Motives for Substance Use Among Male Psychiatric Inpatients with Psychotic Disorders

Abstract

Background: Substance Use Disorder (SUD) is more prevalent among individuals with psychotic disorders than in the general population and is associated with poorer functioning, treatment adherence, and outcomes. Understanding motives for substance use in this group is essential for targeted interventions. Methods: Motives were assessed using the 26-item Reasons for Substance Use Questionnaire in 118 male patients admitted for a psychotic episode between October 2024 and September 2025. Results: In total, 20.3% of the participants were first-admission patients. Enhancement motives were most frequently endorsed, followed by coping and social motives; conformity and relief were least endorsed. In exploratory unadjusted analyses, patients with multiple hospital admissions reported greater relief related motives, including alleviating positive symptoms and medication side effects. Motives varied by primary substance used. Conclusions: Mood enhancement and coping were predominant motives; relief motives appeared to be stronger in patients with multiple admissions. Further research is needed to improve treatment strategies.

1. Introduction

Extensive scientific literature consistently demonstrates that drug use is prevalent among individuals receiving psychiatric services. Numerous authors have shown that substance use disorders frequently co-occur with mental health conditions such as depressive disorders, anxiety disorders, and psychotic disorders [1,2,3]. In the context of psychotic disorders, the relationship between illicit drug use and psychopathology has been extensively investigated. A meta-analysis by Hunt et al. [4] reported that the prevalence of any Substance Use Disorder (SUD) among individuals with schizophrenia was 42%, a figure that has remained relatively stable over time. Similarly, Mousavi et al. [5] found that 38% of psychotic inpatients met criteria for a comorbid SUD.

These findings consistently demonstrate that individuals with psychotic disorders use drugs at substantially higher rates than the general population [6,7]. Hartz et al. [8] found that individuals with psychotic disorders are 3.5 times more likely to use marijuana and 4.5 times more likely to use other recreational drugs compared to the general population.

Across psychiatric populations, cigarettes (tobacco) and alcohol remain the most frequently used substances [8,9]. Cannabis use is also highly prevalent. Barnett et al. [7] observed that more than half of individuals presenting with first-episode psychosis had used cannabis, with other studies reporting similarly high prevalence rates [10,11].

In recent years, there has been a notable increase in interest regarding the use of novel psychoactive substances (NPS). These synthetic compounds mimic the psychoactive effects of controlled substances but are engineered to circumvent existing legal restrictions [12,13]. NPS constitute a highly heterogeneous category, encompassing synthetic cannabinoids, synthetic cathinones, ketamine analogues, phenethylamines, piperazines, tryptamines, aminoindanes, and phencyclidine-type substances, among others [14]. Owing to the rapid proliferation of chemical analogues, the exact composition and pharmacological properties of these substances often remain uncertain, creating challenges for toxicological screening and regulatory control [15]. In Romania, as in other countries, legislative responses to NPS have relied on repeated emergency bans and broad analogue scheduling, yet the market continues to evolve faster than regulatory updates. As a result, synthetic cannabinoids and cathinones remain readily available in urban areas, including among high-risk psychiatric populations [16,17].

As with other drugs of abuse, NPS use has been associated with heightened risk of psychosis [18]. Studies show that individuals with psychotic disorders use NPS, particularly synthetic cannabinoids and synthetic cathinones, at substantially higher rates than the general population, with estimates in psychiatric settings ranging from 10% to 22% [19,20]. Among the NPS, synthetic cannabinoids are most frequently involved in the onset or exacerbation of psychotic symptoms [13].

A broad array of motives underlying drug use among individuals with psychotic disorders has been documented in the scientific literature. Recurring themes include efforts to enhance social connection, increase pleasure, alleviate boredom, or manage symptoms of underlying psychiatric conditions such as depressive symptoms, anxiety, or auditory hallucinations [21,22,23,24]. Asher and Gask [25] noted that some individuals report using street drugs to sharpen their focus on persecutory voices in order to cope better with them.

Regardless of the motives for using illicit drugs, the clinical implications are well-documented. Substance use is strongly associated with relapse, symptom exacerbation, and reduced responsiveness to antipsychotic medication [26,27]. It remains one of the strongest predictors of medication non-adherence, which may partly explain poor treatment response [28,29]. Patients with comorbid SUD experience more frequent and prolonged hospitalizations, as well as higher rates of involuntary psychiatric admission [4]. Substance use also represents a major risk factor for violent behaviour and legal problems among individuals with psychosis [30]. Furthermore, comorbidity with a SUD is associated with elevated mortality, including deaths related to overdose, suicide, and co-occurring medical illness [31].

