SAN DIEGO (FRONTLINE MEDICAL NEWS)Adolescents with substance abuse and depression should be simultaneously treated for both conditions – and preferably by the same provider or clinical team, said Dr. Paula Riggs, professor of psychiatry and director of the division of substance dependence at the University of Colorado at Denver, Aurora.

“It’s hard to be successful in drug treatment under the best of circumstances. If you have an untreated Axis I mental health disorder, it’s not going to go well,” said Dr. Riggs, who is an expert in treating comorbid adolescent substance abuse and psychiatric disorders.

“Adolescent depressions usually do not remit with abstinence” from drugs and alcohol, Dr. Riggs said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. “If you have a kid walk through your door with depression and SUD [substance abuse disorder], treating the SUD won’t make the depression go away. Once you’ve got both, you’ve got two things you’ve got to address – and preferably in an integrated fashion.”

Successful treatment of childhood depression does reduce the risk of later substance abuse, especially if the depression remits within 12 weeks of starting treatment, said Dr. Riggs. “But the converse is not true,” she said.

About 25%-50% of adolescents who present for mental health treatment meet criteria for SUDs, Dr. Riggs said. And more than half of preteens with mental health problems are at risk for developing a SUD by the time they reach adolescence, she said. “By and large, psychiatric problems are pediatric-onset illnesses, and we know from ample research that most adults who suffer from addiction started using when they were adolescents,” she added.

But all too often, teens with comorbid SUD and Axis I disorders go without treatment, said Dr. Riggs.

In a recent pooled analysis of 2,111 adolescents with comorbid major depression and SUD, 48% were treated for depression and 10% received help for substance abuse, she noted. Furthermore, being in the juvenile justice system was the strongest predictor of dual treatment. “I don’t know why people aren’t up in arms about that,” she said. “We kind of require kids to fall in the hole to get treatment.”

In 2013, the Substance Abuse and Mental Health Services Administration recommended that adolescents with comorbid SUD and depression receive integrated, simultaneous treatment for both disorders, Dr. Riggs noted. No matter which problem arose first, “recovery depends on treating both the addiction and the mental health problem,” she said.

Currently, the best treatment for adolescent SUD is motivational enhancement, “totally integrated with cognitive behavioral therapy,” Dr. Riggs said. Motivational incentives should encourage attendance, abstinence, and alternative activities that do not involve drugs, she added.

Individual therapy is more effective than group therapy for treating comorbid substance abuse and psychiatric disorders. But studies also suggest that the patient’s family should be involved in treatment, Dr. Riggs said. Furthermore, coordinating mental health care, substance abuse treatment, and family therapy has been shown to significantly alleviate symptoms in patients with SUDs who also have Axis I major depressive disorder, attention-deficit/hyperactivity disorder, or an anxiety disorder, she said.

Data support the judicious use of antidepressants for adolescents who have major depressive disorder with comorbid SUD, Dr. Riggs said.

In her randomized controlled trial of fluoxetine versus placebo in teens with major depression and SUD, fluoxetine showed “about the same safety profile as in kids who were not using drugs, despite nonabstinence.” And overall treatment gains lasted for a year after treatment, she said. “If you don’t see remission in the first month of substance abuse treatment, I would not hesitate to use fluoxetine,” she added. “You have got to do a comprehensive diagnostic assessment at baseline, and get a really good longitudinal history to map symptom onset. The bottom line is, if you are carefully monitoring the substance, and if the kid is in substance treatment, continue the fluoxetine.”

Clinicians and parents should not look the other way when the substance in question is cannabis, Dr. Riggs emphasized. “Prenatal exposure to marijuana can cause irritable babies, deficits in abstract reasoning and memory, symptoms that look like ADHD, and executive functioning deficits,” she said. “Marijuana use in adolescence doubles your risk of developing depression or an anxiety disorder in your twenties. And all of it adds up to poor academic achievement and underachievement in adulthood.”

Dr. Riggs reported receiving research support from the National Institute on Drug Abuse and the ENCOMPASS substance abuse treatment program.


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