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A MODERATED MEDIATION MODEL OF AGE-RELATED DECLINE IN SELECTIVE EXECUTIVE
FUNCTIONS AND QUALITY OF LIFE IN MEN WITH SUBSTANCE USE DISORDER
Shameem Fatima, Sajid Hassan, Farhat Jameel
Clinical Neuropsychiatry (2024) 21, 2, 143-152
Citaon: Fama, S., Hassan, S.,
Jameel, F. (2024). A Moderated
Mediaon Model of Age-Related
Decline in Selecve Execuve
Funcons and Quality of Life in Men
with Substance Use Disorder. Clinical
Neuropsychiatry, 21(2), 143-152.
doi.org/10.36131/
cnorieditore20240103
CC BY-NC-SA This arcle is published
under a Creave Commons license.
For more informaon: hps://cre-
ativecommons.org/licenses/by-nc-
sa/4.0/
Funding: None.
Compeng interests: None.
Acknowledgement: The authors
acknowledge the parcipants for their
voluntary parcipaon in the research.
Corresponding author
Dr. Shameem Fama, Tenured
Associate Professor Psychology,
Chairperson Department of
Humanies, COMSATS University
Islamabad, Lahore, Pakistan.
E-mail: shameemfama@cuilahore.
edu.pk
OPEN ACCESS
Abstract
Objective: It is known from earlier literature that substance use is associated
with diminished executive functioning and decreased quality of life (QoL). The
study extended this knowledge by assessing whether selective executive function
components would mediate the association between age and QoL domains in young
men with substance use disorder and whether family history of substance use would
moderate these mediated associations.
Method: A sample of 212 young inpatient men with substance use disorder (105
positive family history and 107 negative family history of substance use disorder) was
selected from drug units/wards of government sector hospitals.
Results: The participants with positive family history compared to those with
the negative association of age with psychological, social, and environmental QoL.
associations with stronger indirect negative associations in participants having a
family history of substance use disorder compared to those with no such history.
Conclusions: It is concluded that inhibitory control, which is vulnerable to aging,
substance use, and family history of substance use, is an important factor related to
QoL in young substance abuser men.
Key words
disorder, substance use disorder
Shameem Fatima PhD1, Sajid Hassan2, Farhat Jameel PhD3
1 Department of Humanities, COMSATS University Islamabad, Lahore, Pakistan. Email:
shameemfatima@cuilahore.edu.pk
2 Department of Psychology, University of Management and Technology, Lahore,
Pakistan. Email: sajidhassan99@gmail.com
3 Department of Psychology, Beaconhouse National University, Lahore, Pakistan. Email:
farhat.nadeem@bnu.edu.pk
143
RESEARCH PAPER
Introduction
Substance use disorder is a pervasive public health
to world wide data for 2022, nearly 300 million people
Drugs and Crime, 2022). Undoubtedly, substance abuse
undesirably impacts individuals’ lives and societies (e.g.,
Daley, 2013; Schulte & Hser, 2014). Not surprisingly,
executive control mechanisms are often impaired in
individuals with substance abuse (e.g., Fernández-
Serrano et al., 2010; Hester & Garavan, 2004; Morein-
Zamir & Robbins, 2015). Likewise, dysregulation of
frontal areas underlying executive control mechanisms
such as the prefrontal and anterior cingulate cortex is also
implicated in individuals with substance use disorder
(Goldstein & Volkow, 2011; Kaufman et al., 2003).
Evidence from limited functional magnetic resonance
imaging studies provide underlying neural support to
hypoactivity in anterior cingulate cortex in cocaine and
methamphetamine users compared to healthy controls
(Hester & Garavan, 2004; Kaufman et al., 2003; Li et al.,
2008; Morein-Zamir et al., 2013). Lining up with this, in a
recent correlational study on a sample of late adolescents
and young adults, executive functions (EF) are reported
to be negatively associated with number of substances
used and frequency of substance use (Gustavson et al.,
2017).
Age-Related Weakening of EF in Individuals
with Substance Use Disorder
Another noticeable feature of the evidence base is
the emphasis given to declining EF abilities in aging
adults. Empirical evidence supports that EF such as
related decline in adults (Fatima et al., 2020; Peng et al.,
studies which provide structural and functional evidence
Abdulhadi Kocabas et al.
