Community studies on adolescent substance use,abuse, or dependence and psychiatric comorbidity

A literature review on community studies of adolescent substance use, abuse, or dependence (SU/AID) and psychiatric comorbidity yielded 22 articles from 15 studies with information on rates, specificity, timing, and differential patterns of comorbidity by gender, race/ethnicity, and other factors. Results revealed that 60% of youths with SU/A/D had a comorbid diagnosis, and conduct disorder (CD) and oppositional defiant disorder (not attention-deficit/hyperactivity disorder) were most commonly associated with SU/A/D, followed by depression. Child psychopathology (particularly CD) was associated with early onset of substance use and abuse in later adolescence. The authors suggest that available data relevant to SU/A/D and psychiatric comorbidity can be used to better address such questions.     

Prospective relations between bulimic pathology, depression, and substance abuse: unpacking comorbidity in adolescent girls

To elucidate the processes that contribute to the comorbidity between bulimic pathology, depression, and substance abuse, the authors tested the temporal relations between these disturbances with prospective data from adolescent girls (N = 496). Multivariate analyses indicated that depressive symptoms predicted onset of bulimic pathology but not of substance abuse, bulimic symptoms predicted onset of depression but not of substance abuse, and substance abuse symptoms predicted onset of depression but not of bulimic pathology. Results suggest that the comorbidity arises because certain disorders are risk factors for the other disorders. Findings also provide support for select etiologic theories and further establish the clinical significance of these conditions by showing that they increase risk for onset of other psychiatric disturbances.     

Dissociation, PTSD, and substance abuse: an empirical study

Few studies have examined the relationship between posttraumatic stress disorder (PTSD), substance use disorder, and dissociation. We studied 77 women with current PTSD and substance dependence, classified into high- versus low-dissociation groups per the Dissociative Experiences Scale. They were compared on trauma- and substance-related symptoms, cognitions, coping skills, social adjustment, trauma history, psychiatric symptoms, and self-harm/suicidal behaviors. We found the high-dissociation group consistently more impaired than the low-dissociation group. Also, the sample overall evidenced relatively high levels of dissociation, indicating that even in the presence of recent substance use, dissociation remains a major psychological phenomenon. Indeed, the high-dissociation group reported stronger expectation that substances could manage their psychiatric symptoms. The high-dissociation group also had more trauma-related symptoms and childhood histories of emotional abuse and physical neglect. The discussion addresses methodology, the "chemical dissociation" hypothesis, and the need for a more nuanced understanding of how substances are experienced in relation to dissociative phenomena.     

Comorbid substance and mental disorders among rural Americans: results from the National Comorbidity Survey

BACKGROUND: The purpose of this study was to examine whether rural inhabitants were more likely than urban inhabitants to meet the criteria for comorbid mental health and substance abuse or dependence disorders. METHODS: Data were from the National Comorbidity Survey, and included 5185 (532=rural; 4653=urban) persons age 14-54 years of age who were interviewed using the Composite International Diagnostic Interview (CIDI). Logistic regression that accounted for the complex survey data and weighting scheme was utilized. RESULTS: Participants residing in rural areas were more likely to meet the DSM-III-R criteria for past month alcohol abuse or dependence if they also met the diagnostic criteria for past month major depressive disorder (MDD) or lifetime antisocial personality disorder (ASPD), adjusting for age, race, gender, education and income. Similarly, rural participants were more likely to meet the criteria for comorbid drug abuse or dependence in the past month if they met the diagnosis for either past month MDD, generalized anxiety disorder or lifetime ASPD, controlling for demographic characteristics. Rural residents with any current mental disorder also were less likely to seek treatment than their urban counterparts. LIMITATIONS: Data were collected in 1991 and do not capture changes in prevalence of comorbidities. Also, the small number of rural residents sampled resulted in small cell sizes for some comorbidities. CONCLUSIONS: Rural residents were significantly more likely to meet the criteria for substance disorders given they also met the criteria for a mental disorder, and those with any current mental disorder were less likely to seek treatment. Since the overall prevalence of these disorders does not differ between rural and urban inhabitants, findings suggest that rural persons may lack access to adequate treatment for their mental health disorders and subsequently may be self-medicating with alcohol and/or drugs.     