Understanding the motives underlying substance use in patients with psychotic disorders is essential for tailoring both medical and psychosocial interventions to address the person’s core needs rather than merely targeting the substance use itself, which may function as a coping strategy [32]. When clinicians focus exclusively on abstinence without exploring the emotional or psychological drivers underlying patient’s substance use, patients can feel misunderstood [33]. This can undermine the therapeutic alliance, which is foundational for effective treatment [34]. Recognizing these motives and adapting treatment strategies accordingly may benefit patients, who are less likely to relapse into substance use or experience a recurrence of psychotic symptoms [34].

Despite substantial research on the prevalence of substance use across psychiatric diagnoses and a smaller but important body of work on patients’ self-reported motives for use, these domains have largely evolved separately. Few studies have simultaneously explored how psychiatric diagnoses, types of substances used, and underlying motives intersect within the same population. Addressing this gap is crucial for designing individualized, motive-focused interventions and integrated treatment models that align with patients’ psychological and clinical profiles.

The aim of this study was to examine substance use motives among psychiatric inpatients with psychotic symptomatology requiring hospitalization. By evaluating the types of substances used and the motives for use in psychotic patients, the present study seeks to provide exploratory groundwork to inform more individualized, motive-focused approaches to dual-diagnosis treatment in the future.

2. Material and Methods

2.1. Study Design

This cross-sectional study evaluated motives for substance use in adult patients who were admitted to the Addiction Department of the Prof. Dr. Alexandru Obregia Clinical Hospital of Psychiatry in Bucharest, Romania between October 2024 and September 2025. Ethical approval was obtained from the hospital’s Research Ethics Committee (Approval No. 34991/05.11.2024), and data collection subsequently commenced.

2.2. Participants

Eligible participants were adults with substance use disorder (SUD) and a comorbid psychotic disorder who were clinically stable and able to provide informed consent; severe intellectual disability was an exclusion criterion. Participants were considered clinically stable when they were no longer acutely intoxicated or behaviorally disorganized, and were able to participate in the assessment process. Each participant was evaluated once, during their first admission within the study period. A total of 118 patients agreed to participate (see

Table 1. Exploratory factor analysis of the reasons for use scale using principal axis factoring with Promax rotation.

Item	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5
15. Because you feel more self-confident and sure of yourself	0.85
14. To get away from the voices	0.63
19. To decrease restlessness	0.58			−0.32
13. To help you talk to others	0.51
10. Because it is fun	0.50	−0.41
24. It helps when you feel depressed	0.47
22. To be liked		0.62
17. Because it is what most of your friends do when you get together		0.59
26. Because it makes you feel good		0.53			0.34
20. To help me concentrate		0.47
23. So you will not feel left out		0.46
18. As a way to celebrate		0.41
6. To be part of a group		0.39	0.35
3. To slow down racing thoughts			0.69
1. To relieve boredom			0.60
2. To make it easier to sleep			0.56
21. Because your friends pressure you to do it			0.43
5. To relax			0.40		−0.35
7. To get high				0.79
16. Because it helps when you feel nervous				0.53
4. To be sociable				0.45
25. To feel more motivated				0.38
8. To decrease suspiciousness/paranoia				0.38
12. Because it makes a social gathering more enjoyable					0.71
9. To forget your worries					0.56
11. To reduce side effects of medication					0.52
Factor Statistics	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5
Eigenvalue	5.80	2.62	1.85	1.60	1.56
Variance Explained (%)	20.13	7.99	4.84	4.02	3.75
Cumulative Variance Explained (%)	20.13	28.12	32.96	36.97	40.72

Note. Extraction method = principal axis factoring. Rotation method = Promax with Kaiser normalization. Only factor loadings ≥ |0.30| are displayed. Factors were retained based on eigenvalues greater than 1. The five-factor solution explained 40.72% of the total variance. Several items demonstrated secondary loadings across factors, particularly Items 5, 6, 10, 19, and 26. Rotation converged in seven iterations. Interpretation of item content suggested broad correspondence between the extracted factors and the original domains proposed by Spencer et al. (2002) [35], including coping with unpleasant affect, enhancement, conformity and acceptance, and relief of positive symptoms and medication side effects.

for sociodemographic characteristics of the study participants). As the ward admits only male patients, the final sample consisted exclusively of men. All psychiatric diagnoses were established in accordance with ICD-10 criteria. To classify a substance as a patient’s main substance of use, the patient had to meet the ICD-10 diagnostic criteria for dependence on that specific substance, as well as identify it as their most frequently used substance. A substance was classified as a secondary substance of use if the patient had used it within the previous month, based on the patient’s report. Patient self-reports were checked against the qualitative toxicological tests routinely performed as part of the hospital clinical documentation procedures.

