Pharmacotherapy for adolescent alcohol use disorder

Alcohol use disorder (AUD) occurs in few young adolescents, but is as common as in adults by the late teens. To address problems with the current American Psychiatric Association DSM-IV criteria, the anticipated DSM-V will eliminate the distinction between substance abuse and dependence in favour of a single category. For adolescents, pharmacotherapy for AUD may target alcohol withdrawal symptoms, alcohol consumption reinforcement properties, craving or co-morbid mental disorders. While uncommon among adolescents, severe alcohol withdrawal may require the closely monitored application of benzodiazepines. Disulfiram alters alcohol metabolism and has been shown to increase abstinence in adolescents with AUD, but sufficient motivation to maintain abstinence is needed for this approach to be appropriate. Medications to reduce alcohol craving, including naltrexone and acamprosate, may also assist some adolescents in maintaining abstinence. Adolescents with AUD typically also have co-morbid mental disorders and problems with other substances. Co-morbid mental disorders, such as major depressive disorder and attention-deficit hyperactivity disorder, may be addressed by pharmacotherapy. The potential for interactions between prescribed medications and alcohol or illicit substances necessitates patient education and monitoring. While there is a paucity of empirical information on the applicability of these pharmacotherapy approaches in adolescents, cautious application of these medications in selected cases in the context of systematic psychosocial interventions is warranted to promote abstinence and address associated problems.     

Understanding comorbidity between substance use,anxiety and affective disorders: Broadening the research base

In this paper, we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders; 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus on the effects on comorbidity of primary and secondary prevention interventions for substance use, anxiety, affective and conduct disorders among children and adolescents; and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.     

Reprint of “Understanding comorbidity between substance use,anxiety and affective disorders: Broadening the research base”

In this paper, we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders; 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus on the effects on comorbidity of primary and secondary prevention interventions for substance use, anxiety, affective and conduct disorders among children and adolescents; and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.     

Comorbidity of mental disorders and alcohol- and drug-use disorders: analysis of New South Wales inpatient data

Introduction and Aims. Alcohol‐ and other drug‐use disorders have been found to be associated with mental disorders, however, complete characteristics of these comorbid mental disorders are not completely clear in early population based studies. This study aimed to explore the extent and profiles of comorbid mental disorders with alcohol‐ and other drug‐use disorders using a large inpatient dataset. Methods. The data source was the New South Wales (NSW) Inpatient Statistic Data Collection which collects the clinical data of hospital admissions in NSW, Australia. The data were coded using the International Classification of Diseases—10th Revision (ICD‐10). The data were from 1 July 2005 to 30 June 2006 the Australian financial year and statistical analysis was performed using SAS. Results. Of 1 592 156 patients admitted, 91 510 (6%) had at least one mental disorder diagnosis and 18 283 (1.1%) had at least one alcohol‐ or other drug‐related diagnosis. Of these patients, an overall 9.6% had dual diagnoses. Comorbidity was nearly five times higher in alcohol‐ and other drug‐use disorders than in mental health disorders (52.4% vs. 10.5%). Comorbidity was higher in males than females (12% vs. 7.1%) and was the most common in patients aged from 20 to 49 regardless of sex. There was a significantly increased risk of developing a comorbid condition in all age groups above 10 years. The most common mental health disorders were major depressive disorders, followed by dementia, anxiety and severe stress. Alcohol‐use disorder was the most common diagnosis, followed by cannabis and opioids. Discussion and Conclusion. This study shows the characteristics of comorbid mental and alcohol‐ or other drug‐use disorders. The study extends our understanding of issues addressed in previous population studies.[Lai HMX, Huang QR. Comorbidity of mental disorders and alcohol‐ and drug‐use disorders: Analysis of New South Wales inpatient data. Drug Alcohol Rev 2009]     

Treating adolescents for substance abuse and comorbid psychiatric disorders

Recent research has identified a cluster of standardized approaches that effectively treat adolescents with substance abuse disorders. Many of these approaches share elements that may be adopted to improve outcomes in substance treatment programs. In adolescents, treatment goals should be informed by a comprehensive assessment that includes the adolescent patient's developmental history and evaluation of psychiatric comorbidity. Treatment for behavioral, psychosocial, and psychiatric problems should be integrated with substance abuse interventions. The author describes practical clinical guidelines, grounded in current research, for providing integrated treatment services. Special emphasis is given to strategies for integrating the treatment of comorbid psychiatric disorders with substance use disorders in adolescents.     

