Integrated chemical-dependency and mental-health treatment best for adolescents

May 15, 2005

Adolescents with alcohol- and drug-use disorders often have co-occurring mental-health disorders. Furthermore, patients with co-occurring substance-abuse and mental-health problems tend to have less successful chemical-dependency (CD) treatment outcomes. A recent study of adolescent patients in private, managed-care CD treatment has found that those individuals who receive needed psychiatric services are more likely to be abstinent from both alcohol and drugs than those not receiving these services. Results are published in the May issue of Alcoholism: Clinical & Experimental Research.

"Studies of public programs have found that from one half to two thirds of adolescents in CD treatment have psychiatric conditions," said Stacy A. Sterling, a researcher with the Kaiser Permanente Northern California division of research and corresponding author for the study. "So it is a big problem for many teens entering drug and alcohol treatment. However, while there is growing recognition in treatment programs that many of their young patients may actually have dual diagnoses, the resources may not exist to adequately assess and treat those problems, and so they often are not assessed, or go un- or under-treated."

"While this may seem like common sense, few alcohol and other drug (AOD) programs for adolescents currently have the resources to provide psychiatric services in practice," concurred Michael Dennis, a senior research psychologist at Chestnut Health Systems. "Moreover, many medium to small urban and rural communities have no psychiatrist specializing in child and adolescent psychiatry. Adult psychiatrics and mental-health professionals tend to focus on common internalizing disorders, such as depression or anxiety. Child and adolescent psychiatrists and mental-health professionals focus more on trauma-related disorders - for example, from child maltreatment - and externalizing disorders, such as attention deficit, hyperactivity, oppositional-defiant and conduct disorders that are typically more common among adolescents presenting for substance-abuse treatment. The difference in focus can be very important."

"Adolescent patients with comorbid mental-health and substance-use problems tend to drop out of treatment earlier than those with only substance-use problems," added Sterling. "They have also been found to relapse to drug and alcohol use following treatment more often, and to experience more problems in other areas of their lives, such as legal problems, than those without."

For this study, participants included 419 adolescents (277 males, 142 females), ages 12 to 18 years, seeking treatment at four CD managed-care programs in northern California, as well as a parent or guardian for each adolescent. Researchers surveyed the patients at intake as well as six months later, and also examined clinical and administrative data regarding diagnoses, as well as CD and psychiatric utilization.

Results show that 55 percent of the adolescent patients had at least one psychiatric diagnosis in addition to a substance-use disorder.

"Our findings are similar to what other studies have found," said Sterling. "Many studies have found that the majority of adolescents in substance abuse treatment also have mental health problems, however, most of these studies have been conducted in public programs. We found that even in a private, commercially insured population that has good access to services, these rates were high. Clearly," she added, "these high levels of psychiatric symptomology demonstrate a need for psychiatric services."

The results also show that adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving those services.

"This is one of the few studies that explicitly demonstrates that providing psychiatric services during AOD treatment dramatically improves outcomes," said Dennis. "Moreover, those who could receive AOD and psychiatric services in the same clinic were twice as likely to actually initiate AOD sessions after intake and had higher parental satisfaction. Conversely, those with psychiatric disorders who did not receive psychiatric services had worse outcomes."

"Because so many of these teens are experiencing mental-health problems along with their drug and alcohol problems, these mental-health problems are likely making it more difficult to stay in treatment and realize the benefits of treatment, or to cause relapse, if they are not treated," said Sterling. "Many CD treatment programs do not provide psychiatric assessment and treatment, however, and our findings suggest that these services are important, either to provide internally, or if that is not possible, through community referrals."

"Addressing co-occurring psychiatric problems and improving the odds of recovery are also important because AOD disorders are often chronic conditions that can last for decades," added Dennis. "Of those adults with AOD disorders, 90 percent started using as adolescents - half younger than the age of 15. Their use typically lasts for decades - lasting longer for those who start younger, shorter for those who go to treatment sooner - and it often takes three or more episodes of treatment before they can sustain recovery. This does not mean it is hopeless. What it means is that the sooner we intervene, the more effective the earlier treatment, and the more we proactively monitor and re-intervene if they relapse ... all the better for the adolescent, their families, and society at large."

"It is important for adolescents with drug and alcohol problems to also be assessed for mental health problems, such as depression, anxiety, oppositional defiant disorder and ADHD," said Sterling. "Parents of adolescents entering treatment should ask for assessments of their youth when they enter treatment. If it is found that they do have one or more of these problems, patients and their parents should, whenever possible, seek out integrated CD and psychiatric services. If that is not possible, they should still pursue concurrent mental-health treatment. Conversely, CD treatment providers should work toward incorporating mental health services into their programs as much as is feasible. When it is not, they should work toward strengthening linkages with community mental-health services in order to facilitate the greatest possible coordination of care."
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. The co-author of the ACER paper, "Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes," was Constance Weisner of the Division of Research at Kaiser Permanente Northern California as well as the Department of Psychiatry at the University of California, San Francisco. The study was funded by the Robert Wood Johnson Foundation, the Center for Substance Abuse Treatment, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism.

Alcoholism: Clinical & Experimental Research

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