2.3. Questionnaire

The motives for psychoactive substance use were assessed using the 26-item Reasons for Substance Use Questionnaire [35], derived from the Drinking Motives Questionnaire [36]. Items are rated on a 5-point Likert scale (1 = almost never/never to 5 = almost always/always). The scale was translated from English into Romanian using a forward-translation procedure and reviewed thoroughly by the research team in both languages. Internal consistency for the Romanian translation was modest to acceptable: Enhancement (α = 0.62), Social Motives (α = 0.69), Coping with Unpleasant Affect (α = 0.77), Conformity and Acceptance (α = 0.66), and Relief of Positive Symptoms and Side Effects (α = 0.51). Lower reliability values for the Relief of Positive Symptoms and Side Effects paralleled findings from the original English instrument [35].

Exploratory factor analysis was conducted using principal axis factoring with Promax rotation and Kaiser normalization. The dataset was suitable (KMO = 0.71; Bartlett’s p < 0.001) and broadly supported the expected multidimensional structure. The 26 questions clustered into five (5) subgroups, which accounted for 40.7% of the common variance, suggesting moderate support for the multidimensional structure. Factors were retained based on eigenvalues greater than 1. The original questionnaire domains included: enhancement motives (using to enhance positive mood or well-being), social motives (using to obtain positive social rewards), coping motives (using to reduce or regulate negative emotions), conformity motives (using for social acceptance), and relief motives (using to cope with psychotic symptoms or to reduce side effects of medication). The extracted factors only partially corresponded to these original domains.

While Enhancement, Social Motives, and Conformity emerged as broadly identifiable factors, several items demonstrated moderate secondary loadings across domains, and some factors reflected mixed motivational content. Factor correlations (r = 0.13–0.39) indicated that some of the domains were related but non-redundant. Factors 1 and 3 showed the closest correspondence with coping motives, although both included items from other domains. Factor 2 combined social acceptance items with enhancement-related motives. Factors 4 and 5 included items from enhancement, coping and social acceptance motives. This factor analysis suggests a partial overlap among motive domains, rather than a clean replication of the original subscale structure. Ultimately, we retained the original subscales for several reasons. Our study, which is exploratory and not designed as a full validation of a new Romanian factor structure, is based on a modest and specific clinical sample. The extracted factors may therefore be sample-specific. Despite moderate secondary loadings and explained variance, the subscales maintained theoretical coherence, broadly aligned with the structure of the original instrument, and demonstrated acceptable internal consistency for exploratory use. Retaining the original domains preserved theoretical interpretability and comparability with the original instrument. Findings derived from these subscales should be interpreted cautiously and considered exploratory. Table 1 shows the details of the exploratory factor analysis, and questionnaire items are listed in

Table A1. Items in reasons for use scale (Spencer, Castle, Michie, 2002 [35]: based on DMQ: Cooper, 1992 [36]).

Subscale	Items
Enhancement motives	To get high
	Because it’s fun
	Because it makes you feel good
Social motives	As a way to celebrate
	Because it’s what most of your friends do when you get together
	To be sociable
	Because it makes a social gathering more enjoyable
Coping with unpleasant affect	To relax
	To forget your worries
	Because you feel more self-confident and sure of yourself
	Because it helps when you feel nervous
	Because it helps when you feel depressed
	To make it easier to sleep
	To feel more motivated
	To relieve boredom
	To slow down racing thoughts
	To decrease restlessness
	As a way to concentrate
Conformity motives	Because your friends pressure you to do it
	To be liked
	So you won’t feel left out
	To help you talk to others
	To be part of a group
Relief of positive symptoms & medication side effects	To get away from the voices
	To decrease suspiciousness/paranoia
	To reduce side effects of medication

.

A trained clinical examiner (i.e., a psychiatrist or a psychiatry trainee) administered the questionnaire, reading items aloud and recording verbatim responses.

