Managing Adolescents With Comorbid Depression and Substance Abuse

BENJAMIN I. GOLDSTEIN

KEY POINTS

Assessment and Monitoring

Evaluate depression and other comorbidities as suggested in Chapters 3 and 17.
Collect information from multiple sources, including the adolescent, parents, and school.
Learn as much as possible about the adolescent’s world (including family and peer influences), in an attempt to answer the question “Why does he or she continue to use?”
Collect laboratory specimens such as urine drug screens (UDS) regularly. Know in advance whom you will tell, under what circumstances, and how you will use the information.
Know when to refer.

Risk Behaviors

Because of the increased risk posed by comorbid substance use disorders (SUDs), implement a safety plan at the first in-person contact with the adolescent, and maintain increased vigilance for suicidality during follow-up.
Ascertain historical details regarding legal problems and history of violence, and maintain increased vigilance for violence and legal problems during follow-up.
Provide or arrange for detailed education regarding safe-sex, sexually transmitted diseases (STDs), including HIV, and contraception.
Help adolescents access appropriate resources, including condoms, oral contraception, pregnancy testing, and STD screening as indicated.
Prioritize getting parents “on board” with these efforts.
Educate the adolescent regarding the synergistic impact of depression and substance use on these risks.

Treatment

Reframe “self-medication:” Drugs and alcohol are not acceptable “treatments” for depression.
Deliver integrated rather than sequential treatment; don’t wait for abstinence before starting antidepressant treatment.
Antidepressants such as fluoxetine may be effective for reducing depressive symptoms, but their impact on substance use is likely to be modest.
Medications to reduce substance use should be used judiciously; although little is known about these medications, untreated SUD confers significant health risks in its own right.
Manual-based therapies should be considered; those focusing on family therapy, motivation-enhancement, and cognitive behavioral therapy (CBT) are publicly available.
Significant family involvement in treatment should be sought, even if an option other than family therapy is selected.

Introduction

Findings from community samples suggest that the prevalence of mood disorders increases significantly with increasing substance use, from 5% of youth with no lifetime substance use to approximately five times this rate among youth who use alcohol weekly or who use illicit substances even annually.1 Similarly, depression is associated with increased risk of substance use. The prevalence of significant substance use among depressed adolescents in the community is 20% compared with 5% among nondepressed adolescents.2 These disorders have a mutually exacerbating impact, both in terms of decreased treatment response and increased relapse and recurrence, and in terms of multiple hazardous consequences. For example, youth with comorbid depression and SUDs (i.e., abuse or dependence of alcohol or drugs) are at a markedly elevated risk of suicide and suicidal behaviors, legal difficulties, familial disruption, STDs and unplanned pregnancy, medication nonadherence, and academic difficulties.

Fortunately, recent years have seen a surge in research on this topic and there are now several evidence-based options for assessment, psychosocial interventions, and pharmacotherapy. Historically, clinicians treating youth with depression have often deferred antidepressant treatment when presented with an actively substance-using patient. The extant literature suggests that an integrated, parallel treatment process is optimal. The question remains, however, as to what practicing clinicians can do if they do not have specific training in addictions. Granted, there are certain circumstances in which specialized addiction services are warranted. For example, an adolescent who is using cocaine or heroin daily and who is not interested in engaging in treatment is probably not appropriate for a general psychiatry or depression clinic, or an adolescent medicine clinic for that matter. Indeed, a discussion of the management of intoxication or withdrawal syndromes is beyond the scope of this chapter. However, most depressed youth with comorbid SUD are not cocaine or heroin dependent. Most youth with SUD do not demonstrate the same level of physical health compromise that is frequently seen in adults. Most use cannabis or alcohol, and they tend to meet criteria for abuse or dependence more quickly and at lower frequencies and amounts of consumption than adults with SUD. What does this imply? A substantial proportion of youth with comorbid depression and SUD can be safely managed in clinical settings that do not specialize in SUD, provided certain modifications are made to incorporate a specific focus on SUD in assessment and treatment. The central aim of this chapter is to provide information regarding how to incorporate such an integrated perspective and to provide a starting point from which to acquire sufficient knowledge and confidence to maintain an integrated clinical practice.

