Addictive Behaviors 45 (2015) 39–44

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Addictive Behaviors

Familial expressed emotion among heroin addicts in methadone maintenance treatment: Does it matter? Lee Chun-Hung a,d,⁎, Wang Tso-Jen a, Tang Hsin-Pei b, Liu Yu-Hsin c, James Bell d a

Jianan Psychiatric Centre, MOHW, Taiwan Tainan Municipal An-Nan Hospital, Taiwan Florence Nightingale School of Nursing & Midwifery, King's College London, UK d Addiction Unit, Institute of Psychiatry, King's College London, UK b c

H I G H L I G H T S • • • • •

Little evidence on how EE affects the treatment outcomes of heroin addicts. We examined the relationships between EE and treatment outcomes in MMT. Perceived criticism was correlated with depression among heroin addicts in MMT. Lower perceived criticism and lower depression predicted longer retention in MMT. The mechanism how EE affects the outcome of MMT needs to be further investigated.

a r t i c l e

i n f o

Available online 21 January 2015 Keywords: Expressed emotion Heroin dependence Methadone maintenance treatment

a b s t r a c t Background: Expressed emotion (EE) is the quality of the atmosphere between a relative and a family member with mental illness. Substantial research has focused on the relationship between the level of EE and the outcomes of mental illness. However, no prior study has explored the role of EE relative to heroin addicts. Aim: The aims of this study were to investigate the influence of EE on patient outcome in methadone maintenance treatment (MMT) and the relationship between the EE of heroin addicts and other demographic and psychological variables. Methods: A total of 117 heroin addicts who entered MMT were enrolled. Each subject underwent a comprehensive interview to record demographic data and drug use history. The Family Emotional Involvement Scale (FEICS), Beck Depression Inventory (BDI), and Beck Anxiety Depression Inventory (BAI) were used at baseline. All subjects were followed for 12 months. The results of monthly urine tests and the treatment retention were recorded for further analysis. Results: Perceived criticism was correlated with depression (r = 0.20, P b 0.01). The overall retention rate in 12-month MMT was 54.70%. Lower perceived criticism (OR = 1.84, 95% CI = 1.20–3.60, P b 0.01) and lower depression (OR = 1.24, 95% CI = 0.65–1.80, P = 0.02) predicted longer retention in MMT. Conclusion: EE, especially perceived criticism, has its influences on outcomes among heroin addicts in MMT. This suggested the potential benefits of family therapy among high EE heroin addicts in MMT. Furthermore, the mechanism how EE affects the outcome of MMT needs to be further investigated. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Dependence on heroin damages physical, mental, and social health and leads to consequences that include blood-borne viral transmission, bacterial infection, venous damage, involvement in crimes, escalating ⁎ Corresponding author at: Jinan Psychiatric Centre, MOHW, 71742 No. 80, Ln. 870, Zhongshan Rd., Rende Dist., Tainan City 717, Taiwan. Tel.: +886 6 2795019 1542; fax: +886 6 2497713. E-mail address: [email protected] (C.-H. Lee).

http://dx.doi.org/10.1016/j.addbeh.2015.01.014 0306-4603/© 2015 Elsevier Ltd. All rights reserved.

involvement in crime, decreased social integration, reduction of meaningful interpersonal relationships, overdose and suicide (Mold, 2008; Strang & Gossop, 2005). Solid evidence has consistently indicated that MMT is an effective treatment for opiate dependence (Fareed et al., 2011; Farrell et al., 1994; Garrido & Troconiz, 1999; Joseph, Stancliff, & Langrod, 2000), and longer retention time has been consistently associated with better outcomes (Flynn, Joe, Broome, Simpson, & Brown, 2003; Gossop, Marsden, Stewart, Lehmann, & Strang, 1999; Hubbard, Craddock, & Anderson, 2003; Joe, Simpson, & Broome, 1999). That is, retention is a critical issue, because dropping out from MMT can lead

