RESEARCH ARTICLE

Cannabis use in male and female first episode

of non-affective psychosis patients: Long-term
clinical, neuropsychological and functional
differences
Esther Setién-Suero1,2,3*, Karl Neergaard4, Mariluz Ramı́rez-Bonilla1, Patricia Correa-
Ghisays2,5, Lourdes Fañanás2,6, Benedicto Crespo-Facorro1,2,3‡, Rosa Ayesa-Arriola1,2,3‡

1 University Hospital Marqués de Valdecilla, Department of Psychiatry, School of Medicine, University of

Cantabria, Santander, Spain, 2 CIBERSAM, Biomedical Research Network on Mental Health Area, Madrid,
Spain, 3 IDIVAL, Valdecilla Biomedical Research Institute, Santander, Spain, 4 Laboratoire Parole et
a1111111111 Langage, Aix-Marseille University, Aix-en-Provence, France, 5 Faculty of Psychology, University of Valencia,
a1111111111 Valencia, Spain, 6 Departament de Biologia Animal, Facultat de Biologia, Universitat de Barcelona, Institut de
Biomedicina de la Universitat de Barcelona (IBUB), Barcelona, Spain
a1111111111
a1111111111 ‡ These authors jointly supervised this work.
a1111111111 * setiensuero@hotmail.com

Abstract
OPEN ACCESS

Citation: Setién-Suero E, Neergaard K, Ramı́rez-

Bonilla M, Correa-Ghisays P, Fañanás L, Crespo-
Background
Facorro B, et al. (2017) Cannabis use in male and Numerous studies show the existence of a high prevalence of cannabis use among patients
female first episode of non-affective psychosis
with psychosis. However, the differences between men and women who debut with a first
patients: Long-term clinical, neuropsychological
and functional differences. PLoS ONE 12(8): episode of psychosis (FEP) regarding cannabis use have not been largely explored. The
e0183613. https://doi.org/10.1371/journal. aim of this study was to identify the specific sex factors and differences in clinical evolution
pone.0183613 associated with cannabis use.
Editor: Kenji Hashimoto, Chiba Daigaku, JAPAN

Received: May 12, 2017 Method

Accepted: August 8, 2017 Sociodemographic characteristics at baseline were considered in our sample of FEP
patients to find differences depending on sex and the use of cannabis. Clinical, functional
Published: August 23, 2017
and neurocognitive variables at baseline, 1-year, and 3-years follow-up were also explored.
Copyright: © 2017 Setién-Suero et al. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which Results
permits unrestricted use, distribution, and
A total of 549 patients, of whom 43% (N = 236) were cannabis users, 79% (N = 186) male
reproduction in any medium, provided the original
author and source are credited. and 21% (N = 50) female, were included in the study. There was a clear relationship
between being male and being a user of cannabis (OR = 5.6). Cannabis users were
Data Availability Statement: All relevant data are
included within the paper and its Supporting younger at illness onset. Longitudinal analysis showed that women significantly improved in
Information files. all three dimensions of psychotic symptoms, both in the subgroup of cannabis users and in
Funding: The author(s) received no specific the non-users subgroup. Conversely, subgroups of men did not show improvement in the
funding for this work. negative dimension. In cognitive function, only men presented a significant time by group
Competing interests: The authors have declared interaction in processing speed, showing a greater improvement in the subgroup of canna-
that no competing interests exist. bis users.

PLOS ONE | https://doi.org/10.1371/journal.pone.0183613 August 23, 2017 1 / 17

 Sex differences in FEP patients cannabis users

Conclusion
Despite knowing that there is a relationship between cannabis use and psychosis, due to
the high prevalence of cannabis use among male FEP patients, the results showed that
there were very few differences in clinical and neurocognitive outcomes between men and
women who used cannabis at the start of treatment compared to those who did not.

Introduction
To date, studies of sex differences in the manifestation of psychotic disorders have consistently
shown that there are differences between men and women in terms of sociodemographic
and clinical characteristics, as well as with both premorbid and cognitive functioning [1–3].
Many studies conclude that women tend to experience a less severe course of illness and better
prognosis as they show a later age-at-onset and more affective symptoms than men [1, 2, 4].
Meanwhile, women reached higher functional remission as compared to male participants,
with significantly more female participants having achieved recovery at the 1-year follow-up
[5].
On the other hand, numerous studies show the existence of a high prevalence of cannabis
use among first episode psychosis (FEP) patients and those with schizophrenia [6–10]. This
prevalence is well above the norm found in the Spanish general population, according to the
National Plan on Drugs [11], and coincides with trends of substance use in the United States
[12, 13]. The meta-analysis by Koskinen et al. [7] reports a median lifetime rate of cannabis
use disorders at 27.1% in people with a schizophrenia diagnosis compared with only 8% in the
general population. However, the impact of cannabis on psychotic symptoms is unclear. Some
studies demonstrate significant associations between cannabis use and increased positive
symptoms [14, 15] while other studies report no significant associations [16, 17]. In the study
of Barrowclough et al. [18] after adjustment for covariates, there were no significant associa-
tions between cannabis use and psychotic symptoms (positive or negative) or functioning. In
addition, change in cannabis use did not significantly predict change in PANSS symptom mea-
sures, nevertheless an increase in cannabis use predicted poorer functioning. Several studies
have described the differences that appear between patient cannabis users and patient non-
users in terms of socio-demographic, clinical, and neurocognitive profiles. However, only a
few studies in patients with FEP and cannabis use have included sex in the study of the hypoth-
esis or considered this a primary study variable [19–22]. For this reason, given the importance
of sex differences that have emerged from prior studies of patients with an FEP, the study of
sex implications for understanding psychotic disorders that occur with the use of cannabis is
warranted.
The main aim of this study was to clarify the prevalence of cannabis use in male and female
patients with a first episode non-affective psychosis and to explore the influence of sex in the
pattern of substance use. The second purpose of this study was to investigate the long-term
(1-year and 3-year) course of the symptoms in these subgroups of patients, as well as the evolu-
tion of the cognitive functions (at 3-year). We sought to study the relationship between the
course of symptoms and cognition, and cannabis use specific to sex.
We hypothesized that FEP male will consume higher quantities of cannabis than female.
Furthermore, cannabis user male and female will present more severe psychotic symptoms
and poorer cognitive functioning, and will have worse clinical and functional outcomes than
male and female non-users.