ASSESSMENT AND MONITORING

The following section focuses specifically on substance use and SUD. See previous chapters for information regarding evaluation of depression (see Chapter 3) and of comorbidities other than SUD (see Chapter 17).

GATHER INFORMATION FROM MULTIPLE INFORMANTS

An important consideration in the assessment and monitoring of substance use among adolescents is to ascertain information from multiple sources. Information can be obtained from the adolescent via direct interview and self-report instruments. Collateral information should be obtained from parents or caregivers. School reports can be helpful because they may reflect inconsistency, repeated absences, and other behaviors that may raise suspicion of substance use. Mental status examination can help identify signs of acute intoxication or withdrawal. Finally, urine toxicology provides an invaluable source of objective information. Although adolescents do not always reliably report their substance use, adolescent self-report is an important source of information that can be maximized when confidentiality is maintained. Exercising an appropriate level of confidentiality during the assessment and treatment of SUD is part of the minimal standard of care.3 Therefore, it is important to clarify with the parent and adolescent precisely what information the clinician is obliged to share with parents or others. Generally, breaches of confidentiality may be indicated when there is a threat to the health or safety of
the adolescent or others. Parents are unaware of their adolescent’s substance use approximately 50% of the time, and parent interview correctly identifies only about 25% of cases of adolescent SUD.4 The yield from parent interview may depend on the age of the adolescent and degree of substance use. For example, parent reports may help identify substance use among early adolescents (12 to 13 years of age), whereas history of substance use can be ascertained directly for the vast majority of older adolescents. Parent reports for older adolescents may be more helpful in determining diagnoses of SUD.4

BECOME FAMILIAR WITH THE SYMPTOMS OF SUD

Whereas most clinicians who work with depressed adolescents can reel off the symptoms of depression from memory, the diagnostic criteria for SUD are often less familiar. It is relatively common to decide that an adolescent has a SUD based on a clinical gestalt. The drawback of using this approach is that it serves as a barrier to the systematic assessment of symptoms, particularly those that may not necessarily be brought to clinical attention spontaneously. The following are helpful mnemonics for the DSM-IV criteria for substance abuse and dependence:5

Substance dependence is ADDICTD:

Activities are given up or reduced (criterion 6)
Dependence, physical: tolerance (criterion 1)
Dependence, physical: withdrawal (criterion 2)
Intrapersonal (Internal) consequences, physical or psychological (criterion 7)
Can’t Cut down or Control use (criterion 4)
Time-consuming (criterion 5)
Duration or amount of use is greater than intended (criterion 3)

Substance abuse is WILD:

Work, school, or home role obligation failures (criterion 1)
Interpersonal or social consequences (criterion 4)
Legal problems (criterion 3)
Dangerous use (criterion 2)

WHAT ABOUT SUBTHRESHOLD SUBSTANCE USE?

The term “diagnostic orphans” has been used to describe adolescents who meet less than full criteria for substance dependence but yet do not meet criteria for substance abuse. The assessment and treatment of these adolescents follows the same principles as for those with full-threshold SUD.

WHAT ABOUT INFREQUENT SUBSTANCE USE OR EXPERIMENTATION?

Clinicians often wonder how much substance use is “normative” for adolescents with depression. Data from adults suggest that even moderate alcohol use may be associated with negative outcomes among people with depression.6 Moreover, even infrequent use of substances among adolescents is associated with increased suicidality.7 Depressed adolescents, and at times parents, argue that occasional drinking is normal and social. Treating clinicians are often loath to promote abstinence because of reluctance around limiting the adolescent’s social circle or hedonic activities, particularly if the adolescent is not a so-called problem drinker. However, much like drinking during pregnancy, there is no known “safe” amount of substances for youth with depression. Given the alternatives that exist for socializing and relaxation, abstinence from all psychoactive substances is likely the safest treatment goal.