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C.-H. Lee et al. / Addictive Behaviors 45 (2015) 39–44

to relapse and further adverse consequences (Gerstein, 1994; Pettinati et al., 2008; Rabinowitz & Marjefsky, 1998; Simpson, Joe, & Rowan-Szal, 1997). Many factors affect the retention and outcomes of MMT. The effectiveness of previous treatment may predict the outcomes of current treatment (Hser, Grella, Hsieh, Anglin, & Brown, 1999). Higher dosage of methadone can maintain the therapeutic effects of MMT, which prevent patients from craving and relapse (Caplehorn & Bell, 1991; Faggiano, Vigna-Taglianti, Versino, & Lemma, 2003; Farre, Mas, Torrens, Moreno, & Cami, 2002; Practice Guideline for the Treatment of Patients with Substance Use Disorders: Alcohol, Cocaine, Opioids, 1995; Preston, Umbricht, & Epstein, 2000; Strain, Bigelow, Liebson, & Stitzer, 1999). Psychosocial interventions, such as cognitive–behavioral therapy and contingency management (Epstein, Hawkins, Covi, Umbricht, & Preston, 2003; Epstein et al., 2009; Ghitza, Epstein, & Preston, 2008; Ghitza et al., 2008), are able to enhance the therapeutic effects of MMT. In addition, how heroin addicts interact with peers, family, and community affects treatment. A recent study in Taiwan revealed high heroin expenses, perceived lower family support, and lower methadone dosage at 3 months after starting MMT increased the risk of dropout (Lin et al., 2013). It is suggested that family relationships among heroin addicts may become a potential predictor for evaluating the therapeutic effects of MMT. The link between family relationships and health status is highlighted by accumulating evidence. Familial factors can influence disease susceptibility, adaptation to disease, recovery from disease, utilization of health care services, disability and quality of life (Cole & Reiss, 1992). One particular approach that focuses on the quality of relationships between patients and their relatives, and the course of chronic illness is the measurement of interpersonal attitudes: Expressed Emotion (EE). Higher EE reflects relatively more critical, hostile, or emotionally over-involved attitudes of a family member toward a relative with a disorder or impairment (Leff & Vaughn, 1985). The development of EE theory began with series studies, which investigated the relationship between clinical outcomes in psychiatric patients and the quality of interpersonal relationship between the patients and significant family members, by the Medical Research Council's Social Psychiatry Unit in London during the 1950s and 1960s (Leff & Vaughn, 1985). They found that close emotional ties between patients with schizophrenia and their family members can cause elevated physiological arousal and patients' difficulties to cope with. The Camberwell Family Interview (CFI), a semi-structured interview, developed then as a gold standard for measuring EE. It consists of five major domains: criticism, hostility, warmth, positive comments and emotional overinvolvement (Bertrando, Bressi, Clerici, Cunteri, & Cazzullo, 1989). Each domain are rated for classifying relatives as high- or low-EE which reflect the level of negative dimensions of criticism, hostility and marked emotional over-involvement. However, the CFI required well-trained interviewers to code and lots of time to finish. Each patient needs 1 to 2 h to complete CFI with an additional equivalent time to rate EE form. Thus, Some questionnaires were developed to replace EE for assessing EE from patients' aspects, such as the Level of Expressed Emotion (LEE) (Vaughn & Leff, 1976), Influential Relationship Questionnaire (IRQ) (Baker, Helmes, & Kazarian, 1984), Perceived Criticism Scale (PCS) (Hooley & Teasdale, 1989), and Family Emotional Involvement and Criticism Scale (FEICS) (Shields, Franks, Harp, McDaniel, & Campbell, 1992). Various studies have reported the significant connection between high EE and relapse of mental illness, such as schizophrenia, depression, and eating disorder (Hodes & Le Grange, 1993; Mino et al., 1995; Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). Patients who live in a family with significantly critical, hostile, or emotionally overinvolved or intrusive attitudes are at a higher risk of early relapse than patients who do not. In the field of substance use disorders research, EE is studied by some researchers only. Fichter, Glynn, Weyerer, Liberman, and Frick (1997) enrolled 100 patients with alcohol abuse problems who participated in a 12-week treatment program and

