SUSAN B. WILSON PHD MBALICENSED CLINICAL PSYCHOLOGISTASSISTANT PROFESSOR, PSYCHIATRY
UMKC SCHOOL OF MEDICINE
Depression and Adolescence: Treating Linkages to Substance
Abuse
Today’s objectives
Explore the impact that depression and other disorders play in triggering and maintaining adolescent substance abuse.
Discuss strategies for treating adolescents
Considerations for culturally-responsive treatment will be offered.
Adolescence: the dilemma
Adolescence is a time of sweeping developmental changes in identity, mood and social adjustment
Intense peer pressure “It’s just a phase” thinkingNeuroscience research and brain developmentTeens without goals , caring adults other
protective factors are at riskSchool problems are both a risk factor and a
consequence
Current status
National Co-morbidity Survey found half of adolescents sampled met criteria for one or more psychiatric disorders in addition to a substance abuse disorder (Co-morbidity rates of 50-90% in later studies)
11 percent of adolescents have a depressive disorder by age 18 .
Girls are more likely than boys to experience depression.
The risk for depression increases as a child gets older.
Most common co-occurring disorders
Mood disordersAttention deficit disordersConduct disordersYet in many substance abuse prevention and
treatment settings for adolescents, these problems are often overlooked!
Working with adolescents with co-occurring disorders is “ a more challenging clinical phenomena that either problem alone.”Rowe et.al Impact of psychiatric co-morbidity on treatment of adolescent drug abusers. Journal of Substance Abuse Treatment, 26,129-140.
Teens with dual diagnoses face…
Earlier onset of substance abuse
More frequent useUse substances over
longer periodsEarly life issuesHave greater rates of
family, school, and legal problems, and
SA Treatment barriers including:
Funding Inadequately trained
staff “Abstinence first”
philosophy
Assessing COD in teens
Adolescent Diagnostic Interview (wps.com)
Diagnostic Interview Schedule for Children (DISC-R)
Depression screening in AOD programs
SA screening in MH settings
Depression: Recognizing the signs
Signs that are slightly different from the typical adult symptoms of depression.
Physical complaints, withdrawal , school problems, sulking , loss of interest/extreme boredom, negativity or feeling misunderstood.
Complicating matters, these same symptoms can be a result of drug use itself
Recognizing the symptoms
Emotional outbursts Acting out behaviorReckless risk-taking
behaviorExquisite sensitivityProblems fitting inExtremely low self
esteem
Common Dilemma
It can be hard to tell the difference between normal teen behavior and when teenagers are on drugs.
However, the combined presence of a few of the above warning signs most likely indicate a problem.
Who’s problem is it?Gateway vs. recreational?Cultural cannabis
Depression and substance abuse linked
Teens who are depressed and who have probably not been diagnosed are simply seeking a release from the overwhelming hopelessness of depression=self medication
Alcohol can worsen the effects of depression; re-bound affects of stimulant drugs and marijuana can contribute to depression
Depression
Rates of death by suicide have increased in recent years (ages 10-14)
Teens who are bullied at higher risk
Lesbian and gay teens are thought to be 2-6 times more likely to make a suicide attempt
Can trigger attempts to self-medicate with AOD
A word about …Attention Deficit Disorder
Linked to school failure and peer problems
Failure experiences lead to low self esteem
Difficulty following rules and listening can lead to conduct disorder and depression
All of the above place a teen at higher risk for substance abuse
Race/Ethnicity and Substance abuse
Investigators led by Duke University psychiatrist Dan G. Blazer analyzed data collected between 2005 and 2008 from confidential national surveys of 72,561 adolescents aged 12 to 17
Abuse of alcohol, marijuana, cocaine, and opioids among white, Hispanic, African-American, Native American, Asian, Pacific Islander, and multiple race/ethnicity adolescents.
37 percent said they had used alcohol or drugs in the past year while 7.9 percent met the criteria for a substance-use disorder -
Race/ethnicity and substance abuse
Native Americans (31.5 percent), multiracial (25.2 percent), white race/ethnicity (25.2 percent), and Hispanics (21 percent) had the highest rates of substance-related disorders
Adolescents of African, Asian, and Pacific Islander descents abused alcohol and drugs the least.
Marijuana was the most heavily used, followed by stimulants and then alcohol.
Trend: heroin abuse among white teens
But wait a minute…
Although studies show African American adolescents abused alcohol and drugs the least=> underreporting?
