Comorbidity of substance use disorders and other psychiatric disorders among adolescents: evidence from an epidemiologic survey

Outcomes among youth attending inpatient treatment for co-occurring disorders

AIM

An emerging body of research is identifying effective outpatient integrated treatment approaches for youth with co-occurring psychiatric and substance use disorders, though few studies exist examining inpatient treatment. The current study aimed to address this gap by examining response to treatment during admission to, and in the year following discharge from, a specialized inpatient program for youth with co-occurring disorders.

METHODS

A single-cohort longitudinal design examined change in adaptive functioning, mental health symptoms, and substance use frequency among N = 142 youth (69.1% female) aged 14-21 (M = 16.9, SD = 1.5) attending the program. Participants completed self-report measures at admission, discharge, and 1-, 6- and 12-months post-discharge.

RESULTS

Analyses indicated significant improvements in adaptive functioning, internalizing and externalizing symptoms, and substance use frequency during admission. There was some loss of gains in adaptive functioning over the 12-months post-discharge. Improvements were maintained in internalizing symptoms and substance use frequency, and improvements in externalizing symptoms continued over the 12-months post-discharge. There was no significant interaction between change in functioning and internalizing symptoms at admission or type of substance use disorder diagnosis. There was a significant interaction with externalizing symptoms, such that those with clinically significant levels of externalizing symptoms at admission experienced greater improvement in functioning, though the groups ended treatment with comparable functioning scores.

CONCLUSIONS

The results provide preliminary support for integrated treatment for co-occurring disorders delivered in an inpatient setting. However, the results also reflect the significant needs of youth with co-occurring disorders and the importance of ongoing care post-discharge from intensive treatment settings.

Cannabis and Anxiety: A Critical Review

Introduction

Cannabis has been reported to have both anxiogenic and anxiolytic effects. Habitual cannabis use has been associated with anxiety disorders (AD). The causal pathways and mechanisms underlying the association between cannabis use (CU)/cannabis use disorder (CUD) and anxiety remain unclear. We examined the literature via a systematic review to investigate the link between cannabis and anxiety. The hypotheses studied include causality, the common factor theory, and the self-medication hypothesis.

Methods

Critical systematic review of published literature examining the relationship of CU/CUD to AD or state-anxiety, including case reports, literature reviews, observational studies, and preclinical and clinical studies. A systematic MEDline search was conducted of terms including: [anxiety], [anxiogenic], [anxiolytic], [PTSD], [OCD], [GAD], [cannabis], [marijuana], [tetrahydrocannabinol], [THC].

Results

While several case-control and cohort studies have reported no correlation between CU/CUD and AD or state anxiety (N = 5), other cross-sectional, and longitudinal studies report significant relationships (N = 20). Meta-analysis supports anxiety correlating with CU (N = 15 studies, OR = 1.24, 95% CI: 1.06-1.45, p = 0.006) or CUD (N = 13 studies, OR = 1.68, 95% CI: 1.23-2.31, p = 0.001). PATH analysis identifies the self-medication hypothesis (N = 8) as the model that best explains the association between CU/CUD and AD or state-anxiety. Despite the support of multiple large cohort studies, causal interpretations (N = 17) are less plausible, while the common factor theory (N = 5), stress-misattribution hypothesis, and reciprocal feedback theory lack substantial evidential support.

Conclusion

The association between cannabis and anxiety is best explained by anxiety predisposing individuals toward CU as a method of self-medication. A causal relationship in which CU causes AD incidence is less likely despite multiple longitudinal studies suggesting so.

Cigarette, electronic cigarette, and marijuana use among young adults under policy changes in California

Introduction

Since 2016, California has implemented a series of policies, including prohibiting the sale of tobacco products and electronic cigarettes (e-cigarettes) to persons under 21, cigarette tax increase, and recreational marijuana legalization. The study aims to examine the use of cigarettes, e-cigarettes, and marijuana among young adults (ages 18-25) and their associations with other factors in the context of these policy changes.

Methods

We used the data from the California Health Interview Survey (CHIS) 2017-2018 to compare the rates of using cigarettes, e-cigarettes, and marijuana separately or any use of the three. Using CHIS 2018 data, weighted logistic regression models were used to examine associations of using cigarettes, e-cigarettes, and marijuana separately or any use of these products/substance with demo-socioeconomic factors, psychological distress, and use of each product/substances.

Results

Cigarette smoking remained flat while the use of e-cigarettes and marijuana escalated among young adults from 2017 to 2018. Using tobacco products increased the use of marijuana or vice versa among young adults. Severe psychological distress was significantly associated with cigarette use (adjusted odds ratio [AOR] = 4.06; 95% CI = 1.32, 12.55), marijuana use (AOR = 2.32; 95% CI = 1.10, 4.48), and any use (AOR = 4.11; 95% CI = 1.93, 8.77). Moderate psychological distress was also significantly associated with the use of these products/substance. Underage (ages 18-20) young adults had lower odds of using cigarettes than other young adults (ages 21-25).

Conclusions

Our findings highlight the importance of addressing the use of cigarettes, e-cigarettes, and marijuana simultaneously through policies to curtail tobacco and marijuana use among young adults.

Impact Potpourri: A Multimethod Survey Study on Youth Substance Use During COVID-19

BACKGROUND

Given the important implications of youth substance use, it is essential to document and describe changes in substance use during the coronavirus disease 2019 pandemic.

METHODS

This multimethod survey study examines the impacts of the coronavirus disease 2019 pandemic on youth substance use among 149 Canadian youth who were using substances at a mid-pandemic period. Participants were 21.9 years of age on average (SD=2.2), including 99 girls/young women, 42 boys/young men, and 8 transgender or nonbinary individuals. The majority were Caucasian and born in Canada. Qualitative and quantitative findings are reported, with thematic analysis combined with descriptive and inferential statistical analyses.

RESULTS

Qualitatively, many youth reported increases or shifts in their substance use over the course of the pandemic. Youth reported using substances with limited numbers of peers, with family, or alone. Many reported using substances out of boredom and to cope. While legal substances remained highly accessible, illegal substances were reported to be more difficult to acquire and less trustworthy. Spending had increased. Quantitative findings suggested alcohol use has decreased, but other substance use has remained stable in the sample as a whole, although for each substance, some youth reported increases.

DISCUSSION

Despite minimal quantitative change, qualitative findings show that some youth increased their use of some substances during the pandemic, decreased others, changed their motivation to use, and decreased in safety behaviors. Youth-serving organizations should be aware of individual differences, the changing context of substance use, and the potential long-term impacts.

Psychological distress in a sample of Moroccan prisoners with drug-dependence

Research regarding mental illness and drug addiction among inmates in Morocco requires increased knowledge; previous literature reported that prisoners suffer from severe psychological distress. The present study aimed to provide information about Moroccan prisoners' psychological distress and define the differences in psychological distress levels among inmates with and without drug-dependence. A sample of 177 male inmates completed a set of surveys, including the Drug Use Disorders Identification Test (DUDIT) and the Brief Symptom Inventory (BSI). The "Drug dependence" group scored significantly higher psychological distress levels in each of the BSI domains. The strongest differences were measured in the General Severity Index (GSI), hostility, and depression scales. Moroccan prison inmates have high psychological distress, and those with drug-dependence have even higher. There is a need of psychiatric assessment, selection, and care possibilities in prison inmate populations.

Sex differences in bidirectional associations between conduct problems and cannabis use across two years of adolescence

BACKGROUND

There is a large body of research that has identified bidirectional associations between conduct problems and cannabis use. Despite growing knowledge regarding comorbidities between conduct problems and cannabis use, it remains unclear whether these findings generalize across both males and females. The current study examined sex differences in longitudinal associations between conduct problems and cannabis use in a predominantly Hispanic sample of adolescents followed over a two-year period.

METHODS

Participants were 401 adolescents (89.8% Hispanic, 46% female; M_age = 15.5) taking part in a two-year longitudinal investigation examining the associations between neurocognitive functioning and cannabis use. The sample consisted predominantly of youth selected for risk of cannabis escalation, with 90% reporting using cannabis, nicotine, or alcohol prior to baseline. Negative binomial cross-lagged regressions and simple slope difference tests were used for all analyses.

