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The causal effect of resilience on risk for drug abuse: a Swedish national instrumental variable, co-relative and propensity-score analysis

Published online by Cambridge University Press:  07 January 2020

Kenneth S. Kendler Open the ORCID record for Kenneth S. Kendler [Opens in a new window] ,
Henrik Ohlsson ,
Sean Clouston ,
Abigail A. Fagan ,
Jan Sundquist  and
Kristina Sundquist
Kenneth S. Kendler*
Affiliation:
Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA Department of Psychiatry, Virginia Commonwealth University, RichmondVA, USA
Henrik Ohlsson
Affiliation:
Center for Primary Health Care Research, Lund University, Malmö, Sweden
Sean Clouston
Affiliation:
Department of Family, Population, and Preventive Medicine, Program in Public Health, Stony Brook University Health Sciences Center, Stony Brook, NY, USA
Abigail A. Fagan
Affiliation:
Department of Sociology, Criminology & Law, University of Florida, Gainesville, FL, USA
Jan Sundquist
Affiliation:
Center for Primary Health Care Research, Lund University, Malmö, Sweden Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA Department of Functional Pathology, Center for Community-based Healthcare Research and Education (CoHRE), School of Medicine, Shimane University, Japan
Kristina Sundquist
Affiliation:
Center for Primary Health Care Research, Lund University, Malmö, Sweden Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA Department of Functional Pathology, Center for Community-based Healthcare Research and Education (CoHRE), School of Medicine, Shimane University, Japan
*
Author for correspondence: Kenneth S. Kendler, E-mail: kenneth.kendler@vcuhealth.org
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Abstract

Background

We sought to quantify and investigate the causal nature of the association between resilience at age 18 and future drug abuse (DA).

Method

In a national sample of Swedish men (n = 1 392 800), followed for a mean of 30.3 years, resilience was assessed during military conscription and DA defined from medical, criminal and pharmacy registers. For causal inference, we utilized three methods: (i) instrumental variable analyses with the month of birth as the instrument; (ii) co-relative analyses using the general population, cousins, siblings and monozygotic twins; and (iii) propensity scoring on a subsample (n = 48 548) with strong resilience predictors. Cox proportional hazards models were utilized to examine survival time till DA diagnosis.

Results

Low resilience was most robustly predicted from internalizing symptoms. Lower levels of standardized resilience strongly predicted the risk for DA (HR = 2.31, 95% CIs 2.28–2.33). In instrumental, co-relative, and propensity score analyses, the association between resilience and DA was estimated at HR = 3.06 (2.44–3.85), 1.34 (1.28–1.39), and 1.40 (1.28–1.53), respectively. Sensitivity analyses suggested that our instrument was weak and, despite our large sample, likely under-estimated confounding.

Conclusions

Low resilience strongly predicts DA risk. Three different causal analysis methods, with divergent assumptions, concurred in estimating that an appreciable proportion of this association was causal, probably around 40%, with the remainder arising from confounding variables many of which are likely familial. Consistent with prior interventions focused on substance use prevention, our results suggest that prevention programs that increase resilience in adolescence should meaningfully reduce the long-term risk for DA.

Keywords

Causalitydrug abuseresilience
Type
Original Article
Information
Psychological Medicine , Volume 51 , Issue 5 , April 2021 , pp. 846 - 852
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Copyright
Copyright © The Author(s) 2020. Published by Cambridge University

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