Assessing the efficacy of medical treatments for alcohol use disorders

Alcohol use disorders (AUDs) are common health problems that have a significant impact on society as a whole. There is a need for more effective treatments. In the last two decades, evidence for the efficacy of pharmacological approaches to treatment has increased. Although it has long been clear that medications are needed for the treatment of the alcohol withdrawal syndrome, the important role of medications in the longer-term treatment of AUDs has only recently been appreciated. In particular, naltrexone, acamprosate and topiramate appear to be efficacious treatments, especially when combined with psychosocial interventions that emphasise compliance with medication and encourage treatment retention. The goal of this review is to bring together the existing literature supporting the usefulness of pharmacological treatments for the alcohol withdrawal syndrome, for longer-term treatment of AUDs, and for comorbid AUDs and other psychiatric disorders. In addition, opportunities for future research will be identified.     

Assessing the efficacy of medical treatments for alcohol use disorders

Alcohol use disorders (AUDs) are common health problems that have a significant impact on society as a whole. There is a need for more effective treatments. In the last two decades, evidence for the efficacy of pharmacological approaches to treatment has increased. Although it has long been clear that medications are needed for the treatment of the alcohol withdrawal syndrome, the important role of medications in the longer-term treatment of AUDs has only recently been appreciated. In particular, naltrexone, acamprosate and topiramate appear to be efficacious treatments, especially when combined with psychosocial interventions that emphasise compliance with medication and encourage treatment retention. The goal of this review is to bring together the existing literature supporting the usefulness of pharmacological treatments for the alcohol withdrawal syndrome, for longer-term treatment of AUDs, and for comorbid AUDs and other psychiatric disorders. In addition, opportunities for future research will be identified.     

Cigarette Smoking in Youths With Mental Health and Substance Use Problems: Prevalence,Patterns, and Potential for Intervention

Mental health symptoms and substance use disorders are clear risk factors for cigarette smoking and nicotine dependence among young people, yet research on cigarette smoking among youths with concurrent mental health and substance use disorders (“dual diagnosis”) is considerably lacking. We examined smoking history and perspectives regarding smoking, cessation, and mental health and substance use in 97 adolescents and emerging adults (ages 14 to 24) referred to a program for youths with concurrent mental health and substance use disorders in Canada. Results show high rates of cigarette smoking, and modest interest in quitting but little interest in attending formalized programs to assist with cessation. Many participants reported smoking more when mental health was worse; most reported that they frequently smoke cigarettes and use drugs or alcohol concurrently. Current smokers perceived more benefits from cigarette smoking in regulating emotions and ameliorating their mental health symptoms than former smokers. In contrast, perceived detrimental effects of smoking were unrelated to current smoking status. Results suggest a need for integrated treatment that incorporates emotion regulation as part of cessation approaches. Integrating smoking cessation approaches into existing mental health and substance use treatments may be more palatable to adolescents and emerging adults than stand-alone smoking cessation programs.     

Alcohol use disorders comorbid with anxiety,depression and drug use disorders. Findings from the Australian National Survey of Mental Health and Well Being

The aim of this paper is to report the prevalence of 12-month comorbidity between DSM-IV alcohol use disorders (abuse or dependence) and anxiety, affective and drug use disorders in the adult Australian general population and to examine the disability and health service utilisation associated with this comorbidity. The study uses data from the National Survey of Mental Health and Well Being (NSMH&WB). The NSMH&WB is a cross-sectional survey of 10,641 Australian adults conducted in 1997 that measured the prevalence of DSM-IV mental disorders in the previous 12 months and associated disability and health service utilisation. Results show approximately one-third of respondents with an alcohol use disorder (abuse or dependence) met criteria for at least one comorbid mental disorder in the previous 12 months. They were 10 times more likely to have a drug use disorder, four times more likely to have an affective disorder and three times more likely to have an anxiety disorder. Respondents with an alcohol use disorder and a comorbid mental disorder were significantly more disabled and higher users of health services than respondents with an alcohol disorder and no comorbid mental disorders. These results reinforce the need for both mental health and drug and alcohol professionals to be provided with education to assist with appropriate identification, management and referral of clients presenting with this complex range of disorders.     