2.4. Data Analysis

Statistical analysis was performed using the Software Package for the Social Sciences, version 31.0.2.0 (SPSS Inc., IBM Corp, Armonk, NY, USA). Descriptive statistics are presented as counts, mean values, standard deviations, and percentages. Wilcoxon Signed Rank Sum test, Student’s t-test, Fisher’s exact test, chi-Square test and ANOVA were used to compare subgroups. A p-value of less than 0.05 was considered statistically significant. Given the exploratory nature of the study and the modest sample size, formal correction for multiple comparisons was not applied. Therefore, reported p-values should be interpreted cautiously, particularly for subgroup analyses and secondary outcomes.

3. Results

Of the 149 patients admitted to the Addiction Department between October 2024 and September 2025, 118 (79.19%) consented to participate in the study. Among these, 24 (20.3%) were at their first admission, while 94 (79.7%) had a history of previous hospitalizations. The most frequent diagnosis in the sample was Brief Psychotic Disorder (n = 63; 53.4%), followed by Schizophrenia (n = 23; 19.5%) and Substance-Induced Psychotic Disorder (n = 17; 14.4%).

Regarding the main substance of use, cannabis was the most commonly reported drug (n = 49; 41.5%), followed by synthetic cathinones (n = 29; 24.6%), synthetic cannabinoids (n = 12; 10.2%), and cocaine (n = 10; 8.5%). In terms of secondary substance use, 34 (28.8%) participants reported cannabis use, followed by synthetic cathinones (n = 29; 24.6%), cocaine (n = 24; 20.3%), and alcohol (n = 14; 11.9%).

Patients admitted for the first time differed significantly from those with previous admissions with respect to age (p = 0.004), psychiatric diagnosis (p = 0.03), primary substance of use (p = 0.015), route of administration (p = 0.008), and employment status (p = 0.025). The main characteristics of both groups, as well as of the overall sample, are summarised in

Table 2. Sociodemographic and clinical characteristics of the sample by hospital admission status.

	Total (n = 118; 100%)	First Admission (n = 24; 20.33%)	Multiple Admissions (n = 94; 79.66%)	Group Difference
				p-value	Test statistic	df
Age	M = 31.25; SD = 7.32; Range = 18–49	M = 27.87; SD = 6.37; Range = 19–44	M = 32.11; SD = 7.32; Range = 18–49	0.004	t = −2.812	40
Diagnostic group	Brief psychotic disorder (n = 63; 53.4%) Substance-induced psychotic disorder (n = 17; 14.4%) Bipolar disorder, manic episode with psychotic symptoms (n = 10; 8.5%) Persistent delusional disorder (n = 1; 0.8%) Schizo-affective disorder (n = 4; 3.4%) Schizophrenia (n = 23; 19.5%)	Brief psychotic disorder (n = 17; 70.8%) Substance-induced psychotic disorder (n = 5; 20.8%) Bipolar disorder, manic episode with psychotic symptoms (n = 2; 8.3%)	Brief psychotic disorder (n = 46; 48.9%) Substance-induced psychotic disorder (n = 12; 12.8%) Bipolar disorder, manic episode with psychotic symptoms (n = 8; 8.5%) Persistent delusional disorder (n = 1; 1.1%) Schizo-affective disorder (n = 4; 4.3%) Schizophrenia (n = 23; 24.5%)	0.030	χ2 = 11.10	5
Primary drug of use	Amphetamines (n = 3; 2.5%) Cocaine (n = 10; 8.5%) Synthetic cathinones (n = 29; 24.6%) Heroin (n = 10; 8.5%) Inhalants (n = 2; 1.7%) Cannabis (n = 49; 41.5%) Synthetic cannabinoids (n = 12; 10.2%) Ketamine (n = 1; 0.8%) MDMA (n = 1; 0.8%) Psychedelics (n = 1; 0.8%)	Amphetamines (n = 2; 8.3%) Cocaine (n = 4; 16.7%) Synthetic cathinones (n = 5; 20.8%) Heroin (n = 2; 8.3%) Inhalants (n = 1; 4.2%) Cannabis (n = 8; 33.3%) Ketamine (n = 1; 4.2%) Psychedelics (n = 1; 4.2%)	Amphetamines (n = 1; 1.1%) Cocaine (n = 6; 6.4%) Synthetic cathinones (n = 24; 25.5%) Heroin (n = 8; 8.5%) Inhalants (n = 1; 1.1%) Cannabis (n = 41; 43.6%) Synthetic cannabinoids (n = 12; 12.8%) MDMA (n = 1; 1.1%)	0.015	Fisher’s exact	-
Route of administration	Smoked/Inhaled (n = 87; 73.7%) Intramuscular (n = 1; 0.8%) Intravenous (n = 13; 11.0%) Intranasal (n = 15; 12.7%) Orally (n = 2; 1.7%)	Smoked/Inhaled (n = 13; 54.2%) Intramuscular (n = 1; 4.2%) Intravenous (n = 2; 8.3%) Intranasal (n = 7; 29.2%) Orally (n = 1; 4.2%)	Smoked/Inhaled (n = 74; 78.7%) Intravenous (n = 11; 11.7%) Intranasal (n = 8; 8.5%) Orally (n = 1; 1.1%)	0.008	Fisher’s exact	-
Secondary drug of use	Yes (n = 97; 82.2%) No (n = 21; 17.8%)	Yes (n = 20; 83.3%) No (n = 4; 16.7%)	Yes (n = 77; 81.9%) No (n = 17; 18.1%)	0.871	χ2 = 0.026	1
Living situation	With parents (n = 72; 61%) With spouse/partner (n = 12; 10.2%) Alone (n = 25; 21.2%) Homeless (n = 9; 7.6%)	With parents (n = 13; 54.2%) With spouse/partner (n = 4; 16.7%) Alone (n = 5; 20.8%) Homeless (n = 2; 8.3%)	With parents (n = 59; 62.8%) With spouse/partner (n = 8; 8.5%) Alone (n = 20; 21.3%) Homeless (n = 7; 7.4%)	0.607	χ2 = 1.817	3
Marital status	Married/Partner (n = 22; 18.6%) Divorced (n = 19; 16.1%) Single (n = 77; 65.3%)	Married/Partner (n = 7; 29.2%) Divorced (n = 5; 20.8%) Single (n = 12; 50.0%)	Married/Partner (n = 15; 16.0%) Divorced (n = 14; 14.9%) Single (n = 65; 69.1%)	0.194	χ2 = 3.282	2
Education level	0–4 years (n = 11; 9.3%) 4–8 years (n = 26; 22.0%) 8–12 years (n = 19; 16.1%) Highschool (n = 54; 45.8%) University (n = 8; 6.8%)	0–4 years (n = 5; 20.8%) 4–8 years (n = 5; 20.8%) 8–12 years (n = 2; 8.3%) Highschool (n = 10; 41.7%) University (n = 2; 8.3%)	0–4 years (n = 6; 6.4%) 4–8 years (n = 21; 22.3%) 8–12 years (n = 17; 18.1%) Highschool (n = 44; 46.8%) University (n = 6; 6.4%)	0.240	χ2 = 5.226	4
Employment status	Student (n = 2; 1.7%) Employed (n = 25; 21.2%) Unemployed (n = 75; 63.6%) Retired (n = 16; 13.6%)	Student (n = 1; 4.2%) Employed (n = 10; 41.7%) Unemployed (n = 12; 50.0%) Retired (n = 1; 4.2%)	Student (n = 1; 1.1%) Employed (n = 15; 16.0%) Unemployed (n = 63; 67.0%) Retired (n = 15; 16.0%)	0.025	χ2 = 9.396	3
Legal history	Yes (n = 55; 46.6%) No (n = 63; 53.4%)	Yes (n = 8; 33.3%) No (n = 16; 66.7%)	Yes (n = 47; 50.0%) No (n = 47; 50.0%)	0.544	χ2 = 0.369	1
Infectious disease status	HIV (n = 11; 9.3%) HBV (n = 6; 5.1%) HCV (n = 25; 21.2%)	HIV (n = 2; 8.3%) HBV (n = 0; 0.0%) HCV (n = 4; 16.6%)	HIV (n = 9; 9.6%) HBV (n = 6; 6.4%) HCV (n = 21; 22.3%)	0.852 0.345 0.544	χ2 = 0.035 Fisher’s exact χ2 = 0.369	1 - 1

Note. Values are presented as mean (SD) and range for continuous variables and n (%) for categorical variables. Group differences for continuous variables were examined using independent samples t-tests. Categorical variables were analyzed using Pearson’s χ² tests or Fisher’s exact tests when expected cell counts were <5. p < 0.05 indicates statistical significance. HIV = Human Immunodeficiency Virus; HBV = Hepatitis B Virus; HCV = Hepatitis C Virus. MDMA = 3,4-methylenedioxymethamphetamine.

.

The most frequently reported motives for use in the main group were “To relax” (mean 3.48; SD 1.663), “Because it makes you feel good” (mean 3.47; SD 1.506), “To forget your worries” (mean 3.42; SD 1.676), “Because it helps when you feel depressed” (mean 3.39; SD 1.612) and “To get high” (mean 3.26; SD 1.538). When the motives for use were grouped into the 5 subgroups, enhancement motives were the most frequently endorsed (mean 3.16; SD 1.18), followed by coping (2.95; SD 0.93) and social motives (mean 2.49; SD 1.11), whereas conformity (mean 1.71; SD 0.80) and relief motives (mean 1.56; SD 0.83) were the least frequently reported.

