The relationship between substance use and self-reported aspects of social functioning in patients with a psychotic disorder
Department of Psychiatry, Amstredam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
Department of Healthy Living, Public Health Service Amsterdam, Amsterdam, The Netherlands
Department of Public Mental Health, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
Abstract
Background
In patients with a psychotic disorder, rates of substance use (tobacco, cannabis, and alcohol) are higher compared to the general population. However, little is known about associations between substance use and self-reported aspects of social functioning in patients with a psychotic disorder.
Methods
In this cross-sectional study of 281 community-dwelling patients with a psychotic disorder, linear regression models were used to assess associations between substance use (tobacco, cannabis, or alcohol) and self-reported aspects of social functioning (perceived social support, stigmatization, social participation, or loneliness) adjusting for confounders (age, gender, and severity of psychopathology).
Results
Compared to nonsmokers, both intermediate and heavy smokers reported lower scores on loneliness (E = −0.580, SE = 0.258, p = 0.025 and E = −0.547, SE = 0,272, p = 0.046, respectively). Daily cannabis users reported less social participation deficits than non-cannabis users (E = −0.348, SE = 0.145, p = 0.017). Problematic alcohol use was associated with more perceived social support compared to non-alcohol use (E = 3.152, SE = 1.102, p = 0.005). Polysubstance users reported less loneliness compared to no users (E = −0.569, SE = 0.287, p = 0.049).
Conclusions
Substance use in patients with psychosis is associated with more favorable scores on various self-reported aspects of social functioning.
Untitled section
Keywords: alcohol, cannabis, psychotic disorder, smoking, social functioning
Article notes
Untitled section
Received 2023 Aug 23; Revised 2024 Jan 17; Accepted 2024 Jan 21; Collection date 2024.
Introduction
In patients with psychosis, disruptions in social functioning are a fundamental characteristic of the disease [1]. One of the factors that is studied in relation to social functioning is substance use [2]. The prevalence of substance use is extremely high among patients with psychosis [3]. To illustrate, a large cohort study [4] demonstrated that 62% of individuals diagnosed with a psychotic disorder reported current tobacco smoking, compared to 20% of the general population [5]. Cannabis use among patients with psychotic disorders is more than twice as high as that among the general population [6]. With respect to alcohol, patients with a psychotic disorder exhibit a fourfold increased risk of heavy alcohol consumption [7]. Importantly, the use of substances in psychotic disorders is associated with several adverse effects, including a threefold increase in psychotic relapses [8] and higher rates of violence and suicides compared to nonusers [9].
The association between substance use and social functioning remains less clear. In a meta-analysis conducted by Large et al. [2] among patients with psychosis, the overall conclusion was that substance use was not linked to diminished social functioning. It is noteworthy, however, that the term “social functioning” is a broad concept encompassing several components. In the aforementioned meta-analysis [2], social functioning in the majority of studies was defined by clinician-rated assessments. Some authors concluded that patients’ perspectives on aspects of social functioning in psychosis may differ from assessments made by clinicians [10]. There is an increasing effort to encompass the personal experience of participation and recovery in patients with psychosis [11]. In that light, studying the patient’ perspective on social functioning might be of interest.
When focusing on self-reported aspects of social functioning, loneliness was positively associated with comorbid drug or alcohol use [12]. Furthermore, one fairly recent study in patients with psychosis showed that smoking was negatively associated with self-reported participation in prosocial activities [13]. Another study in psychosis found that patients with problematic alcohol use reported more problems in interpersonal and family relationships [14]. To the best of our knowledge, the relationship between cannabis use and self-reported aspects of social functioning among patients with psychosis has not yet been studied.
Taken together, the literature on the relationships between substance use and various aspects of self-reported social functioning in patients with a psychotic disorder is scarce. In most studies that explored these relationships, clinician-rated scales [15–17] were used, thereby missing potential important self-reported information. What is more, the majority of studies concentrated on general substance use (including cannabis, alcohol, and stimulants), rather than exploring the relationships between social aspects and specific substances separately. This approach may overlook possible different associations between different substances and self-reported social aspects.
Therefore, the aim of the current study is to examine the specific associations of tobacco, cannabis or alcohol use with different self-reported aspects of social functioning (perceived social support, stigmatization, reported social participation, and loneliness).
Method
Study sample and design
A cross-sectional study was performed that was based on a local research cohort “Deinstitutionalization Amsterdam.” This cohort consisted of a representative sample of adults with a severe mental illness living independently (i.e., not clinically admitted). Participants were recruited from the SMI patient populations of the two largest mental health care institutions located in Amsterdam, where they receive mental health care. Detailed information about the composition of this cohort and the study procedures is described elsewhere [18]. In the current study, we included 281 patients diagnosed with a psychotic disorder (according to the DSM-V criteria). Within this sample, 172 (61.2%) patients had a schizophrenia spectrum disorder (DSM-IV 295.4 and 295.9), 56 (19.9%) were diagnosed with a schizoaffective disorder (DSM-IV 295.7), and 53 (18.9%) had a diagnosis of unspecified psychosis (293.81, 297.1, and 298.8). Inclusion criteria were an age range from 18 to 65 years and proficiency in either Dutch or English. The study was approved by the medical ethical review committee of the Amsterdam University Medical Centre (METC-AMC W16_276 # 16.324). Prior to the interview, participants provided written informed consent concerning both the interview and retrieval of information from patient files. All participants received a financial compensation of 15 euros. The data were obtained by research assistants from the mental health care institutions who interviewed the participants using a series of structured and validated questionnaires on among others substance use and social functioning. Data were collected between December 2017 and February 2020.
