Background
A substance use disorder (SUD) can be a serious clinical condition causing major health problems and affecting a wide range of life domains [
1,
2]. In times of illness, the family is a primary source of support for patients [
3,
4]. This support includes facilitating patients’ adaptation to living with the illness, improving their compliance with treatment, and in that way promoting recovery [
5]. Thus, family cohesion has been considered a buffer against drinking and substance use, and a significant protective factor of substance abuse relapse among populations with such problems [
6,
7]. Conversely, poor levels of family cohesion are related to greater levels of drinking and substance use [
8]. However, when an SUD exists within a family, there is a risk that the strain the family experiences will lead to exhaustion or broken relationships [
9,
10]. Efforts to support the family in order to enhance cohesion among family members, would thus seem beneficial both to the patient and to the family as a whole [
7,
11]. Support from networks beyond the family (e.g., peer support, support groups, self-help groups) may be an additional resource to help patients cope with practical and emotional consequences, as well as in maintaining remission [
12,
13]. Higher level of social support, defined as being socially connected [
14], has been associated with reduction of substance use and improved mental health for persons experiencing an SUD [
15‐
17].
The aim of the present study was to examine patients’ own perception of family cohesion and social support. To put findings from the SUD treatment field into perspective, we compared SUD patients with patients from two other patient groups: those with mental disorders (MDs) and those with physical disorders (PDs). Family cohesion and social support are relevant to recovery, as described above, and we are not aware of any study that has examined these support factors across several patient groups including patients with SUDs. The rationale for the comparison was that family cohesion and social support is said to be equally important for patients with MDs. Stronger network support has the potential to reduce relapse and hospital admissions, encourage compliance with medication and, of direct relevance here, to reduce social impairment and improve general functioning [
18,
19]. Positive change in perceived social support is recognized as a mediator of change in subsequent depressive and anxious symptomatology, and a higher level of social support has been associated with symptom reduction in patients with MDs [
19,
20]. Thus, lack of family cohesion and social support would make patients with MDs and SUDs vulnerable in the recovery phase. Due to the often sudden onset of physical problems (e.g., cancer diagnosis) we considered the PD group likely to resemble more those of the general population in terms of the familial and social situation. We hypothesized that patients admitted to SUD treatment units would rate family cohesion and general social support at least as low as the MD group and considerably lower than those admitted to PD treatment units.
As a main dependent or “outcome” variable in our analyses, we used the concept of quality of life (QoL); an overarching construct of health and well-being, considered to be a general aim across different patient groups and disorders [
21,
22]. Thus, we aimed to examine how support variables were associated with QoL across patient groups. Among people experiencing an SUD, studies have reported significantly lower QoL compared with the general population [
23]. Furthermore, substance abuse and/or mental distress is associated with low QoL [
9,
24,
25]. For the present analysis, we expected that the SUD and MD groups would exhibit the lowest QoL and that greater family cohesion and social support would be positively associated with QoL.
Discussion
Family cohesion was lowest in the SUD and MD groups, and these two groups also rated their social support at a similarly low level, substantially lower than did the PD sample. The QoL score of the MD group was markedly lower than in the PD sample. In contrast, the SUD sample exhibited a somewhat lower QoL than did the PD sample, but their QoL was still above the cut-off for a markedly low QoL. When examining factors associated with QoL, mental distress came out as the strongest factor, and was negatively related to QoL.
A main aim of this study was to determine differences between patients with SUDs compared to MDs and PDs in their perceptions of family cohesion, social support, and QoL. While family and extended social support networks can be helpful in improving substance use outcomes, reducing mental distress, and supporting recovery [
15,
39], it is thought that the longer-term strain and broken relationships might ‘test’ the ongoing level of support from the family and/or social network [
9,
10]. The current data support this notion, with lower levels of family cohesion and social support for the MD and SUD groups. The strain and broken relationships might be illustrated in the current data with significantly longer duration of the illness (approximately three times longer for the SUD group compared with the PD group) and more patients in the SUD and MD groups having no partner. It has been observed that SUDs in a family have a disruptive effect on the functioning of a family and, as the illness progresses, it is followed by a decline in the quality of family relationships [
10]. For a patient with an SUD, this is doubly lamentable, as it means that positive familial restraining influences may no longer be present and there may be a lack of motivational support to promote necessary behavioral changes in the patient.
