| Abstract|| |
Introduction: Opium dependence and abuse are a topic of interest for clinicians due to its negative social consequences and risk of suicide. Suicide itself is correlated with some personality traits. This study is aimed to assess the relationship between suicidal thought and personality traits in opium dependent patients who are currently on methadone maintenance therapy. Materials and Methods: Ninety opium-dependent men on methadone maintenance therapy were randomly selected from addiction treatment centers in Rasht and entered this cross-sectional study. Beck scale for suicidal ideation (BSSI), big five inventory (BFI), beck depression inventory (BDI-II), and demographic questionnaire were used for evaluation. Data were analyzed by SPSS 22. Results: Mean ages of patients were 45.6 ± 21.37 years. 58.9% were married. 40% were minimally depressed, 36.7% were mildly depressed, and 23.3% were moderately depressed. There was a correlation between BDI and BSSI scores (r = 0.613, P = 0.001). Spearman correlation coefficient showed a positive correlation between BFI and BSSI scores, regarding occupational states and methadone dosage. Conclusion: Regarding the high prevalence of suicidal attempt among addicted patients, assessing personality traits and social factors in patients on agonist therapy is necessary to find appropriate solutions to reduce or prevent suicide.
Keywords: Depression, methadone, opioid-related disorders, personality traits, suicide
|How to cite this article:|
Shokrgozar S, Soleimani R, Esfandyari H, Aram S, Abdollahi E. Evaluating personality traits and suicidal ideation in substance-dependent patients on methadone maintenance therapy in addiction treatment centers in Rasht. Ann Trop Med Public Health 2017;10:1631-6
|How to cite this URL:|
Shokrgozar S, Soleimani R, Esfandyari H, Aram S, Abdollahi E. Evaluating personality traits and suicidal ideation in substance-dependent patients on methadone maintenance therapy in addiction treatment centers in Rasht. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Oct 17];10:1631-6. Available from: http://www.atmph.org/text.asp?2017/10/6/1631/222686
| Introduction|| |
Opium dependence and abuse are a specific topic for clinicians because of negative social consequences and risk of suicide. In recent decades, rate of suicide a major health problem among young people has increased. Several theories have been proposed regarding suicide and substance abuse. Due to one of these theories, substance abuse increases suicide rate through increasing impulsivity. Others believe that there are some common root factors with each of them causing addiction and suicide, separately. Research proposed a relationship between suicidal behavior and substance abuse among young adults. Suicidal behavior is a main problem among opium-dependent patients who are seeking treatment. In a study in England, about one-third of patients had suicidal thought before entering treatment programs. Research has shown that personality traits, lifestyle, social relationships, attitudes, ideas, and maladaptive behaviors formed during developmental process have a major role in developing substance abuse and dependence. Some studies regarding personality traits in those who attempted suicide showed that personality traits, especially neurotic tendencies, affect suicidal thought, and behavior are major factors.,,
Considering psychological characteristics of opium-dependent patients, high prevalence of substance abuse, depressive mood, and antisocial personality traits were observed, whether they attempt suicide or not. O'Boyle and Brandon study revealed the high prevalence of suicidal thought and behavior among addicted female, and in those, who abused higher amounts of substances. They reported that there was relationship between high neurotic scores and suicidal behavior among addicted patients due to personality theories. Neuroticism is defined by anxiety, dysthymia, guilt feeling, capriciousness, restlessness, and emotional instability. Studies revealed that depression and anxiety are strongly correlated with suicidal behavior. Those who attempt suicide have a history of substance abuse and dependence, comparing to general population. Methadone maintenance therapy may be the most acceptable method in substance abuse treatment programs  that decreased harmful events and risk of suicide significantly., Although there are several studies regarding relationship between personality traits and suicidal behavior in general population, research assessing this relationship in patients on methadone maintenance therapy is lacking.