Assessment instruments
Substance use
Severity and frequency of substance use (tobacco, cannabis, and alcohol) were assessed using the Measurements in the Addictions for Triage and Evaluation, which was found to be reliable in patients with substance use problems [19].
With respect to tobacco use, all patients were asked how much they smoked on average per day in the past 30 days: 0 cigarettes/day (nonusers), 1–9 cigarettes/day (low users), 10–19 cigarettes/day (moderate users), and 20 or more cigarettes/day (heavy users) [20]. In the current analyses, low and moderate users (1–19 cigarettes per day) were collapsed into a single user group due to the small sample sizes, which would limit the power of the analyses.
The use of cannabis was assessed by asking participants how many days they used cannabis on average in the past 30 days [21]. Patients were categorized into three different categories: nonusers, non-daily users, and daily users [22].
Hazardous alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT) [23], ranging from 0 to 40, which differentiates between non-problematic and problematic alcohol use. Cut-off cores were set at eight or higher in males and six or higher in females [24].
Covariates
All participants provided information on sociodemographic features. A priori, we selected age, gender, and severity of psychopathology as potential confounders as these variables are associated with substance use and several aspects of social functioning [33, 34]. To rate the severity of psychopathology, the Brief Psychiatric Rating Scale (BPRS) was administered [35]. The BPRS is a widely used 24-item tool to measure the presence and severity of several psychiatric symptoms and behavior in patients with a psychiatric disorder by observation and self-reports during a semi-structured interview.
The BPRS consists of five different subscales (positive symptoms, negative symptoms, affectivity, resistance, and activation). In the analyses, the BPRS total score was included as a covariate. The BPRS has been tested for validity and reliability, which appeared to be satisfactory [36].
Statistical analyses
Statistical analyses were performed using IBM SPSS Statistics version 26. The normality of the distribution of scores on the outcomes of interest was assessed by visual inspection of the histograms, which showed no deviations from normality. Linear regression models were used to evaluate the associations between substance use and social aspects. Each substance was entered as an independent variable with each of the self-reported aspects of social functioning as the dependent variable while correcting for age, gender, and psychopathology. As the independent variables were multi-categorical, dummy variables were created with “no use” being the reference group. As sensitivity analyses, a second set of linear regression analyses, were performed with the independent variables number of cigarettes smoked per day and the amount of cannabis smoked per day (uniformed in grams) instead of the multi-categorical variables. Finally, we explored the potential differences in self-reported aspects of social functioning between no users, single substance users, and polysubstance users (≥two substances). All statistical tests were two-sided, and significance was set at p < 0.05.
Results
As shown in Table 1, all participants had data available on tobacco, cannabis use, and alcohol use. Summary scores of the self-reported aspects of social functioning per substance group are listed in Supplement 1.
| Gender | |
| Male | 193 (68.7%) |
| Female | 88 (31.3%) |
| Age (years) | 48 (9.8) |
| Education a | N = 279 |
| Primary education | 181 (64.9%) |
| Secondary education | 69 (24.7%) |
| Higher education | 29 (10.4%) |
| Psychopathology | |
| BPRS – positive symptoms | 1.93 (1.03), N = 274 |
| BPRS – negative symptoms | 1.72 (0.74), N = 273 |
| BPRS – depressive symptoms | 2.03 (0.90), N = 272 |
| BPRS – disorganization symptoms | 1.43 (0.47), N = 273 |
| BPRS – mean total score | 1.75 (0.52), N = 273 |
| Tobacco | |
| No use (0 cigarette/day) | 123 (43.8%) |
| Low-intermediate use (1–19 cig/day) | 82 (29.2%) |
| Heavy use (≥20 cigarettes/day) | 76 (27.0%) |
| Cannabis use | |
| Non-use | 216 (76.9%) |
| Non-daily use | 38 (13.5%) |
| Daily use | 27 (9.6%) |
| Alcohol use | |
| No use | 106 (37.7%) |
| Non-problematic use | 112 (39.9%) |
| Problematic use | 63 (22.4%) |
| Polysubstance use b | |
| No substances | 59 (21.0%) |
| Single substance | 92 (32.7%) |
| Two substances | 78 (27.8%) |
| Three substances | 52 (18.5%) |
The prevalence estimate of tobacco use was 55.8%, and tobacco users smoked 19 cigarettes per day on average. A total of 23.1% patients used cannabis, with 13.5% on a non-daily and 9.6% on a daily basis. With respect to alcohol, 62.3% of all participants used alcohol and 22.4% were problematic alcohol users. Concerning polysubstance use, 92 (32.7%) patients used one substance (tobacco, cannabis, or alcohol) and 130 (46.3%) patients were polysubstance users, of which 78 (27.8%) used two of the above-mentioned substances and 52 (18.5%) used all three substances.
