Adolescent Substance Abuse and Mental Health: Problem Co-Occurrence and Access to Services

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Mental health service use of young people in child welfare services in Quebec, Canada

Background

Youth involved in child welfare have high rates of mental health problems and are known to receive mental health services from multiple settings. Still, gaps remain in our understanding of service use patterns across settings over the course of youth's involvement with child welfare.

Objective

To examine the settings, reasons for contact, persons involved in initiating care, and timing of each mental health service contact for individuals over their involvement with the child welfare system, and to identify factors that predict multi-setting use.

Methods

Data on mental health service contacts were collected retrospectively from charts for youth aged 11-18 (n=226) during their involvement with child welfare services in Montreal, Quebec. Logistic regression analysis was conducted to determine predictors of multi-setting mental health services use (defined as ≥3 settings).

Results

83% of youth had at least one mental health service contact over the course of their child welfare services follow-up, with 45% having multi-setting use. Emergency Departments were the top setting for mental health services. Youth with a higher number of placements and from neighborhoods with greater social and material deprivation were significantly likelier to use ≥3 mental health service settings over the course of their follow-up.

Conclusion

These findings suggest a need for enhanced collaboration between youth-serving sectors to ensure that continuous and appropriate mental health care is being offered to youth followed by child welfare systems. The relationship between placement instability and multi-setting mental health service use calls for specific policies to ensure that young people do not experience multiple discontinuities of care.

Young people in foster care and substance use

Adolescents are at high risk for using substances and for young people in foster care, substance use rates are estimated to be as high as 49 %. Adolescence is an important period for preventing substance use and SUD. Universal screening, brief interventions, and substance use treatment can be used to decrease substance use and substance use disorders among adolescents. Brief interventions often used with adolescents include motivational interviewing and contingency management. Of the many types of outpatient therapies utilized to treat adolescents with substance use disorder, some of the most established include cognitive behavioral therapy, family-based therapy, and a combination of different types of interventions. Medication treatment is less frequently offered to adolescents due to buprenorphine being the only drug FDA approved for youth under the age of 18. Residential treatment is also an option if lower levels of care are not adequate to safely support youth. Lastly, limited research has looked at the effectiveness of continuing care options to support youth in maintaining treatment results.

The Influence of the Great Recession on Adolescent Major Depressive Episodes and Treatment in the United States: An Interrupted Time Series Analysis

PURPOSE

In the United States, adolescent depression increased beginning in 2008-2010, coinciding with the Great Recession. We investigated whether this time of changing economic circumstances impacted adolescent depression and treatment.

METHODS

We analyzed data for adolescents aged 12-17 years from the 2004-2019 National Survey on Drug Use and Health (N = 256,572). Adolescents' past-year major depressive episodes (MDEs) were measured by self-reported symptoms. MDE treatment included seeing a health professional or receiving MDE medication. We tested how MDE and MDE treatment changed from pre-Great Recession (2004 to Fall 2007) to post-Great Recession (Winter 2007-2019) using interrupted time-series segmented regression models, accounting for seasonality and autocorrelation and testing for moderation by household poverty.

RESULTS

The Great Recession was not associated with an immediate increase in MDE prevalence (β:-0.77 [i.e., quarter-year change in prevalence], 95% confidence interval (CI): -2.23, 0.69). However, the increase in MDE prevalence accelerated following the Great Recession (β: 0.29, 95% CI: 0.13, 0.44). The Great Recession was not associated with immediate or long-term changes in adolescent MDE treatment (immediate β: -2.87, 95% CI: -7.79, 2.04; long-term β: 0.03, 95% CI: -0.46, 0.51). Effects were similar for households by poverty status.

DISCUSSION

The Great Recession was not associated with increased adolescent depression prevalence, although there was an acceleration in the trend of adolescent MDE following the recession. The prevalence of MDE treatment remained stable. Adolescent depression prevention efforts should be heightened as prevalence increases, including actively engaging caregivers as family supports to alleviate potential negative implications of economic distress for adolescent MDE.

