SUDs are described as a problematic pattern of using alcohol or another substance, resulting in impairment in daily life (1). The Burden of Drug Use Disorders, by the Pan American Health Organization, states that drug use disorders were responsible for 791.2 disability-adjusted life years per 100,000 population, 409.1 years lived with disability per 100,000 population, and 332 years of life lost per 100,000 population due to premature deaths in 2019.(2)
Recognizing the gravity of SUDs, Chile has implemented advanced monitoring programs, yet the long-term health impact of such interventions still needs to be studied. A study by the governmental “Servicio Nacional para la Prevención y Rehabilitación de Drogas y Alcohol” (SENDA) and other institutions estimated the economic cost of alcohol consumption in Chile at US$ 2,240 million, with direct health costs comprising 30.1% of this total (3).
Treatment objectives involve achieving abstinence or reducing the frequency of substance use, minimizing relapse occurrences, and enhancing psychological and social functioning (4). Treatment completion, a key measure of treatment success, is influenced by various factors, such as age, education, employment, and substance use severity (5). Older age, higher education, and employment have consistently been associated with a greater likelihood of treatment completion (6). On the contrary, the severity of substance intake, the presence of mental illness, and homelessness are factors that may lower the odds of completing treatment (7).
Failure to complete treatment, often labeled as drop-out, is common and a key factor affecting the effectiveness of SUD treatment (8). According to the specific treatment modality, it was defined as not attending after the first assessment or otherwise (9). Another definition of drop out is ceasing treatment before a set number of sessions or specified “dose” of treatment. The number of sessions may be set arbitrarily or defined as completing an evidence-based treatment (10).
For example, one study reports a mean dropout rate of around 30.4% (n = 31) in patients admitted to outpatient psychosocial treatment during 12 months of planned treatment. This rate varies with the treated population, the targeted substance, and the treatment characteristics (11).
Limited research has delved into demographic and psychological predictors of drop-out. For instance, in a study exploring factors associated with treatment drop-out in SUDs at six months, 43.3% of unemployed patients dropped out of treatment compared to 23.8% of employed patients (12). Among psychological factors, one study showed that patients with attention, memory, and spatial ability deficits had higher drop-out rates than treatment completers at 12 weeks (13). Along the same lines, a study revealed that anxiety sensitivity predicts drop-out or treatment completion among individuals with heroin or crack/cocaine dependency (14).
There is only one study in Chile, made by the "Dirección de Presupuestos del Ministerio de Hacienda" (DIPRES) in association with the "Centro de Estudios Justicia y Sociedad, Instituto de Sociología UC (ISUC)" in the results of SENDA's Treatment and Rehabilitation Programs, between 2012 and 2017, that has explored some demographic and clinical factors associated with drop-out, both in adults and adolescents, and the influence of family involvement (e.g., childcare support, family functioning). The study of treatment dropouts highlights aspects such as the social and contextual circumstances in which patients live, such as maintaining a job, distance from the treatment center, or lack of time to attend the clinic due to family or work obligations. Other aspects highlighted in the study were childcare support and lack of interest or dissatisfaction with the treatment (15).
Regarding psychological factors, it is worth mentioning that the age between 18 and 39, known as emerging adulthood, is marked by significant psychosocial transitions. For instance, this phase involves pivotal role changes, education completion, first employment, and the formation of romantic relationships. Studies suggest that a successful transition to adult responsibilities, such as marriage and employment, can mitigate the risk of SUDs. (16)
The Erikson model states that to understand adult human development across the lifespan, individuals must address a broad range of psychosocial developmental tasks from infancy to death, such as their relationship to society (17). Table 1 summarizes task development defined by Erickson and the recently updated version proposed by Vaillant (18).
Table 1
Eriksonian Psychosocial Development
Vaillant developmental tasks | Description of developmental Erikson (1950) | operationalization of adult developmental tasks Vaillant |
Basic Trust | Ability to rely on the continuity of caregivers and ultimately the self | |
Autonomy | Development of increased independence and ability for “free choice” | |
Initiative | Ability to approach what one desires with increased accuracy, planning, and energy | |
Industry | Learning to work, be productive, and be a potential provider | |
Identity | The development of a new sense of “continuity and sameness” in one’s own eyes while being aware of the being in the “eyes of others” | “to live independently of family and to be self-supporting” (Vaillant, 2012, p. 150) |
Intimacy | The ability to commit to others in partnership and maintain this even at the cost of compromise and sacrifice | “the capacity to live with another person in an emotionally attached, interdependent and committed relationship for 10 or more years” (p.151) |
Career consolidation | | Developing a “career” characterized by commitment, compensation, contentment, and competence |
Generativity | Concern for establishing and guiding the next generation | Concern for establishing and guiding the next generation |
Keepers of the meaning or guardianship | | Concern and active commitment for preserving values that benefit culture as a whole |
Integrity | The acceptance and emotional integration regarding one’s own life, the human life-cycle, and a place in one’s culture/history | “The capacity to come to terms constructively with our pasts and futures in the face of inevitable death” (p. 157). |
Extracted from Malone, J. C., Liu, S. R., Vaillant, G. E., Rentz, D. M., & Waldinger, R. J. (2016). Midlife Eriksonian psychosocial development: Setting the stage for late-life cognitive and emotional health. Developmental Psychology, 52(3), 496–508 and Vaillant, G. E. (2012). Triumphs of experience: The men of the Harvard Grant study. Cambridge, MA: Harvard University Press. |
Insert Table 1 here.
In this model, two crucial stages, Identity and Intimacy, are particularly relevant. Identity involves the individual's search for uniqueness and a sense of place, while Intimacy refers to the capacity to sustain emotionally attached relationships, which underscores the necessity of stable relationships, building on a foundation of individual identity (19). Erikson's model emphasizes achieving a clear sense of identity and self-sufficiency, concepts integral to successful SUD treatment. Failure to reach this developmental stage may impede self-understanding (18). Therefore, individuals 18 + who are not studying and still live with their parents may have a less clear sense of identity and lower motivation to complete a therapeutic process. A proxy variable to explore these developmental tasks is the living arrangements. People living with a partner and children may have reached a higher developmental stage (Intimacy stage) than other people living with family of origin or living alone.
In Chile, the age group of 18 to 29 is vulnerable to SUDs, with higher prevalence rates compared to the general population. Family dynamics play a crucial role in an individual's biopsychosocial development, and dysfunctional family perceptions are common among those with SUDs. Housing conditions further complicate family dynamics, with diverse living arrangements observed, ranging from single-person households to complex family structures (20).
According to theory and many studies, the biopsychosocial development of the individual is highly influenced by the family and its relational dynamics, as well as an adequate hierarchical organization (21). In Chile, a study shows that subjects with SUD in and out of treatment perceive their families as highly dysfunctional, with a degree of disintegration and lack of family organization (22).
Housing conditions further complicate family dynamics, with diverse living arrangements observed in Chile. These range from single-person households to complex family structures, including relationships termed "allegados" and even instances of informal self-built settlements known as camps. The 2017 National Census reveals a notable increase in single-person households, underscoring the evolving nature of living arrangements (23, 24). The 2017 National Census (CENSO) data observed a rise in single-person households, from 8.5% in the 1992 measurement to 17.8% in 2017 (25).
The present study aimed to explore the survival rates and treatment retention by different living arrangements (living alone, with parents, and with couple and children) at admission to first treatment and the time until first treatment drop-out at 6 and 12 months after admission, of emerging adulthood patients (aged 18–29), admitted to public SUDs treatments between 2010–2019 in Chile.