Tobacco
Compared to nonsmokers, both intermediate and heavy smoking patients showed lower scores on loneliness (E = −0.580, SE = 0.258, p = 0.025 and E = −0.547, SE = 0,272, p = 0.046, respectively) when correcting for confounders, as shown in Table 2. A post hoc analysis (Supplement 2) revealed a negative association between the number of cigarettes smoked per day and levels of loneliness (E = −0.017, SE = 0.008, p = 0.042). Perceived social support, reported social participation, and stigmatization were not significantly associated with tobacco after adjusting for confounders.
| Intermediate smoker versus No smoker | Heavy smoker versus No smoker | |
|---|---|---|
| Outcome variable | Estimate (SE) [95% CI], p-value | Estimate (SE) [95% CI], p-value |
| Social support | 0.053 (0.992) [−1.900–2.005], p = 0.958 | 0.858 (1.052) [−1.214–2.930], p = 0.416 |
| Stigmatization – disclosure | −1.237 (1.186) [−0.079 – −1.043], p = 0.298 | −0.631 (1.288) [−0.028 – −0.490], p = 0.625 |
| Stigmatization – discrimination | −1.028 (1.138) [−3.274–1.217], p = 0.367 | 2.055 (1.248) [−0.406–4.516], p = 0.101 |
| Stigmatization – positive aspects | 0.706 (0.495) [−0.269–1.681], p = 0.155 | 0.979 (0.533) [−0.072–2.031], p = 0.068 |
| Lack of social participation | 0.035 (0.100) [−0.163–0.232], p = 0.729 | 0.075 (0.107) [−0.134–0.285], p = 0.479 |
| Loneliness | −0.580 (0.258) [−1.088 – −0.072], p = 0.025* | −0.547 (0.272) [−1.083 – −0.011], p = 0.046* |
| Non-daily cannabis versus No cannabis | Daily cannabis versus No cannabis | |
| Outcome variable | Estimate (SE) [95% CI], p-value | Estimate (SE) [95% CI], p-value |
| Social support | 1.475 (1.237) [−0.960–3.910], p = 0.234 | 0.567 (1.444) [−2.276–3.411], p = 0.695 |
| Stigmatization – disclosure | −0.984 (1.500) [−3942 – −1.974], p = 0.513 | 0.671 (1.663) [−2.609–3.950], p = 0.687 |
| Stigmatization – discrimination | 0.792 (1.431) [−2.030–3.615], p = 0.580 | −0.623 (1.638) [−3.854–2.607], p = 0.704 |
| Stigmatization – positive aspects | 0.524 (0.625) [−0.709–1.757], p = 0.403 | 0.351 (0.715) [−1.058–1.760], p = 0.624 |
| Lack of social participation | −0.115 (0.124) [−0.359–0.129], p = 0.355 | −0.348 (0.145) [−0.633 – −0.063], p = 0.017* |
| Loneliness | −0.203 (0.324) [−0.804–0.434], p = 0.531 | 0.276 (0.382) [−0.475–1.028], p = 0.470 |
| Non-problematic alcohol versus No alcohol | Problematic alcohol versus No alcohol | |
| Outcome variable | Estimate (SE) [95% CI], p-value | Estimate (SE) [95% CI], p-value |
| Social support | 0.883 (0.912) [−0.912–2.678], p = 0.334 | 3.152 (1.102) [0.982–5.321], p = 0.005* |
| Stigmatization – disclosure | 0.193 (1.123) [−2.021–2.408], p = 0.864 | −1.618 (1.372) [−4.323–1.086], p = 0.239 |
| Stigmatization – discrimination | −0.148 (1.085) [−2.288–1.993], p = 0.892 | 1.175 (1.321) [−1.431–3.781], p = 0.375 |
| Stigmatization – positive aspects | 0.700 (0.466) [−0.219–1.619], p = 0.135 | 0.222 (0.572) [−0.906–1.350], p = 0.698 |
| Lack of social participation | −0.044 (0.093) [−0.227–0.139], p = 0.637 | −0.200 (0.113) [−0.422–0.022], p = 0.078 |
| Loneliness | −0.077 (0.243) [−0.554–0.401], p = 0.544 | −0.350 (0.292) [−0.926–0.225], p = 0.232 |
Cannabis
Patients who used cannabis daily reported less social participation deficits than patients who did not use cannabis (E = −0.348, SE = 0.145, p = 0.017). In a sensitivity analysis, we explored whether a dose–response relationship existed between the amount of cannabis smoked per day (uniformed in grams) and reported social participation. No significant association was found, as shown in Supplement 3. Neither perceived social support, reported stigmatization, nor loneliness were significantly associated with cannabis use when correcting for confounders (Table 2).
Alcohol use
Problematic alcohol use was associated with more perceived social support compared to no-alcohol use (E = 3.152, SE = 1.102, p = 0.005) after adjusting for confounders, as shown in Table 2. Given differences in the literature regarding the cut-off scores for problematic alcohol use [24, 37], we also explored whether this association remained significant when raising the AUDIT cut-off score to 16, indicating severe problematic use [37]. As shown in Supplement 4, outcomes were not affected (E = 3.394, SE = 1.581, p = 0.033). Alcohol use was not significantly related to social participation, stigmatization, and loneliness when correcting for all confounders.
Polysubstance use
Patients with polysubstance use reported less loneliness compared to no users (E = −0.569, SE = 0.287, p = 0.049) (Supplement 5). No significant differences were found between no users, single substance users, and polysubstance users on all other self-reported aspects of social functioning.
