Dian-Jeng Li,1,2,* Joh-Jong Huang,3,* Su-Ting Hsu,1 Hui-Ching Wu,4 Kuan-Ying Hsieh,1 Guei-Ging Lin,1 Pei-Jhen Wu,1 Chin-Lien Liu,1 Frank Huang-Chih Chou1

1Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; 2Department of Nursing, Meiho University, Pingtung, Taiwan; 3Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan; 4Department of Social Work, Taiwan Social Resilience Center, National Taiwan University, Taipei, Taiwan

Correspondence: Frank Huang-Chih Chou, Kaohsiung Municipal Kai-Syuan, Psychiatric Hospital, No. 130, Kaisyuan 2nd Road, Lingya District, Kaohsiung, 802211, Taiwan, Tel +886 7-751-3171 Ext. 2302, Fax +886 7-771-2494, Email [email protected] Hui-Ching Wu, Department of Social Work, National Taiwan University, No. 1, Section 4, Roosevelt Road, Taipei, 10617, Taiwan, Tel +886 2-3366-9483, Fax +886 2-2368-0532, Email [email protected]

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has had an impact on patients with substance use disorder (SUD). We aimed to investigate factors associated with confidence and adherence to governmental policies against COVID-19 (social desirability) among patients with SUD.
Methods: This cross-sectional study was conducted during 2020 to 2021. Patients with SUD and healthy controls were recruited. The severity of sleep disturbance, social desirability, drug dependence, vaccine worries, other psychological burdens and demographic variables were collected through self-administrated questionnaires. Differences between the SUD and control groups were estimated. Hierarchical regression analysis was used to identify significant relationships between social desirability and other factors.
Results: In total, 58 of patients with SUD and 47 healthy controls were recruited. The patients with SUD had a lower level of social desirability and more severe sleep disturbance than the control group. Older age, more severe sleep disturbance, lower level of drug dependence, and lower level of vaccine worries were significantly associated with a higher level of social desirability among the patients with SUD.
Conclusion: Our results show the importance of timely interventions for drug dependence and to address vaccine worries in patients with SUD.

Keywords: drug dependence, coping strategies, sleep disturbance, vaccine worries, COVID-19

Introduction Impact of the COVID-19 Pandemic on Patients with Substance Use Disorder

The coronavirus disease 2019 (COVID-19) pandemic has resulted in fear, anxiety, and depression in the public and affected mental health.1 In Taiwan, an online survey with public reported that 55.8% of the participants had sleep disturbance, and 10.8% reported having suicidal ideas.2 Moreover, the COVID-19 pandemic has also led to an increased psychological burden in patients with mental illnesses.3 Previous studies have revealed increased rates of substance use disorder (SUD), including tobacco, marijuana, and alcohol, after major disasters such as hurricanes, earthquakes or terrorist attacks.4–6 Hypothesis of self-medication7 and social cognitive theory8 have been proposed to suggest post-disaster substance abuse and mental health burdens, and subjects have been shown to have decreased self-efficacy of their coping, increased psychological burden and subsequently increased self-medication for substance after a disaster.9 Increased rates of substance and alcohol use have been reported during the COVID-19 pandemic.10 Moreover, individuals with SUD have been shown to have a higher risk of COVD-19 infection11 and also undesirable outcomes due to the progression of SUD.12 For instance, social-economic burden caused by the pandemic may exaggerate stressors and interfere with adherence to treatment.12 Another study also highlighted the vulnerable nature of patients with substance-related problems.13 Consequently, further studies on the burden of the COVID-19 pandemic in individuals with SUD are warranted.

