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Depressive Disorder & Adolscent Substance Use Disorder

Depressive Disorder & Adolscent Substance Use Disorder. Elham Shirazi M.D. Board of General Psychiatry Board of Child & Adolescent Psychiatr y. The comorbidity of SUD with psychiatric disorders is now recognized as a common problem among patient with SUDs at any age (Regier, 1990).

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Depressive Disorder & Adolscent Substance Use Disorder

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  1. Depressive Disorder & Adolscent Substance Use Disorder Elham Shirazi M.D. Board of General Psychiatry Board of Child & Adolescent Psychiatry

  2. The comorbidity of SUD with psychiatric disorders is now recognized as a common problem among patient with SUDs at any age (Regier, 1990). • MDD is common among adolescents with SUD (Fleming, 1990; Kandel, 1997). • Depressive disorders are among the most common comorbid diagnoses in clinical populations of adolescents with SUD. • They are the most common comorbid diagnoses in adults with SUD (Bukstein, 1992; Clark, 1997; Kessler,1994, 1997; Reichler, 1983).

  3. Studies involving clinical populations have demonstrated an even stronger association between SUD & comorbid MDD among adolescents & young adults with SUD, as compared to community samples (Bukstein, 1989, Clark, 1997; Deykin, 1992; Rohde, 1991). • Depression is more common among individuals with adolescent-onset than among adult-onset SUD (Clark, 1998). • Comorbid depression is more common among teenagers & young adults than among older adults (Blazer, 1994; Stinson, 2005).

  4. SUD + MDD is a major & growing public health problem among adolescents & young adults. • The importance of treating depression + SUD is heightened by negative outcomes in adolescents with both disorders (Grella, 2001).

  5. This comorbidity can be associated with severe consequences such as: • School failure • Motor accidents • Risky sexual behavior • Suicidal behavior • .... (Bukstein, 1989)

  6. There has been a shift in major depression to an earlier age of onset • With increased rates for MDD between the ages of 15 & 19 years (Wittchen, 1994). • The earlier onset of MDD is associated with greater comorbidity (Kash, 1996). • Adolescent-onset depression is associated with a higher level of comorbidity than adult-onset depression (Rohde, 1991).

  7. MDD is more prevalent among females with SUD than among males (Brady, 1993; Fabrega, 1993; Hesselbrock, 1989; Stinson, 2005). • Depressive symptoms are more severe among women with SUD (than among men with SUD)(Cornelius, 1995; Pettinati, 1997). • Among adolescents, MDD is more strongly associated with alcohol dependence in females than in males (Clark, 1997) .

  8. Women with comorbid disorders are more likely than men with comorbid disorders to display primary (rather than secondary) depression (Dunne, 1993). • Comorbid MDD & SUD are more commonly diagnosed among those of lower SES(Cornelius, 1993; Fabrega, 1993; Stinson, 2005). • Having a MDD episode doubles the risk for the development of subsequent SUDs (Christie, 1998).

  9. Factors associated with mood disorders that are associated with the subsequent development of SUDs: • Genetic factors (Hesselbrock, 2005; Hopfer,2005; Kendler, 1994) • Neurodevelopmental dysregulation (Dawes, 2000; Tarter, 2003) • ADHD (Clark, 1997) • Comorbid anxiety disorders(Sung,2004) • Subsequent psychiatric disorders in adulthood (Brook, 1998, 2002)

  10. Prior cigarette & alcohol use (Merrill, 1999) • Underage drinking & substance use (Donovan, 2004; Kash, 1996; Sung, 2004) • Parental SUD (Brook, 2002; Clark, 2005; Clark, 2004) • Physical & sexual abuse (Clark,2003) • Affiliation with deviant peers (Moss, 2003)

  11. For most children & adolescents the index episode of MDD is the beginning of a chronic, recurrent, lifelong disorder (Birmaher, 2002). • Adolescents with MDD display a higher rate of recurrence of MDD (than adults with MDD). • Adolescents with comorbid disorders display a higher risk of recurrent MDD (than noncomorbid adolescents).

  12. The comorbid presence of MDD is associated with earlier relapse among adolescents (Cornelius, 2004). • The presence of affective symptoms among adolescents affects the course of SUD adversely (Bukstein, 1989).

  13. In clinical settings, adolescents should be routinely screened for: • SUD • Depressive disorders • Suicidality (Cornelius, 1995, 1996; Kelly, 2004)

  14. If SUD is detected or suspected upon initial screening, a follow-up urine drug screen should be considered. • If the diagnostic or the urine drug screen is positive, then referral should be made for further evaluation & treatment.

  15. Information should be obtained about the: • Onset of symptoms of SUD & depression • Their chronological relationship to each other • Depressive symptoms during periods of abstinence • Past treatment history & response • Family history of mood disorders

  16. If mood disorders are suggested, use specific rating scales that quantitatively measure mood symptom severity. • In SUD-depressive disorder, it is often difficult to ascertain whether dysfunctional domains are due to the substance use, depression, or their combination .

  17. SSRIs are a promising form of therapy for adolescents with MDD & SUD (AACAP, 2005). • Continued treatment is often needed to prevent recurrences of MDD (Cornelius, 2004, 2005) • It is essential to treat psychiatric comorbidities in adolescents with SUD (AACAP, 2005) • Integration of psychotherapy & pharmacotherapy is thought to be the best treatment of this population (Riggs, 2002; AACAP, 2005)

  18. Adolescents with MDD + SUD should have specific SUD treatment. • Preferably in a treatment center • With professionals sensitive to the needs of adolescents with mood disorders. • Treatment of depression should follow guidelines for the treatment of adolescent depression(AACAP, 2007).

  19. Sensitivity might include: • Psychoeducation about each disorder • Their potential influence upon one another • Monitoring & ongoing assessment of depressive symptoms

  20. If medication is initiated, clinicians should monitor: • Substance use • Urine toxicology results • Adverse effects • Medication compliance • Motivation • Suicidality • Behavior change • Psychosocial functioning (Riggs, 2002)

  21. Those with a family history of BD should monitored for onset of mania or mixed state. Youth with depression should be seen every week for the 1st month & biweekly thereafter.

  22. Suicide: • Adolescents with SUD or depressive disorders are at higher risk of attempting suicide (Kelly, 2004). • The number of patients needed to treat to observe one adverse event that can be attributed to the active treatment (Number Needed to Harm-NNH) for antidepressants in pediatric depression is 11. • Thus nearly 11 times more depressed patients may respond favorably to antidepressants than might spontaneously report suicidal ideation or suicidal behavior.

  23. With the increase in usage of SSRIs over the past decade, there has been a dramatic decline in adolescent suicide (Olfson, 2003). • Pharmacoepidemiological studies support a positive relationship between SSRI use & the reduction in the adolescent & young adult suicide rate (Gibbons, 2005, 2006; Olfson, 2003).

  24. Depressed patients & those receiving antidepressants, should be monitored for: • Suicidal thoughts & behavior • Side effects possibly associated with increased suicidality: • Akathisia • Irritablity • Withdrawal effects • Sleep disruption • Agitation • Induction of mania & mixed state In the first 4 weeks of treatment

  25. Patients at an increased risk for suicide are those with: • Current or prior suicidality • Impulsivity • SUD • History of sexual abuse • Family history of suicide

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