Citation
Marel, C. and Mills, K.L. (2017), "The importance of identifying, managing, and appropriately treating comorbidity in young people", Advances in Dual Diagnosis, Vol. 10 No. 4, pp. 125-129. https://doi.org/10.1108/ADD-09-2017-0018
Publisher
:Emerald Publishing Limited
Copyright © 2017, Emerald Publishing Limited
The importance of identifying, managing, and appropriately treating comorbidity in young people
High rates of mental and substance use disorders have consistently been reported in national youth surveys conducted around the world (Ravens-Sieberer et al., 2008; Lawrence et al., 2015; Green et al., 2005; Kessler et al., 2012). Adolescence and young adulthood can be a difficult, turbulent time for many people, with an individual’s thoughts, feelings, and behaviour affected by issues of change, development, identity formation, experimentation, rebellion, and uncertainty (Marsh et al., 2013). Adolescence is also often the time during which the first presentations of psychosis and symptoms of depression and anxiety emerge (Health, 2008). Half of all lifetime mental disorders develop prior to the age of 14 years, and three-quarters by age 24 (Kessler et al., 2005) making them the leading cause of disability in young people worldwide (Erskine et al., 2015). Five of the top ten causes of disability-adjusted life-years among young people directly relate to mental health or alcohol or other drug (AOD) use disorders (Gore et al., 2011).
Young people are also at high risk of experiencing comorbidity across disorders (Baker et al., 2007; Kramer et al., 2003; Bolton et al., 2009; Slade et al., 2009; Chan et al., 2008). The most recent large-scale epidemiological survey to be conducted in the UK found that one-in-ten (10 per cent) young people aged 5-16 years had been diagnosed with a mental disorder, one in five of whom experienced more than one disorder (Green et al., 2005). In Australia, one in seven (14 per cent) of those aged 4-17 years have been found to experience a 12-month mental disorder, 30 per cent of whom experience two or more disorders (Lawrence et al., 2015). Although neither the UK survey nor the Australian survey assessed for the presence of a substance use disorder, they did find higher rates of substance use among those with mental disorders. Young people in the UK aged 11-16 years with an emotional disorder (anxiety or depression) were more likely to have ever smoked tobacco (23 vs 8 per cent), used alcohol at least once per week (13 vs 8 per cent) and ever used drugs (cannabis, inhalants, ecstasy, amphetamines, LSD, tranquilisers, cocaine, heroin; 20 vs 8 per cent) than those without emotional disorders (Green et al., 2005). Similarly, those with conduct disorders were more likely than those without to have ever smoked tobacco (34 vs 8 per cent), to be drinking alcohol at least once per week (32 vs 16 per cent), and to have used other drugs (28 vs 8 per cent). Similar patterns were observed in the most recent Australian national survey on child and adolescent mental health and well-being, which found elevated rates of alcohol, cannabis, smoking, and other drug use among young people with self-reported major depressive disorder compared to those with no mental disorders (alcohol: 65 vs 34 per cent; cannabis: 29 vs 9 per cent; smoking: 30 vs 6 per cent; other drugs: 16 vs 3 per cent) (Lawrence et al., 2015).
Not only does research indicate that there is an increased prevalence of comorbidity among young people, but there is evidence to suggest that adolescents with AOD and co-occurring mood and anxiety disorders also display greater severity of AOD use and associated problems, including reduced academic performance and social abilities, greater social disadvantage, increased disability and suicidal behaviour, and poorer treatment outcomes (Szirom et al., 2004; Grella et al., 2001; Riggs et al., 1995; Rowe et al., 2001; Lewinsohn et al., 1995; Wittchen et al., 1998; Andrews et al., 2002). Furthermore, young people with higher levels of emotional symptoms are more likely to consume alcohol at risky levels, a relationship demonstrated by Birrell et al. (2017) in this special issue of Advances in Dual Diagnosis.
