Previous studies have documented high rates of psychiatric comorbidity in adolescents reporting the use of alcohol, nicotine and other substances. But many questions remain. Do psychiatric symptoms underlie or contribute to substance use? Or does the use of certain substances, especially at higher doses, increase risk for psychiatric symptoms? A recent study from Brendon Tervo-Clemmens, PhD, Randi Schuster, PHD, and colleagues from the Center for Addiction Medicine explores whether there is a dose-dependent relationship between substance use and various psychiatric symptoms among high school students and whether this association varied based on the type of substance used.
In this study, the team analyzed data from two large, independent surveys of high school students. The first sample included students from 36 Massachusetts high schools who completed the 2022-2023 Substance Use and Risk Factor (SURF) Survey, providing self-reported data from 15,626 SURF participants (7231 males, 46.3%) on substance use and psychiatric symptoms, including suicidal ideation, depressive symptoms, anxiety, psychotic experiences, and inattention or hyperactivity.
This regional cohort was compared to a national sample of 17,232 students (8816 males, 51.2%) participating in the 2021 Youth Risk Behavior Survey (YRBS).
The researchers observed that in both samples, the use of cannabis, alcohol, and/or nicotine was associated with a higher prevalence of suicidal thoughts, depression or anxiety symptoms, psychotic experiences, and attention deficit hyperactivity disorder (ADHD) symptoms. There did not appear to be a specific relationship between use of a particular substance and a particular pattern of psychiatric symptoms. Rather, use of any substance appeared to be associated with a wide array of psychiatric symptoms.
In addition, the research team observed a dose-response relationship between substance use and psychiatric symptoms in both cohorts, such that daily and near-daily users were more likely to experience psychiatric symptoms and to exhibit greater severity of symptoms than peers who did not report use of substances. For example, students who reported using substances on a daily or near-daily basis were about five times more likely to have suicidal thoughts compared to their peers who reported no use of substances.
This study noted that even students with relatively low levels of substance use exhibited increases in psychiatric symptoms. While cross-sectional studies cannot be used to establish causality, this finding suggests that adolescents with low levels of substance use may be using substances in an attempt to alleviate their symptoms and that their relatively modest substance use is not likely the cause of their mental health problems. Yet the fact that high-frequency use was associated with higher levels of psychiatric symptoms indicates that this is likely a two-way street, where higher levels of use causes or exacerbates psychiatric symptoms.
Clinical Implications
In a video published on HCPLive, senior author Randi Schuster, PhD discusses findings of this study and outlines clinical implications, as well as future research projects.
This cross-sectional study demonstrated a dose-dependent association between alcohol, cannabis, and nicotine use and psychiatric symptoms among high school students participating in the Substance Use and Risk Factor Survey and the Youth Risk Behavior Survey. Although the findings were consistent across two large data sets, the cross-sectional nature of the study cannot show directionality between substance use and psychiatric symptoms. Longitudinal studies are needed to clarify this relationship. Senior author, Randi Schuster, PhD is currently spearheading a longitudinal study focusing on the relationship between substance use and psychiatric symptoms over time. This research aims to inform the development of interventions to better support mental health and minimize problematic substance use in adolescents.
This study underscores the importance of comprehensive psychiatric evaluation in adolescents reporting any level of substance use. Because significant psychiatric symptoms could be seen among adolescents with even relatively low levels of use, it would be important to assess for psychiatric comorbidity across the spectrum of substance use severity. This study also highlights the need for opportunity for targeted approaches addressing substance use, as well as psychiatric comorbidity.
Read More
Tervo-Clemmens B, Gilman JM, Evins AE, Bentley KH, Nock MK, Smoller JW, Schuster RM. Substance Use, Suicidal Thoughts, and Psychiatric Comorbidities Among High School Students. JAMA Pediatr. 2024 Jan 29:e236263.