Therefore, due to the lack of statistical reports in Iran and specifically in Guilan province, this study aim was to assess relationship between personality traits and suicidal thought in opium dependent patients who are currently on methadone maintenance therapy.
| Materials and Methods|| |
This cross-sectional study is designed to assess the opium-dependent male patients who are on methadone maintenance therapy in addiction treatment centers in Rasht. Stratified sampling was done in two phases. In phase I, three addiction treatment centers were randomly selected. In phase II, ninety eligible patients were selected through simple randomization, among these three centers. Case selection was proportionate to the number of patients in each center.
- At least 1-month methadone maintenance therapy
- Signing informed consent
- Ages 18–60 years
- Negative urine rapid tests in the last 3 days before entering the study
- Absence of substance intoxication or withdrawal symptoms.
- Serious medical disease
- Mental retardation.
After signing the informed consent, a demographic questionnaire was filled for each patient including age, marital status, occupational status, education level, duration of addiction, substance type, number of abstinence periods, methadone dosages, and duration of methadone maintenance therapy. Beck scale for suicidal ideation (BSSI), big five inventory (BFI), and beck depression inventory (BDI-II) were then filled for each patient. Sample size was 90 patients based on the correlation coefficient in the previous studies (r = 0.7).
Beck scale for suicidal ideation
This questionnaire consists of 10 items, each item scores from zero to two, therefore, the total score varies in the range of 0–38. This questionnaire is aimed to assess attitudes, behaviors, and seventy of attempting suicide in the previous week. Factor analysis revealed that BSSI consists of three factors: tendency to die (5 questions), readiness for suicide (7 questions), and tendency for actual suicide (4 questions). Two other questions about preventing or secret suicidal behavior were not included in any of those three factors.
Final scores are as follows: 0–3 no suicidal thought, 4–11 low risk for suicidal thought, and 12–38 high risk for suicidal thought. This scale had an internal consistency of 89.0% and a reliability of 83 (r = 83), and concurrent validity of 69.0 (r = 69.0) (P < 0.001). This scale has a high reliability because Cronbach's Alpha was 54.0.
Big five inventory
The summary from of BFI is a pen and paper test including 44 items. This questionnaire assesses the main features of five main factors (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness) through short statements. This questionnaire is graded from 1 = completely disagree to 5 = completely agree based on Likert five-degree scale; negative items are graded inventory.
Moradi et al. calculated reliability by Cronbach's Alpha to be 80.0, 70.0, 56.0, and 82.0 for neuroticism, extraverness, agreeableness, and conscientiousness respectively.
Beck depression inventory
This questionnaire is the most appropriate scale to assess depression. It contains 21 items and evaluate somatic, behavioral, and cognitive aspects of depression. Each item includes four options and is graded from 0 to 3; therefore depression is finally categorized from minimal to severe. The maximum score is 63 and the minimum is zero. Scores 0–15 means minimal depression, scores 16–31 means mild depression, scores 32–47 means moderate depression, and scores 48–63 means severe depression. Test–retest reliability based on duration between two tests and population characteristics was in the range of 48.0–86.0. Beck and Brown reported internal consistency of this questionnaire between 73.0 and 92.0 (mean 86.0).
Data were entered and analyzed by SPSS 22.0 (Armonk, NY: IBM Corp.). Descriptive results were reported by median, standard deviation and frequency. Regression model was used to determine relationship between suicidal thought and personality traits if data were normally distributed, Pearson's correlation coefficient was used and if they were not normally distributed, Spearman correlation coefficient was used. Normality was determined based on Kolmogorov– Smirnov test.
