The prevalence of co-occurring disorders among the studied patients was 14% (87/622; 95% CI= 11%-17%). The diagnosis of a substance induced disorder was found in 23.8% of the studied patients (95% CI= 21%-27%), while the isolated diagnosis of an SUD was found among 62.2% of them (95% 58%-66%). Of cases of co-occurring disorders there were 26 with schizophrenia (30%), 36 with depression (41.5%), 13 with bipolar disorder (15.0%) and 12 with anxiety disorders (13.5%) (Table 5).

Discussion

Male patients represent 96.6% of our sample. This may be explained by the fact that in addition to the absence of a female rehabilitation inpatient treatment unit in ASPH, most of the time families avoid to open files for their daughters in the local psychiatric hospital and prefer to treat them away to avoid stigma.

The mean age of the studied patients was 32.1 ± 9.2 years ranging between 16 and 76 years, with 45.8% of them aged less than 30 years. This distribution is similar to what was found in our previous sample of 98 patients having the diagnosis of captagon use disorder (2016-2017), with a mean age of 33.2 ± 8.7, and 48% of them between 16 and 33 (6). Also, the Study of the Addiction Phenomenon in Saudi Society (SAPSS), a survey done between 13 June 2010 and 3 June 2011 covering 792 patients admitted in four addiction treatment centres, found that 44.5% of cases were between 24 and 33 years (8). This younger age group reflects what is recognized in medical literature that experimentation with drugs often starts in adolescence, as does the process of addiction (9).

In our sample 70.7% of cases were single, 10.1% divorced and only 19.1% married. This distribution was similar to what was found by Ibrahim et al. while studying 612 patients representing all patients admitted in Al-Qassim psychiatric rehabilitation centre during the year of 2016. They found that 54.9% were single, 9.5% divorced, 0.7% widower and 35 % married (10). This propensity of single patients in our sample can be explained by the fact that with their early age of onset these patients start the process of addiction early in their life and find themselves as ineligible bachelors in a society where marriage is always arranged between families. In our sample at least one out of three of those who got married ended by being divorced and in Al-Qassim sample the percentage of divorcees was around 9.5%. This reflects the close relation, going both ways, between substance use and divorce in medical literature. In United States of America, Amato et al. used the national panel data collected between 1980 and 1997 to classify 208 people's open-ended responses to a question on why their marriages ended in divorce. Drinking or drug use came as third reason after infidelity and incompatibility (11). In Sweden, Edwards et al. examined the association between divorce and the onset of drug abuse in a population-based Swedish cohort born during 1965–1975 (n = 651,092) and found, in both sexes, an association between the increase of the risk of drug-abuse and the onset divorce (12).

In SAPSS, family history was positive for substance use in 35.3% of patients with 18.3% of them having families containing 3 or more substance users (8). In our sample 90% reported a negative family history of substance use. This may reflect more pressure for treatment from families less tolerant to substance use compared to families where substance use is endemic.

In medical literature, there is a proved overuse of medical services by SUD patients (13,14). Around a third of our sample visited the emergency department (ED) at least once during the month prior to their evaluation, and many of these patients visited the ED more than 3 times during this period.

The most frequently used substances were by far captagon (69.8%), then cannabis (63%) and alcohol (30.7%) (table 2). This frequency echoed the shift in type of substance use among treatment-seeking subjects emphasized by AbuMadini et al. They studied 12,743 patients admitted in Alamal hospital in Dammam from 1986 to 2006. They compared relative frequencies of different types of substances in the first decade to those in the second decade and found an increase in relative frequencies of amphetamine and cannabis and a decrease in relative frequencies of heroin and other substances, while the relative frequency of alcohol stayed relatively the same (27.1 first decade and 26.7 the second decade) (7). Noteworthily, in our current sample the percentage of alcohol use was 30% and relatively the same frequency was found in Almadinah’s sample of captagon users 2016-2017 which was at 35% (6,7).

In our sample, alcohol was used in 90.1 % of cases in a context of multiple substance abuse, while only 40% of users used the substance continuously. The intermittent and multiple substance use patterns may reflect the cognitive dissonance these patients may have toward their alcohol use because of the stigma and constraints faced in a religious society.

