Factors associated with problematic drug use among psychiatric outpatients 1

ABSTRACT Objective: to examine the factors associated with problematic drug use among psychiatric outpatients. Method: a cross-sectional study was carried out in two mental health services. Eligible individuals were patients of these mental health services, who used them within the data collection period. Instruments: standardized questionnaire with sociodemographic, social network, social harm, and clinical information; Alcohol, Smoking and Substance Involvement Screening Test; Barratt Impulsiveness Scale; Holmes and Rahe Stress Scale. Statistical analysis was performed using parametric statistics considering a significance level of p ≤ 0.05. Study participants were 243 patients, with 53.9% of these presenting problematic drug use. Results: the most important independent predictors of problematic drug use were marital status (OR = 0.491), religious practice (OR = 0.449), satisfaction with financial situation (OR = 0.469), having suffered discrimination (OR = 3.821) and practicing sports activities in previous 12 months (OR = 2.25). Conclusion: the variables found to be predictors were those related to the social context of the patient, there, it is recommended that mental health services valorize psychosocial actions, seeking to know the social support network of patients, their modes of socialization, their financial needs, and their experiences of life and suffering.


Introduction
A growing body of research has shown that the prevalence of problematic drug use is high among people with psychiatric disorders (1) . In the previous decades, there has been an increasing interest in the study of the prevalence and characteristics of dual diagnosis, as it has been argued that dual diagnosis patients present higher morbidity, poorer prognoses and more clinical treatment difficulties (2)(3) . The literature indicates that some sociodemographic characteristics may be associated with this dual pathology. These mainly include gender (3)(4) , marital status (5) , age (5) , educational level (3,5) , employment (5) , and social support (3) . It also indicates that clinical characteristics may be associated, these being treatment adherence (3)(4) , number of hospital admissions (3)(4) , and family history of substance use (5) . It is important to note that these studies were conducted in other countries, with no references found for studies in Brazil that were designed to identify variables associated with drug use by individuals undergoing treatment in community mental health services.
In Brazil, as in the majority of countries, the psychosocial care network is divided between services that specialize in problems related to drug use and mental health services (6) . Thus, people with a dual diagnosis, in which the drug problem is evident, are quickly referred to services that specialize in treatment for drug users.
However, there are a considerable number of drug users in mental health services whose consumption is not the main complaint, with this representing a problem coping strategy or even being a way of dealing with the adverse effects of the medication therapy. These people are usually not identified as problematic users or, when identified, their consumption is not considered by professionals to be justification for referral. Despite the dual diagnosis leading to a worse prognosis, the literature indicates that mental health services tend not to investigate this association, failing to act preventively and offer comprehensive treatment (7) . Greater investment is suggested in the training of mental health professionals to instrumentalize them in caring for this population, and efforts are recommended to improve the pharmacological and nonpharmacological therapeutic approaches (6) . and all the patients that did not make use of any of the drugs screened for or presented low-risk consumption with 0. This variable was considered as the dependent variable and created taking into account an international study that used ASSIST to investigate drug use among psychotic patients (9) .
Barratt Impulsiveness Scale (BIS-11): instrument used for the evaluation of Impulsivity, adapted for use with adults in Brazil (10) . The BIS-11 is a self-report scale consisting of 30 items related to the manifestations of impulsivity. The score of the scale items varies from 1 to 4, ranging from rarely/never to almost always/always and the score total of the instrument varies between 30 and 120. According to suggestions of the literature the total score of 72 or above was used to classify an individual as highly impulsive (11) . associations were observed between problematic drug use and marital status, with this being more frequent in those who did not live with a steady partner. Statistically significant associations were also observed between problematic drug use and religious practice, in which this use was more frequent in those who did not practice any religion, and between problematic drug use and dissatisfaction with the financial situation ( Table 2).

Holmes and Rahe Stress
Corradi-Webster CM, Gherardi-Donato ECS. It was sought to evaluate whether problematic   of trouble with the police). The variable "previous psychiatric hospitalizations" was also added, as this is cited in the literature as associated with problematic drug use among psychiatric patients (2) .
The variables that were found to be predictors of problematic drug use in the sample were marital status, religious practice, satisfaction with financial situation, experience of having suffered discrimination, and participation in sports activities in the previous year.
Thus, according to this model, not living with a steady partner, not practicing religion, dissatisfaction with the financial situation, have suffered discrimination and having participated in sports activities are risk factors for problematic drug use among psychiatric outpatients (Table 5). Corradi-Webster CM, Gherardi-Donato ECS.

Discussion
This study aimed to examine associations between sociodemographic, clinical and contextual characteristics and problematic drug use among psychiatric outpatients of community mental health services. Even with the division in the care network between mental health services and services specializing in the care of problematic drug users, most mental health services attend people that consume substances (6) . Knowing the characteristics of these people can help in establishing prevention and intervention strategies. In this study, characteristics related to the social context of the patient, such as marital status, religious practice, practicing sports, dissatisfaction with the financial situation, and having suffered discrimination were those shown to be risk factors for problematic drug use.
It was found that not residing with a steady partner, whether married or cohabiting, was a risk factor for problematic drug use in this population. This information confirms the findings of other studies in the drugs area, with marital status being associated with a higher relapse rate among people with psychiatric diagnoses (13) .
A Canadian population survey also highlighted that people with a partner were more likely to have positive mental health than those who were widowed, separated, divorced or single (14) . However, the results differ from those found in a study of psychiatric patients in Tanzania, where the authors observed there were no differences in alcohol use according to marital status (5) .
To reside with a steady partner appears to protect individuals from problematic drug use, since the partner can assist in coping with stressful situations, without the subject having to resort to drugs. Furthermore, in Brazil, many psychiatric patients have their autonomy controlled by family members, who take care of the money and with this, control the use of substances (15) . A lack of religious practice has also been shown as a risk factor for problematic drug use. It is noteworthy that religion provides beliefs and explanations that assist in coping with situations of stress, which is associated with positive mental health (14) . Furthermore, when individuals practice a religion, they are usually part of a large social support network, which helps in everyday situations and also exerts behavioral control.  (16) .
In this study it was found that practicing sports activities was another risk factor for problematic drug use in this population. At first this may seem strange, as authors highlight that practicing sports can serve as a protective factor with regard to drug consumption (17) .
However, the literature is also controversial, and it has been found that, among adolescents, practicing sports is associated with the abusive use of alcohol (18) .
It is considered that cultural aspects should be taken into consideration for comprehending the relationship between practicing sports and using drugs. In Brazil, the most popular sport is football.
This is strongly associated with the consumption of alcoholic beverages, with it being common for friends to meet weekly to play football and drink beer after the game. It is common that this consumption is seen as a socialization resource, encouraged by the media and performed in an abusive way. Thus, the data found in this study deserve closer inspection, i.e. new investigations that seek to explore in greater detail the association between practicing sports and using drugs in this population.
To have experienced discrimination was also indicated as a risk factor for problematic drug use among psychiatric patients in this study. Daily discrimination alone, for example, due to the skin color of the individual, can lead to increased depressive symptoms, showing a relationship between discrimination and mental health (19) .
In addition, to feel discriminated against or stigmatized is very common among people with psychiatric diagnoses. for verifying whether a problem exists in a given place and is considered a way to obtain useful preliminary information concerning a particular health issue, these data cannot be used to estimate the prevalence of the event in the general population (21) . In this study, following international research recommendations (7) ,