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2014 4 th ANNUAL DC SUMMIT Child/Youth & Co-Occurring Disorders

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Objectives Review the prevalence of co-occurring substance use and psychiatric disorders in youth. Review the relationship between substance use and specific co-occurring mental health disorders. Understand effective treatment approaches and challenges for youth with co-occurring disorders.

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Introduction Psychiatric disorders 3/4 by age 24 Most adults with SUD started using as adolescents 60-85% adolescents with SUD have co-occurring psychiatric disorder(s).

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Co-Occurrence of MH & SUD Substance abuse treatment helps to reduce the frequency of use and the number of abuse/dependence symptoms but has only indirect impact on emotional and behavioral problems (M. Dennis, 2004) Psychiatric treatment alone for youth with mood disorders and co-occurring SUD does not significantly reduce substance use (Geller et al., 1998)

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Risk Factors: Familial Influence on Substance Use Familial influencebiological and behavioral A common genetic influence accounts for comorbid substance use during adolescence, specifically problem use of tobacco, alcohol, and cannabis. Approximately 50% of the risk of substance abuse or dependence in adolescence is genetically influenced. Exposure to parental substance use increases childrens risk

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A Day in the Life of American Adolescents: Substance Use Facts

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Table 1. Illicit drug use in the past month among individuals aged 12 or older: 2013 SubstanceAged 12 or olderAged 12 to 17Aged 18 or older Number (in thousands) PercentNumber (in thousands) PercentNumber (in thousands) Percent Illicit drug use24,5739.42,1978.82,23769.4 Marijuana and hashish19,8107.51,7627.118,0487.6 Cocaine1,5490.6430.21,5050.6 Inhalants4960.21210.53750.2 Hallucinogens1,3330.51540.61,1790.5 Heroin2890.1130.12770.1 Nonmedical use of prescription-type drugs 6,4842.55492.25,9352.5 Pain relievers4,5211.74251.74,0961.7 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH )

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Substance use disorder (SUD) in the past year among individuals aged 12 or older: 2013

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Mental health issues in the past year among adolescents aged 12 to 17 and adults aged 18 or older: 2013

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Co-occurring Substance Use Disorders and Mental Health Issues among Adolescents and Adults

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4,333 Total Child/Youth Served (DBH) - FY13 MH SUD COD 3693 640 221 5%

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Primary Substance Type Substance TypeCountPercentage Alcohol105% Cocaine/Crack52% Heroin10% Marijuana/Hashish/THC12054% Other84% Other Opiates and Synthetics21% Other Stimulants31% PCP94% No Primary Listed6329% Total221100%

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Diagnoses vs. Medications

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CFSA Youth with Co-occurring Disorders

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PIW Stats 75-85% of children/adolescents treated at PIW have past or current substance use issues

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Chicken or Egg? Substance-induced Mood Disorder There is no Cannabis-induced Depressive D/O Not in DSM-IV TR Not in DSM-5 Self-medication

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ADHD Prevalence approx. 3-5% but those receiving medications for ADHD is 1- 20% Male:Female is 4:1 Medication treatment for ADHD is one of the most studied areas in C&A psychiatry Over- vs. under-medication

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Course of ADHD Rule of 1/3s: 1/3 show significant improvement over time 1/3 have a few symptoms into adulthood (inattention) 1/3 continue to have significant problems into adulthood Untreated: Increased risk of MVAs, drop outs, family discord, and substance use (15% comorbidity)

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Stimulant Medications Absolute Contraindications: Cardiovascular disorders, hypertension Hyperthyroidism Glaucoma Active Psychosis Co-administration with MAO-Is Relative contraindications: Seizures (no evidence of decreasing sz thresold) Drug Abuse

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Major Depressive Disorder At least 2 wks pervasive change in mood manifested by either: Depressed or irritable mood and/or Loss of interest/pleasure Other sx: Same criteria as for adult MDD but presents differently Lack of joy Withdrawal Irritability Boredom Failing grades Act out Aggression

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Treatment Options Mild-moderate depression: psychotherapy Cognitive Behavior Therapy (CBT) Moderate-severe: pharmacotherapy + psychotherapy Pharmacotherapy may not be sufficient alone due to strong psychosocial influences

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Pharmacotherapy SSRIs are the predominant medications used for both depressive disorders and anxiety disorders Older antidepressants (TCAs) have not shown much benefit and have more side effects

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FDA Black Box Warning 24 placebo-controlled trials, >4400 patients: Placebo 2%; on antidepressants 4% Double risk of suicidal thinking/behavior No completed suicides Could be linked to behavioral activation or akathisia Impulsive Agitated UK banned use of all SSRIs except fluoxetine for C/A

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Anxiety Disorders Probably the 2 nd most common group of disorders; however, do not get recognized so people often do not present for tx Prevalence rates from 6-20% for one disorder Children/youth may not recognize fear as unreasonable Very common to have somatic c/o, crying, irritability, outbursts

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Anxiety Disorders Obsessive Compulsive Disorder* DSM-5: Obsessive-Compulsive and Related Disorders Post Traumatic Stress Disorder* DSM-5: Trauma and Stress-Related Disorders Separation Anxiety Disorder School refusal Generalized Anxiety Disorder Panic Disorder Social Phobia Selective mutism Specific Phobia

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Anxiety Disorders Treatment Guidelines Begin with psychotherapy for mild cases: CBT- exposure/response prevention Family and Parent-Child Consider psychotherapy + medication for: Acute symptom reduction for moderately-severely anxious child BZDs vs. buspirone Co-morbid disorder that requires treatment Partial response to psychotherapy Potential for improved outcome with combination

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Bipolar Disorder Commonly has onset in adolescence Gen population lifetime prevalence for Bipolar I is 0.4%- 1.6% For C/A ranges from 1%-13% Overall affects both sexes equally, early-onset pre- dominantly male (esp. onset