Title: Co-Occurring Substance Use and Psychiatric Disorders in Children and Adolescents
1Co-Occurring Substance Use and Psychiatric
Disorders in Children and Adolescents
UCLA
2An Introduction to Co-Occurring Disorders
- Daniel Dickerson, DO, MPH
- Assistant Research Psychiatrist
- UCLA Integrated Substance Abuse Programs
- Larissa Mooney, MD
- Associate Physician
- UCLA Integrated Substance Abuse Programs
3Objectives
- Introduction of workshop context and goals
- Adolescent drug abuse trends
- Epidemiology of co-occurring substance use and
psychiatric disorders (COD) in youth - Clinical implications of COD
- Diagnostic and treatment issues
4Mental Health Services Act (MHSA) and COD
- Mental Health Oversight and Accountability
Commission (MHOAC) created in 2004. - MHOAC to provide oversight, accountability, and
leadership on issues related to the Mental Health
Services Act (MHSA). - MHSA passed by California voters in 2004 as
Proposition 63. - Goal of MHSA to integrate COD treatment.
- Each county in California, including L.A. County,
provided proposition 63 funds to train
psychiatrists in COD.
5COD recognized as an important disease entity
- COD definition Individuals who have at least
one mental disorder as well as an alcohol or drug
use disorder. (SAMHSA, 2002) - Since 1990s, recognition of COD in psychiatric
practice has been steadily increasing - The Presidents New Freedom Commission Goals and
Recommendations (2004) include Screen for
co-occurring mental and substance use disorders
and link with integrated treatment strategies. - SAMHSAs National Advisory Council Subcommittee
on COD reported to Congress on prevention and
treatment on COD (SAMHSA, 2002)
6Adolescent Drug Abuse Trends
- Approximately half of high school graduates have
tried an illicit drug 30 by 8th grade - Monitoring the Future Survey 07 gradual decline
in past-year overall illicit drug use - Past-year modest decline in use of marijuana and
amphetamines - No significant change in use of cocaine,
hallucinogens, heroin, prescription opioids, or
cough medicines - Past-year downward trend in EtOH and tobacco use
- Increase in ecstasy (MDMA) use
7Drug abuse Trends continued
8Why do adolescents use drugs?
- Gain social acceptance
- Elevate mood
- Alleviate anxiety
- Improve self-esteem
- Manage weight (stimulants)
- Aphrodisiac effects
- Analgesic effects (opioids)
9Substance Abuse DSM-IV
- A. Maladaptive pattern of use causing impairment
or distress - One or more within 12-month period
- Recurrent use causing failure to fulfill role
obligation (work, school, home) - Recurrent use in physically hazardous situations
- Recurrent legal problems
- Use despite social or interpersonal problems
- B. Have never met criteria for substance
dependence
10Substance Dependence DSM-IV
- Maladaptive pattern of use causing impairment or
distress - 3 or more of following within 12-month period
- Tolerance
- Withdrawal
- Use in larger amounts over longer period than
intended - Ongoing desire or unsuccessful efforts to cut
down or control use - Excessive time spent obtaining, using, or
recovering from effects - Use despite physical or psychological problem
11Risk Factors for SUD
- Genetic (family hx SUD)
- Social
- Family (attitudes, experiences, divorce)
- Parental (disciplinary skills, guidance, and
nurturing) - Peers (attitudes, use patterns)
- School (failure/dropout)
- Drug availability
- Age of onset of use (Bates and Labouvie, 1997)
- Psychological
- Psychiatric co-morbidity (Buckstein et al., 1989)
- Temperament (impulsivity, negative affectivity,
sensation seeking, aggression) (Bates and
Labouvie, 1997) - History of physical, sexual or emotional abuse
- Stressful life events
(Kaminer and Tarter, 2004)
12Adolescents with Substance Use Disorders...
- Are largely undiagnosed
- Are distributed across diverse health and social
service systems - Are more likely to be involved in the juvenile
justice system - Are more likely to have been victims of child
abuse - Have high co-morbidity with psychiatric conditions
13Early Alcohol Exposure
- Rate of Fetal Alcohol Syndrome (FAS) and
Alcohol-Related Neurodevelopmental Disorders
(ARND) combined approximately 1 in 100 live
births. (Sampson et al., 1997) - Individuals with FAS may be at higher risk for
mental illness, alcohol and other drug abuse,
impulsivity, and history of trauma or abuse
(Baldwin, 2007) - Rodents exposed to alcohol in utero are more
drawn to alcohol, suggesting teens exposed to
alcohol in utero may be more likely to abuse
alcohol (Youngentob et al., 2000) - Maternal drinking during pregnancy had a
significant positive effect on adolescent
daughters' current drinking, but a slight
negative effect on sons lifetime drinking
(Griesler and Kandel, 1998)
14(No Transcript)
15Alcohol Use and Youth
- 75 of teens have used alcohol before graduating
high school 40 by 8th grade (MTF, 2005) - 40 of children who start drinking prior to age
15 will develop alcohol dependence (Grant and
Dawson, 1998) - Heavy binge drinking by adolescents and young
adults associated with increased long-term risk
for heart disease, high blood pressure, type 2
diabetes, and other metabolic disorders (Russell
et al., in press) - Withdrawal risks include seizures, delirium
tremens - Adolescents may be more susceptible to memory
loss than adults (Lubman et al., 2007b) - Heavier use associated with psychiatric disorders
- May cause or exacerbate depressive and anxiety
symptoms (Oligati et al., 2007)
16Marijuana Use and Youth
- Among adolescents, marijuana (MJ) use is 1
illicit drug, second only to alcohol use. - Since 2001, annual prevalence of MJ use declined