Adolescents, substance abuse, and the treatment of insomnia and daytime sleepiness

Adolescence is a time of change that can be both exciting and stressful. In this review, we focus on the central role that disturbed sleep and daytime sleepiness occupies in interactions involving substance abuse and negative health, social, and emotional outcomes. As a means of improving sleep and lowering risk for recidivism of substance abuse, we developed and implemented a six-session group treatment to treat sleep disturbances in adolescents who have received treatment for substance abuse. The components of the treatment are stimulus control instructions, use of bright light to regularize sleep, sleep hygiene education, cognitive therapy, and Mindfulness-Based Stress Reduction. Preliminary evidence indicates that participants who completed four or more sessions in the treatment program showed improved sleep and that improving sleep may lead to a reduction in substance abuse problems at the 12-month follow-up.     

Anxiety disorders comorbidity in bipolar I, bipolar II and unipolar major depression: results from a population-based study in Hungary

BACKGROUND: The aim of this study was to analyze the lifetime comorbidity between DSM-III-R anxiety disorders in separate subgroups of patients with major depression, bipolar II and bipolar I disorder in a community sample of a Hungarian population. METHODS: Randomly selected subjects (aged between 18 and 64 years, N=2953) were interviewed by the Diagnostic Interview Schedule (DIS) which generated DSM-III-R diagnoses. RESULTS: The prevalence of generalized anxiety disorder, agoraphobia and simple phobia was the highest among bipolar II patients (20.8, 37.5 and 16.7%, respectively), social phobia was most prevalent in (nonbipolar) major depression (17.6%), while the rate of panic disorder was the same in the (nonbipolar) major depressive and bipolar II subgroups (12.4 and 12.5%, respectively). Bipolar I patients showed a relatively low rate of comorbidity. CONCLUSIONS: The findings support previous results on the particularly high rate of lifetime comorbidity between anxiety disorders and unipolar major depression and particularly bipolar II illness. LIMITATIONS: Underestimation of the prevalence of bipolar II disorder by the diagnostic methodology used, resulting in a small number of bipolar II cases, lack of analysis of data by gender, no data on obsessive-compulsive disorder.     

Etiology of depression comorbidity in combat-related PTSD: A review of the literature

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD–depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.     

Childhood sexual abuse, stressful life events and risk for major depression in women

BACKGROUND: In animals, early trauma can produce long-lasting changes in sensitivity to the pathogenic effects of stress. To explore whether similar processes occur in humans, we examine whether childhood sexual abuse (CSA) in women alters sensitivity in adulthood to the depressogenic effects of stressful life events (SLEs). METHOD: A history of CSA was obtained from a population-based sample of 1404 female adult twins. Cox Proportional hazard models were used to predict onsets of episodes of DSM-III-R major depression (MD) in the past year from previously assessed levels of neuroticism (N), CSA and past-year SLEs scored on long-term contextual threat. RESULTS: In the best-fit model, onset of MD was predicted by CSA, SLEs and N. Individuals with CSA (and especially with severe CSA) had both an overall increased risk for MD and a substantially increased sensitivity to the depressogenic effects of SLEs. A 'dose-response' relationship between severity of CSA and sensitivity to SLEs was clearer in those with low to average levels of N than in those with high levels of N. CONCLUSION: As documented with physiological responses to a standardized laboratory stressor, CSA increases stress sensitivity in women in a more naturalistic setting. Both genetic and early environmental risk factors can produce long-term increase in the sensitivity of individuals to depressogenic life experiences.     

Sexual assault disclosure in relation to adolescent mental health: results from the National Survey of Adolescents.