Coping Strategies for Individuals During the COVID-19 Pandemic

In addition to the psychological impact of the pandemic, it is also crucial to investigate the effect of other factors, such as coping strategies. Positive coping behaviors and resilience have been shown to be related to positive mental and psychological health outcomes.14,15 In addition, positive thinking, active and adaptive coping strategies have been reported to enhance psychological wellbeing and quality of life when facing challenges during the COVID-19 pandemic.16,17 Among healthcare workers in Taiwan, active coping behaviors (such as seeking COVID-19-related knowledge) have been associated with a better quality of life in mental component summary.18 Another survey recruiting Taiwanese’s publics reported that lower level of risk perception toward COVID-19, higher perceived social support, and higher level of self-reported health before COVID-19 were significantly higher level of self-confidence against COVID-19.19 Moreover, higher level of risk perception mediated the association between lower perceived social support and higher level of active coping with COVID-19.20 In addition, active and adaptive coping have been shown to moderate or decrease psychological burdens including depression, anxiety, sleep disturbance, and burnout.16,21 Regarding the issue of substance use, a previous study reported an association between substance abuse and ignoring social distancing, representing a negative coping mechanism.22 However, factors associated with the coping strategies in patients with SUD have not been fully examined in previous studies. Moreover, active coping has been reported to be potentially associated with sleep disturbance among patients with depressive disorder.3 Due to the inconclusive findings and unexplored factors, further studies are needed to investigate the detailed etiologies between coping strategies and related factors.

Aim of the Study

The psychological impact of COVID-19 on patients with SUD and coping strategies with COVID-19 have been explored. However, few studies have investigated the factors associated with coping strategies against COVID-19 in patients with SUD. As substance abuse has been associated with poor adherence to social distancing,22 exploring factors associated with coping strategies may be beneficial for authorities to better understand the etiologies and develop policies to improve infection control.

We hypothesized that several psychological factors may affect confidence and adherence to governmental policies against COVID-19. Therefore, the aim of this cross-sectional study was to investigate factors associated with coping strategies against COVID-19 among patients with SUD, with a particular focus on coping strategies for confidence and adherence to governmental policies against COVID-19.

Methods Participants, Procedures and Ethics

With reference to our previous works,23–26 this study derived data from a massive survey, which was developed to estimate the psychological and social impacts of the COVID-19 pandemic on patients with mental disorders and healthy subjects at Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (KSPH) and affiliated institutes. Participants were enrolled through printed advertisements. In addition, online advertisements were also posted on social media, including Facebook and LINE. The period of recruitment was from November 11, 2021 to October 31, 2022, and the survey was conducted with paper-and-pencil questionnaires. Research assistants could explain the procedures to each participant before participation. The inclusion criteria of the patients with SUD were those who: 1) were diagnosed with SUD by psychiatrists at KSPH, 2) were followed up at the outpatient department of KSPH, 3) could fully realize the purpose of the study and adhere to the instructions, 4) were aged more than 20 years, and 5) signed inform consent. The exclusion criteria of the patients with SUD were those who: 1) exhibited predominantly cognitive impairment that they could not complete the questionnaires, such as during intoxication or withdrawal, and 2) were diagnosed with major mental disorders such as major depressive disorder, bipolar disorder, schizophrenia, schizoaffective disorder, neurodevelopmental disorders, and neurocognitive disorders. In addition, healthy subjects were recruited as control group. The inclusion criteria of the healthy subjects were those who: 1) were aged more than 20 years, 2) signed inform consent, and 3) reported that they did not have any medical history of mental illness. Subjects with missing data were also excluded. This study was approved by the Institutional Review Board of KSPH (KSPH-2021-17). We conducted these studies according to the current revision of national legal requirements (Human Subjects Research Act, Taiwan) and complied with the Declaration of Helsinki. Each participant provided informed consent prior to participation.

Measures The Disaster-Related Psychological Screening Test (DRPST)

The DRPST was applied to rapidly screen for symptoms of depression and post-traumatic stress disorder (PTSD) at the COVID-19 pandemic. The DRPST has been shown to be reliable and well-validated.27,28 To estimate the severity of depression, three items of the DRPST were applied to measure the level of depressed mood, fatigue or loss of energy, and worthlessness in recent 2 weeks. Each question was graded on a two-point Likert scale, and it ranges from 0 (no) to 1 (yes). A higher total score indicates a higher level of depression.

Four of the questions from the DRPST were used to estimate the symptoms of PTSD, including re-experience of COVID-19, hypervigilance, avoidance, and somatic symptoms. Each question was graded with a five-point Likert scale, where it ranged from 1 (not at all) to 5 (extreme). A higher total score indicates a higher severity of PTSD. Details of the DRPST are listed in Supplementary Table S1.