by 33 among 8th-graders, 25 among 10th-graders,
and 14 among 12th-graders. 10 past-year use 8th
grade. - 60 of youth who use drugs use only MJ
- 2/3 new MJ users per year are between ages 12 and
17 - Cannabis dependence associated with mood and
anxiety disorders (Dorard et al., 2008)
(NHSDA, 2000 MTF, 2001 and 2007)
17Stimulant Use and Youth
- Methamphetamine more potent than amphetamine or
cocaine - Medical consequences include tachycardia,
elevated blood pressure, hyperthermia,
arrhythmias, acute myocardial infarction, stroke,
infectious disease risk - Psychiatric consequences include confusion,
anxiety, depression, psychosis (paranoia,
hallucinations)
(NIDA Research Report Series, 2004 and 2006)
18Inhalant Use and Youth
- Inhalants (including volatile solvents, aerosols
and gases) are among first drugs tried by
children - About 3.0 of U.S. children have tried inhalants
by 4th grade - Prevalence of abuse peaks between 7th and 9th
grades - Rapid CNS effects include euphoria, dizziness,
slurred speech, incoordination users may
experience delusions and hallucinations - Medical consequences include arrhythmias, loss
of consciousness, possible death (sudden
sniffing death)
NIDA Research Report Series, 2005
19Prescription Drug Abuse and Youth
- 15.4 high school seniors reported nonmedical use
of at least one prescription drug in past year
(Monitoring the Future, 2007) - 2003 NSDUH 4 of youth ages 12-17 and 6 of
18-25 year olds reported nonmedical use of
prescription medications in the past month. - 12-13 year olds reported higher rates of
prescription drug use than marijuana - Between ages 12-17, females more likely to abuse
prescription drugs than males
(NIDA Research Report, 2005 Prescription Drug
Abuse)
20Club Drugs and Hallucinogens
- LSD
- Altered sensory perception, mood swings,
hallucinations, delusions, flashbacks - Ecstasy (MDMA)
- Stimulant and hallucinogenic effects
restlessness, insomnia, altered sensory
perception - Medical risks tachycardia, hyperthermia,
hyponatremia, and seizure - May cause neurotoxicity
- Ketamine and PCP
- Dissociative anesthetics
NIDA Research Report Series, 2001 and 2005
21Dextromethorphan (Coricidin HBP) Use and Youth
- Cough medicine abuse among adolescents has been
increasing - Coricidin HBP Cough and Cold is an
over-the-counter cough suppressant containing a
high amount of dextromethorphan - Is easily attainable (in stores) and is often
stolen in large amounts - Psychiatric consequences include transient
substance-induced psychosis, potential for
depression and suicidal behavior (Dickerson et
al., 2008) - Medical consequences include cardiac toxicity and
liver failure (Dickerson et al., 2008)
22Epidemiology of COD
- Epidemiological studies consistently report high
rates of co-morbid mental health problems among
adolescents with substance use disorders (SUD).
(Armstrong and Costello, 2002 Kandel et al.,
1999 Rhode et al., 1996) - In a large community sample of adolescents in the
United States, more than 80 of those with an
alcohol use disorder had some form of lifetime
psychopathology, with almost half (48) reporting
a history of depression. (Rhode et al., 1996) - In the Methods for the Epidemiology of Child and
Adolescent Mental Disorders (MECA) study, 32 of
adolescents with a current SUD had a co-occurring
mood disorder. (Kandel et al., 1999) - Utilizing data from the US National Co-morbidity
Survey, co-occurrence of SUD with mental health
disorders was highest among those aged
1524 years. (Kessler et al., 1996)
23Psychiatric/SUD Co-morbidity
- Limited studies to date on psychiatric d/o
prevalence rates in youth with SUD - Alcohol, tobacco, and illicit drug use frequency
associated with development of psychiatric d/o,
especially conduct d/o (Kandel DB et al., 1999) - Onset of psychiatric d/o more often precedes SUD,
especially conduct and anxiety d/o (Burke JD et
al, 1994 Kessler RC et al., 1996) - Increased risk of suicide attempts in adolescents
with co-occurring SUD and mood d/o - (Kelly et al., 2004)
24Co-morbidity MECA Study
Current Co-morbid D/O SUD () No SUD () OR 95 CI
Any Anxiety D/O 20.0 15.7 1.5 0.5-4.4
Any Mood D/O 32.0 11.2 3.7 1.4-10.1
Any Disruptive D/O/ASPD 68.0 10.1 20.3 7.1-57.8
Any Anx/Mood/ASPD 76.0 24.5 8.2 3.0-22.2
Kandel, DB et al., 1999
25Age of First Use of Primary Substance Younger
than 12 for Admissions Aged 13-17, by Psychiatric
Diagnosis Status 2003
(SAMHSA, 2003)
26Primary Source of Referral of Adolescent
Admissions, by Psychiatric Diagnosis Status 2003
(SAMHSA, 2003)
27Race/Ethnicity of Adolescent Admissions, by
Psychiatric Diagnosis Status 2003
(SAMHSA, 2003)
28Completion of Highest Grade at Least 1 Year
Behind Appropriate Age/Grade Level for Adolescent
Admissions Psychiatric Diagnosis Status 2003
- Completion rates at least 1 year behind
Age at Admission Adolescents with Co-Occurring Disorders Adolescents without Co-Occurring Disorders
12 82 73
13 80 77
14 82 78
15 88 83
16 91 87
17 90 89
(SAMHSA, 2005)
29Mood and Anxiety d/o and SUD
- Baseline depressive symptoms predict poor
substance use outcome following adolescent
residential treatment. (Subramaniam et al., 2007) - Depressive disorders frequently precede SUD in
adolescents. (Bukstein et al., 1992) - Order of onset of anxiety disorders and SUD more
variable social phobia typically precedes SUD,
panic d/o and GAD usually follow SUD. (Kushner et
al., 1990) - Any use of cannabis at baseline predicted a
modest increase in the risk of first major
depression (odds ratio 1.62 95 confidence
interval 1.06-2.48) and bipolar disorder (odds
ratio 4.98 95 confidence interval 1.80-13.81).
