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  • Making the Case for Assessing Co-occurring Disorders in Adolescents

  • By Anthony Spirito, Ph.D., ABPP

    December 2010. Vol. 26, No. 12

    Mood disorders accompanied by substance use and abuse in adolescents can complicate the treatment process and negatively affect outcomes in depression treatment. However, substance use is not routinely assessed in outpatient psychotherapy practice.

    December 2010 Vol. 26, No. 12

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    This article was published in the Brown University Child and Adolescent Behavior Letter
    in cooperation with Bradley Hospital.

    How screening falls short

    We recently conducted a survey of 30 treatment providers from both substance abuse and mental health clinics regarding common practice in the assessment and treatment of co-occurring depression and substance use disorders in adolescence (Lichtenstein, Zimmerman, & Spirito, in press). We found that the use of structured self-report and interview assessment/ screening methods is uncommon.

    Although mental health providers were four times more likely to formally assess for depressed mood in their adolescent patients than substance use providers, only 30% of the mental health clinic therapists in this sample did so. Even fewer clinicians (23%) formally screened for substance use, although substance use providers were 10 times more likely to do so than mental health providers. Thus, clinicians were unlikely to formally assess for disorders outside of their main area of expertise: only one mental health provider reported formal screening for substance use, and only one substance use provider reported formal screening for depression. Several published studies have reported similar findings.

    Importance of a structured interview

    It is not surprising that a small number of clinicians reported using formal assessment measures. Standard practice is to conduct an informal or unstructured "clinical interview" to generate diagnostic information and determine a basic treatment plan. Nonetheless, mental health providers may be missing substance use in adolescents who present with behavioral or emotional concerns if they do not systematically assess for its presence.

    There are other potentially significant problems with reliance on clinical impressions to derive diagnostic information and treatment plans. Chief among them is the possibility that the diagnosis may be incorrect, or that a primary diagnostic emphasis is given to a condition that is not the most pressing concern. Jensen-Doss and Weisz (2008) found that diagnostic agreement (between a clinical diagnosis and a research-generated diagnosis) predicted fewer treatment no-shows, cancellations, and drop outs.

    Cases in which there was "disagreement" were five times more likely to drop out of treatment against clinician advice. Jensen- Doss and Weisz also found some evidence to suggest poorer treatment outcomes for adolescents with diagnostic mismatch. When substance use and depression are involved - both risk factors for suicidal behavior - misdiagnosis could have serious treatment implications. Thus, structured assessments in this population appear particularly important. It is not only prudent to formally assess substance use at intake but to continue to assess for substance use as therapy proceeds. Adolescents may be more willing to disclose substance use after establishing a therapeutic relationship.

    The rarity of formal assessment is especially noteworthy given that the respondents in our survey felt that they commonly saw adolescents with depressive and substance use disorders and epidemiologic studies support their impressions. My own impressions from providing psychotherapy supervision to psychology and psychiatry residents and fellows over the last 25 year is that mental health clinicians vary greatly about whether to formally assess and when to treat, refer, or ignore substance use in their depressed adolescent patients.

    This may be a function, of limited training in substance use treatment, or a provider's own personal experience with alcohol and marijuana as an adolescent. For many, they ponder the question: At what point does a developmentally appropriate task, experimentation with substances, negatively affect therapy with an adolescent referred for a primary mental health disorder?

    Impact of substance use on MDD outcomes

    A recent psychotherapy and medication treatment study of adolescents with treatment resistant depression (TORDIA) included adolescents with Major Depressive Disorder (MDD) but excluded MDD adolescents with substance use disorders as part of the screening process for enrollment. Nonetheless, more than half the study sample reported using substances at least once and 25% reported experimentation three or more times at their baseline assessment.

    My colleagues and I (Goldstein et al., 2009) conducted post-hoc analyses in which we calculated a substance use impairment rating and then examined its effect on the depression outcome data from TORDIA. We found that there was significant improvement in substance-related impairment among MDD responders. MDD response after 12 weeks of treatment was greatest for teens with low 12-week substance-related impairment, regardless of whether they had high or low baseline substance-related impairment. MDD response at 12 weeks was significantly lower among teens with high 12-week substance- related impairment.

    Although the adolescents in TORDIA were somewhat atypical in that they had already failed treatment with antidepressant medication, these findings suggest that it is important to characterize substance- related impairment even among teens with MDD who do not have a substance use diagnosis.

    Need for evidence-based treatment approaches

    In the survey mentioned above, very few (10%) of the 30 providers reported being aware of or using treatment protocols specifically designed to treat cooccurring depression and substance use in adolescents. Thus, it is possible that many adolescents with co-occurring conditions are being adequately treated only for one condition (i.e., depression or substance abuse), whichever one is identified as primary by their treating clinician. Several specific therapeutic approaches (e.g., ecological family therapy, cognitivebehavioral therapy (CBT), and brief motivational interventions) have shown superiority to treatment as usual in studies of adolescent substance use.

    It is important to characterize substance-related impairment even among teens with MDD who do not have a substance use diagnosis.

    Because these approaches, especially CBT, have also shown success in treating other adolescent mental health concerns including depression, providers may have increased success in treating comorbid conditions in adolescents if such evidence- based treatment approaches were used more commonly. Interestingly, 29 of the 30 providers reported that they would like to have access to such protocols and indicated they would have an average of almost 8 hours of professional time for training in such an intervention.

    Despite its small size, our survey makes a simple yet important point: community- based mental health and substance use treatment providers are not routinely assessing for co-occurring mental health and substance use disorders in their adolescent clients. Such practice is strongly recommended and there are numerous self-report measures available for such purposes. Furthermore, clinicians are rarely using treatment protocols (evidence-based or otherwise) for these adolescents with multiple problems.

    Here the blame lies elsewhere. Very few studies have examined the effects of substance use on the treatment of adolescent depression. Even more rare are studies examining the treatment of both depression and substance use in adolescents. Thus, it is important that the field develop, test, and ultimately train clinicians in such protocols.

    Anthony Spirito, Ph.D., ABPP, is a clinical child psychologist who conducts treatment research in adolescent depression/suicidality and substance abuse. He is Professor and Director of the Division of Clinical Psychology in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University.


    Goldstein BI, Shamseddeen W, Spirito A, et al.: Substance use and the treatment of resistant depression in adolescents. JAACAP 2009; 48:1182-1192.

    Jensen-Doss A, Weisz JR: Diagnostic agreement predicts treatment process and outcomes in youth. J Consult Clin Psychology 2008; 76(5):711- 722.

    Lichtenstein D, Zimmermann R, Spirito A: Assessing and treating co-occurring disorders in adolescents: Examining typical practice of community- based mental health and substance use treatment providers. Community Mental Health J (in press).