were followed up for 18 months. Less EE, especially less scores on criticism subscale from relatives, and greater warmth were associated with a lower risk of relapse; however, contrary to the findings among those with eating disorders, emotional over-involvement from the significant other was associated with more abstinence (Fichter et al., 1997). O'Farrell, Hooley, Fals-Stewart, and Cutter (1998) investigated the influence of EE on alcoholic patients and found that subjects with high-EE spouses had a higher relapse rate, shorter time to relapse, and drank more during the treatment (O'Farrell et al., 1998). Fals-Stewart et al. (2001) enrolled 106 males diagnosed with substance use problems and followed them for one year. Patients who rated their spouse as highly critical had significantly fewer abstinent days and were more likely to relapse. Pourmand, Kavanagh, and Vaughan (2005) recruited 67 patients with dual diagnoses of schizophrenia and substance use disorders, and 58 of them completed the assessment over the following 9 months. They found that higher EE leads to more relapse and substance use during follow-up (Pourmand et al., 2005). Those results showed the potential of applying the EE model to substance use disorders, and deserve to be elaborated and investigated more comprehensively. However, there is little evidence on how EE affects the treatment outcomes of heroin addicts. In this study, we aimed to evaluate how EE can modulate retention in MMT and drug use during treatment. 2. Methods The study population was recruited from the outpatient MMT clinic in the Jianan Psychiatric Centre, which is a mental health hospital provided MMT to around 230 patients per day in southern Taiwan. Inclusion criteria were local residents who (1) met DSM-IV criteria for heroin dependence, (2) could and would attend the MMT clinic to receive methadone for treatment, and (3) were over 18 years old and less than 65 years old. Patients meeting the following criteria were excluded from the trial: (1) having any severe mental or physical illness that would render them unsuitable for MMT or fail to engage in MMT, (2) less than 18 years old or over 65 years old, and (3) pregnant or intending to become pregnant. Each subject underwent a comprehensive interview by a psychiatrist to record basic demographic data (name, age, gender, educational level, marital status, employment status, income) and the variants of drug use history (age at first heroin use, duration of heroin use, number of criminal records, current route and dosage of heroin use, and if sharing equipment with other addicts, whether they had a history of past or current treatment with methadone or other modalities). Main caregiver (i.e., spouse, parents, children) which provided major care of subject's life was identified by subject himself. All subjects received serum viral tests for HCV and HIV at the beginning of study, and monthly drug urine screen for opiates and methamphetamine was done for 6 months after the initial survey. The Chinese-language version of the BDI (Beck Depression Inventory) and BAI (Beck Anxiety Inventory) were used to evaluate the psychological status of the subjects at baseline before they entered MMT. EE was also measured at baseline using a Chinese-language modification of the Family Emotional Involvement and Criticism Scale (FEICS), which consisted of 14 items on subscales of family emotional involvement and criticism (Lue, Leung, Fan-Jiang, & Chen, 1995; Shields et al., 1992). Each item is rated on a 5-point Likert scale ranging from “almost never” to “almost always” (Shields et al., 1992). High scores indicate high levels of EE. Psychometric analysis of the original scale revealed a Cronbach's α of 0.74 for the family emotional involvement subscale and 0.82 for the perceived criticism subscale. Factor analysis of the Chinese-language scale revealed 3 factors, which explained 51.9% of the total variance (Lue et al., 1995). The Cronbach's α of the Chinese scale in the present study was 0.92. Subjects who could not tolerate the side effects of methadone or who were not abstinent for 14 continuous days were counted as drop-outs. Each subject was well informed about the ethical and confidentiality issues and had signed the study agreement. All subjects were