(van Laar et al., 2007)
30Adolescent PTSD and SUDs
- Higher prevalence of PTSD in adolescents with SUD
(Clark et al., 1995) - Individuals with PTSD were more likely to have
- a higher number of co-morbid mental health and
substance use disorders - used more drugs in their lifetime
- to report higher scores on the CESD
- lower scores on the QOL-SF, including the
psychological and environmental subscales.
(Lubman et al., 2007)
31Adolescent Psychosis and SUD
- Abuse of alcohol and illicit substances is common
among people with psychotic illnesses (Barnett et
al., 2007) - Recent emphasis on the possible links between
cannabis and psychosis (Arseneault et al., 2004
Fergusson et al., 2006). - A high prevalence of cannabis use among patients
with established psychotic disorders has been
observed (Green et al., 2005 Barnett et al.,
2007). - Dextromethorphan/Coricidin HBP abuse may be
associated with transient, undiagnosed
substance-induced psychosis (Dickerson et al.,
2008)
32Adolescent ADHD and SUDs
- Increasing concern regarding the likelihood of
developing a SUD among teenagers with ADHD - ADHD alone and in combination with co-occurring
psychopathology may be a risk factor for the
development of SUDs in adulthood. - Pharmacotherapeutic treatment of ADHD in children
reduces the risk for later cigarette smoking and
SUDs in adulthood (Wilens Fusillo, 2007) - However, one study reports diminished probability
of developing a SUD among teenagers with ADHD
when co-occurring Conduct Disorder is considered
(Elkins, 2007) - Stimulant diversion continues to be of concern,
particularly in older adolescents and young
adults
33COD Diagnosis in Adolescents
- Potential problems with the diagnostic process
increase almost exponentially when substance use
disorders and psychiatric disorders occur
together. (Schukit, 2006) - Perform comprehensive psych evaluation including
SUD screening - Obtain info from multiple sources
- Have a high index of suspicion for SUD
co-morbidity when patient not responding to tx
34COD Treatment Issues
- Individualize and integrate treatment for CODs
whenever possible - Consider developmental needs and stages
- Consider random drug testing
- Consider need for higher level of care
- Consult addiction medicine specialist if
necessary
35Treating COD within a family context
- Facilitating familial involvement is key
- parental collaboration
- family groups
- rapport building with family is important
- Parent education groups are effective
- orient parents to the treatment process
- educate parents about addiction
- encourage social support among parents and Al-Anon
(Bohs, 2007)
36Treating COD in an ethnically-diverse population
- Los Angeles is one of the most ethnically diverse
regions in the U.S. - Differences in cultural beliefs and attitudes may
significantly influence how psychiatric and
substance use disorders manifest. - Demonstrate an interest in understanding your
patients ethnic and cultural belief system - Achieving cultural competency is a life-long
endeavor
37Co-Occurring Disorders,Adolescent Substance
Abuse, and Psychiatric IllnessAssessment
Guidelines
- Eraka Bath, MDDirector, Child Forensic Services
Assistant Professor of Psychiatry - UCLA/NPI Division of Child and Adolescent
Psychiatry
38SUD EpidemiologyClinical Implications
- Assessment and diagnosis is critical
- SUD co-occurs frequently with most classes of the
major psychiatric disorders - Failure to diagnose means failure to treat and
confers greater morbidity from psychiatric
illness - Greater morbidity confers lifelong ramifications
on educational attainment, employment, service
utilization, teen parenting
39AssessmentGeneral Guidelines
- Assessing the stage of substance involvement
- More appropriate method for youth in terms of
development and use pattern - Adolescents tend to begin with experimentation
but use can be progressive - Using stage based assessment
- helps determine the severity of use
- assists in specific treatment planning with
regards to level of care,etc.