The significance of results was defined on Type I error of 0.05.
| Results|| |
Ninety men on methadone maintenance therapy aged 18–60 years from addiction treatment centers in Rasht were included in this study. Mean age of the patients was 45.6 ± 21.37. 58.9% were married, 2.2% were uneducated, 20% were under diploma, 52.2% were diploma, and 25.6% had university education. 21.1% were unemployed, 15% were laborers, 20% were employees, and 48.9% had miscellaneous jobs [Table 1]. Data regarding patient addiction characteristics is shown in [Table 2]. 40% (36 patients) were minimally depressed, 36.7% (33 patients) were mildly depressed, 23.3% (21 patients) were moderately depressed, and none of them were severely depressed.
|Table 1: Demographic data of opium-dependent patients who are currently on methadone maintenance therapy|
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|Table 2: Characteristics of opium dependent patients on methadone maintenance therapy in addiction treatment centers in Rasht|
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According to BSSI, more than half of the patients (77.8%) were at no/low risk of suicide [Table 3]. It was determined by Kolmogorov–Smirnov that BSSI Scores were not normally distributed (Z = 92.2, P = 0.0001). The higher scores in BFI belonged to A, C and O as shown in [Table 4] (30.7%, 30.4% and 29.6%, respectively). BFI Score were normally distributed based on Kolmogorov–Smirnov test (Z = 0.1, P = 27.0).
There was no correlation between BFI and BSSI scores based on spearman correlation coefficient (P = 0.814, r = 0.025), but while assessing BFI subscale scores and severity of intention for suicide, BSS1 and BSS2 were well correlated with N-BFI subscale (P < 0.01). There was a correlation between BDI-II and BSSI scores (P = 0.0007, r = 0.613, [Table 5]). Spearman correlation coefficient showed no correlation between BFI and BSSI scores regarding different ages (P = 0.134, P = 0.7, P = 0.114), gender (P = 0.913, P = 0.58), educational level (P = 0.176, P = 0.96, P = 0.72), marital status (P = 0.68, P = 0.68), depression severity (minimal, mild, and moderate) (P = 0.179, P = 0.9, P = 0.097), duration of addiction (P = 0.142, P = 0.27, P = 0.81), number of abstinence periods (P = 0.12, P = 0.77, P = 0.90), duration of methadone treatment (<6 months, 6–12 months, 12–24 months, and more than 24 months) (P = 0.26, P = 0.43, P = 0.23, P = 0.79) and substance type (methamphetamine, cannabis, morphine) (P = 0.558, P = 0.837, P = 0.912). There was a correlation between BFI and BSSI scores regarding occupational states (Laborer, employee) (P = 0.22, P = 0.145, P = 0.22, P = 0.019) and methadone dosage (60–80 mg) (P = 0.0006).
|Table 5: Correlation between personality traits and severity of depression with suicidal thought|
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| Discussion|| |
The aim of this study was to assess the associations between personality traits and suicidal thought in opium-dependent patients on methadone maintenance therapy in addiction treatment centers in Rasht. Mean age of patients was 45.6 ± 21.37 years, 58.9% were married, 2.2% were uneducated, 20% were under diploma, 52.2% were diploma, and 25.6% had university education. 21.1% were unemployed, 48.9% had miscellaneous jobs, 10% were Laborer, and 20% were employee. Duration of substance dependence was <5 years in 18.9% of cases, 5–10 years in 15.1% and more than 10 years in 31% of patients. Mean duration of dependency was 8.8 ± 4.3 years. 50% of cases were methamphetamine users, 8.7% were cannabis users, and 42.2% were morphine users. 35.6% of patients had history of <2 abstinence periods, 14.1% had 2-4 abstinence periods, and 23.3% had more than 4 abstinence periods. 36.7% of patients have used methadone for <6 months, 35.6% for 6–12 months, 16.7% for 12–24 months, and 11.1% for more than 24 months. Methadone dosage was <20 mg in 14.4% of patients, 20–40 mg in 24.4%, 40–60 mg in 34.4%, and 60–80 mg in 26.7% of patients. 40% were minimally depressed, 36.7% were mildly depressed, 23.3% were moderately depressed, and none of them were severely depressed. While assessing personality characteristics, higher scores were seen in agreeableness (A), openness (O) and conscientiousness (C).
