Original Article

Depression and Suicidal Ideation among Patients Receiving Opioid Maintenance Treatments Considering Cognitive Flexibility


Objective: Cognitive flexibility is associated with psychiatric disorders. Drug addicts experience more psychiatric disorders. This research aimed to examine depression and suicidal ideation among those receiving opioid maintenance treatment (OMT), taking into account the mediating role of cognitive flexibility.

Method: This cross-sectional research was conducted on patients who were enrolled in the OMT program in Semnan in 2021 and abstained from opioid use for at least one year. 126 participants (115 males and 11 females) were randomly selected from among patients in three therapeutic groups (42 from each of the methadone, buprenorphine, and opium tincture groups). The main data collection tools were the Beck Scale for Suicide Ideation (BSSI), Cognitive Flexibility Inventory (CFI), and Beck Depression Scale (BDI-II). Data analysis was done through logistic regression models.

Results: Correlation analysis between depression scores, suicidal ideation, and cognitive flexibility showed a significant correlation between each of them. Adjusting for the type of treatment, the increase in cognitive flexibility was associated with a decreasing chance of depression (odds ratio [OR] = 0.87; 95% CI [0.82, 0.92]), and the use of buprenorphine (OR = 15.1) and opium tincture (OR = 9.3), compared to methadone, were associated with a depression increase. Yet, multivariate analysis did not show an independent and significant association between cognitive flexibility and the risk of suicide.

Conclusion: Based on the results, patients receiving maintenance treatments are in different conditions in terms of depression and suicide, and psychological flexibility is in correlation with depression and suicidal thinking and behavior in them. This suggests that these patients seem to benefit from cognitive training, at least in reducing their depression.

