Treating Mental Health and Substance Use Disorders in Adolescents: What Is on the Menu?

Specific treatments targeting adolescents with substance use disorders (SUDs) have been developed over the last couple of decades. Despite these developmentally tailored treatments, long-term abstinence rates remain relatively low among adolescents receiving care. Research over the last decade has increasingly focused on adolescents with comorbid substance use and psychiatric disorders, in recognition of the barriers caused by inadequate treatment of co-occurring psychiatric disorders. Treatments targeting dually diagnosed youth are now regarded as essential to improving SUD treatment outcomes, but remain underutilized. A variety of treatment modalities such as behavioral therapy, family therapy, 12-step groups, motivational interviewing, contingency management, and combinations of these interventions have been modified for adolescents. In this article, we review the research on these treatments, as they apply to dually diagnosed youth. Furthermore, we explore the evidence for various treatments targeting comorbid SUD, specific to the presence of externalizing or internalizing disorders. The current evidence base supports the importance of integrated treatment targeting both SUD and psychiatric disorders simultaneously. High-quality treatment programs offering combinations of behavioral and family therapy, particularly with motivational interviewing and contingency management, are particularly well supported. In addition, we review various psychotropic medication treatments that have also been studied in conjunction with adolescent SUD treatment. Finally, we review research on post-treatment, supportive care that has been shown to improve long-term SUD outcomes. Recently conceptualized modular treatments, which offer personalized combinations of evidence-based treatments for specific disorders, have been proposed as a means of improving outcomes. Future research on modular programs must test the efficacy of individualized treatments when applied to combinations of psychiatric and SUDs in adolescents.     

First episode schizophrenia-related psychosis and substance use disorders: acute response to olanzapine and haloperidol

BACKGROUND: Co-occurring substance use disorders, mostly involving alcohol, cannabis or cocaine, occur commonly in patients with schizophrenia and are associated with increased morbidity and mortality. Available but limited data suggest that substance use disorders (especially cannabis use disorders) may also be common in first-episode patients and appear linked to a poor outcome in these patients. Strategies to curtail substance use form an important dimension of the treatment program for both first-episode and chronic patients. We report on rates of co-occurring substance use disorders in patients within their first episode of schizophrenia-related psychosis from a multicenter, international treatment trial of olanzapine vs. haloperidol. METHODS: The study involved 262 patients (of 263 who were randomized and who returned for a post-randomization evaluation) within their first episode of psychosis (schizophrenia, schizoaffective disorder or schizophreniform disorder) recruited from 14 academic medical centers in North America and Western Europe. Patients with a history of substance dependence within 1 month prior to entry were excluded. RESULTS: Of this sample, 97 (37%) had a lifetime diagnosis of substance use disorder (SUD); of these 74 (28% of the total) had a lifetime cannabis use disorder (CUD) and 54 (21%) had a lifetime diagnosis of alcohol use disorder (AUD). Patients with SUD were more likely to be men. Those with CUD had a lower age of onset than those without. Patients with SUD had more positive symptoms and fewer negative symptoms than those without SUD, and they had a longer duration of untreated psychosis. The 12-week response data indicated that 27% of patients with SUD were responders compared to 35% of those without SUD. Patients with AUD were less likely to respond to olanzapine than those without AUD. DISCUSSION: These data suggest that first-episode patients are quite likely to have comorbid substance use disorders, and that the presence of these disorders may negatively influence response to antipsychotic medications, both typical and atypical antipsychotics, over the first 12 weeks of treatment.     

Doppeldiagnose Psychose und Sucht

The prevalence of comorbidity of psychosis and substance abuse/addiction has been on the rise during the last 10-20 years. Meanwhile, dual diagnosis patients (DD patients) represent a large core group among patients with schizophrenia, and they are difficult to treat. Biological, psychological, and social factors may account for the comorbidity, and the single factors may interact with each other. DD patients tend to have poor compliance and unfavorable outcomes with frequent psychotic relapses and hospitalizations. Efficient treatment models integrate traditional psychiatric therapy and therapy of addiction and modify or adjust the two components to each other. The most successful programs offer integrated treatment for both disorders in one setting. These programs focus on outpatient treatment, they offer pharmacotherapy, motivation therapy, psychoeducation, cognitive-behavioral therapy, and family interventions, and they can achieve significant improvements of social adjustment and decreases of substance use.     