RESULTS

We found support for bidirectional associations between conduct problems and cannabis use, controlling for demographics, covariates, and baseline frequencies. Simple slope difference tests revealed that there was a significant, positive association between baseline cannabis use and subsequent conduct problems among females but not males. In contrast, the association between baseline conduct problems and subsequent frequency of cannabis use did not differ as a function of sex.

CONCLUSIONS

Our results underscore the importance of viewing cannabis use as a risk factor for maladjustment rather than solely as a consequence, particularly among female adolescents. Information gained from temporal sequencing of cannabis use and conduct problem symptoms can guide the selection of intervention programs for referred youth.

Longitudinal Emergence of Concurrent Mental Health and Substance Use Concerns in an Ontario School-Based Sample: The Research and Action for Teens Study

OBJECTIVES

This study characterizes patterns of mental health, substance use and their co-occurrence, and identifies developmental trajectories associated with progression from single to concurrent mental health and substance use concerns in an Ontario school-based population. It is a longitudinal extension of the Ontario Student Drug Use and Mental Health Survey, as part of the RAFT collaborative project.

METHODS

In this study, an Ontario-wide survey was administered to students across three biennial waves starting in grades 7-8 (ages 12-14). We explored how developmental patterns of externalizing, internalizing and co-occurring symptoms were differentially associated with late-adolescent (ages 17-19) problematic substance use.

RESULTS

On average, students exhibited early (ages 12-14) moderate risk of an internalizing and/or externalizing disorder and approached the low threshold for a diagnostic concern for substance use disorder at age 17-19. The pattern confirmed a potential pathway from early mental health concerns to later adolescent problematic substance use, with rates of co-occurrence increasing with age. Youth with early moderate-to high externalizing and co-occurring internalizing and externalizing symptomology had the highest levels of problematic substance use, with scores indicating high likelihood of a substance use disorder diagnosis.

CONCLUSIONS

Given the overall pattern of progression, early identification and referral of at-risk youth, especially youth with co-occurring mental health concerns, is of critical importance. Findings support the importance of integrated and co-located mental health and substance use services for youth to more effectively serve a diverse population of youth with varying levels of need.

A randomized trial of an integrated cognitive behavioral treatment protocol for adolescents receiving home-based services for co-occurring disorders

The current study conducted a preliminary test of whether community mental health clinic staff could implement a multicomponent cognitive behavioral treatment, developed for adolescents with substance misuse (alcohol and/or marijuana) and comorbid psychiatric symptoms. We randomized a total of 111 families, with an adolescent 12-18 years old, referred to a home-based services program for youth with co-occurring substance use and mental health problems, to receive treatment from either masters-level therapists who received intensive cognitive behavioral therapy (I-CBT) training or from masters-level therapists who took part in a typical brief continuing education-style CBT workshop (treatment as usual, or TAU). Each family's therapist and insurance company determined the frequency and intensity of treatment. We administered follow-up assessments at 3, 6, and 12 months. There was a small, but not statistically significant, reduction in the percent days of heavy drinking and marijuana use over time for both conditions, with the overall effect across the three follow-up points favoring the I-CBT condition. There were no differences on alcohol use days or other drug use. There was also a small, but nonsignificant, positive effect over time on externalizing symptoms, depressed mood, and anxiety, favoring the I-CBT condition. Youth in the I-CBT condition relative to TAU had significantly fewer juvenile justice contacts, while the pattern of costly service use varied, with higher rates at 6-month and lower rates at 12-month follow-ups. If therapists pay greater attention to parent training and provide more parent-adolescent communication sessions, outcomes may improve above standard community care. Training enhancements, to better meet the needs of community therapists and their clinic settings, may also produce better overall results for parents and adolescents.

Comorbid Anxiety Increases Suicidal Risk in Bipolar Depression: Analysis of 9720 Adolescent Inpatients

Objective: To evaluate the risk of association between suicidal behaviors and comorbid anxiety disorders in adolescents with bipolar depression. Methods: We conducted a cross-sectional study using the nationwide inpatient sample (NIS) from the United States. This study included 9720 adolescent inpatients with bipolar depression and further grouped by co-diagnosis of anxiety disorders. Logistic regression analysis was used to evaluate the odds ratio (OR) of suicidal behaviors due to comorbid anxiety after controlling demographic confounders and psychiatric comorbidities. Results: Out of total inpatients, 34.8% (n = 3385) had comorbid anxiety disorders with a predominance in females (70.3%) and White patients (67.7%). About 54.1% of inpatients with comorbid anxiety had suicidal behaviors versus 44.6% in the non-anxiety cohort (p < 0.001). Comorbid anxiety disorders were associated with 1.35 times higher odds (95% CI 1.23–1.47, p < 0.001) for suicidal behaviors. Conclusion: Suicidal behaviors are significantly prevalent in bipolar depression adolescents with comorbid anxiety disorders. Anxiety disorders are an independent risk factor in bipolar depression that increase the risk of suicidal behaviors by 35%. This necessitates careful assessment and management of comorbid anxiety disorders in bipolar youth to mitigate suicidality.

Comorbidity Patterns Among Patients With Opioid Use Disorder and Problem Gambling: ADHD Status Predicts Class Membership

Objective: Psychiatric comorbidities are highly prevalent among individuals affected by substance use disorders and those with non-substance-related addictive disorders such as gambling disorder. More recently, the frequent co-occurrence of substance use disorders and attention-deficit hyperactivity disorder (ADHD) has received particular attention. The aim of our study was to identify patterns of psychiatric comorbidity and to examine associations between patient group and ADHD status with class membership. Methods: Participants were patients with opioid use disorder enrolled in opioid maintenance treatment (OMT), either recruited from the community (n = 142; M age = 35.8 years; 38.7% female) or prison (n = 133; M age = 35.7 years; 21.8% female), and patients undergoing treatment for problem gambling (PrG; n = 80; M age = 43.1 years; 20% female). To enable direct comparisons, the following instruments were applied: Mini International Neuropsychiatric Interview, Adult ADHD self-report scale, Wender Utah Rating Scale, and European Addiction Severity Index. We used a latent class analysis (LCA) to identify psychiatric comorbidity patterns and a multinomial logistic regression to examine associations between patient group, ADHD status, age, and gender with class membership. Results: The LCA resulted in a three-class solution: (1) a class of individuals with a relatively low probability of current psychiatric comorbidities, except for a high probability of substance use disorders; (2) a class with markedly increased probabilities of current and recurrent psychiatric comorbidities, especially for major depression; and (3) a class with very low probabilities of psychiatric comorbidities, except for moderate probabilities of substance use disorders and antisocial personality disorder. Both OMT patients recruited from the community and those in prison were less likely than PrG patients to be assigned to the most burdened class with respect to psychiatric comorbidity (class 2). Further, both individuals with ADHD in childhood and those with adult ADHD were more likely members of class 2. Conclusions: PrG patients seem to be at an even higher risk for psychiatric comorbidities compared to OMT patients. Raising awareness among practitioners for the high prevalence of psychiatric comorbidities among patients with gambling disorder and individuals with ADHD is crucial to initiate adequate treatment and to improve response.

Cross-domain correlates of cannabis use disorder severity among young adults

BACKGROUND

Correlates of cannabis use and dependence among young adults have been widely studied. However, it is not known which factors are most strongly associated with severity of cannabis use dependence (CUD) severity. Identification of the salient correlates of CUD severity will be of increasing clinical significance as use becomes more socially normative.

METHODS

This study used a data-driven, hypothesis-free approach to examine the most robust correlates of CUD severity among a sample of 76 young adults (ages 18 to 25 years) who used cannabis at least weekly. Seventy-one candidate variables were examined for association with CUD severity. These included demographic variables, self-reported and psychodiagnostic assessments of mood and anxiety, self-reported measures of personality, cannabis and other substance use characteristics, and objective and subjective measures of cognition.

