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Co-Occurring Substance Use and Psychiatric Disorders in Children and Adolescents


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Title: Co-Occurring Substance Use and Psychiatric Disorders in Children and Adolescents

Co-Occurring Substance Use and Psychiatric
Disorders in Children and Adolescents
An 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

  • 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

Mental 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.

COD 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)

Adolescent 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
  • 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

Drug abuse Trends continued
Why do adolescents use drugs?
  • Gain social acceptance
  • Elevate mood
  • Alleviate anxiety
  • Improve self-esteem
  • Manage weight (stimulants)
  • Aphrodisiac effects
  • Analgesic effects (opioids)

Substance 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

Substance Dependence DSM-IV
  • Maladaptive pattern of use causing impairment or
  • 3 or more of following within 12-month period
  • Tolerance
  • Withdrawal
  • Use in larger amounts over longer period than
  • 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

Risk Factors for SUD
  • Genetic (family hx SUD)
  • Social
  • Family (attitudes, experiences, divorce)
  • Parental (disciplinary skills, guidance, and
  • 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)
Adolescents 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
  • Have high co-morbidity with psychiatric conditions

Early 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)

(No Transcript)
Alcohol 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
  • 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)

Marijuana 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
  • 60 of youth who use drugs use only MJ
  • 2/3 new MJ users per year are between ages 12 and
  • Cannabis dependence associated with mood and
    anxiety disorders (Dorard et al., 2008)

(NHSDA, 2000 MTF, 2001 and 2007)
Stimulant Use and Youth
  • Methamphetamine more potent than amphetamine or
  • Medical consequences include tachycardia,
    elevated blood pressure, hyperthermia,
    arrhythmias, acute myocardial infarction, stroke,
    infectious disease risk
  • Psychiatric consequences include confusion,
    anxiety, depression, psychosis (paranoia,

(NIDA Research Report Series, 2004 and 2006)
Inhalant Use and Youth
  • Inhalants (including volatile solvents, aerosols
    and gases) are among first drugs tried by
  • About 3.0 of U.S. children have tried inhalants
    by 4th grade
  • Prevalence of abuse peaks between 7th and 9th
  • 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
Prescription 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
Club Drugs and Hallucinogens
  • LSD
  • Altered sensory perception, mood swings,
    hallucinations, delusions, flashbacks
  • Ecstasy (MDMA)
  • Stimulant and hallucinogenic effects
    restlessness, insomnia, altered sensory
  • Medical risks tachycardia, hyperthermia,
    hyponatremia, and seizure
  • May cause neurotoxicity
  • Ketamine and PCP
  • Dissociative anesthetics

NIDA Research Report Series, 2001 and 2005
Dextromethorphan (Coricidin HBP) Use and Youth
  • Cough medicine abuse among adolescents has been
  • 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)

Epidemiology 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)

Psychiatric/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)

Co-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
Age of First Use of Primary Substance Younger
than 12 for Admissions Aged 13-17, by Psychiatric
Diagnosis Status 2003
(SAMHSA, 2003)
Primary Source of Referral of Adolescent
Admissions, by Psychiatric Diagnosis Status 2003
(SAMHSA, 2003)
Race/Ethnicity of Adolescent Admissions, by
Psychiatric Diagnosis Status 2003
(SAMHSA, 2003)
Completion 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)
Mood 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)

Adolescent 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)
Adolescent 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.,
  • Dextromethorphan/Coricidin HBP abuse may be
    associated with transient, undiagnosed
    substance-induced psychosis (Dickerson et al.,

Adolescent 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

COD 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

COD 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

Treating 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)
Treating 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

Co-Occurring Disorders, Adolescent Substance
Abuse, and Psychiatric Illness Assessment
  • Eraka Bath, MD Director, Child Forensic Services
    Assistant Professor of Psychiatry
  • UCLA/NPI Division of Child and Adolescent

SUD Epidemiology Clinical 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
  • Greater morbidity confers lifelong ramifications
    on educational attainment, employment, service
    utilization, teen parenting

Assessment General 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.

