Comparing the Effectiveness of Mindfulness-Based Group Therapy and Methadone Maintenance Therapy on Psychological Symptoms (Obsession, Interpersonal Sensitivity, Depression, Anxiety, and Aggression) among Opioid-Dependent Patients

1. Background

Addiction is one of the most pervasive mental disorders. The problem of drug abuse and dependence is a complex and multifaceted issue. The main reasons for abusing drugs are various and can be related to different social, economic, interpersonal, and individual factors identifying which often seems very difficult. In many cases, solving this problem is much more difficult than understanding its causes and identifying its causative and facilitating factors. According to conducted studies, the number of opioid-dependent patients, in our country, is increasing. When opioid-dependent patients’ family members, who for various reasons struggle with and suffer from the problems caused by drug abuse, are taken into consideration, one notices that a considerable part of our people are dealing with this issue (1).

About 90% of people who are dependent on narcotics have to deal with other psychiatric diagnosis as well. The most common psychiatric diagnoses are major depression disorder, alcohol use disorder, antisocial personality disorder, and anxiety disorders. Moreover, nearly 15% of the people who are dependent on narcotics have attempted to commit suicide at least once (2).

Several studies have indicated the existence of psychiatric disorders among opioid-dependent patients. The results of a study conducted by Parvizifard (3) showed that respectively 72% and 28% of self-introduced opioid-dependent patients had a diagnostic criteria for mood and anxiety disorders (other than the drug use disorder). Among mood disorders, major depression (66%) and dysthymic (6%) were the most common disorders. Among anxiety disorders, generalized anxiety disorder (12%), panic disorder (8%), posttraumatic stress disorder (6%), and obsessive-compulsive disorder (2%) were respectively the most prevalent disorders. Creating neurological-psychiatric symptoms, which are impartible from symptoms of common mental disorders that have no known reasons (like schizophrenia and mood disorder), is one of the consequences of drug abuse. This means that mental disorders and substance-related disorders affecting the brain are related (2). In a study, Miller (4) mentioned the results obtained in a study conducted by Regier et al. who reported the prevalence of mental disorders among drug and alcohol abusers. The results were as follows: mood disorders 26.3%, anxiety disorders 28.3%, schizophrenia 6.7%, antisocial personality 17.7%, and other mental disorders 21%. In general, addiction can be regarded as a form of self-medication.

The conducted studies aimed to examine the etiology of substance abuse and recurrence of compulsive behaviors, and demonstrated that in the treatment of addiction relapse prevention, positive and negative emotional states, desire and temptation (5), negative affect, impulsivity, the role of negative emotions especially anxiety and depression (6), emotion dysregulation, low distress tolerance, emotional avoidance (7), habitual behaviors conducted without thinking (8), ruminative thought (9), bias towards symptoms of abusing drugs, low self-efficacy and deficits in coping skills (10), and spiritual vacuum (11) can be considered among the most important risk factors playing roles in the relapse. The relapse may be the result of the interaction of different variables such as emotional variables (positive or negative mood states), behavioral variables (impulsivity), cognitive variables (attitude towards the recovery), environmental and interpersonal variables (lack of family disability, social pressure caused because of drug abuse), physiological variables (such as craving, withdrawal symptoms, and the like), spiritual variables (such as guilt and shame, a sense of emptiness, and a feeling that life is meaningless), and treatment-related variables (such as negative attitudes towards therapists and inadequate healthcare) (12).

Various researchers and theorists, who conducted several studies to examine the etiology of drug abuse and the recurrence of compulsive behaviors, mentioned deficits in emotion regulation, low distress tolerance, emotional avoidance, habitual behaviors conducted without thinking, rumination, positive bias towards symptoms of drug abuse, low self-efficacy, deficits in coping skills, and spiritual vacuum as factors affecting the relapse (9-11). Therefore, treating the addiction relapse is of significant importance.