RESULTS

Of the 71 candidate variables considered, 27 were associated with CUD severity on a univariate level at a p-value ≤.20. Correlates of CUD severity in the multivariable model using stepwise selection were: more frequent cannabis use in the past 90 days, greater expectancies that cannabis causes cognitive and behavioral impairment, greater self-reported metacognitive deficits, greater anxiety, and lower reaction time variability on a test of sustained attention. Internal validation tests support high prediction accuracy of all variables in the multivariable model, except for lower reaction time variability.

CONCLUSIONS

Cannabis use frequency, beliefs about use, perceived cognitive abilities, and anxiety are robustly associated with CUD severity in young adult, regular cannabis users, and may be important in guiding prevention and treatment efforts.

Clinical presentations, social functioning, and treatment receipt among individuals with comorbid life-time PTSD and alcohol use disorders versus drug use disorders: findings from NESARC-III

AIMS

To compare individuals with comorbid life-time post-traumatic stress disorder (PTSD) and alcohol use disorders [AUD; i.e. no drug use disorders (DUD)] with those with comorbid PTSD and DUD on past-year prevalence of these disorders, social functioning, life-time psychiatric comorbidities, and treatment receipt. The comorbid groups were also compared with their single diagnosis counterparts.

DESIGN AND SETTING

Cross-sectional cohort study using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III).

PARTICIPANTS

The total sample size was 36 309. Six groups were established: PTSD/AUD, PTSD/DUD, AUD, DUD, PTSD, and neither PTSD nor AUD/DUD. Life-time prevalence of AUD among those with PTSD/DUD was 80.2% and among those with DUD was 73.8%.

MEASUREMENTS

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 version assessed life-time and past-year psychiatric disorders and treatment receipt. Demographics and social stability indicators were queried. Group characteristics were summarized using weighted means. Prevalences and estimates for adjusted differences in means and adjusted odds ratios (aORs) were derived from multiple linear regression and logistic regression models, respectively. Analyses were conducted in R and accounted for the NESARC-III's complex survey design, clustering, and non-response.

FINDINGS

Compared with those with life-time PTSD/AUD, those with life-time PTSD/DUD were significantly less likely to have neither disorder in the past year (PTSD/AUD = 16.1%; PTSD/DUD = 8.5%; aOR = 0.54), and were more likely to report worse social and psychiatric functioning, and to have received both addiction and mental health treatment (PTSD/AUD = 18.4%; PTSD/DUD = 43.2%; aOR = 3.88). Compared with their single disorder counterparts, those with PTSD/DUD reported greater impairment than both groups, whereas the comorbid PTSD/AUD group differed more from the AUD than the PTSD group.

CONCLUSIONS

People with comorbid PTSD and drug use disorder have greater social and psychiatric impairment and may require different types and intensity of intervention than people with comorbid post-traumatic stress disorder and alcohol use disorder.

Neural mechanisms of risky decision making in adolescents reporting frequent alcohol and/or marijuana use

Because adolescence is a period of heightened exploration of new behaviors, there is a natural increase in risk taking including initial use of alcohol and marijuana. In order to better understand potential differences in neurocognitive functioning among adolescents who use drugs, the current study aimed to identify the neural substrates of risky decision making that differ among adolescents who are primary users of alcohol or marijuana, primary users of both alcohol and marijuana, and controls who report primary use of neither drug. Participants completed the Balloon Analogue Risk Task (BART) while undergoing functional magnetic resonance imaging. Comparison of brain activation during risky decisions versus non-risky decisions across all subjects revealed greater response to risky decisions in dorsal anterior cinguate cortex (dACC), anterior insula, ventral striatum, and lateral prefrontal cortex. Group comparisons across non-using controls, primary marijuana, primary alcohol, and alcohol and marijuana users revealed several notable differences in the recruitment of brain regions. Adolescents who use both alcohol and marijauna show decreased response during risky decision making compared to controls in insula, striatum, and thalamus, and reduced differentiation of increasing risk in dACC, insula, striatum, and superior parietal lobe compared to controls. These results provide evidence of differential engagement of risky decision making circuits among adolescents with varying levels of alcohol and marijuana use, and may provide useful targets for longitudinal studies that explicitly address causality of these differences.

Early Adolescent Substance Use and Mental Health Problems and Service Utilisation in a School-based Sample

OBJECTIVE

This paper reports on substance use, mental health problems, and mental health service utilisation in an early adolescent school-based sample.

METHOD

Participants were 1,360 grade 7 and 8 students from 4 regions of Ontario, Canada. Students completed an in-class survey on mental health and substance use. The sampling strategy and survey items on demographics, substance use, service utilisation, and distress were adapted from the Ontario Student Drug Use and Health Survey. Internalising and externalising mental health problems were assessed using the Global Assessment of Individual Needs - Short Screener. Distress was defined as fair or poor self-rated mental health.

RESULTS

Rates of internalising and/or externalising problems above the threshold exceeded 30%; yet, fewer than half had received mental health services in the past 12 mo. Substance use was associated with increased odds of internalising and externalising problems above the threshold and distress. Youth using cannabis had 10-times the odds of exceeding the threshold for internalising or externalising problems. The use of substances other than alcohol or cannabis was associated with increased odds of fair or poor self-rated mental health among grade 8 students. Of the youth who confirmed at least a substance use problem, most also reported mental health problems; this association was stronger among girls than boys.

CONCLUSIONS

Early adolescent substance use was associated with concurrent self-reported mental health problems in a non-clinical sample. The low levels of service utilisation reported highlight the need for improved access to early identification and intervention to prevent the development of concurrent disorders.

Enhancing prevention and intervention for youth concurrent mental health and substance use disorders: The Research and Action for Teens study

BACKGROUND

Concurrent mental health and substance use disorders among youth are associated with functional impairment in developmentally salient domains, yet research on prevention and intervention for this vulnerable population is sparse. This paper describes the rationale and design of the Research and Action for Teens study, an initiative designed to strengthen the evidence base for prevention, screening, treatment and service delivery for youth concurrent mental health and substance use concerns.

METHODS

Four sub-studies were developed: (1) a cohort study examining the emergence of mental health and substance use concerns from early to mid-adolescence; (2) a screening and diagnosis study validating screening tools with a diagnostic interview; (3) a treatment study examining the feasibility and effectiveness of dialectical behaviour therapy skills training interventions for youth and family members; and (4) a systems study implementing cross-sectoral collaborative networks of youth-serving agencies using a common screening tool.

RESULTS

Multiple stakeholders, including service providers from youth-serving agencies across sectors, consumer groups and family members participated in an initial consultation, and in the implementation of 4 sub-studies.

CONCLUSIONS

Collaboration with community stakeholders across sectors and disciplines throughout the research process is challenging but feasible, and is important for the production of applicable knowledge across the continuum of care.

Examining the Association and Directionality between Mental Health Disorders and Substance Use among Adolescents and Young Adults in the U.S. and Canada-A Systematic Review and Meta-Analysis

Background: The purpose of this systematic review was to examine the association and directionality between mental health disorders and substance use among adolescents and young adults in the U.S. and Canada. Methods: The following databases were used: Medline, PubMed, Embase, PsycINFO, and Cochrane Library. Meta-analysis used odds ratios as the pooled measure of effect. Results: A total of 3656 studies were screened and 36 were selected. Pooled results showed a positive association between depression and use of alcohol (odds ratio (OR) = 1.50, 95% confidence interval (CI): 1.24–1.83), cannabis (OR = 1.29, 95% CI: 1.10–1.51), and tobacco (OR = 1.65, 95% CI: 1.43–1.92). Significant associations were also found between anxiety and use of alcohol (OR = 1.54, 95% CI: 1.19–2.00), cannabis (OR = 1.36, 95% CI: 1.02–1.81), and tobacco (OR = 2.21, 95% CI: 1.54–3.17). A bidirectional relationship was observed with tobacco use at baseline leading to depression at follow-up (OR = 1.87, CI = 1.23–2.85) and depression at baseline leading to tobacco use at follow-up (OR = 1.22, CI = 1.09–1.37). A unidirectional relationship was also observed with cannabis use leading to depression (OR = 1.33, CI = 1.19–1.49). Conclusion: This study offers insights into the association and directionality between mental health disorders and substance use among adolescents and young adults. Our findings can help guide key stakeholders in making recommendations for interventions, policy and programming.