Trémeau et al. in a study found that neuroticism and extraverness significantly reduced overtime and reached normal population during methadone maintenance therapy. Oskuie Shomali et al. carried out a 6-month study on 102 patients on methadone maintenance therapy and concluded that those who had slipped periods had lower neuroticism scores than those without slipped periods. They also found out that substance-dependent patients were different from normal population regarding personality traits. There was no correlation between BFI and BSSI scores, but there was a correlation between severity of sociality and BFI subscales, and also between of severity of depression and suicidal thought. There was no correlation between personality traits and suicidal thought regarding different ages, gender, educational level, marital status, severity of depression, duration of education, methadone dosage, and substance type. On the other hand, there was a correlation between BFI scores and suicidal thought regarding occupational states (laborer and employee) and methadone dosage (60–80 mg). Zhang identified correlation between BFI and BSSI scores regarding marital status  which was different from what we observed in our study. This discrepancy may be explained by social and occupational consequences of addiction in our society. Chen et al. found that suicidal attempt following methadone maintenance therapy was common in Taiwan. 11% of them attempted suicide in the previous month. Mokhber et al. also carried out a study on patients on methadone maintenance therapy and concluded that suicidal risk of the patients decreased significantly after 6 months follow up. Thompson et al. reported of suicidal thought in 11% of opium dependent patients. In our study, 20% of patients were at high or ultra-high risk of suicide based on BSSI scores. Different factors including opium dependence contributed to recent suicidal attempts. Those with higher heroin dependency were more prone to attempted suicide. We found out no correlation between substance type and suicidal thought. Regarding the absence of heroin-dependent patients, suicidal rate was higher comparing to similar studies; it seems that other factors such as social and cultural differences were missed and needs further evaluation. Other area of interest is about higher suicidal rate in patients on methadone maintenance therapy comparing substance dependent patients in other studies. As it has been established before  substance-related disorders need both short-term and long-term treatment programs; therefore, our finding is an alarm for methadone maintenance therapy centers to pay more attention to psychosocial aspects of this population.
Unemployment is psychologically, socially, and economically stressful, and suicidal attempt was much more common among unemployed patients., Our findings showed a correlation between BFI and BSSI scores regarding occupational states (laborer and employee), that is, compatible with similar studies., We concluded that unemployment is a risk factor for patient's mental health; both unemployment and depression were more common in those who attempted suicide. In our study, 23.3 of patients were moderately depressed, 36.7% were mildly depressed, and 40% were minimally depressed. As it is mentioned before, BFI and BSSI scores were correlated regarding severity of depression. In the previous studies  carried out on acute depressive states, suicidal thought and attempt were correlated with severity of depression. It is not surprising that depression and stressful events are related to increased suicidal attempt. Previous studies reported more severe current depression in addicted patients with a history of suicidal attempt. Due to Chen et al. study, recent suicidal attempt was correlated to severity of opium dependence, severity of depression, and stressful life events. In a study by Peles et al. 50% of patients suffered from depression (HAM-D-21), women had lower levels of depression comparing to men. Due to this similar study, risk factors for comorbid depression in patients on methadone maintenance therapy were usage of psychedelic drugs and methadone dosage more than 120 mg/d. As it is obvious in our study, there was a positive correlation between BFI and BSSI scores regarding 60–80 mg/d methadone dosage. It was repeated in the previous studies that higher dosage was correlated with depression, therefore this finding was predictable. In Phillips et al. study  those violent patients who attempted suicide in previous 30 days were more likely to be woman. Patients with previous suicidal attempt had lower educational level. BSSI scores were correlated with serious life events in previous 30 days and also with severity of depression. Marijuana usage was significantly correlated with suicidal ideation although other substance indices (such as number of days spending on substance abuse in previous month and number of drugs have been consumed during the previous month) were not correlated with suicidal attempt. Current studies indicate that history of antisocial behavior especially violent behavior may contribute to risk of suicide among depressed opium-dependent patients. This finding may be due to the severity of dependency or methadone dosage needed to prevent opium abuse.
| Conclusion|| |
Due high prevalence of suicidal attempt among substance-dependent patients, assessing personality traits and social characteristics of opium abusers is necessary to find appropriate solutions to reduce or prevent suicide. In summary, unmet psychological needs are a serious problem in patients on methadone maintenance therapy. Psychiatric interventions are needed to eliminate these problems. We propose routine screening for the previous or recent suicidal attempts to be a part of treatment programs in substance-dependent patients. Because of high prevalence of depression among opium abusers, screening programs should include other known risk factors such as depressed mood.
