Moderators of Substance Use Disorder Treatment for Adolescents

Narrative review: Revised Principles and Practice Recommendations for Adolescent Substance Use Treatment and Policy

OBJECTIVE

In 2014, the U.S. National Institute on Drug Abuse released the "Principles of Adolescent Substance Use Disorder Treatment," summarizing previously established evidence and outlining principles of effective assessment, treatment, and aftercare for substance use disorders (SUD). Winters et al. (2018) updated these principles to be developmentally appropriate for adolescents. This review builds on that formative work and recommends updated adolescent assessment, treatment, and aftercare principles and practices.

METHOD

The Cochrane, MEDLINE-PubMed, and PsychInfo databases were searched for relevant studies with new data about adolescent substance use services. This article updates the 13 original principles; condenses the 8 original modalities into 5 practices; and highlights implications for public policy approaches, future funding, and research.

RESULTS

Key recommendations from the principles include integrating care for co-occurring mental health disorders and SUDs, improving service accessibility including through the educational system, maintaining engagement, and addressing tension between agencies when collaborating with other youth service systems. Updates to the treatment practices include adoption of Screening, Brief Intervention and Referral to Treatment (SBIRT), investment in social programs and family involvement in treatment, expanding access to behavioral therapies and medications, increasing funding to harm reduction services, supporting reimbursement for continuing care services, and increasing investment in research.

CONCLUSION

These revised principles of adolescent assessment, treatment, and aftercare approaches and practices aim to establish guidance and evidence-based practices for treatment providers, while encouraging necessary support from policymakers and funding agencies to improve the standard of care for adolescent SUD services.

Additive effects of adjunctive app-based interventions for mental disorders - A systematic review and meta-analysis of randomised controlled trials

Background

It is uncertain whether app-based interventions add value to existing mental health care.

Objective

To examine the incremental effects of app-based interventions when used as adjunct to mental health interventions.

Methods

We searched PubMed, PsycINFO, Scopus, Web of Science, and Cochrane Library databases on September 15th, 2023, for randomised controlled trials (RCTs) on mental health interventions with an adjunct app-based intervention compared to the same intervention-only arm for adults with mental disorders or respective clinically relevant symptomatology. We conducted meta-analyses on symptoms of different mental disorders at postintervention. PROSPERO, CRD42018098545.

Results

We identified 46 RCTs (4869 participants). Thirty-two adjunctive app-based interventions passively or actively monitored symptoms and behaviour, and in 13 interventions, the monitored data were sent to a therapist. We found additive effects on symptoms of depression (g = 0.17; 95 % CI 0.02 to 0.33; k = 7 comparisons), anxiety (g = 0.80; 95 % CI 0.06 to 1.54; k = 3), mania (g = 0.2; 95 % CI 0.02 to 0.38; k = 4), smoking cessation (g = 0.43; 95 % CI 0.29 to 0.58; k = 10), and alcohol use (g = 0.23; 95 % CI 0.08 to 0.39; k = 7). No significant effects were found on symptoms of depression within a bipolar disorder (g = -0.07; 95 % CI -0.37 to 0.23, k = 4) and eating disorders (g = -0.02; 95 % CI -0.44 to 0.4, k = 3). Studies on depression, mania, smoking, and alcohol use had a low heterogeneity between the trials. For other mental disorders, only single studies were identified. Only ten studies had a low risk of bias, and 25 studies reported insufficient statistical power.

Discussion

App-based interventions may be used to enhance mental health interventions to further reduce symptoms of depression, anxiety, mania, smoking, and alcohol use. However, the effects were small, except for anxiety, and limited due to study quality. Further high-quality research with larger sample sizes is warranted to better understand how app-based interventions can be most effectively combined with established interventions to improve outcomes.

Predictors of problematic adult alcohol, cannabis, and other substance use: A longitudinal study of two samples

This study examined whether a key set of adolescent and early adulthood risk factors predicts problematic alcohol, cannabis, and other substance use in established adulthood. Two independent samples from the Child Development Project (CDP; n = 585; 48% girls; 81% White, 17% Black, 2% other race/ethnicity) and Fast Track (FT; n = 463; 45% girls; 52% White, 43% Black, 5% other race/ethnicity) were recruited in childhood and followed through age 34 (CDP) or 32 (FT). Predictors of substance use were assessed in adolescence based on adolescent and parent reports and in early adulthood based on adult self-reports. Adults reported their own problematic substance use in established adulthood. In both samples, more risk factors from adolescence and early adulthood predicted problematic alcohol use in established adulthood (compared to problematic cannabis use and other substance use). Externalizing behaviors and prior substance use in early adulthood were consistent predictors of problematic alcohol and cannabis misuse in established adulthood across samples; other predictors were specific to the sample and type of substance misuse. Prevention efforts might benefit from tailoring to address risk factors for specific substances, but prioritizing prevention of externalizing behaviors holds promise for preventing both alcohol and cannabis misuse in established adulthood.

Do adverse experiences predict unemployment and need of psychiatric help after treatment for drug use disorders?