Validation of the Substance Use Risk Profile Scale (SURPS) With Bulgarian Substance Dependent Individuals

Background: The Substance Use Risk Profile Scale (SURPS) is a 23-item self-report questionnaire that assesses four well-validated personality risk factors for substance misuse (Impulsivity, Sensation Seeking, Anxiety Sensitivity, and Hopelessness). While the SURPS has been used extensively with adolescents at risk for substance dependence, its properties with adult substance-dependent populations have been understudied. Further, the validity of the Bulgarian version of the SURPS has not been evaluated. The aims of the present study were to examine the factor structure of the Bulgarian version of the SURPS, its psychometric properties, and its ability to distinguish individuals with substance dependence from healthy controls. Methods: Participants included 238 individuals ages 18 to 50 (45% female): 36 "pure" (i.e., mono-substance dependent) heroin users, 34 "pure" amphetamine users, 32 polysubstance users, 64 controls with no history of substance dependence, 43 unaffected siblings of heroin users, and 29 unaffected siblings of amphetamine users. We explored the factor structure of the Bulgarian version of the SURPS with confirmatory factor analyses, examined its reliability and validity, and tested for group differences between substance dependent and non-dependent groups. Results: Confirmatory factor analyses (CFA) replicated the original four-factor model of the SURPS. The four subscales of the SURPS demonstrated good internal consistency (Cronbach's alphas ranged from 0.71 to 0.85) and adequate concurrent validity. Significant group differences were found on the Impulsivity and Sensation Seeking subscales, with the three substance dependent groups scoring higher than controls. Conclusions: The SURPS is a valid instrument for measuring personality risk for substance use disorders in the Bulgarian population. The Bulgarian version of the SURPS demonstrates adequate to good reliability, concurrent validity, and predictive validity. Its ability to distinguish between groups with and without a history of substance dependence was specific to externalizing traits such as Impulsivity and Sensation Seeking, on which opiate, stimulant, and polysubstance dependent individuals scored higher than non-dependent controls.

A comparative study of the effectiveness of group-based cognitive behavioral therapy and dialectical behavioral therapy in reducing depressive symptoms in Iranian women substance abusers

Various therapeutic approaches have been used to improve depressive symptoms in substance abusers. In a quasi-experimental study with a pretest-posttest design and experimental and control groups, we examined and compared the effectiveness of two group-based treatment strategies-cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT)-in reducing depressive symptoms among Iranian women substance abusers. The statistical population included all female addict patients who referred to addiction treatment centers of Birjand city in 2015. A sample of 30 subjects were selected through the available sampling method and randomly assigned into experimental (CBT and DBT) and control groups (each group, 10 patients). The data collection instrument was the Beck Depression Inventory (BDI) questionnaire. The patients in the experimental groups were given skills in eight sessions of 90 min. The data were analyzed by the SPSS-19 software by using mean, standard deviation, and percentages at the descriptive level and analysis of covariance (ANCOVA) test at the inferential level. The comparison of the mean depression score before intervention in all the groups showed no significant difference. However, after intervention, the findings showed that both CBT and DBT interventions could reduce the mean scores of depression in women substance abusers, 17.5 ± 3.0 vs 29.3 ± 4.1 (F[1,17] = 51.91, p value < 0.01) and 14.7 ± 1.8 vs 29.3 ± 4.1 (F[1,17] = 106.62, p value < 0.01), respectively, for CBT and DBT. Post-treatment effect sizes were large and did not differ statistically for CBT (ηp2, 0.75) and DBT (ηp2, 0.86). Therefore, this study highlights the importance of CBT and DBT skills training to substance abusers and provides initial evidence of their effectiveness.

Factors related to cigarette smoking and intent to quit among adolescent inpatients with psychiatric and substance use disorders

PURPOSE

Smoking behaviors and intent to quit have not been well studied among adolescent psychiatric patients. The current study examined the relationships between smoking-related variables (smoking status/heaviness and intent to quit), psychiatric diagnoses and symptomatology, and substance use among adolescents receiving psychiatric inpatient care.

METHODS

Baseline data from a randomized controlled trial, testing the effect of a brief intervention on substance use, with 151 psychiatrically hospitalized adolescents with comorbid psychiatric and substance use disorders (diagnosed using semi-structured interviews) were examined for this study.

RESULTS

Of 151 inpatients aged 13-17 years, 112 (74.2%) were smokers (self-report), of whom 59 (52.7%) expressed intent to quit within 3 months and 36 (32.1%) within 30 days. There were no differences in psychiatric diagnoses or alcohol, marijuana, or any drug use among smokers and nonsmokers. On the other hand, smokers reported significantly greater occurrences of negative consequences from alcohol use, drug use, and total substance use than nonsmokers. Separate analyses also revealed that heavier smokers reported greater negative consequences from alcohol/drug/total use. Similarly, while no difference in externalizing or internalizing symptoms was observed across smokers vs. nonsmokers, heavier smokers reported significantly more severe externalizing symptoms, but not internalizing symptoms, than lighter smokers. Intention to quit smoking did not vary as a function of psychiatric symptomatology or substance use.

CONCLUSIONS

Smoking was related to several psychiatric and substance use problems. Notably, adolescent psychiatric inpatient smokers reported intention to quit smoking regardless of psychiatric disorders, psychiatric symptom severity, or other substance use.

The Causal Role of Alcohol Use in Adolescent Externalizing and Internalizing Problems: A Mendelian Randomization Study

BACKGROUND

The co-occurrence of alcohol use and externalizing/internalizing problems threatens adolescents' mental health. Research on whether alcohol use and these problems are causal and the direction of the potential causal relationships is needed to understand the mechanisms of the co-occurrence.

METHODS

A Mendelian randomization analysis was conducted in which the aldehyde dehydrogenase 2 (ALDH2) rs671 polymorphism was used as an instrumental variable for alcohol use phenotypes. In total, 1,608 Chinese adolescents (mean age 14.11 ± 1.83 years) were genotyped for the ALDH2 rs671 polymorphism. Three externalizing problems (aggression, delinquency, and attention problems) were measured with the Youth Self-Report inventory, and 2 internalizing problems (depression and anxiety) were measured with the self-reported Children's Depression Inventory and the Trait subscale of the State-Trait Anxiety Inventory.

RESULTS

Alcohol use was positively associated with all 3 externalizing and 2 internalizing problems, and the ALDH2 polymorphism had a significant effect on alcohol use. Aggression and attention problems were also significantly affected by the ALDH2 polymorphism, whereas no significant association was observed between the ALDH2 polymorphism and delinquency, anxiety, or depression.

CONCLUSIONS

The results suggest that alcohol use is a cause of adolescent aggression and attention problems but not adolescent delinquency, anxiety, or depression.

Youth Services System Review: Moving From Knowledge Gathering to Implementation Through Collaboration, Youth Engagement, and Exploring Local Community Needs

This article describes a two-phase, multi-sectoral project aimed at enhancing youth services addressing substance use in Ontario. In the information gathering phase, a youth-focused website and survey, focus groups, and interviews were used to elicit perspectives from multiple stakeholders. In the implementation phase, capacity-building and consultations on transition-aged youth needs were conducted to inform youth transition-readiness checklists. We discuss the importance of engaging youth as collaborators as well as respondents and the processes used to tailor findings to local contexts for implementation.

Are childhood externalizing disorders the harbinger of early-onset alcohol dependence?

BACKGROUND & OBJECTIVES

The subtyping of alcohol dependence (AD) into early-onset (EO) and late-onset (LO) subgroups has been shown to have clinical and biological validity. As externalizing disorders (EDs) predate AD, the link of ED with age of onset of alcohol dependence needs to be investigated. The aim of this study was to examine the relationship of EDs such as disruptive behaviour disorder (DBD) and attention deficit hyperactivity disorder (ADHD) with age at onset of AD in a sample of male subjects.