The impact of substance use disorders on clinical outcome in 643 patients with first-episode psychosis

OBJECTIVE: Studies investigating the impact of comorbid substance use disorders (SUD) in psychosis have tended to focus on cross-sectional data, with few studies examining the effects of substance use course on clinical outcome. The main aim of the present study was to assess the impact of baseline SUD and course of SUD on remission of positive symptoms. METHOD: The Early Psychosis Prevention and Intervention Centre admitted 786 first-episode psychosis (FEP) patients between 1998 and 2000. Data on SUD and clinical outcome were collected from patients' medical records (MR) of 643 patients who met inclusion criteria. RESULTS: Lifetime prevalence of SUD was 74%, with 62% having a SUD at baseline. This reduced to 36% in those patients who completed 18 months of treatment at the EPPIC program. A Cox regression analysis indicated that a decrease or cessation of substance use significantly increased the probability of remission, whilst persistent SUD substantially reduced the likelihood. In addition, patients who reduced use appeared to have better outcomes at 18 months than those patients who had never used substances. Baseline SUD was not found to have any significant influence on symptom remission. CONCLUSION: Patients presenting with FEP have high rates of SUD. Effective management of psychosis within a specialized service is associated with reductions in SUD over the course of treatment, although persistent substance use is associated with non-compliance, treatment drop-out and poor remission rates. As such, young people with FEP and comorbid substance use should be offered integrated treatment that addresses both disorders.     

Substance abuse and related diagnoses in early psychosis

Substance abuse seems to be common among those with early signs of evolving psychosis. This article seeks to determine the prevalence of substance abuse and substance use disorders (SUDs) and the association of abuse and SUD with vulnerability psychosis among a sample of first-degree relatives of schizophrenic patients (n = 70), help-seekers (n = 29), and control subjects (n = 34). The Structured Interview for Prodromal Symptoms (SIPS) 1.0 was used to define the vulnerability status and the Structured Clinical Interview for DSM-IV Axis I to diagnose the subjects. Data on various other measures, including premorbid adjustment, personality disorder symptoms, psychological distress, and abuse of substances, were collected. Those who were identified as vulnerable to psychosis reported significantly more lifetime alcohol abuse and had more commonly an SUD than controls. Substance use disorder, as well as alcohol and drug abuse, correlated significantly with personality disorder symptoms and current positive SIPS score and both types of abuse also with disorganization SIPS score. The odds ratio for having an SUD among those vulnerable to psychosis was 6.33 (95% confidence interval, 1.77-22.73). Early psychosis and substance abuse frequently occur together.     

Hepatitis C testing and infection rates in bipolar patients with and without comorbid substance use disorders

OBJECTIVES: To determine and compare hepatitis C (HCV) screening and testing rates among four groups: those with (i) bipolar disorder [BD group (history of BD but no substance use disorder)]; (ii) substance use disorders [SUD group (history of SUD but no BD)]; (iii) co-occurring disorders [DD group (history of both BD and an SUD)]; and (iv) a control group (no history of either bipolar disorder or substance use disorder). Our hypothesis was that HCV antibody testing rates and HCV prevalence would be higher in the BD, SUD, and DD groups than the control group. METHODS: Data were retrospectively collected on 325,410 patients seen between 1998 and 2004 within facilities and clinics of the Veterans Integrated Service Network (VISN) 20 Northwest Veterans Health Care Administration from electronic medical records. HCV screening and prevalence rates were compared between the BD, SUD, DD, and control groups. Odds ratios and relative risks were determined and compared between groups. RESULTS: Patients in the BD, SUD, and DD groups had been tested at a higher rate than controls and were at increased risk for HCV infection compared with controls. These high-risk groups had a 1.31-fold, 4.86-fold, and 5.46-fold increase in the relative risk of HCV infection, respectively. Overall, compared to the control group, the relative risk of a patient having HCV if he or she had BD (with or without an SUD) was 3.6. CONCLUSIONS: Patients with BD and comorbid SUD had an over fourfold increase in relative risk for HCV than our control group and a similar risk as patients in our SUD group. Furthermore, even if bipolar patients did not have a comorbid SUD (the BD group), their relative risk of HCV was significantly higher than that of the control group. This suggests that patients with BD, particularly those with a comorbid SUD, should be screened and tested for HCV.     

Substance use in severe mental illness: self-medication and vulnerability factors

The aim of this article is to examine the onset and clinical correlates of substance use in patients with psychotic disorders. One hundred and eight inpatients and outpatients with DSM-IV psychotic disorders were evaluated with the SCI-SUBS, an instrument designed to explore the spectrum of substance use and its clinical correlates. Comparisons were made between subjects with (n = 47) and without (n = 61) a DSM-IV diagnosis of substance use disorder (SUD). In patients with an early onset of psychosis (< 17 years), the onset of SUD was subsequent. Patients with SUD had higher substance sensitivity, higher sensation-seeking traits and were more likely to self-medicate than patients without SUD. The reasons for self-medication endorsed by patients with SUD included relieving depression, achieving or maintaining euphoria, improving self-confidence and social abilities. Our results, based on a cross-sectional study, suggest that early onset of psychosis, substance sensitivity and sensation-seeking traits represent vulnerability factors for SUD. The relationships between SUD and psychosis should be examined systematically and clarified in longitudinal studies.     