40AssessmentGeneral Guidelines
- All adolescents presenting with mental health
problems should be screened for substance abuse - Any change in behavior, mood, or cognitive
functioning may signal SUD is major or
contributing factor - Multiple Domains need to be assessed
- Think of the biopsychosocial framework as a
roadmap for assessment
41AssessmentGeneral Guidelines
- Severity of Use
- Consequences for the adolescent
- Patterns of Use
- Age of onset
- Amount
- Frequency
- Types of agents
- Negative Consequences
- How obtained
42AssessmentGeneral Guidelines
- Defining times
- Places of use
- Peer use
- Antecedents
- Consequences
- Failures to control use for each type
- Because teens may minimize and under-report use
collaterals from family, school, peers, legal
authorities and review of past treatment records
is essential
43Warning Signs
- Behavioral Changes
- Disinhibition
- Lethargy
- Hyperactivity
- Somnolence
- Hyper-vigilance
- Mood Changes
- Depression
- Euphoria
- Apathy
- Nervousness
- Lability
- Irritability
- Cognitive Changes
- Impaired Concentration
- Changes in Attention
- Perceptual Disturbance
- New onset problems in psychosocial and academic
functioning - Family Conflict
- School Failure
- Interpersonal Conflict
44American Academy of Child and Adolescent
Psychiatry (AACAP) 2005Practice Parameters
- Screening
- MH Assessment of children gt 9 yrs requires
screening questions about ETOH and other
substances MS - Asking about the quantity and frequency
- Presence of adverse consequences of use
- Adolescent's attitude toward use
45AACAP 2005 Practice Parameters
- Evaluation
- If screening raises concerns about substance use,
the clinician should conduct a more formal
evaluation MS - Toxicology should be a routine part of the formal
evaluation and ongoing assessment of substance
abuse both during and after treatment MS
AACAP Practice Parameters 2005
46AACAP 2005 Practice Parameters
- Co-morbidity
- Adolescents with SUD should receive thorough
evaluations for co-morbid psychiatric disorders
MS - Co-morbid Conditions should be appropriately
treated MS - Co-morbidity may affect an individuals ability to
effectively engage in treatment (Riggs and
Whitmore, 1999) - Co-morbidity (esp. depression) increases rate and
rapidity of relapse (Cornelius et al. 2003)
47SUD and Co-morbid Psychiatric d/o Implications
for Assessment
- Co-morbidity is the rule
- Presence of a psychiatric disorder should be a
red flag for triaging for SUD - More so with certain disorders, such as BPD, CD
- Presence of a SUD should prompt triage for mental
health issues
48SUD and Co-morbid Psychiatric d/o Implications
for Assessment
- Be prepared to allocate a significant amount of
time to interview to probe for substance use - Asking only one question is grossly insufficient
- Dont ignore level of functioning and functioning
should be explored in multiple domains across
multiple spheres
49Stages of UseSTAGE I
- Experimental or Social Stage
- Beginning stage of use
- Curiosity
- Following the crowd
- Thrill of doing something off limits
- Use helps gain acceptance of peers
- Increased use can lead to Stage II
Chatlos, 1996 MacDonald, 1984 Nowinski, 1990
Jaffe and Solhkhah, 2006
50Stages of UseSTAGE II
- Substance Misuse
- Actively seeking pleasurable experiences
- Often learns that misuse helps facilitate escape
- Use is primarily on the weekends
- Usually some deterioration of grades and problems
confirming with rules are noted - Increased use can led to Stage III
51Stages of UseSTAGE III
- Substance Abuse Disorder
- DSM-IV TR criteria for Substance Abuse met
- Harmful involvement and preoccupied with using
drugs/ETOH - Peer group is primarily a drug/ETOH abusing group
- Knows how to obtain and is increasingly involved
in activities related to obtaining and using - Significant impairment in school/home functioning
- Secretive, deceptive, dishonest
- Further involvement may lead to Stage IV
52Stages of UseSTAGE IV
- Substance of Chemical Dependence Disorder
- DSM-IV TR Substance Dependence criteria met
- Tolerance
- Withdrawal (rare in adolescent) may be met
- Attempts to control usage have been unsuccessful
- May also have sober periods but when using the
use rapidly goes out of control with negative
consequences
53Diagnostic Limitations ofDSM IV-TR
- Diagnostic criteria ignore reasons and
antecedents for drug use - Diagnostic criteria were developed for the adult
population - Validity in adolescents has not been demonstrated
- Diagnostic criteria are do not take in
consideration development
Kaczynski Martin, 1995 Martin, Kaczynski,
Maisto, Tarter, 1996 Winters et al., 1999
54Diagnostic Limitations ofDSM IV-TR
- Withdrawal and drug-related medical problems are
rare - One abuse symptom yields a diagnosis
- Abuse symptoms do not always precede dependence
- Many heavy and regular users report one of two
dependence but no abuse symptoms so end up not
being categorized by DSM - These diagnostic orphans still need intervention
Kaczynski Martin, 1995 Martin, Kaczynski,
Maisto, Tarter, 1996 Winters et al., 1999, 2001
55Standardized Assessment Instruments CRAFFT
- Have you ever ridden in a Car driven by someone
(including yourself) who was high or had been
using ETOH/Drugs - Do you ever use ETOH/Drugs to Relax, feel better
about yourself, or fit in - Do you ever use ETOH/Drugs while you are by
yourself or Alone - Do your ever Forget things you did when using
ETOH/Drugs - Do your Family or Friends ever tell you that you
should cut down? - Have you ever gotten into Trouble while using
ETOH/Drugs? - 2 or more yes answers suggest serious problems
and warrants more assessment
Knight et. al, 1999
56Heads First Structured Interview
- Home relationships, privacy, support
- Education expectations, achievements
- Abuse emotional, verbal sexual, physical
- Drugs Tobacco, ETOH, other
- Safety seatbelts, helmets
- Friends peer groups, peer pressure
- Image self-esteem, appearance, body image
- Recreation exercise, TV/video games, sports
- Sexuality sexual identity, activity
- Threats harm to self or others
Heyman et al., 1997
57Standardized Assessment Instruments
- Drug Use Screening Inventory (DUSI)
- This self-report instrument consists of 149
yes/no questions, identifies specific problem
areas in the 10 domains that further evaluations - Adolescent Diagnostic Interview (ADI)
- Structured interview to assess substance abuse,
school and interpersonal functioning and
psychosocial stresses
(CSAT 1999 Winters 2001)
58Standardized Assessment Instruments
- Personal Experience Screening Questionnaire
(PESQ) - Initial screening tool
- 38 Self report questions
- Measures severity and drug use history
- Includes a validity scale for lying
- Chemical Dependency Assessment Profile (CDAP)
- 235 item Self-report to assess drug involvement
59Standardized Assessment Instruments
- Problem Orientated Screening Instrument for