C.-H. Lee et al. / Addictive Behaviors 45 (2015) 39–44

asked to attend the clinic once a month regularly and receive a adequate methadone dose adjusted by psychiatrists on a daily basis, except the first month when the patients were allowed to attend the clinic once a week to adjust the methadone dose and evaluate the clinical status. All subjects were followed for 12 months and the retention, monthly drug urine tests were recorded as outcome measurements for further analysis. All analyses were performed using the Statistical Package for Social Sciences (SPSS) version 12.0 (Norusis, 2004). Descriptive statistics were used to treat the demographic and substance use history data. The distribution of dependent and independent variables was examined. For binary variables, correlation analysis was used to examine the association with other continuous variables. The chi-square test was used to compare proportional differences among different groups. Pearson's correlation test was applied to evaluate significant trends. Family emotional involvement, perceived criticism, depression, anxiety and other continuous variables were examined with bivariate analysis of variance for the intercorrelation of different variants (ANOVA) and multivariate analysis of variance (MANOVA) for investigating whether those factors can predict outcomes: retention days and the proportion of clean urine samples. The number of days in treatment from the first date until the patient quit or the end of follow-up (12 months) was used to calculate cumulative retention in treatment using the Kaplan–Meier method with log–rank test. Variables that were significantly associated with retention in the Kaplan–Meier analysis were included in the Cox-regression multivariate analyses and presented as odds ratio (OR) with 95% confidence interval (95% CI). A value of P b 0.05 was considered statistically significant. 3. Results Of the total 117 heroin addicts, 90 males (59.8%) and 20 females (37.6%) in the MMT program were enrolled to participate in the study for survey and follow-up observation purposes. The mean age at baseline for the whole sample was 37.15 ± 7.32 years (range: 24–55) and the majority of subjects were between 31 and 40 years old. The mean years of education of the subjects were 9.56 ± 2.43 (range: 4–14). Only 32 (27.4%) subjects were married, while 54 (46.2%) were single, 29 (24.8%) were divorced, and 2 (1.7%) were widowed. More than half of the subjects (51.3%) were unemployed, and the remaining participants were employed at baseline. Testing showed that 22.2% of the subjects were HIV positive and 88.8% were HCV positive. Mean duration of the subjects' heroin use was 8.14 ± 6.55 years (range: 0.5–27). The average daily amount of heroin used a week before entering MMT was 0.72 ± 8.39 g (range: 0.2–2). Ninety subjects (76.92%) had shared injection equipment with others. And the mean number of criminal charges in the criminal justice system was 2.19 ± 1.31 (range: 0–8) (Table 1). The subjects generally had minimal to mild symptoms of depression (54.7% of subjects were minimal depression, 19.7% were mild depression, 17.1% were moderate depression, and 8.5% were severe depression) and minimal symptoms of anxiety (72.6% of subjects were minimal anxiety, 18.8% were mild anxiety, 6.8% were moderate anxiety, and 1.7% were severe anxiety). The scores of family emotional involvement subscale was 24.91 ± 3.18 and perceived criticism subscale was 27.21 ± 5.58 (Table 2). The Chi-square test were only demonstrated longer duration of heroin use (P b 0.01) and more criminal charges (P = 0.02) were linked to a higher risk of sharing equipment behaviors, which was related to viral infection with HIV (P = 0.01) and HCV (P b 0.01). The duration of heroin use was also related to rates of HIV infection (P = 0.02) and HCV infection (P b 0.01). In analyzing the factors influencing the level of depression, anxiety symptoms and EE, we found that subjects who were single had significantly higher BDI scores than who were divorced and married (17.74 ± 10.46 versus 13.72 ± 11.2 versus 11.91 ± 7.89, P = 0.03). There was no difference in EE (FEI: P = 0.31, PC: P = 0.11)

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Table 1 Descriptive statistics of study variables: demographic data. Category

N (%)

Mean ± S.D.