Descriptive comparisons across substance groups suggested meaningful variation in motive profiles. Enhancement motives were highest among amphetamine users (M = 3.88, SD = 0.51) and lowest among users of “other” substances (M = 2.93, SD = 1.83). Coping motives were strongest among heroin users (M = 3.34, SD = 0.75) and lowest among synthetic cathinone (M = 2.68, SD = 0.94) and cocaine users (M = 2.67, SD = 1.19). Social motives were highest in the “other substances” group (M = 3.35, SD = 0.67) and the amphetamine group (M = 3.25, SD = 0.43). Conformity motives were low across all categories, ranging from M = 1.45 (synthetic cannabinoids) to M = 2.86 (amphetamines). Relief motives were also scarcely reported and were endorsed mostly by cannabis (M = 1.72, SD = 0.92) and synthetic cannabinoid users (M = 1.58, SD = 0.98). Because group sizes were highly unequal (n range = 5–49), these exploratory comparisons were unadjusted and should be interpreted as descriptive rather than inferential. Full description of the results can be found in

Table 3. Motives for use according to main substance of use.

Main Substance	Enhancement	Coping	Social	Conformity	Relief
Amphetamines	3.88 (0.51)	3.18 (0.98)	3.25 (0.43)	2.86 (0.64)	1.33 (0.33)
Cocaine	2.99 (0.99)	2.67 (1.19)	2.82 (1.17)	1.64 (0.86)	1.33 (1.05)
Synthetic cathinones	3.04 (1.13)	2.68 (0.94)	2.03 (1.04)	1.51 (0.59)	1.40 (0.63)
Cannabis	3.21 (1.14)	3.08 (0.90)	2.57 (1.09)	1.77 (0.88)	1.72 (0.92)
Synthetic cannabinoids	3.00 (1.33)	2.84 (0.77)	2.31 (1.26)	1.45 (0.45)	1.58 (0.98)
Heroin	3.13 (1.21)	3.34 (0.75)	2.32 (1.30)	1.70 (0.86)	1.46 (0.56)
Other †	2.93 (1.83)	3.05 (0.98)	3.35 (0.67)	2.36 (0.76)	1.46 (0.64)

Note. Values are Mean (SD). ^† = Inhalants, psychedelics, ketamine, MDMA.

.

Intercorrelations among motives (

Table 4. Intercorrelations among motives for substance use in psychotic inpatients (N = 118).

Subscale	1	2	3	4	5
1. Enhancement	—	0.349 **	0.448 **	0.263 **	0.146
2. Social		—	0.298 **	0.488 **	0.229 *
3. Coping			—	0.369 **	0.506 **
4. Conformity				—	0.426 **
5. Relief					—

Note. Values are Pearson correlation coefficients. * p < 0.05, ** p < 0.01.

) suggest that coping and relief motives were strongly associated (r = 0.50, p < 0.001), as were social and conformity motives (r = 0.49, p < 0.001). Several other pairings showed moderate correlations (rs = 0.30–0.45). Enhancement motives showed only weak associations with other domains and were not significantly related to relief motives (r = 0.14, p = 0.12). These analyses are exploratory and unadjusted.

A binary logistic regression tested whether substance-use motives predicted high-risk administration (i.e., intravenous (IV) compared to non-IV). The model was not significant, and interpretation was substantially limited by severe class imbalance and the small number of IV users (105 non-IV vs. 13 IV). Consequently, the analysis was underpowered and did not identify meaningful associations. Therefore, this model should be considered exploratory rather than inferential. For a detailed description of the regression results, see

Table A2. Binary logistic regression predicting IV route (N = 118).

Predictor	OR	95% CI	p
Enhancement	0.99	0.55–1.78	0.977
Social	0.66	0.33–1.32	0.237
Coping	1.01	0.45–2.27	0.977
Conformity	1.13	0.41–3.12	0.811
Relief	0.90	0.37–2.21	0.818

Model fit: χ²(5) = 2.03, p = 0.845; Nagelkerke R² = 0.034; Hosmer–Lemeshow χ²(8) = 9.11, p = 0.333.

