While some of the “immediate relapsers” did report that they just wanted to use “once and then quit” (ID3, 30-year old female), the respondents who relapsed later were more vocal in their desire to quit and “start a new life” (ID13, 34-year old male) after release. Some employed proactive measures by avoiding any contact with drug users, physically or socially. One respondent, who relapsed six months after release, described how he removed drugs and drug users from his home environment. Interviewer: “After you were released, did you feel like using drugs?” Respondent: “No, I even got rid of and trampled on them [drugs] […] I didn’t know what I was doing with them […] I also chased all of them [drug users] out by the entrance (of the apartment building)” (ID 22, age 32).

Stimulants and alcohol use as precursors to heroin relapse

Using stimulants or alcohol prior to resuming heroin use was also common. One woman described her experience of not wanting to immediately begin using heroin but eventually falling back into the cycle of addiction after using ephedrine, a stimulant. Several respondents mentioned how the negative effects of ephedrine led to an acute episode of depression, which was remedied by injecting heroin:

I used ephedrine and just wanted to stop it and feel good, and get rid of the depression. So I got [heroin] through my friend who I met in prison. I don’t remember where I met her when I got the drugs, just took them and shot up at home (ID11, 28-year old female).

The use of alcohol, often in the company of friends, was also mentioned as an important antecedent to the heroin relapse episode. Similar to ephedrine use, heroin was used to remedy the negative effects of heavy alcohol consumption. Additionally, alcohol use was also cited as a facilitator of impaired judgment, which eventually led to heroin use:

Oh, I felt really bad after drinking heavily and the drugs helped me go to sleep and feel normal the next day. They helped reduce the effects of drinking, from the alcohol. Then I took it and started using drugs again. And after that I became addicted (ID15, 30-year old female).

You could say that he [friend] provoked me. While drunk, it is hard to control oneself in any kind of way. If the friend did not suggest it to me when I was drunk, I might not have used drugs. What was the reason for my relapse? The alcohol or my friend? Maybe if I had not met my friend and I were sober […] (ID7, 31-year old male).

Experience of post-release overdose

Almost half the sample had experienced an opioid overdose after release, with the median time to overdose occurring 30 days after release. A few respondents who were experienced injectors mentioned that the only time they had ever overdosed was after they were released from prison. “I had an overdose only once in my life. My friends often pass out, but I always bring them back and never leave them, but for me, I had an overdose only once” (ID8, 27-year old male). However, respondents did not explicitly link the vulnerable time after their release to the overdose. Interviewer: “Were you worried that you could overdose?” Respondent: “No, I always inject carefully. But on this day it [overdose] just happened” (ID4, 40-year old male). Mixing of alcohol with heroin after the relapse episode was often associated with the overdose. Respondents did not report being aware of the synergistic effects of consuming both alcohol and heroin and the increased risk of overdose:

Interviewer: Tell me more about the day that you overdosed due to opioids, after you were released from prison. What happened earlier that day?

Respondent: Nothing special. I drank, shot up, and then overdosed. After that, I don’t remember. Interviewer: How soon after you were released?

Respondent: Within two months.

Interviewer: Before this moment when the overdose happened, what happened on that day?

Respondent: Nothing. Drank a lot, shot up, and then overdosed. Doctors told me that it was too much alcohol and I injected too much (ID3, 30-year old female).

Discussion

PWID leaving prisons in St Petersburg encounter numerous reentry challenges. All respondents were confronted with environmental challenges that impeded their ability to stabilize themselves after release. Many of these challenges were perceived as being external and outside the control of the respondent. Financial security, avoiding further detention by or harassment by law enforcement officials, residence in neighborhoods with heavy and easily observed drug use, and reuniting with other PWID were identified as significant barriers to reentry stabilization. Most respondents relapsed within the first few days (many on the same day of release), and half had overdosed since their most recent release.

These results illustrate a “hierarchy of needs” in that basic needs such as addressing problems with documents, securing employment, avoiding arrest, and providing for children superseded attention to any substance use or disease-related concern (Springer et al., 2011). Some attributed the persistent rejection from society, as evidenced by not being able to find legal employment, as a reason for resumption of drug use. This is consistent with a previous study, which found that PWID who were unemployed in St Petersburg were over four times as likely to relapse sooner to injection drug use after release from prison than PWID who were employed (Cepeda et al., 2014). Additionally, the repeated rejection when applying for legal employment at release, as some had experienced, could have reinforced the stigma of being a former prisoner (Moran, 2012) and might have contributed to resumption of drug use, reengagement with drug using circles, and earning money via illegal means (Strathdee et al., 2010). Russian policymakers have acknowledged the need for employment support for released prisoners since only 20 percent of former prisoners are able to find a job in their first year after release (Salnik, 2013).