METHODS

One hundred consecutive male subjects with AD presenting to the De-Addiction Services and an equal number of biologically unrelated non-substance-dependent control subjects were included in the study. The AD subjects were divided into EO (age of onset of AD ≤25 yr; n = 21) and LO (age of onset of AD >25 yr; n = 79). Subjects were examined for evidence of DBD and ADHD in childhood, and current ADHD using structured instruments such as Semi-Structured Assessment for the Genetic of Alcoholism-IV (SSAGA-IV) and Kiddie - SADS - Present and Lifetime Version (K-SADS-PL). The odds ratio of association of EDs with EO and LO AD was calculated by comparing these subgroups with the biologically unrelated control group. Later, both the subgroups of alcohol dependence were compared for the presence of EDs.

RESULTS

All EDs (DBDs/childhood or adult ADHD) were more common in AD individuals as compared to the controls. However, when AD subgroups were compared with controls, the association of DBDs and ADHD reached a significant level only in the EO subgroup. A comparison of EO and LO AD showed that more EO individuals had history of both childhood disruptive disorder and ADHD compared to LO subgroup. Adult ADHD was also over-represented in EO subgroup.

INTERPRETATION & CONCLUSIONS

Our study showed more EDs in alcohol dependent individuals compared to controls. Further, the association observed between EDs and EO alcohol dependence points towards a developmental continuum between these two conditions.

Examination of Veteran Fathers' Parenting and Their Adolescent Children's Substance Use in the United States

BACKGROUND

Adolescent children of U.S. military veterans may be at increased risk for engaging in substance use; however, this has yet to be examined using nationally representative data. Parental involvement and communication are potential protective factors to target with prevention efforts, but veterans' parenting has not been studied in general, nonclinical populations.

OBJECTIVES

This study presents data on parenting characteristics among fathers who are veterans of the U.S. military and the substance use behaviors of their adolescent children.

METHODS

Data were analyzed from approximately 2,200 veteran fathers, 13,100 nonveteran fathers, and their children aged 12 to 17 who participated in the National Survey on Drug Use and Health from 2004 to 2013. Parenting characteristics and adolescent substance use were compared by fathers' veteran status.

RESULTS

Compared with nonveteran fathers, veteran fathers were less likely to have talked with their children about the dangers of substance use, were more likely to believe that their children used substances, and were just as likely to be parentally involved. Higher percentages of adolescent children of veterans than those of nonveterans engaged in tobacco use and nonmedical use of psychotherapeutic drugs. Parental involvement and father-child communication about the dangers of substance use did not explain differences in substance use among adolescents with veteran versus nonveteran fathers. Conclusions/Importance: Adolescent children of veterans appear to be a group in particular need of substance use prevention services. Parental involvement and father-child communication may be appropriate protective factors to address in prevention efforts.

Is alexithymia related to cannabis use disorder? Results from a case-control study in outpatient adolescent cannabis abusers

OBJECTIVE

In recent decades, alexithymia has been considered a risk factor for multiple somatic and psychiatric conditions. Yet, whereas alexithymia has been extensively studied in adults with a substance misuse, only one study has reported data on cannabis abusers from the general population. Hence, our main objective was to explore alexithymia in a clinical sample of treatment-seeking young outpatients with a DSM-IV cannabis dependence or abuse diagnosis compared to controls.

METHODS

120 young patients (95 males - mean age 17.9years (SD=2.8; 14 to 25)) with a cannabis dependence or abuse (DSM-IV-TR criteria evaluated with the MINI), seeking treatment in an addiction unit, and 110 healthy control subjects (77 males - mean age 18.2years (SD=3.4; 14 to 25)) participated in the study. They completed a battery of self-reports measuring alexithymia (TAS-20; BVAQ-B), depression (BDI-13) and state and trait anxiety (STAI).

RESULTS

35.3% of cannabis users were alexithymic, and logistic regression analysis showed that the alexithymic components of difficulties identifying and describing feelings combined with trait anxiety predicted group membership.

CONCLUSION

This first study on young cannabis abusers and dependent subjects further emphasizes the importance of considering the affective style, and particularly the anxious temperament and alexithymia features, as factors associated with substance misuse during late adolescence.

The impact of sleep and psychiatric symptoms on alcohol consequences among young adults

OBJECTIVE

Independent lines of research have documented links between psychiatric symptoms and poor sleep quality, psychiatric symptoms and alcohol use, and alcohol use and poor sleep quality. The current study examined the synergistic effect of poor sleep quality and psychiatric symptoms on alcohol-related consequences in heavy-drinking young adults.

METHOD

Matriculating college students reporting at least one heavy drinking episode over the first nine weeks of the semester (N=385, 52% female) were categorized as experiencing 'good' (n=280) versus 'poor' sleep quality (n=105) and screening 'positive' (n=203) or 'negative' (n=182) for a psychiatric disorder. Sleep quality was assessed using the Pittsburgh Sleep Quality Index; psychiatric diagnosis was assessed using the Psychiatric Diagnostic Screening Questionnaire; and alcohol-related consequences were assessed using the Brief Young Adult Alcohol Consequences Questionnaire. General linear models were used to examine the main effects and interaction between sleep quality and psychiatric symptoms on alcohol-related consequences.

RESULTS

Sleep quality moderated the association between psychiatric screen and alcohol-related consequences among heavy-drinking college students, such that psychiatric symptoms were associated with more alcohol-related consequences in the context of poor sleep quality.

CONCLUSIONS

The combination of poor sleep quality and psychiatric symptoms is associated with increased alcohol-related consequences among heavy-drinking college students. Given the significant interaction between these symptoms, healthcare providers are encouraged to screen for the presence of sleep and psychiatric disorders among heavy-drinking young adults and to provide empirically-supported treatments as appropriate.

Screening, Brief Intervention, and Referral to Treatment

Screening, Brief Intervention, and Referral to Treatment is a quick, effective technique with which to manage substance use in adolescents and young adults. Use of a validated measure for detecting substance use and abuse is significantly more effective than unvalidated tools or provider intuition. There are a variety of validated tools available to use in the adolescent/young adult population, and there are opportunities to increase the efficiency and scalability of screening by using computerized questionnaires. This area continues to evolve rapidly.

[Which psychiatric comorbidities in cannabis dependence during adolescence? Comparison of outpatients and controls]

BACKGROUND

The use of illicit substances, in particular cannabis, among French adolescents and young adults has become an important public health concern. A better understanding of the mechanisms involved in pathological substance use is nowadays critical. Psychiatric comorbidities have been previously reported in adult substance abusers but are less documented in adolescents, especially regarding cannabis dependence.

OBJECTIVES

We investigated mental health problems in adolescents and young adults, seeking treatment for their problematic cannabis use, comparatively to healthy controls, taking into account the participant's gender and age. Moreover, we explored the relationships between psychiatric diagnosis and substance use modalities.

METHODS

In total, 100 young patients (80 males - mean age 18.2 (SD=2.9; [14 to 25] years old)) with a cannabis dependence (DSM-IV-TR criteria) seeking treatment in an addiction unit, and 82 healthy control subjects (50 males - mean age 18.3 (SD=3.4; [14 to 25] years old)) with no substance misuse diagnostic other than for alcohol, participated in the study. The MINI was administered to evaluate cannabis dependence, and DSM-IV axis I comorbid diagnosis, and a semi-structured interview was used to determine psychoactive substance use.