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In an exploratory unadjusted comparison using independent samples t-tests, patients at first admission and those with multiple admissions did not differ significantly on enhancement, coping, social, or conformity motives, and observed effect sizes were small. In contrast, patients with multiple admissions reported higher relief motive scores than first-admission patients (mean difference for first vs. multiple admissions = −0.297, 95% CI −0.551 to −0.042, p = 0.011).

4. Discussion

In our sample, inpatients diagnosed with a psychotic disorder most strongly endorsed mood enhancement and coping motives for their substance use, with moderate endorsement of social motives. Conformity and symptom-relief motives were the least frequently reported. Compared with patients at their first admission, those with a history of multiple admissions, in an exploratory, unadjusted analysis, reported higher endorsement of motives related to alleviating positive psychotic symptoms and mitigating medication side effects.

The motive profile in patients with psychosis indicates that substance use in this population is primarily affect-driven, either to enhance positive emotional states or to manage unpleasant emotional experience. This pattern is consistent with evidence that psychosis is closely tied to negative affect and impaired emotional regulation [37], making substance use a plausible strategy for transient mood elevation or reduction in intense anxiety [21].

Previous qualitative research has shown that individuals with psychosis often use substances as a strategy for regulating internal tension, low mood, anxiety, and negative symptoms [25,38,39]. Pleasure enhancement and relief from dysphoria have been identified as the most frequently reported motives in earlier studies [40,41], while other research has highlighted substance use as a means of enhancing social experience by alleviating boredom, reducing social anxiety, and facilitating relaxation in social settings [21]. The relatively low endorsement of social and conformity motives in our sample likely reflects the restricted social networks and limited peer interaction characteristic of individuals with psychotic disorders, particularly among those with symptom severity necessitating hospitalization.

Motives for substance use appear to cluster in meaningful and theoretically coherent ways. Individuals who use substances to cope are also likely to use them for distress relief, reflecting a classic negative-reinforcement process in which drug use reduces psychiatric discomfort. This mechanism is central to the development of habitual use [42], and coping motives often reflect attempts to manage the distress arising from the person’s underlying psychiatric disorder [43]. By contrast, individuals who use substances for social motives may do so to align with perceived expectations of their peer group, consistent with social-reinforcement models. In some populations, such social contingencies have been shown to sustain substance use [44]. This could explain why social and conformity motives cluster. Importantly, the inverse is also true: social disapproval and stigma can act as protective factors that deter drug use [45]. In contrast to both social and distress-relief motives, using substances to enhance positive affect aligns with positive-reinforcement mechanisms. Evidence suggests that the binge/intoxication stage of addiction is mediated by reward-circuit activity, whereas the negative-affect stage is mediated by stress-circuit activation [46], suggesting that enhancement motives may arise from a separate physiological system than social motives.

Motives for use varied by substance of use. Most of our patients used cannabis, followed by synthetic cathinones and synthetic cannabinoids. Mood enhancement motives were mostly reported by cannabis and amphetamine users. Coping motives were mostly reported by heroin users, and social motives were endorsed primarily by amphetamine and other drug users (MDMA, ketamine, psychedelics). Conformity and relief motives were scarcely reported across all categories.

Cannabis is the most extensively studied substance among individuals with psychotic disorders, due to the bidirectional relationship between cannabis use and psychosis. Research indicates that cannabis use constitutes a risk factor for the development of psychosis and that continued use following illness onset is associated with poorer clinical outcomes [47]. Evidence suggests that early initiation and heavy cannabis use are more common among individuals with a pre-existing predisposition to psychosis [48]. This suggests a shared underlying vulnerability contributing to both cannabis use and psychotic disorders [49].

In the scientific literature, reported motives for cannabis use include to increase pleasure, to relax, to get high or to feel better, as well as to reduce social anxiety, and social discomfort [50,51,52]. Our study does not find supporting evidence that cannabis is used to alleviate the side effects of antipsychotic medication.

Stimulant drugs such as amphetamines and cocaine act directly on dopaminergic pathways by hijacking the brain’s reward circuitry and producing strong positive reinforcement, making them more likely to be used for enhancement motives [53]. Previous studies revealed that some patients tend to use amphetamines to compensate for emotional flattening [24], which reflects our finding that patients with psychosis frequently report using amphetamines to feel better.

By contrast, substances with sedative or anxiolytic effects, such as heroin, are more often used to manage internal anxiety or psychological tension, with negative mood shown to increase heroin-seeking behaviours [54]. This is consistent with self-medication and tension-reduction models: individuals with anxiety disorders frequently report using cannabis to manage distress, and opiate-dependent individuals commonly use heroin to alleviate negative affect [55,56].

