Impact of psychiatric comorbidity on treatment of adolescent drug abusers

Drug abuse risk and protective factors among black urban adolescent girls: a group-randomized trial of computer-delivered mother-daughter intervention

A group-randomized design tested a mother-daughter intervention in which researchers aimed to increase protective factors in a community sample of Black urban adolescent girls. Girls and their mothers at 2 community agencies were pretested and, by agency, were randomized to either an intervention arm or a control arm. Intervention arm girls and their mothers received a program for improving mother- daughter rapport. Posttest data collected 3 weeks after program delivery revealed that intervention arm mothers and daughters improved more than did control arm mothers and daughters on measures of communication and closeness. At 3-month follow-up, intervention arm mothers, relative to control arm mothers, continued to report better communication with and closeness to their daughters. Girls and mothers in the intervention arm rated the computer program favorably on parameters of enjoyment, comfort, relevance, usefulness of information, improvements to their relationship with one another, and whether they would recommend the computer program to friends.

Mental disorder comorbidity in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE

To show the extent and patterning of 12 month mental disorder comorbidity in the New Zealand population, and its association with case severity, suicidality and health service utilization.

METHOD

A nationwide face-to-face household survey was carried out in October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. The measurement of mental disorder was with the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0). Comorbidity was analysed with hierarchy, consistent with a clinical approach to disorder count.

RESULTS

Comorbidity occurred among 37% of 12 month cases. Anxiety and mood disorders were most frequently comorbid. Strong bivariate associations occurred between alcohol and drug use disorders and, to a lesser extent, between substance use disorders and some anxiety and mood disorders. Comorbidity was associated with case severity, with suicidal behaviour (especially suicide attempts) and with health sector use (especially mental health service use).

CONCLUSION

The widespread nature of mental disorder comorbidity has implications for the configuration of mental health services and for clinical practice.

Comorbid psychopathology in adolescents and young adults treated for substance use disorders: a review

OBJECTIVE

In a recent review, the prevalence of comorbid psychiatric disorders in non-treated adolescents and young adults with substance use disorders (SUD) in the general population was summarized. This review looks into the prevalence of psychiatric comorbidity in adolescents and young adults treated for SUD.

METHOD

A computerized literature search was conducted resulting in ten eligible studies.

RESULTS

The prevalence of comorbid psychiatric disorders varied from 61% to 88%. Externalizing disorders, especially Conduct Disorder (CD), were most consistently linked to SUD in treatment seeking adolescents. Girls are distinguished by their high rate of comorbid internalizing disorders.

CONCLUSIONS

Comparison with data from community and juvenile justice studies shows an ascending trend of comorbidity rates of externalizing disorders from community to clinical and finally to juvenile justice samples. It seems that young addicts with comorbid disorders are at high risk of ending up in the juvenile justice system.

The prevention of HIV transmission in Hispanic adolescents

This article reviews the state of the science in HIV prevention for Hispanic adolescents. The article discusses the importance of preventing HIV in Hispanic adolescents. Literature is reviewed in three broad areas: (1) the prevalence rates of drug and alcohol misuse, sexual practices, and HIV infection; (2) risk and protective factors for drug and alcohol misuse and unprotected sex (in general and specifically for Hispanics); and (3) the state of HIV prevention intervention development and evaluation targeting Hispanic youth. Seven specific recommendations are advanced in areas that have the potential to further the field of HIV prevention for Hispanic adolescents.

Adolescents entering chemical dependency treatment in private managed care: ethnic differences in treatment initiation and retention

PURPOSE

There has been little research on adolescents of different ethnicities in chemical dependency (CD) treatment, despite a focus on ethnic disparities in health care in recent years. In particular, little is known about ethnic differences in utilization of adolescent CD services.

METHODS

We examined treatment initiation and treatment retention in a sample of African American, Native American, Latino, Asian American, and Caucasian adolescents entering CD treatment in a private, managed care health plan (n = 419). Our conceptual framework included ethnicity as the main factor as well as measures of external pressure and internal motivation/readiness for treatment, family environment, psychiatric co-morbidities, and severity of alcohol and drug problems. Logistic and Poisson regression were used to examine differences.

RESULTS

The study found ethnic differences in treatment initiation and treatment retention. Native American adolescents had lower odds of returning after intake to initiate treatment compared with Caucasians (odds ratio [OR] .35, p = .009), and African American youth spent less time in treatment than Caucasians (RR: .49, p < .001).

CONCLUSIONS

Study findings indicate differences in treatment initiation for Native Americans and in treatment retention for African Americans. Intake and orientation sessions offer an opportunity to intervene with Native American youth. Given their high psychiatric co-morbidity, they may also benefit from the availability of psychiatric services. Even after adjusting for severity, we found shorter treatment retention for African American adolescents and suggest that organizational factors, such as cultural competency, may play an important role.