Assessment General 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

Assessment General Guidelines
  • Severity of Use
  • Consequences for the adolescent
  • Patterns of Use
  • Age of onset
  • Amount
  • Frequency
  • Types of agents
  • Negative Consequences
  • How obtained

Assessment General 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

Warning 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
  • Family Conflict
  • School Failure
  • Interpersonal Conflict

American Academy of Child and Adolescent
Psychiatry (AACAP) 2005 Practice 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

AACAP 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
AACAP 2005 Practice Parameters
  • Co-morbidity
  • Adolescents with SUD should receive thorough
    evaluations for co-morbid psychiatric disorders
  • 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)

SUD 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

SUD 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

Stages of Use STAGE 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
Stages of Use STAGE 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

Stages of Use STAGE III
  • Substance Abuse Disorder
  • DSM-IV TR criteria for Substance Abuse met
  • Harmful involvement and preoccupied with using
  • 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

Stages of Use STAGE 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

Diagnostic Limitations of DSM IV-TR
  • Diagnostic criteria ignore reasons and
    antecedents for drug use
  • Diagnostic criteria were developed for the adult
  • 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
Diagnostic Limitations of DSM IV-TR
  • Withdrawal and drug-related medical problems are
  • 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
Standardized 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
  • Do your Family or Friends ever tell you that you
    should cut down?
  • Have you ever gotten into Trouble while using
  • 2 or more yes answers suggest serious problems
    and warrants more assessment

Knight et. al, 1999
Heads 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
Standardized 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)
Standardized Assessment Instruments
  • Personal Experience Screening Questionnaire
  • 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

Standardized Assessment Instruments
  • Problem Orientated Screening Instrument for
    Teenagers (POSIT)
  • Self Report questionnaire consists of 139
    true/false questions identifies problems in 10
  • 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

Standardized 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

Standardized Assessment Instruments
  • Adolescent Drug Abuse Diagnosis (ADAD)
  • Provides severity on rating multiple domains of
  • Comprehensive Addiction Severity Index for
    Adolescents (CASI-A)
  • Interview to assess drug involvement and
    psychosocial factors

Standardized 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

Standardized 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

LADMH 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.

Parent/Caregiver Questionnaire (MH 552)
  • Screening for substance use risk factors
  • Asks directly about substance use
  • Given to all parents and caregivers to complete

The Child/Adolescent Substance Use Self
Assessment (MH 554)
Any Yes answer will lead to the need for a
further assessment.
Risk 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

Risk 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

Risk Factors and Prognosis
  • Pre-treatment factors associated with poor
  • 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

Risk Factors and Prognosis
  • Post-treatment factors
  • Thought to be the most important determinants of
  • Include association with non-using peers
  • Involvement in leisure time, activities, work and

Link 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)
Brief Intervention
  • What are the ingredients of successful brief
  • Include feedback of personal risk and advice to
  • 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

Provide 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

Offer 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
Elicit Patient Concern
  • What are your thoughts about your screening
    results, particularly the one for alcohol?
  • (Take note of patients change talk)

Source McGree, 2005
Coax 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
Helping People Change
  • Helping people change involves
  • increasing their awareness of their need to
  • helping them begin to move through the stages of
  • Start where the client is
  • Positive approaches are more effective than

Mood 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

  • Co-morbidity
  • Developmental Factors
  • Epidemiology
  • Mood Disorders
  • Anxiety Disorders
  • Diagnostic Considerations
  • Treatment Considerations

Case 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

Case Study (drugs)
  • First drink at age 12, has been drunk a few
  • Tried coke and snorted some Adderall
  • Denies other drug use

Case Study (parent report)
  • Terrible mood swings, gets angry for no reason,
    yells, threatens, breaks things
  • Stays up all night, wont wake up, is missing
  • 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

Case Study (parent report)
  • Feels stressed a lot, about school
  • Parents nag him all the time and make him feel
  • 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?

Case Study (questions)
  • Is Bipolar Disorder the most likely diagnosis?
  • Depression
  • Anxiety
  • Substance Abuse
  • Is medical marijuana indicated for this patients
  • Should this patient get treatment for substance
  • If so, what treatment?

Case Study
  • Answers at the end of presentation

  • Co-occurring disorders
  • Co-morbid disorders
  • Dual Diagnosis

  • 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
  • May be Axis I disorders or Axis II disorders
  • For children and adolescents, personality
    disorders are not typically diagnosed

What 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

What 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

Mood Disorders
  • Bipolar Disorder
  • Major Depressive Disorder

Anxiety Disorders
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Obsessive Compulsive Disorder
  • Post Traumatic Stress Disorder
  • Will be discussed at another presentation
  • Somatization Disorder
  • Eating Disorders

Substance Use Disorders
  • Abuse
  • Dependence
  • Alcohol
  • Cannabis
  • Cocaine
  • Polysubstance
  • Intoxication
  • Withdrawal
  • Seeking Behaviors
  • Chronic Effects

Developmental Factors
  • Anxiety
  • Mood
  • Bipolar
  • Depression
  • Substance Use Disorders
  • Alcohol

Age 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?