Level of Sleep Disturbance

The Pittsburgh Sleep Quality Index (PSQI) was developed to comprehensively assess sleep status, and it has been verified with acceptable validity and reliability.29 Four questions of the PSQI were selected to measure the severity of sleep disturbance in the current study, including waking up in the middle of the night, difficulty to fall asleep, enthusiasm, and subjective sleep quality in the preceding one month (Supplementary Table S1). Each item was rated on a four-point Likert scale, and the scores ranged from one to four. A higher total score indicates more severe sleep disturbance.

The Societal Influences Survey Questionnaire (SISQ)

The SISQ was established to measure the coping strategies and psychosocial impact on subjects during the COVID-19 pandemic, and it has good validity and reliability.30,31 The SISQ contains 15 items in five categories, namely social distance, social desirability, social anxiety, social adaptation, and social information. For the coping strategies against COVID-19 we focused on the social desirability category, which includes questions that assess the level of confidence and adherence to governmental policies against COVID-19 (Supplementary Table S1). Each item was estimated with a four-point Likert scale, with scores ranging from one (never) to four (often). A higher total social desirability score indicated higher confidence and adherence toward governmental policies against COVID-19.

The Severity of Dependence Scale (SDS)

For individuals with SUD, the Severity of Dependence Scale (SDS) is used to estimate the severity of substance dependence.32 The SDS is composed of five items, and it uses a four-point Likert scale to measure the severity of addiction to illicit substances (Supplementary Table S1). A higher total SDS score indicated a higher severity of dependence. The Chinese version of the SDS has been verified with acceptable test-retest reliability (0.88) and internal consistency (Cronbach’s alpha: 0.75).33

Vaccination Attitude Examination (VAX) Scale

The Vaccination Attitude Examination (VAX) scale was developed to estimate the attitudes of participants to vaccination for COVID-19, and it has been verified to be a validated and reliable questionnaire.34 The Chinese version of the VAX has also been reported to have acceptable reliability.23 It contains four categories of questions including mistrust of vaccine benefits, preference for natural immunity, concerns about commercial profiteering, and worries about unforeseen future effects. In the current study, we used the category of concerns about commercial profiteering to estimate vaccine worries (Supplementary Table S1). This category contains items on mistrust toward governmental policies of vaccination, and the contents are comparable to the scales of social desirability. Each item was graded on a six-point Likert-type scale ranging from “strongly agree” to “strongly disagree”. A higher total score indicates stronger antivaccination attitudes and mistrust of the authorities.

Demographic Variables

The continuous variables included the participants’ age and educational level (years). The categorical variables included sex, employment status (unemployed or employed), marital status (without partner or with partner), drinking alcohol (≥3 times per week or not), smoking (yes or no), regular diet (three or four meals a day, ≥5 days per week or not), and regular exercise (≥3 days per week or not).

Statistical Analysis

Initially, descriptive analysis was performed on the demographic characteristics. Differences between the patients with SUD and healthy subjects were compared using Pearson’s χ2 test or the independent t-test. To verify the reliability and validity of the selected items of PSQI, we performed further analysis. The internal consistency (Cronbach alpha values) was used to test the reliability of each factor, where a value greater than 0.7 indicated acceptable reliability.35 To estimate the construct validity, exploratory factor analysis was applied. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett test were used. A KMO value of >0.60 and statistically significant value of p<0.05 from Bartlett testing indicated the data was acceptable for factor analysis.36 Total variance explained was also estimated. The amount of variance indicates how well a relevant construct can be measured. For the studies of social sciences, it is common to consider a solution that accounts for 50% of the total variance as satisfactory.37 We then analyzed the predictors of confidence and adherence to governmental policies against COVID-19 (social desirability). Standardized regression coefficients of hierarchical regression analysis38 were applied to identify the significant relationships between social desirability and psychological impact (severity of depression, PTSD, sleep disturbance, and drug dependence) as well as vaccine worries in a controlled model. We measured the invariance, which involved comparing models that imposed successive restrictions on model parameters in order of basic demographics (age, sex, employment status, educational level, marital status, smoking or not, drinking or not, regular exercise or not, and regular diet or not), psychological impact (severity of depression, PTSD, sleep disturbance, and drug dependence), and vaccine worries. Each model tested the invariance of the index parameters, including restrictions from the previous model. Hierarchical regression analysis was applied to verify whether the association with executive control remained significant when the effects of covariates were considered. All tests were two-tailed for multiple comparisons, and significance was defined as α < 0.05 and exclusion of zero in the 95% of confidence interval (CI). Data were processed using SPSS version 23.0 for Windows (IBM Inc., Armonk, NY, USA).