Availability and Accessibility of Mental Health Services for Youth: A Descriptive Survey of Safety-Net Health Centers During the COVID-19 Pandemic

Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are critical access points for families with adolescents needing mental health care, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility. This study aims to describe the availability and accessibility of outpatient mental health services for children and adolescents at safety-net health centers in a large metropolitan county. Approximately one year after the COVID-19 pandemic began in the U.S., a comprehensive sample of 117 CMHCs and 117 FQHCs were called and administered a 5-minute survey. Approximately 10% of health centers were closed, and 20% (28.2% of FQHCs and 7.7% of CMHCs) reported not offering outpatient mental health services. Despite CMHCs having 5.4 more clinicians on staff on average, reported wait times were longer at CMHCs than FQHCs. These findings indicate that online directories intended to be a comprehensive and accessible resource, such as the SAMHSA Treatment Locator, are often inaccurate or out-of-date.

A multilevel model of the help-seeking behaviors among adolescents with mental health problems

Objective

Mental health problems are highly prevalent among adolescents yet the utilization of mental health services among such a population is very low. This study was conducted to examine mental health problems and related help-seeking behaviors among a Chinese sample of adolescents.

Methods

A total of 3,480 students were recruited from four middle- and high schools in Changsha City, Hunan province, and completed an online questionnaire that assessed their general information, mental health problems including depression, anxiety, self-harm, and suicide ideation, as well as their help-seeking behaviors from both formal (including psychological teachers and mental health professionals) and informal sources (including family, friends, and teachers).

Results

The participants had a prevalence of 13.7% for depression, 11.5% for anxiety, 9.8% for self-harm, and 9.1% for suicide ideation. Although a high rate of help-seeking behaviors was observed (73.0%), most were concentrated in informal sources (99.3%), while only a small portion of participants resorted to formal sources (13.9%). Being female (OR: 1.45, 95% CI: 1.15-1.83), higher grade (OR: 1.32, 95% CI: 1.01-1.73), school mental health resources not available (OR: 1.39, 95% CI: 1.02-1.88), without suicide ideation (OR: 2.03, 95% CI: 1.42-2.90) were all associated with increased likelihood of formal help-seeking behaviors. On the other hand, complete middle school (OR: 0.36, 95% CI: 0.22-0.59), the middle level of academic ranking (OR: 0.64, 95% CI: 0.42-0.97), and higher father education levels (OR: 0.54-0.56, 95% CI: 0.33-0.90) were all associated with a decreased likelihood of formal help-seeking behaviors.

Conclusion

Our results showed a higher prevalence of help-seeking behavior for emotional or psychological problems during the past year. Compared to the high rate of informal help-seeking behaviors, students showed a lower propensity to seek formal help for their mental health problems, which may be explained by individual-level, family-level, and school-level factors. Our findings provide important implications for the development and popularization of targeted, needs-based mental health promotion and education programs in the future.

Survey of substance use among adolescent drug offenders referred from juvenile courts in Taiwan: Clinical epidemiology of single versus multiple illicit substance use

BACKGROUND

Substance use during adolescence might cause substantial health burden. Little is known regarding profiles of multiple illicit substance users compared to single illicit substance users in adolescent population in Taiwan.

METHODS

We enrolled 106 adolescent illicit drug users who received addiction treatment referred by juvenile courts in Taiwan between September, 2016 and September, 2021. We divided them into two groups: single versus multiple illicit drug users, and further compared their socio-demographic characteristics, psychiatric and substance comorbidities. The independent t test or Mann-Whitney U test was used for continuous variables and Pearson's chi-square test for nominal variables. Multivariate logistic regression was used to examine the suicide and violence risk among adolescents.

RESULTS

71.7% of participants were multiple illicit drug users while 28.3% of them were single drug users. Multiple illicit substance users were more likely to use methamphetamine (p = 0.005), ketamine (p < 0.001), new psychoactive substance (NPS) (p < 0.001), MDMA (p = 0.003), and nitrous oxide (p < 0.001) compared to single illicit substance users. In addition, multiple illicit drug users were more likely to have ADHD (p = 0.030), major depressive disorder (p = 0.050), and lifetime suicidal attempts (p = 0.048) compared to single illicit drug users. In further analysis (NPS vs. traditional drugs), we found NPS users tended to use larger numbers of illicit drugs (p < 0.001) and were more likely to have substance-induced psychotic disorder (p = 0.008), ADHD (p = 0.011), suicidal attempts (p = 0.020).

CONCLUSION

Our findings highlight the distinct profiles of multiple illicit drug users compared to single illicit drug users among adolescent population. High suicidality and high psychiatric comorbidities in multiple illicit drug users call for special need for suicide screening and a more integrated care incorporating psychiatric and substance treatment.

Structure and trends of externalizing and internalizing psychiatric symptoms and gender differences among adolescents in the US from 1991 to 2018

PURPOSE

We aimed to estimate the structure of internalizing and externalizing symptoms and potential time dynamics in their association. This is understudied among adolescents, despite increasing internalizing and decreasing externalizing symptoms in recent years.

METHODS

We analyzed data from US Monitoring the Future cross-sectional surveys (1991-2018) representative of school-attending adolescents (N = 304,542). Exploratory factor analysis using maximum likelihood estimation method and promax rotation resulted in a two-factor solution (factor correlation r = 0.24) that differentiated eight internalizing and seven conduct-related externalizing symptoms. Time-varying effect modification linear regression models estimated the association between standardized internalizing and externalizing symptoms factor scores over time overall and by gender.

RESULTS

In 2012, trends in average factor scores diverged for internalizing and externalizing factors. The average standardized internalizing factor score increased from - 0.03 in 2012 to 0.06 in 2013 and the average externalizing factor score decreased from - 0.06 in 2011 to - 0.13 in 2012. We found that for every one-unit increase in standardized internalizing factor score, standardized externalizing factor score increased by 0.224 units in 2010 (95% CI: 0.215, 0.233); the magnitude of this increase was 22.3% lower in 2018 (i.e., 0.174 units; 95% CI: 0.160, 0.188). Decoupling of internalizing and externalizing symptoms began earlier among boys (~ 1995) than among girls (~ 2010).

CONCLUSION

The decoupling of internalizing and externalizing symptoms among adolescents suggests that changes in the prevalence of shared risk factors for adolescent psychiatric symptoms affect these dimensions in opposing directions, raising the importance of considering symptoms and their risk factors together in prevention and intervention efforts.

The interRAI Child and Youth Suite of Mental Health Assessment Instruments: An Integrated Approach to Mental Health Service Delivery

Various biological, social, psychological, and environmental factors impact children and youth living with mental health problems across their lifespan. To meet the wide-ranging challenges of mental illness, service system integration is needed to improve efficiencies and reduce fragmentation. Unfortunately, the mental health system has been plagued by the lack of coordination across services. There is a general consensus that mental health service delivery must ensure a child or youth's needs are addressed in a collaborative, coordinated, and seamless manner. A key element to successful integration is the development of a comprehensive standardized screening and assessment system. Numerous assessments have been developed to assess child mental health and functioning, but they typically have a very narrow focus with limited use and utility. Not only does this reduce the ability to take a life course perspective to mental health, but this uncoordinated approach also results in redundancies in information collected, additional resources, and increased assessor burden for children, youth, and their families. The interRAI child and youth mental health assessment suite was developed in response to the need for an integrated mental health system for young persons. This suite includes screening and assessment instruments for in-patient and community settings, emergency departments, educational settings, and youth justice custodial facilities. The instruments form a mental health information system intentionally designed to work in an integrated fashion beginning in infancy, and incorporate key applications such as care planning, outcome measurement, resource allocation, and quality improvement. The design of these assessment tools and their psychometric properties are reviewed. Data is then presented using examples related to interpersonal trauma, illustrating the use and utility of the integrated suite, along with the various applications of these assessment systems.