Patterns and predictors of substance use disorders and daily tobacco use in first-episode psychosis

OBJECTIVE: To investigate the patterns and predictors of substance use disorders (SUD) and daily tobacco use in first-episode psychosis (FEP). METHOD: In this study, consecutive admissions of 126 patients with an initial presentation for FEP were recruited from three psychiatric services. Each patient was assessed with a comprehensive assessment package in order to collect demographic information, to diagnose psychotic disorders and SUD, to estimate the duration of untreated psychosis and to assess premorbid functioning and the severity of psychiatric symptoms. RESULTS: The rates of lifetime SUD and daily tobacco use were 71% and 77%, respectively. The onset of SUD pre-dated the onset of positive psychotic symptoms in 91% of relevant cases. In multivariate analyses, male gender, younger age, Australian birth and unemployed status were the most consistent demographic predictors of SUD and daily tobacco use. There were no associations found between SUD and symptom severity, premorbid adjustment, psychotic disorder diagnosis or hospitalization. CONCLUSIONS: Male gender and younger age are reliable predictors of SUD in FEP. Patients with and without SUD appear to have similar clinical characteristics at initial presentation.     

Predictors of Community Functioning in Schizophrenia and Substance Use Disorder Patients

Community functioning is a broad term that encompasses various ‘real world’ measures of disability among schizophrenia patients. It includes outcomes such as independent living, social competence and behavioural problems—all of which are priorities for treatment among schizophrenia patients, mental health care providers, and family members. An important goal for rehabilitation programs is to identify predictors of community functioning which, in turn, could be used as targets for intervention. The present case–control study examined socio-demographic and substance use disorder (SUD) variables as well as psychiatric, extrapyramidal, and cognitive symptoms as predictors of community functioning in schizophrenia patients with (DD patients; n = 31) and without comorbid SUDs (SCZ patients; n = 31), and non-psychosis substance abusers (SUD patients; n = 39). Psychiatric and extrapyramidal symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia and the Extrapyramidal Symptoms Rating Scale. Cognition was evaluated using the Cambridge Neuropsychological Test Automated Battery (speed of processing, explicit and working memory). In SCZ patients, community functioning was predicted by explicit memory performance. In DD patients, community functioning was predicted by substance abuse, depression and speed of processing. In SUD patients, community functioning was predicted by substance abuse, positive symptoms and education. Our results suggest that cognition should be among the top treatment priorities in SCZ patients, whereas the key treatment targets in DD patients should be substance abuse and depression. Future studies will need to replicate the current findings, using prospective research designs.     

Extrapyramidal symptoms in substance abusers with and without schizophrenia and in nonabusing patients with schizophrenia

Extrapyramidal symptoms (EPS) such as parkinsonism, dystonia, dyskinesia, and akathisia are conditions of impaired motor function, which are associated with chronic antipsychotic treatment in schizophrenia. In addition, EPS is often exacerbated by psychoactive substance (PAS) abuse, which is frequently observed in this population. Few studies, however, have investigated the contribution of PAS abuse on EPS in PAS‐abusers without comorbid psychosis. This study compared the occurrence of EPS in outpatient schizophrenia patients with (DD group; n= 36) and without PAS abuse (SCZ group; n = 41) as well as in nonschizophrenia PAS abusers undergoing detoxification [substance use disorder (SUD) group; n = 38]. Psychiatric symptoms were measured using the Positive and Negative Syndrome Scale and the Calgary Depression Scale for schizophrenia. Extrapyramidal symptoms were evaluated with the Extrapyramidal Symptoms Rating Scale and the Barnes Akathisia Scale. SUD diagnoses were complemented with urine drug screenings. We found that DD patients exhibited significantly more parkinsonism than SCZ patients. Our subanalyses revealed that cocaine and alcohol abuse/dependence was responsible for the increase in parkinsonism in DD patients. Additionally, we found that SUD individuals exhibited significantly more akathisia than SCZ patients. In these latter individuals, subanalyses revealed that alcohol and cannabis abuse/dependence was responsible for the increase in akathisia. Our results suggest that PAS abuse is a contributor to EPS in individuals with and without schizophrenia. © 2010 Movement Disorder Society.     