In recent years, novel psychoactive substances (NPS) have been increasingly used by young individuals and have been linked to the onset of psychotic symptoms as well as the exacerbation of psychotic episodes among individuals with pre-existing psychiatric disorders [13]. However, any thorough investigation of the neurobiological mechanisms of these substances and their psychopathological consequences is particularly challenging due to the heterogeneity of compounds encompassed within this category and the substantial variability in their pharmacological profiles.

Findings from our study indicate that both synthetic cathinones and synthetic cannabinoids are predominantly consumed for mood enhancement motives, although scores obtained by this group of patients are moderate. This finding may suggest that continued use persists despite diminished positive effects, which could indicate habitual use.

Our study did not identify any predictive relationship between substance use motives and IV use. One explanation is that IV drug use may be shaped less by internal psychological drivers and more by practical considerations and local drug culture norms. Prior work suggests that, for many individuals who inject drugs, factors such as availability, price, purity, social networks, and established injection practices exert a stronger influence on initiation and maintenance than distress-related motives [57]. The rapid intensification of drug effects via injection also introduces a powerful pharmacological reinforcement that may operate independently of users’ stated motives. At the same time, only 13 participants in our sample reported IV use, substantially limiting statistical power; as such, our findings should be interpreted cautiously and should be considered as exploratory, not inferential.

Substance use remains a robust predictor of psychotic relapse [58], and our sample reflects this clinical reality, as all participants were admitted with psychiatric symptoms occurring in the context of substance use. Consequently, understanding and tackling the motives for substance use may contribute to more effective relapse prevention.

The present study highlights a clinically relevant motive profile largely characterized by mood enhancement and coping motives that may inform motive-focused assessment and intervention, even though these motives did not independently predict high-risk behaviours. Including patients’ needs and perspectives in the management plan may prove beneficial for the therapeutic relationship, thus increasing the chances of treatment adherence and a better long-term outcome for patients with a dual diagnosis. Individuals with psychosis may benefit from developing alternative sources of enjoyment and from learning healthier strategies to manage distress, negative symptoms, and boredom. Future research should replicate these findings in larger, multi-site samples, using longitudinal designs to examine how motives change over time, and to explore how motive profiles interact with factors such as clinical severity, trauma history, treatment engagement, and social determinants in shaping substance use trajectories among people with psychotic disorders.

4.1. Strengths and Limitations

To our knowledge, this study is among the first studies to examine the motives for multiple substance use, including novel psychoactive substances, in an acutely admitted population of patients with psychotic disorders, particularly within a Romanian setting. Whereas previous research has primarily focused on cannabis use among patients with psychotic disorders, the present study examined motive profiles related to both cannabis and other substances.

Several limitations should be considered. The sample was recruited from a single psychiatric inpatient unit, included a relatively small number of participants, excluded outpatients, and consisted exclusively of men due to the profile of the department. In addition, the cross-sectional design limited the ability to assess long-term outcomes and the effects of treatment over time; a longitudinal approach would provide a more comprehensive evaluation of these aspects. Furthermore, reliance on self-report questionnaires raises the possibility of recall bias, fluctuating insight, and symptom-related distortions that may affect data accuracy. Systematic biological confirmation of all reported substances of use was not performed.

Conclusions based on the relief subscale are limited by the relatively low internal consistency of this subscale. Additional limitations include the heterogeneity of diagnoses within the sample, which may have obscured diagnostic-specific patterns. Given the exploratory nature of this study, formal correction for multiple comparisons was not applied. Multiple comparisons, including among routes of administration, motive subscales, and other predictors, increase the risk of Type 1 error and highlight the need for cautious interpretation of our findings until they can be replicated in larger samples.

4.2. Conclusions

Regardless of illness duration, patients experiencing psychotic episodes reported using substances primarily for enhancement and coping motives. Only patients with a higher number of hospital admissions endorsed using various substances for relief motives, which may suggest greater psychological distress or symptom burden within this subgroup. However, this finding should be interpreted with caution, as the participants with first-time admissions and those with multiple admissions differed across several sociodemographic and clinical characteristics, and because the relief subscale demonstrated relatively low internal consistency. Differences in motives for use were observed across substance categories, with patients who used cannabis and amphetamines more often reporting using these substances to improve their mood, whereas heroin users more frequently reported using it for coping motives. A better understanding of the motives underlying substance use among patients experiencing psychosis is important for tailoring treatment interventions aimed at discontinuing or reducing substance use.