Comorbidity of substance abuse and other psychiatric disorders in adolescents

Psychopathology coexisting with substance abuse in adolescents is often encountered in a variety of clinical settings. Research findings suggest a major role for substance use in the etiology and prognosis of psychiatric disorders such as affective disorders, conduct disorder and antisocial personality disorder, attention-deficit hyperactivity disorder, and anxiety disorders. Psychiatric disorders also appear to have an important role in the etiology of and vulnerability to substance use problems in adolescents. Although the comorbidity of substance abuse and other psychiatric disorders in adolescents is recognized as an important factor in the treatment of adolescents, further research is needed to establish its prevalence, genetics, and clinical implications.     

Five-year diagnostic stability among adolescents in an inpatient psychiatric unit

IntroductionIn childhood, diagnoses made at the first admission to a psychiatric unit are frequently unstable and temporary. In this study, we examined the stability of DSM-IV-TR disorders and groups of disorders among adolescents followed-up for 5 years after hospitalization.MethodAll inpatients admitted for the first time between 2007 and 2008 were included and contacted after 5 years for re-evaluation. The final sample comprised 72 patients. At admission, diagnoses were based on the DSM-IV-TR criteria, Fourth Edition. At five years, diagnoses were made using structured clinical interviews for DSM-IV axis I Disorders and for axis II (SCID-I and SCID-II) as well as the Personality Diagnostic Questionnaire, Fourth Edition (PDQ-4). We also evaluated and collected information on the global assessment of functioning using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) instrument. Depending on the distribution of variables, we used the chi-squared and Fisher exact tests or the Student t and McNemar tests for statistical analyses.ResultsThe most stable diagnoses were schizophrenia spectrum disorders, bipolar disorder, generalized anxiety disorder, obsessive–compulsive disorder, attention deficit hyperactivity disorder, Tourette syndrome, and pervasive developmental disorder. The most unstable diagnoses were disruptive disorders. Participants were satisfied with their quality of life and the global outcomes of the sample were positive.ConclusionMajor psychiatric disorders, including mood and schizophrenia spectrum disorders, were significantly more stable than other diagnoses and tended to continue into adulthood. In the case of study participants, suffering a mental disorder during adolescence did not appear to affect global functioning outcomes.     

Association of substance abuse and depression among adolescent psychiatric inpatients.

OBJECTIVE: To determine whether depression levels differ among suicide-attempting and non-suicide-attempting adolescent inpatients in relation to their alcohol use. METHOD: Ninety-eight adolescents hospitalized at a midwestern psychiatric hospital completed the Children's Depression Inventory and the Rutgers Alcohol Problem-Drinking Index (RAPI). Based on RAPI scores, adolescents were classified as heavy drinkers (n = 36) or light drinkers and nondrinkers (n = 62). RESULTS: Heavy drinkers had significantly more depression than those who were classified as light drinkers or nondrinkers regardless of suicide-attempting status. CONCLUSIONS: The results demonstrate a positive association between depression levels and problems with alcohol in adolescents, indicating that youth who both suffer from depression and abuse alcohol may be at higher risk for a suicide attempt.     

Adolescent substance abuse and psychiatric comorbidities

The use and abuse of substances-including alcohol, nicotine, marijuana, inhalants, and other drugs-are commonly found to be comorbid with psychiatric conditions in adolescents. This dual diagnosis requires special attention and treatment, especially as substance use often begins during this developmental period. Adolescents may be diagnosed with substance abuse, substance dependence, or substance use disorder not otherwise specified, which indicates a developing substance use problem that includes symptoms of but does not meet criteria for substance dependence. Psychiatric comorbidity in adolescents who abuse substances is the rule rather the exception, and common comorbidities include depression, anxiety, bipolar disorder, conduct disorder, and attention-deficit/hyperactivity disorder. Treatment of the psychiatric disorder often helps to alleviate the substance use disorder as well. This activity discusses the epidemiology, assessment, and treatment of this dual diagnosis.     