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
144 Clinical Neuropsychiatry (2024) 21, 2
earlier in the lives of young adults with substance use
disorder because declining mental capacities including
executive mechanisms (e.g., Salmani et al., 2020),
status may appear earlier due to substance use coupled
with aging processes (Laudet & White, 2010).
Though there is little evidence regarding the
association of age-related EF decline with QoL in
individuals with substance abuse, nonetheless, the
evidence based on other clinical samples supports the
connection of EF ratings with QoL (e.g., Stern et al.,
2017). Findings from another recent study have revealed
that men with substance use disorder presented weak
EF leading to problems with everyday simple tasks,
eventually needing assistance despite having high self-
reasonable to propose that decreasing QoL is associated
with age-related weakening of EF in individuals with
substance use disorder. Accordingly, the study formulates
in EF mediates the age-QoL link (H1).
The present study assesses two selective EF
from two stand-alone tests taken from Delis-Kaplan
Executive Function System (D-KEFS) test battery (Delis
et al., 2001). Considering the unique feature of the battery
that tests are independent of each other and investigator
can use any number of these tests in any combination,
the two selective tests were focused assessing two
Inhibition/inhibitory control being one of the core EF
describes the ability to control one’s attention, behavior,
thoughts, and/or emotions to override a strong internal
predisposition in favor of a more appropriate or needed
response (Diamond, 2013). The D-KEFS Color-Word
Interference Test is the most commonly used verbally
mediated measure of inhibition (Eglit et al., 2020) and
is designed to be more complex and improved than the
Stroop task by including an inhibition/switching trial.
However, available data from clinical samples support
that inhibition/switching task assessed by D-KEFS
Color-Word Interference Test is not necessarily harder
than inhibition only Stroop task (Lippa & Davis, 2010).
(Diamond, 2013; Miyake & Friedman, 2012). D-KEFS
Design Fluency test is typically assumed to assess
et al., 2001).
Family History as a Moderator
Beyond age related linear changes in EF and QoL in
adults, the age-related decline in EF in men with substance
use disorder may also depend on other personal and
familial factors. Family history of substance use disorder
can be an important factor which may likely moderate
the proposed mediational age-EF-QoL link. Studies
have shown that family history of substance use disorder
(Shoal & Giancola, 2001) and substance dependence
(Tapert & Brown, 2000) to predict neuropsychological
presumed that family history of substance use disorder
may interact with age to predict EF and to moderate the
age-EF-QoL mediated link to propose that the speed
of age-related changes in EF may not be similar across
groups with and without family history. This may lead to
of age-related changes in brain regions associated with
EF (Elderkin-Thompson et al., 2008). In typically
developing Pakistani population, EF trajectory shows
an inverted U shape curve with a continuous maturation
up till adolescent and emerging adulthood years (Fatima
& Shahid, 2020; Fatima & Sharif, 2017; Fatima et al.,
2016), stability after emerging adulthood years, and a
declining trend beginning from middle adulthood years
in 40s (e.g., Fatima, Jamil, et al., 2019; Fatima, Khan,
et al., 2020). Traditionally, studies have investigated the
aging-EF link in normal aging adults, however, the link
may well extend to adults with substance use disorder.
It seems intuitive to discuss that the cognitive trajectory
who are more vulnerable to accelerated decline in EF.
It is presumed that the impact of aging on EF may
begin earlier in individuals with substance use disorder
because substance abuse experience may drive faster the
deterioration of mental health and physical capacities.
A review report by Murman (2015) discusses that
individuals’ unhealthy life choices such as drug use as
well as age related diseases can speed up the process
of neuronal dysfunction, neuronal loss, and cognitive
decline. Studies comparing EF ratings and EF task
performance between young adults with substance abuse
and healthy adults provide only indirect support for an
earlier decline in EF in individuals with substance use
on young adults with substance use disorder referred to
addiction treatment have reported poor performance on
tasks measuring selective EF abilities including working
memory, inhibition, and shifting attention compared to
healthy adults in young adulthood years (Salmani et al.,
2020). Findings from a similar comparative study have
also revealed that adults with polysubstance abuse scored
lower on ratings of all EF measures on BRIEF inventory
compared to healthy control (Hagen et al., 2016). Based
on these considerations, it may be presumed that age-
related EF decline starts earlier in young adulthood years
in individuals with substance use disorder, which is the
focus of this study.