HIV-RISK BEHAVIORS AMONG PSYCHIATRICALLY HOSPITALIZED ADOLESCENTS WITH AND WITHOUT COMORBID SUD

OBJECTIVE: The purpose of this study was to examine HIV-risk behaviors among a sample of psychiatric inpatient adolescents with and without comorbid SUD. METHOD: 239 adolescents (60.7% female; mean age=15.3) were interviewed while hospitalized in a psychiatric inpatient treatment facility. Adolescents with and without substance use disorder (SUD) were compared on a number of HIV-risk behaviors and the association between HIV-risk behaviors and other types of mental health problems were examined. RESULTS: Compared to those without SUD, adolescents with SUD, after controlling for age, gender, and other psychiatric disorders, were at an increased risk for being currently sexually active (AOR=2.01, CI=1.00-4.04, p<.05) and for having used alcohol or drugs prior to last sexual intercourse (AOR=5.48, CI=1.91-15.72, p<.01). HIV-risk behaviors were more evident among adolescents with externalizing disorders and those with higher levels of self-reported distress. CONCULSION: Adolescents in psychiatric settings, especially those with substance use disorders and/or externalizing problems, are an important population for whom prevention efforts are needed to reduce the risk of HIV infection.     

Comorbidity between alcohol dependence and illicit drug dependence in adolescents with antisocial behavior and matched controls

BACKGROUND: Knowledge regarding the causes of comorbidity among substance use disorders can have significant impact on future research examining the etiology of these disorders. Unfortunately, the conclusions of past studies examining the comorbidity among substance use disorders are conflicting; some studies emphasize familial influences common to multiple substances, while others emphasize substance-specific influences. Discrepancies in results may reflect different analytical approaches or differences in the samples. Here, we examine the causes of comorbidity between alcohol dependence and illicit drug dependence in adolescents. METHODS: We ascertained a clinical sample of adolescents treated for antisocial behavior and substance use disorders and their siblings and a matched control sample. A model fitting approach was used to test 13 alternative hypotheses for the causes of comorbidity. RESULTS: The best supported hypothesis for the comorbidity between alcohol dependence and illicit drug dependence was a model hypothesizing that comorbid disorders are alternate forms of a single underlying liability. The next best fitting models were two of the correlated liabilities models (correlated risk factors and reciprocal causation). DISCUSSION: The results suggest that the best hypotheses explaining the comorbidity between alcohol and illicit drug dependence in adolescents are that alcohol dependence and illicit drug dependence are manifestations of a single general liability to develop substance dependence or that there are separate liabilities that are highly correlated.     

‘The great unmentionable’: Exploring the pleasures and benefits of ecstasy from the perspectives of drug users

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

What are the implications for clinical management and service development of prevalent comorbidity in UK mental health and substance misuse treatment populations?

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

Psychiatric disorders among older adolescents treated in emergency departments on weekends: a comparison with a matched community sample

OBJECTIVE: This study was undertaken to explore the characteristics of young patients treated in emergency departments (EDs) who follow through with an evaluation for psychiatric disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and to investigate differences in rates of psychiatric disorders between ED-treated adolescents and demographically similar adolescents recruited from the community. METHOD: Sixty three older adolescents (40 males) who were treated at two urban university hospital EDs were matched one-to-one on age, gender and race with 63 adolescents recruited from the community for participation in studies at an alcohol research center. Comprehensive psychiatric interviews were conducted with both groups. RESULTS: ED-treated adolescents were diagnosed with higher rates of current alcohol use disorders (AUDs), current drug use disorders and current major depression than were community controls. The ED sample had a particularly high rate of the DSM-IV "hazardous use" of alcohol symptom. ED-treated adolescents also had a higher rate of lifetime comorbid alcohol use disorders and drug use disorders, as well as a higher rate of lifetime comorbid alcohol use disorders and major depression, compared with the community controls. CONCLUSIONS: Adolescents who are treated in EDs should be routinely assessed for the presence of AUD, drug involvement and depressive disorders.     