PLOS ONE | https://doi.org/10.1371/journal.pone.0183613 August 23, 2017 2 / 17

 Sex differences in FEP patients cannabis users

Methods
Study setting
Data for the present investigation were obtained from a large epidemiological and 3-year lon-
gitudinal intervention programme of FEP (Programa Asistencial Fases Iniciales de Psicosis
[PAFIP]) conducted at the outpatient clinic and the inpatient unit at the University Hospital
Marques de Valdecilla, Santander, Spain. It conformed to international standards for research
ethics and was approved by the local institutional review board (NCT02534363). Written
informed consent was obtained from all subjects after complete description of the study.
When minors were included in PAFIP, parents/legal guardian signed a parental permission
consent document. A more detailed descriptions of our programme have previously been
reported [23, 24].

Subjects
All patients included in the current study were assessed over the period between February
2001 and October 2015, and identified as eligible to receive treatment for a first episode of a
psychotic disorder under the PAFIP programme.
Patients included in the study were between 15–60 years of age, lived in the catchment area,
were experiencing their first episode of psychosis, met the DSM-IV criteria for schizophrenia
(50.6%), schizophreniform disorder (28.1%), brief psychotic disorder (11.1%), not otherwise
specified (NOS) psychosis (8.4%), schizoaffective disorder (1.5%), or delusional disorder
(0.4%) and had no prior treatment with antipsychotic medication or, if previously treated, had
a total life time of adequate antipsychotic treatment of less than 6 weeks.
Patients were excluded from the final analysis if they had intellectual disability, brain injury
or neurological disease, or had been diagnosed with drug or alcohol dependence according to
the DSM-IV criteria.

Premorbid and sociodemographic variables

Premorbid and sociodemographic information was recorded from patients, relatives and med-
ical records at admission. For the present study we considered: sex, age, years of education,
family history of psychosis, hospitalizations, socioeconomic status derived from the parents’
occupations (“low qualification worker” vs. “others”), living area (“urban” vs. “rural”), rela-
tionship status (“married/cohabiting” vs. “single/divorced/separate or widowed”), living status
(“living with parents” vs. “other”), employment status (“employed” vs. “unemployed”).
For the purposes of this report, patients were grouped according to the presence or absence
of cannabis use prior to illness (psychosis) onset, as “users” or “non-users”. Age of cannabis
use onset, duration of cannabis use, amount of cannabis used, and classification of subjects as
users or non-users, was based on the verbal report by the patients taken during clinical inter-
views by the clinical team.

Clinical and neurocognitive variables

The following are the clinical variables considered in the study: duration of untreated illness
(DUI), defined as the time from the first unspecific symptoms related to psychosis to initiation
of adequate antipsychotic drug treatment (for such a symptom to be considered, there should
be no return to previous stable level of functioning); duration of untreated psychosis (DUP),
defined as the time from the first continuous psychotic symptoms (present most of the time)
to initiation of adequate antipsychotic drug treatment; insight, assessed with the Scale Un-
awareness of Mental Disorders (SUMD) [25]. The symptoms of psychosis were assessed by

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 Sex differences in FEP patients cannabis users

mean scores on the Scale for the Assessment of Negative Symptoms (SANS) [26], and the
Scales for the Assessment of Positive Symptoms (SAPS) [27]. The SANS and SAPS scores were
used in generating dimensions of positive, disorganized and negative symptoms [28]. Depres-
sion symptoms were evaluated using the Calgary Depression Scale for Schizophrenia (CDSS)
[29]. The schizophrenia diagnoses were confirmed through the use of the Structured Clinical
Interview for DSM-IV (SCID-I) [30]. Functional assessment was conducted with The Disabil-
ity Assessment Scale (DAS) Spanish version [31] and with Global Assessment Functioning
(GAF) [32]. The data that comprise the current study were collected at baseline to the pro-
gram, and at 1 and 3 years post entrance.
A composite metric known as Global Cognitive Functioning (GCF) was also used. Follow-
ing previously reported transformations [33], it comprises results from tasks representing
seven cognitive domains: 1) Verbal Memory, assessed with The Rey Auditory Verbal Learning
Test (RAVLT) [34]; 2) Visual Memory, assessed with Rey Complex Figure (RFC) [35]; 3)
Working Memory, assessed with WAIS-III digits backward subtest [36]; 4) Executive Func-
tion, assessed with Trail Making Test (TMT) [37]; 5) Processing Speed, assessed with WAIS-III
digits symbol subtest [36]; 6) Motor Dexterity, assessed with Grooved Pegboard Test [38]; and
7) Attention, assessed with Continuous Performance Test (CPT) [39]. For purposes of the cur-
rent study baseline and 3-year assessment were considered.

