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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 1990’s, recognition of COD in psychiatric
practice has been steadily increasing
• The President’s New Freedom Commission Goals
and Recommendations (2004) include: “Screen for
co-occurring mental and substance use disorders
and link with integrated treatment strategies.”
• SAMHSA’s 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
• Increase in ecstasy (MDMA) use
Drug abuse Trends – continued
Why do adolescents use
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:
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
– Use despite physical or psychological problem
Risk 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)
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
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)
- previous history
- expectation
- learning
- social interactions
- stress
- conditioned stimuli
- genetics
- circadian rhythms
- disease states
- gender
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 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)
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 10thgraders, and 14% among 12th-graders. 10% pastyear 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)
Stimulant 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,
(NIDA Research Report Series, 2004 and 2006)
Inhalant 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
• 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
NIDA Research Report Series, 2005
Prescription Drug Abuse and
• 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)
Club Drugs and Hallucinogens
– 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
Dextromethorphan (Coricidin
HBP®) Use and Youth
• Cough medicine abuse among adolescents has
been increasing
• Coricidin HBP® Cough and Cold is an over-thecounter 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 comorbid 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, cooccurrence of SUD with mental health disorders was highest
among those aged 15–24 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
SUD (%) No SUD
95% CI
Any Anxiety D/O
Any Mood D/O
Any Disruptive
Kandel, DB et al., 1999
Age of First Use of Primary Substance Younger than 12 for
Admissions Aged 13-17, by Psychiatric Diagnosis Status:
(SAMHSA, 2003)
Primary Source of Referral of Adolescent
Admissions, by Psychiatric Diagnosis Status:
(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 CoOccurring Disorders
Adolescents without
Co-Occurring Disorders
(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 1.8013.81). (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
– 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.,
• Recent emphasis on the possible links between
cannabis and psychosis (Arseneault et al., 2004; Fergusson et al.,
• 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 substanceinduced psychosis (Dickerson et al., 2008)
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 cooccurring Conduct Disorder is considered (Elkins, 2007)
• Stimulant diversion continues to be of concern, particularly
in older adolescents and young adults
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 comorbidity 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
• 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 AlAnon
(Bohs, 2007)
Treating COD in an ethnicallydiverse 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 patient’s ethnic and cultural belief
• Achieving cultural competency is a life-long
Co-Occurring Disorders,
Adolescent Substance Abuse,
and Psychiatric Illness
Assessment Guidelines
Eraka Bath, MD
Director, Child Forensic Services Assistant Professor of Psychiatry
UCLA/NPI Division of Child and Adolescent Psychiatry
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 illness
• Greater morbidity confers lifelong
ramifications on educational attainment,
employment, service utilization, teen
General Guidelines
• Assessing the stage of substance
• 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.
General Guidelines
• All adolescents presenting with mental health
problems should be screened for substance
• 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
General Guidelines
Severity of Use
Consequences for the adolescent
Patterns of Use
Age of onset
Types of agents
Negative Consequences
How obtained
General Guidelines
Defining times
Places of use
Peer use
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
Warning Signs
• Behavioral Changes
• Mood Changes
• Cognitive Changes
– Impaired Concentration
– Changes in Attention
– Perceptual Disturbance
• New onset problems
in psychosocial and
academic functioning
– Family Conflict
– School Failure
– Interpersonal Conflict
American Academy of Child and Adolescent
Psychiatry (AACAP) 2005
Practice Parameters
• Screening
– MH Assessment of children > 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
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,
• 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
• Asking only one question is grossly
• Don’t ignore level of functioning and
functioning should be explored in multiple
domains across multiple spheres
Stages of Use
• 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
• 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
• 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
Substance of Chemical Dependence Disorder
DSM-IV TR Substance Dependence criteria met
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
• Diagnostic criteria ignore reasons and
antecedents for drug use
• Diagnostic criteria were developed for the
adult population
• Validity in adolescents has not been
• Diagnostic criteria are do not take in
consideration development
Kaczynski & Martin, 1995; Martin, Kaczynski, Maisto, & Tarter, 1996;
Winters et al., 1999
Diagnostic Limitations of
• Withdrawal and drug-related medical problems are
• One abuse symptom yields a diagnosis
• Abuse symptoms do not always precede
• 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
• Do your ever Forget things you did when using ETOH/Drugs
• Do your Family or Friends ever tell you that you should cut