As expected, we observed more problematic substance abuse in the SUD group, higher mental distress in the MD group, and lower physical QoL score ratings for the PD group. Unexpectedly, the SUD group exhibited near-to-normal physical health, while there was a very low physical health rating in the MD group, equally low as in the PD group, as represented by the physical QoL score. Low patient-reported rating of physical health among persons with MDs has also been observed in previous research. A large European study found that patients with many categories of mental disorders, for example, dysthymia, any mood disorders and post-traumatic stress disorder, rated their physical health on a similarly low level as people with chronic physical diseases like diabetes, lung disease, and arthritis [
40]. Physical health ratings in SUD treatment studies are inconsistent. A large European epidemiological study found near-to-normal reported physical health among patients with SUDs [
40], while a previous Norwegian study of patients with severe SUDs admitted to a detoxification (detox) center reported similarly low physical health among patients with SUDs as inpatients admitted to a general medical ward [
23]. The patients with SUDs in that study had also low physical health ratings similar to the MD group of the present study. Thus, it is likely that the severity level of the SUD will influence rating of physical health.
The overall QoL score of the SUD group was close to the normal range and was only slightly lower than that seen in the PD group. This is unexpected in light of previous studies reporting substantially lower QoL among patients with SUDs compared with normative populations and compared with patients admitted to general medical wards [
23,
24,
41]. The relatively high QoL level in the SUD group is also puzzling in light of the familial and social strain reported by this group. In contrast, the MD group reported a markedly low QoL, which represented a clinically significant reduction in QoL according to the interpretative guidelines [
35]. We note here that the present respondents had already been in treatment for a substantial period (median 19 and 16 months for the SUD and MD group, respectively). Although we do not have data from their treatment admission, it is possible that their QoL has improved more with time than that of the MD group or, alternatively, that the MD group started at an even lower QoL at admission.
When examining associations with QoL, we found that family cohesion and social support related positively to QoL, as hypothesized, while elevated mental distress was negatively and strongly related to QoL: a one-point higher mental distress score resulted in a substantial 0.15 lower QoL score. From a predictive perspective, previous studies of SUD treatment have found that worse mental health at baseline also predicted worse QoL at a later follow-up [
42]. Seen from the perspective of the patients with SUDs, it is important to pay attention also to their mental health, as it is widely accepted that an SUD combined with a comorbid MD and/or elevated levels of mental distress can have a negative impact on the patient’s condition and functioning [
43]. Thus, although the mean level of mental distress among the SUD group in the present study was only slightly above the clinical cut-off, it is important to also follow up on their mental health [
44].
Based on our study, we propose further research on family cohesion and social support in families with parental substance use disorder. We specifically recommend developing models for clinical support and guidance for families related to better family cohesion and increased social support. Furthermore, we recommend implementation studies with fidelity- and effect measurements.
Methodological considerations
The usual caveat about the interpretation of causality in cross-sectional research must be kept in mind: using this design, we cannot determine whether the independent variables caused the variation in QoL. The inclusion of patients was based on the treatment service the patient was admitted to, not on their diagnosis. Thus, we cannot rule out that some patients might have had diagnoses that would make them eligible for inclusion in another patient group.
There are some indications in the data that could lead to speculation about whether the SUD group consisted of patients with a less severe SUD. These include the relatively high QoL score and the fact that the CAGE-AID detected only 6 of 10 in the SUD group as having an SUD. There was also a low proportion of the SUD group who reported uncertainty about the future development of the condition. However, the longevity of the SUD patients’ problems argues against their having less severe SUDs. There is also a health system argument against the assumption of a mild SUD: to get access to specialized SUD treatment services in Norway, one has to present with at least a moderately severe SUD. The unexpectedly high QoL in the SUD group might be related to the assessment being performed in the midst of a treatment period combined with the relatively high optimism in the SUD group. The latter might indicate that this group had higher prognostic optimism than patients with MDs or PDs. Being in SUD treatment may have brought about a higher expectation of improvement and hope of recovery than in the other two groups. Alternatively, there might have been different selection bias across groups. The research assistant indicated that the families with the most difficult and challenging care situation were less likely to participate and this was more noticeable for patients and families recruited from the MD and SUD treatment units. Thus, the differences between patient groups would have been even larger in disfavour of the MD and SUD groups if this selection bias could have been avoided.
Acknowledgements
We would like to thank the participating hospitals; Sørlandet Hospital, Akershus University Hospital, Vestre Viken Hospital, Helse Stavanger University Hospital, Nordland Hospital, and Rogaland A-senter. We would also like to thank the Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, for technical support in the collection of data, and the BarnsBeste (Children’s Best Interest) network for contributing user perspective to this study.
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