Attachment in substance misuse, depression and healthy controls. V1.0
Research type
Research Study
Full title
A comparison of attachment styles in people with comorbid substance misuse and depression, depression alone and healthy controls.
IRAS ID
320396
Contact name
Ruby Ramsden
Contact email
Sponsor organisation
University of Oxford / Research Governance Ethics and Assurance
Duration of Study in the UK
0 years, 11 months, 31 days
Research summary
During infanthood, all people develop an ‘attachment style’ (or type of emotional/relational bond) to their caregivers, based on how their caregivers respond to their needs. This attachment style influences how they develop relationships with others and cope with difficult emotions, throughout childhood and adulthood. This study will investigate whether there are differences in attachment styles of people with substance use difficulties (SUDs) and depression, compared to people with depression alone and healthy controls.
People with both conditions are vulnerable and tend to have poorer treatment outcomes and increased relapse rates, compared to people with SUDs or depression only. This may be due to them finding it more difficult to engage with/attend services or treatment. Engagement with services/professionals may be impacted by attachment style.
Understanding the relationship between attachment styles, SUDs and depression will help to understand how services/professionals can better support people with both conditions, in hope of improving outcomes and reducing relapses.Participants will be recruited online and through a substance use service. The research will be conducted both online and via paper questionnaires. Participants will be asked to complete questionnaires about alcohol use, drug use, depression and attachment style. After completing the questionnaires, participants meeting the inclusion criteria, will be divided into three groups depending on their answers:
1) SUDs and depression
2) Depression (only)
3) Healthy controlStatistical analysis will be used to compare the attachment styles of each group, as well as to see if attachment traits are related to severity of SUDs and/or depression.
LAY SUMMARY OF STUDY RESULTS:
Background
During infanthood, all people develop an ‘attachment style’ (or type of emotional/relational bond) to their caregivers, based on how their caregivers respond to their needs. This attachment style influences how they develop relationships with others and cope with difficult emotions, throughout childhood and adulthood. Insecure attachment styles (anxious, avoidant and fearful/disorganised) are associated with later mental health (MH) difficulties, whilst a secure attachment style may impart resilience from developing such difficulties. This study primarily investigated whether there are differences in attachment styles of people with substance use difficulties (SUDs) and depression (known as a dual diagnosis [DD]), compared to people with depression alone and a control group.
People with both conditions are vulnerable and have poorer treatment outcomes and increased relapse rates, compared to people with only depression or SUDs. This may be due to them finding it more difficult to engage with services/professionals, possibly impacted by attachment style. Understanding the relationship between attachment styles, SUDs and depression can help to understand how services/professionals can better support people with both conditions.
Research Questions
The current research aimed to answer the following questions:
1. Do attachment styles differ in people with comorbid SUDs and depression (DD) compared to people with depression alone and controls?
2. Which insecure attachment style is most prevalent in people with DD?
3. Is attachment style associated with current substance use or depression severity?Method
The survey-based study was advertised online via social media (Facebook, Twitter and Instagram) and within a substance misuse service (Change Grow Live [CGL]). It was also shared by addiction charities CGL, UK Smart Recovery and The Bridge Programme via their social media and webpages. Participants were eligible to partake if they were aged 18 or above and could read the English language well enough to consent and participate.
People could participate online by accessing the survey platform Qualtrics via weblink, alternatively people accessing support in CGL services could request a paper copy. Those who wanted to partake: (1) read the participant information sheet or watched the information video, (2) consented to partake, (3) completed the anonymous survey, (4) received a written debrief.
The survey consisted of questions about the participant’s background (i.e. age, ethnicity, gender and history of substance use, depression, professional support and other MH needs), an alcohol use questionnaire, a drug use questionnaire and three attachment subscales (exploring insecure attachment styles: anxious, avoidant and fearful/disorganised).
Participants meeting the main inclusion criteria were divided into three groups based on their answers, those not meeting these criteria were included within secondary analyses.
The main three groups were:
1. Dual diagnosis (people with depression and SUDs): participants scoring above the given cut off on the depression scale as well as the alcohol and/or drug use scales.
2. Depression only: participants scoring above the given cut off on the depression scale and below the given cut offs on the alcohol and drug use scales. They also had to confirm no previous difficulties or treatment for SUDs.
3. Control group: participants scoring below the given cut offs on the depression, alcohol and drug use scales. They also had to confirm no previous difficulties with or treatment for depression or SUDs.
Participants in the DD and depression only groups, also had to confirm depression and/or SUDs was currently their main MH difficulty.
The survey data collected was statistically analysed to answer the research questions.
Results and Key Findings
A total of 183 participants completed the study (N=183). Of these, 111 were eligible for the main analysis: 36 met DD criteria, 36 met depression only criteria and 39 met control criteria. Of the DD group, 7 had alcohol difficulties, 21 had drug difficulties and 8 had both.
No significant differences in insecure attachment styles were found between people with DD and depression only, although both groups had significantly higher levels of insecure attachments (anxious, avoidant and fearful/disorganised) than the control group. People with DD had higher levels of anxious attachment than avoidant attachment. Additionally, anxious attachment was found to be associated with current depression severity but not substance use severity (across all participants). These findings add novel contribution to the literature, suggesting people who develop DD and depression only, experience similar pre-disposing attachment related factors but may cope with these in different ways (i.e. by self-medicating with substances). Findings also suggest insecure attachment does not account for the poorer treatment outcomes and higher relapse rates for people with DD compared to depression only.
Limitations
The current study attempted to recruit participants representative of people who access MH and SUD services, by including people with additional secondary MH needs. However, this may have caused bias within the results. Furthermore, it may have been beneficial to divide DD participants based on the different substances they used, due to the differing physiological and psychological effects.
Two of the attachment subscales used in the study (anxious and avoidant) were modified to include consideration of non-romantic relationships (as not everybody experiences romantic relationships), which may have reduced their reliability and/or validity. Findings are also limited by the lack of diversity within participant characteristics (most identified as female and white), meaning they may not be generalisable.
Implications and Future Research
Given current findings, MH and substance use services and clinicians should consider that those accessing their support (with depression and/or SUDs) have significantly high levels of insecure attachment (compared to those without these needs), and should adapt accordingly by providing attachment-informed care/treatment. However, clinicians should not be concerned about insecure attachment being an increased barrier to creating therapeutic relationships with people with DD, as there is no difference in attachment presentation compared to those with depression only. This is important as people with DD face stigma and additional barriers to accessing services.
Findings suggest attachment style may not account for current substance use severity, or differences in treatment outcomes, engagement and relapse rates of people with DD compared to those with depression only. Therefore, it is important future research explores other possible contributing factors i.e. stigma and limited access to services.REC name
West Midlands - Coventry & Warwickshire Research Ethics Committee
REC reference
23/WM/0100
Date of REC Opinion
3 Jul 2023
REC opinion
Further Information Favourable Opinion