Drawing on three years of data collected as part of a cluster randomised controlled trial among Australian adolescents (mean age of 13.4 years at study entry), Birrell et al. (2017) examined the relationship between trajectories of emotional symptoms and alcohol consumption at 16 years of age. Adolescents classified as experiencing stably high levels of emotional symptoms were more likely to have used alcohol (77 per cent) and engaged in binge drinking (51 per cent) by the age of 16 years, compared to adolescents whose emotional symptoms were moderate and stable, or increasing. Champion et al. (2017) similarly identified several psychosocial risk factors that were independently and consistently associated with harmful alcohol and cannabis use in their longitudinal analysis of Australian adolescents. Specifically, higher levels of hyperactivity/inattention, more days of truancy and being female were independently and consistently associated with binge drinking over time, while conduct problems was the only factor to be independently and consistently associated with cannabis use over time. As discussed by both Birrell et al. (2017) and Champion et al. (2017), universal and targeted prevention efforts are key to halting progression of harmful use and the development of primary or secondary disorders. In this issue, Pidd et al. (2017) also point to the need for psychosocial interventions targeted toward specific at-risk groups. A cross-sectional survey of first-year apprentices in the construction industry revealed elevated rates of substance use and psychological distress when compared to age/gender-equivalent population norms.
Given the multitude of adverse outcomes and risk factors described, it is not surprising that young people with comorbidity frequently come into contact with a diverse range of service systems, including health, social welfare, educational, and criminal justice systems (Suarez et al., 2012), and present a significant challenge to service providers. What can clinicians do to address comorbidity among young people? Although evidence suggests that comorbidity is the norm rather than the exception for youth presenting to services, young people are commonly undertreated (Burgess et al., 2009; McGorry, 2009). Analysis of the second Australian National Survey of Mental Health and Wellbeing revealed that although more than one-quarter of those aged between 16 and 24 years experienced a 12-month mental disorder, less than 25 percent accessed health services in a 12-month period (Reavley et al., 2010).
In terms of tailoring programs and services for youth, evidence suggests that AOD and mental health conditions take place in different physical, attitudinal, psychological, and social contexts for young people, and it would be appropriate to adapt treatment accordingly (Substance Abuse and Mental Health Services Administration, 2005; American Psychiatric Association, 2006). For instance, treatment should be “youth friendly”, include follow-up for missed appointments, easy to access, deliver prompt screening and assessment, have drop-in capability, be flexible, have strong links to other relevant agencies to ensure holistic treatment, and deliver interventions that recognise and cater to differences in cognitive developmental and maturational capacities (Health, 2008). Young people are not little adults (Hall et al., 2016). Young people are fundamentally different from adults in ways that are likely to affect treatment utilisation, adherence, and outcomes (Schwartz et al., 2005; McDermott et al., 2010; Winters, 1999; Masten et al., 2004) as such it would be inappropriate to simply replicate adult-focussed treatment for young people. Rather, this group requires specialised treatment, focussed on meeting developmental and engagement needs.
It may also be particularly useful to provide young clients with practical and concrete strategies relating to mental health and AOD use (particularly relapse prevention and urge control). For instance, a behavioural treatment programme consisting of stimulus control, urge control, social contracting, problem solving, relationship enhancement, anger management, and communication skills training has been shown to be particularly effective in continued abstinence in adolescents with AOD issues (Azrin et al., 1994), while cognitive and behavioural therapies have shown positive outcomes for mental health disorders (Compton et al., 2002; Lewinsohn et al., 1995; Moak et al., 2003; Farmer et al., 2002). Towers (1997) argues that it is unrealistic to expect many young people to completely cease using all substances and engaging in other risk-taking behaviours (such as driving at high speeds, promiscuity), at least initially. Therefore, it is particularly important to include harm reduction strategies when working with young people.
E-health interventions may be particularly useful for this population (Gould et al., 2002; Valaitis, 2005; Nicholas et al., 2004; Deady et al., 2013), and have been described as one of the most important revolutionary additions to modern healthcare (Jolly, 2011). E-health interventions provide the opportunity to overcome traditional barriers to treatment that often prevent young people seeking help (via flexibility, anonymity, and accessibility) (Rickwood et al., 2007). Widespread internet usage by young people (Poushter, 2016; ABS, 2016), combined with research suggesting that youth feel empowered online, and feel comfortable accessing health information and mental health treatment online (Valaitis, 2005; Gould et al., 2002; Nicholas et al., 2004), makes the use of e-health interventions among young people particularly encouraging. Evidence has demonstrated that e-health interventions allow for the delivery of clinically effective, cost-effective treatment, based on gold standard programs, which are highly engaging (Nicholas et al., 2010; Andersson et al., 2013; Cuijpers et al., 2010; Grist and Cavanagh, 2013; Marks et al., 2007).
Although comorbidity among young people is the norm, rather than the exception, there is a considerable lack of research examining the confidence and capacity of workers to respond to young clients with comorbidity. That which does exist suggests that there is an absence of appropriate training and support (Marel et al., 2016). As such, it is essential that evidence-based education and training opportunities, including ongoing professional development activities, be available for youth workers and clinicians, in formats that enhance the uptake of evidence-based care. Accordingly, it is also critical that research continue to examine the efficacy of novel interventions and methods to most effectively engage young people with services.