Due to the extent of the problem of addiction, numerous treatments, including pharmacotherapy and psychotherapy, have been presented and examined. Although various studies have supported the effectiveness of the existing therapies, this effectiveness is relative and there is still no cure, which can be considered as the definite solution to the problem of addiction. Since, on one hand, the pharmacotherapy has several side effects, and, on the other hand, despite the fact that many psychotherapies are effective in treating addiction, they are still faced with high rates of relapse. In fact, while the main objective of treating disorders is to complete the process of recovery, many patients fail to achieve this goal or to keep their body in a condition without any symptoms. The existence of residual symptoms in this disorder, even in patients who show a complete recovery, is common. These residual symptoms are strong predicators of relapse. The rate of relapse in patients with residual symptoms is 3 to 6 times more than that in patients without such symptoms. These results suggested the inadequacy of current treatments and the need for more effective treatments for this disorder.

Mindfulness is a method to observe and accept thoughts, images, and feelings without getting involved with the content of these thoughts or testing the reality and challenging negative thoughts with classic cognitive-behavioral techniques. In mindfulness, distraction techniques are used to suppress or avoid negative thoughts (13).

In recent years, mindfulness meditation practices have been used as important methods in combining different interventions applied to treat disabilities and distress. Although these meditation practices were initially introduced for physical diseases, including chronic low back pain, their effectiveness in improving emotional disorders, especially anxiety and depression, has been determined (14). Growing evidence has suggested that mindfulness is effective in dealing with clinical situations especially psychiatric ones (15) and increasing the number of research has shown the usefulness of mindfulness in various cases such as chronic pain (16), posttraumatic stress disorder, somatization, stress management models, coping and resilience (17), addictive behaviors (18), behavioral abnormalities such as aggression and substance abuse (19), impulsivity (20), social anxiety (21), and rumination and depression (22). Based on the conducted studies, the mindfulness affects depression in at least 2 ways: by confronting mental ruminations and through reducing the number of emotional automated responses, which impact the insula (23). The mindfulness-based therapy is also effective in reducing stress, anxiety, and depression (24).

According to the results obtained from the previously conducted studies, combining training preventive methods with mindfulness can have relatively successful effects on judgment and aversion of opioid-dependent patients who inject drugs (25, 26). The mindfulness therapy is effective in reducing drug abuse (1). Moreover, temptation is the strongest predicator of relapse among other predicator variables (even comorbidity with other disorders such as anxiety and depression) and mindfulness therapy is effective in reducing negative effects of temptation to use drugs (27). The greater the severity of mindfulness associated with spirituality, the less the use of alcohol, tobacco, and other drugs (16).

Indeed, by minimizing the involvement of thoughts and feelings, MBRP combined with meditation and specific mental orientations towards an experience can be applied to encourage awareness to the present moment in a non-judgmental way. This therapy is derived from cognitive-behavioral therapies and is considered as an important component of the third wave of psychological therapy models. All mindfulness-based exercises are designed to enhance attention to the body. The significant role of the body was proven in new interdisciplinary fields including mind-body medicine. Studies that applied mindfulness laid the emphasis on interactions among physical, cognitive, and emotional processes. In practice, extensive research conducted on adult population revealed the efficiency of this therapy in dealing with various issues including managing stress and anxiety as well as promoting emotion regulation skills (27). Therefore, given the effectiveness of mindfulness in treating mental disorders, the current study aimed to compare the effectiveness of mindfulness-based group therapy and methadone maintenance therapy on psychological symptoms (obsession, interpersonal sensitivity, depression, anxiety, and aggression) among opioid-dependent patients.

2. Methods

2.1. Participants

The statistical population under study included all opioid-dependent patients who were referred to addiction treatment centers in Tehran. Among these people, 57 individuals who were willing to receive treatment services were selected and randomly placed into 2 experimental groups and 1 control group. Since this was a group study and considering the Morgan’s table, 15 to 25 people could be assigned to each group. With regard to the sample size placed in the mindfulness-based therapy group, the methadone maintenance therapy group, and the control group, as well as the possibility of dissuasion of the group members, the sample size was considered 19 individuals for each group. Given that some participants abandoned the study, the number of participants in the considered groups, i.e. the mindfulness-based therapy group, the methadone maintenance therapy group, and the control group, decreased respectively to 13, 12, and 14 individuals.

