Single Substance Not Linked to Single Psychiatric Symptom in Adolescents

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A new survey study of high schoolers found alcohol, cannabis, and nicotine were linked to significant, moderate dose-dependent associations with worse symptoms of depression, anxiety, ADHD, general mental health, as well as suicidal thoughts.

Although a new study confirmed using substances, such as alcohol, cannabis, and nicotine, is linked to worsened psychiatric symptoms, investigators found a single type of substance is not linked to a particular psychiatric disorder.1

“We sought to determine whether substance use was dose-dependently associated with various psychiatric symptoms in a large sample [of] high school students and whether these associations differed depending on the type of substance used,” said senior author Randi M. Schuster, PhD, professor of psychology in the Department of Psychiatry at Massachusetts General Hospital, in a press release.

Previous research has already linked substance use to psychiatric symptoms, but no clear evidence suggested that substances were linked to specific psychiatric symptoms. According to the National Institute of Mental Health, people with substance use disorder may have other mental disorders including anxiety disorders, depression, ADHD, bipolar disorder, personality disorders, and schizophrenia among others.2

A study, led by Brenden Tervo-Clemmens, PhD, from the University of Minnesota Medical School, obtained data from 2 large independent surveys to assess what substances are linked to what psychiatric symptoms.1 They used 1 regional and 1 national survey.

The 2022-2023 Substance Use and Risk Factor (SURF) survey included students from 36 Massachusetts high schools who self-reported substance use. They had to report lifetime and past-month alcohol, cannabis, and nicotine use (either nicotine vaping, cigarette, or cigar use), as well as psychiatric symptoms and past-year suicidal thoughts. To get a national sample, the team analyzed the 2021 Youth Risk Behavior Survey (YRBS), another self-reported survey assessing all the same symptoms but including past-month overall mental health.

The team categorized substance use frequency as never, ever but noncurrent, monthly, weekly, and daily or near-daily use. To analyze results, the investigators used statistical models adjusted for age and sex and calculated effect size on original scale units.

The sample included 15,626 SURF participants with 46.3% males and a mean age of 15.75 years, as well as 17,232 YRBS participants with 51.2% males and a mean age of 15.67 years.

Ultimately, they found alcohol, cannabis, and nicotine use was linked to significant, moderate dose-dependent associations with worse psychiatric symptoms. Psychiatric symptoms in SURF and YRBS participants include depression and anxiety symptoms (alcohol: difference, 1.38; cannabis: 0.50; nicotine: 0.46; P < .001), ADHD symptoms (alcohol: 2.18; nicotine: 1.05; nicotine: 1.40; P < .001), suicidal thoughts (alcohol: difference, 10.11 and 12.8; cannabis: 7.15 and 5.80; P <.001), and general mental health in just YRBS participants (alcohol: difference, 0.21; cannabis: 0.12; nicotine: 0.12; P < .001).

Pairwise comparisons showed ever use vs. never use of a substance was linked to greater psychiatric symptoms for all symptoms measures (cannabis with suicidal thoughts: difference, 22.87 [95% CI, 19.09 to 26.64] and 16.47 [95% CI, 12.15 to 20.79]; P < .001). As for high schoolers who use substances daily or near-daily use vs. ever use was linked with moderate increases in symptoms (alcohol with suicidal thoughts: difference, 30.34 [95% CI, 18.03 to 42.64] and 38.49 [95% CI, 25.65 to 51.33]; P < .001). In contrast, weekly or monthly use was not associated with an increase in symptoms (monthly alcohol with suicidal thoughts: difference, −2.40 [95% CI, −5.74 to 0.95; P = .19] and 7.02 [95% CI, 3.65 to 10.39; P < .001].

A limitation the team highlighted was using a cross-sectional self-report, making it impossible to show the directionality between substance use and psychiatric symptoms. To make this type of conclusion, a longitudinal study is required.

“Our study’s results highlight the prevalence of psychiatric co-morbidities among young people who use substances, and they lend strong support for the notion that screening, prevention, intervention and policy efforts need to comprehensively address targets beyond substance use alone,” Tervo-Clemmens said in a press release. “Also, these efforts may not need to necessarily be specific to a given substance, but rather reflect the multifaceted mental health needs of all adolescents who use substances.”


  1. Tervo, Clemmens, B, Gilman, J, Evins, A, et al. and Psychiatric ComorbiditiesAmong High School Students. JAMA Pediatrics. 2024. doi:10.1001/jamapediatrics.2023.6263.
  2. Substance Use and Co-Occurring Mental Disorders. National Institute of Mental Health. Accessed January 26, 2024.