FORMULATE BY GETTING THE DETAILS AND BECOMING AN EXPERT

It is important for the treating clinician to become an expert regarding adolescents’ substance use:

Are there particular internal triggers for use, such as boredom, sadness, anger, or anxiety?
Are there external cues such as offers from others or lack of parental supervision?
Do their peers smoke cigarettes? Drink? Use drugs?
What strategies have helped in the past to diminish craving or avert use?
What type of expectancies do they have regarding substance use?
Where do they use, and with whom?
What is their relationship with that person?
How much do they typically use, and what is the most they will use?
What is their substance of choice? Do they ever combine substances?
Do they pay for it? If yes, with what money? If no, who provides it and why?
What was going on at the time?
Was it planned?
What was their mood like before? After? Did any symptoms improve? Did any get worse? What about the next day?
How did they function, sleep, take medication, converse, get along with family?
Any cutting? Illegal behaviors? Unprotected sex?
What are the positive and negative consequences of substance use according to the adolescent? What about the parent?
Could the use have been prevented?

Clinicians should collect this information to formulate the adolescent’s substance use as they would the adolescent’s depression:

What factors predispose the adolescent to substance use? Is there a family history of SUD?
What precipitated substance use in general, and what are common precipitants for recurrent episodes of use?
Are there perpetuating factors that make it difficult for the adolescent to abstain? Does a household member (parent, sibling) use substances? What about peers?
What about protective factors that clinicians can draw on, such as interests in athletics or art, or prosocial activities or friendships that the adolescent has more recently neglected?

A comprehensive “assessment” of substance use can also have therapeutic value because it allows adolescents to see the objective association between all of these factors over time, and because it demonstrates to the adolescents that clinicians are interested in their overall health in a holistic way and want to know more about them as unique individuals rather than just another high-risk youth.

EVALUATE FOR BIPOLAR DISORDER AND OTHER COMORBIDITIES

Depression is commonly the presenting mood disturbance for youth with bipolar disorder. Therefore, as mentioned in Chapters 1 and 3, it is important to evaluate for family history of bipolar disorder as well as for previous symptoms or episodes of mania and hypomania in order to rule out bipolar disorder. More specific to this chapter is the fact that bipolar disorder carries the greatest risk of SUD of all axis I disorders, so the presence of SUD should increase the threshold of suspicion for bipolar disorder even further. This is important in light of the risk of treatment-emergent mania or cycle acceleration if antidepressants are used without mood stabilizers.

Comorbid conduct disorder is a potent risk factor for SUD also and should similarly raise the threshold of suspicion for SUD. Other comorbidities such as ADHD, anxiety disorders (particularly panic disorder), and eating disorders (particularly bulimia or binge-eating disorder), also raise the risk of SUD to varying degrees. Identification and management of these comorbidities, as outlined in Chapter 17, is of central importance because they perpetuate substance use if left untreated.

USE STANDARDIZED QUESTIONNAIRES

Many instruments may be used to assess and quantify substance use and SUD. The following are examples of instruments that are relatively straightforward and provide important information regarding quantity, frequency, and consequences of substance use. Some are used to screen for substance problems, and others are used to monitor changes in substance problems, but all can be helpful to the clinician by highlighting important domains to assess.

Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS):8 The A-OCDS is a 14-item self-report instrument that examines the frequency of thoughts about drinking, efforts made to resist those
thoughts, distress caused by the thoughts, and frequency and intensity of drinking. It changes with treatment and therefore can be used to monitor response, as well as in the prediction of relapse.
Alcohol Use Disorders Identification Test (AUDIT):9 The AUDIT is a 10-item multiple-choice questionnaire that measures alcohol consumption, drinking-related behavior, and alcohol-related problems. Items are scored from 0 to 4 for a maximum possible score of 40, and scores of ≥8 are highly suggestive of problematic alcohol consumption.
CRAFFT:10 CRAFFT is a mnemonic for a general screen for substance problems. A score of ≥2 on the CRAFFT is suggestive of problematic substance use.

Ask the adolescent the following questions:

Car: Have you ever ridden in a Car driven by someone who was “high” or had been using alcohol or drugs?
Relax: Do you ever use alcohol or drugs to Relax, feel better about yourself or fit in?
Alone: Do you ever use alcohol or drugs while you are by yourself, Alone?
Forget: Do you ever Forget things you did while using alcohol or drugs?
Friends: Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
Trouble: Have you ever gotten in Trouble while you were using alcohol or drugs?