Age 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
  • Beginning or ending college
  • Prevalence may decrease slightly during adulthood
  • Mortality plays a greater role with advancing age

Age of Onset Depression
  • Rate increases to approximately adult rate early
    in adolescence
  • Depression is episodic
  • A patient may be euthymic and then gets depressed

Age 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

Age of Onset Bipolar Disorder
  • Controversial diagnosis in children
  • Overlap with ADHD
  • Rapid cycling
  • Mixed states
  • Average onset using adult/strict criteria is 18

Age 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

DSM-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
  • Adolescents may be seen early in the development
    of the disorder
  • May not meet the full diagnostic criteria.

Sequence of Co-morbidity
  • I started drinking because I was depressed
  • Evidence of mental illness prior to substance
  • vs.
  • Drinking makes me depressed
  • No evidence of mental illness prior to substance
  • Temporal association of mental illness and
    substance abuse does not demonstrate causality

  • 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

Co-morbidity Genetic
  • Anxiety
  • Mood
  • Substance Use Disorders

Co-morbidity Epidemiologic
  • Anxiety
  • Mood
  • Substance Use Disorders

Co-morbidity Predictive
  • Heavy alcohol use in college
  • Will persist into adulthood in 20 or more
  • Who are these individuals who exhibit persistent
    heavy drinking?
  • Hostility
  • Anxiety symptoms
  • Depressive symptoms

Co-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
  • Depression
  • Anxiety

Diagnostic Overlap
  • Symptoms of depression / anxiety are similar to
    symptoms of substance use/intoxication

Anxiety 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

Mood Disorders and Mood Altering Drugs
Depression and Alcohol
  • Chronic use may mimic depression or cause

Alcohol and Depression
  • Significantly increased risk of suicide when

Mood 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

Substance Use Interaction with mood/anxiety
  • Trigger symptoms or relapse
  • Worsen symptoms
  • Change the clinical course
  • Interfere with treatment

Treatment 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?

Treatment Approaches
  • If
  • Depression led to substance abuse
  • or
  • Relapses from substance abuse will be caused by
  • Then
  • Treatment must begin with treatment of depression?

Treatment Approaches Previous 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

Treatment Internalizing 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

  • When adolescents are involved, clinicians have to
    work not only with their patient but with the
  • 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

Parents as historians
  • May be totally unaware of their childs substance
  • 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)

Adolescents and trust
  • Drug testing
  • May require MD orders to obtain laboratory
    quality results

Drug testing advantages
  • Objective information about drug use
  • Allows adolescent to demonstrate that they can be
  • 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

Drug 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
  • Trying to get adolescents to comply may cause
    family conflict

Case 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
  • Using Medical Marijuana

Case 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

Case 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

Case 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

Psychosis and Addiction
  • Andrew Lee, MD
  • UCLA

  • No competing interests

  • Psychosis, psychotic disorders
  • Substances
  • Developmental

  • Soul diseased/abnormal
  • Ernst von Feuchtersleben 1845
  • Neurosis
  • Mind vs Nervous System
  • Bleuler, Kraepelin
  • Dementia praecox vs manic-depression

Primary Psychosis
  • Psychotic features
  • Morbidity
  • Syntonic

  • Nine individual diagnoses
  • Schizophrenia, Schizoaffective, Schizophreniform
  • positive and negative symptoms
  • Brief psychotic d/o
  • Delusional d/o, Shared psychotic d/o (folie a
  • Substance-induced Psychosis, Psychosis due to a
    general medical condition
  • Psychosis NOS

APA 2000
Psychotic Disorders
  • Schizo-spectrum
  • Delusions
  • Mood with features
  • Organic
  • Dissociation vs Trauma

  • Dimensions
  • Aberrant perceptions/beliefs
  • Introversion/Anhedonia
  • Conceptual disorganization

Allardyce et al., 2007
  • Development
  • Research limitations
  • Progression vs symptoms

  • 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
Logistic Repression Results for Variables
Distinguishing Primary Psychotic Disorder from
Substance-Induced Psychosis
Caton, C. L. M. et al. Arch Gen Psychiatry
Substance-Induced Psychosis
  • Vs primary psychosis
  • 400 ER referrals, dx
  • Parental substance
  • Psych sxs
  • Dependence
  • Visual hallucinations