Statistical analysis
The Statistical Package for Social Science, version 19.0, was used for statistical analyses [40].
The normality of the distribution was assessed using the Kolmogorov-Smirnov test. Paramet-
ric (t-test) and nonparametric (Mann-Whitney U) tests were used for comparisons of continu-
ous variables, with Cohen’s d effect size (ES) analysis performed to determine the magnitude
of the differences. Categorical variables were compared by using a chi-square test. A repeated
measure ANCOVA was performed for clinical, functional, and cognitive variables. Effects of
time (longitudinal dimension), group (cross-sectional dimension) and time by group (interac-
tion effect) were examined. All post-hoc comparisons were Bonferroni corrected.

Results
A total of 549 patients were included in this study: 43% (N = 236) were cannabis users, of
which 79% (N = 186) were male and 21% (N = 50) were female. The subgroup of cannabis
users was characterized by being significantly younger at the time of entry into the program
(u = 17646; p0.001). There was a significant relationship between being male and being a
cannabis user (OR = 5.6; X2 = 82.81; p0.001).

Differences between cannabis users and non-users by sex

Differences between male cannabis users and non-users. As observed in Table 1, male
cannabis users were characterized by having significantly earlier illness onset (t = -6.942;
p<0.001), less completed education (u = 9100.5; p = 0.002) and being more often single
(X2 = 8.375; p = 0.004) than non-users. In clinical and functional variables, cannabis users
presented significantly more severe positive [SAPS (u = 9793.5; p = 0.018)] and disorganized
[disorganized dimension (u = 9583.5; p = 0.008)] symptoms, but better functioning [DAS
(u = 7590; p = 0.001)] than non-users. Concerning cognitive function, cannabis users per-
formed significantly worse in processing speed (t = -2.76; p = 0.006) and better in attention
(u = 5001; p = 0.017), showing significant better global cognitive functioning [GCF (t = -2.106;
p = 0.037)].

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 Table 1. Differences between cannabis users and non-users by sex.

Male Female Gender comparison

Cannabis users Non-users Cannabis Non-users Cannabis users
users
N Mean (SD/ N Mean (SD/ p value Effect N Mean (SD/ N Mean (SD/ p value Effect P value Effect
%) %) size %) %) size size
SOCIODEMOGRAPHIC
VARIABLES
Age, years 186 24.84 125 31.42 p<0.001** -0.840 50 27.01 188 35.37 p<0.001** -0.903 p = 0.206 -0.309
(5.59) (9.54) (8.14) (10.25)
Years of education 184 8.95 (2.68) 123 10.12 p = 0.002** -0.387 50 10.60 180 11.19 p = 0.243 -0.153 p = 0.002** -0.550
(3.29) (3.51) (3.18)
Familyhistory of psychosis 186 38 124 30 p = 0.433 50 15 (30%) 187 44 p = 0.347 p<0.150
(20.43%) (24.19%) (23.52%)
Hospitalization 186 135 125 91 (72.8%) p = 0.966 50 32 (64%) 187 121 p = 0.926 p<0.236
(72.58%) (64.70%)
Low socio-economic status 179 98 121 62 p = 0.550 49 23 182 99 p = 0.353 p<0.332
(54.74%) (51.23%) (46.93%) (54.39%)
Urbanarea 183 133 124 84 p = 0.351 50 37 (74%) 183 132 p = 0.793 p<0.852
(72.67%) (67.74%) (72.13%)
Living withparents 184 119 124 70 p = 0.146 50 16 (32%) 185 68 p = 0.533 p<0.001**
(64.67%) (56.45%) (36.75%)
Unmarried 185 169 125 100 (80%) p = 0.004** 49 33 185 95 p = 0.045* p<0.001**