Psychiatric problems are common in patients on methadone maintenance therapy but they almost always remain unknown and untreated. There should be a connection between addiction treatment centers and social workers in addition to medical staff.
Given that this study was carried out with a small sample size and only in one city, it is recommended further studies should be undertaken with larger sample size and in multiple geographic regions with more emphasis on methods of suicidal attempts.
Sample size was small, all participants were male, psychiatric clinical interview was not carried out, and questionnaires were the only method of evaluation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Clin Psychol Psychiatry 2006;47:372-94.
Hirschfeld RMA, Davidson L: Risk factors for suicide, in American Psychiatric Press Review of Psychiatry, vol 7. Edited by Frances AJ, Hales RE. Washington, DC, American Psychiatric Press, 1988, pp 307–33
Jessor R. Risk behavior in adolescence: A psychosocial framework for understanding and action. J Adolesc Health 1991;12:597-605.
Ilomäki E, Räsänen P, Viilo K, Hakko H, STUDY-70 Workgroup. Suicidal behavior among adolescents with conduct disorder – The role of alcohol dependence. Psychiatry Res 2007;150:305-11.
Chen VC, Lin TY, Lee CT, Lai TJ, Chen H, Ferri CP, et al.
Suicide attempts prior to starting methadone maintenance treatment in Taiwan. Drug Alcohol Depend 2010;109:139-43.
Javanmard QH. Examining the causes of addiction with respect to the addicts of maraqah's self-introduced addicts center. Peyke Noor Journal 2004;1:67-75.
Segal DL, Marty MA, Meyer WJ, Coolidge FL. Personality, suicidal ideation, and reasons for living among older adults. J Gerontol Series B Psychol Sci Soc Sci 2012;5:68-74.
Roy A. Characteristics of cocaine-dependent patients who attempt suicide. Am J Psychiatry 2001;158:1215-9.
Fisher LA, Elias JW, Ritz K. Predicting relapse to substance abuse as a function of personality dimensions. Alcohol Clin Exp Res 1998;22:1041-7.
Ashoori A, Habibi Asgarabad M, Torkman Malayeri M, Javan Esma'li A. Relationship between suicidal ideation and personality in substance abusers. Journal of Behavioral Sciences 2009;3:249-55.
O'Boyle M, Brandon EA. Suicide attempts, substance abuse, and personality. J Subst Abuse Treat 1998;15:353-6.
Useda JD, Duberstein PR, Conner KR, Beckman A, Franus N, Tu X, et al.
Personality differences in attempted suicide versus suicide in adults 50 years of age or older. J Consult Clin Psychol 2007;75:126-33.
Farrell M, Ward J, Mattick R, Hall W, Stimson GV, des Jarlais D, et al.
Methadone maintenance treatment in opiate dependence: A review. BMJ 1994;309:997-1001.
Maloney E, Degenhardt L, Darke S, Nelson EC. Investigating the co-occurrence of self-mutilation and suicide attempts among opioid-dependent individuals. Suicide Life Threat Behav 2010;40:50-62.
Conner KR, Britton PC, Sworts LM, Joiner TE Jr. Suicide attempts among individuals with opiate dependence: The critical role of belonging. Addict Behav 2007;32:1395-404.
Van-Orden KA, Lynam ME, Hollar D, Joiner TE. Perceived burdensomeness as an indicator of suicidal symptoms. Cognit Ther Res 2006;30:457-67.