Range

Age 21–30 31–40 41–50 N50 Education (yr) Lower (0–9) Secondary (10–12) Higher (N13) Gender

117 25 (21.4) 54 (46.2) 27 (23.1) 11 (9.4) 70 (59.8) 44 (37.6) 3 (2.6)

37.15 ± 7.32

24–55

9.56 ± 2.43

4–14

Male: 90 (76.9) Female: 27 (23.1) Single: 54 (46.2) Married: 32 (27.4) Divorced: 29 (24.8) Widow: 2 (1.7) Job: 51 (48.7) Jobless: 60 (51.3) 3 (2.6) 22 (18.8) 32 (27.4) 60 (51.3)

Marital status

Employment

Monthly income N45,000 NT/month 30,000–45,000 NT/month 15,000–30,000 NT/month b15,000 NT/month Duration of heroin use (yr) Mean daily heroin use (g) Sharing of equipment No. of criminal charges Had ever received MMT or currently on MMT New enroller Viral Infection

8.14 ± 6.55 0.72 ± 8.39 90 (76.92%) 2.19 ± 1.31

0.5–27 0.2–2.0 0–8

74 (63.25%) 43 (36.75%) HIV: 26 (22.2) HCV: 103 (88.00)

between the genders. Unemployed subjects had higher perceived criticism (23.45 ± 4.25 versus 20.92 ± 4.83, P b 0.01), but no significant differences in psychological distress and family emotional involvement than who were employed. Furthermore, subjects within the highest monthly income group had less perceived criticism (PC: 20.67 ± 1.53, P = 0.02). HIV carriers had significantly less family emotional involvement than non-carriers (21.22 ± 4.85 versus 18.7 ± 4.72, P = 0.02); however, there were no differences among HCV carriers. Older subjects tended to have less education (r = −0.53, P b 0.01), longer duration of heroin use (r = 0.84, P b 0.01), and more previous

Table 2 Psychosocial distress and expressed emotion: descriptive statistics. Category Depression (BDI) Minimal depression (0–13) Mild depression (14–19) Moderate depression (20–28) Severe depression (29–63) Anxiety (BAI) Minimal anxiety (0–7) Mild anxiety (8–15) Moderate anxiety (16–25) Severe anxiety (26–63) Family Emotional Involvement (FEI) Perceived criticism (PC)

N (%) total

M

F

64 (54.7) 23 (19.7) 20 (17.1) 10 (8.5)

48 18 17 7

16 5 3 3

85 (72.6) 22 (18.8) 8 (6.8) 2 (1.7)

62 19 7 2

23 3 1 0

Mean ± S.D.

Range

14.95 ± 8.76

3–57

6.44 ± 5.99

0–32

24.91 ± 3.18 27.21 ± 5.58

11–36 13–38

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C.-H. Lee et al. / Addictive Behaviors 45 (2015) 39–44

Table 3 Correlation between psychosocial distress, EE and other continuous variables. Variables

1

2

3

4

5

6

7

8

1. Age 2. Education (yr) 3. Duration (heroin use) 4. Daily heroin use 5. Number of charges 6. Depression 7. Anxiety 8. FEI 9. PC

– −0.53⁎⁎ 0.84⁎⁎ 0.23 0.40⁎⁎ −0.11 0.03 −0.04 0.03

– −0.57⁎⁎ −0.26⁎ −0.30⁎ 0.04 0.02 0.06 −0.04

– 0.30⁎ 0.41⁎⁎ −0.10 0.04 −0.09 0.04⁎

– 0.11 −0.08 −0.22 −0.10 0.04

– −0.05 0.08 −0.02⁎ 0.03⁎

– −0.02 −0.03⁎ 0.20⁎⁎

– −0.14⁎ 0.06⁎

– −0.32⁎⁎

FEI: family emotional involvement, PC: perceived criticism. ⁎ P b 0.05. ⁎⁎ P b 0.01.