Teenagers (POSIT) - Self Report questionnaire consists of 139
true/false questions identifies problems in 10
domains - Free of Charge from NIDA
- Personal Experience Inventory (PEI)
- Self-Report questionnaire with 300 items
- Measures problem severity of substance use and
personal risk factors
60Standardized Assessment Instruments
- Teen-Addiction Severity Index (T-ASI)
- Semi-structured interview that rates severity in
seven domains - Intended for use in follow-up studies (Kaminer et
al. 1991) - Global Appraisal of Individual Needs (GAIN)
- Standardized Semi-structured interview
- Measures Patient characteristics
- Used for diagnosis and outcome monitoring
61Standardized Assessment Instruments
- Adolescent Drug Abuse Diagnosis (ADAD)
- Provides severity on rating multiple domains of
functioning - Comprehensive Addiction Severity Index for
Adolescents (CASI-A) - Interview to assess drug involvement and
psychosocial factors
62Standardized Assessment Instruments
- Adolescent Chemical Health Inventory (ACHI)
- Self-report to assess drug involvement and
psychosocial factors - Adolescent Drinking Index (ADI)
- 24 item that assesses drug involvement and
psychosocial factors
63Standardized Assessment Instruments
- Minnesota Multiphasic Personality Inventory-
Adolescent version (MMPI-A) - Stein et. al (2003) determined that the MMPI-A
may be very useful too in adolescent SUD research
as it can discern those who may fake good and
underreport their symptoms
64LADMH Tools to assist in the screening and
assessment process
- There are two DMH screening tools
- Parent/Caregiver Questionnaire (MH 552) given to
all parents and caregivers to complete. - The Child/adolescent Substance Use Self
Assessment (MH 554) self report by youth 11 and
above and by discretion of the therapist,
verbally administered to youth under 11 or to
those who cannot read. - THESE ASSESSMENT INSTRUMENTS ARE GIVEN AS PART
OF THE DMH INTAKE PROCESS
65Parent/Caregiver Questionnaire (MH 552)
- Screening for substance use risk factors
- Asks directly about substance use
- Given to all parents and caregivers to complete
66The Child/Adolescent Substance Use Self
Assessment (MH 554)
Any Yes answer will lead to the need for a
further assessment.
67Risk factors for development of SUD
- Genetic
- Presence of a substance abuse problem in on e or
both parents - Constitutional
- Psychiatric co-morbidity
- History of abuse
- History of attempted Suicide
- Socio-Cultural Family
- Parental experiences and positive attitudes
toward use - History of parental divorce or separation
- Low expectations for child
68Risk factors for development of SUD
- Socio-Cultural Peers
- Friends who use drugs
- Friends positive attitudes toward use
- Antisocial or delinquent behavior
- Socio-Cultural School
- School Failure or dropping out
- Socio-Cultural Community
- Positive attitudes toward drug use
- Economic and social deprivation
- Availability of drugs and ETOH (including
Cigarettes)
69Risk Factors and Prognosis
- Pre-treatment factors associated with poor
outcome - Nonwhite race
- Increased seriousness of substance use
- Lower educational status
- In-treatment factors
- Time in treatment
- Involvement of family use
- Use of Practical problem solving
- Provision of comprehensive services
70Risk Factors and Prognosis
- Post-treatment factors
- Thought to be the most important determinants of
outcome - Include association with non-using peers
- Involvement in leisure time, activities, work and
school
71Link Screening/Assessment Results to the
Appropriate Intervention
Low Risk
Moderate Risk
High Risk
Feedback, BI and Referral
Feedback and Information
Feedback and Brief Intervention (BI)
72Brief Intervention
- What are the ingredients of successful brief
interventions? - Include feedback of personal risk and advice to
change - Offer a menu of change options
- Place the responsibility to change on the patient
- Based on a Motivational Interviewing, or
counseling style, and typically incorporate the
Stages of Change Model
73Provide Feedback
- Use the screening/assessment forms to provide
patient feedback -
- Id like to share with you the results of the
questionnaire you just completed. Your answers to
these questions about alcohol and drug use
indicate that your risk of having problems
related to your use are low/moderate/high. - (Show the client their forms to demonstrate the
results)
74Offer Advice
- The best way to reduce your risk of alcohol
related harm is to cut back on your use, that is
reduce the behavior that is putting you at risk.
- Educate patient about sensible drinking limits
based on NIAAA recommendations - no more than 14 drinks/week for men (2/day)
- no more than 7 drinks/week for women and people
65 yrs (1/day)
Source McGree, 2005
75Elicit Patient Concern
- What are your thoughts about your screening
results, particularly the one for alcohol? - (Take note of patients change talk)
Source McGree, 2005
76Coax Patient to Weigh the Benefits and Costs of
At-Risk Use
- What are some of the good things about using for
you personally? - What are some of the not-so-good things?
- What are some of your concerns about these
not-so-good things?
Source McGree, 2005
77Helping People Change
- Helping people change involves
- increasing their awareness of their need to
change - helping them begin to move through the stages of
change - Start where the client is
- Positive approaches are more effective than
confrontation
78Mood and Anxiety Disorders in Adolescents
Co-Morbidity with Substance Use Disorders
- Robert Suddath, MD
- Assistant Clinical Professor at UCLA
- Division of Child and Adolescent Psychiatry
79Outline
- Co-morbidity
- Developmental Factors
- Epidemiology
- Mood Disorders
- Anxiety Disorders
- Diagnostic Considerations
- Treatment Considerations
80Case Study (Intro)
- 16 year old male discharged from inpatient
service 1 month ago where he was hospitalized due
to aggression and suicidal thoughts - Diagnosis was Bipolar Disorder
- Discharge Medications
- Lamotrigine 100 mg BID
- Risperidone 4 mg HS
- Aripiprazole 5 mg QAM
- Gabapentin 100 mg up to QID prn
81Case Study (drugs)
- First drink at age 12, has been drunk a few
times - Tried coke and snorted some Adderall
- Denies other drug use
82Case Study (parent report)
- Terrible mood swings, gets angry for no reason,
yells, threatens, breaks things - Stays up all night, wont wake up, is missing
school - Medicines are not working
- Reluctantly agreed to initiating medical
marijuana, in desperation, after patient begged
them saying it is the only thing that helps, they
have noticed no difference
83Case Study (parent report)
- Feels stressed a lot, about school
- Parents nag him all the time and make him feel
worse - Medications helped him to sleep at first but
dont work now - Only medical marijuana helps, can you tell my
parents to let me use it more?
84Case Study (questions)
- Is Bipolar Disorder the most likely diagnosis?
- Depression
- Anxiety
- Substance Abuse
- Is medical marijuana indicated for this patients
condition? - Should this patient get treatment for substance
abuse/dependence? - If so, what treatment?
85Case Study
- Answers at the end of presentation
86Co-morbidity
- Co-occurring disorders
- Co-morbid disorders
- Dual Diagnosis
87Co-morbidity
- Usually specifically to substance
abuse/dependence and another psychiatric illness - Sometimes co-morbid symptoms but not necessarily
co-morbid disorders that meet full DSM-IV
criteria - May be Axis I disorders or Axis II disorders
- For children and adolescents, personality
disorders are not typically diagnosed
88What Psychiatric disorders can be co-morbid with
substance use?
- Developmental /Learning Disorders
- Medical/Cognitive Disorders
- Psychotic Disorders
- Mood Disorders
- Anxiety Disorders
- Somatoform Disorders
- Eating Disorders
- Impulse Control Disorders
- Adjustment Disorders
89What Psychiatric disorders can be co-morbid with
substance use?
- Developmental /Learning Disorders
- Medical/Cognitive Disorders
- Psychotic Disorders
- Mood Disorders
- Anxiety Disorders
- Somatoform Disorders
- Eating Disorders
- Impulse Control Disorders
- Adjustment Disorders
90Mood Disorders
- Bipolar Disorder
- Major Depressive Disorder
91Anxiety Disorders
- Generalized Anxiety Disorder
- Panic Disorder
- Obsessive Compulsive Disorder
- Post Traumatic Stress Disorder
- Will be discussed at another presentation
- Somatization Disorder
- Eating Disorders
92Substance Use Disorders
- Abuse
- Dependence
- Alcohol
- Cannabis
- Cocaine
- Polysubstance
- Intoxication
- Withdrawal
- Seeking Behaviors
- Chronic Effects
93Developmental Factors
94Genetics
- Anxiety
- Mood
- Bipolar
- Depression
- Substance Use Disorders
- Alcohol
95Age of Onset
- Frequency increases with age?
- Environmental exposures/opportunity
- Similar to coronary artery disease
- or
- Prevalence is consistent across ages?
- Genetic disorders
- Similar to cystic fibrosis
- or
- Complex relationship between age/development and
substance abuse?
96Age of Onset Substance Use
- Very rare in pre-adolescents
- Greatest increase in rate is in adolescence
- Highest prevalence is in early adulthood
- For some populations, prevalence changes
significantly with external markers of
development - Beginning or ending college
- Prevalence may decrease slightly during adulthood
- Mortality plays a greater role with advancing age
97Age of Onset Depression
- Rate increases to approximately adult rate early
in adolescence - Depression is episodic
- A patient may be euthymic and then gets depressed
98Age of Onset Anxiety
- Symptoms tend to be chronic
- Specific types of anxiety may change with age
- Separation anxiety in children
- Social anxiety in adolescents
- Symptoms worsen significantly with stress but
persist even with limited stress
99Age of Onset Bipolar Disorder
- Controversial diagnosis in children
- Overlap with ADHD
- Rapid cycling
- Mixed states
- Average onset using adult/strict criteria is 18
years
100Age and Alcohol Use
- Increases adolescence to early adulthood then
falls off - Any other disorders follow this trend?
- Completed suicide
- Cause or effect or its just hard to be an
adolescent?
101DSM-IV Diagnostic Criteria for substance use
disorders and age
- The diagnostic criteria represent steps along a
developmental continuum - Patients who ultimately are diagnosed with
Substance Dependence - Initially met one criteria
- As the disorder progresses met additional
criteria. - Adolescents may be seen early in the development
of the disorder - May not meet the full diagnostic criteria.
102Sequence of Co-morbidity
- I started drinking because I was depressed
- Evidence of mental illness prior to substance
abuse - vs.
- Drinking makes me depressed
- No evidence of mental illness prior to substance
abuse - Temporal association of mental illness and
substance abuse does not demonstrate causality
103Epidemiology
- Depression is the most common major Axis I
disorder in adolescents - Anxiety disorders (grouped) are the next most
common major Axis I disorders in adolescent
104Co-morbidity Genetic
- Anxiety
- Mood
- Substance Use Disorders
105Co-morbidity Epidemiologic
- Anxiety
- Mood
- Substance Use Disorders
106Co-morbidity Predictive
- Heavy alcohol use in college
- Will persist into adulthood in 20 or more
individuals - Who are these individuals who exhibit persistent
heavy drinking? - Hostility
- Anxiety symptoms
- Depressive symptoms
107Co-morbidity Predictive
- 20-80 of Adolescents with substance use
disorders had a psychiatric disorder prior to
developing a substance use disorder - What disorders most commonly preceded the
development of a substance use disorder in
adolescents? - Depression
- Anxiety
108Diagnostic Overlap
- Symptoms of depression / anxiety are similar to
symptoms of substance use/intoxication
109Anxiety and Stimulant Use/ Intoxication
- Clinical dosing
- Mild increase in anxiety
- Recreational dosing
- Picking, nail biting, hair pulling
- Tics (motor and vocal)
- Restlessness, agitation
- Tachycardia
- High dose
- Paranoia
- hallucinosis
110Mood Disorders and Mood Altering Drugs
111Depression and Alcohol
- Chronic use may mimic depression or cause
depression
112Alcohol and Depression
- Significantly increased risk of suicide when
intoxicated
113Mood Disorders and Cannabis
- Cannabis use is associated with significantly
increased risk of bipolar disorder in adulthood - Cannabis use is associated with modestly
increased risk of depression in adulthood - No predictive relationship with anxiety disorders
114Substance UseInteraction with mood/anxiety
- Trigger symptoms or relapse
- Worsen symptoms
- Change the clinical course
- Interfere with treatment
115Treatment Approaches
- If
- Depression was caused by substance use
- or
- Recovery from depression will be impeded by
substance use - Then
- Treatment must begin with treatment of substance
use disorder?
