Transcript Depression and Adolescence: Treating Linkages to Substance

Depression and Adolescence:
Treating Linkages to
Substance Abuse
SUSAN B. WILSON PHD MBA
LICENSED CLINICAL PSYCHOLOGIST
ASSISTANT PROFESSOR, PSYCHIATRY
UMKC SCHOOL OF MEDICINE
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
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changes in identity, mood and social adjustment
Intense peer pressure
“It’s just a phase” thinking
Neuroscience research and brain development
Teens without goals , caring adults other protective
factors are at risk
School 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 disorders
 Attention deficit disorders
 Conduct disorders
 Yet 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
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substance abuse
More frequent use
Use substances over
longer periods
Early life issues
Have 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 behavior
 Reckless risk-taking
behavior
 Exquisite sensitivity
 Problems fitting in
 Extremely low self
esteem
Common Dilemma
 It can be hard to tell the
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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; rebound 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
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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 sustainable
Monitoring medication adherence and SA use
Parent 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 Therapy
 Focus is on social and
family behaviors
 Engages multiple
systems in teens life
 4-6 months
 Small case loads (5-6)
 Counselors available
24/7
 Services 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 Therapy
1. Adolescent drug abuse is a complex and multidimensional
2. Problem situations provide information and
opportunity.
3. Change is determined by many factors
4. 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 phases
9. 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 training
 Applicability to all populations
 Lack of infrastructure
 Nonetheless, 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
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accepted by culturally different individuals
Strengths-based approaches are better received
Incorporating cultural content, values and music can
be effective, with caveats
Keep 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 neighborhoods
 Pro-social activities
 Awareness of family SA risk factors
 School success and life goals
 Coping and problem-solving skill development
 Breaking the cycle in families
 Reducing 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 attention!
[email protected]