Child sexual assault is a risk factor for a wide range of emotional and behavioral problems. Little is known about mental health functioning in relation to victims' decisions to tell someone (or not) about their assault. This study used data from a nationally representative sample of 4,023 adolescents to examine the relation between sexual assault disclosure characteristics and mental health outcomes. Results indicated that youth who disclosed the assault to someone within 1 month were at reduced risk for current major depressive episode (MDE) and delinquency. No relation was found between disclosure latency and risk for posttraumatic stress disorder (PTSD) or substance use problems. Notably, disclosure to mothers was associated with significantly reduced risk for current PTSD and delinquency.     

Risk factors for adolescent substance abuse and dependence: data from a national sample

A national household probability sample of 4,023 adolescents aged 12 to 17 years was interviewed by telephone about substance use, victimization experiences, familial substance use, and posttraumatic reactions to identify risk factors for Diagnostic and Statistical Manual of Mental Disorders--(4th ed.; American Psychiatric Association, 1994) defined substance abuse/dependence. Age and ethnicity data were available for 3,907 participants. Major findings were (a) adolescents who had been physically assaulted, who had been sexually assaulted, who had witnessed violence, or who had family members with alcohol or drug use problems had increased risk for current substance abuse/dependence; (b) posttraumatic stress disorder independently increased risk of marijuana and hard drug abuse/dependence; and (c) when effects of other variables were controlled, African Americans, but not Hispanics or Native Americans, were at approximately 1/3 the risk of substance abuse/dependence as Caucasians.     

Comparison of the MMPI-PTSD subscale with PTSD and substance abuse patient populations.

War-related PTSD frequently presents as a dual disorder. Questions have been raised about whether the MMPI-PTSD subscale developed by Keane, Malloy, and Fairbank (1984) is identifying a separate PTSD syndrome or is a measure of generalized distress common to various diagnostic categories, including substance abuse. In this study, veterans with PTSD with and without substance abuse were compared to veterans with substance abuse only on the MMPI-PTSD subscale (n = 22 in each of the four categories). Results support the ability of the test to distinguish between groups of veterans with PTSD and those with substance abuse only. The findings lend indirect support to the validity of a distinct PTSD symptom cluster.     

Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up

BACKGROUND: Although generalized anxiety disorder (GAD) and major depressive episode (MDE) are known to be highly co-morbid, little prospective research has examined whether these two disorders predict the subsequent first onset or persistence of the other or the extent to which other predictors explain the time-lagged associations between GAD and MDE. METHOD: Data were analyzed from the nationally representative two-wave panel sample of 5001 respondents who participated in the 1990-1992 National Comorbidity Survey (NCS) and the 2001-2003 NCS follow-up survey. Both surveys assessed GAD and MDE. The baseline NCS also assessed three sets of risk factors that are considered here: childhood adversities, parental history of mental-substance disorders, and respondent personality. RESULTS: Baseline MDE significantly predicted subsequent GAD onset but not persistence. Baseline GAD significantly predicted subsequent MDE onset and persistence. The associations of each disorder with the subsequent onset of the other attenuated with time since onset of the temporally primary disorder, but remained significant for over a decade after this onset. The risk factors predicted onset more than persistence. Meaningful variation was found in the strength and consistency of associations between risk factors and the two disorders. Controls for risk factors did not substantially reduce the net cross-lagged associations of the disorders with each other. CONCLUSIONS: The existence of differences in risk factors for GAD and MDE argues against the view that the two disorders are merely different manifestations of a single underlying internalizing syndrome or that GAD is merely a prodrome, residual, or severity marker of MDE.     