Interventions and Patterns of Risk in Adolescent HIV/AIDS Prevention

Mid-way through the third decade of experience in preventing HIV/AIDS among adolescents, behavioral interventions and outcomes for high risk subgroups have generated evidence extremely instructive for navigating future priorities in reducing transmission risk behavior. Youth who abuse alcohol or drugs, who are detained or incarcerated, or have mental health co-morbidity such as externalizing disorders, represent the most significant challenge to current and future efforts to control the epidemic among the adolescent population. Although there is no unambiguous, standard intervention approach with adolescents, patterns of risks and outcomes with these subgroups are instructive in the critical priority of creating more sustainable gains with our HIV prevention resources. This article provides a synthesis of the evidence with these subgroups, discusses important limitations and difficulties in the current intervention science and highlights promising directions for the next generation of effort in reducing adolescent HIV-related sexual risk behavior. Because individual-level interventions have had only modest effects, a key current emphasis within the field is to develop multilevel interventions with a more ecological or contextual focus. We review various pragmatic responses that acknowledge this priority and the debt owed to individual-level intervention work with adolescents.

Relapse to alcohol and other drug use in treated adolescents: review and reconsideration of relapse as a change point in clinical course

Relapse serves as an early warning sign of a failure to maintain desired behavioral change. Although rates of and time to relapse appear to be similar for treated adolescents and adults, this critical review of the literature on adolescent relapse begins with an overview of developmental differences between adolescent and adult substance users that need to be considered when studying relapse. A summary of rates of relapse in treated teens is followed by a review of results on the predictive validity of different relapse definitions. Next, characteristics of teens' initial relapse in terms of substances involved, situational context, and factors associated with relapse are described. Because relapse is ideally understood in the context of longer-term patterns of use, the review also discusses the extent to which early episodes of use mark clinically significant change points in post-treatment course, and how knowledge of longer-term clinical course is essential to understanding the relapse process and mechanisms underlying the maintenance of behavioral change.

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.

Chemical dependency and psychiatric services for adolescents in private managed care: implications for outcomes

BACKGROUND

Many adolescents with alcohol and drug problems have mental health comorbidities. The literature suggests that patients entering chemical dependency (CD) treatment with co-occurring problems have less successful outcomes, including treatment dropout and relapse. We examined the impact of psychiatric services on treatment initiation, retention, and alcohol and drug abstinence outcomes for adolescents in CD treatment.

METHODS

Participants were 419 adolescents aged 12-18 years who were seeking treatment at four CD programs of a nonprofit, managed care, group model health system and a parent or guardian for each adolescent. We surveyed participants at intake and 6 months and examined clinical and administrative data on diagnoses and CD and psychiatric utilization. Six-month response rates were 91% for adolescents and 93% for parents.

RESULTS

Fifty-five percent of the patients with treatment intakes had at least one psychiatric diagnosis in addition to a substance use disorder. Compared with matched controls, patients with CD intakes had higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder, and conduct disorder including oppositional defiant disorder. Thirty-one percent of the full sample had psychiatric visits in the 6 months after intake; among those with a psychiatric diagnosis, 54% had a psychiatric visit. Girls and those with higher Youth Self-Report internalizing scores were more likely to have a psychiatric visit (OR = 2.27, p < 0.001 and OR = 1.05, p < 0.0001, respectively). Adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving these services (OR = 1.57, 95% CI = 0.98-2.5) and more likely to be alcohol abstinent (OR = 1.68, 95% CI = 1.00-2.85). Those adolescents at colocated clinics had higher odds of abstinence from both alcohol and drugs (OR = 1.57, 95% CI = 1.03-2.39) and drugs (OR = 1.84, 95% CI = 1.87-2.85) and of returning after intake to initiate CD treatment (OR = 2.28, 95% CI = 1.44-3.61, p < 0.001) than others.

CONCLUSIONS

Our results demonstrate the need for psychiatric treatment of adolescents in CD treatment and highlight the importance of their receiving such services.

Psychological symptoms and drug use severity among Israeli adolescents presenting for outpatient drug abuse treatment

The objective of this study was to assess the rates of externalizing and internalizing symptoms, and the relation between psychological symptoms and drug use severity, among 117 Israeli adolescents presenting for outpatient drug abuse treatment. Psychological symptoms were assessed via both adolescent self-report and parent report. Drug use was assessed using both adolescent self-report and urinalysis. Results showed that 58% of the sample evidenced clinical levels of psychological symptoms, with girls evidencing higher rates of externalizing and mixed symptomatology than boys. Parents' report of adolescents' internalizing symptoms predicted severity of drug use. These findings suggest that treatment for this population should be multidimensional, and address not only drug use per se, but also psychological risk factors.

Substance misuse and psychiatric comorbidity in adolescents

PURPOSE OF REVIEW

Many young people are misusing and becoming dependent on multiple substances (especially nicotine, alcohol, and cannabis), with a complex variety of psychological effects.