1. Hickman M, Steer C, Tilling K, Lim AG, Marsden J, Millar T, et al. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction. 2018;113(8):1461-76.
2. Shakeri H, Hejrati R, Hojjat SK, Khalili MN, Farazmand T, Mollazadeh S. Effects of methadone, opium tincture and buprenorphine maintenance therapies on thyroid function in patients with OUD. J Addict Dis. 2020;38(4):514-9.
3. Nikoo M, Moazen-Zadeh E, Nikoo N, Javidanbardan S, Kazemi A, Choi F, et al. Comparing opium tincture and methadone for medication-assisted treatment of patients with opioid use disorder: Protocol for a multicenter parallel group noninferiority double-blind randomized controlled trial. Int J Methods Psychiatr Res. 2019;28(1):e1768.
4. Anderson IB, Kearney T. Use of methadone. West J Med. 2000;172(1):43-6.
5. Lawrinson P, Ali R, Buavirat A, Chiamwongpaet S, Dvoryak S, Habrat B, et al. Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS. Addiction. 2008;103(9):1484-92.
6. Protocol on management of opioid dependence with methadone. Ministry of Health and Medical Education. 2014.
7. Stanciu CN, Glass OM, Penders TM. Use of Buprenorphine in treatment of refractory depression-A review of current literature. Asian J Psychiatr. 2017;26:94-8.
8. Yeoh SL, Eastwood J, Wright IM, Morton R, Melhuish E, Ward M, et al. Cognitive and Motor Outcomes of Children With Prenatal Opioid Exposure: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(7):e197025.
9. de Cubas MM, Field T. Children of methadone-dependent women: developmental outcomes. Am J Orthopsychiatry. 1993;63(2):266-76.
10. Andersen JM, Høiseth G, Nygaard E. Prenatal exposure to methadone or buprenorphine and long-term outcomes: A meta-analysis. Early Hum Dev. 2020;143:104997.
11. Rapeli P, Fabritius C, Kalska H, Alho H. Cognitive functioning in opioid-dependent patients treated with buprenorphine, methadone, and other psychoactive medications: stability and correlates. BMC Clin Pharmacol. 2011;11:13.
12. Butler K, Le Foll B. Impact of Substance Use Disorder Pharmacotherapy on Executive Function: A Narrative Review. Front Psychiatry. 2019;10:98.
13. 1. Luijten M, Machielsen MW, Veltman DJ, Hester R, de Haan L, Franken IH. Systematic review of ERP and fMRI studies investigating inhibitory control and error processing in people with substance dependence and behavioural addictions. J Psychiatry Neurosci. 2014;39(3):149-69.
14. Hatami H, Khodakarim S, EghbaliGhahyazi H, Rajabpour M. The Investigation of Executive Functions in Patients under Methadone and Buprenorphine Maintenance Treatment. Koomesh J. 2016;17(3):643-50.
15. Verdejo-Garcia A, Lorenzetti V, Manning V, Piercy H, Bruno R, Hester R, et al. A Roadmap for Integrating Neuroscience Into Addiction Treatment: A Consensus of the Neuroscience Interest Group of the International Society of Addiction Medicine. Front Psychiatry. 2019;10:877.
16. Kidorf M, Disney ER, King VL, Neufeld K, Beilenson PL, Brooner RK. Prevalence of psychiatric and substance use disorders in opioid abusers in a community syringe exchange program. Drug Alcohol Depend. 2004;74(2):115-22.
17. Dolan SL, Martin RA, Rohsenow DJ. Self-efficacy for cocaine abstinence: pretreatment correlates and relationship to outcomes. Addict Behav. 2008;33(5):675-88.
18. Lin WC, Chou KH, Chen HL, Huang CC, Lu CH, Li SH, et al. Structural deficits in the emotion circuit and cerebellum are associated with depression, anxiety and cognitive dysfunction in methadone maintenance patients: a voxel-based morphometric study. Psychiatry Res. 2012;201(2):89-97.
19. Darke S, Ross J. Suicide among heroin users: rates, risk factors and methods. Addiction. 2002;97(11):1383-94.
20. Michel L, Lions C, Maradan G, Mora M, Marcellin F, Morel A, et al. Suicidal risk among patients enrolled in methadone maintenance treatment: HCV status and implications for suicide prevention (ANRS Methaville). Compr Psychiatry. 2015;62:123-31.
21. Poorolajal J, Haghtalab T, Farhadi M, Darvishi N. Substance use disorder and risk of suicidal ideation, suicide attempt and suicide death: a meta-analysis. J Public Health (Oxf). 2016;38(3):e282-e91.
22. Deykin EY, Buka SL. Suicidal ideation and attempts among chemically dependent adolescents. Am J Public Health. 1994;84(4):634-9.
23. Gossop M, Marsden J, Stewart D. Remission of psychiatric symptoms among drug misusers after drug dependence treatment. J Nerv Ment Dis. 2006;194(11):826-32.
24. Darke S, Degenhardt L, Mattick R. Mortality amongst Illicit Drug Users: Epidemiology, Causes and Intervention. Cambridge: Cambridge University Press; 2006.
25. Fontanella CA, Warner LA, Hiance-Steelesmith DL, et al. . Service use in the month and year prior to suicide among adults enrolled in Ohio Medicaid. Psychiatr Serv. 2017;68(7):674–680.
26. Botega NJ. Suicidal behavior: Epidemiology. Psicologia USP. 2014;25(3):231-6.
27. Botega NJ, Marín-León L, Oliveira HB, Barros MB, Silva VF, Dalgalarrondo P. [Prevalence of suicidal ideation, suicide plans, and attempted suicide: a population-based survey in Campinas, São Paulo State, Brazil]. Cad Saude Publica. 2009;25(12):2632-8.
28. Association AP. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC2013.
29. Dennis JP, Vander Wal JS. The Cognitive Flexibility Inventory: Instrument Development and Estimates of Reliability and Validity. Cogn Ther Res.. 2010;34(3):241-53.