PLOS ONE | https://doi.org/10.1371/journal.pone.0183613 August 23, 2017

(91.35%) (67.34%) (51.35%)
Unemployed 184 93 124 59 p = 0.610 50 18 (36%) 185 65 p = 0.910 p<0.068
(50.54%) (47.58%) (35.13%)
Age of cannabis use onset 164 16.93 46 18.48 p = 0.10 -0.322
(years) (4.10) (5.42)
Duration of cannabis use 151 8.06 (4.76) 42 8.02 (6.76) p = 0.962 0.007
Amount (joints/week) 160 27.68 43 18.26 p = 0.004** 0.439
(24.59) (17.69)
CLINICAL VARIABLES
DUI (months) 177 18.77 113 27.86 p = 0.206 -0.259 49 14.43 175 23.23 p = 0.242 -0.215 p = 0.025* 0.133
(22.37) (44.16) (40.16) (41.35)
DUP (months) 185 8.61 120 16.08 p = 0.091 -0.304 49 3.73 (4.94) 182 16.48 p = 0.421 -0.477 p = 0.035* 0.522
(12.33) (32.44) (37.41)
SAPS 186 14.41 125 13.32 p = 0.018* 0.252 50 13.84 187 13.40 p = 0.542 0.092 p = 0.464 0.123
(4.20) (4.43) (5.01) (4.45)
SANS 184 6.82 (6.34) 125 7.54 (6.69) p = 0.368 -0.110 50 6.34 (5.51) 185 5.83 (5.74) p = 0.242 0.090 p = 0.980 0.080
Psychoticdimension 186 7.71 (2.39) 125 7.55 (2.52) p = 0.483 0.064 50 7.30 (2.38) 187 7.03 (2.51) p = 0.608 0.110 p = 0.211 0.171
Negativedimension 186 4.92 (5.71) 125 5.95 (5.99) p = 0.064 0.064 50 4.10 (5.16) 187 4.05 (5.32) p = 0.596 0.009 p = 0.547 0.150
Disorganizeddimension 186 6.70 (3.40) 125 5.77 (3.39) p = 0.008** -0.175 50 6.54 (3.60) 187 6.36 (6.60) p = 0.425 0.049 p = 0.916 0.045
DAS 168 1.32 (1.52) 115 1.93 (1.59) p = 0.001** 0.273 45 1.31 (1.32) 167 1.17 (1.42) p = 0.335 0.101 p = 0.697 0.007
GAF 109 52.11 81 43.79 p = 0.109 -0.390 34 55.35 123 61.36 p = 0.345 -0.194 p = 0.457 -0.104
(32.16) (28.67) (29.89) (31.93)
CDDS 185 2.21 (3.31) 125 2.14 (2.98) p = 0.984 0.273 50 2.18 (3.01) 187 2.39 (3.29) p = 0.641 -0.066 p = 0.743 0.009
(Continued)

5 / 17
Sex differences in FEP patients cannabis users
 Table 1. (Continued)

Male Female Gender comparison

Cannabis users Non-users Cannabis Non-users Cannabis users
users
N Mean (SD/ N Mean (SD/ p value Effect N Mean (SD/ N Mean (SD/ p value Effect P value Effect
%) %) size %) %) size size
Schizophrenia diagnosis 186 98 125 77 (61.6%) p = 0.120 50 21 (42%) 188 82 p = 0.837 p<0.180
(52.68%) (43.61%)
SUMD: insight mental illness 167 60 113 52 p = 0.091 45 19 170 83 p = 0.430 p<0.438
(35.92%) (46.01%) (42.22%) (48.82%)
NEUROCOGNITIVE
VARIABLES
Verbal Memory 137 6.85 (2.89) 101 7.10 (3.20) p = 0.538 -0.081 39 8.05 (3.51) 149 8.05 (3.33) p = 0.994 0 p = 0.057 -0.372
Visual Memory 136 19.30 100 17.95 p = 0.153 0.187 39 16.80 147 16.29 p = 0.665 0.078 p = 0.044* 0.374
(6.84) (7.51) (6.47) (6.56)
Working Memory 137 5.50 (1.70) 101 5.47 (1.62) p = 0.897 0.018 39 5.23 (1.81) 149 5.28 (1.97) p = 0.925 -0.026 p = 0.285 0.153
Executive Function 133 55.81 99 60.79 p = 0.525 -0.113 36 49.94 142 68 (57.32) p = 0.158 0.385 p = 0.534 -0.159
(40.10) (47.24) (33.21)
Processing speed 137 5.57 (2.62) 100 6.60 (3.10) p = 0.006** -0.358 39 7.36 (3) 150 7.93 (2.62) p = 0.239 -0.202 p<0.001** -0.635
Motor dexterity 133 71.47 98 79.42 p = 0.131 -0.284 39 66.66 144 72.14 p = 0.120 -0.302 p = 0.060 0.355
(14.23) (36.93) (12.72) (22.26)
Attention 128 72.75 96 66.52 p = 0.017* 0.428 37 68.97 140 67.07 p = 0.619 0.138 p = 0.059 0.329
(10.67) (17.60) (12.21) (15.09)

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Premorbid Intelligence (IQ) 132 8.40 (2.74) 99 9.29 (2.99) p = 0.076 -0.309 39 8.85 (2.46) 146 9.92 (2.38) p = 0.008** -0.440 p = 0.365 -0.172
GCF 123 1.38 (0.86) 91 1.67 (1.11) p = 0.037* -0.292 34 1.19 (0.84) 129 1.35 (0.94) p = 0.356 -0.179 p = 0.257 0.223

SAPS: Scale for the Assessment of Positive Symptoms; SANS: Scale for the Assessment of Negative Symptoms; CDSS: Calgary Depression Scale for Schizophrenia; SUMD: Scale
Unawareness of Mental Disorders; DUI: Duration of untreated illness; DUP: duration of untreated psychosis; DAS: The Disability Assessment Scale; GAF: Global Assessment
Functioning; GCF: Global Cognitive Functioning.

