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LARGE YOUTH STUDY REINFORCES IMPORTANCE OF ADDRESSING SUBSTANCE USE IN MENTAL HEALTH TREATMENT

LARGE YOUTH STUDY REINFORCES IMPORTANCE OF ADDRESSING SUBSTANCE USE IN MENTAL HEALTH TREATMENT

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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 symptomsFor 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.

LIMITATIONS
  1. As a cross-sectional study, where participants were only assessed at one timepoint, causality and directionality between substance use and mental health symptoms cannot be inferred from the current work.
  2. The sample used in the current study was unusually large, yet it comes from a single outpatient mental health clinic and thus limits the potential generalizability of the results to other adolescents or other mental health settings.
  3. The study didn’t assess substance use disorder directly, only substance use frequency. Therefore, the number of participants meeting substance use disorder criteria in the sample and the extent to which the results from the current work may generalize to new samples with substance use disorders remains unclear.

BOTTOM LINE

Substance use is common among adolescents in outpatient mental health treatment, and recent substance use may be a marker of greater overall clinical risk. While techniques that identify common patterns or profiles of this co-occurrence can help identify adolescents that may most benefit from integrated mental health and substance use treatment, longitudinal studies that follow participants over many time points are needed before more concrete conclusions or treatment recommendations can be offered.

  • For individuals and families seeking recoveryCo-occurring substance use is common among adolescents in mental health treatment. This study showed adolescents with more recent substance use have a complex and more acute clinical presentation than adolescents with mental health symptoms alone. Given the risks inherent in ongoing substance use in this high-risk mental health population, findings highlight a need to understand more fully the complex and dynamic nature of the relationships among substance use and mental health to detect which youth may need integrated and formalized types of treatment, compared to those youth where substance use is more transient and less impactful.
  • For treatment professionals and treatment systemsResults confirm prior findings but using a large clinical sample and by delineating further youth subgroups. Results confirm that recent substance use remains a marker of greater overall clinical severity (e.g., self-harm, suicidal ideation/attempt) in adolescents seeking outpatient mental health treatment. The type of data-driven techniques used in the current work may one day be able to support refined diagnostic pictures that can inform treatment. However more research, particularly with longitudinal data, is required.
  • For scientists: Data-driven cluster analyses (including the latent profile analysis used in the current work) are important exploratory hypothesis generating techniques to parse mental health and substance use heterogeneity. This study adds to this literature with a relatively large sample in the understudied setting for this research area: outpatient mental health care, without substance use specialty care. The data-driven techniques and model comparison strategies suggested three clusters were optimal with the one class associated with elevated substance use likewise displaying elevated levels of emotional and behavioral mental health disorder symptoms, as well as broader clinical correlates of acuity (e.g., self-harm, suicidal ideation, and emergency room visits). However, more research is needed to both replicate and expand the current work. Repeating these analyses across multiple health care setting and with longitudinal data will be important to establish generalizability, determine causal directions between mental health difficulties, substance use, and clinical acuity, and further refine classes to determine their clinical robustness and thus potential clinical utility in developing more tailored treatments.
  • For policy makersCo-occurring substance use is common for adolescents in mental health treatment. This study used advanced mathematical modeling to identify common patterns of mental health and substance use co-occurrence for adolescents receiving mental health treatment. However, more research is needed to translate this research to clinical care. Continued support for research on substance use and mental health co-occurrence can help translate this type of research to more personalized recommendations. Continued support for investigating integrated mental health and substance use treatment models is also essential to provide existing evidence-based strategies for those adolescents in need of concomitant substance use and mental health support.

CITATIONS

Halladay, J., Georgiades, K., MacKillop, J., Lipman, E., Pires, P., & Duncan, L. (2023). Identifying patterns of substance use and mental health concerns among adolescents in an outpatient mental health program using latent profile analysis. European Child and Adolescent Psychiatry, [Epub ahead of print]. doi: 10.1007/s00787-023-02188-7

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