Drug Use Screening Inventory (DUSI):11 The DUSI is a self-administered questionnaire that quantifies drug use, examines insight into the presence of substance problems, and assesses the severity of substance-related problems in multiple domains. The DUSI quantifies severity of involvement with drugs and alcohol and commonly-associated health, psychiatric, and psychosocial problems. Domains that are assessed include social, familial, academic, and recreational functioning. The DUSI yields severity scores for each domain, and for overall problems, reflecting severity of disturbance from 0% to 100%.
Timeline Follow-Back (TLFB):12 The TLFB is a standardized calendar-style method of obtaining information on day-to-day substance use. Adolescents are provided with “memory aid” prompts around important dates such as holidays and birthdays. Other techniques include asking about days of complete abstinence and days of heavy use, and establishing a range of use by employing an exaggeration technique to help the adolescent identify quantities of use. The TLFB may offer specific advantages when quantifying substance use among adolescents with depression. Using a calendar method linked to significant events affords an opportunity to examine the temporal association between negative life events and substance use. For example, depressed adolescents with SUD may find that cannabis use in fact precedes self-injurious behavior or suicide attempts, or that interpersonal difficulties often stem from drinking alcohol rather than alcohol being a self-medication for the distress associated with such difficulties. The degree to which this instrument can be therapeutic as well as quantitative depends in part on the extent of the details that are obtained regarding the precipitants and context of substance use.

COLLECT LABORATORY SPECIMENS

Among psychiatric illnesses, SUD offers the advantage of having objective biologic tests. Specimens include hair samples and urinary drug screens (UDS) (drugs), liver enzymes (alcohol), and exhaled carbon monoxide (cigarettes). However, many youth with SUD do not have the same pattern of use as adults, and they may suffer consequences of substance use at lower frequencies and amounts of consumption. Indeed, although markers such as carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) may be sufficiently sensitive and specific in the detection of heavy alcohol consumption among adults, they may be less helpful in identifying adolescents with alcohol dependence who often demonstrate patterns of intermittent binge drinking. Although CDT and GGT are not generally considered part of the standard of care for adolescent SUDs, it is important to monitor hepatotoxicity in youth with heavy or chronic alcohol consumption.

In contrast to CDT and GGT, a qualitative UDS is part of the minimal standard of care for SUD.3 Current practice parameters state that toxicology “should be a routine part of the formal evaluation
and ongoing assessment of substance use both during and after treatment.” It is important to consider several factors in advance of obtaining a UDS:

Has the adolescent knowingly consented to the UDS?
Has the decision to request a UDS been unduly influenced by parental suspicion, or was it reached after taking into consideration the entire clinical picture?
Who will be informed of the results?
How will the process of reporting the results transpire? For example, will adolescents be given an opportunity to divulge their substance use prior to the results being reported?
How will the information be used if the UDS is positive versus negative?

It is important to bear in mind that substances such as amphetamines, cocaine, and opiates are not likely to be detectable in urine after 1 to 4 days. Although cannabis is often considered detectable 3 to 4 weeks after the most recent use, this estimate can be shorter if use is infrequent and quantity is low. UDS remains an important tool because although a negative test does not always rule out cannabis use, false-positive tests are rare.

The availability of these laboratory tests does not obviate the need for careful screening via interview and self-report, but they are an important tool in the assessment and monitoring of substance use. Moreover, use of UDS increases the reliability of the adolescent’s self-reported substance use, which can have therapeutic value in itself. One approach to requesting UDS is to tell adolescents that it is likely to be positive if they have used cannabis in the past month. If the adolescent endorses substance use, the clinician may not wish to obtain a UDS. Another common clinical and research practice is to consider a refused UDS as equivalent to a positive UDS. See the National Institute of Drug Abuse (NIDA) and Substance Abuse and Mental Health Services Administration (SAMHSA) websites, provided in the resources section, for further details regarding laboratory specimens. A specific link is provided to the NIDA monograph on UDS.

KNOW WHEN TO REFER

The American Academy of Child and Adolescent Psychiatry (AACAP) has outlined a level-of-care utilization system to help clinicians determine in a standardized way which patients can safely be managed as regular outpatients and which require higher levels of care.13 Current practice parameters advise that adolescents with SUD should be treated in the least restrictive setting that is safe and effective.3 Several factors influence the choice of treatment setting: