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Journal of Child & Adolescent Mental Health

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Dual diagnosis in adolescence — An escalating health risk

Anusha Lachman

To cite this article: Anusha Lachman (2012) Dual diagnosis in adolescence — An escalating health risk, Journal of Child & Adolescent Mental Health, 24:1, v-vii, DOI: 10.2989/17280583.2012.698113

To link to this article: https://doi.org/10.2989/17280583.2012.698113

Published online: 16 Jul 2012.

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EDITORIAL

Dual diagnosis in adolescence — An escalating health risk

Adolescence is traditionally a period characterised by transition. Changes in brain neural develop- ment and cognitive and physical maturity are accompanied by an escalation in high risk behaviours such as sexual experimentation and substance use (Casey and Jones 2010). Despite widespread media awareness and social initiatives highlighting the adverse consequences of drug use, substance misuse continues to be a growing problem among adolescents and is a major cause of morbidity (Brindis, Park and Ozer 2002). Compared with their adult counterparts, adolescents are generally less sensitive to the aversive aspects of drug use, and their experience with drugs is often more rewarding (Doremus-Fitzwater et al. 2010). This combination may contribute to increased drug experimentation during adolescence and may be superimposed on an apparent shared underlying genetic vulnerability to both substance use disorders (SUD) and mental illness (Caspi et al. 2005).

The term “dual diagnosis” commonly refers to the presence of both a primary substance use disorder (abuse or dependence) and a major psychiatric disorder (such as schizophrenia, mood or anxiety disorders) that co-occur. Substance use disorders are frequently found to be co-morbid in adolescents with psychiatric disorders (Deas and Brown 2006), but diagnosing this co-morbidity is often complicated by symptom overlap and symptom fluctuation. Non-substance use disorders commonly pre-date the substance use disorder, but the reverse can also occur. According to bio-behavioural models (Tsuang et al. 2001), dual diagnoses may be considered as a combination of shared genetic antecedents of mental illness (vulnerable substrates, early brain trauma etc.) that interact with environmental factors (e.g. early exposure to drug use, availability and social accept- ability) and result in phenotypes of addictive and non-addictive disorders. While no biomarkers exist to assist in differentiation, questions remain about the phenomenology of dual diagnosis and their variability across ethnicities and societies.

Co-morbidities Shrier et al. (2003) report correlations between SUDs and mood disorders (dysthymia and major depressive disorder), attention deficit hyperactivity disorder (ADHD), eating disorders and psychosis in adolescents. Community studies in adolescents with SUD have revealed psychiatric co-morbidity in 60% of the sample, with conduct disorder and oppositional defiant disorder being the most commonly co-occurring disorders, followed by depression (Armstrong and Costello 2002). Interestingly, the aforementioned study also reported that child psychopathology, especially conduct disorder, was associated with early debut of substance use and resulting substance misuse later in adolescence.

Increased alcohol use was found to be associated with increased occurrence of depressive disorders, disruptive behaviour disorders, other substance use disorders and anxiety disorders in more than 80% of a sample of adolescents with alcohol abuse/dependence, in a study by Rohde et al. (1996). Alcohol disorders in general followed rather than preceded the onset of psychiatric disorders in this sample. In another large adolescent population-based study, Mieuttenen et al. (2008) concluded that cannabis use was associated with prodromal symptoms (of schizophrenia) in adolescents. In addition, this effect was not secondary to the confounding effects of other drugs, emotional or behavioural problems, or family background.

Patients with prolonged methamphetamine abuse (especially those with a young age of drug debut using higher doses of methamphetamine) are at risk of persistent psychotic features and show poor response to antipsychotic treatment, even after they stop methamphetamine use (Grelotti, Kanayama and Pope 2010).

Outcomes Patients with a dual diagnosis have typically greater clinical severity, greater exposure to environ- mental risk factors and poorer response to standard treatments. Treating such patients therefore faces special challenges.

These challenges are further complicated by the lack of integrated treatment interventions and the split in management of the psychiatric disorders from SUD. Lehman et al. (1994) attempted to describe outcomes between patients with (1) concurrent but independent SUDs and psychi- atric disorders; and (2) those with primary substance use disorders who present with psychi- atric symptoms which are induced by a particular substance. The result was an important clinical cohort of dual diagnosis (the “a” group) patients who had worse outcomes, poorer compliance with treatment and who were more difficult to treat. Dixon (1999) further supported this by suggesting that a co-morbid substance use disorder be considered one of the major obstacles to the effective treatment of people with schizophrenia, and that co-morbid SUD was associated with earlier onset of schizophrenia. Drake and Brunette (1998) described a wide range of negative outcomes in the dual diagnosis population such as increased rates of relapse, treatment non-compliance, frequent re-admission to hospital, violent behaviours, social and family stress, and HIV infection.

Adolescents who drink alcohol, use other drugs or indulge in both are more likely to be sexually active than are those who do not; they are also more likely to engage in unprotected sex (Plüddemann et al. 2008). In addition to this risk, psychiatric and psychotic illnesses may convey a greater cumulative risk of cognitive and judgment impairments that increase the risk of contracting sexually transmitted diseases, further affecting overall health and well-being.

The way forward The current service model traditionally divides the care of patients with a dual diagnosis into separate psychiatric treatment and substance abuse intervention components. Adolescents are expected, firstly, to be treated for their psychiatric disorders by mental health services before access to specific substance abuse interventions is considered. Lehman et al. (1994) suggests “hybrid” programmes that provide acute detoxifi cation, substance intervention or both while also providing co-ordinated pharmacological intervention if necessary for the psychiatric disorder. One of the major challenges faced by child and adolescent mental health (CAMH) services is the barrier to integration of treatment modalities, as a result of service fragmentation. This manifests itself in the subsequent high rate of relapses and re-admissions of adolescents into psychiatric services before access to and utilisation of substance abuse services can even occur (Sterling et al. 2010). The optimal treatment of dual diagnosis therefore requires careful attention and sensitivity to these psychiatric co-morbidities (Meuser et al. 1998) and the specific treatment needs of a substance abusing adolescent, which may differ from those of an adult. Sterling et al. (2010) further suggest that integrated treatment should include social services (often responsible for substance treatment programmes) and the education (academic decline often follows substance use (Pludderman et al. 2008)) and health sectors.

This may be a challenge in resource limited settings such as South Africa, but research shows that separately run services for substance abuse and mental health do not adequately meet the needs of this unique population (Weich and Pienaar 2009). Health care professionals, in particular those involved in mental health care, must simultaneously screen for substance use disorders in adolescents who present with primary psychiatric disorders. An awareness of the complexity of dual diagnosis is the first step in the pursuit of promoting a more integrated and supportive treatment intervention for adolescents with psychiatric illnesses and co-existing substance use disorders.

References

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Casey BJ, and Jones RM. 2010. Neurobiology of Substance Use in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 49: 1189–1201.

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Anusha Lachman Child and Family Unit, Department of Psychiatry, Stellenbosch University e-mail: [email protected]