criminal charges (r = 0.40, P b 0.01). Subjects who had more years of education had shorter duration of heroin use (r = − 0.57, P b 0.01), less daily heroin use (r = −0.26, P = 0.04) and fewer previous criminal charges (r = − 0.30, P = 0.02). Subjects with a longer heroin use history had more daily heroin use (r = 0.30, P = 0.02) and more previous criminal charges (r = 0.41, P b 0.01). Family emotional involvement and perceived criticism were correlated with each other (r = −0.32, P b 0.01). Family emotional involvement only had statistical correlation with anxiety (r = −0.14, P = 0.03), the number of previous criminal charges (r = − 0.02, P = 0.03) and depression (r = − 0.03, P = 0.02). Perceived criticism was weakly correlated with depression (r = 0.20, P b 0.01), but statistically significantly associated only with the number of charges (r = 0.03, P = 0.04) and anxiety (r = 0.06, P = 0.04) (Table 3). The overall retention rate in the 12-month MMT was 54.70%. Results of multivariate analysis of variance (MANOVA) revealed that the score of BDI (P ≤ 0.01, F = 3.31, d.f. = 45) and perceived criticism (P = 0.03, F = 1.66, d.f. = 45) were related to retention days (Table 4). Subjects who have high perceived criticism group showed significantly lower retention (OR = 1.84, 95% CI = 1.20–3.60, P b 0.01, Fig. 1). The subjects who had moderate to severe depression at baseline had a lower MMT retention rate (OR = 1.24, 95% CI = 0.65–1.80, P = 0.02; Fig. 2). Other categorical predictors for retention in MMT in this study, using Cox-regression multivariate analyses, revealed no statistical significance in this study. Results of multivariate analysis of variance (MANOVA) reported the proportion of urine samples free of heroin was associated with depression (P b 0.01, F = 3.83, d.f = 11) and perceived criticism (P b 0.01, F = 3.15, d.f. = 11) (Table 4). The proportion of urine samples free of methamphetamine was only associated with depression (P b 0.01, F = 3.30, d.f. = 12) (Table 4). Other predictive variables was noted related to the portion of urine samples free of heroin or methamphetamine.

4. Discussion Among our samples, most subjects in this study were unmarried male, young to middle-aged adults, and nearly half of the subjects were unemployed at baseline. Subjects had more HIV and HCV infection than subjects in Western countries (Baklan, Gorisek, Poljak, & Pisec, 2004; Crofts, Nigro, Oman, Stevenson, & Sherman, 1997; Latt, 2009). Gossop, Griffiths, Powis, and Strang (1993) reported that sharing of equipment behaviors were related to more severe heroin dependence and more transmission of blood-borne viruses (Gossop et al., 1993). Our results showed the same results, that longer duration of heroin use (P b 0.01) or a greater number of criminal charges (P = 0.02) were linked to sharing of equipment behaviors, and, in turn, contributed to more HIV or HCV infection. Thus, the adequate approach of harm reduction program still needs to be implemented in Taiwan. Our subjects revealed a notable proportion with depressive symptoms compared with other studies (19.7% were mild depression, 17.1% were moderate depression, and 8.5% were severe depression). Teesson et al. (2005) examined the rate of major depressive disorder among entrants to treatment for heroin dependence in 3 treatment modalities and a non-treatment comparison group (Teesson et al., 2005). They determined the rate of major depressive disorder ranged from 26% in the treatment groups (23% in the MMT group, 25% in the detoxification group, and 31% in the drug-free residential rehabilitation group) and 16% in the non-treatment group. Co-occurrence with post-traumatic stress disorder (PTSD), attempted suicide within the previous 12 months, severe physical disability and female gender was found to be significantly related to depression among heroin-dependent patients. However, compared with other studies, the prevalence of depression in our study seemly revealed differences with other studies (Brienza et al., 2000; Golub et al., 2004). Despite the difference of sample size, one reason for the different depression rates compared with other studies may be the methodological difference: the diagnostic or surveying tools utilized to

Table 4 Multiple regression results for predictive factors on retention days and substance use. Outcome variables Retention in MMT (days)

Predictive variables Age Education years Duration of heroin use Criminal charges Depression (BDI score) Anxiety (BAI score) FEI PC

Substance use (percentage of negative heroin urine test)

Substance use (percentage of negative methamphetamine urine test)

P value

F

d.f.