Childhood parental loss and risk for first-onset of major depression and alcohol dependence: the time-decay of risk and sex differences

BACKGROUND: Whereas a number of studies have suggested that parental loss is associated with increased risk for major depression (MD), much less is known about possible gender differences, diagnostic specificity and the time course of the impact of loss. METHOD: First-onsets for MD and alcohol dependence (AD) were assessed at personal interviews in 5070 twins from same-sex (SS) and 2118 from opposite-sex (OS) twin pairs ascertained from a population-based registry. Cox Proportional Hazard (PH) and Non-Proportional Hazard (NPH) models, examining first onsets of MD and AD, were used with twins from SS pairs and conditional logistic regression for OS pairs. Parent-child separations prior to age 17 were divided into death and separation from other causes. RESULTS: The PH assumptions of constant increased risk were rejected for the impact of loss on risk for MD but not for AD. NPH models found significantly increased risk for MD after both death and separation with the risk lasting much longer for separations. For AD, the PH model found significantly increased risk after parental separation but not death. In both SS and OS twin pairs, no sex differences were seen in the impact of parental loss on risk for MD whereas the association between separation and risk for AD was significantly stronger in females than in males. CONCLUSION: Consistent sex differences in the association with parental loss were seen for AD but not MD. The analysis of the time-course of increased risk after loss suggests three different patterns which may reflect different relationships: parental death and MD (return to baseline within approximately 12 years), separation and MD (return to baseline within approximately 30 years) and separation and AD (no change in risk over time).     

Identifying psychophysiological risk for psychopathology: Examples from substance abuse and schizophrenia research

A problem confronting the search for psychopathology-related genes concerns the difficulty identifying gene carriers. Psychiatric diagnosis provides imperfect identification of affected individuals, and unaffected gene carriers go undetected. Psychophysiological measures may assist molecular genetic investigations by indicating genetic susceptibility for psychopathology, thus increasing the probability of identifying affected and unaffected gene carriers. Research strategies based on these premises are applied to the study of psychoactive substance use disorders and schizophrenia. Data are presented illustrating (1) that individual differences in inhibitory control involving autonomic and antisaccade eye movement measures and the P3 component of the event-related potential may be sensitive to susceptibility for substance use disorders, and (2) that eye tracking variables may identify genetic risk for schizophrenia.     

Minor depression: risk profiles, functional disability, health care use and risk of developing major depression

BACKGROUND: minor depression has been found to affect quality of life, result in a increased service utilization, and lead to an increased risk of developing a major depression. In this study we examine risk profiles, functional disability, service utilization and the risk of developing major depression in minor depression. METHODS: a random sample of the Dutch population (n=7076) was interviewed at baseline and 1 and 3 years later (response rate: 69.7%). Five categories of depression status were defined: major depression with seven to nine symptoms; with five or six symptoms; minor depression; one key symptom only; no depressive symptoms. Independent variables included: functional disability; care utilization; sociodemographic characteristics. RESULTS: functional disability was more pronounced in more severe categories of depression. Health care use was also found to be most intensive for more severe depression. The risk of developing major depression in subjects with minor depression was found to be 8.0% after 2 years. Limitations: there had already been some attrition from the study when minor depression was measured. A definition of minor depression which approached the DSM-IV definition. Absence of homeless individuals in the dataset. CONCLUSIONS: depressive disorders seem to exist on a continuum, rather than in separate categories. Subjects with minor depression make less use of professional services than subjects with major depression, but because minor depression is more prevalent than major depression, the absolute number of subjects with minor depression receiving professional help is considerable.     

Adolescent substance abuse treatment outcome: the role of substance abuse problem severity, psychosocial, and treatment factors

A structural equation model incorporating substance abuse problem severity, psychosocial risk and protection, and treatment variables examined adolescent drug abuse treatment outcome pathways across 6- and 12-month follow-up points. Findings on resiliency factors and an empirical method adapted from previous research were used to select and assign 10 psychosocial factors to either a multiple protective factor index or a risk factor index. Gender, substance abuse problem severity, treatment modality, treatment length, and aftercare participation were also examined as outcome predictors. The findings suggest that treatment intensity decisions may be better informed by pretreatment psychosocial risk level rather than by substance abuse problem severity. The present study also suggests that drug-abusing adolescents who receive sufficiently long treatment, participate in aftercare, and possess at least 1 individual or interpersonal protective factor during their recovery process have the best chance to maintain gains made during treatment.