RECENT FINDINGS

Analysis of interactions between smoking, drinking, and cannabis use indicates that the relationship between substance use and psychiatric comorbidity is primarily explained by regular smoking. In some studies the use of cannabis on a regular basis was associated with an increased risk of psychiatric illness. This is by no means the case for all studies, so this area of work remains controversial. Children with attention deficit hyperactivity disorder who are substance misusers have a poorer prognosis than those without it so there is concern about treatment with stimulant drugs: this fear appears not to be substantiated by one study. Young people with anxiety disorders are at increased risk of substance use disorders. Clinical trials for adolescent substance abuse treatment have provided support for the benefits of cognitive behavioural interventions. There is an accumulating evidence base for pharmacological treatment for adult substance misusers that can inform treatment for younger patients. It is estimated that, of those adolescents who were likely to be in need of help, only about 9% received treatment.

SUMMARY

Since psychiatric disorders beginning in childhood may continue into adult life, there is an opportunity to intervene to prevent or reduce conditions complicated by substance misuse, if services are accessible. The need for longitudinal work is vital to explore the patterns of comorbidity, and implement and evaluate appropriate treatment interventions.

Psychiatric comorbidity in children and adolescents

PURPOSE OF REVIEW

This review critically discusses recent research findings on psychiatry comorbidity in children and adolescent persons.

RECENT FINDINGS

Several epidemiological studies have confirmed previous findings in relation to the high rates of psychiatric comorbidity in children and adolescents. In particular, psychiatric comorbidity has been detected in children with substance abuse, and with conduct and oppositional defiant, anxiety and attention deficit-hyperactivity disorders. These studies have also investigated the impact comorbidity has on symptom presentation, outcome and service utilization. Although the presence of concurrent psychiatric disorders in children and adolescents is well established, there has been limited research on the need for different treatment modalities in children suffering from more than one disorder.

SUMMARY

It is widely accepted that children and adolescents frequently present with more than one psychiatric diagnosis. The substantial variation in psychiatric comorbidity found in the literature may be due to the different methods of data collection as well as to the classification system used. Whether children and adolescents fulfil diagnostic criteria for a mixed condition (International Classification of Diseases-10) or multiple disorders (Diagnostic and Statistical Manual of Mental Disorders-IV), it is important that the concurrent psychopathology be recognized and treated.

Adolescent alcohol misuse: methodological issues for enhancing treatment research

AIMS

The objective of this article is to present an overview of the current state of the field of adolescent alcohol treatment research and to discuss several priorities for future research directions.

METHOD

The authors identified trends in adolescent alcohol treatment research from multiple sources, including searches of the National Institutes of Health grantee listings, proceedings from annual meetings of the Research Society on Alcoholism and relevant English-language journal articles available in MEDLINE and PSYCHLIT databases over the past decade.

RESEARCH RECOMMENDATIONS

This field must build on its major strength, which has been its success in appreciating the unique developmental characteristics of adolescence and meaningfully incorporating them into adolescent alcohol treatment approaches. Priorities for future research include: empirically investigating the potential value of harm reduction approaches for promoting public health and reducing total harm for adolescents; developing efficacious interventions across a wide range of intensities and settings; increasing the reach and relevance of randomized treatment efficacy trials and their products, with a particular focus on enhancing the recruitment and retention of diverse treatment samples; increasing a focus on key individual difference variables such as co-occurring diagnoses, that may serve as the basis for treatment tailoring; and exploration of the potential benefits of transdisciplinary research.

Family-based therapies for adolescent alcohol and drug use: research contributions and future research needs

OBJECTIVE

To characterize the developmental status of the family-based adolescent alcohol and drug treatment specialty by identifying and discussing research and clinical advances.

METHOD

Selective and interpretative literature review and analysis.

STUDY SELECTION

Controlled trials and mechanisms of change studies of family-based treatments for adolescent alcohol and drug misuse.

RESULTS

Clinical innovations of family-based treatments include development of detailed therapy, training/supervision, and adherence manuals. Different family-based treatments have been tested with success in controlled trials and process studies. Different versions of the same approach might vary on parameters such as treatment dose, setting, and client characteristics. Research advances include findings that engagement and retention rates for family-based treatments are superior to standard treatment engagement/retention methods. Also, in clinical trials in which they are compared with alternative interventions, in the majority of studies, family-based treatments produce superior and stable outcomes with significant decreases on target symptoms of alcohol and drug use, and related problems such as delinquency, school and family problems, and affiliation with substance abusing peers. Mechanisms of change studies support the theory basis of family-based treatments. For instance, improvements in family interaction patterns coincide with decreases in core target alcohol and drug misuse symptoms.

CONCLUSIONS

Once in the shadows of the adult substance abuse field, the adolescent substance abuse specialty has become a unique, clinically creative, and empirically-based area. Research and clinical advances of family-based treatments have implications for non-family-based interventions in the adolescent substance misuse treatment specialty.