P value

F

d.f.

P value

F

d.f.

0.91 0.72 0.98 0.35 b0.01 0.84 0.46 0.03

0.69 0.85 0.56 1.11 3.31 0.38 1.02 1.66

45 45 45 45 45 45 45 45

0.99 0.85 0.88 0.98 b0.01 0.61 0.22 b0.01

0.24 0.56 0.52 0.33 3.83 0.83 1.32 3.15

11 11 11 11 11 11 11 11

0.82 0.58 0.70 0.84 b0.01 0.86 0.92 0.06

0.62 0.87 0.75 0.60 3.30 0.58 0.49 1.77

12 12 12 12 12 12 12 12

C.-H. Lee et al. / Addictive Behaviors 45 (2015) 39–44

Survival Functions 1=low PC, 2=high PC

1.0

1 2 1-censored 2-censored

Cum Survival

0.8

0.6

0.4

0.2

0.0 0.00

2.00

4.00

6.00

8.00

10.00

12.00

Fig. 1. Comparison of high PC and low PC groups for retention in MMT.

identify depression. In our study, we used Beck Depression Inventory to measure the severity of depressive symptoms; Brienza et al. used Structured Clinical Interview for the DSM-III-R (SCID) to identify depressive disorders. Although our study showed different results regarding the prevalence of depression, results still revealed that depression is a strong predictor for retention and illicit substance uses during treatment. The combination of depression and drug addiction creates a high risk for suicide, so depressive symptoms need to be detected early and treated to alleviate further consequences (Weissman, Slobetz, Prusoff, Mezritz, & Howard, 1976). That may lead to abstinence or quite from MMT among patients with heroin problems. Compared with another study investigating healthy elderly in Taiwan, heroin addicts tended to have higher scores on the family emotional involvement subscale (24.91 ± 3.18) and perceived criticism subscale (27.21 ± 5.58) (Lue et al., 1995). Regression analysis in this study revealed that family emotional involvement had a weak negative correlation with the number of previous criminal charges (r = −0.02, P = 0.03), depression (r = −0.03, P = 0.02) and anxiety (r = −0.14, P = 0.03); perceived criticism was correlated with depression (r = 0.20, P b 0.01), and weakly correlated with the number of criminal charges (r = 0.03, P = 0.04) and anxiety (r = 0.06, P = 0.04). However, results only showed the statistical significance but not clinical significance. Heroin dependence with bio-psycho-social consequences presents a huge burden for family members. EE, especially perceived criticism, interacts with depression and anxiety and may be linked to further relapse among heroin addicts. Depression may serve as an important mediator between perceived criticism and antisocial or

Survival Functions 1=minimal depression, 2=mild depression, 3=moderate depression, 4=severe depression

1.0

Cum Survival

0.8

1 2 3 4 1-censored 2-censored 3-censored 4-censored

0.6

0.4

0.2

0.0 0.00

2.00

4.00

6.00

8.00

10.00

12.00

Fig. 2. Comparison of groups with different levels of depression for retention in MMT.