The mean AOI of our sample was around 21 years (captagon 21.9 ± 5.9, cannabis 21.8 ± 5.8, alcohol 21.3 ± 5.6) with 74.8% of captagon users, 78.9% of cannabis users and 73.3% of alcohol users having used the substance before the age of 25 (table 3). It is known that adolescents are prone to experimenting with drugs (13,15,16) due to the delayed maturation of the prefrontal cortex until the mid-twenties (17). The earlier the onset of substance use the higher the risk of development of SUD (18). This peak of experimentation among adolescents and young adults was clearly manifested in SAPSS’s sample (8) and in the sample of captagon use disorder study in Almadinah (6).

Risk factors that occur at earlier ages pre-dispose to exposure to other risk factors later in the individual’s life, often multiplying their effect, and that adverse social environments also increase the risk of drug use and SUDs across adulthood (4). The additive effect of different types of risk factors, with time, may explain why 20% of patients in our sample had a late onset of substance use; starting their use after the age of 25 (24.2 % of captagon users, 21.2% of cannabis users and 26.7% of alcohol users). Risk factors of substance use in Saudi society were studied by SAPSS. They divided risk factors into two main groups: the presence of risk factors and the absence of protective factors. They found that the most important risks were first, those related to experiences of adolescence where the presence of risk factors was 61.7% and the absence of protective factors was 60%. Second, experiences in neighbourhood environment where the presence of risk factors was 54.1% and the absence of protective factors was 53.6%. Third, the school environment with 45.3% for the presence of risk factors and 40% for the absence of protective factors (8).

The presence of a psychiatric disorder is associated with an increased risk for SUDs, and SUDs are associated with an increased risk for mental disorders (4). In our sample, the prevalence of co-occurring disorders among the studied patients was at 14%. There were 26 with schizophrenia (30%), 36 with depression (41.5%), 13 with bipolar disorder (15.0%) and 12 with anxiety disorders (13.5%).

In our sample 23.8% were diagnosed with a substance induced disorder, reflecting the fact that individuals predisposed to develop a primary psychotic disorder might have a predisposition to using substances and that the abuse of drugs might accelerate the course of an underlying psychotic disorder (19).

The delay between initiation to substance use and FPS in our sample was shortest with captagon (5.2 ± 3.7), followed by cannabis (7.3 ± 4.2), and alcohol (8.3 ± 4.8). These substances were mostly used in a context of multiple substance use (going from 66.1% for captagon to 90.1% for alcohol and even 100% for the 15 methamphetamine users). Studies failed to demonstrate an additional effect of polysubstance use on the period between the AOI and the age of FPS (20,21,22).

Regarding the limitation of this study, this is a retrospective study in which information was gathered at the beginning from medical files where data were compiled with an unknown reliability and validity. If necessary, as a second step, the data will be completed by a patient’s interview that will also expose it to possible recall bias. In addition, some factors were not studied and need to be included in future research like topographical location, familial socioeconomic classes, parental divorce, tobacco use and school performance. Furthermore, our sample is almost exclusively male although substance abuse in females started recently to be a problem in need for specific attention.

Conclusion

There is an urgent need for large scale, locally sponsored, retrospective, prospective and survey studies to fill the knowledge gap present in substance use, substance use management and in mental health in general. In addition, the fact that 90% of our sample reported a negative history of substance abuse with about 4 out of 5 having an early AOI to substance use, with some starting as early as elementary school, emphasizes the urgent need for preventive efforts of psychoeducation on substance abuse and dependence, targeting our youths and their families, particularly in fields like school and neighbourhoods.

Disclosure

Conflict of interest:

None

Funding

None

Data availability

Data that support findings of this study are embedded within the manuscript.

Ethical Consideration

Ethical approval (with the IRB log No: 30-22) was obtained from King Salman bin Abdulaziz Medical City (KSAMC) Institutional Review Board, National Registration Number with NCBE, KSA: (H-03-M-11).

Author Contribution

All authors contributed to data collection, drafting, and to the final writing of the manuscript.