116Treatment Approaches
- If
- Depression led to substance abuse
- or
- Relapses from substance abuse will be caused by
depression - Then
- Treatment must begin with treatment of depression?
117Treatment ApproachesPrevious 2 sides are WRONG
- For the purposes of treatment, it does not matter
which disorder came first - Trying to identify the primary disorder may
simply allow some providers to shift the
treatment burden to other providers - The most effective treatment is to treat both
disorders simultaneously and aggressively
118TreatmentInternalizing vs. externalizing
- A little good news for the anxious/depressed
adolescent substance abusers - Internalizing disorders have been associated with
an increase compliance with treatment - Patients may be miserable and thus more motivated
to participate in treatment
119Parents
- When adolescents are involved, clinicians have to
work not only with their patient but with the
parents - Parents
- Consent to medical treatment
- Have the right to make decisions regarding most
confidential medical information (privilege) - Exceptions in CA to parent privilege for specific
(limited) substance use treatment situations
120Parents as historians
- May be totally unaware of their childs substance
abuse - May believe that their childs symptoms are only
due to substance abuse - Do not want to accept the possibility of another
psychiatric illness - May be able to provide symptoms that the
adolescent would deny - Money/objects missing from home (child may be
using to fund drug use)
121Adolescents and trust
- Drug testing
- May require MD orders to obtain laboratory
quality results
122Drug testing advantages
- Objective information about drug use
- Allows adolescent to demonstrate that they can be
trusted - May allow adolescents an excuse to just say no
and save face - my parents make me pee in a cup every weekend,
if they catch me using I am grounded for life
123Drug testing disadvantages
- Tests are flawed, not always accurate
- Only a subset of drugs are screened for
- Alcohol is not routinely tested for
- Detection windows
- Stimulants only detectable for most recent day
- Positive marijuana screens may not reflect recent
use - Trying to get adolescents to comply may cause
family conflict
124Case Study (follow-up)
- 16 year old Bipolar male discharged from
inpatient service 1 month ago where he was
hospitalized due to aggression and suicidal
thoughts, treated with multiple meds - Admits to some use of alcohol, cocaine and
stimulants - Using Medical Marijuana
125Case Study (diagnosis)
- Major Depressive Disorder with a prominent
irritable mood is the most common cause of
symptoms reported - Anxiety with rigid/inflexible thought and angry
behavior is next most likely cause - Co-morbid substance abuse would generally
exacerbate the symptoms - Bipolar disorder is possible
126Case Study (treatment)
- Identify diagnosis
- Family history
- Consider drug testing
- If co-morbid substance use and depression or
anxiety disorder is identified - Combination treatment
- Treat depression with medication and therapy
- Treat substance use disorder with appropriate
therapies / support
127Case Study (medical marijuana)
- Medical marijuana indicated for improving
appetite and reducing nausea - Chemotherapy
- Combination anti-viral therapy
- No indication for psychiatric illness
- Most adolescents would not want to take a
medication that made them hungry and helped gain
or maintain weight - Side effects
- Cognitive impairment memory
128Questions
129Psychosis and Addiction
130Disclosures
131Overview
- Psychosis, psychotic disorders
- Substances
- Developmental
132Psychosis
- Soul diseased/abnormal
- Ernst von Feuchtersleben 1845
- Neurosis
- Mind vs Nervous System
- Bleuler, Kraepelin
- Dementia praecox vs manic-depression
133Primary Psychosis
- Psychotic features
- Morbidity
- Syntonic
134DSM-IV-TR
- Nine individual diagnoses
- Schizophrenia, Schizoaffective, Schizophreniform
disorders - positive and negative symptoms
- Brief psychotic d/o
- Delusional d/o, Shared psychotic d/o (folie a
deux) - Substance-induced Psychosis, Psychosis due to a
general medical condition - Psychosis NOS
APA 2000
135Psychotic Disorders
- Schizo-spectrum
- Delusions
- Mood with features
- Organic
- Dissociation vs Trauma
136Schizotypy
- Dimensions
- Aberrant perceptions/beliefs
- Introversion/Anhedonia
- Conceptual disorganization
Allardyce et al., 2007
137Adolescence
- Development
- Research limitations
- Progression vs symptoms
138Differential
- Age of onset
- WHO World Mental Health Surveys
- Nonaffective psychoses late teens early 20s
- 1/2 of lifetime mental disorders start by
mid-teens, 3/4 by mid-20s - Less severe in childhood, followed by more severe
Kessler et al. 2007
139Logistic Repression Results for Variables
Distinguishing Primary Psychotic Disorder from
Substance-Induced Psychosis
Caton, C. L. M. et al. Arch Gen Psychiatry
200562137-145.