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Sex differences in FEP patients cannabis users
 Sex differences in FEP patients cannabis users

Differences between female cannabis users and non-users. The female cannabis users
were younger at illness onset (u = 2327.5; p<0.001) and more often single (X2 = 4.00;
p<0.045) than non-users. Premorbid intelligence resulted significantly different, showing
female non-users higher premorbid IQ (u = 2060.5; p = 0.008). Attending clinical and func-
tional variables, no significant differences arose.
Differences between male and female cannabis users. We found that males presented
significantly longer duration of untreated illness (DUI) (u = 3429; p = 0.025) and duration of
untreated psychosis (DUP) (u = 3645; p = 0.035) than females. In the male subgroup there was
a higher percentage of patients who lived with their parents than in the female subgroup (X2 =
17.196; p<0.001). In addition, the majority of males were single when compared to females
(X2 = 18.909; p<0.001). Male cannabis users had a lower level of education than female canna-
bis users (u = 3323; p = 0.002). Regarding neurocognitive variables, men performed signifi-
cantly better in visual memory (t = 2.03; p = 0.044) and worse in processing speed (t = -3.64;
p<0.001) than women. Men used significantly more joints per week than women (u = 2461;
p = 0.004).

Change in symptoms, functioning and cognition over time

Cross-sectional between cannabis users and non-users. The results for the clinical vari-
ables in patient cannabis users and non-users at baseline, 1-year, and 3-years follow-up assess-
ments are shown in Table 2. Significant differences between cannabis users and non-users
were found in the male subgroup in symptomatology [negative dimension (F = 4.469; p =
0.036); disorganized dimension (F = 6.389; p = 0.012)] at baseline, showing cannabis users
less severe negative symptoms but higher levels of disorganized severity. In function [DAS
(F = 7.067; p = 0.008)] male cannabis non-users showed more pronounced functional deficit.
In the female subgroup, no significant differences were found between cannabis users and
non-users.
Regarding cognitive function, the male subgroup significantly differed in motor dexterity
(F = 5.212; p = 0.025), attention (F = 7.168; p = 0.009) and global cognitive function (F = 9.948;
p = 0.002). After Bonferroni correction, male cannabis users significantly outperformed non-
users in attention at baseline (F = 4.524; p = 0.036) and at 3-year follow-up (F = 6.783; p =
0.011), showing also better GCF at baseline (F = 4.987; p = 0.028) and at 3-year follow-up
(F = 10.108; p = 0.002) than non-users. In motor dexterity male cannabis users significantly
outperformed non-users only at 3-year follow-up (F = 4.606; p = 0.034). No significant differ-
ences were observed in the female subgroup (See Table 3).

Longitudinal course
As observed in Table 2, the male subgroup showed significant improvement in clinical vari-
ables [SAPS (F = 23.396; p0.001), SANS (F = 7.718; p = 0.001), psychotic dimension
(F = 19.915; p0.001), negative dimension (F = 3.845; p = 0.022), disorganized dimension
(F = 12.081; p0.001)] but not in function (DAS and GAF). Post-hoc analyses revealed
changes in SAPS, SANS, psychotic dimension and disorganized dimensions, between baseline
and 1-year, and between baseline and 3-year follow-up assessments, for both users and non-
users (all p<0.05). No significant differences were found between 1-year and 3-year follow-up.
In the female subgroup, the main effects of time were significant across all clinical variables
[SAPS (F = 33.101; p0.001), SANS (F = 5.915; p = 0.003), psychotic dimension (F = 36.381;
p0.001), negative dimension (F = 3.312; p = 0.038), disorganized dimension (F = 12.621;
p0.001)], but not in function. Post-hoc analyses revealed an improvement in SAPS, psychotic
and disorganized dimensions between baseline and 1-year, and between baseline and 3-year

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 Sex differences in FEP patients cannabis users

Table 2. Change in function and symptoms over time.

Cannabis users Non-users F values
Baseline 1 year 3 years Baseline 1 year 3 years Time Group Time x Group
SAPS
Male 14.33 (4.29) 2.16 (3.61) 2.82 (4.44) 12.96 (4.41) 1.45 (2.49) 1.58 (2.93) 23.396** a, 2.135 0.578
b
Female 13.76 (4.29) 0.52 (1.61) 1.72 (4.55) 13.44 (4.24) 0.84 (2.03) 0.94 (2.45) 33.101** a, 0.169 0.359
b
SANS
Male 7.22 (6.48) 5.23 (5.88) 4.83 (5.73) 7.11 (6.45) 5.43 (5.65) 5.48 (6.48) 7.718** b 3.110 0.316
Female 8 (6.92) 2.92 (4.08) 1.92 (2.43) 6.19 (5.41) 4.49 (5.36) 2.92 (4.39) 5.915** a, c 0.227 1.285
Psychotic
dimension
Male 7.74 (2.38) 1.44 (2.32) 1.67 (2.66) 7.54 (2.44) 1.08 (1.93) 1.18 (2.30) 19.915** a, 0.004 0.056
b
Female 6.85 (2.92) 0.34 (1.02) 0.73 (1.46) 7.13 (2.39) 0.57 (1.53) 0.51 (1.45) 36.381** a, 0.426 0.488
b
Negative
dimension
Male 5.24 (5.87) 4.75 (5.30) 4.15 (5.05) 5.64 (5.84) 5.17 (5.38) 4.98 (5.99) 3.845* 4.469* f 0.440
Female 5.68 (6.14) 2.56 (3.57) 1.56 (2.22) 4.02 (4.90) 3.98 (4.90) 2.52 (3.92) 3.312* d,e 0.164 1.866
Disorganized
dimension
Male 6.58 (3.36) 0.72 (1.68) 1.15 (2.43) 5.38 (3.42) 0.36 (0.96) 0.38 (1.04) 12.081** a, 6.389* g 1.916
b
Female 6.80 (2.94) 0.16 (0.62) 0.96 (3.33) 6.33 (3.51) 0.28 (0.83) 0.43 (1.31) 12.621** a, 0.834 0.339
b
DAS
Male 1.38 (1.55) 1.58 (1.49) 1.46 (1.42) 1.72 (1.55) 1.88 (1.46) 1.68 (1.56) 2.015 7.067** 0.242
h
Female 1.13 (1.12) 1.17 (1.09) 0.88 (1.91) 1.08 (1.36) 1.35 (1.42) 0.84 (1.22) 1.640 0.077 0.471
GAF
Male 51.48 (31.52) 74.71 73.53 47.44 71.87 72.35 0.712 0.525 0.148
(23.93) (25.44) (28.09) (23.99) (25.78)
Female 57.12 (28.36) 80.06 87.12 63.99 79.84 83.27 1.593 0.566 1.541
(13.30) (12.77) (30.81) (19.05) (17.68)