References
ABS (2016), Household Use of Information Technology, Australia, 2014-15, 8146, Australian Bureau of Statistics, Canberra.
Andersson, G., Carlbring, P., Ljótsson, B. and Hedman, E. (2013), “Guided internet-based CBT for common mental disorders”, Journal of Contemporary Psychotherapy, Vol. 43 No. 4, pp. 223-33.
Andrews, G., Slade, T. and Issakidis, C. (2002), “Deconstructing current comorbidity: data from the Australian National Survey of Mental Health and Wellbeing”, British Journal of Psychiatry, Vol. 181 No. 4, pp. 306-14.
American Psychiatric Association (2006), “Practice guideline for the treatment of patients with substance use disorders, 2nd edition”, American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium, American Psychiatric Association, Arlington, VA, pp. 291-563.
Azrin, N., Donohue, B., Besalel, V., Kogan, E. and Acierno, R. (1994), “Youth drug abuse treatment: a controlled outcome study”, Journal of Child and Adolescent Substance Abuse, Vol. 3 No. 3, pp. 1-16.
Baker, K., Lubman, D., Cosgrave, E., Killackey, E., Yuen, H., Hides, L., Baksheev, G., Buckby, J. and Yung, A. (2007), “Impact of co-occurring substance use on 6 month outcomes for young people seeking mental health treatment”, Australian and New Zealand Journal of Psychiatry, Vol. 41 No. 11, pp. 896-902.
Birrell, L., Newton, N., Stapinski, L., Prior, K., Champion, K., Mackie, C., Teesson, M. and Slade, T. (2017), “Trajectories of emotional symptoms in adolescence: impact on alcohol use”, Advances in Dual Diagnosis, Vol. 10 No. 4, pp. XX-XX.
Bolton, J., Robinson, J. and Sareen, J. (2009), “Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions”, Journal of Affective Disorders, Vol. 115 No. 3, pp. 367-75.
Burgess, P., Pirkis, J., Slade, T., Johnston, A., Meadows, G. and Gunn, J. (2009), “Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing”, Australian and New Zealand Journal of Psychiatry, Vol. 43 No. 7, pp. 615-23.
Champion, C., Barrett, E., Slade, T., Teesson, M. and Newton, N. (2017), “Psychosocial factors associated with adolescent substance use: a longitudinal investigation”, Advances in Dual Diagnosis, Vol. 10 No. 4, pp. 142-154.
Chan, Y., Dennis, M. and Funk, R. (2008), “Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment”, Journal of Substance Abuse Treatment, Vol. 34 No. 1, pp. 14-24.
Compton, S., Burns, B., Egger, H. and Robertson, E. (2002), “Review of the evidence base for treatment of child psychopathy: internalising disorders”, Journal of Consulting and Clinical Psychology, Vol. 70 No. 6, pp. 1240-66.
Cuijpers, P., Donker, T., van Straten, A., Li, J. and Andersson, G. (2010), “Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies”, Psychological Medicine, Vol. 40 No. 12, pp. 1943-57.
Deady, M., Teesson, M., Mills, K., Kay-Lambkin, F., Baker, A., Baillie, A., Shand, F., Manns, L., Christensen, H. and Haber, P. (2013), One Person, Diverse Needs: Living with Mental Health and Alcohol and Drug Difficulties, NHMRC Centre of Research Excellence in Mental Health and Substance Use, Sydney.
Erskine, H., Moffitt, T.E., Copeland, W., Costello, E., Ferrari, A., Patton, G., Degenhardt, L., Vos, T., Whiteford, H. and Scott, J. (2015), “A heavy burden on young minds: the global burden of mental and substance use disorders in children and youth”, Psychological Medicine, Vol. 45 No. 7, pp. 1551-63.
Farmer, E., Compton, S., Burns, B. and Robertson, E. (2002), “Review of the evidence base for treatment childhood psychopathology: externalising disorders”, Journal of Consulting and Clinical Psychology, Vol. 70 No. 6, pp. 1267-1302.
Gore, F.M., Bloem, P.J.N., Patton, G.C., Ferguson, J., Joseph, V., Coffey, C., Sawyer, S.M. and Mathers, C.D. (2011), “Global burden of disease in young people aged 10-24 years: a systematic analysis”, The Lancet, Vol. 377 No. 9783, pp. 2093-102.