Discussion
Main findings
The current study mapped substance use among community-dwelling patients with a psychotic disorder in the Netherlands and examined associations between the use of specific substances (tobacco, cannabis, alcohol) and several self-reported aspects of social functioning.
Tobacco use (intermediate and heavy use) was associated with less self-reported loneliness compared to those who did not smoke. Patients with cannabis use reported more social participation compared to non-cannabis-using patients. Problematic alcohol use was associated with more self-reported social support compared to non-problematic alcohol use. On the subscales of the stigma scale (including self-stigma [disclosure] and experienced stigma [discrimination]), no differences were found between any of the substance user groups. Finally, we found that self-reported loneliness was less prevalent among patients with polysubstance use than among nonusers. In summary, severe use of both cannabis and alcohol seems to be associated with better self-reported scores on some of the outcomes investigated. Concerning tobacco, this relationship was also found in patients with low to intermediate use and heavy use.
Current findings in the light of previous literature
The prevalence estimate of tobacco use in our study (55.8%) is consistent with the rate (62%) found in a large population of patients with a psychotic disorder [4]. With respect to cannabis, the prevalence of daily use in our study population (9.6%) was lower compared to rates of cannabis abuse in psychotic patients in general (20%), as shown in a meta-analysis [38]. Concerning alcohol, the prevalence estimate of problematic use of 22.4% obtained in our study was consistent with the literature [39]. With respect to polysubstance use, our prevalence rate of 46.3% was higher compared to rates (30%) found by another study [40]. This could be explained by the fact that the latter study only included patients who misused two or more substances, whereas in our study, patients who used two or more substances were also included. One study [41] suggested that cannabis use can be regarded as a proxy-measure for the use of other drugs. This notion appears to be confirmed in our study, as there were only two patients who used cannabis but none of the other substances.
To the best of our knowledge, no previous studies evaluated the relationship between tobacco use (smoking) and perceived loneliness in patients with a psychotic disorder. Smoking was associated with less perceived loneliness. The direction of this association remains unclear. Based on findings in the general population, where three large studies [42–44] concluded that smoking increased self-reported feelings of loneliness and social isolation, this finding was contrary to our expectations.
One could argue that assessments made by clinicians may differ from those self-reported by patients with psychosis. Indeed, a study indicated that elevated levels of perceived loneliness in individuals with psychosis were not dependent on objective social isolation [12], challenging the assumption that perceived loneliness is solely a consequence of limited social contact in psychosis. In that light, it is of interest to explore in future psychosis studies the relationship between substance use and both self-reported and clinician-rated aspects of social functioning. Furthermore, it is widely recognized that patients with psychosis experience increased feelings of loneliness compared to the general population [45]. For patients experiencing psychosis, smoking was perceived as a way to find relief from loneliness [46, 47] – even though this may not be associated with a reduction in objective social isolation.
To the best of our knowledge, no other studies evaluated the relationship between cannabis and self-reported social participation. The existing literature utilizing clinician-rated scales on social aspects reported conflicting findings. For instance, a study [48] demonstrated that patients without cannabis use disorder showed significant improvements in social functioning over time. This aligns with two other studies reporting that continued cannabis correlated with poorer social functioning [49–51], while others concluded that cannabis use was linked to enhanced global social functioning in individuals with an increased risk for psychosis [52]. Given these conflicting results, future studies could investigate the relationship between cannabis use and both self-reported and clinician-rated aspects of social functioning.
An explanation for the positive relationship between cannabis and more self-reported social participation in our study could also be related to potential differences in the patients’ profile: it might be that cannabis use may precipitate psychosis in individuals who would otherwise not transit to a psychotic disorder [53], compared to patients who converted without using cannabis [54]. This explanation is in line with the vulnerability-stress model, in which cannabis use is a risk factor to pass the threshold and develop a psychotic disorder [55]. Hence, those with cannabis use and a psychotic disorder might be better socially functioning with less severe cognitive impairments than non-cannabis-using patients, who are thought to be more vulnerable due to genetic factors [56]. Another explanation is that cannabis use occurs within a bidirectional social-cannabis context, wherein the craving for cannabis adds active engagement with a specific peer group mutually reinforced each other, resulting in increased cannabis consumption.
With respect to alcohol, we found that problematic alcohol use was associated with higher scores on perceived social support, which was at odds with another study [14], where patients reported more alcohol associated-problems in interpersonal and family relationships compared to non-problematic users. This is in line with Cetty et al [57], who found that hazardous alcohol use predicted lower self-reported scores on social relationships in patients with a first-episode psychosis. Differences in the exact outcome scores (perceived social support vs. the quality of relationships) might play a role in these divergent findings.
It might be that patients with increased social interaction are more at risk for problematic alcohol use as they may go along with individuals with problematic alcohol use. Some support for this explanation comes from a recent study conducted in the general population that found that adolescents with less social interest used alcohol less frequently [58]. Furthermore, a number of psychosis studies have found that alcohol use, including binge drinking [59] and hazardous drinking [57], was associated with lower severity of negative symptoms [60–62]. It has been suggested that impaired rewarding systems in patients with severe negative symptoms could be associated with diminished reinforcing effects of alcohol use [61]. Given the overlap between lower negative symptom severity and higher social support as an outcome in the current study, this could play a role in explaining our findings.