A Comparison of Treatment Outcomes for Individuals with Substance Use Disorder Alone and Individuals with Probable Dual Diagnosis

The co-occurrence of substance use and mental health problems, often referred to as dual diagnosis (DD), is increasingly recognised as commonplace within substance abuse treatment programs. Two-hundred and thirty-four individuals from 9 Australian Salvation Army drug and alcohol rehabilitation programs completed a 3-month post-discharge telephone follow-up. Using a cut-off score from the Psychiatric Subscale of the Addiction Severity Index (5^th ed.), 66.7% were classified as likely to have DD and 33.3% as substance use disorder only (SUD). Both groups reported comparable and decreased substance use levels at follow-up, yet DD individuals perceived less improvement in substance use problems. Comparable improvements were reported in the areas of: symptom distress and recovery from symptoms. This was despite greater scope for improvement in individuals with DD. Duration of treatment and access to post treatment services were also assessed. Understanding factors effecting treatment outcomes is imperative for the implementation of effective, evidence based treatment programs.     

Pharmacotherapy of adolescent substance use disorders: a review of the literature

OBJECTIVE: Substance use disorders (SUD) are increasingly conceptualized as developing during adolescence. Moreover, adolescent SUD are viewed as one of the most difficult mental health conditions to treat. The role of pharmacotherapy for adolescents with SUD is not well delineated. We systematically reviewed existing pharmacotherapy studies of adolescent SUD. METHODS: A computerized search of the literature addressing the pharmacotherapy of SUD in adolescents was performed. Data from relevant peer-reviewed scientific presentations were also included. RESULTS: Five case reports (n = 8 subjects), six open studies that primarily addressed SUD with comorbid psychiatric disorders (n = 73 subjects), and five placebo-controlled studies (n = 156 subjects) on the pharmacological treatment of youths with SUD were identified. Pharmacological agents appear to reduce comorbid psychopathology with a milder reduction in SUD symptoms. The most robust evidence exists for the treatment of SUD comorbid with affective disorders. There is a limited database supporting the use of agents to reduce substance craving and the preventative effects of pharmacotherapy on subsequent SUD development in adolescents with specific psychiatric disorders. CONCLUSION: Further controlled studies directed at reducing drug use and craving, and guiding the integration of pharmacotherapy and psychosocial interventions for SUD with the treatment of comorbid psychiatric illness, are necessary.     

Prevalence and correlates of comorbidity 8 years after a first psychotic episode

OBJECTIVE: While rates and correlates of comorbidity have been investigated in the early course of psychosis, little is known about comorbidity in the medium-to-longer term or its relationship with outcome. METHOD: A total of 182 first-episode psychosis (FEP) patients who met DSM-IV criteria for a current psychotic disorder 8 years after index presentation were grouped according to concurrent comorbidity [no concurrent axis I disorder; concurrent substance use disorder (SUD); other concurrent axis I disorder; concurrent SUD and other axis I disorder]. Outcomes were compared between groups controlling for relevant covariates. RESULTS: As much as 39% met criteria for one or more concurrent axis 1 diagnoses. Comorbidity was associated with greater severity of general psychopathology, but not with measures of functioning, treatment or negative symptoms. CONCLUSION: Specific combinations of comorbid disorders may influence patterns of psychotic symptomatology. Routine examination of axis I disorders is warranted in the ongoing management of psychosis.     

Comorbidity of substance use and other psychiatric disorders--theoretical foundation and evidence based therapy

The coincidence of two or more psychiatric disorders in the same person (comorbidity or dual diagnosis) is no rare exception. It is rather common and therapeutically highly relevant. Comorbid patients exhibit frequently severe manifestations of the disorder(s) and they require intensive treatment to meet their special needs and the interdependencies of their disorders. The present overview deals with the theoretical foundations of comorbidity of substance use and other psychiatric disorders. We present data on the prevalence of different comorbidities and discuss the models, which have been proposed to explain how substance use and other disorders relate with each other. Furthermore, we describe the clinical characteristics and long-term course of comorbid patients, as well as some general therapeutic principles including the advantages of integrated therapeutic programmes. In addition, we carried out a systematic literature search on specific pharmaco- and psychotherapies for common comorbidities using the databases MEDLINE, EMBASE and PsycInfo (up to December 2007), and assessed the methodological quality of the identified trials. Based on this search we present the empirical evidence for the effectiveness of specific treatments and make therapeutic recommendations which are graded according to the strength of existing evidence. In conclusion, integrated treatment programs are more effective, provided they take into account the multiple deficits of comorbid patients, adjust and adapt the different therapeutic components to each other, and set realistic goals. The next step should be a broader application of integrated treatment programs and their adoption as standard treatment within the national health systems.     