Rutter PA, Behrendt AE. Adolescent suicide risk: Four psychosocial factors. Adolescence 2004;39:295-302.
John OP, Donahue EM, Kentle RL. The Big Five Inventory – Versions 4a and 54. University of California, Berkeley. Berkeley, CA: Institute of Personality and Social Research; 1991.
Moradi S, Garcia D. Adolescents' temperament and character: A longitudinal study on happiness. J Happiness Stud 2012;13:931-46.
Khademi A, Alleyassin A, Agha-Hosseini M, Ahmadi Abhari A, Esfhandi H, Fakhimi Derakhshan K. Depression and infertility: Evaluation of 681 infertile women using Beck depression inventory. Hayat 2004;10:13-21.
Trémeau F, Darreye A, Leroy B, Renckly V, Ertlé S, Weibel H, et al.
Personality changes in opioid-dependent subjects in a methadone maintenance treatment program. Encephale 2003;29:285-92.
Oskuie Shomali A, Rostami R, Hedayati M, Zarei J. A comparative study of five personality factors in opiate dependent individuals in treatment with methadone and normal subjects. Procedia Soc Behav Sci 2011;30:129-32.
Zhang X, Xu H, Gu J, Lau JT, Hao C, Zhao Y, et al.
Depression, suicidal ideation, and related factors of methadone maintenance treatment users in Guangzhou, China. AIDS Care 2016;28:851-6.
Mokhber N, Afshari R, Farhoodi F. Evaluation of the suicide risk factors among methadone maintenance treatment of opiate dependent individuals: A six month assessment. Open J Psychiatry 2012;2:91.
Thompson R, Kane V, Cook JM, Greenstein R, Walker P, Woody G, et al.
Suicidal ideation in veterans receiving treatment for opiate dependence. J Psychoactive Drugs 2006;38:149-56.
Sadock BJ, Sadock VA. Kaplan and Sadockâ€™s synopsis of psychiatry: behavioural sciences/clinical psychiatry. 9th ed. Philadelphia:Lippincott Williams & Wilkins; 2003, p. 622.
Kerkhof AJFM, Hawton K, van Heeringen K. Attempted suicide: patterns and trends, International handbook of suicide and attempted suicide, 2000. 1st ed., Chichester, United Kingdom. John Wiley & Sons. p. 49-64.
Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in suicide ideation, plans, gestures, and attempts in the united states, 1990-1992 to 2001-2003. JAMA 2005;293:2487-95.
Darke S, Ross J, Williamson A, Teesson M. The impact of borderline personality disorder on 12-month outcomes for the treatment of heroin dependence. Addiction 2005;100:1121-30.
Peles E, Schreiber S, Naumovsky Y, Adelson M. Depression in methadone maintenance treatment patients: Rate and risk factors. J Affect Disord 2007;99:213-20.
Phillips J, Carpenter KM, Nunes EV. Suicide risk in depressed methadone-maintained patients: Associations with clinical and demographic characteristics. Am J Addict 2004;13:327-32.
Aharonovich E, Liu X, Nunes E, Hasin DS. Suicide attempts in substance abusers: Effects of major depression in relation to substance use disorders. Am J Psychiatry 2002;159:1600-2.
Pud D, Zlotnick C, Lawental E. Pain depression and sleep disorders among methadone maintenance treatment patients. Addict Behav 2012;37:1205-10.
Gu J, Lau JT, Xu H, Zhong Y, Hao Y, Zhao Y, et al.
randomized controlled trial to evaluate the relative efficacy of the addition of a psycho-social intervention to standard-of-care services in reducing attrition and improving attendance among first-time users of methadone maintenance treatment in China. AIDS Behav 2013;17:2002-10.
Department of Psychiatry, Kavosh Cognitive Behaviour Sciences and Addiction Research Center, School of Medicine, Shafa Hospital, Guilan University of Medical Science, Rasht
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]