Age-Related Changes in EF and Quality of
Life: Proposed Mediational Link
of life (QoL) as a person’s perception of one’s position
in life within the context of culture and value systems
and in connection to personal goals, expectations,
and standards. Beyond reduced executive control
mechanisms, individuals with substance use disorder
compared to general population and compared to those
with other serious psychiatric disorders (Levola et al.,
2020; Patra et al., 2016; Smith & Larson, 2003; Tracy
et al., 2012). Beside substance use, aging is another
factor which covaries with subjective evaluation of QoL.
Traditionally, studies on older adult samples have reported
that normal aging is associated with decreased QoL (e.g.,
Figueira et al., 2008). It has been argued in literature that
declining physical and mental health status and changing
QoL and wellbeing (e.g., Bowling, 2005; Netuveli et
al., 2006). While a recent study on a sample of young
men (M age=27.73, SD=5.25) with substance use has
QoL domains in relatively younger years (e.g., Fatima,
2022). Building up on this line of evidence, it appears
reasonable to propose that diminished QoL is featured
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
Clinical Neuropsychiatry (2024) 21, 2 145
FH-=105) inpatient men with substance use disorder in
age range from 19 to 40 years (M=27.61 & SD=5.38)
was selected. The sample were selected from drug wards/
drug rehabilitation centers of government and private
hospitals from Lahore, the second largest metropolitan
region with more than 12 million population. Eligibility
criteria included being young adults with substance use
disorder, having a minimum of primary education, being
with managed withdrawal symptoms. Participants
having a history of any co-morbid psychiatric diagnosis
or neurological disorder, physical conditions associated
with withdrawal state such as pain, or being in disoriented
state were not included in the study. Such conditions
were regarded in the exclusion criteria to approach a
more homogenous sample as the variability due to such
conditions could not be considered as an additional
variable, given the already planned reasonable number
and under treatment in a controlled environment. Of
the sample, 198 participants were using illicit drugs
chemical easily available in departmental stores) in
addition to some illicit drug use. Regarding number and
type of substances, majority of the sample were using
multi-substance (n=154). The remaining participants
(single substance users) were using alcohol (n=22),
cannabis (n=26), heroin/opium (n=4), and cocaine (n=6).
Demographic characteristics of the sample are presented
in table 1.
Variables and Assessment Measures
Executive Functions
Two selective EF components namely inhibition and
used two performance measures namely Color Word
Interference Test and Design Fluency Test taken from
a test battery named Delis Kaplan Executive Functions
System-DKEFS (Delis et al., 2001) to assess inhibition
Color Word
Interference Test
two conditions assessing basic cognitive functions of
fundamental visual, perceptual, and linguistic abilities.
Condition 1 involved naming the colors and condition
2 involved reading the color words printed in black ink.
link for both groups. Therefore, the study formulates a
secondary hypothesis to assess whether the meditational
across men with substance use disorder with and without
family history of substance use (H2). Assessing these
objectives on a sample of Pakistani men with substance
use disorder becomes a prime concern given the data
showing increasing rates of substance abuse in Pakistan
(Aslam, 2019). Women were not included in the study
because of limited accessibility to women with substance
use disorder. Limited accessibility of the women is
on Drugs and Crime (2010) which argues that similar to
many developing countries, the magnitude of substance
abuse among women is masked by national denial
in Pakistan. Moreover, keeping the former and latter
literature from this region pertaining to these domains is
Hence, the study will evaluate age as an independent
variable, EF components as two mediators, and QoL as
a criterion variable. Also, it will assess family history of
substance use as a moderator of the age-EF link. Several
theories including the prefrontal-executive theory
(Hasher & Zacks, 1988) imply that older adults are more
structural and functional changes associated with aging
in the prefrontal cortex. A hypothesized model has been
shown in gure 1.
hypotheses based on the literature review.
HI
would partially mediate the negative association between
age and QoL domains in men with substance use disorder.
H2: Family history of substance use would moderate
the mediated associations between age, selective EF
men with substance use disorder.
Method
Participants
The study used a cross sectional research design.
Sample size was calculated using G power analysis.
