Comorbidity and Treatment in Substance Use Disorders

By Rowles, Brieana M.; Ellington, Aaron et al. | International Public Health Journal, April 1, 2015 | Go to article overview

Comorbidity and Treatment in Substance Use Disorders


Rowles, Brieana M., Ellington, Aaron, Tarr, Andrew R., Hertzer, John L., Findling, Robert L., International Public Health Journal


Introduction

Substance use disorders (SUDs) are fairly common among adolescents and young adults in the United States, with prevalence rates ranging from approximately 8% (1) to approximately 35% (2). Not only are SUDs common, but they also frequently co-occur with other psychiatric disorders. The National Survey on Drug Use and Health reported that in 2010, 22.1% of adolescents aged 12 to 17 (N = 379,000) with substance dependence or abuse in the past year also had a major depressive episode during the same time period (3). Additionally, the most recent practice parameter from the American Academy of Child and Adolescent Psychiatry reported that up to 50% of adolescents with SUDs in clinical populations have a comorbid psychiatric disorder (4).

Common comorbid psychiatric conditions

Studies of community-based samples of children and adolescents generally report attention-deficit/hyperactivity disorder and disruptive behavior disorders as the most commonly occurring comorbid psychiatric conditions in SUDs, at rates just under 70% (5, 6). In addition, ADHD complicated by co-occurring oppositional defiant disorder or conduct disorder is associated with significant risk for developing SUDs (7). The next most frequently reported comorbid psychiatric conditions at approximately 20-30% are mood disorders (both depressive disorders and bipolar disorders) (5, 8). Anxiety disorders occur at a rate of approximately 20% in children and adolescents with SUDs (5).

Clinical samples

Similar to data from community samples, clinical samples of children and adolescents report rates suggesting that ADHD and disruptive behavior disorders are the most common conditions comorbid with SUDs (9-12). Approximately 40-50% of young patients diagnosed with an SUD meet diagnostic criteria for comorbid ADHD (9, 10, 12). It has been suggested that ADHD during childhood/adolescence is a significant risk factor for developing an SUD (13). Further, longitudinal assessments of the relationship of ADHD in adolescence to later SUD have found that not only are co-occurring oppositional defiant disorder or conduct disorder significant predictors of SUD (13,14), but also that comorbid conduct disorder predicts SUD in pediatric ADHD (15,16). Conduct disorder has been reported to co-occur in approximately 50% of children and adolescents with an SUD (10-12).

Mood disorders also are commonly comorbid with juvenile SUDs in clinical settings (9, 12). Approximately 20% to more than 50% of children and adolescents with SUDs suffer from major depressive disorder (4, 11, 17, 18). Bipolar disorders (BPD) occur in 15% to 30% of juvenile SUD cases (19, 20). Further, juvenile BPD has been found to be a predictor of later SUD (21), and preliminary data suggest that co-occurring BPD and post-traumatic stress disorder increase the risk of subsequent SUD (22). Post-traumatic stress disorder and other anxiety disorders occur at rates of approximately 10% to 40% in juvenile SUD in clinical settings (4,12,18).

While psychotic disorders are not uncommonly comorbid with SUDs, the onset of the psychotic disorder generally occurs in late adolescence to early adulthood (23). Thus, clinical sample data are generally limited to adults. Of note, substance use and SUDs, particularly cannabis use, are associated with earlier age of onset of psychotic symptoms (24-28). Accordingly, adolescents with SUDs may be at increased risk for developing a comorbid psychotic disorder.

General principles of assessment and diagnosis

Considering the serious risks associated with SUDs and co-occurring psychiatric conditions, and high rates of comorbid individuals, proper assessment is critical. Although validated psychometric instruments are used frequently in scientific investigations, research has shown that only a small number of treatment providers report using formal assessment measures (e.g., self-reports, structured interviews, etc.) when determining proper treatment referrals (29). …

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