While some of our findings, such as employment barriers due to being a former inmate are consistent with qualitative studies from the USA (Luther et al., 2011; Seal et al., 2007; Bahr et al., 2010; Binswanger et al., 2011), other challenges appeared to be more particular to Russia and other former Soviet countries. For example, harassment, extortion, and violence from law enforcement officers directed toward PWID have been documented (Sarang et al., 2010; Rhodes et al., 2003; Odinokova et al., 2014). Our study adds to these findings in that the persistence of structural violence on behalf of law enforcement after release makes PWID returning from prison easy targets since they are already familiar to the police and are susceptible to either working as informants or paying bribes to avoid detainment. Financial stability, in terms of having enough money to take care of basic needs, is of paramount importance to PWID (Bobrova et al., 2006), yet in reality this would be difficult to achieve if bribes are necessary to pay off corrupt police officers. Alternatively, if PWID remain off the streets to avoid contact with law enforcement, then it will be more challenging to link these individuals to harm reduction services and treatment (Sarang et al., 2008). Indeed, this has been reported among former HIV positive inmates in Ukraine, a country with similar HIV and injection drug use epidemics as Russia (Izenberg et al., 2013). Interestingly, in contrast to studies from the USA (Adams et al., 2011; van Olphen et al., 2009; Binswanger et al., 2012), only one respondent expressed concerns about homelessness or stable housing. In most instances respondents returned to their pre-incarceration residences, which eventually led them to the same drug using social circles. Transitional drug-free housing as terms of conditional release may be one structural approach in reducing the likelihood of immediate relapse after release.

Many respondents had experienced an overdose since their release. While this connection has been well-established (Seaman et al., 1998; Binswanger et al., 2007; Bird and Hutchinson, 2003; Merrall et al., 2010), our study provides additional context to this risk environment. Oftentimes another substance resulted in escalation to heroin use as a way either to manage the negative effects of that substance (e.g. depression following stimulant use, hangover from heavy drinking) or through disinhibition. These additional substances, especially alcohol, put the respondent at much greater risk of overdose (Sporer, 1999). It is uncertain to what extent PWID were aware of the synergistic depressive effect of alcohol and heroin use on breathing, which increases the risk of overdose (Sporer, 1999). Further, despite the fact that experiencing a post-release overdose was so prevalent in this sample, respondents rarely attributed this to the long period of abstinence or lower tolerance due to incarceration as a potential contributor to their overdose. This may suggest a need for including education about overdose risk, especially as it relates to concomitant consumption of alcohol and heroin, for soon-to-be released PWID.

Limitations

Since we conducted interviews only with current PWID who had been incarcerated in the past two years, we did not have a corresponding comparison group of people who were recently incarcerated and remained abstinent after release. By having such a group, we could identify and compare differences in their post-release transitions that may have contributed to one group relapsing and the other refraining from doing so. Furthermore, we could not recruit high-risk PWID who were recently released from prison but who may have died after release.

Conclusions

To address the syndemic that includes incarceration and injection drug use, interventions tackling both individual and structural-level barriers are needed for PWID following discharge from prison. Structural barriers to accessing legal employment for former prisoners should be reduced and work-release programs need to be developed (Seiter and Kadela, 2003; Inciardi et al., 1997). Changes in law enforcement strategies should limit targeting of non-violent drug users so that they may obtain documents and access harm reduction, HIV care, and job placement services. An eventual downstream goal is to develop an intervention to mitigate the negative effects of being released from prison to high risk, often hostile environments. None of the respondents reported being successfully linked to case management or health care services upon release, indicating that there is an urgent need to address the reentry challenges of this vulnerable population. Services helping former inmates in St Petersburg do exist (personal communication with director at NGO Stellit), however, the lack of knowledge and utilization of these services suggests that linkage to these services from prison needs to be optimized. With respect to overdose prevention, PWID should receive response training and naloxone kits at discharge to diminish the likelihood of fatal overdose upon reentry (Green et al., 2014; Strang et al., 2013).

Acknowledgments

The authors gratefully acknowledge support from the National Institutes of Health (F31DA03570901, 5R01DA02988804, 5T32MH020031 and 2P30MH06229411, 5D43TW00102814). The authors also thank Roman Skochilov, Artem Kopelev, and Natalia Posokhova for help with various aspects related to interpretation and translation. Finally, the authors thank all participants in the study. The National Institutes of Health did not have a role in the study design, conduct, or reporting of results.

Footnotes

Paper type

Research paper

Contributor Information

Javier A. Cepeda, Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.

Marina V. Vetrova, Bekhterev Research Psychoneurological Institute, St Petersburg, Russia.

Alexandra I. Lyubimova, NGO Stellit, St Petersburg, Russia.

Olga S. Levina, NGO Stellit, St Petersburg, Russia.

Robert Heimer, Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.

Linda M. Niccolai, Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.

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