The calculated sample size for the independent sample
Figure 1. Hypothesized Moderated mediation model assessing the mediating role of executive functions in
association between age and quality of life domainsand the moderating role of family history of substance use
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
146 Clinical Neuropsychiatry (2024) 21, 2
rest 24 items assessed four QoL domains. Responses
to all items were recorded on a 5 points Likert scale.
Composite scores for each of the four subscales were
computed by adding the relevant items of each subscale.
Higher scores on the subscales indicated greater levels
of the corresponding QoL domain. The current study
the four QoL domains (i.e., .73, .72, .70, and .71, for
physical, psychological, social, and environmental QoL
domains respectively).
Family History of Substance Use Disorder and Socio-
demographic Covariates
Participants reported the family history of substance
use disorder on a dichotomous response format of yes
or no. The item, “has any of your immediate family
members (parents, siblings, spouse, children) been
involved in problematic substance use which require
medical attention” was asked to assess the family
history of substance use disorder. Participants also
reported their socio-demographic information including
their age (in years), education (completed education
in number of year), perceived socioeconomic status (3
categories: Low, middle, or high) and ethnicity (South
Asian, or others). In addition, for clinical information,
they reported onset age of substance use (age in years),
duration of substance use (in years), and number and
type of substances used. Severity index of substance use
as assessed by Addiction Severity Index (ASI) was taken
in 5 categories in hospital record (no problem, slight,
moderate, considerable, extreme) as per ASI manual,
however, considering the very small sample number in
no problem category (n=2), no problem severity was
merged with slight problem. Likewise, considering
the very small number in extreme problem (n=3), this
category was combined with considerable problem
category. The resulting 3 categories were named as low,
moderate and high severity.
Procedure
After obtaining approval from the Ethical Review
Committee vide letter number CUI-LHR/HUM/
ERC/18/049 and reviewing all the ethical considerations,
the approval for data collection was obtained from the
Last two conditions (3 & 4) assessed higher executive
ability of inhibition. Third condition involved naming
the ink color of the words printed with a mismatched
ink color (e.g., the word “blue” was printed with green
ink). Condition 4 involved switching between reading
the words within the box and naming the ink color for
words without box. Task completion time and number
of errors on each of the four conditions were taken as
two response measures of inhibition on the test. Before
calculating two composite time and error scores, the
individual scores were reversed. The composite score
thus obtained represented higher levels of inhibition
from higher composite scores. Later on, looking at the
high correlation between time and error measures of
inhibition (r = .72, p <.001), scores on both measures
were combined to give a composite score of inhibition.
standardized before calculating a composite score of
inhibition.
The Design Fluency Test
condition involved drawing designs by joining empty
All three conditions were preceded by practice sessions.
There were certain rules for drawing the designs which
were required to be observed for scoring them to be
correct. The response measure on this test was number
of correct designs drawn within a 60 seconds time period
on each of the three conditions. The composite score
obtained by adding scores on 3 conditions represented a
Considering the unavailability of norms on DKEFS tests
for Pakistani participants, the raw scores on both DKEFS
tests were used for data analyses.
Quality of life
The study used the Urdu version of World Health
Organization Quality of Life Assessment Instrument—
short version, 26 items (Khan et al., 2003) to assess QoL
in four domains namely physical, psychological, social,
and environmental QoL. First two items of the scale
assessed general QoL and general health status; and the
Table 1. Demographic Characteristic of the Sample
Variables Full sample (N=212) FH - (N=107) FH+ (N=105)
Mean(SD) Mean(SD) Mean(SD)
Age 27.61(5.38) 26.64(4.92) 28.59(5.76)
Educaona11.22(2.69) 11.71(2.68) 10.71(2.61)
Onset Age 22.29(3.58) 22.92(3.59) 21.65(3.48)
Duraon of substance use 4.66(3.63) 3.66(3.59) 5.67(3.40)
Socioeconomic statusb Low= 103
Middle=92
High= 17
Low=54
Middle=44
High= 9
Low= 49
Middle=48
High= 8
Severity of substance usecLow = 20
Moderate= 133
High = 59
Low = 11
Moderate= 69
High = 27
Low = 9
Moderate= 64
High = 32
Number of Substances used One=58
Mul=154
One=31
Mul=73
One=27
Mul=81
Note: FH+ = posive family history of substance use; FH- = negave family history of substance use; a = educaon was assessed
number of years of completed educaon; b =self-reported socioeconomic status; c= severity index of substance use was taken
from paent prole.