Empowering teachers to screen, guide, and refer schoolchildren with behavioral and mental health problems. A pilot study to promote mental health in Iran

BACKGROUND

Schools are ideal for promoting the mental health of school-age children, but the teachers' current knowledge is insufficient to play an influential role in mental health services at schools. Fortunately, however, teachers have a high sense of responsibility, interest, and talent to receive knowledge and the ability to participate in this field. This study aimed to examine whether a protocol focused on the role of teachers could identify, guide, and care for school-age children with behavioral and mental health problems.

METHOD

The current research was a "before and after" pilot quasi-experimental study conducted in three elementary, secondary, and high schools. The main intervention consisted of a 5-h workshop based on a ready-to-use booklet for teachers conducted separately in each school. A total of 58 teachers and 872 school-age children were included using a judgmental sampling technique.

RESULTS

The pre-and post-workshop mean scores of teachers' knowledge about common mental disorders in school-age children were 6.21 ± 4.58 and 12.50 ± 7.27, respectively. According to the Strengths and Difficulties Questionnaire (SDQ), the teachers made 127 referrals, of whom 102 school-age children had problems. Consultants diagnosed 114 school children who reflected 90% of all teachers' recommendations needing psychological care and counseling. Finally, only 50 diagnosed school-age children were followed up and attended therapy sessions at counseling centers. The sensitivity and specificity of this brief intervention in detecting school-age children with psychological problems were respectively 80.3 and 98.0%.

CONCLUSIONS

This study's results support teacher empowerment training's effectiveness in identifying and guiding school-age children needing mental health care. Psychological counseling programs in schools in various quantitative and qualitative dimensions, including responding to school-age children's needs and psychological problems, should be adequately evaluated, and appropriate measures should be taken to promote mental health services. Collaboration between health systems and the education department will increase the effectiveness of mental health programs' promotion and drug abuse prevention. These pilot data lead the way to designing scientifically sound follow-up studies that will concretely ascertain the benefit of this program.

Patterns of substance use among adolescents: A systematic review

PURPOSE

This review characterizes empirically derived patterns of multiple (multi-) substance use among adolescents. A secondary objective was to examine the extent to which mental health symptomatology was included in the empirical analyses examining substance use patterns.

METHODS

Eligible studies included those that used cluster-based approaches, included the assessment of at least two different substances, and were based on study samples with mean ages between 11 and 18 years. 4665 records were screened including 461 studies for full-text screening.

RESULTS

70 studies were included with common clusters being: low use, single or dual substance use, moderate general multi-use, and high multi-use. The most common patterns of single or multi-substance use were: alcohol only, alcohol with cannabis and/or tobacco, and use of alcohol, tobacco, and cannabis with and without other drugs. Lower socioeconomic status, older age, and male gender were consistent predictors of multi-use clusters. Only 37 % of studies compared differences in levels of mental health across clusters with symptoms consistently associated with a greater likelihood of multi-use. Only 29 % of studies included mental health indicators in cluster-based analyses, with over half identifying distinct mental health and substance use clusters. Fit indices in cluster analyses and measurement properties of substance use were heterogeneous and inconsistently reported across studies.

CONCLUSIONS

Distinct patterns of substance use were derived but methodological differences prevented direct comparison and reduced capacity to generalize across studies. There is a need to establish standardized methodological approaches to identify robust patterns of substance use to enhance etiological, prognostic, and intervention research.

Co-occurring mental disorder and substance use disorder in young people: aetiology, assessment and treatment

Dual diagnosis is one of several terms used to identify individuals diagnosed with a co-occurring mental disorder and substance use disorder. The existence of a dual diagnosis in adolescents is often associated with functional impairment in various life domains, causing physical health problems, relational conflicts, educational/vocational underachievement and legal problems. Dual diagnosis is difficult to treat and can result in tremendous economic burden on healthcare, education and justice systems. It is essential for clinicians caring for young people to be knowledgeable about dual diagnosis to ensure that it is identified early and treated. This article aims to provide an overview of dual diagnosis, increase its awareness and promote a realistic treatment approach.