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maladaptive behaviors (Lue et al., 1995). That might be the phenomenon of EE is dynamic and changes all the time. It might be helpful to measure EE repeatedly for presenting individual's quality of relationships within their families. Furthermore, FEICS was adopted as an alternative choice in this study considering the time and resources involved in performing CFI for the assessment of EE. Although the internal consistency of FEICS is good, there is no clear cut-off score, construct validity or suitable predictive validity compared with the “gold standard”: CFI. In addition, comprehensively interpreting the role of EE relative to heroin addicts in this study was difficult. Retention and illicit substance use are the two important elements in a successful MMT program and widely accepted as an indicator of program success (Ward, Mattick, & Hall, 1998). This study examined the impact of different predictive variables on the retention rate of MMT and illicit substance uses among a total of 117 heroindependent patients in Taiwan. Overall, our sample showed a good retention rate (54.5%) and opiate discontinuation rate (61.2%). When survival analysis was added, perceived criticism (OR = 1.84, 95% CI = 1.20–3.60, P b 0.01) and level of depressive symptoms (OR = 1.24, 95% CI = 0.65–1.80, P = 0.02) could predict retention in MMT. Results of multivariate analysis of variance (MANOVA) reported the retention days (P ≤ 0.01, F = 3.31, d.f. = 45) and proportion of urine samples free of heroin (P ≤ 0.01, F = 3.83, d.f = 11) was associated with depression. Similar with previous studies, our results reported depressive symptoms is a sensitive predictor for retention and illicit substance use during MMT (Broome, Flynn, & Simpson, 1999; Joe et al., 1999). In other words, patients with a high level of depressive symptoms are more likely to show more illicit drug use and lower retention in treatment than patients with lower or no depressive symptoms (McLellan, Luborsky, Woody, O'Brien, & Druley, 1983; Rounsaville, Kosten, Weissman, & Kleber, 1986). Thus, a comprehensive interview with a detailed survey of concurrent depressive symptoms has an impact on later MMT. Continuing to follow depressive symptoms during treatment, considering their clinical manifestations under the influence of methadone and providing treatment if necessary can enhance the treatment effects of MMT among those patients. The results of our study rejected the null hypothesis and showed that perceived criticism can be used as a predictor of retention (P = 0.03, F = 1.66, d.f. = 45) in MMT among heroin addicts. Otherwise, perceived criticism was also related to the proportion of urine samples free from heroin (P ≤ 0.01, F = 3.15, d.f. = 11). However, the influence of perceived criticism and how it affects retention in MMT needs further investigation to elaborate and interpret. Although we found that perceived criticism is indeed related to the therapeutic effects of MMT, the role of perceived criticism was not clearly examined in this study. The interaction between the family dynamic and EE and the potential of family therapy for high EE subjects still need to be investigated in further studies. The present study was a longitudinal observational study. Since heroin dependence is a complex phenomenon, multiple potential predictive variables need to be investigated. Moreover, due to the limitations of manpower, time, and the willingness of the participants, this study was unable to provide more background data (i.e., childhood traumatic experiences) and a more detailed mental health assessment, as well as in-treatment variables (i.e., therapeutic alliance). In addition, our sample size and observation period may be insufficient. Some subjects with comorbid psychiatric illness may distort the perception of family atmosphere. Other subjects may be reluctant to disclosure family secrets in public. Heroin withdrawal symptoms and difficulties with reality (i.e., criminal offenses or financial problems) may confound the assessment of depressive symptoms. However, our results demonstrated the potential role of EE, especially perceived criticism on the therapeutic effects of MMT, reassurance of the importance of assessing and treating depression among heroin addicts in MMT and the potentiality of family therapy focusing on high EE subjects among heroin addicts in MMT. This is the first study to investigate EE among heroin

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C.-H. Lee et al. / Addictive Behaviors 45 (2015) 39–44

addicts, and it is also one of the few studies to investigate the influence of familial atmosphere on MMT among ethnic Chinese. Although EE was measured only at baseline before entering MMT and our study does not establish the causality between EE and outcomes of MMT, further study to elaborate the mechanism how EE affects the outcome of MMT is certain worthwhile. Role of Funding Sources Self-founded by Jianan Psychiatric Centre. Contributors None. Conflict of Interest None.

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