Psychopathology in adolescent alcohol abuse and dependence

Adolescents who abuse or are dependent on alcohol often have coexisting mental disorders. These disorders may both precipitate alcohol use disorders and result from them. In addition, both types of disorders may arise independently in adolescents at high risk. Mental disorders that commonly co-occur with alcohol use disorders in adolescents include antisocial disorders, mood disorders, and anxiety disorders. Treatment programs for adolescents with alcohol use disorders should seek not only to eliminate alcohol and other drug use but also to improve the symptoms of other mental disorders.     

Dual Diagnosis and Drinking Behaviors in an Outpatient Treatment Seeking Sample of Adolescents with Alcohol Use Disorders

ABSTRACT

Objectives: Co-occurring psychiatric disorders are common in adolescents with substance abuse. While many studies have explored the prevalence of psychiatric disorders in adolescent substance using samples, few have explored the relationship between comorbid psychiatric disorders and drinking behaviors. This study examined this relationship to investigate whether certain psychiatric disorders impact severity of drinking behaviors in adolescents with alcohol use disorders.

Methods: We examined 34 outpatient adolescents with alcohol use disorders for comorbid psychiatric disorders using the K-SADS. Their drinking behavior patterns were examined using the Time-Line Follow-Back. The alcohol drinking parameters were (1) drinks per drinking day (DDD), (2) percent heavy drinking days (PHD), (3) percent heavy drinking days when drinking (PHDD), and (4) percent days abstinent (PDA).

Results: The diagnoses that afforded sufficient power to examine the effect of that diagnosis on drinking behavior were any mood or anxiety disorder vs. neither; oppositional defiant disorder (ODD) vs. no ODD; and attention-deficit hyperactivity disorder (ADHD) vs. no ADHD. Results revealed no significant effect of either ODD or any mood/anxiety disorder on drinking indices, both p values > .10; MANOVA revealed a significant effect of ADHD diagnosis, p = .04. Univariate analysis showed that for all four drinking indices, the group with ADHD had more severe alcohol use, all p values < .05.

Conclusions: Our results suggest that adolescents with ADHD who meet diagnostic criteria for alcohol use disorders have greater drinking severity than those without ADHD.     

Readiness for mental health treatment and for changing alcohol use in patients with comorbid psychiatric and alcohol disorders: Are they congruent?

Patients with comorbid psychiatric and alcohol disorders may be ready to change one problem but not the other. This study compared 132 dually diagnosed patients' readiness for mental health treatment to their readiness to change alcohol use. The patients completed a measure of readiness to change alcohol use [the University of Rhode Island Change Assessment Scale-Alcohol (URICA-A)] and the new Readiness for Mental Health Treatment measure. Confirmatory factor analysis (CFA) reveals that the measures have similar factor structures, but correlation and cluster analyses suggest that separate levels of patient motivation exist for mental health treatment and changing alcohol use. The newly developed mental health treatment measure will help clinicians tailor interventions to their patients' needs.     

Mental health and alcohol, drugs and tobacco: a review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs

This paper reviews some major epidemiological studies undertaken in high-income countries during the last 15 years which have reported the prevalence of mental disorders and substance use disorders and their relationship. Comorbidity between mental and substance use disorders is highly prevalent across countries. In general, people with a substance use disorder had higher comorbid rates of mental disorders than vice versa, and people with illicit drug disorders had the highest rates of comorbid mental disorders. There is a strong direct association between the magnitude of comorbidity and the severity of substance use disorders. While causal pathways differ across substances and disorders, there is evidence that alcohol is a casual factor for depression, in some European countries up to 10% of male depression. Policies that reduce the use of substances are likely to reduce the prevalence of mental disorders. Treatment should be available in an integrated fashion for both mental and substance use disorders. There is a need to expand the evidence base on comorbidity, particularly in low-income countries.