The inclusion criteria of the current study were as follows: 1. being 20 to 45 years old, 2. having at least an elementary school education, 3. abusing opioids and not being dependent on stimulant drugs, 4. obtaining patient’s written consent to participate in this study, 5. not having mental retardation, 6. not having psychotic disorders, and 7. not dealing with structural brain abnormalities. The exclusion criteria considered in this study were as follows: Having serious suicidal thoughts revealed through interviews conducted by a psychiatrist and

2.2. Baseline and Post-Intervention Assessment

2.3. Materials

The clinical interview was conducted based on the diagnostic and statistical manual of mental disorders: the structured and semi-structured diagnostic interviews contain a systematic collection of specific questions formed to evaluate those behavioral patterns, thoughts, and feelings that are typically associated with diagnosing a special disorder in a person (28). Using the DSM-V, the severity of drug addiction was in a moderate level (having 4 variables out of the 9 variables).

2.4. Symptom Checklist-90-Revised (SCL-90-R)

This scale was developed to assess those physical and mental conditions, which indicate the extent and severity of symptoms of mental disorders in people ranging from normal to abnormal ones.

Later in 1976, Derogatis revised this scale. This scale includes 9 dimensions and 3 subscales. Several studies examined the criterion validity of this scale and reported that this scale was highly correlated with the Minnesota multiphasic personality inventory, the middlesex health questionnaire, and various indicators were used to examine abnormal psychiatric states. This scale can be applied for examining the following: depression and sexual dysfunction, physical and sexual abuse, drugs, stress, and oncology. Studies that assessed the reliability of this scale indicated its good test-retest reliability and internal consistency. In Iran, the SCL-90-R is among the reliable and widely used scales, which was translated into Persian years ago. Its cut-off point, reliability coefficient, sensitivity, features, and efficiency were respectively 0.04, 0.97, 0.94, 0.98, and 0.96. Using the test-retest method, the reliability of this scale was reported between 0.77 and 0.90. This scale has been used in a number of studies (29).

2.5. Procedure

The method of this study was the quasi-experimental (including pretest, posttest, and follow-up) with a control group. The groups receiving the mindfulness-based group therapy and methadone maintenance therapy were considered as the experimental groups and a group, which did not receive any such treatments was regarded as the control group (camp group).

The study was carried out through conducting the following steps:

1) Conducing the pretest in all 3 groups

2) Implementing the independent variable (the mindfulness-based group therapy) on the experimental groups

3) Carrying out the posttest in all 3 groups

4) Implementing the follow up period for all the experimental groups and the control group.

Additionally, the following ethical considerations were observed in the current study: the sample was selected using the convenience sampling method, the participants voluntarily took part in this study, the essential information on the method of conducting the study was provided, the participants were ensured that the obtained information would remain confidential, the method, which was found more effective based on the results obtained in the current study was taught to the control group.

2.6. Mindfulness Procedures

The related experimental group participated in 8 training sessions held once a week; however, the control group (camp) did not receive any psychotherapy or pharmacotherapy interventions. A form including the place and time of holding these sessions was provided and distributed among the participants. The following measures were taken in the training sessions: the mindfulness-based therapy was conducted on the experimental group based on the Bowen, Chawala, and Marlatt treatment protocol (30), during 8 group sessions. These sessions were held once a week for 2 months. Each session lasted for 90 minutes.

MBRP sessions included the following:

First session: automatic pilot and relapse

Second session: awareness of triggers and craving

Third session: mindfulness in daily life

Fourth session: mindfulness in high risk situations

Fifth session: acceptance and skillful actions

Sixth session: seeing thoughts as thoughts

Seventh session: self-care and lifestyle balance

Eighth session: social support and continuing practice

3. Results

The results indicate that the frequency distribution of participants in all 3 groups, the mindfulness-based therapy group, the control (camp) group, and the methadone maintenance therapy group, was respectively 33.3, 35.9, and 30.8. The highest level of education in the mindfulness-based therapy group was diploma (38.5%) and the highest level of education in the control group (42.9%) and the methadone maintenance therapy group (58.3%) was middle school education. Most of the participants placed in these 3 groups were married. The frequency distribution of participants’ jobs was as follows: without a job (42.3%), employed (50%), and self-employed, respectively had the highest frequency in the mindfulness-based therapy group, the control (camp) group, and the methadone maintenance therapy group. The means and standard deviations related to age, age of onset of drug abuse, duration of the recent treatment, the number of unsuccessful quits, and the last time they used drugs were also examined, the results of which are presented in Table 1.