MAPI personality correlates of comorbid substance abuse among adolescent psychiatric inpatients

This study investigated MAPI scale patterns among adolescent psychiatric inpatients along a dimension of substance abuse deviancy; no substance abuse; alcohol abuse only; alcohol and marijuana abuse only; other substance abuse plus alcohol and/or marijuana abuse. The findings showed the most notable distinction involved the issue of non-alcoholic substance abuse. Psychiatric inpatients who abuse alcohol were little different from patients with no substance abuse diagnosis. Conversely, those patients who abuses the more culturally deviant non-alcoholic substance were markedly different than non-substance abusing or alcohol-only abusing patients in several respects; highly negativistic attitudes toward family, authority and conformity; personality styles marked by aggressiveness and labile negativism and low conscientiousness; behavioral trait of impulsivity; poor sense of academic confidence. Only these non-alcoholic substance abusing psychiatric patients may require a distinctively different treatment plan than the protocol for uncomplicated psychiatric disorder.     

Consulting for substance abuse: mental disorders among adolescents and their parents

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.     

Bullying and discrimination experiences among Korean-American adolescents

The bullying experiences of Korean-American adolescents (N = 295) were explored in relation to discrimination and mental health outcomes. Bullying experiences were assessed by the Bully Survey (Swearer, 2005), discrimination by the Perceived Ethnic and Racial Discrimination Scale (Way, 1997) and depression by the Center for Epidemiological Studies – Depression Scale (CES-D). Those who reported being bullied (31.5%) as well as those who reported both being bullied and bullying others (15.9%) experienced a higher level of depression, which was elevated beyond the clinically significant level of CES-D. The results of a LISREL model suggest that the experiences of bullying among Korean/Asian-American adolescents and their related mental health issues need to be addressed in a comprehensive context of their discrimination experiences, acculturation, family and school environments.     

Alcohol and substance abuse among schizophrenic patients presenting to an emergency psychiatric service

To obtain information regarding patterns of alcohol and substance use, portions of the Diagnostic Interview Schedule (DIS) were administered to 53 schizophrenic patients who presented to the crisis service of an emergency room in a major general hospital. The number of individuals in the sample qualifying for a lifetime diagnosis of an alcohol abuse-related disorder was quite high (47%), and there was a strong correlation between disorders of alcohol abuse and the use of other drugs. Other than alcohol, marijuana was the most frequently abused drug. Individuals who qualified for a diagnosis of an alcohol-related disorder were compared with those who did not on a variety of diagnostic and demographic variables. The authors conclude by suggesting that the high-risk rates of drug use-related disorders reported in this sample may be due to the preferential use of emergency services by schizophrenic patients with alcohol and drug abuse-related disorders.     

Religiosity and substance use and abuse among adolescents in the National Comorbidity Survey

OBJECTIVE: To replicate previous findings among adults of an inverse association between religiosity and substance use among a nationally representative sample of adolescents. METHOD: Subjects were 676 (328 female and 348 male) adolescents in the National Comorbidity Survey who were assessed for substance use and abuse with the Composite International Diagnostic Interview. Religiosity was assessed through affiliation with religious denomination and through response to 7 questions concerning belief and practice. RESULTS: Confirmatory factor analyses replicated in adolescents the 2 religiosity factors of personal devotion and personal conservatism previously identified by Kendler among adults, although the 2 factors were more highly correlated in adolescents than in adults. Personal devotion (a personal relationship with the Divine) and affiliation with more fundamentalist religious denominations were inversely associated with substance use and substance dependence or abuse across a range of substances (alcohol, marijuana, cocaine, or any contraband drug). Personal conservatism (a personal commitment to teaching and living according to creed) was inversely associated with use of alcohol only. CONCLUSION: Low levels of religiosity may be associated with adolescent onset of substance use and abuse.     

Racial and gender differences in utilization of Medicaid substance abuse services among adolescents

OBJECTIVE: This study examined race and gender disparities in utilization of substance abuse treatment among adolescents enrolled in Medicaid in Tennessee. METHODS: By using Medicaid enrollment, encounter, and claims data, utilization of substance abuse services for the population of adolescents enrolled in TennCare was examined in two ways. The first utilization measure considered annual utilization rates and probability of use of substance abuse services for the statewide population of enrolled adolescents (approximately 170,000 per year). The second examined the age at which the first substance abuse service was received for the 8,473 youths who had that service paid for by TennCare during state fiscal years 1997 to 2001. RESULTS: Proportionally, among adolescents, more whites than blacks and more males than females used substance abuse services. The disparities were greater than differences in prevalence rates explain. Black females had the greatest disparity in service utilization. Whites and females received their first substance abuse service at a younger age than blacks or males in this Medicaid population. However, the age difference may not be clinically significant. CONCLUSIONS: The low utilization rates, in general, and the disparities in service use by race and gender raise questions about the identification of substance use problems at both provider and system levels.     