30. Johnco C, Wuthrich VM, Rapee RM. Reliability and validity of two self-report measures of cognitive flexibility. Psychol Assess. 2014;26(4):1381-7.
31. Shareh H, Farmani A, Soltani E. Investigating the Reliability and Validity of the Cognitive Flexibility Inventory (CFI-I) among Iranian University Students. PCP 2014;2(1):43-50.
32. Esfahani M, Hashemi Y, Alavi K. Psychometric assessment of beck scale for suicidal ideation (BSSI) in general population in Tehran. Med J Islam Repub Iran. 2015;29:268.
33. Crane C, Barnhofer T, Duggan DS, Eames C, Hepburn S, Shah D, et al. Comfort from suicidal cognition in recurrently depressed patients. J Affect Disord. 2014;155(100):241-6.
34. Hirsch JK, Conner KR. Dispositional and explanatory style optimism as potential moderators of the relationship between hopelessness and suicidal ideation. Suicide Life Threat Behav. 2006;36(6):661-9.
35. Pinninti N, Steer RA, Rissmiller DJ, Nelson S, Beck AT. Use of the Beck Scale for suicide ideation with psychiatric inpatients diagnosed with schizophrenia, schizoaffective, or bipolar disorders. Behav Res Ther. 2002;40(9):1071-9.
36. Beck AT, Steer RA, Brown GK. BDI-II: Beck Depression Inventory Manual. 2nd ed. San Antonio: Psychological Corporation; 1996.
37. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian-language version of the Beck Depression Inventory--Second edition: BDI-II-PERSIAN. Depress Anxiety. 2005;21(4):185-92.
38. Brienza RS, Stein MD, Chen M, Gogineni A, Sobota M, Maksad J, et al. Depression among needle exchange program and methadone maintenance clients. J Subst Abuse Treat. 2000;18(4):331-7.
39. Peles E, Schreiber S, Naumovsky Y, Adelson M. Depression in methadone maintenance treatment patients: rate and risk factors. J Affect Disord. 2007;99(1-3):213-20.
40. Witkiewitz K, Villarroel NA. Dynamic association between negative affect and alcohol lapses following alcohol treatment. J Consult Clin Psychol. 2009;77(4):633-44.
41. Dean AJ, Bell J, Christie MJ, Mattick RP. Depressive symptoms during buprenorphine vs. methadone maintenance: findings from a randomised, controlled trial in opioid dependence. Eur Psychiatry. 2004;19(8):510-3.
42. Alizadeh A, Yousefi E, Farvareshi M, Zoghi M. predict symptoms of depression based on cognitive flexibility, rumination and mindfulness in students. Shenakht J Psychol Psychiatry. 2015;2(1):15-29.
43. Brooks BL, Iverson GL, Sherman EM, Roberge MC. Identifying cognitive problems in children and adolescents with depression using computerized neuropsychological testing. Appl Neuropsychol. 2010;17(1):37-43.
44. Esmail Soltani, Hossein Shareh, Seyed Abdolmajid Bahrainian, Azam Farmani. The mediating role of cognitive flexibility in correlation of coping styles and resilience with depression. Pajoohande J. 2013;18(2):88-96.
45. Serafini G, Adavastro G, Canepa G, De Berardis D, Valchera A, Pompili M, et al. The Efficacy of Buprenorphine in Major Depression, Treatment-Resistant Depression and Suicidal Behavior: A Systematic Review. Int J Mol Sci. 2018;19(8):2410.
46. Ahmadi J, Sarani EM, Jahromi MS. Rapid effect of a single-dose buprenorphine on reduction of opioid craving and suicidal ideation: A randomized, double blind, placebo-controlled study. Ci Ji Yi Xue Za Zhi. 2020;32(1):58-64.
47. Gibbs HM, Price D, Delgado PL, Clothier JL, Cáceda R. Buprenorphine use for pain and suicidal ideation in severely suicidal patients. Int J Psychiatry Med. 2020;55(6):387-96.
48. Benhamou OM, Lynch S, Klepacz L. Case Report: Buprenorphine-A Treatment for Psychological Pain and Suicidal Ideation? Am J Addict. 2021;30(1):80-2.
49. 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(1-3):139-43.
50. O'Boyle M, Brandon EA. Suicide attempts, substance abuse, and personality. J Subst Abuse Treat. 1998;15(4):353-6.
51. 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(1):126-33.
52. Thoma P, Wiebel B, Daum I. Response inhibition and cognitive flexibility in schizophrenia with and without comorbid substance use disorder. Schizophr Res. 2007;92(1-3):168-80.
53. McCracken LM, Patel S, Scott W. The role of psychological flexibility in relation to suicidal thinking in chronic pain. Eur J Pain. 2018;22(10):1774-81.
54. MacPherson HA, Kudinova AY, Schettini E, Jenkins GA, Gilbert AC, Thomas SA, et al. Relationship between cognitive flexibility and subsequent course of mood symptoms and suicidal ideation in young adults with childhood-onset bipolar disorder. Eur Child Adolesc Psychiatry. 2022;31(2):299-312.
55. Khobragade B, Sharma V, Deshpande SN. Cognitive function in women with major mental illnesses who use tobacco. Psychiatry Res. 2021;295:113603.
56. Verdejo A, Toribio I, Orozco C, Puente KL, Pérez-García M. Neuropsychological functioning in methadone maintenance patients versus abstinent heroin abusers. Drug Alcohol Depend. 2005;78(3):283-8.
IssueVol 18 No 3 (2023) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijps.v18i3.13005
Addiction Executive Function Depression Opioid Suicide

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Rajabpour M, Mirmohammadkhani M, Paknazar F. Depression and Suicidal Ideation among Patients Receiving Opioid Maintenance Treatments Considering Cognitive Flexibility. Iran J Psychiatry. 2023;18(3):285-293.