Gould, M., Munfakh, J., Lubell, K., Kleinman, M. and Parker, S. (2002), “Seeking help from the internet during adolescence”, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 41 No. 10, pp. 1182-89.
Green, H., McGinnity, A., Meltzer, H., Ford, T. and Goodman, R. (2005), Mental Health of Children and Young People in Great Britain, 2004, Palgrave Macmillan, Hampshire.
Grella, C., Hser, Y., Joshi, V. and Rounds-Bryant, J. (2001), “Drug treatment outcomes for adolescents with comorbid mental and substance use disorders”, Journal of Nervous and Mental Disease, Vol. 189 No. 6, pp. 384-92.
Grist, R. and Cavanagh, K. (2013), “Computerised cognitive behavioural therapy for common mental health disorders, what works, for whom under what circumstances? A systematic review and meta-analysis”, Journal of Contemporary Psychotherapy, Vol. 43 No. 4, pp. 243-51.
Hall, W.D., Patton, G., Stockings, E., Weier, M., Lynskey, M., Morley, K.I. and Degenhardt, L. (2016), “Why young people’s substance use matters for global health”, The Lancet Psychiatry, Vol. 3 No. 3, pp. 265-79.
Health, N.D.o (2008), Drug and Alcohol Psychosocial Interventions: Professional Practice Guidelines Mental Health and Drug and Alcohol Office, Sydney.
Jolly, R. (2011), The E Health Revolution: Easier said than Done, Parliamentary Library, Canberra.
Kessler, R.C., Avenevoli, S., Costello, E.J., Georgiades, K., Green, J.G., Gruber, M.J., He, J.-p., Koretz, D., McLaughlin, K.A., Petukhova, M., Sampson, N.A., Zaslavsky, A.M. and Merikangas, K.R. (2012), “Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement”, Archives of General Psychiatry, Vol. 69 No. 4, pp. 372-80.
Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R. and Walters, E.E. (2005), “Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication”, Archives of General Psychiatry, Vol. 62 No. 6, pp. 593-602.
Kramer, T., Robbins, J., Phillips, S., Miller, T. and Burns, B. (2003), “Detection and outcomes of substance use disorders in adolescents seeking mental health treatment”, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 42 No. 11, pp. 1318-26.
Lawrence, D., Johnson, S., Hafekost, J., Boterhoven de Haan, K., Sawyer, M., Ainley, J. and Zubrick, S.R. (2015), “The mental health of children and adolescents: report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing”, Australian Government Department of Health, Canberra.
Lewinsohn, P., Rohde, P. and Seeley, J. (1995), “Adolescent psychopathology III: the clinical consequences of comorbidity”, Journal of American Academy of Child and Adolescent Psychiatry, Vol. 34 No. 4, pp. 510-19.
McDermott, B., Baigent, M., Chanen, A., Fraser, L., Graetz, B., Hayman, N., Newman, L., Parikh, N., Peirce, B., Proimos, J., Smalley, T., Spence, S. and Committee, b. E.W. (2010), Clinical Practice Guidelines: Depression in Adolescents and Young Adults, beyondblue: the national depression initiative, Melbourne.
McGorry, P. (2009), “Should youth mental health become a specialty in its own right? Yes”, British Medical Journal, p. 339, available at: https://search.proquest.com/docview/1778003972?pq-origsite=gscholar
Marel, C., Deady, M., Mills, K., Kingston, R. and Teesson, M. (2016), “Training and support needs of youth substance use and mental health workers in relation to comorbidity”, NDARC Technical Report No. 333, National Drug and Alcohol Research Centre UNSW, Sydney.
Marks, I., Cavanagh, K. and Gega, L. (2007), Hands-On Help: Computer-Aided Psychotherapy, Psychology Press, Hove.
Marsh, A., O’Toole, S., Dale, A., Willis, L. and Helfgott, S. (2013), Counselling Guidelines: Alcohol and other Drug Issues, Western Australia Alcohol and Drug Authority, Perth.
Masten, A., Burt, K., Roisman, G., Obradovic, J., Long, J. and Tellegen, A. (2004), “Resources and resilience in the transition to adulthood: continuity and change”, Development and Psychopathology, Vol. 16 No. 4, pp. 1071-94.
Moak, D., Anton, R., Latham, P., Voronin, K., Waid, R. and Durazo-Arvizu, R. (2003), “Sertraline and cognitive behavioral therapy for depressed alcoholics: results of a placebo-controlled trial”, Journal of Clinical Psychopharmacology, Vol. 23 No. 6, pp. 553-62.