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
Clinical Neuropsychiatry (2024) 21, 2 147
of EF with participants having a positive family history
scoring lower on three EF scores (two inhibition scores
EF abilities compared to those with a negative family
history. Furthermore, participants having a positive
family history of substance use disorder scored lower
on three of four QoL domains including psychological,
social, and environmental as well as on general QoL
and general health.
Correlations of age and both EF measures with
four QoL domains as well as with general health and
general QoL were calculated and presented in Table 3.
Of the two selected EF scores, inhibition was positively
correlated with all four QoL domains as well as with
general QoL and general health indicating better
inhibition ability to be associated with improved QoL
positively correlated with psychological, social, and
environmental but not with physical QoL. Also, this
measure was a positive correlate of general QoL and
general health.
models (each analyzing one QoL domain) were
heads of psychiatry wards and rehabilitation centers.
assistance of the clinical psychologists working in each
selected hospital’s drug unit. Next, the participants were
approached and briefed about the study. After taking
their consent, they were assessed on the study measures
in individual setting. Order of the assessment measures
was counterbalanced across participants to cancel out
Finally, they were cordially thanked for their cooperation
in the study.
Data Analyses and Results
Data set was checked and corrected for data entry
errors, missing data and outliers. Missing data were less
than 2% for all variables. Missing data were handled
using single imputation method using series mean to
replace missing values. Descriptive statistics and group
history of substance use on EF measures and QoL domains
were calculated and presented in table 2. The results
Table 2. Descriptive Statistics and Group Dierences on Study Variables between men with Substance Use with
a Positive or Negative Family History of Substance Use
Variable Full sample (N=212) FH - (N=107) FH+(N=105) t value
Mean(SD) Alpha Range Mean (SD) Mean (SD)
Inhibion Ta265.11(110.71) .93 10-397 280.72(98.48) 249.2(120.31) 2.09*
Inhibion Ea89.01(29.10) .95 4-117 100.24(14.46) 77.58(35.04) 6.17***
Cognive
Flexibility
15.36(6.93) .84 4-28 16.81(6.76) 13.89(6.82) 3.13**
Physical QOL 17.96(2.61) .73 13-26 17.66 (2.63) 18.26(2.57) -1.69
Psychological QOL 14.83(3.02) .72 10-23 15.72(2.71) 13.91(3.05) 4.56***
Social QOL 7.04(2.11) .70 4-13 7.45(2.11) 6.62(2.03) 2.92**
Environmental
QOL
17.85 (4.42) .71 12-31 19.32(4.36) 16.34(3.95) 5.17***
GQOL 1.87(.85) - 1-4 2.07(.89) 1.66(.74) 3.68***
GH 2.28(.92) - 1-5 2.69(.93) 1.87(.69) 7.28***
Note. *= p< .05, **= p< .01, ***= p< .001; T = Time score of Inhibition; E =error score of inhibition; GQOL= General
substance use; a = time and error scores on inhibition measure are reversed
Table 3. Correlation between Age, Inhibition, Cognitive Flexibility, and Quality of Life Domains
Variables 5 6 7 8 9 10 11 12
1.Educaon .55*** .61*** -.03 .20** .04 .19** .25*** .17*
2.DuraonSA -.52*** -.35*** .20** -.16* -.03 -.16* -.28*** -.21**
3.Onset age .24*** .01 .38*** .13 .05 .13 .26*** .26***
4.Age -.58*** -.33*** -.12 -.43*** -.30** -.23** -.22** -.22**
5. Inhibiona - .62*** .23** .50*** .43*** .41*** .18* .26***
6. Cog Flex - .07 .35*** .14* .20** .38*** .29***
7.Ph.QoL - .67*** .53*** .56*** .03 -.20**
8.Psy.QoL - .50*** .77*** .40*** .01
9.S.QoL - .34*** .17* .13
10.Env.QoL - .16* .03
11.GQoL - .15*
12.GH -
Note=*p < .05, **=p < .01; SA=Substance Abuse; SES=Socioeconomic Status; Cog Flex=Cognitive Flexibility;
Ph. QoL= Physical Quality of Life; Psy.QoL =Psychological Quality of Life; S. QoL= Social Quality of Life;
Dependent=Environmental Quality of Life; Gol= General Quality of Life; GH= General Health; a = Time and error scores on
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
148 Clinical Neuropsychiatry (2024) 21, 2
links and the family history of substance use disorder
moderated these mediational links. Despite being the
mediator of the age-QoL domains links in the presence
of inhibition.