[The Association Between Illicit Drug Use, Borderline Personality Disorder and Depression in a Help-Seeking Sample of Adolescents]

The Association Between Illicit Drug Use, Borderline Personality Disorder and Depression in a Help-Seeking Sample of Adolescents Risk-taking behavior is a common phenomenon in adolescence. Even prevalence rates for illicit drug use are considerably high in youth and associated with a range of psychiatric disorders, especially depression and Borderline Personality Disorder (BPD). However, there is a lack of data investigating differences in psychopathology between different substance user groups. Therefore, aim of the study was to investigate occurrence of depression and BPD symptoms in different drug risk groups (no use vs. occasional use vs. frequent use). Further aim of the study was to examine risk profiles regarding single BPD criteria. Data of n = 347 adolescents (81.7 % female, mean age 14.95, SD = 1.50) presenting at the specialized outpatient clinic for risk-taking and self-harming behavior (AtR!Sk) in Heidelberg were analyzed. Results show that BPD is clearly associated with illicit drug use in adolescence. There is no difference between occasional and frequent users in terms of mean number of BPD criteria. However, frequent users differ from occasional users regarding greater number of impulsivity and anger criteria. After adjusting for sociodemographic variables there was no association between drug use and depression. Since even single events of illicit drug use are associated with higher levels of BPD, clinicians should rapidly target to stop consumption. Further, psychotherapeutic interventions for BPD in high-risk consumers should especially focus on facilitating adaptive emotion regulation skills in regards to impulsivity and anger.

Substance use frequency and related characteristics among adolescents presenting to an emergency department in Turkey

It has been reported that drug-related visits to emergency department (ED) by youth have been increased in recent years. We aimed to determine the frequency of, and associated risk factors for, substance abuser adolescents presenting to the emergency department. We conducted a biphasic (retrospective-prospective), observational study of all adolescents, presenting to our emergency department with complaints related to recreational drug use and having a positive urine drug screening from January, 2013 to December 2016. To obtain some spesific data, a telephone interview was done. Baseline demographic and clinical data were obtained. During the study period urine toxicology screen was positive for illicit drugs in 131 (0.9%) patients. The total of substance users by years were respectively 17 (13%) in 2013, 27 (20%) in 2014, 39 (30%) in 2015 and 48 (37%). The median age was 16 years and 65% were male. Majority of substance users (61%) had neuropsychiatric complaint. Amphetamine type stimulants (60%) were the most commonly used substance. Rate of cigarette and alcohol use in this adolescent group was respectively 95% and 88%. This group also had some specific features such as low income (59%) and single-parent family (54%). Our findings suggest that the number of illicit drug use has been steadily increasing among adolescents. The most common identified substance was amphetamine type stimulants. They had poor socioeconomic conditions.

Predictors of substance use treatment initiation and engagement among adult and adolescent Medicaid recipients

Background: It is important to understand patterns and predictors of initiation and engagement in treatment for Medicaid-covered individuals with substance use disorders because Medicaid is a major source of payment for addiction treatment in the United States. Our analysis examined similarities and differences in predictors between adults and adolescents. Methods: An analysis of Oregon Medicaid claims data for the time period January 2010 through June 2015 assessed rates of substance use and of treatment initiation and engagement using the Healthcare Effectiveness Data and Information Set (HEDIS) definitions. The analysis included individuals aged 13-64 with a new alcohol and other drug dependence diagnosis who met the HEDIS enrollment criteria and did not have cancer. We created 4 logistic regression models to assess treatment initiation and engagement, separately for adults (ages 18-64) and adolescents (ages 13-17). Independent predictors included age, gender, race, the interaction of gender and race, urban/rural residence, presence of any chronic disease, a psychiatric diagnosis, or a pain diagnosis. Results: Among adults, odds of initiation were lower in white males than in nonwhite males, white females, and nonwhite females. Conversely, among adolescents, odds of initiation were higher in white males than in the other gender/race groups. Predictors of initiation also went in opposite directions for presence of a psychiatric diagnosis (negative in adults, positive in adolescents) and urban residence (positive in adults, negative in adolescents). We found similar patterns in models of engagement, although for engagement those with a psychiatric diagnosis had lower odds of engagement in both adults and adolescents. Conclusions: Predictors of treatment initiation and engagement for alcohol and drug use disorders differed between adults and adolescents on Medicaid. A better understanding of these differences will enable development of targeted treatment programs that are effective within age groups.

Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014

IMPORTANCE

Opioid use disorder (OUD) frequently begins in adolescence and young adulthood. Intervening early with pharmacotherapy is recommended by major professional organizations. No prior national studies have examined the extent to which adolescents and young adults (collectively termed youth) with OUD receive pharmacotherapy.

OBJECTIVE

To identify time trends and disparities in receipt of buprenorphine and naltrexone among youth with OUD in the United States.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using deidentified data from a national commercial insurance database. Enrollment and complete health insurance claims of 9.7 million youth, aged 13 to 25 years were analyzed, identifying individuals who received a diagnosis of OUD between January 1, 2001, and June 30, 2014, with final follow-up date December 31, 2014. Analysis was conducted from April 25 to December 31, 2016. Time trends were identified and multivariable logistic regression was used to determine sociodemographic factors associated with medication receipt.

EXPOSURES

Sex, age, race/ethnicity, neighborhood education and poverty levels, geographic region, census region, and year of diagnosis.

MAIN OUTCOMES AND MEASURES

Dispensing of a medication (buprenorphine or naltrexone) within 6 months of first receiving an OUD diagnosis.

RESULTS

Among 20 822 youth diagnosed with OUD (0.2% of the 9.7 million sample), 13 698 (65.8%) were male and 17 119 (82.2%) were non-Hispanic white. Mean (SD) age was 21.0 (2.5) years at the first observed diagnosis. The diagnosis rate of OUD increased nearly 6-fold from 2001 to 2014 (from 0.26 per 100 000 person-years to 1.51 per 100 000 person-years). Overall, 5580 (26.8%) youth were dispensed a medication within 6 months of diagnosis, with 4976 (89.2%) of medication-treated youth receiving buprenorphine and 604 (10.8%) receiving naltrexone. Medication receipt increased more than 10-fold, from 3.0% in 2002 (when buprenorphine was introduced) to 31.8% in 2009, but declined in subsequent years (27.5% in 2014). In multivariable analyses, younger individuals were less likely to receive medications, with adjusted probability for age 13 to 15 years, 1.4% (95% CI, 0.4%-2.3%); 16 to 17 years, 9.7% (95% CI, 8.4%-11.1%); 18 to 20 years, 22.0% (95% CI, 21.0%-23.0%); and 21 to 25 years, 30.5% (95% CI, 30.0%-31.5%) (P < .001 for difference). Females (7124 [20.3%]) were less likely than males (13 698 [24.4%]) to receive medications (P < .001), as were non-Hispanic black (105 [14.8%]) and Hispanic (1165 [20.0%]) youth compared with non-Hispanic white (17 119 [23.1%]) youth (P < .001).

CONCLUSIONS AND RELEVANCE

In this first national study of buprenorphine and naltrexone receipt among youth, dispensing increased over time. Nonetheless, only 1 in 4 commercially insured youth with OUD received pharmacotherapy, and disparities based on sex, age, and race/ethnicity were observed.

Perceived Barriers and Enablers of Help-Seeking for Substance Use Problems During Adolescence