SAPS: Scale for the Assessment of Positive Symptoms; SANS: Scale for the Assessment of Negative Symptoms; DAS: The Disability Assessment Scale;
GAF: Global Assessment Functioning
*: p<0.05
**: p<0.01.
Covariates were age and years of education.
a. Users have more symptoms at baseline than at 1-year and at 3-years
b. Non-users have more symptoms at baseline than at 1-year and at 3-years
c. Non-users show differences at all times
d. Users have more symptoms at baseline than at 3-years
e. Non-users have more symptoms at baseline than at 3-years, and at 1-year than 3-year
f. At baseline non-users have more symptoms than users
g. At baseline users have more symptoms than non-users
h. At 1-year users show better function than non-users.

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 Sex differences in FEP patients cannabis users

Table 3. Change in cognition over time.

Cannabis Non-users F
users values
Baseline 3 years Baseline 3 years Time Group Time x
Group
Verbal Memory
Male 6.82 (2.94) 7.97 6.94 7.70 0.379 0.323 0.387
(3.26) (3.08) (3.41)
Female 8.87 (3.64) 9.73 8.25 9.62 3.725 0.421 1.110
(3.03) (3.17) (3.03)
Visual Memory
Male 19.54 (7.01) 22.08 18.38 21.26 0.343 2.083 0.100
(7.10) (7.78) (6.66)
Female 16.33 (7.90) 17.47 16.37 19.17 0.137 0.372 0.653
(6.43) (6.65) (5.84)
Working
Memory
Male 5.45 (1.90) 5.66 5.55 5.85 0.185 0.712 0.008
(1.67) (1.73) (1.78)
Female 5.00 (1.46) 5.00 5.37(1.96) 5.53 0.519 0.749 0.286
(1.46) (1.73)
Executive
Function
Male -56.77 -49.13 -59.72 -52.68 1.479 1.107 0.015
(43.91) (40.42) (45.92) (45.24)
Female -58.07 -43.43 -69.75 -47.14 4.343*a 0.068 0.524
(41.54) (29.59) (63.58) (47.32)
Processing
speed
Male 5.31 (2.60) 6.95 6.67 7.10 0.366 0.190 8.814*
(3.04) (3.31) (2.64)
Female 6.67 (3.56) 9.00 7.70 9.18 2.297 0.567 0.565
(3.46) (2.56) (2.94)
Motor dexterity
Male -72.29 -66.48 -78.65 -70.30 3.967*a 5.212*b 0.941
(16.20) (14.36) (41.83) (19.67)
Female -74.00 -62.43 -72.85 -67.12 3.677 0.035 0.444
(16.91) (11.13) (23.94) (17.04)
Attention
Male 72.17 74.29 67.67 69.59 0.172 7.168*c 0.031
(11.90) (10.15) (16.02) (14.16)
Female 72.33 (8.91) 76.00 65.73 71.24 0.075 1.441 0.053
(6.73) (16.35) (11.16)
Global Cognitve
Functioning
Male 1.40 (0.83) 1.22 1.65 1.69 0.318 9.948*c 1.151
(0.89) (1.15) (1.11)
Female 1.27 (1.15) 1.08 1.34 1.20 0.993 0.034 0.097
(1.34) (0.89) (0.99)

*: p<0.05.
**: p<0.01.
Covariates were age, years of education and premorbid IQ.
a. Non-users show better performance at 3-year than at baseline
b. Users outperform non-users at 3-year
c. Users outperform non-users at baseline and 3-year.