Following the mediation hypothesis, age was found
to be the negative correlate of inhibition and cognitive
Although evidence from existing literature based on
the Western samples shows declining tendencies in
EF in mid-twenties in typically developing young
adults (Park et al., 2002), however, studies from South
Asian culture report that EF remain stable during
typical young adulthood years (Fatima, Jamil, et
al., 2019; Fatima, Khan, et al., 2020). Contrarily, the
present study based on data from the same South Asian
cultural context shows declining tendencies in EF in
young adulthood years in individuals with substance
use disorder despite the evidence of stability of EF till
mid 40s in the same cultural context in normal adults
that continuous substance use may correlate with earlier
age-related decline in EF in young adulthood years in
individuals with substance use disorder. Therefore,
young individuals with substance use disorder may
have presented slower speed on cognitive tasks, took
more processing time, and made more errors. Also, it is
quite possible that changes in basic cognitive resources
(visual, perceptual, and linguistic abilities) associated
with substance use may underline the poor functioning
in another way, that is, age is strongly correlated with
inhibition indicating that inhibitory control component of
to aging in men with substance use disorder. Similar
pronounced with increased duration and dependency on
after controlling the duration of substance use for the
present sample.
Pertaining to aging-QoL link, though evidence
from healthy samples shows decreasing QoL in aging
from the current study sample of young men with
substance use disorder have revealed an earlier age-
related decline in QoL during young adulthood years.
rarely available data (e.g., Fatima, 2022). Third, the
based on studies conducted on typically developing
adults which describe young adulthood years to be very
be attributed to substance abuse.
Pertaining to mediation hypothesis, it was found
that inhibition was a strong mediator of the association
of age with three QoL domains namely psychological,
social, and environmental QoL in the current study
sample. The results line up with the previous literature
based on other clinical samples showing a link between
EF ratings and QoL (Stern et al., 2017). Although
mediational hypothesis and population of interest, the
current study provides initial evidence that inhibition
is a predictor of all QoL domains as well as a mediator
of age-QoL link in an Asian sample of young men with
substance use disorder. Currently, on one hand, the
calculated by computing Model 4 in Process to assess
the simultaneous mediating roles of inhibition and
QoL domains. The second hypothesis was assessed
by analyzing the moderated mediation models (Model
7 in Process; Preacher & Hayes, 2008) to assess the
conditional mediating roles of selected EF components
age and QoL domains across two groups of individuals
with substance use disorder, with and without family
history of substance use. Raw scores on all variables
before analyzing the multimediation and moderated
were covaried in mediation and moderated mediation
explained variance, regression weights, Sobel z value
that age was negatively correlated with three QoL
domains (psychological, social, and environmental),
multimediation and moderated mediation models
were calculated only for these three QoL domains.
demographics, education and duration of substance
use were taken as covariates in multimediation and
moderated mediation analysis.
Findings from multimediation models showed
that only inhibition out of two EF mediators
with psychological, social, and environmental QoL
after controlling the confounding due to potential
demographics (see Model 4, table 4
Sobel z value for inhibition as well the total, direct,
-.60, & -.30 to -.52, -.30, & -.27 for psychological,
social, and environmental QoL domains respectively
(see gure 2
the presence of inhibition.
Finally, results from the moderated mediation
models showed that family history of substance use
with psychological, social, and environmental QoL
domains. Further detail of moderated mediational
inhibition were stronger for participants with a positive
family history and weaker for those with a negative
family history of substance use (see Model 5, table 4).
gure 2
inhibition were stronger for participants with positive
family history of substance use compared to those with
negative family history.
Discussion
The objectives of the study were to assess the
mediating roles of selective EF components—inhibition
and QoL domains in young men with substance use
disorder and to assess whether these mediated links
or a negative family history of substance use disorder.