Aim. Receiving professional help early can reduce long-term harms associated with substance use. However, little is known about the factors that influence help-seeking for substance use problems during early-mid adolescence, prior to the emergence of disorder. Given that beliefs regarding help-seeking are likely to develop early, understanding adolescent views of help-seeking during this period is likely to provide important information for prevention and intervention efforts. The current study identifies perceptions that would facilitate or prevent adolescents from seeking support for substance use problems from formal and informal help sources. Method. Thirty-four 12- to 16-year-olds from two schools in Melbourne, Victoria, Australia, were recruited. A qualitative interpretative design was used, incorporating semistructured, audio-recorded interviews. Results. Three overlapping themes that reflected barriers or enablers to help-seeking were identified: approachability, confidentiality and trustworthiness, and expertise. Help-seeking was facilitated when adolescents believed that the help source would be supportive and understanding, would keep information confidential, and had expertise in the alcohol and drug field. Conversely, adolescents were reluctant to seek help from sources they believed would be judgmental, lacked expertise, or would inform their parents. Conclusions. These findings highlight perceptions that may influence help-seeking for alcohol and drug problems during adolescence. Further research is needed to determine if help-seeking can be facilitated by improving parents’ and peers’ knowledge and promoting health professionals’ expertise in working with young people’s alcohol and drug issues.

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic

An epidemic of drug overdose deaths has led to calls for programs and policies to limit misuse and diversion of opioid medications. Any parallel call to consider the risk of iatrogenic addiction when treating pain has been muted in comparison. We have moved beyond questions of nonmedical use, abuse, and diversion to highlight the role of prescription opioids in causing addiction even when prescribed and used appropriately. Unfortunately, current evidence is insufficient, and a rapid expansion of longitudinal research is urgently needed to guide clinicians in balancing the need for opioids with the risk of adverse consequences. Meanwhile, medical education should place greater emphasis on the abuse liability of prescription opioids, and providers should endeavor to attenuate risk when possible.

Depression and anxiety and their association with healthcare utilization in pediatric lupus and mixed connective tissue disease patients: a cross-sectional study

BACKGROUND

Depression and anxiety adversely affects outcomes in systemic lupus erythematosus (SLE) and healthcare utilization is high for pediatric SLE. We aimed to characterize the prevalence of depression and anxiety in pediatric SLE, and their association with healthcare utilization.

METHODS

We conducted a cross-sectional analysis of pediatric SLE and mixed connective tissue disease (MCTD) subjects and healthy controls aged 8 years and above. We used the Patient Health Questionnaire 9 (PHQ-9) and the Screen for Childhood Anxiety Related Disorders (SCARED) to identify depression, suicidal ideation and anxiety symptoms, respectively. We compared symptom prevalence in SLE/MCTD and healthy subjects using logistic regression. For SLE/MCTD subjects, we calculated the rate of annual outpatient visits [rheumatology/nephrology, primary care provider (PCP) and emergency department], hospitalizations and rheumatology/nephrology telephone consultations in the preceding year. We compared these outcomes in those with and without depression and anxiety using negative binomial regression.

RESULTS

We identified depression symptoms in 10 (20%) SLE/MCTD and 4 (8%) healthy subjects, representing a trend towards increased prevalence in unadjusted analysis (OR = 2.9, 95% CI 0.8-9.9, p = 0.09). Adjusted analysis did not show a significant difference; however, non-white race was a statistically significant independent risk factor for depression symptoms compared to white race (OR = 5.4, 95% CI 1.1-27.2, p = 0.04). We identified anxiety symptoms in 11 (22%) SLE/MCTD and 13 (26%) healthy subjects, which was not statistically different. Suicidal ideation was present in 7 (14%) SLE/MCTD and 2 (4%) healthy subjects, which was a statistically significant difference (OR = 5.4, 95% CI 1.02-28.3, p = 0.047). Of the 34% of SLE/MCTD subjects with any symptoms, only 24% had previous mental health care. Those with depression symptoms had a statistically significant lower rate of visits to the PCP (IRR = 0.38, 95% CI 0.19-0.76, p < 0.001). Anxiety symptoms were not associated with the healthcare utilization outcomes.

CONCLUSIONS

Depression and anxiety symptoms were prevalent, and suicidal ideation significantly more common in SLE/MCTD than in healthy subjects. Non-white race was an independent risk factor for depression. Despite prevalent symptoms, there were poor rates of prior mental health treatment, and less frequent PCP visits among those with depression symptoms. Further investigation of barriers to mental health care and interventional strategies for symptomatic youth with SLE/MCTD is needed.