More juvenile and later incarceration for drugs
Marijuana and alcohol—drugs of choice—linked to music culture
Still may increase risk factors that lead to legal and school problems for AA youth who are already at risk
Impact of COD on treatment Outcomes
Risk factor for relapse
Interferes with treatment engagement=>treatment drop-out=> Relapse
Pre-treatment coping skills improve outcomes
Implications for Treatment
Both disorders must be treated simultaneously with a flexible, behaviorally- based treatment modality +appropriate medications
Parents and teens must be educated about the link between the mood disorder and drugs
Evidence-based treatments that teach affect regulation skills are preferred
Treatment Principles : Depression and SA
Focus: building relationships and motivating teen to attend treatment
Using evidence-based approaches—but modify them based on cultural group
Skill-building is key: impulse control, stress management, problem solving, affect regulation (e.g. DBT methods).
Realistic changes that are sustainableMonitoring medication adherence and SA useParent involvement—especially if parents use
Depression + SA
The Treatment for Adolescents with Depression Study (TADS) found that combination treatment of medication and psychotherapy works best for most teens with depression.
FDA Black box warning Youth and young adults should be closely monitored especially during initial weeks ; advised against alcohol use.
Therapist with experience in SA who can assist teen with skill building and affect regulation
Cognitive Behavioral Therapy (CBT)
Focus is on the link between thoughts, feeling and behaviors
Replacing unhealthy thoughts and behaviors with healthy ones
Found to produce significant results in substance abuse clients
Family Evidenced -based treatments
Multisystemic TherapyFocus is on social and
family behaviorsEngages multiple
systems in teens life4-6 monthsSmall case loads (5-6)Counselors available
24/7Services delivered in
various locations
Other variants:Ecologically Based
Family Therapy (Homebuilders)
Behavioral Family Counseling (BFC)
Multidimensional Family Therapy: Use with teen Cannabis abuse
Principles of Multidimensional Family Therapy1. Adolescent drug abuse is a complex and
multidimensional 2. Problem situations provide information and
opportunity.3. Change is determined by many factors4. Motivation can change.5. Working relationships are critical.6. Interventions are individualized.7. Planning and flexibility are two sides of the same
therapeutic coin.8. Treatment is in phases9. The therapist’s responsibility is emphasized.10. The therapist’s attitude is fundamental to success.
Multidimensional family treatment: Cannabis abuse
The family is a primary for developing a healthy teen.
Family influence can buffer against the deviant peer subculture.
Adolescents need to develop an interdependent rather than an emotionally separated relationship with their parents.
Symptom reduction and increasing positive behaviors is key
Other Evidence -based Approaches
Motivational Enhancement Therapy/Cognitive Behavioral
Adolescent Community Reinforcement Approach (ACRA)—
Family Support Network (FSN)Individual Cognitive Problem Solving (ICPS)
Challenges with evidence-based treatments
Lack of trainingApplicability to all populationsLack of infrastructureNonetheless, utilizing some of the principles
and techniques will likely yield better outcomes than no methods
Applicability to cultural competence
Studies show that skill-based treatments are better accepted by culturally different individuals
Strengths-based approaches are better receivedIncorporating cultural content, values and
music can be effective, with caveatsKeep in mind that the treatment practice on
encouraging a total change in “ people, places and things” may not apply
Allowing for “structured flexibility” is essential in maintaining a treatment alliance
Prevention is still an important focus
Caring families, adults neighborhoodsPro-social activitiesAwareness of family SA risk factorsSchool success and life goalsCoping and problem-solving skill
developmentBreaking the cycle in familiesReducing mental health stigma and
reluctance to address mental health issues
RESOURCES
Adolescent Substance Abuse: Psychiatric Comorbidity and High Risk Behaviors edited by Yifrah Kaminer, Oscar Bukstein
Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don’t Know edited by Dwight L. Evans, M.D., Edna B. Foa, Ph.D., Raquel E. Gur, M.D., Ph.D., Herbert Hendin, M.D., Charles P. O'Brien, M.D., Ph.D., Martin E. P. Seligman, Ph.D., B. Timothy Walsh, M.D.
Adolescent Substance Abuse: Evidence-Based Approaches to Prevention and Treatment edited by Carl Leukefeld, Thomas P. Gullotta, Michelle Staton-Tindal
http://www.nimh.nih.gov/health/publications/depression-in-children-and-adolescents/index.shtml
Thank you for your [email protected]
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