Results Demographic Analysis and Reliability/Validity of Selected PSQI Items

In total, we recruited 105 participants (58 in the SUD group and 47 in the control group), and the mean age was 47.54 ± 11.51 years. Thirty-six (62.1%) of the patients with SUD had opioid use disorder alone, four (6.9%) had amphetamine use disorder alone, and 18 (31.0%) had multiple substance use disorder. Compared with the control group, the SUD group had a significantly higher proportion of males (67.2% vs 29.8%, p < 0.001), lower proportion of having a partner (41.4% vs 76.6%, p < 0.001), higher proportion of smoking (62.1% vs 12.8%, p < 0.001), and lower proportion of regular exercise (56.9% vs 78.7%, p = 0.018). On the other hand, the SUD group had a lower educational level (11.78 ± 3.33 years vs 13.81 ± 3.02 years, p = 0.002), higher sleep disturbance score (7.17 ± 4.14 vs 5.45 ± 3.02, p = 0.019), and lower social desirability score (8.91 ± 2.53 vs 9.87 ± 1.90, p = 0.029). There were no significant differences in the other demographic data between the two groups (Table 1). On the other hand, the internal consistency coefficients (Cronbach’s alpha) of selected items of PSQI were 0.838 for control group and 0.844 for patents with SUD, where they demonstrated with acceptable reliability.35 Results of construct validity also indicated that the selected items of PSQI were validated for control group (KMO value: 0.743; Bartlett testing: p<0.001; total variance explained: 71.97%) and SUD group (KMO value: 0.695; Bartlett testing: p<0.001; total variance explained: 68.94%).

Table 1 Characteristics of Demographic and Quantitative Variables

Predictors of Social Desirability Estimated Using Hierarchical Regression Analysis

We then examined associations between social desirability and psychological impact (severity of depression, PTSD, sleep disturbance, and drug dependence) as well as vaccine worries after controlling for covariates. The results are summarized in Table 2 and 3. After multiple adjustments, older age (β = 0.54, 95% CI: 0.07 to 0.3, p = 0.004), higher level of sleep disturbance (β = 0.43, 95% CI: 0.01 to 0.6, p = 0.046), lower level of drug dependence (β = −0.54, 95% CI: −0.74 to −0.13, p = 0.008), and lower level of vaccine worries (β = −0.33, 95% CI: −0.4 to −0.13, p = 0.038) predicted a higher level of social desirability.

Table 2 Preliminary Model with Hierarchical Regression Analysis for Predictors of Social Desirability

Table 3 Final Model for Predictors of Social Desirability Estimated with Hierarchical Regression Analysis Among Patients with Substance Use Disorder

Discussion Main Findings of the Current Study

We investigated the differences between patients with SUD and healthy controls, and found that the SUD group had a significantly lower level of confidence and adherence to governmental policies against COVID-19 and more severe sleep disturbance than the control group. We then examined the predictors of the lower level of adherence and confidence to governmental policies among the patients with SUD, and found that the significant predictors were older age, higher level of sleep disturbance, lower level of drug dependence, and lower level of vaccine worries.

Differences Between the SUD and Control Groups

The patients with SUD had a significantly lower educational level, higher proportion of males, and higher rate of smoking compared to the controls, which is comparable with previous studies.39,40 Since our patients had a higher proportion of opioid use disorder, the significantly higher rate of smoking is reasonable due to the association between smoking and opioid use.41 The patients with SUD also had a significantly lower rate of regular exercise than the controls. Although no previous research has discussed differences in regular exercise between patients with SUD and healthy controls, we suppose that it may be affected by the association between SUD and poor quality of life.42

We also found a higher level of sleep disturbance among the patients with SUD compared with the healthy controls. Alcohol and substance use have been associated with insufficient hours of sleep.43 Furthermore, an association between opioid use disorder and sleep disturbance has also been reported.40,44 Importantly, we found that the patients with SUD had a lower social desirability score, indicating a lower level of confidence and adherence to governmental policies. This is consistent with a previous study that demonstrated an association between substance abuse and poor adherence to social distancing.22 Our findings highlight the importance of further interventions to enhance confidence and adherence to policies for infection control in patients with SUD.

Associations Between Social Desirability and Age as Well as Psychological Impact

After adjustments, we found that older age was associated with a higher level of social desirability. This is consistent with our previous study,30 in which we demonstrated positive coping strategies among older subjects. We hypothesize that older individuals may be more willing to follow authorities’ instructions due to the higher mortality rate in older patients infected with COVID-19.45 On the other hand, our results showed that a lower level of drug dependence was associated with a higher social desirability score. The association between coping strategies and severity of substance use or dependence has seldom been investigated before. A previous study showed that behavioral disengagement and self-blame coping were associated with more severe PTSD-related illicit substance use among trauma-exposed individuals.46 This echoes our findings, and highlights the role of maladaptive or negative coping in the severity of substance use or dependence. Moreover, our results extend the application of previous evidence to coping strategies against COVID-19.

Another important finding in this study is that a higher level of sleep disturbance predicted a higher level of social desirability, demonstrating the impact of sleep disturbance on confidence and adherence to governmental policies. Although this finding is comparable with a previous study which reported an association between active coping and sleep disturbance,3 it is not supported by other evidence.16 The inconclusive findings of the correlation between positive coping and sleep disturbance highlight the complexity of the etiologies. In addition, excessive positive coping and related behaviors may be related to an increased mental health burden. For example, excessive media exposure to COVID-related news might trigger anxiety and psychological distress among the public.47 Although the coping strategies discussed in the previous studies are not entirely comparable to social desirability, it may reflect the “too much of a good thing” aspect of positive coping. Further studies are warranted to explore the etiologies of the relationship between coping strategies and psychological burden.

The Impact of Vaccine Worries on Social Desirability

We also found that a lower level of vaccine worries was related to a higher level of social desirability. Previous studies have investigated the interaction between attitude toward vaccinations and coping strategies. For example, refusal to receive the human papillomavirus vaccination has been associated with behavioral disengagement and negative coping in female students.48 Another study demonstrated that actively focusing on problems (coping with stress) drives satisfaction and confidence in vaccine information from the authorities.49 However, this is not entirely comparable with our previous work, in which we found that higher vaccine worries were associated with a higher level of awareness of the pandemic situation among healthcare workers.23 We hypothesize that our findings may be due to differences in the studied population and coping strategies (awareness of the pandemic vs adherence to policies). Nevertheless, our findings may show the importance of proper interventions for those with vaccine worries.

Limitations

There are several limitations to the current study. First, the data were derived from one cross-sectional survey. Thus, we cannot identify the time effect on the association between social desirability and other variables. Second, the study was conducted at a single center, and this may limit the interpretation of the results and generalizability compared with a multi-center study. Third, due to the high comorbidity between SUD and other mental illnesses, excluding participants with major mental illnesses may limit the generalizability and applicability to the real world.

Conclusions

The patients with SUD had a significantly lower level of confidence and adherence to governmental policies against COVID-19 than the healthy controls. Furthermore, we identified that a higher level of sleep disturbance, lower level of drug dependence, and lower level of vaccine worries were associated with a higher level of confidence and adherence to governmental policies against COVID-19. Our findings highlight the clinical implications and importance of timely interventions for individuals with drug dependence and vaccine worries. Due to the shortage of resources for SUD treatment during the COVID-19 pandemic,12,13 authorities should establish proper treatment programs for those with SUD. Furthermore, timely and accurate information of COVID-19 vaccines should be provided by authorities, as this may reduce the misunderstand and mistrust of vaccinations. On the other hand, regular screening and prompt interventions for sleep disturbance and other psychological burdens are also crucial for patients with SUD, especially during the COVID-19 pandemic. Further studies with comprehensive assessments are suggested to better understand the etiologies of the association between psychological burden and positive coping. In addition, longitudinal follow-up studies may also be helpful to clarify the time effect of the association between coping strategies and psychological burden as well as vaccine worries.

Funding

This study is supported by grants from the National Science and Technology Council, Taiwan (MOST 112-2314-B-280-001).

Disclosure

Dian-Jeng Li and Joh-Jong Huang are co-first authors for this study. The authors alone are responsible for the content and writing of this paper, and all authors declare that they have no conflicts of interest for this work.

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