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 Sex differences in FEP patients cannabis users

follow-up assessments, in users and non-users (all p<0.05). Concerning negative symptoms,
female cannabis non-users showed significant improvement in SANS at all time points, and in
negative dimension between baseline and 3-years, and 1 to 3-year follow-up assessments. Can-
nabis users showed significant differences in improvement in SANS between baseline and
1-year, and between baseline and 3-year in SANS and in negative dimension. Finally, despite
the lack of significant differences in repeated measures analysis, Bonferroni correction
revealed significant improvement in DAS between 1-year and 3-year in non-users, and in
GAF between baseline and 1-year, and baseline and 3-year follow-up assessments, in users and
non-users (See Table 2).
With regard to the cognitive variables, the male subgroup showed significant improvement
in motor dexterity between baseline and 3-year follow-up assessment (F = 3.967; p = 0.049).
Post-hoc analyses revealed an improvement in non-users (F = 6.964; p = 0.010). The female
subgroup showed as well significant improvement in executive function (F = 4.343; p = 0.040).
Similar to males, after Bonferroni correction, the improvement was confirmed just in the non-
users subgroup (F = 13.800; p0.001).
The repeated measures analyses did not reveal any significant time by group interaction in
clinical and functional variables, between cannabis users and non-users, for either men or
women (See Table 2). In terms of cognitive function, one significant time by group interaction
was found for processing speed in the male subgroup. The magnitude of the improvement
was greater in the subgroup of cannabis users than in non-users. (F = 8.814; p = 0.004) (See
Table 3).

Discussion
Our results show that sex and age are related to the use of cannabis in first psychotic episode
patients. We found differences between male and female cannabis users in cross-sectional ana-
lyzes, as well as some differences in the clinical outcome, which are discussed below.

Cross-sectional differences between subgroups

Young men were more often users of cannabis. At the same time, cannabis users, both male
and female, debuted with symptoms of the disease earlier than non-users. These characteristics
of cannabis users are consistent with findings from previous studies [15, 41–44], in which
being a young male and an early onset of psychosis were significantly associated with cannabis
use, [45, 46]. This could be interpreted in two ways: on the one hand, cannabis use somehow
precipitates the disease for those individuals genetically vulnerable to the disease, while on the
other hand, an early onset of symptoms connotes a search for self-medication as a method to
cope with the disease [47–49]. The self-medication hypothesis has not been supported in previ-
ous studies [8, 50].
Whereas some studies did not show significant differences between FEP cannabis users and
non-users in the number of years of formal education [14, 51], our sample showed that non-
users were significantly more likely to achieve a higher education in the male subgroup, but
not so in the female subgroup. In a study carried out in Australia with a sample of 6000 sub-
jects from the general population [52], they examined the relationship between the age of
onset of cannabis use and educational performance. They found a significant association
between the age of onset and the years of education, so that achievements were higher for sub-
jects who had not used cannabis before 18 and lower for those who started consuming before
the age of 15. This same article showed a trend which suggests that cannabis use has more det-
rimental effect on men than women on education, supporting an earlier study [53] which said
that the effects of cannabis use on education level may be specific of sex, showing more effects

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 Sex differences in FEP patients cannabis users

on male academic performance than female. Future studies taking into account the age of
onset of cannabis use are warranted to shed light on the possible relationship between age at
first exposure to cannabis and the level of education reached, and also to check differences
between male and female.
Regarding clinical variables, our sample showed significant differences between users and
non-users of cannabis on scores of SAPS and the disorganized dimension, but these differ-
ences only appear in the male subgroup. In both cases, cannabis users presented higher scores,
which is equivalent to the presence of more severe symptoms. These data are contrary to previ-
ous studies that did not show differences in symptoms between cannabis users and non-users
[54–57]. However, except in the study of Rabin et al. [57], the samples were not divided by sex,
so that the difference in results may be due to the influence exerted in these studies by the
female group.
Interestingly and contrary to what we would have expected, the Global Cognitive Function-
ing of cannabis users showed better overall performance in the male subgroup. However, by
examining the cognitive domains separately, we see differences only in attention and process-
ing speed. Patient users had better performance in attention and worse in processing speed
than non-users. Several studies that compared global cognition between cannabis users and
non-users have shown no significant difference between the two subgroups according to global
cognition [58]. Moreover, in a meta-analysis of Yücel et al. [59], the results differed depending
on whether comparisons were made between the non-user group and with patients with a his-
tory of cannabis use or with current/recent users. The results showed that better cognitive per-
formance is seen only in lifetime users but not in recent users.

Longitudinal changes in symptomatology and functionality

As observed in other studies, all the subgroups analyzed in this study showed improvement of
both positive and negative symptoms at follow-up assessments [19]. After Bonferroni correc-
tion, in the female subgroup, this improvement was significant in all three dimensions of psy-
chotic symptoms, in the subgroup of cannabis users and in the non-users subgroup. However,
the male subgroup did not show improvement in the negative dimension. These data coincide
with results obtained in another study, showing men after two years had a less pronounced
improvement than women in negative symptoms [60].
In several studies it has been observed that men present more severe symptoms than women.
However, previous studies did not investigate the effect of cannabis use on symptoms [61, 62].
The only study found to refer to the effect of drug use on long-term symptoms is that of Thorup
et al. [63] who states that men are more susceptible to negative symptoms than women, regardless
of substance use or non-use. The FEP male patients present a defined pattern, with more negative
symptoms at all assessments than females and with an evolution less favorable than that found
with females. This is a fact of great importance since, as Malla et al. [64] showed in his systematic
review, negative symptoms are predictors of poor disease progression.
We found that functioning, measured with scores of DAS and GAF, despite not showing
significant differences in repeated measures analysis, Bonferroni correction revealed improve-
ment over time in all subgroups, with the exception of scores on the DAS scale in the male sub-
group, in which we found that male cannabis users showed a slight worsening of social
functioning after 3 years, while in the non-users subgroup a small improvement appeared.
Conversely, female substance users and non-users had better social functioning than males at
all time points, a fact that coincides with previous studies [65].
These results lead us to believe that the poor evolution of the male subgroup according to
the negative dimension of the symptoms could be related to the poor evolution of functionality