Nicholas, J., Oliver, K., Lee, K. and O’Brien, M. (2004), “Help-seeking behaviour and the internet: an investigation among Australian adolescents”, Australian e-Journal for the Advancement of Mental Health, Vol. 3 No. 1, pp. 16-23.
Nicholas, J., Proudfoot, J., Parker, G., Gillis, I., Burckhardt, R., Manicavasagar, V. and Smith, M. (2010), “The ins and outs of an online bipolar education program: a study of program attrition”, Journal of Medical Internet Research, Vol. 12 No. 5, p. e57.
Pidd, K., Duraisingam, V., Roche, A. and Trifonoff, A. (2017), “Young construction workers: substance use, mental health, and workplace psychosocial factors”, Advances in Dual Diagnosis, Vol. 10 No. 4, pp. 155-168.
Poushter, J. (2016), Smartphone Ownership and Internet usage Continues to Climb in Emerging Economies, Pew Research Center, Washington, DC.
Ravens-Sieberer, U., Wille, N., Erhart, M., Bettge, S., Wittchen, H.-U., Rothenberger, A., Herpertz-Dahlmann, B., Resch, F., Hölling, H., Bullinger, M., Barkmann, C., Schulte-Markwort, M. and Döpfner, M. (2008), “Prevalence of mental health problems among children and adolescents in Germany: results of the BELLA study within the National Health Interview and Examination Survey”, European Child & Adolescent Psychiatry, Vol. 17 No. S1, pp. 22-33.
Reavley, N., Cvetkovski, S., Jorm, A.F. and Lubman, D.I. (2010), “Help-seeking for substance use, anxiety and affective disorders among young people: results from the 2007 Australian National Survey of Mental Health and Wellbeing”, Australian and New Zealand Journal of Psychiatry, Vol. 44 No. 8, pp. 729-35.
Rickwood, D., Deane, F. and Wilson, C.J. (2007), “When and how do young people seek professional help for mental health problems?”, Medical Journal of Australia, Vol. 187 No. 7, pp. S35-39.
Riggs, P., Baker, S., Mikulich, S., Young, S. and Crowley, T. (1995), “Depression in substance-dependent delinquents”, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 34 No. 6, pp. 764-71.
Rowe, C., Liddle, H.A. and Dakof, G.D. (2001), “Classifying clinically referred adolescent substance abusers by level of externalizing and internalizing symptoms”, Journal of Child and Adolescent Substance Abuse, Vol. 11 No. 2, pp. 41-65.
Schwartz, S., Côté, J. and Arnett, J. (2005), “Identity and agency in emerging adulthood two developmental routes in the individualization process”, Youth and Society, Vol. 37 No. 2, pp. 201-29.
Slade, T.J.A., Teesson, M., Whiteford, H., Burgess, P., Pirkis, J. and Saw, S. (2009), “The mental health of Australians 2: report on the 2007 National Survey of Mental Health and Wellbeing”, Department of Health and Ageing, Canberra.
Suarez, L., Belcher, H., Briggs, E. and Titus, J. (2012), “Supporting the need for an integrated system of care for youth with cooccuring traumatic stress and substance abuse problems”, American Journal of Community Psychology, Vol. 49 Nos 3-4, pp. 430-40.
Substance Abuse and Mental Health Services Administration (2005), Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42, Substance Abuse and Mental Health Services Administration, Rockville, MD.
Szirom, T., King, D. and Desmond, K. (2004), Barriers to Service Provision for Young People with Presenting Substance Misuse and Mental Health Problems, Australia National Youth Affairs Research Scheme, Canberra.
Towers, T. (1997), “Responding to youth drug issues”, in Helfgott, S. (Ed.), Helping Change: The Addiction Counsellors Training Program, Western Australian Alcohol and Drug Authority, Perth.
Valaitis, R. (2005), “Computers and the internet: tools for youth empowerment”, Journal of Medical Internet Research, Vol. 7 No. 5, p. e51.
Winters, K. (1999), “Treating adolescents with substance use disorders: an overview of practice issues and treatment outcome”, Substance Abuse, Vol. 20 No. 4, pp. 203-25.
Wittchen, H., Nelson, C. and Lachner, G. (1998), “Prevalence of mental disorders and psychosocial impairments in adolescents and young adults”, Psychological Medicine, Vol. 28 No. 1, pp. 109-26.