Mental health concerns and substance use often co-occur, particularly among adolescents and young adults. This study identified common patterns of their co-occurrence for adolescents receiving mental health treatment to inform best practices for this age group.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Individuals’ first experiences with substance use often occur during adolescence. Among adolescents who use substances, those with co-occurring mental health concerns may be at heightened risk for developing a substance use disorder. New research has sought to clarify the potentially complex patterns linking multiple mental health concerns to different types of substance use and identify those adolescents that may most benefit from integrated mental health and substance use treatment.
Adolescents who use substances commonly use more than one (e.g., alcohol, cannabis, nicotine) concurrently. Likewise, it is common for adolescents to experience multiple mental health symptoms. Therefore, due in part to the multifaceted nature of both substance use and mental health symptoms, as well as their dynamic nature, understanding relevant associations between substance use and mental health, as well as specific treatment needs therein, can be particularly challenging.
One relatively new method for understanding links between multiple substance use types and mental health symptoms uses advanced mathematical modeling to identify common patterns or “clusters” of their co-occurrence. Instead of examining the average relationship between substance use and mental health symptoms in all adolescents in mental health treatment, such “cluster-based” models can help identify particular sub-types, which then allows clinicians to tailor and target treatments based on their unique clinical needs, thereby improving recovery outcomes.
In a large sample of adolescents attending outpatient mental health treatment, this study used advanced, “cluster-based” models to identify common patterns of co-occurrence of substance use and mental health symptoms.
HOW WAS THIS STUDY CONDUCTED?
This study included 916 adolescents (ages 12-17-years-old; 53% cis-gender female, 31% cis-gender male, 14% transgender or gender diverse) presenting to a generalized outpatient mental health service that does not provide specific substance use disorder treatment. Participants were consecutively recruited from all patients presenting to the clinic with no other reported inclusion/exclusion criteria.
Participants completed measures of substance use frequency in the past 6 months for alcohol, cannabis, and nicotine products (including cigarettes, e-cigarettes, and referred to in the article as (e-) cigarette/tobacco), and lifetime use (yes/no) for other drug use. The study team also assessed how frequently participants experienced symptoms of mental health disorders in the past 6 months, spanning what the authors refer to as emotional disorders (social phobia, generalized anxiety, major depressive episode) and behavioral disorders (attention deficit hyperactivity, oppositional defiant, conduct). Participants also completed measures relating to prior physical or sexual abuse, self-harm, and suicidal ideation and attempts.
As noted above, statistical analyses utilized a “cluster-based” technique (latent profile analysis) to identify common patterns (also referred to as profiles in the article) of co-occurrence between the multiple assessed substance use types and mental health symptoms. This is a data-driven technique, meaning scientists using them don’t have hypotheses per se, but instead let the mathematical model determine the number of relevant “clusters” of participants (via a series of model comparison techniques) and their relevant patterns of substance use and mental health co-occurrence. After using the model to determine the participant “clusters,” the research team also examined whether these differed with respect to key sociodemographic factors (e.g., age, race/ethnicity, etc.) and clinical variables.
WHAT DID THIS STUDY FIND?
Adolescents with high levels of substance use also had elevated mental health symptoms.
A profile that emerged from the analyses that included adolescents with the highest levels of substance use also had elevated levels of emotional and behavioral mental health symptoms, constituting 26% of the sample. Another two profiles that emerged represented patterns of low substance use but high (48%) or low to moderate (26%) levels of emotional and behavioral mental health symptoms. The figure below illustrates levels of substance use and mental health symptoms for each of the 3 profiles.
Adolescents with substance use were more clinically severe.
Compared to the group with low substance use and low symptoms of emotional and behavioral mental health disorders (-SU/-EBS), the group with substance use (who again, also had high mental health symptoms: +SU/+EBS) was older and more likely to be male. Adolescents with substance use were also more likely to display elevated overall clinical severity, including self-harm, suicidal ideation and attempt, and visits to the emergency room.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study of a large sample of adolescents in outpatient mental health treatment examined clusters of substance use and mental health symptom co-occurrence. Using data-driven techniques, the authors identified three common patterns or profiles characterized as 1) high levels of substance use and high levels of mental health symptoms, 2) low levels of substance use and high levels of mental health symptoms, and 3) low levels of substance use and low to moderate levels of mental health symptoms. These groups also importantly differed with respect to clinical correlates, with the group who had elevated levels of substance use also displaying higher levels of broader clinical severity, including self-harm, suicidal ideation and attempt, and visits to the emergency room. The results of this study thus confirm prior findings but using a large clinical sample and by delineating further youth subgroups, importantly further highlight that among adolescents in general mental health care, patients with recent substance use (e.g., in the past 6 months) are more likely to have a complex and more acute clinical presentations. This suggests the need for more consideration of integrated and collaborative substance use and mental health care.
This study adds to existing work examining the co-occurrence of substance use and mental health symptoms. For the evidence-based Adolescent Community Reinforcement Approach, in the main cannabis youth treatment study targeting those with cannabis use disorder – 60% had co-occurring conduct disorder or ADHD and 60% with one or more instances of lifetime victimization. Owing to the current study’s sample that was recruited from a general outpatient mental health treatment clinic that does not provide specific substance use disorder treatment, the current work emphasizes the need to understand the potential treatment implications of substance use and mental health disorder co-occurrence. While there are limitations of the current study to consider (see below), as more evidence is accumulated, scientists and clinicians can better take advantage of insights from studies like these to identify those adolescents that may most benefit from integrated mental health and substance use treatment.