Gender differences in the associations between posttraumatic stress symptoms and problematic substance use in psychiatric inpatient adolescents

This study examined gender differences in the associations between posttraumatic stress symptoms and problematic substance use in psychiatrically hospitalized adolescents. Ninety-five adolescent inpatients (38 boys, 57 girls) were systematically evaluated with a battery of psychometrically well-established self-report measures to assess trauma exposure, posttraumatic stress symptoms, problematic alcohol and drug use, and internalizing and externalizing psychopathology. Twenty-three percent (N = 22) of patients met DSM-IV-based symptom criteria for PTSD, and 37% (N = 35) and 34% (N = 32) of patients endorsed problematic levels of drug and alcohol use, respectively. Posttraumatic stress symptoms were significantly associated with problematic drug and alcohol use in girls but not in boys. There were no significant gender differences in posttraumatic stress symptoms and/or problematic substance use, to account for the gender differences in the association between PTSD and substance use. Our findings suggest that the link between substance abuse and PTSD may be especially salient for female adolescents.     

Sexual abuse, antisocial behaviour and substance use: gender differences in young community adolescents

OBJECTIVE: To investigate gender-specific relationships between self-reported sexual abuse, antisocial behaviour and substance use in a large community sample of adolescents. METHOD: A cross-sectional study of students aged, on average, 13 (n = 2596), 14 (n = 2475) and 15 years (n = 2290), from 27 schools in South Australia with a questionnaire including sexual abuse, frequency and severity of substance use, depressive symptomatology (CES-D), family functioning (McMaster Family Assessment Device), and antisocial behaviour (an adapted 22-item Self-Report Delinquency Scale). Logistic regression analyses using HLM V5.05 with a population-average model were conducted. RESULTS: In the model considered, reported sexual abuse is significantly independently associated with antisocial behaviour, controlling for confounding factors of depressive symptomatology and family dysfunction, with increased risks of three- to eightfold for sexually abused boys, and two- to threefold for sexually abused girls, compared to nonabused. Increased risks of extreme substance use in sexually abused girls (age 13) and boys (ages 13-15) are more than fourfold, compared to nonabused. Age differences were not statistically significant. CONCLUSION: Childhood sexual abuse is a risk factor for the development of antisocial behaviour and substance use in young adolescents. Clinicians should be aware of gender differences.     

Pattern of substance abuse in psychiatric inpatients

This study examined the pattern of substance abuse in a sample of 114 psychiatric inpatients using a standardized diagnostic interview. As predicted, psychiatric inpatients reported a significantly higher rate of substance abuse than a randomly selected community sample. Approximately three-quarters of the inpatients abused at least one substance. Almost one-half of the patient sample reported abusing more than one substance. These findings emphasize the need to screen psychiatric inpatients for substance abuse using a standardized diagnostic instrument and to develop treatment programs for substance abuse in psychiatric patients.     

A short-term psychiatric inpatient program for adolescents.

Third-party payers have become increasingly unwilling to fund long-term hospitalizations for adolescents. Inpatient adolescent programs have had to develop strategies to treat this difficult patient population much more rapidly. In late 1989 a short-term adolescent treatment program, known as the STAT program, was developed and implemented at a private psychiatric hospital in Massachusetts. The program aimed for a two- to three-week length of stay, a reduction of 30 to 50 percent. To accomplish this goal, the program shifted from a treatment-based approach to a focus on crisis management, patient evaluation and stabilization, and transition to outpatient services. Many staff concerns were allayed during the program's implementation. Short-term treatment for adolescents can be viable if appropriate exclusion criteria are developed for admissions and an adequate range of outpatient treatment services are available.