Due to the small sample size and since the assumption of normal distribution of data was violated and the variances were not equal, to compare the means of these 3 groups in variables of age, age of onset of drug abuse, duration of the recent treatment, the number of unsuccessful quits, and the number of recent relapses, the Kruskal-Wallis nonparametric test was used. The obtained results indicate that considering the variables of age (X² = 4.49, df = 2, P < 0.105), age of the onset of drug abuse (X² = 0.785, df = 2, P < 675), and the number of recent relapses (X² = 1.44, df = 2, P < 0.485), there were no significant differences among these 3 groups. Moreover, with regards to the duration of the recent treatment (X² = 29.16, df = 2, P < 0.000) and the number of unsuccessful quits (X² = 14.37, df = 2, P < 0.01), there were significant differences among these groups.

This was a quasi-experimental study; therefore, it included an intragroup factor (the experimental groups and the control group) and a number of intergroup factors (various dependent variables). Since the dependent variables under study were assessed in 3 levels in these groups, the method of the current study followed a multivariate binary design. To examine the results and to answer the research questions and hypotheses, a two-way repeated measures analysis of variance with an intergroup variable (measured 3 times in three stages, i.e. the pretest, posttest, and follow-up) and an intragroup variable (the mindfulness-based therapy, the control (camp) group, and the methadone maintenance therapy group) was used. The means and standard deviations of these 3 groups on variables of mindfulness (observing, describing, acting with awareness, nonjudging, and nonreactivity) in the pretest, posttest, and follow-up are presented in Table 2.

The results of Mauchly’s test presented in Table 3 demonstrates that the assumption of sphericity is rejected (P > 0.05); therefore, to interpret this test, a conservative test, like Geisser-Greenhouse test, should be applied for variables of mindfulness.

Considering the observation variable, interpersonal sensitivity, depression, anxiety, and aggression, the results presented in Table 4 show that the main effect is significant. This means that there is at least a difference between the means obtained in 2 stages of measurement (F (1, 36) = 22.22, P < 0.000, Partial eta Squared = 0.32).

When analyzing the results of Table 4, the main effect of stage and the interactional effect of group with stage with regard to the observation variable were important for us. At this stage, given the significance of the interactional effect, 2 simple effects of the group and stage were examined. Initially, using one-factor repeated measures analysis of variance with 3 stages of measurement in various levels (the mindfulness therapy group, the control group, and the methadone maintenance therapy group), the simple effect of stage (regardless of the intragroup factor) was examined comparing the means of the observation variable obtained in 3 stages.

The results of Table 5 indicates that considering the observation variable, interpersonal sensitivity, depression, anxiety, and aggression, there are no significant differences at least in 2 stages of measurement among the mindfulness therapy group, the control (camp) group, and the methadone maintenance therapy group. To further examine the results and conducting pairwise comparisons of the pretest, posttest, and follow-up, the pairwise comparisons were conducted with the Benferroni correction.

Considering the groups considered in this study (the mindfulness therapy group, the control (camp) group, and the methadone maintenance therapy group), to examine the simple intergroup effect, in each stage of measuring including the pretest, posttest, and follow-up, one-way analysis of variance (ANOVA) was used (Table 7).

The results of post hoc test show that in pretest, there were no significant differences among these groups’ mean scores. In the posttest, the mean score of the mindfulness therapy group was significantly lower than the mean scores of the control group and the methadone maintenance therapy group and no significant difference was found between the control group and the methadone maintenance therapy group. In the follow-up, the mean score of the mindfulness therapy group was significantly lower than the mean scores of the control group and the methadone maintenance therapy group and no significant difference was found between the control group and the methadone maintenance therapy group.