• 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
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
• 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
• 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
– 235 item Self-report to assess drug involvement
Standardized Assessment
• 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
• 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
• 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
• Adolescent Chemical Health Inventory
– Self-report to assess drug involvement and
psychosocial factors
• Adolescent Drinking Index (ADI)
– 24 item that assesses drug involvement and
psychosocial factors
Standardized Assessment
• Minnesota Multiphasic Personality InventoryAdolescent 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
Parent/Caregiver Questionnaire (MH 552)
• Screening for substance use risk factors
• Asks directly about substance use
• Given to all parents and caregivers to
The Child/Adolescent Substance
Use Self Assessment (MH 554)
Any ‘Yes’
answer will
lead to the
need for a
Risk factors for development of SUD
• Genetic
– Presence of a substance abuse problem in on e or both
• 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 Cigarettes)
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 outcome
– 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
Intervention (BI)
BI and
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
– 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
“I’d 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
(Show the client their forms to demonstrate the results)
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
• 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
(Take note of patient’s “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
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
Developmental Factors
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
• 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, won’t 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 worse
• Medications helped him to sleep at first but
don’t 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
patient’s condition?
• Should this patient get treatment for
substance abuse/dependence?
– 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
• 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
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
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
• Prevalence is consistent across ages?
– Genetic disorders
– Similar to cystic fibrosis
• 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
– 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
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
• “Drinking makes me depressed”
– No evidence of mental illness prior to substance
• Temporal association of mental illness and
substance abuse does not demonstrate
• Depression is the most common major Axis I
disorder in adolescents
• Anxiety disorders (grouped) are the next
most common major Axis I disorders in
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 adolescents?
– Depression
– Anxiety
Diagnostic Overlap
• Symptoms of depression / anxiety are similar
to symptoms of substance use/intoxication
Anxiety and Stimulant Use/
• 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
• Cannabis use is associated with modestly
increased risk of depression in adulthood
• No predictive relationship with anxiety
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
– 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
– Relapses from substance abuse will be caused
by depression
• Then:
– Treatment must begin with treatment of
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
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
• 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
Parents as historians
• May be totally unaware of their child’s
substance abuse
• May believe that their child’s 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 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”
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 use
• 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
• 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 disorders
• 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
Mood with features
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 midteens, 3/4 by mid-20s
– Less severe in childhood, followed by more
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 2005;62:137-145.
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
A. Prominent hallucinations or delusions
– Exclude if insight sxs are substance-induced
B. Develop within month of intox or withdrawal OR
– or From medication use
C. 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
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
• 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
• Causes psychosis?
Buckley 2006, Esterberg et al., 2007
• Nicotine receptor associated with
• Partial agonist improved neurocognition
• Self-medication hypothesis
Olincy et al. 2006, Green 2007
• 173 pts, 100 controls – Spain
– Why do you smoke?
Gurpegui et al. 2007
Nicotine treatment
• Bupropion
– Dopamine transporter, plus serotonin
• Varenicline
– Partial nicotinic agonist
– Suicidal ideation
• Chronic use
– Alcohol withdrawal
– Delirium Tremens
– Alcohol hallucinosis
– Korsakoff’s psychosis
– Hepatic encephalopathy
• Co-morbidity in adult schizophrenia more
• 72% HS seniors ‘07
– 55% Drunk
• Intervention?
• Secondary psychosis unlikely in kids
Monitoring the Future
Alcohol treatment
• Naltrexone*
– oral vs depot
Johnson 2008
Alcohol treatment research
• 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
• 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 >
• Bupropion, divalproate, nefazodone do not
appear effective
– 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
– Rare case reports
Sessa and Nutt, 2007
• Multiple case-reports: irreversible
schizophrenia-like state
• Antipsychotics
– Typicals of limited use
– Atypicals better
• Evidence: clozapine > olanzapine > quetiapine >
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 populations
– 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