Background: This study prospectively examined the association between adverse experiences (physical abuse, sexual abuse and parental substance use problems [SUPs]), not being employed, in education or training (NEET) and being in need of acute psychiatric help among patients receiving treatment for substance use disorders. Methods: A total of 580 adolescents and early adults aged 15-25 years enrolled in treatment for drug use disorders were included in the analyses. Treatment data were linked to participants' register data on employment, education and acute contact to psychiatric services for the following two years. Multivariable logistic regression models were used to examine associations between the three adverse experiences, NEET and need of acute psychiatric help, adjusting for confounders such as age, gender, ethnicity, treatment response and treatment condition. Results: More than half of the participants were NEET two years after treatment enrolment. After controlling for demographics and treatment conditions, NEET was predicted by parental substance use problems (odds ratio [OR] = 1.89, 95% confidence interval [CI] 1.31- 2.70), exposure to physical abuse (OR = 1.48, 95% CI 1.03-2.13) and non-abstinence (abstinence was negatively associated with NEET, OR = 0.53, 95% CI 0.37-0.76). Being exposed to two (OR = 3.17, 95% CI 1.93-5.21) and three types of adverse experiences (OR = 3.14, 95% CI = 1.47-6.70) predicted NEET more strongly than exposure to one type. One out of 10 participants sought acute care from psychiatric services at least once within two years after treatment. Only sex and ethnic minority status were associated with contacting psychiatric services acutely. Conclusion: The present study suggests that adverse experiences, such as being exposed to parental problematic substance use and physical abuse, may be important predictors for NEET after treatment for SUDs.

Substance-Use Disorders in Children and Adolescents

BACKGROUND

The most common substance use disorders in childhood and adolescence have to do with alcohol and cannabis. These disorders begin as early as puberty, are often accompanied by other mental disorders, and, if untreated, very frequently persist into adulthood.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed on substance use disorders in children and adolescents.

RESULTS

Substance use disorders are among the commonest mental disorders in childhood and adolescence. In Germany, approximately 10% of adolescents have tried cannabis at least once. The prognosis is negatively affected by individual (bio-)psychological traits, mental comorbidities, laws that facilitate consumption, socioeconomic disadvantage, consuming peers, and parental substance use disorders. A timely diagnosis, motivation by the pediatrician, and referral to specialized child and adolescent psychiatric services helps assure that those affected receive appropriate treatment, with the goal of abstinence from the substance as well as improvement in emotional regulation, affectivity, and attention. According to studies from the English-speaking countries and considering all treatment forms, treatment is completed by approximately 60% to 65% of children and adolescents; 20% to 40% of these patients are abstinent six months after the end of treatment. No studies of this type have been carried out to date in Germany.

CONCLUSION

As the results of treatment are generally poor, there is a major need for research on the treatment and care of children and adolescents with substance use disorders. In particular, the interfaces between outpatient and inpatient care need further improvement.

Embracing Scientific Humility and Complexity: Learning "What Works for Whom" in Youth Psychotherapy Research

Clinical psychological scientists have spent decades attempting to understand "what works for whom" in the context of youth psychotherapy, toward the longstanding goal of personalizing psychosocial interventions to fit individual needs and characteristics. However, as the articles in this Special Issue jointly underscore, more than 50 years of psychotherapy research has yet to help us realize this goal. In this introduction to the special issue, we outline how and why "aspiration-method mismatches" have hampered progress toward identifying moderators of youth psychotherapy; emphasize the need to embrace etiological complexity and scientific humility in pursuing new methodological solutions and propose individual and structural strategies for better-aligning clinical research methods with the goal of personalizing mental health care for youth with diverse identities and treatment needs.

Psychiatric comorbidity of developmental trauma disorder and posttraumatic Stress disorder: findings from the DTD field trial replication (DTDFT-R)

Background: Developmental Trauma Disorder (DTD) has extensive comorbidity with internalizing and externalizing disorders distinct from posttraumatic stress disorder (PTSD). Objective: To replicate findings of DTD comorbidity and to determine whether this comorbidity is distinct from, and extends beyond, comorbidities of PTSD. Method: DTD was assessed by structured interview, and probable DSM-IV psychiatric disorders were identified with KSADS-PL screening modules, in a multi-site sample of 271 children (ages 8-18 years old; 47% female) in outpatient or residential mental health treatment for multiple (M = 3.5 [SD = 2.4]) psychiatric diagnoses other than PTSD or DTD. Results: DTD (N = 74, 27%) and PTSD (N = 107, 39%) were highly comorbid and shared several DSM-IV internalizing and externalizing disorder comorbidities. Children with DTD with or without PTSD had more comorbid diagnoses (M = 5.7 and 5.2 [SD = 2.4 and 1.7], respectively) than children with PTSD but not DTD (M = 3.8[SD = 2.1]) or neither PTSD nor DTD (M = 2.1[SD = 1.9]), F[3,267] = 55.49, p < .001. Further, on a multivariate basis controlling for demographics and including all potential comorbid disorders, DTD was associated with separation anxiety disorder, depression, and oppositional defiant disorder after controlling for PTSD, while PTSD was associated only with separation anxiety disorder after controlling for DTD. Both DTD and PTSD were associated with suicidality. Conclusions: DTD is associated with psychiatric comorbidity beyond that of PTSD, and DTD warrants assessment for treatment planning with children in intensive psychiatric services.