Substance Abuse and Co-Existing Psychiatric Disorder

Introduction

Despite recent studies that show adolescent drug and alcohol use has remained essentially stable, adolescent substance abuse remains a concern. With increased availability of "club drugs" such as ecstasy (MDMA), ketamine and GHB (gamma hydroxy-butyrate) over the past several years, as well as evidence that the age of first use of drugs continues to get younger and younger, it is hard to claim victory in the "War on Drugs." In fact, the average youth in America first experiments with drugs between the sixth and seventh grades.

Evidence also suggests that some people may use alcohol or other drugs of abuse in part to self-medicate distressing mental states associated with underlying psychiatric conditions. Adolescents with substance use disorders (SUD) especially exhibit a high prevalence of psychiatric problems compared to the general population. These co-existing psychiatric disorders, which occur frequently with SUD, are discussed later in this paper. They include the following:

1. Anxiety disorders
2. Depression
3. Attention-deficit/hyperactivity disorder (ADHD)
4. Bipolar Disorder
5. Conduct disorder

Not only are specific psychiatric disorders associated with drug abuse, but other problems affecting teenagers such as suicide, violence, and pregnancy are also associated with increased risk of substance use. Few studies exist on the risks (or benefits) of prescribing medications for substance abuse issues or for those with SUD and co-morbid psychiatric disorders.

The Scope of the Problem

A recent large study estimates that some problem with drug or alcohol abuse affects over 1 in 5 adults at some point during their lifetimes. In adolescent psychiatric inpatients, between 15% and 50% have a co-morbid SUD. The number is obviously higher if smoking is included. Likewise, in adolescent substance abuse programs, up to 80% of patients have a psychiatric disorder.

Risk Factors

Certain factors put children and adolescents at risk for developing an SUD. These include:

Genetic factors

• Having one of both parents with a substance abuse problem

Constitutional and psychological factors

• Psychiatric problems
• History of physical, sexual, or emotional abuse
• History of attempted suicide

Sociocultural factors

• Family
  
  • Parental experiences and attitudes towards drug use
  • History of parental divorce (or separation)
  • Low expectations for child
• Peers
  
  • Friends who use drugs
  • Friends' attitude towards drug use
  • Antisocial or delinquent behavior
• School
  
  • School failure or dropping out
• Community
  • Community attitudes towards drug use
  • Economic and social deprivation
  • Availability of drugs and alcohol (including cigarettes)  

Co-existing psychiatric disorders and how they are treated

• Anxiety Disorders
  Anxiety disorders are among the most common psychiatric conditions co-existing in adolescents and adults with SUD. Typically, these include posttraumatic stress disorder (PTSD), social phobia, or generalized anxiety disorder. Many teenagers, as well as adults, believe that drugs and alcohol may reduce anxiety and stress, and this may lead to first use or continued abuse. To make things more confusing, there are some well-done studies showing that teenagers who never experiment with drugs or alcohol may be at higher risk to develop anxiety problems later in life. This is not to say that drug use prevents anxiety. Rather, it is possible that a youth with a mental health problem such as an anxiety disorder does not engage in social experiences involving drugs or is more isolated from peers who use drugs.

Luckily, there are many good treatments available for anxiety, such as cognitive behavioral therapy (CBT) or serotonin medications (e.g. Paxil or Zoloft). Effective treatment of anxiety often leads to reduction in problems with substance abuse.

• Depression
  Adolescent substance abusers are also at great risk for developing a major depressive disorder or dysthymia ("minor" depression). Practitioners are often faced with a "chicken-or-the-egg" dilemma when attempting to determine which came first. Of note, while adult depressive symptoms often times resolve within a few weeks of abstinence from drugs or alcohol, in adolescents this is rarely the case. Moreover, one of the greatest risk factors for teen suicide is intoxication with either drugs or alcohol.

  Depressive symptoms in substance-abusing adolescents often require initiation of treatment with antidepressants. Again, treatment with serotonin medications (e.g. Paxil or Zoloft), or "atypical" antidepressants (e.g. Wellbutrin) has been shown to be effective. Additionally, cognitive-behavioral therapy (CBT) or individual psychotherapy may be part of the treatment plan recommended by the psychiatrist.

• Attention-Deficit/Hyperactivity Disorder (ADHD)
  Studies continue to report the high risk for developing an SUD in children and adolescents diagnosed with ADHD. This is of particular concern, since the treatments of choice are psychostimulants such as Ritalin, or Adderall. However, these have the potential to be abused. On the other hand, recently it has been suggested that appropriate treatment for ADHD may lead to a decreased chance for developing an SUD. To lessen the risk of possible abuse in at-risk adolescents, use of medications such as Wellbutrin or Concerta is often indicated.

• Bipolar Disorder
  The diagnosis of bipolar disorder may be among the hardest to make in children and adolescents and is even more difficult in substance-abusing teens. Behaviors, such as changes in sleeping patterns and mood swings, can be symptoms of bipolar disorder, substance abuse, or even normal adolescence. The diagnosis of bipolar disorder should certainly be considered in substance-abusing youth, particularly those with binge patterns. Treatment is often complex, utilizing medications, psychotherapy, and other resources.

• Conduct Disorder
  Conduct disorder is frequently diagnosed in substance abusing teenagers. It is common and often difficult to treat. Perhaps the highest risk for development of a problem with either drugs or alcohol occurs in young persons with both conduct disorder and a mood disorder (either depression or bipolar disorder). As in bipolar disorder, diagnosis and treatment are often complex issues. Frequently youth with co-morbid conduct disorder and SUD require long-term residential treatment for control of these symptoms.

In sum, psychiatric disorders and substance abuse frequently occur together. This leads to difficulty in both assessment and treatment. Psychiatric medications, such as antidepressants, mood stabilizers, psychostimulants, and others are often of benefit. However, care must be taken to avoid potential interactions between the illicit drugs and the prescribed medications. Additionally, groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or "Double-Trouble" groups can be useful adjuncts to treatment psychiatric or psychological treatment. Consultation with a substance abuse specialist often helps clarify many of these issues for parents and their children.