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 Sex differences in FEP patients cannabis users

Fig 1. Change in symptoms and functionality over time. DAS: The Disability Assessment Scale.
https://doi.org/10.1371/journal.pone.0183613.g001

measured with the DAS scale (See Fig 1). This would support the idea that more severe symp-
toms predict lower functioning and higher disability, as shown in the Usall et al. study [65] in
which there was a significant association between functionality and negative symptoms in
their male group.
As for the evolution of cognitive functions, we found few differences between the sub-
groups. Specifically, we found a significant interaction of time by group in the processing
speed domain, only in the male subgroup. Processing speed is one of the domains most fre-
quently reported as significantly impaired in a large body of schizophrenia studies [66].
However, among patients with schizophrenia, those who are cannabis users show better
performance than non-users. In the Yücle et al. meta-analysis [59], eight studies examined
the speed of processing, in which it was observed that schizophrenia patient cannabis users
had significantly faster processing speeds than patient non-users. In the same study, when
recent use and lifetime defining studies was examined separately, patient cannabis users per-
formed significantly better than non-users only within the lifetime defining studies, but not
in those studies with recent use criteria. These data are contrary to the ones found in our

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 Sex differences in FEP patients cannabis users

sample, in which, despite the fact that male cannabis users showed a greater magnitude of
improvement than non-users, the cross-sectional analysis showed that there were no signifi-
cant differences between the users and the non-users, neither at baseline nor at 3-year follow-
up assessment.
To summarize, longitudinally there were changes in almost all clinical variables in the sub-
groups of patients over time among both male and female (except for male negative symp-
toms). However, there were no differences in the evolution between patients who were
cannabis users at the onset of the disease and those who were not. On the other hand, regard-
ing cognitive functions and functionality, patients, both male and female, users and non-users,
have negligible changes over time.

Strengths and limitations

The main strengths of this study lie in its sampling (N = 549) and long-term design, taking
into account sex and cannabis use in FEP patients. However the study has several limitations.
Firstly, the classification of patients into users or non-users was based on interviews. No con-
firmation by toxicological urinalysis was performed. However, information and self-reports
given by subjects tend to be relatively accurate [67–69]. It should be noted that patients
enrolled in our program go through a process in which both clinical and behavioral data are
collected from both themselves and their relatives. We thus feel confident as to the utility of
self-report measurement of substance use in our sample. Secondly, the number of women who
use cannabis is well below the number of male cannabis users. This is consistent with most
studies conducted thus far. A third limitation is that the quality and quantity of cannabis used
has not been taken into account. The type of cannabis used by patients is unknown, and the
classification was done according to being present or absent regardless of the intensity of use,
nor the strength of the drug used. Finally, the fourth limitation was the lack of knowledge
about the time elapsed since the last use of cannabis until the time of the interview, which
could directly affect the psychotic symptomatology and functionality.
To conclude, there is evidence that cannabis use is associated with an earlier onset of psy-
chotic illness. This strongly suggests that the reduction of substance use among high-risk
groups could have a significant effect on the incidence of psychosis. However, cannabis use
appears to have no effect on psychotic symptoms over time, and to have very little effect on
cognitive functions, indicating that it could not influence the course of the disease. There are
few studies that discuss the connection that cannabis use may have with psychotic disorders
depending on sex. Further studies are needed to elucidate the true relationship between psy-
chosis and cannabis use according to sex.

Supporting information
S1 File. Database 1.
(SAV)
S2 File. Database 2.
(SAV)

Acknowledgments
The authors wish to thank the PAFIP research team and all patients and family members who
participated in the study.

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 Sex differences in FEP patients cannabis users

Author Contributions
Conceptualization: Esther Setién-Suero, Rosa Ayesa-Arriola.
Data curation: Mariluz Ramı́rez-Bonilla, Benedicto Crespo-Facorro.
Formal analysis: Esther Setién-Suero.
Funding acquisition: Benedicto Crespo-Facorro, Rosa Ayesa-Arriola.
Investigation: Esther Setién-Suero, Benedicto Crespo-Facorro, Rosa Ayesa-Arriola.
Methodology: Esther Setién-Suero, Lourdes Fañanás, Rosa Ayesa-Arriola.
Supervision: Benedicto Crespo-Facorro, Rosa Ayesa-Arriola.
Writing – original draft: Esther Setién-Suero, Karl Neergaard, Mariluz Ramı́rez-Bonilla,
Patricia Correa-Ghisays, Benedicto Crespo-Facorro, Rosa Ayesa-Arriola.
Writing – review & editing: Esther Setién-Suero, Karl Neergaard, Mariluz Ramı́rez-Bonilla,
Patricia Correa-Ghisays, Lourdes Fañanás, Benedicto Crespo-Facorro, Rosa Ayesa-Arriola.

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