4. Discussion

The results of the current study indicated the effectiveness of the mindfulness-based group therapy in improving the psychological symptoms (obsession, interpersonal sensitivity, anxiety, depression, and aggression) among the opioid-dependent patients in the posttest and follow-up. This effectiveness was statistically significant and after carrying out the mentioned therapies, the need to abuse drugs reached a moderate level.

The obtained results indicated that the mindfulness-based group therapy significantly affected obsession and improved the mindfulness-based components among the opioid-dependent patients. These findings are in line with the results of studies conducted by Breslin et al. (31), Leigh et al. (16), Bowen et al. (32), Fathi-Ashtiani and Dastani (29), Garland et al. (33).

The results of Fernandez et al. (34) indicated the effectiveness of the mindfulness-based therapy in decreasing obsession and improving mindfulness-based skills among opioid-dependent patients. To explain these results, it can be mentioned that compared to other conventional therapies, the mindfulness-based group therapy was more effective. This effectiveness may be due to strengthening motives among patients and increasing their awareness and knowledge of their performance. These findings demonstrated the effectiveness of the mindfulness-based therapy in improving the symptoms of obsession. The results obtained from the current study supported the results obtained from previously conducted studies. These findings are consistent with the results of other researchers indicating that conventional methods including medication, methadone maintenance treatment, and the like alone cannot treat drug addiction and psychological interventions such as the mindfulness therapy can be considered as an important part of treating drug addiction (35, 36).

When evaluating the results in the pretest and posttest, the results showed the statistically significant effectiveness of the mindfulness-based group therapy in decreasing the symptoms of stress, anxiety, and depression among opioid-dependent patients. Therefore, the results of the present study are in line with the results of similar studies (16, 17, 27, 31, 35). On the other hand, since it was effective in decreasing stress, anxiety, and depression, the results are in line with the results of several previously conducted studies (22, 24, 36-42).

Training mindfulness skills is effective in preventing the onset or recurrence of the psychological symptoms. Mindfulness is the ability to manage a particular issue and stay focused on it, which guarantees the success of the treatment. Thus, the ability to focus is the main key to mindfulness. As a result of mindfulness interventions, patients understand how to focus their attention on the experience of a moment and stay away from negative thoughts and ruminations (43). Mindfulness is an indescribable and non-judgmental consciousness gained based on the present moment and is focused on the experience itself. Moreover, acknowledging and accepting the mentioned experience are involved in determining the severity of anxiety and depression symptoms (44) and in decreasing stress, anxiety, and depression (39, 40, 45).

To explain these results, it can be mentioned that according to Segal, Teasdale, and Williams (46), various strategies can be applied when dealing with stress, anxiety, and depression. One of these strategies is that through abusing drugs, an opioid-dependent patient may attempt to escape from situations, which create stress, anxiety, and depression, while the other strategy considers this condition as an opportunity to focus on what is happening in the present moment. They believed that despite the fact that employing the first strategy has short-term benefits, there is some evidence that using this strategy does not have any long-term advantages, since it does not change the patients’ attitudes towards painful feelings. However, the second strategy, through making these people more and more aware of the psychological symptoms, such as stress, anxiety, and depression, and aiding them to stay focused on states that they experience in these conditions, makes these people able to learn how to deal with the issue in another way. Since all the people experience being anxious or sad and no one is immune from having negative thoughts, sooner or later these thoughts, anxiety, and sadness should be dealt with, because even if an attempt is made to escape from these thoughts and negative moods, they still exist.

Therefore, it seems that through applying mindfulness, one can associate with any kind of experience (even an unpleasant one) without being stuck in it. In this condition, the main task of an opioid-dependent patient who experiences stress, anxiety, and sad mood is to welcome the painful experience, just like the pleasant experience, rather than trying not to deal with it.