RESULTS

Statistical analyses revealed that 79 % of the patients reported at least one other non-drug or alcohol comorbid diagnosis, versus 30.5 % in the control group (χ²=16.83; P<0.001). Logistic regression indicated that participants with a psychiatric diagnosis had an 8.6 times higher risk (P<0.001; OR 95 % CI=[4.38-16.81]) of being patients. Significant inter-group differences and OR were noted for several diagnoses: dysthymia over the previous 2years (χ²=14.06; P<0.001; OR=10.63; OR 95 % CI=[2.41-46.87]), life-time panic attack disorder (χ²=4.15; P<0.042; OR=3.59; OR 95 % CI=[0.98-13.19]), alcohol abuse (χ²=47.72; P<0.001; OR=66.27; OR 95 % CI=[8.87-495.11]) and dependence (V=0.230; P=0.001) and generalized anxiety disorder (χ²=7.46; P=0.006-OR=3.57; OR 95 % CI=[1.37-9.30]). On the whole, the females (n=20) of our clinical sample presented significantly more comorbid diagnoses than the males (n=80) (95 % versus 75 %; χ²=6.25, P=0.011). These significant gender differences were found for life-time eating disorder (V=0.352; P=0.007) and generalized anxiety disorder diagnoses (V=0.278; P=0.013). Moreover, young adult patients (19-25years old; n=35) presented, on the whole, significantly more comorbid diagnoses than adolescent patients (14-18years old; n=65) (70.8 % versus 94.3 %; χ²=7.58, P=0.006). These age inter-group differences were found for several diagnoses: alcohol dependence (6.2 % versus 20 %; V=0.211, P=0.047), dysthymia over the past 2years (13.8 % versus 34.3 %; χ²=5.73, P=0.017) and generalized anxiety disorder (12.3 % versus 40 %; χ²=10.17, P=0.001). Various associations were observed between psychiatric comorbid diagnosis and substance use indicators.

CONCLUSION

This study demonstrates that cannabis dependence in adolescents and young adults is related to great psychological distress and puts emphasis on the importance of substance use prevention as early as middle school. Moreover, the psychiatric features of adolescents and young adults need to be taken into consideration for treatment planning.

Cannabis and development of dual diagnoses: A literature review

BACKGROUND

The use of cannabis has garnered more attention recently with ongoing efforts at marijuana legalization. The consequences of cannabis use are not clearly understood and remain a concern.

OBJECTIVES

To review the acute and persistent effects of cannabis use and associations with psychiatric disorders.

METHODS

Using Pubmed and PsychInfo, we conducted a narrative review of the literature on cannabis and psychiatric comorbidity using the keywords cannab*, marijuana, schizo*, psychosis, mood, depression, mania, bipolar, and anxiety.

RESULTS

There is substantial evidence of cannabis use leading to other illicit drug use and of an association between cannabis use and psychosis. A few reports suggest an association with bipolar disorder while the association with depression and anxiety disorders is mixed.

CONCLUSIONS

Whenever an association is observed between cannabis use and psychiatric disorders, the relationship is generally an adverse one. Age at the time of cannabis use appears to be an important factor with stronger associations observed between adolescent onset cannabis use and later onset of psychiatric disorders. Additional studies taking into account potential confounds (such as withdrawal symptoms, periods of abstinence, and other substance use) and moderators (such as age of initiation of cannabis use, the amount and frequency of drug use, prior history of childhood maltreatment, and gender) are needed to better understand the psychiatric consequences of cannabis use.

Neurobiological signatures associated with alcohol and drug use in the human adolescent brain

Magnetic resonance (MR) techniques provide opportunities to non-invasively characterize neurobiological milestones of adolescent brain development. Juxtaposed to the critical finalization of brain development is initiation of alcohol and substance use, and increased frequency and quantity of use, patterns that can lead to abuse and addiction. This review provides a comprehensive overview of existing MR studies of adolescent alcohol and drug users. The most common alterations reported across substance used and MR modalities are in the frontal lobe (63% of published studies). This is not surprising, given that this is the last region to reach neurobiological adulthood. Comparatively, evidence is less consistent regarding alterations in regions that mature earlier (e.g., amygdala, hippocampus), however newer techniques now permit investigations beyond regional approaches that are uncovering network-level vulnerabilities. Regardless of whether neurobiological signatures exist prior to the initiation of use, this body of work provides important direction for ongoing prospective investigations of adolescent brain development, and the significant impact of alcohol and substance use on the brain during the second decade of life.

Executive functioning before and after onset of alcohol use disorder in adolescence. A TRAILS study

INTRODUCTION

The aim of the present study was to investigate whether executive functioning (EF) in early adolescence predicted alcohol use disorder (AUD) in late adolescence and whether adolescents with AUD differed in maturation of EF from controls without a diagnosis.

METHODS

We used the data from the Tracking Adolescents' Individual Lives Survey (TRAILS), a cohort of 2230 Dutch adolescents. Working memory, inhibition, and attention were measured at ages 11 and 19. At age 19, lifetime DSM-IV diagnoses were determined, resulting in a control group (n = 1111) and two AUD groups, i.e., alcohol abusers (n = 381) and alcohol dependents (n = 51). Regression analyses assessed whether EF at age 11 predicted the transition to AUD in late adolescence and whether AUD affected maturation of EF from age 11 to 19.

RESULTS

EF in early adolescence did not predict AUD in late adolescence. A significant interaction effect emerged between gender and alcohol dependence for shift attention (β = 0.12, SE=0.36), with girls showing smaller maturational rates. This effect remained significant after controlling for alcohol intake (ages 16 and 19) and comorbid psychiatric disorders.

DISCUSSION

Our results do not replicate the finding that EF in early adolescence is a significant predictor of AUD in late adolescence. Furthermore, for the majority of tasks, adolescents with AUD do not differ in EF maturation over the course of adolescence. Alcohol dependent girls however, show less maturation of shift attention. This is independent of the quantity of alcohol intake, which could suggest that non-normative maturation of EF is associated with the behavioural components of AUD.

Emotional self-control and dysregulation: A dual-process analysis of pathways to externalizing/internalizing symptomatology and positive well-being in younger adolescents

OBJECTIVES

There is little knowledge about how emotional regulation contributes to vulnerability versus resilience to substance use disorder. With younger adolescents, we studied the pathways through which emotion regulation attributes are related to predisposing factors for disorder.

METHODS

A sample of 3561 adolescents (M age 12.5 years) was surveyed. Measures for emotional self-control (regulation of sadness and anger), emotional dysregulation (angerability, affective lability, and rumination about sadness or anger), and behavioral self-control (planfulness and problem solving) were obtained. A structural model was analyzed with regulation attributes related to six intermediate variables that are established risk or protective factors for adolescent substance use (e.g., academic involvement, stressful life events). Criterion variables were externalizing and internalizing symptomatology and positive well-being.

RESULTS

Indirect pathways were found from emotional regulation to symptomatology through academic competence, stressful events, and deviance-prone attitudes and cognitions. Direct effects were also found: from emotional dysregulation to externalizing and internalizing symptomatology; emotional self-control to well-being; and behavioral self-control (inverse) to externalizing symptomatology. Emotional self-control and emotional dysregulation had independent effects and different types of pathways.

CONCLUSIONS

Adolescents scoring high on emotional dysregulation are at risk for substance dependence because of more externalizing and internalizing symptomatology. Independently, youth with better behavioral and emotional self-control are at lower risk. This occurs partly through relations of regulation constructs to environmental variables that affect levels of symptomatology (e.g., stressful events, poor academic performance). Effects of emotion regulation were found at an early age, before the typical onset of substance disorder.

Substance abuse and personality disorder comorbidity in adolescent outpatients: are girls more severely ill than boys?

BACKGROUND

Substance use disorders (SUDs) constitute a major health problem and are associated with an extensive psychiatric comorbidity. Personality disorders (PDs) and SUDs commonly co-occur. Comorbid PD is characterized by more severe addiction problems and by an unfavorable clinical outcome. The present study investigated the prevalence of SUDs, PDs and common Axis I disorders in a sample of adolescent outpatients. We also investigated the association between PDs and SUDs, and how this association was influenced by adjustment for other Axis I disorders, age and gender.

METHODS

The sample consisted of 153 adolescents, aged 14-17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. SUDs and other Axis I conditions were assessed using the mini international neuropsychiatric interview. PDs were assessed using the structured interview for DSM-IV personality.

RESULTS

18.3 % of the adolescents screened positive for a SUD, with no significant gender difference. There was a highly significant association between number of PD symptoms and having one or more SUDs; this relationship was practically unchanged by adjustment for gender, age and presence of Axis I disorders. For boys, no significant associations between SUDs and specific PDs, conduct disorder (CD) or attention deficit hyperactivity disorder (ADHD) were found. For girls, there were significant associations between SUD and BPD, negativistic PD, more than one PD, CD and ADHD.

