198 Chapter 7 Substance use Regarding substance use, we found negative treatment effects in forensic psychiatric patients with a primary substance use disorder in the intervention group compared to patients in the usual care group on hospitalization duration (chapter 5). The opposite was found for patients without a primary substance use disorder, revealing more positive treatment effects on hospitalization duration. It is difficult to explain this result, but it might be related to adherence to the intervention, which could be more challenging for patients with primary substance use disorders as well as other psychiatric disorders (George & Krystal, 2000; Herbeck et al., 2005). Previous studies examining the effectiveness of a social network intervention among patients with substance use disorders also encountered low compliance levels (Day et al., 2018; Leigh et al., 1999). Based on our experiences and anecdotical evidence from our research, we consider it likely that primary substance use problems interfered with the implementation of the social network intervention. Comorbidity Regarding comorbidity, our study showed stronger treatment effects of hospitalization duration in patients with comorbid disorders who were allocated to the social network intervention compared to patients in usual care. Furthermore, patients without comorbidity allocated to the social network intervention showed negative treatment effects compared to patients in usual care. At this point we can only speculate about these findings, as no previous study has shown similar results. One case-control trial did show (non-significant) reduced hospitalizations in patients with severe mental illnesses who received a community-based family support intervention compared to usual care, specifically in a subgroup of patients with schizophrenia and psychotic spectrum disorders (Villemoes et al., 2018). Therefore, we consider it plausible that a more holistic approach, including a focus on the patient's social network, is preferable and probably more effective for treating patients with complex problems and needs. Strengths and limitations Although a large body of research emphasized the importance of supportive social networks in the recovery of psychiatric patients, and interventions aimed at enhancing supportive networks have been studied and applied in numerous countries worldwide, the scientific evidence for the effectiveness remained inconclusive. Moreover, research on the effectiveness of social network interventions in forensic psychiatric patients is scarce. Therefore, the fact that this dissertation is the first RCT to examine the effectiveness of an
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