Considering what was mentioned earlier, the mindfulness skills training program, which is effective in reducing the levels of stress, anxiety, and depression, can be applied to reduce the severity of mental symptoms among opioid-dependent patients. The mindfulness intervention program with extensive content in all areas of life, such as exercises (yoga, meditation, and mindfulness of breathing), controlling the attention and focus, gaining appropriate and effective coping skills to deal with stressful life events, understanding the disease and changing the patients’ attitudes towards it, changing attitudes and thought patterns, training advanced relaxation, training time management and stress management and creating a happy and joyful mood, can be effective in reducing the levels of stress, anxiety, and depression among opioid-dependent patients, decrease the severity of the disease, and possibly reduce the adverse consequences of drug abuse.

Although the mindfulness group therapy and conventional therapies have a number of goals, including improving psychological symptoms among opioid-dependent patients, decreasing drug abuse, creating positive expectations of the therapy, establishing facilitating therapeutic relations, and the like, in common, the mindfulness-based group therapy can be significantly effective through applying reciprocity and complex human experiences, known as therapeutic elements, which are considered as the main strength of this therapy. These therapeutic elements are as follows: 1. Creating Hope: The hope created through feedbacks provided by a therapist and other group members can build trust in the treatment method and increase its positive results. Patients can benefit from both therapeutic effects and the aid of their group members as a significant source of hope. 2. Providing a Public Experience: When taking part in such a treatment for the first time, many people feel that their distress is unique; however, since this group therapy does not emphasize the uniqueness of patients’ feelings, opioid-dependent patients feel relieved in the group. After listening to other group members’ problems and finding similarities with their own thoughts, patients find out that their issues are not exclusive. 3. Providing Information: Usually at the end of a successful session, patients learn a lot about various concepts including symptoms, group and interpersonal dynamics, and the process of psychotherapy. Compared to other conventional therapies, using this advantage, the mindfulness-based group therapy can be more effective in increasing the possibility of identifying and controlling internal and external factors playing role in having a craving for abusing drugs. 4. Creating Altruism: Compared to other conventional therapies, the mindfulness-based group therapy creates more support and assurance and aids patients to take advantage of using their group members’ tips. This aids opioid-dependent patients to understand their problems result from opioid-dependence better. 5. Modifying Behaviors: Compared to other conventional therapies, the mindfulness-based group therapy modifies opioid-dependent patients’ behaviors through simulating conditions similar to which these people experience at home. In this way, some family members’ reactions can be simulated and members of the treatment group have the opportunity to modify these reactions. 6. Encouraging Social Learning: Another important therapeutic element of the mindfulness-based group therapy is that it aids patients to improve their social skills and this increases the efficiency of the mindfulness-based group therapy compared to other conventional therapies.

Like any other studies, the current study had some limitations mentioning which can pave the way for researchers to conduct more accurate studies. 1. The sample of this study was just limited to the methadone maintenance treatment centers and camps in Tehran. 2. In terms of methodology, the main limitation of this study was in generalizing the results. Although the significant results obtained from smaller samples are more accurate, the limited number of participants placed in the experimental groups decreased the external validity of the study. Conducting future intervention studies with larger samples can compensate for this deficiency. 3. The participants placed in the experimental groups were all selected among male opioid-dependent patients. This makes it difficult to generalize the results to females. However, because of the nature of drug abuse disorder that is more common in males and according to their availability and possibility of taking part in the study, the sample was selected from among the male population. Other researchers are recommended to attempt to eliminate these limitations.

4.1. Conclusions

Although the mindfulness group therapy and conventional therapies have some common goals, such as improving psychological symptoms among opioid-dependent patients, reducing the amount of drug abuse, creating positive expectations towards the treatment, establishing facilitating therapeutic relationships and the like, due to transactional and complex human experiences known as therapeutic elements, which are considered as one of the strength of this therapy, the mindfulness-based group therapy was more effective compared to other conventional therapies. It can be said that mindfulness had a more significant impact on risky behaviors compared to other conventional and maintenance therapies (the methadone maintenance therapy and the spiritual therapy). The results of this study demonstrated the effectiveness of mindfulness therapy in increasing mindfulness components. All the findings obtained in the current study supported the results obtained from the previously conducted studies.