CONCLUSIONS

We found no significant gender difference in the prevalence of SUD in a sample of adolescents referred to a general mental health outpatient clinic. The association between number of PD symptoms and having one or more SUDs was practically unchanged by adjustment for gender, age and presence of one or more Axis I disorders, which suggested that having an increased number of PD symptoms in itself may constitute a risk factor for developing SUDs in adolescence. The association in girls between SUDs and PDs, CD and ADHD raises the question if adolescent girls suffering from these conditions may be especially at risk for developing SUDs. In clinical settings, they should therefore be monitored with particular diligence with regard to their use of psychoactive substances. Trial registration The regional committee for medical research ethics for eastern Norway approved the study protocol in October 2004 (REK: 11395). Address correspondence and reprint requests to: Hans Ole Korsgaard, The Nic Waal Institute, Lovisenberg Diakonale Hospital, P.O. Box 2970 Nydalen, N-0440 Oslo, Norway; E-mail hansole.korsgaard@tele5.no.

Association of comorbid psychopathology with the duration of cannabis use disorders

Risk factors for the development of cannabis use disorders (CUDs) have been well-researched. Comparatively little is known, however, about factors associated with the persistence of CUDs over time. This research explored whether the temporal sequencing of comorbid psychiatric disorders in relation to the onset of the index CUD episode were associated with the length of this episode. Four comprehensive diagnostic assessments were conducted between ages 16 and 30 with a large and regionally representative community sample (n = 816), among which 173 persons were diagnosed with a lifetime CUD. In separate unadjusted analyses, any internalizing disorder and any mood disorder with onset prior to that of the index CUD episode were each significantly and negatively associated with CUD duration. These effects, however, were reduced to trend level in adjusted analyses that controlled for putative confounders. Following the onset of the index CUD episode, the subsequent occurrence of any Axis I disorder, internalizing disorder, externalizing disorder, or other substance use disorder during the index CUD episode was significantly and positively associated with the duration of that episode in both unadjusted and adjusted analyses. These findings collectively suggest that the presence of internalizing-spectrum disorders prior to the onset of the index CUD episode affords some modest protection against protracted episodes, whereas the emergence of broad-spectrum psychopathology within the index CUD episode, most notably noncannabis substance use disorders, is associated with greater disorder persistence. The relevance of these findings for various motivational models of cannabis addiction is discussed.

Representation of Drug Use in Biomedical Standards, Clinical Text, and Research Measures

Drug misuse is a prominent cause of morbidity and mortality in the United States. Recent focus on behavioral and social domains in the electronic health record (EHR) has highlighted the need for comprehensive examination of social history information, such as drug use. In this study, representation of drug use was examined in three types of sources: (1) standards from HL7 and openEHR, (2) clinical text from publicly accessible clinical notes and a local EHR, and (3) research measures from the PhenX Toolkit and CDE Browser. In total, 27 elements were identified across the examined sources, revealing a diverse set of values that were found to be associated with drug use type, frequency, method, time frame, and amount. The findings of this study provide insight into the representation of drug use information that may contribute to efforts for standardizing collection and use of these data to support clinical care and research.

Co-occurrence between mental distress and poly-drug use: a ten year prospective study of patients from substance abuse treatment

INTRODUCTION

Longitudinal research investigating psychiatric trajectories among patients with poly-drug use patterns remains relatively scant, even though this specific population is at elevated risk for multiple negative outcomes. The present study examined temporal associations between poly-drug use (i.e. heroin, cannabis, tranquilizers, and amphetamines) and mental distress over a 10-year period.

METHODS

A clinical cohort of 481 patients was recruited from substance use treatment facilities in Norway, and prospectively interviewed 1, 2, 7 and 10years after the initial data collection at treatment admission. At each assessment participants completed a questionnaire addressing their substance use and mental distress. Longitudinal growth models were used to examine whether, and if so, how, levels of drug use were associated with the level and rate of change in mental distress over time.

RESULTS

Results from the longitudinal growth models showed a co-occurrence between active poly-drug use and mental distress, such that there was a dose-response effect where mental distress increased both in magnitude and over time with the number of drugs used. Reduction in mental distress during the 10-year study period was evident only in the no-drug use condition. Use of multiple drugs and mental distress appear strongly co-related over time.

CONCLUSIONS

Pre-treatment assessment should carefully identify individuals manifesting poly-drug use and mental disorders. Treatment and follow-up services should be tailored to their specific needs.

A multi-method exploratory study of stress, coping, and substance use among high school youth in private schools

There is growing awareness that students' experiences of stress may impede academic success, compromise mental health, and promote substance use. We examined these factors in an under-studied population, private/independent high school students, using a multi-method (qualitative and quantitative), iterative data collection and analytic process. We first conducted qualitative interviews with faculty and staff at a number of highly competitive private schools, followed by an anonymous quantitative survey with 128 11th grade students from two of these settings. We then conducted a qualitative exploration of the quantitative results with a subset of students. Next, a set of Expert Panel members participated in qualitative interviews to reflect on and interpret study findings. Overall, we found students experienced high levels of chronic stress, particularly in relation to academic performance and the college admissions process. While students described a range of effective, adaptive coping strategies, they also commonly internalized these serious pressures and turned to alcohol and drugs to cope with chronic stress, although not typically at problematic levels. We discuss study implications for both schools and families derived from the Expert Panel.

Motivational Interviewing to Reduce Substance Use in Adolescents with Psychiatric Comorbidity

Substance use among adolescents with one or more psychiatric disorders is a significant public health concern. In this study, 151 psychiatrically hospitalized adolescents, ages 13-17 with comorbid psychiatric and substance use disorders, were randomized to a two-session Motivational Interviewing intervention to reduce substance use plus treatment as usual (MI) vs. treatment as usual only (TAU). Results indicated that the MI group had a longer latency to first use of any substance following hospital discharge relative to TAU (36 days versus 11 days). Adolescents who received MI also reported less total use of substances and less use of marijuana during the first 6 months post-discharge, although this effect was not significant across 12 months. Finally, MI was associated with a significant reduction in rule-breaking behaviors at 6-month follow-up. Future directions are discussed, including means of extending effects beyond 6 months and dissemination of the intervention to community-based settings.

Psychiatric Symptom Clusters as Risk Factors for Alcohol Use Disorders in Adolescence: A National Study

BACKGROUND

Few epidemiologic studies have examined a full range of adolescent psychiatric disorders in the general population. The association between psychiatric symptom clusters (PSCs) and DSM-IV alcohol use disorders (AUDs) among adolescents is not well understood.

METHODS

This study draws upon the public-use data from the 2000 National Household Survey on Drug Abuse, including a study sample of 19,430 respondents aged 12 to 17. Logistic regression and exploratory structural equation modeling assess the associations between PSCs and DSM-IV AUDs by gender. The PSCs are based on brief screening scales devised from the Diagnostic Interview Schedule for Children Predictive Scales.

RESULTS

Several PSCs were found to be significantly associated with DSM-IV AUDs, including separation anxiety, generalized anxiety, depression, oppositional defiant disorder, and conduct disorder among both genders, and panic disorder and obsessive/ compulsive disorder among females. Consistent with the literature, the analysis of PSCs yields 3 factors identical for both genders-2 internalizing factors (fear and anxiety-misery) and 1 externalizing factor. Adolescents who scored higher on the externalizing factor tended to have higher levels of the AUD factor. Female adolescents who scored higher on the internalizing misery factor and lower on the internalizing fear factor also tended to have higher levels of the AUD factor.

CONCLUSIONS

The associations that we found between PSCs and AUDs among adolescents in this study are consistent with those found among adults in other studies, although gender may moderate associations between internalizing PSCs and AUDs. Our findings lend support to previous findings on the developmentally stable associations between disruptive behaviors and AUDs among adolescents as well as adults in the general population.

Alcohol, Isolation, and Access to Treatment: Family Physician Experiences of Alcohol Consumption and Access to Health Care in Rural British Columbia

OBJECTIVE

The purpose of this project was to study the experiences of physicians who treat persons with alcohol-attributed diseases in rural areas of British Columbia, Canada.

METHOD

A cross-sectional survey was distributed to primary health care physicians that had a family practice in a designated rural community using the Rural Coordination Centre of British Columbia's community isolation rating system. Data were collected through a mail and online survey sent to primary health care physicians. Purposeful sampling was used to select participants that had a primary health care practice in a designated rural community.

RESULTS

Surveys were returned by 22% of potential participants (N = 67) that had an average of 15.8 years in family practice. The majority of participants (95.4%) reported that alcohol had a negative impact on population health, and physicians expressed particular concern for alcohol consumption in relation to mental health (85.1%) and physical illness (82.1%). Most participants had referred patients out of the community for treatment; however, 76.4% reported difficulty with referrals, including long wait-lists, limited services, and issues related to transportation and leaving the community for substance use treatment.

CONCLUSION

Rural physicians showed an awareness and concern for alcohol consumption in their community, but they also reported difficulties referring patients for substance use treatment. Additional study is required to understand how to improve the continuity of care provided to persons with alcohol-related issues in rural British Columbia.

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.

Does depression and substance abuse co-morbidity affect socioeconomic status? Evidence from a prospective study of urban African Americans

Studies have established a graded association between mental health and socioeconomic status (SES). However, scarce research has examined the impact of substance use disorders (SUD) and depression comorbidity on SES. We use data from the Woodlawn Study, a longitudinal cohort study, which recruited a cohort of first graders from Chicago starting 1966-1967 (N=1242). Analyses focus on those interviewed in young adulthood and followed up through midlife. Regression analyses adjusting for childhood confounders showed that young adults with depression and SUD comorbidity had higher likelihood of having any periods of unemployment, higher likelihood of being unemployed for 3 or more months, and lower household income in midlife than those with neither disorder. Moreover, young adults with SUD without depression had higher odds of having any periods of unemployment and higher odds of being unemployed for 3 or more months than those with neither disorder. Findings point to the possibility of social selection where depression and SUD comorbidity contributes to a downward drift in SES. Clinical interventions that integrate the treatment of SUD and depression may be more effective at reducing socioeconomic disparities among minority populations.

Comorbidity of PTSD, Major Depression, and Substance Use Disorder among Adolescent Victims of the Spring 2011 Tornadoes in Alabama and Joplin, Missouri

OBJECTIVE

The purpose of this study was twofold: (1) to estimate the prevalence of comorbid posttraumatic stress disorder (PTSD), major depressive episode (MDE), and substance use disorder (SUD); and (2) to identify risk factors for patterns of comorbidity among adolescents affected by disasters.

METHOD

A population-based sample of 2,000 adolescents (51% female; 71% Caucasian, 26% African American) aged 12 to 17 years (M = 14.5, SD = 1.7) and their parents was recruited from communities affected by the spring 2011 tornadoes in Alabama and Joplin, Missouri. Participants completed structured telephone interviews assessing demographic characteristics, impact of disaster, prior trauma history, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), symptoms of posttraumatic stress disorder (PTSD) and major depressive episode (MDE), and substance use disorder (SUD) symptoms. Prevalence estimates were calculated for PTSD + MDE, PTSD + SUD, MDE + SUD, and PTSD + MDE + SUD. Hierarchical logistic regression was used to identify risk factors for each comorbidity profile.

RESULTS

Overall prevalence since the tornado was 3.7% for PTSD + MDE, 1.1% for PTSD + SUD, 1.0% for MDE + SUD, and 0.7% for PTSD + MDE + SUD. Girls were significantly more likely than boys to meet criteria for PTSD + MDE and MDE + SUD (ps < .05). Female gender, exposure to prior traumatic events, and persistent loss of services were significant risk factors for patterns of comorbidity. Parental injury was associated with elevated risk for PTSD + MDE. Adolescents should be evaluated for comorbid problems, including SUD, following disasters so that appropriate referrals to evidence-based treatments can be made.

CONCLUSIONS

Results suggest that screening procedures to identify adolescents at risk for comorbid disorders should assess demographic characteristics (gender), impact of the disaster on the family, and adolescents' prior history of stressful events.

Comorbidity and continuity of psychiatric disorders in youth after detention: a prospective longitudinal study

IMPORTANCE

Psychiatric disorders and comorbidity are prevalent among incarcerated juveniles. To date, no large-scale study has examined the comorbidity and continuity of psychiatric disorders after youth leave detention.

OBJECTIVE

To determine the comorbidity and continuity of psychiatric disorders among youth 5 years after detention.

DESIGN, SETTING, AND PARTICIPANTS

Prospective longitudinal study of a stratified random sample of 1829 youth (1172 male and 657 female; 1005 African American, 296 non-Hispanic white, 524 Hispanic, and 4 other race/ethnicity) recruited from the Cook County Juvenile Temporary Detention Center, Chicago, Illinois, between November 20, 1995, and June 14, 1998, and who received their time 2 follow-up interview between May 22, 2000, and April 3, 2004.

MAIN OUTCOMES AND MEASURES

At baseline, the Diagnostic Interview Schedule for Children Version 2.3. At follow-ups, the Diagnostic Interview Schedule for Children Version IV (child and young adult versions) and the Diagnostic Interview Schedule Version IV (substance use disorders and antisocial personality disorder).

RESULTS

Five years after detention, when participants were 14 to 24 years old, almost 27% of males and 14% of females had comorbid psychiatric disorders. Although females had significantly higher rates of comorbidity when in detention (odds ratio, 1.3; 95% CI, 1.0-1.7), males had significantly higher rates than females at follow-up (odds ratio, 2.3; 95% CI, 1.6-3.3). Substance use plus behavioral disorders was the most common comorbid profile among males, affecting 1 in 6. Participants with more disorders at baseline were more likely to have a disorder approximately 5 years after detention, even after adjusting for demographic characteristics. We found substantial continuity of disorder. However, some baseline disorders predicted alcohol and drug use disorders at follow-up.

CONCLUSIONS AND RELEVANCE

Although prevalence rates of comorbidity decreased in youth after detention, rates remained substantial and were higher than rates in the most comparable studies of the general population. Youth with multiple disorders at baseline are at highest risk for disorder 5 years later. Because many psychiatric disorders first appear in childhood and adolescence, primary and secondary prevention of psychiatric disorders offers the greatest opportunity to reduce costs to individuals, families, and society. Only a concerted effort to address the many needs of delinquent youth will help them thrive in adulthood.

A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population--a meta-analysis of 31 studies

BACKGROUND

The aim of the current study was to investigate the association between anxiety and cannabis use/cannabis use disorders in the general population.

METHODS

A total of N = 267 studies were identified from a systematic literature search (any time- March 2013) of Medline and PsycInfo databases, and a hand search. The results of 31 studies (with prospective cohort or cross-sectional designs using non-institutionalised cases) were analysed using a random-effects meta-analysis with the inverse variance weights. Lifetime or past 12-month cannabis use, anxiety symptoms, and cannabis use disorders (CUD; dependence and/or abuse/harmful use) were classified according to DSM/ICD criteria or scores on standardised scales.

RESULTS

There was a small positive association between anxiety and either cannabis use (OR = 1.24, 95% CI: 1.06-1.45, p = .006; N = 15 studies) or CUD (OR = 1.68, 95% CI: 1.23-2.31, p = .001; N = 13 studies), and between comorbid anxiety + depression and cannabis use (OR = 1.68, 95% CI: 1.17-2.40, p = .004; N = 5 studies). The positive associations between anxiety and cannabis use (or CUD) were present in subgroups of studies with ORs adjusted for possible confounders (substance use, psychiatric illness, demographics) and in studies with clinical diagnoses of anxiety. Cannabis use at baseline was significantly associated with anxiety at follow-up in N = 5 studies adjusted for confounders (OR = 1.28, 95% CI: 1.06-1.54, p = .01). The opposite relationship was investigated in only one study. There was little evidence for publication bias.

CONCLUSION

Anxiety is positively associated with cannabis use or CUD in cohorts drawn from some 112,000 non-institutionalised members of the general population of 10 countries.