Both hypotheses were partially supported from the
current data set as only inhibition out of two selected
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
Clinical Neuropsychiatry (2024) 21, 2 149
Table 4. Moderated Mediation Models Representing Conditional Indirect Associations between Age, Inhibition, and QOL Domains
Predictors Outcome Variables
Model 4 Model 7 Model 4 Model 7 Model 4 Model 7
Psy.QoLaInhibionbCog.Flex.bSocial QoLaInhibionbCog.Flex.bEnv.QoLaInhibionbCog.Flex.b
Educaon .03(.03) .16(.02)*** .23(.02)*** -.03(.03) .16(.02)*** .24(.02)*** .01(.03) .15(.02)*** .25(.02)***
Duraon SA .13(.02)*** .04(.02) .07(.02)** .12(.02)*** .04(.02)* .06(.02)* .03(.03) .04(.02)* .06(.02)**
Age -.52(.10)*** -.19(.07)* -.50(.10)*** -.32(.10)** -.20(.07)** -.48(.10)*** -.04(.11) -.21(.08)** -.48(.10)***
Inhibion .37(.09)*** - - .60(.09)*** - - .50(.10)*** - -
cognive exibility .04(.08) - - -.14(.08) - - -.12(.09) - -
FHc- -.31(.08)*** -.13(.10) - -.30(.08)*** -.16(.10) - -.29(.08)*** -.15(.10)
Age X FH - -.70(.08)*** .20(10) - -.69(.08)*** .20(10) - -.68(.08)*** .18(10)
R2.37 .70 .48 .32 .69 .46 .18 .69 .48
Model t (5,204)23.65*** (5,206)90.59*** (5,206)37.08*** (5,206)19.26*** (5,206)90.53*** (5,206)35.61*** (5,204)8.78*** (5,206)89.77*** (5,206)37.03***
Total eect -.75(.09) -.62(.09) -.30(.10)
Direct eect -.52(.10) -.32(.10) -.04(.11)
Indirect eect -.23(.06) -.30(.06) -.27(.08)
Indirect eect (inhibion) -.21(.06), Sobel z = -3.72*** -.35(.06), Sobel z =-5.21*** -.31(.09), Sobel z =-4.22***
Indirect eect (cog. Flex.) -.02(.03), Sobel z = -0.54 .05(.03), Sobel z = 1.59 .04(.03), Sobel z = 1.18
Condional Indirect eect
(inhibion)
FH+ = -.33(.09)
FH-= -.07(.03)
FH+ = -.54(.08)
FH-= -.12(.05)
FH+ = -.45(.11)
FH-= -.11(.05)
Condional Indirect eect
(cog. Flex.)
FH+= -.01(.02)
FH- = -.02(.04)
FH+= .04(.03)
FH- = .07(.04)
FH+= .03(.03)
FH- = .06(.05)
Note. *= p< .05, **= p< .01; *** = p
of substance use; FH- = negative family history of substance use; a = Dependent variables; b = Mediator; C = moderator; Values in parentheses are SE; Model 4 = Mediation model calculated in
Process; Model 7 = Moderated mediation model calculated in Process
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
150 Clinical Neuropsychiatry (2024) 21, 2
the moderating role of family history of substance use
disorder on the mediational associations between age,
selective EF components, and QoL domains. From the
moderated mediation analyses, it was found that inhibition
more strongly explained the negative link of age with
psychological, social, and environmental QoL in men
with substance use disorder having a positive compared
to those having a negative family history of substance
use disorder having a positive compared to those having
a negative family history. The individuals with substance
use disorder with a positive family history clearly
presented poorer scores. Although the age-related decline
in EF may occur in response to substance use in young
men, it is possible that this declining tendency becomes
more apparent in individuals with substance use disorder
with a positive family history, which may have led to
Giancola (2001) supported the same that the high-risk
group of adolescent boys with a positive family history
scored lower on EF tasks compared to the low-risk group
with a negative family history and that the family history
moderated the negative correlation between frequency
of substance use and EF. This empirical evidence
can be regarded as a remote support for the present
study because the direct supporting evidence for the
conditional mediated associations across groups with a
positive versus negative family history of substance use
is not present in the previous literature.
