TREATING TEENS

The comorbidity of substance use disorders (SUD) and other mental health disorders is one of the most prevalent and important challenges facing professionals treating youth today (Kendall & Charkin, 1992). As awareness of these joint problems in youth has increased over the past two decades, so has research. In the 1980s, 24 empirical studies were published of adolescent substance abusers with comorbid psychopathology, whereas in the 1990s over 125 such studies were published (Abrantes & Brown, In Press).

Comorbidity refers to the co-occurrence of two or more disorders (Perin & Last, 1995), which can be present simultaneously or sequentially. The disorder occurring first (Schuckit, Irwin & Brown, 1990) or the disorder with the most dominant symptoms (Klerman, 1990) is referred to as the primary disorder. The order of symptoms and disorder onset has important clinical implications for understanding both the causal pathways to the difficulties these youth face (e.g., Mueser, Drake & Wallach, 1998) as well as the likely clinical course following treatment (Abrantes & Brown, In Press). SUDs and mental health disorders of youth may reflect common risk (e.g., genetic predisposition), or be precipitated or exacerbated by each other (e.g., substance induced mood disorder; conduct disorder provoked by substance use disorder). The prevalence of these etiological pathways varies across mental health disorders and specific drugs of addiction.

Across all service sectors (i.e., alcohol and drug; mental health; juvenile justice) SUD youth are most likely to present with disruptive disorders, mood disorders or anxiety disorders. In adolescent substance abuse treatment programs, approximately two-thirds of youth evidence DSM Axis I psychopathology in addition to their drug problem. According to a recent review of research in this area (Abrantes & Brown, In Press), 54-95% of youth in alcohol and drug treatment have conduct or oppositional defiant disorder. Mood disorders are evident in approximately half of these teens and 15-42% exhibit anxiety disorders (e.g., PTSD; social phobia). In juvenile justice settings conduct disorders are the most common comorbid disorder with SUDs, whereas in inpatient mental health settings depressive disorders are as prevalent as disruptive disorders.

Assessment of mental health disorders among youth in treatment for substance abuse varies remarkably. Mental health disorders are often screened for by using paper and pencil measures completed by the adolescent (e.g., Personal Experiences Screening Questionnaire (PESQ)) or parent (e.g., Child Behavior Checklist (CBCL)). Formal diagnoses require the use of well-standardized interview instruments such as the Diagnostic Interview Schedule for Children (DISC), Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS), or Composite International Diagnostic Interview (CIDI), and should include age of onset. Accurate assessments require information from the adolescent and corroborative information (e.g., parent). Urinalyses are critical in disintegrating mental health diagnoses as youth may have used substances of which they are not aware and which cause specific mental health symptoms (e.g., hallucinations) or exacerbate symptoms (e.g., depression) to a severity normally meriting a psychiatric diagnosis.

Recent studies of SUD youth indicate poorer outcomes for those with comorbid mental health disorders. In particular, disruptive disorders, anxiety disorders and severity of psychiatric symptoms have been associated with higher relapse rates and greater severity of post treatment drug involvement (Brown, 1999). It is unclear whether more adverse outcomes for this population are a reflection of poorer retention or compliance with treatment, more limited personal resources (e.g., coping skills; social supports), greater environmental risks (e.g., stressors), poorer client-treatment match, or some combination thereof. Although intervention research on SUD adolescents with comorbid mental health problems has not progressed as far as such research with adults, integrated treatment of the co-occurring problems appears critical (Dembo, 1996). For example, integrated interventions with youth with comorbid conduct disorder and SUDs have been shown to increase engagement and retention in treatment (Henngellar, Rodick, Borduin, Hanson, Watson & Urey, 1996), which has been identified as a critical aspect to treatment success (Hser, Grella, Hubbard, Hsieh, Fletcher, Brown, B.S., & Anglin, 2001). Similarly, integrated interventions involving family members facilitate engagement as well as retention of such youth (e.g., Liddle & Dakof, 1995), producing improved outcomes. At present, the efficacies of specific forms of intervention have not been well explicated for SUD youth with comorbid disorders; however, joint treatment of the SUD and psychiatric disorder appears advisable.

Comorbidity: Key Issues/Questions

1. Are mental health disorders routinely assessed?
2. Are standardized instruments used to make the diagnosis?
3. Is withdrawal taken into account before the mental health disorder diagnosis is made?
4. What are the training requirements of staff who make the diagnoses of mental health disorders?
5. Is corroborative information (e.g., parent interview; urinalysis) used to rule in or rule out a disorder which may be substance induced?
6. How are mental health disorders considered in the treatment plan?
7. Are staff trained to treat common mental health disorders in this setting?
8. Is treatment for mental health disorders conducted simultaneously or sequentially with treatment for substance use disorders?
9. Are mental health disorders reevaluated after periods of sustained abstinence?
10. Are psychiatrists and psychologists available for formal assessments, integrated treatment planning and interventions?
11. Are special efforts made to engage and retain youth with comorbid mental health and SUDs?
12. Are aggressive aftercare procedures in place to retain youths with comorbidity?

References

Abrantes, A.M., & Brown, S.A. (In Press). "Psychiatric comorbidity among substance abusing adolescents: Assessment issues in clinical research." Clinical Psychology Review.

Brown, S.A. (1999). "Treatment of adolescent alcohol problems: Research review and appraisal." NIAAA Extramural Scientific Advisory Board: Treatment. Chapter 14, pp. 1-26. Bethesda, MD.

Dembo, R. (1996). "Problems among youths entering the juvenile justice system, their service needs and innovative approaches to address them." Substance Use & Misuse. Marcel Dekker Inc: US, 1996 Jan. 31 (1): pp. 81-94.

Henggeler, S.W., Rodick, J.D., Borduin, C.M., Hanson, C.L., Watson, S.M., & Urey, J.R. (1996). "Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interactions." Developmental Psychology, 22, 132-141.

Hser, Y.I., Grella, C.E., Hubbard, R.L., Hsieh, S.C., Fletcher, B.W., Brown, B.S., & Anglin, M.D. (2001). "An evolution of drug treatments for adolescents in 4 US cities." Archives of General Psychiatry, 58, 689-695.

Liddle, H.A., & Dakof, G.A. (1995). "Family-based treatment for adolescent drug use: State of the science. In E.R.D." Czechowicz (Ed.), Adolescent drug abuse: Clinical assessment and therapeutic interventions (Vol. NIH Publications No. 95-3908). Rockville, MD: National Institute on Drug Abuse.

Kendall, P.C., & Clarkin, J.F. (1992). "Introduction to Special Section: Comorbidity and treatment implications." Journal of Affective Disorder, 8, 153,157.

Klerman, G.L., (1990). "Approaches to phenomena of comorbidity." In J.D. Maser & C.R. Cloninger (Eds.), Comorbidity of mood and anxiety disorders (pp. 13-37). Washington, DC: American Psychiatric Press.

Meuser, K.T., Drake, R.E., & Wallach, M.A. (1998). "Dual diagnosis: A review of etiological theories." Addictive Behaviors, 23 (6), 717-734.

Perrin, S., & Last, C.G. (1995). "Dealing with comorbidity." In A.R. Eisen, C.A. Kearney, & C. Schaffer (Eds.), Clinical handbook of anxiety disorders in children and adolescent (pp. 412-435). Northvale, NJ: Jason Aronson, Inc.

Schuckit, M.A., Irwin, M., & Brown, S.A. (1990). "The history of anxiety symptoms among 171 primary alcoholics." Journal of Studies on Alcohol, 51, (1), 34-41.