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

Co-Occurring Substance Use and Psychiatric Disorders in Children and Adolescents . UCLA. An Introduction to Co-Occurring Disorders. Daniel Dickerson, DO, MPH Assistant Research Psychiatrist UCLA Integrated Substance Abuse Programs Larissa Mooney, MD Associate Physician

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

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  1. Co-Occurring Substance Use and Psychiatric Disorders in Children and Adolescents UCLA

  2. 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

  3. Objectives • 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

  4. 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.

  5. 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)

  6. 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 amphetamines • No significant change in use of cocaine, hallucinogens, heroin, prescription opioids, or cough medicines • Past-year downward trend in EtOH and tobacco use • Increase in ecstasy (MDMA) use

  7. Drug abuse Trends – continued

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

  9. 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 dependence

  10. Substance Dependence: DSM-IV • Maladaptive pattern of use causing impairment or distress • 3 or more of following within 12-month period: • Tolerance • Withdrawal • Use in larger amounts over longer period than intended • Ongoing desire or unsuccessful efforts to cut down or control use • Excessive time spent obtaining, using, or recovering from effects • Use despite physical or psychological problem

  11. 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)

  12. 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 abuse • Have high co-morbidity with psychiatric conditions

  13. 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)

  14. PHYSIOLOGICAL HISTORICAL - genetics- circadian rhythms- disease states- gender - previous history- expectation- learning DRUGS ENVIRONMENTAL - social interactions- stress- conditioned stimuli BRAIN MECHANISMS BEHAVIOR ENVIRONMENT

  15. 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)

  16. 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 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)

  17. 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, hallucinations) (NIDA Research Report Series, 2004 and 2006)

  18. 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 grades • Rapid CNS effects include: euphoria, dizziness, slurred speech, incoordination; users may experience delusions and hallucinations • Medical consequences include: arrhythmias, loss of consciousness, possible death (“sudden sniffing death”) NIDA Research Report Series, 2005

  19. 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 Abuse)

  20. Club Drugs and Hallucinogens • LSD • Altered sensory perception, mood swings, hallucinations, delusions, “flashbacks” • Ecstasy (MDMA) • Stimulant and hallucinogenic effects: restlessness, insomnia, altered sensory perception • Medical risks: tachycardia, hyperthermia, hyponatremia, and seizure • May cause neurotoxicity • Ketamine and PCP • Dissociative anesthetics • NIDA Research Report Series, 2001 and 2005

  21. Dextromethorphan (Coricidin HBP®) Use and Youth • Cough medicine abuse among adolescents has been increasing • Coricidin HBP® Cough and Cold is an over-the-counter cough suppressant containing a high amount of dextromethorphan • Is easily attainable (in stores) and is often stolen in large amounts • Psychiatric consequences include: transient substance-induced psychosis, potential for depression and suicidal behavior (Dickerson et al., 2008) • Medical consequences include cardiac toxicity and liver failure (Dickerson et al., 2008)

  22. 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 15–24 years. (Kessler et al., 1996)

  23. 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)

  24. Co-morbidity – MECA Study Kandel, DB et al., 1999

  25. Age of First Use of Primary Substance Younger than 12 for Admissions Aged 13-17, by Psychiatric Diagnosis Status: 2003 (SAMHSA, 2003)

  26. Primary Source of Referral of Adolescent Admissions, by Psychiatric Diagnosis Status: 2003 (SAMHSA, 2003)

  27. Race/Ethnicity of Adolescent Admissions, by Psychiatric Diagnosis Status: 2003 (SAMHSA, 2003)

  28. 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 (SAMHSA, 2005)

  29. 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)

  30. 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)

  31. 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., 2007). • Dextromethorphan/Coricidin HBP abuse may be associated with transient, undiagnosed substance-induced psychosis (Dickerson et al., 2008)

  32. 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 adults

  33. 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

  34. 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 necessary

  35. 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)

  36. 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 patient’s ethnic and cultural belief system • Achieving cultural competency is a life-long endeavor

  37. Co-Occurring Disorders,Adolescent Substance Abuse, and Psychiatric IllnessAssessment Guidelines Eraka Bath, MDDirector, Child Forensic Services Assistant Professor of Psychiatry UCLA/NPI Division of Child and Adolescent Psychiatry

  38. SUD EpidemiologyClinical Implications • Assessment and diagnosis is critical • SUD co-occurs frequently with most classes of the major psychiatric disorders • Failure to diagnose means failure to treat and confers greater morbidity from psychiatric illness • Greater morbidity confers lifelong ramifications on educational attainment, employment, service utilization, teen parenting

  39. AssessmentGeneral 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.

  40. AssessmentGeneral 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

  41. AssessmentGeneral Guidelines • Severity of Use • Consequences for the adolescent • Patterns of Use • Age of onset • Amount • Frequency • Types of agents • Negative Consequences • How obtained

  42. AssessmentGeneral 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

  43. 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 functioning • Family Conflict • School Failure • Interpersonal Conflict

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

  45. 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

  46. AACAP 2005 Practice Parameters • Co-morbidity • Adolescents with SUD should receive thorough evaluations for co-morbid psychiatric disorders [MS] • Co-morbid Conditions should be appropriately treated [MS] • Co-morbidity may affect an individuals ability to effectively engage in treatment (Riggs and Whitmore, 1999) • Co-morbidity (esp. depression) increases rate and rapidity of relapse (Cornelius et al. 2003)

  47. 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

  48. 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 • Don’t ignore level of functioning and functioning should be explored in multiple domains across multiple spheres

  49. Stages of UseSTAGE I • Experimental or Social Stage • Beginning stage of use • Curiosity • Following the crowd • Thrill of doing something off limits • Use helps gain acceptance of peers • Increased use can lead to Stage II Chatlos, 1996; MacDonald, 1984; Nowinski, 1990; Jaffe and Solhkhah, 2006

  50. Stages of UseSTAGE II • Substance Misuse • Actively seeking pleasurable experiences • Often learns that misuse helps facilitate escape • Use is primarily on the weekends • Usually some deterioration of grades and problems confirming with rules are noted • Increased use can led to Stage III

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