140Substance-Induced Psychosis
- Vs primary psychosis
- 400 ER referrals, dx
- Parental substance
- Psych sxs
- Dependence
- Visual hallucinations
Caton et al. 2005
141Substance-Induced Psychosis, DSM criteria
- Prominent hallucinations or delusions
- Exclude if insight sxs are substance-induced
- Develop within month of intox or withdrawal OR
SUD - or From medication use
- Not better accounted for my primary PD
- Symptoms precede
- Symptoms persist greater than 1 month after
withdrawal/intoxication GREATER THAN 6 MONTHS - Substantially in excess of what could be expected
- Not in delirium
Mathias et al. 2008
142Schizophrenia Co-morbid Drugs of Abuse
- Nicotine (58-90)
- Alcohol (25-45)
- Marijuana (31)
- Cocaine (15-50)
- Opiates (minimal)
- Hallucinogens (minimal)
Buckley 2006, Gregg et al. 2007
143Schizophrenia co-morbidity
- 62 First episode psychosis
- 69 lifetime axis 1
- 47 concurrently w episode
Bendall et al. 2008
144Indicators of a Severe Psychotic Disorder
- First episode schizophrenia
- 37 SUD lifetime
- 28 Cannabis, 21 Alcohol
- DD male, earlier onset, more severe, poorer
response - First episode psychotic mania
- 32 SUD, 20 alcohol
Green et al. 2004, Strakowski et al. 2006
145Reasons for use
- 5 Main self-report categories ()
- Intoxication (35-95)
- Social (8-81)
- Dysphoria (2-86)
- Relieve psychosis (0-42)
- Med side effects (0-48)
Gregg et al. 2007
146Neurochemistry
- Dopamine
- Reward pathway
- Antipsychotics
- NMDA/GABA
- Antagonists (LSD) also produce hallucinations
147Tobacco
- US Schizophrenia 70, controls 30
- 1st deg relatives, schizotypy related to smoking
- Causes psychosis?
Buckley 2006, Esterberg et al., 2007
148Nicotine
- Nicotine receptor associated with schizophrenia
- Partial agonist improved neurocognition
- Self-medication hypothesis
Olincy et al. 2006, Green 2007
149Cigarettes
- 173 pts, 100 controls Spain
- Why do you smoke?
- cheerfulness
- agility
- concentration
- calmness
Gurpegui et al. 2007
150Nicotine treatment
- NRT
- Bupropion
- Dopamine transporter, plus serotonin
- Varenicline
- Partial nicotinic agonist
- Suicidal ideation
151Alcohol
- Chronic use
- Alcohol withdrawal
- Delirium Tremens
- Alcohol hallucinosis
- Korsakoffs psychosis
- Hepatic encephalopathy
152Alcohol
- Co-morbidity in adult schizophrenia more severe
- 72 HS seniors 07
- 55 Drunk
- Intervention?
- Secondary psychosis unlikely in kids
Monitoring the Future
153Alcohol treatment
- Naltrexone
- oral vs depot
- Disulfiram
- Acamprosate
- Topiramate
- Baclofen
- Gabapentin
Johnson 2008
154Alcohol treatment research findings
- Co-occurring
- Disulfiram ? incr psychosis
- Naltrexone helped w schizophrenia/alcohol
- Acamprosate, topiramate no trials
- Desipramine mild decrease in cocaine use
Green 2006
155Marijuana
- Schizophrenia link?
- Contested
- COMT
- 91 birth cohort age 3, NZ
- 21 and 26 y, cannabis
- 803 at 26 y, schizophreniform
Caspi et al. 2005
156Caspi et al. 2005
157Marijuana treatment
- All small trials
- Psychosocial gt
- Bupropion, divalproate, nefazodone do not appear
effective - Naltrexone increased positive subjective effects
- Oral THC mild withdrawal improvement
Nordstrom and Levin 2007
158Opioid
- Withdrawal-induced psychosis
- Case reports
- Dextromethorphan
- 10 HS seniors Vicodin use preceding year
Monitoring the Future 2007
159Stimulants
- Induce psychosis
- Auditory hallucinations, paranoia
- Cleared with abstinence
160Cocaine
- ADHD linked with cocaine psychosis
- 243 interviews
- Dx increased sxs
Tang et al. 2007
161Methamphetamine
- Neurotoxic
- Long-lasting vulnerability
- MA induces delusions, IOR, AH
- May alleviate negative symptoms
Baicy and London, 2007
162Methamphetamine, continued
- ISAP study MTP
- 526 adults, multi-site
- Interview, treatment, interview, 3 year f/u,
interview - 13 met criteria 3y f/u for psychosis
- 2x hospitalized
Glasner-Edwards et al. 2008
163Hallucinogens
- LSD, PCP, ketamine
- NMDA antagonists
- Delusions, hallucinations, thought disorder
- Negative symptoms
- MDMA
- Rare case reports
Sessa and Nutt, 2007
164Inhalants
- Multiple case-reports irreversible
schizophrenia-like state
165Pharmacology
- Antipsychotics
- Typicals of limited use
- Atypicals better
- Evidence clozapine gt olanzapine gt quetiapine gt
aripiprazole
Green 2006
166Delay and Addiction
- Autism
- Decreased smoking
- Naltrexone may decrease SIB
Bejerot and Nylander 2003, Elchaar et al. 2006
167Intellectual Disabilities
- Lower SUD when compared to general and psych
populations - Adolescents
- Smoking is higher
- But less than staff
- Less alcohol, later start
Taggart et al. 2006
168Intellectual Disabilities Adults
- Surveys
- vs Non-disabled later start, lower use, fewer
problems - vs Non-using more problems
- Only 1 study looked at targeted treatment
McGillicuddy 2006