Caton et al. 2005
Substance-Induced Psychosis, DSM criteria
  • Prominent hallucinations or delusions
  • Exclude if insight sxs are substance-induced
  • Develop within month of intox or withdrawal OR
  • 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
Schizophrenia 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
Schizophrenia co-morbidity
  • 62 First episode psychosis
  • 69 lifetime axis 1
  • 47 concurrently w episode

Bendall et al. 2008
Indicators of a Severe Psychotic Disorder
  • First episode schizophrenia
  • 37 SUD lifetime
  • 28 Cannabis, 21 Alcohol
  • DD male, earlier onset, more severe, poorer
  • First episode psychotic mania
  • 32 SUD, 20 alcohol

Green et al. 2004, Strakowski et al. 2006
Reasons 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
  • Dopamine
  • Reward pathway
  • Antipsychotics
  • Antagonists (LSD) also produce hallucinations

  • US Schizophrenia 70, controls 30
  • 1st deg relatives, schizotypy related to smoking
  • Causes psychosis?

Buckley 2006, Esterberg et al., 2007
  • Nicotine receptor associated with schizophrenia
  • Partial agonist improved neurocognition
  • Self-medication hypothesis

Olincy et al. 2006, Green 2007
  • 173 pts, 100 controls Spain
  • Why do you smoke?
  • cheerfulness
  • agility
  • concentration
  • calmness

Gurpegui et al. 2007
Nicotine treatment
  • NRT
  • Bupropion
  • Dopamine transporter, plus serotonin
  • Varenicline
  • Partial nicotinic agonist
  • Suicidal ideation

  • Chronic use
  • Alcohol withdrawal
  • Delirium Tremens
  • Alcohol hallucinosis
  • Korsakoffs psychosis
  • Hepatic encephalopathy

  • Co-morbidity in adult schizophrenia more severe
  • 72 HS seniors 07
  • 55 Drunk
  • Intervention?
  • Secondary psychosis unlikely in kids

Monitoring the Future
Alcohol treatment
  • Naltrexone
  • oral vs depot
  • Disulfiram
  • Acamprosate
  • Topiramate
  • Baclofen
  • Gabapentin

Johnson 2008
Alcohol 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
  • Schizophrenia link?
  • Contested
  • COMT
  • 91 birth cohort age 3, NZ
  • 21 and 26 y, cannabis
  • 803 at 26 y, schizophreniform

Caspi et al. 2005
Caspi et al. 2005
Marijuana treatment
  • All small trials
  • Psychosocial gt
  • Bupropion, divalproate, nefazodone do not appear
  • Naltrexone increased positive subjective effects
  • Oral THC mild withdrawal improvement

Nordstrom and Levin 2007
  • Withdrawal-induced psychosis
  • Case reports
  • Dextromethorphan
  • 10 HS seniors Vicodin use preceding year

Monitoring the Future 2007
  • Induce psychosis
  • Auditory hallucinations, paranoia
  • Cleared with abstinence

  • ADHD linked with cocaine psychosis
  • 243 interviews
  • Dx increased sxs

Tang et al. 2007
  • Neurotoxic
  • Long-lasting vulnerability
  • MA induces delusions, IOR, AH
  • May alleviate negative symptoms

Baicy and London, 2007
Methamphetamine, continued
  • ISAP study MTP
  • 526 adults, multi-site
  • Interview, treatment, interview, 3 year f/u,
  • 13 met criteria 3y f/u for psychosis
  • 2x hospitalized

Glasner-Edwards et al. 2008
  • LSD, PCP, ketamine
  • NMDA antagonists
  • Delusions, hallucinations, thought disorder
  • Negative symptoms
  • MDMA
  • Rare case reports

Sessa and Nutt, 2007
  • Multiple case-reports irreversible
    schizophrenia-like state

  • Antipsychotics
  • Typicals of limited use
  • Atypicals better
  • Evidence clozapine gt olanzapine gt quetiapine gt

Green 2006
Delay and Addiction
  • Autism
  • Decreased smoking
  • Naltrexone may decrease SIB

Bejerot and Nylander 2003, Elchaar et al. 2006
Intellectual Disabilities
  • Lower SUD when compared to general and psych
  • Adolescents
  • Smoking is higher
  • But less than staff
  • Less alcohol, later start

Taggart et al. 2006
Intellectual Disabilities Adults
  • Surveys
  • vs Non-disabled later start, lower use, fewer
  • vs Non-using more problems
  • Only 1 study looked at targeted treatment

McGillicuddy 2006