We did not find any significant relationship between any of the substances and perceived stigmatization. It is, nonetheless, important to acknowledge that in one study, patients reported to smoke to relief feelings of stigma by trying to “fit in” [46]. Correspondingly, smoking cessation was associated with fear of being socially ostracized when quitting smoking [63]. However, in the past decades, smoking actually became more associated with stigma [64]. Furthermore, previous literature found that especially those who experience disapproval by others over their inability to give up tobacco feel stigmatized [64]. Patients with a psychotic disorder can be seen as harder-to-treat smokers [65]. Therefore, efforts should be directed toward assisting patients in smoking cessation, not least because quitting has also been associated with reductions in public stigma and discrimination [66] along with decreases of depression, anxiety, and stress [67].
Strengths and limitations
The strengths of the current study are the relatively large sample, representative of patients with psychotic disorders living in the community, and the evaluation of different substances on several self-reported aspects of social functioning, allowing for an in-depth examination of separate relationships between substance use and self-reported aspects of social functioning in patients with a psychotic disorder. However, the current study has several limitations. First, the cross-sectional design of the current study lacks the capability of evaluating the potential causal effects of substance use behavior in relation to several self-reported aspects of social functioning. Second, reverse causality and residual confounding cannot be ruled out due to the cross-sectional analyses and observational design. Third, information concerning the use of medication was missing. Fourth, given the explorative design of the current study, we chose to set the statistical significance at p < 0.05 instead of using a more conservative approach as Bonferroni correction for multiple testing. However, by this decision, we introduced the risk of a type-I error. Fifth, the majority of the study population was male (68.7%) and lower educated (64.9%), although these characteristics are probably representative for the group of patients with longstanding psychotic disorders. Sixth, the assessment of frequency and severity of substance use was based on self-report. Hence, under- or overestimation of substance use cannot be ruled out. Seventh, we did not correct for polysubstance use in our main analyses as dissecting out individual substance use would have drastically decreased the sample size. Nevertheless, we aimed to explore the effects of comorbid use by analyzing no users, single users, and polysubstance users. Finally, the outcome “social participation” was based on one subscale of the SEI-HS that included only four items. This could potentially have led to low content validity.
Clinical implications
In the current study, smoking was associated with less perceived loneliness. As the negative health consequences of tobacco are disastrous, patients should be encouraged to stop smoking. As smoking may be a maladaptive coping strategy, it is beneficial to the patient to replace smoking with healthier coping skills. Referring the patient for psychological and behavioral treatment is required.
Therapists should be alert on the possibility that loneliness may be an issue and that individuals who try to stop smoking may need support in this respect. In the Netherlands, referral to a certified coach for psychological smoking cessation interventions is covered by the health insurance and should be offered more consequently to patients with psychosis.
In the current sample, psychotic patients who use cannabis reported betters scores on social participation. Consequently, for some patients, it might be that cannabis use is considered helpful in facilitating social interactions. However, the overwhelming (long-term) negative effects of cannabis have been documented [68], and cannabis reduction had favorable effects on symptoms and social functioning [69]. Therefore, it is important to help patients in finding education, work, or other structured activities, as these are crucial elements for enabling a reduction in cannabis use and, at the same time, finding alternative social participation [70, 71].
Concerning current findings of the association between (heavy) alcohol use and self-reported aspects of social functioning in patients with a psychotic disorder, longitudinal studies are needed to explore causality.
In the current study, polysubstance users reported less loneliness compared to patients who did not use drugs. A review that explored the reasons for polysubstance use [72] concluded that substances are generally combined to improve experiences and to increase/prolong a state of euphoria. It might be that negative feelings of loneliness are masked by a “high” state caused by polysubstance use. Nonetheless, psychosis risk was found to be associated with the cumulative effect of polysubstance use [41]. What is more, polysubstance use is also related to more psychiatric and psychosocial problems [73]. In future research, it might be interesting to explore other social aspects (for example functional or symptomatic recovery) in polysubstance users compared to single users and no users.
Supporting information
Acknowledgments
The authors would like to thank all participants who took part in the study.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1192/j.eurpsy.2024.9.
Financial support
Funding for this study was received from the “Stichting tot Steun VCVGZ” and the municipality of Amsterdam.
Competing interest
The authors have declared that there are no conflicts of interest in relation to the subject of this study.
References
Untitled section
References
- [1]Metzak PD, Farris MS, Placsko T, Braun A, Bonneville D, Brummitt K, et al. Social functioning and brain imaging in individuals at clinical high-risk for psychosis: A systematic review. Schizophr Res. 2021;233:3–12.
- [2]Large M, Mullin K, Gupta P, Harris A, Nielssen O. Systematic meta-analysis of outcomes associated with psychosis and co-morbid substance use. Aust N Z J Psychiatry. 2014;48(5):418–32.
- [3]Lähteenvuo M, Batalla A, Luykx JJ, Mittendorfer-Rutz E, Tanskanen A, Tiihonen J, et al. Morbidity and mortality in schizophrenia with comorbid substance use disorders. Acta Psychiatr Scand. 2021;144:42–9.
- [4]Dickerson F, Schroeder J, Katsafanas E, Khushalani S, Origoni AE, Savage C, et al. Cigarette smoking by patients with serious mental illness, 1999–2016: An increasing disparity. Psychiatr Serv. 2018;69(2):147–53.
- [5]WHO. WHO global report on trends in prevalence of tobacco use 2000–2025, third edition. Geneva: World Health Organization; 2020.
- [6]Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: Examination of the evidence. Br J Psychiatry. 2004;184(2):110–7.
- [7]Hartz SM, Pato CN, Medeiros H, Cavazos-Rehg P, Sobell JL, Knowles JA, et al. Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry. 2014;71(3):248–54.
- [8]Alvarez-Jimenez M, Priede A, Hetrick SE, Bendall S, Killackey E, Parker AG, et al. Risk factors for relapse following treatment for first episode psychosis: A systematic review and meta-analysis of longitudinal studies. Schizophr Res. 2012;139(1):116–28.
- [9]Darke S, Lappin J, Farrell M. The clinician’s guide to illicit drugs and health. United Kingdom: Silverback Publishing; 2019.
- [10]Jongs N, Penninx B, Arango C, Ayuso-Mateos JL, van der Wee N, Winter-van Rossum I, et al. Effect of disease related biases on the subjective assessment of social functioning in Alzheimer’s disease and schizophrenia patients. J Psychiatr Res. 2022;145:302–8.
- [11]Simonsen C, Faerden A, Ueland T, Vaskinn A, Bjella T, Andreassen O, et al. Self-rated disability in first treated episode of psychosis: A 1-year follow-up study. Compr Psychiatry. 2018;85:48–54.
- [12]Trémeau F, Antonius D, Malaspina D, Goff DC, Javitt DC. Loneliness in schizophrenia and its possible correlates. An exploratory study. Psychiatry Res. 2016;246:211–7.
- [13]Dekker TEG, van der Heijden HS, Schirmbeck F, van Amelsvoort T, Bartels-Velthuis AA, Simons CJP, et al. The association between smoking behaviour, social cognition and social functioning in patients with a non-affective psychotic disorder: A prospective follow-up study. Schizophr Res Cogn. 2021;26:100206.
- [14]Salyers MP, Mueser KT. Social functioning, psychopathology, and medication side effects in relation to substance use and abuse in schizophrenia. Schizophr Res 2001;48(1):109–23.
- [15]Cantwell R. Substance use and schizophrenia: Effects on symptoms, social functioning and service use. Br J Psychiatry. 2003;182:324–9.
- [16]Drake RE, Brunette MF, Mueser KT. Substance use disorders and social functioning in schizophrenia. In Mueser K. T. & Tarrier N. (Eds.) Handbook of social functioning in schizophrenia, Boston, MA: Allyn & Bacon; 1998, p. 280–9. https://www.researchgate.net/publication/313520393_Substance_use_disorders_and_social_functioning_in_schizophrenia
- [17]Swartz MS, Wagner HR, Swanson JW, Stroup TS, McEvoy JP, McGee M, et al. Substance use and psychosocial functioning in schizophrenia among new enrollees in the NIMH CATIE study. Psychiatr Serv. 2006;57(8):1110–6.
- [18]Segeren M, Lauriks S, Kikkert M, Heering J, Lommerse N, van Husen G, et al. Deinstitutionalization from the perspective of community-dwelling adults with a severe mental illness in Amsterdam: A cohort study protocol. BMC Public Health. 2022;22(1):950.
- [19]Schippers GM, Broekman TG, Buchholz A, Koeter MW, van den Brink W. Measurements in the addictions for triage and evaluation (MATE): An instrument based on the World Health Organization family of international classifications. Addiction. 2010;105(5):862–71.
- [20]Ward HB, Lawson MT, Addington J, Bearden CE, Cadenhead KS, Cannon TD, et al. Tobacco use and psychosis risk in persons at clinical high risk. Early Interv Psychiatry. 2019;13(5):1173–81.
- [21]Coutinho LS, Honorato H, Higuchi CH, Cavalcante DA, Belangeiro S, Noto M, et al. Cannabis acute use impacts symptoms and functionality in a cohort of antipsychotic naive first episode of psychosis individuals. Schizophr Res Cogn. 2019;16:12–6.
- [22]Di Forti M, Sallis H, Allegri F, Trotta A, Ferraro L, Stilo SA, et al. Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users. Schizophr Bull. 2014;40(6):1509–17.
- [23]Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The alcohol use disorders identification test: Guidelines for use in primary health care. 2nd ed. Geneva: World Health Organization; 2001.
- [24]Nehlin C, Fredriksson A, Jansson L. Brief alcohol screening in a clinical psychiatric population: Special attention needed. Drug Alcohol Rev. 2012;31(4):538–43.
- [25]van Sonderen FLP. Het meten van sociale steun. Ph.D. Thesis; 1991.
- [26]Kempen G, Eijk L. The psychometric properties of the SSL12-I, a short scale for measuring social support in the elderly. Soc Indic Res. 1995;35:303–12.
- [27]King M, Dinos S, Shaw J, Watson R, Stevens S, Passetti F, et al. The stigma scale: Development of a standardised measure of the stigma of mental illness. Br J Psychiatry. 2007;190:248–54.
- [28]van Bergen APL, Hoff SJM, van Ameijden EJC, van Hemert AM. Measuring social exclusion in routine public health surveys: Construction of a multidimensional instrument. PLoS One. 2014;9(5):e98680.
- [29]van Bergen APL, Hoff SJM, Schreurs H, van Loon A, van Hemert AM. Social exclusion index-for health surveys (SEI-HS): A prospective nationwide study to extend and validate a multidimensional social exclusion questionnaire. BMC Public Health. 2017;17(1):253.
- [30]Terwee CB, Bot SDM, de Boer MR, van der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34–42.
- [31]de Jong-Gierveld J, van Tilburg TG. Manual of the Loneliness Scale. Methoden en technieken; 1999, 10.17605/osf.io/u6gck.
- [32]de Jong-Gierveld J, van Tilburg T. [A shortened scale for overall, emotional and social loneliness]. Tijdschr Gerontol Geriatr. 2008;39(1):4–15.
- [33]Weibell MA, Hegelstad WtV, Auestad B, Bramness J, Evensen J, Haahr U, et al. The effect of substance use on 10-year outcome in first-episode psychosis. Schizophr Bull. 2017;43(4):843–51.
- [34]de Winter L, Couwenbergh C, van Weeghel J, Hasson-Ohayon I, Vermeulen JM, Mulder CL, et al. Changes in social functioning over the course of psychotic disorders: A meta-analysis. Schizophr Res. 2022;239:55–82.
- [35]Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep. 1962;10(3):799–812.
- [36]Thomas A, Donnell AJ, Young TR. Factor structure and differential validity of the expanded brief psychiatric rating scale. Assessment 2004;11(2):177–87.
- [37]Kumar CN, Thirthalli J, Suresha KK, Arunachala U, Gangadhar BN. Alcohol use disorders in patients with schizophrenia: Comparative study with general population controls. Addict Behav. 2015;45:22–5.
- [38]Koskinen J, Lohonen J, Koponen H, Isohanni M, Miettunen J. Rate of cannabis use disorders in clinical samples of patients with schizophrenia: A meta-analysis. Schizophr Bull. 2010;36(6):1115–30.
- [39]Hunt GE, Large MM, Cleary M, Lai HMX, Saunders JB. Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990–2017: Systematic review and meta-analysis. Drug Alcohol Depend. 2018;191:234–58.
- [40]Wade D, Harrigan S, Edwards J, Burgess PM, Whelan G, McGorry PD. Substance misuse in first-episode psychosis: 15-month prospective follow-up study. Br J Psychiatry. 2006;189:229–34.
- [41]Shevlin M, McElroy E, Murphy J, Hyland P, Vallieres F, Elklit A, Christoffersen M. Cannabis and psychosis: The impact of polydrug use. Drugs Alcohol Today. 2017;17(3):186–94.
- [42]Wootton RE, Greenstone HSR, Abdellaoui A, Denys D, Verweij KJH, Munafò MR, Treur JL. Bidirectional effects between loneliness, smoking and alcohol use: Evidence from a Mendelian randomization study. Addiction. 2021;116(2):400–6.
- [43]Philip KE, Bu F, Polkey MI, Brown J, Steptoe A, Hopkinson NS, et al. Relationship of smoking with current and future social isolation and loneliness: 12-year follow-up of older adults in England. Lancet Reg Health Eur. 2022;14:100302.
- [44]Matsuyama Y, Tabuchi T. Does tobacco smoking increase social isolation? A Mendelian randomization study. Am J Epidemiol. 2023. doi: 10.1093/aje/kwad229.
- [45]Michalska da Rocha B, Rhodes S, Vasilopoulou E, Hutton P. Loneliness in psychosis: A meta-analytical review. Schizophr Bull. 2018;44(1):114–25.
- [46]Trainor K, Leavey G. Barriers and facilitators to smoking cessation among people with severe mental illness: A critical appraisal of qualitative studies. Nicotine Tob Res. 2017;19(1):14–23.
- [47]Gregg L, Barrowclough C, Haddock G. Reasons for increased substance use in psychosis. Clin Psychol Rev. 2007;27(4):494–510.
- [48]Gonzalez-Blanch C, Gleeson JF, Koval P, Cotton SM, McGorry PD, Alvarez-Jimenez M. Social functioning trajectories of young first-episode psychosis patients with and without cannabis misuse: A 30-month follow-up study. PLoS One. 2015;10(4):e0122404.
- [49]Bruins J, Pijnenborg GHM, Visser E, Castelein S. The association of cannabis use with quality of life and psychosocial functioning in psychosis. Schizophr Res. 2021;228:229–34.
- [50]Faber G, Smid HG, Van Gool AR, Wunderink L, van den Bosch RJ, Wiersma D. Continued cannabis use and outcome in first-episode psychosis: Data from a randomized, open-label, controlled trial. J Clin Psychiatry. 2012;73(5):632–8.
- [51]Seddon JL, Birchwood M, Copello A, Everard L, Jones PB, Fowler D, et al. Cannabis use is associated with increased psychotic symptoms and poorer psychosocial functioning in first-episode psychosis: A report from the UK national EDEN study. Schizophr Bull. 2015;42(3):619–25.
- [52]Auther AM, McLaughlin D, Carrión RE, Nagachandran P, Correll CU, Cornblatt BA. Prospective study of cannabis use in adolescents at clinical high risk for psychosis: Impact on conversion to psychosis and functional outcome. Psychol Med. 2012;42(12):2485–97.
- [53]Peralta V, García de Jalón E, Moreno-Izco L, Peralta D, Janda L, Sánchez-Torres AM, Cuesta MJ. Long-term outcomes of first-admission psychosis: A naturalistic 21-year follow-up study of symptomatic, functional and personal recovery and their baseline predictors. Schizophr Bull. 2022;48(3):631–42.
- [54]Yücel M, Bora E, Lubman DI, Solowij N, Brewer WJ, Cotton SM, et al. The impact of cannabis use on cognitive functioning in patients with schizophrenia: A meta-analysis of existing findings and new data in a first-episode sample. Schizophr Bull. 2012;38(2):316–30.
- [55]Lemvigh C, Brouwer R, Hilker R, Anhøj S, Baandrup L, Pantelis C, et al. The relative and interactive impact of multiple risk factors in schizophrenia spectrum disorders: A combined register-based and clinical twin study. Psychol Med. 2021;53:1266–1276.
- [56]Kayir H, Ruffolo J, McCunn P, Khokhar JY. The relationship between cannabis, cognition, and schizophrenia: It’s complicated. Curr Top Behav Neurosci. 2023;63:437–61.
- [57]Cetty L, Shahwan S, Satghare P, Devi F, Chua BY, Verma S, et al. Hazardous alcohol use in a sample of first episode psychosis patients in Singapore. BMC Psychiatry. 2019;19(1):91.
- [58]Pijnenburg LJ, Kaplun A, de Haan L, Janecka M, Smith L, Reichenberg A, et al. Autistic traits and alcohol use in adolescents within the general population. Eur Child Adolesc Psychiatry. 2023;32:1633–42.
- [59]Tan JH, Shahwan S, Satghare P, Cetty L, Verma S, Sendren JR, et al. Binge drinking: Prevalence, correlates, and expectancies of alcohol use among individuals with first-episode psychosis. Early Interv Psychiatry. 2019;13(5):1136–45.
- [60]Archie S, Gyomorey K. First episode psychosis, substance abuse and prognosis: A systematic review. Curr Psychiatr Rev. 2009;5:153–63.
- [61]Batki SL, Leontieva L, Dimmock JA, Ploutz-Snyder R. Negative symptoms are associated with less alcohol use, craving, and “high” in alcohol dependent patients with schizophrenia. Schizophr Res. 2008;105(1–3):201–7.
- [62]Van Mastrigt S, Addington J, Addington D. Substance misuse at presentation to an early psychosis program. Soc Psychiatry Psychiatr Epidemiol. 2004;39(1):69–72.
- [63]Filia SL, Baker AL, Gurvich CT, Richmond R, Kulkarni J. The perceived risks and benefits of quitting in smokers diagnosed with severe mental illness participating in a smoking cessation intervention: Gender differences and comparison to smokers without mental illness. Drug Alcohol Rev. 2014;33(1):78–85.
- [64]Castaldelli-Maia JM, Ventriglio A, Bhugra D. Tobacco smoking: From ‘glamour’ to ‘stigma’. A comprehensive review. Psychiatry Clin Neurosci. 2016;70(1):24–33.
- [65]Zeng LN, Zong QQ, Zhang L, Feng Y, Ng CH, Ungvari GS, et al. Worldwide prevalence of smoking cessation in schizophrenia patients: A meta-analysis of comparative and observational studies. Asian J Psychiatr. 2020;54:102190.
- [66]McGinty EE, Goldman HH, Pescosolido B, Barry CL. Portraying mental illness and drug addiction as treatable health conditions: Effects of a randomized experiment on stigma and discrimination. Soc Sci Med. 2015;126:73–85.
- [67]Taylor GM, Lindson N, Farley A, Leinberger-Jabari A, Sawyer K, Te Water Naude R, et al. Smoking cessation for improving mental health. Cochrane Database Syst Rev. 2021;3:CD013522.
- [68]Schoeler T, Monk A, Sami MB, Klamerus E, Foglia E, Brown R, et al. Continued versus discontinued cannabis use in patients with psychosis: A systematic review and meta-analysis. Lancet Psychiatry. 2016;3(3):215–25.
- [69]Setién-Suero E, Neergaard K, Ortiz-García de la Foz V, Suárez-Pinilla P, Martínez-García O, Crespo-Facorro B, Ayesa-Arriola R. Stopping cannabis use benefits outcome in psychosis: Findings from 10-year follow-up study in the PAFIP-cohort. Acta Psychiatr Scand. 2019;140(4):349–59.
- [70]Thornton LK, Baker AL, Lewin TJ, Kay-Lambkin FJ, Kavanagh D, Richmond R, et al. Reasons for substance use among people with mental disorders. Addict Behav. 2012;37(4):427–34.
- [71]de Haan L. It might be a wonderful opportunity when patients with a psychotic disorder use cannabis. Psychol Med. 2022;52(4):601–2.
- [72]Boileau-Falardeau M, Contreras G, Gariépy G, Laprise C. Patterns and motivations of polysubstance use: A rapid review of the qualitative evidence. Health Promot Chronic Dis Prev Can. 2022;42(2):47–59.
- [73]Peters EN, Schwartz RP, Wang S, O’Grady KE, Blanco C. Psychiatric, psychosocial, and physical health correlates of co-occurring cannabis use disorders and nicotine dependence. Drug Alcohol Depend. 2014;134:228–34.