Limitations, implications, and future directions
This is a cross sectional quantitative study which has
provided preliminary evidence of age-related weakening
of selective EF abilities and decreasing QoL starting
from young adulthood years in a sample of young men
with substance use disorder from a patriarchal culture in
South Asian region, yet direction of associations cannot
of substances in EF or QoL could not be assessed or
substance categories. Future studies are recommended
substance use in terms of EF or QoL. In addition, the
study collected self-report data from the participants
only, hence, common method bias may have caused
overestimation of the observed associations. However,
samples and particularly on normal aging adults
(Fatima et al., 2020); and on the other hand, literature
is also available for the EF-QoL link on clinical
samples but earlier studies have not focused to examine
meditational associations between age, EF, and QoL
domains in healthy or clinical samples. Importantly,
the current study has assessed this objective on a
sample of young men with substance use disorder from
South Asian region. Notably, lining up with the existing
literature on EF ratings and task performance (Fatima
a correlate of age and three QoL domains, however,
inhibition which appeared as a more powerful mediator.
QoL domains including psychological, social, and
in several ways. First, with increasing age, continuing
substance use may hamper their psychological and social
QoL by weakening their psychological resistance and
social bonds given the evidence for social support as
a positive correlate of QoL in adult clinical population
substance use may hamper their environmental QoL.
Mainly, the present study used a sample of men only
from a patriarchal culture; it is quite possible that aging
women with substance abuse from the same culture,
men. However, women were not included in the study
considering the gender wise non proportionality of the
data. Obtaining proportionate number of women with
substance use was seemingly impossible because of
gender stereotypical societal attitudes, underrepresented
magnitude of substance uses by women masked by
national denial, and eventual limited accessibility to
women with substance abuse. Of note, inhibition but not
to physical QoL. Though both of the earlier constructs
physical QoL. It seems intuitive to argue that strong
inhibition ability may serve the function of inhibiting
the individuals from unhealthy life choices and habits
in favor of healthy ones predicting good physical QoL.
between alternate or multiple choices may not be directly
relevant in this regard.
A secondary hypothesis was examined to assess
Figure 2. Moderated mediation showing indirect associations between age, inhibition, and QoL domains
partecipants with positive and negative family history of substance use. Values shown are regression weights
Shameem Fatima et al. EF and QoL in Men with Substance Use Disorder
Clinical Neuropsychiatry (2024) 21, 2 151
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assessment methods including performance based and
self-report assessment measures, counterbalancing
the order of assessment measures across participants,
and protecting the participants’ anonymity were used
to control common method bias in the study. Yet the
becomes vulnerable to declining status of mental
capacities and decreasing QoL in younger years due to
substance use, and requires health and support services.
The empirical information on these factors, which are
may guide intervention planners towards improved
treatment planning and clinical practice. Understanding
originated at a younger age and contribute to diminished
QoL by the cycle of substance abuse is paramount
to plan better intervention strategies, tailor treatment
options, and opt psychological services for younger
men with substance use disorder. The increasing age
as a determinant of inhibitory capacities and QoL of
individuals with substance use disorder may highlight
that services should be customized to meet their changing
executive cognitive needs and reduce their increasing
EF training to these individuals which in turn would have
better implications for their QoL.
role of aging in association with cognitive and functional
limitations, which is an emerging area of investigation for
developmental researchers. Assessing these objectives
on the samples with substance use disorder becomes
imperative given the evidence that an increasing number
of individuals with substance use disorder are surviving
into older age (Gossop & Moos, 2008). However, the
population of men with substance use disorder living
in the studied region. Also, the study had a relatively
small sample of men, and did not include women and
middle-aged and older men. The vulnerability of later
groups to aging and substance abuse may vary due to
to treatment services. The study provides avenues to
future researchers to conduct longitudinal studies with
larger and variant ageing cohorts of individuals with
substance use disorder representative of gender and
social status variations from wider geographical regions
related decline in EF and QoL.
Conclusion
inhibition strongly mediated the negative age-QoL link
among men with substance use disorder with a positive
compared to negative family history of substance
introducing EF training particularly incorporating
elements of inhibitory control for better implications for
improved QoL in men with substance use disorder. In
the long run, preventing substance abuse on a large scale
seems essential to decrease the negative consequences
of family history of substance use on EF development
in descendants, which in turn would lead better QoL
outcomes.
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