Outcome of patients with dual diagnosis in secondary psychiatric care

Background: Dual diagnosis (DD) is a common co-morbidity of mental illness and substance use disorder (SUD) and patients with DD are prone to complications. Better knowledge on the outcome, mortality and management of patients with DD in usual secondary psychiatric care would help to inform improved treatment strategies in the future. Aims: To explore the functional outcome and mortality of patients with DD receiving psychiatric treatment. To assess the recognition of substance use disorders (SUDs) in terms of diagnosis, and the associations of clinically diagnosed SUDs with treatment-related variables. Methods: The sample of 330 patients was collected by screening all currently treated patients with the Alcohol Use Disorders Identification Test (AUDIT) and a question about other substances used. The inclusion criteria were AUDIT?>7 and/or reported use of other substances during the preceding 12 months. The Global Assessment of Functioning scale was used to assess functional outcomes during a 2-year follow-up. Information concerning treatment and patient characteristics was collected retrospectively. Results: Level of functioning remained stable among all study patients during follow-up. The mortality rate was not increased. Effective medication use was associated with improved functional outcomes. SUDs were underdiagnosed. A clinically diagnosed SUD seemed to have an impact on the regularity of appointments and the doses of prescribed medications. Conclusions: Given our results suggesting a stable level of functioning, patients with DD appear to be well managed within secondary psychiatric care. Attention should be paid to more precise diagnostics of SUDs and to effective use of medication.     

The Impact of Treatment Orders for Residential Treatment of Comorbid Severe Substance Use Disorders for Youth Suffering from Early Psychosis: a Case Series

Impacts of comorbid severe substance use disorders (SUD) on first-episode psychosis (FEP) patients can, in some cases, be extremely serious (dangerousness, suicidality, homelessness). Traditional treatment approaches for SUD may unfortunately fail or not be acceptable to them. Impacts of mandatory residential SUD treatment (RT) are sometimes integrated to community treatment orders (CTO) but have not been studied. This is a retrospective longitudinal study by medical file review of 16 FEP patients with serious consequences of severe comorbid FEP and substance use disorders, who attended mandatory RT prescribed within a CTO. Outcomes were compared before and after mandatory RT. The mean follow-up was 4.4 years (2.3 years before RT, 2.2 years thereafter). After the mandatory RT, increased likelihood of alcohol, cannabis, amphetamines and cocaine abstinence was observed. The number of patients needing hospitalizations, presenting dangerous behaviours or employment and housing instability, decreased. Further research must be conducted to gain a more in-depth understanding of the clinical and ethical impacts of this legal approach, as well as potential pitfalls.

     

One year follow-up of alcohol and illicit substance use in first-episode psychosis: Does gender matter?

Longitudinal studies on first-episode psychosis (FEP) patients have shown a decrease of substance use disorders (SUDs) over the first years of illness, but there has been less focus on the gender aspect. The present study examines stability of alcohol and illicit substance use, with specific focus on gender, in a one year follow-up investigation of 154 FEP patients (91 men, 63 women) in Oslo, Norway, using criteria for DSM-IV substance use disorder diagnosis, the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT). The results show that cannabis was the most frequently used illicit substance at both times. Significantly more men (34%) than women (13%) had a current illicit SUD at baseline. At follow-up, the rate of illicit SUDs was significantly reduced in men (18%) but not in women (11%). There were no significant gender differences in the rate of current alcohol use disorders (AUD) (men 14%; women 8%) at baseline, and no significant reduction in AUD in any of the genders at follow-up. At follow-up, total AUDIT and DUDIT scores were reduced in men only. In conclusion, the high and persistent rate of SUDs, particularly of cannabis, among men and women during the first year of treatment for psychosis should be addressed in the clinical management of the patients. Female FEP patients who are also substance users may be particularly vulnerable in this regard and warrant closer attention.     

Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders

There is a significant need for advanced understanding of treatment of co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Approximately half of individuals seeking SUD treatment meet criteria for current PTSD, and individuals with co-occurring PTSD-SUD tend to have poorer treatment outcomes compared with those without such comorbidity. However, there is not sufficient empirical evidence to determine a best course of treatment for these individuals. This paper provides a review of the literature relevant to the treatment of co-occurring PTSD-SUD. To date, treatment studies have focused primarily on non-exposure-based psychosocial treatments, exposure-based psychosocial treatments, and medication trials. The most promising outcome data thus far are for psychosocial treatments that incorporate an exposure therapy component; however, further research is needed, particularly as related to how best to implement these approaches in real-world treatment settings.