Deborah Deas

Cigarette Smoking and Psychiatric Comorbidity in Children and Adolescents

OBJECTIVE To review the current state of knowledge of psychiatric comorbidity in adolescent cigarette smokers. METHOD assisted literature search was conducted and seminal articles were cross-referenced for comprehensiveness of the search. For each disorder, a synopsis of knowledge in adults is provided and compared with the knowledge in adolescents. RESULTS Psychiatric comorbidity is common in adolescent cigarette smokers, especially disruptive behavior disorders (such as oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder), major depressive disorders, and drug and alcohol use disorders. Anxiety disorders are modestly associated with cigarette smoking. Both early onset (<13 years) cigarette smoking and conduct problems seem to be robust markers of increased psychopathology, including substance abuse, later in life. In spite of the high comorbidity, very few adolescents have nicotine dependence diagnosed or receive smoking cessation treatment in child and adolescent psychiatric treatment settings. CONCLUSIONS There is increasing evidence for high rates of psychiatric comorbidity in adolescent cigarette smokers. Cigarette smoking in adolescence appears to be a strong marker of future psychopathology. Child and adolescent psychiatry treatment programs may be a good setting for prevention efforts and treatment, which should focus on both nicotine dependence and psychiatric disorders.

A double‐blind, placebo‐controlled trial of sertraline in depressed adolescent alcoholics: a pilot study

In order to preliminarily evaluate the efficacy, safety and tolerability of the serotonin reuptake inhibitor, sertraline, in the treatment of adolescents with a primary depressive disorder and a comorbid alcohol use disorder, a 12‐week double‐blind, placebo‐controlled trial of sertraline plus cognitive behavior group therapy was conducted. Subjects were 10 outpatient treatment‐seeking adolescents. Baseline assessment included the K‐SADS, HAM‐D, SCID, and the Time‐Line Follow‐Back. The HAM‐D and the Time‐Line Follow‐Back were performed weekly thereafter. Both groups showed a significant reduction in depression scores with an average reduction between baseline and endpoint HAM‐D score of −9·8 (F(1,8)=26·14, p⩽0·001), although there were no significant group differences. There was an overall reduction in Percent Days Drinking (PDD); (F(1,8)=8·90, p<0·02) and in Drinks Per Drinking Day (DDD); (F(1,8)=20·48, p<0·002), however, there were no group differences. Depression responders tended to have higher baseline PDD than non‐responders (F(1,8)=3·9, p=0·08) and change in HAM‐D scores tended to correlate with change in PDD (r=0·57, p=0·09). Our data support that sertraline is safe and well tolerated in the treatment of adolescents with depression and alcohol dependence. Small sample size and cognitive behavior group therapy given to all subjects may limit the lack of group differences. Copyright

Bupropion SR and contingency management for adolescent smoking cessation

There is a significant need for evidence-based treatments for adolescent smoking cessation. Prior research, although limited, has suggested potential roles for bupropion sustained-release (SR) and contingency management (CM), but no previous studies have assessed their combined effect. In a double-blind, placebo-controlled design, 134 adolescent smokers were randomized to receive a 6-week course of bupropion SR + CM, bupropion SR + non-CM, placebo + CM, or placebo + non-CM, with final follow-up at 12 weeks. The primary outcome was 7-day cotinine-verified point prevalence abstinence, allowing for a 2-week grace period. Combined bupropion SR + CM treatment yielded significantly superior abstinence rates during active treatment when compared with placebo + non-CM treatment. In addition, combined treatment showed greater efficacy at multiple time points than did either bupropion SR + non-CM or placebo + CM treatment. Combined bupropion SR and CM appears efficacious, at least in the short-term, for adolescent smoking cessation and may be superior to either intervention alone.

Improving Diversity Through Strategic Planning: A 10-Year (2002-2012) Experience at the Medical University of South Carolina

The Medical University of South Carolina launched a systematic plan to infuse diversity among its students, resident physicians, and faculty in 2002. The dean and stakeholders of the College of Medicine (COM) embraced the concept that a more population-representative physician workforce could contribute to the goals of providing quality medical education and addressing health care disparities in South Carolina. Diversity became a central component of the COMs strategic plan, and all departments developed diversity plans consistent with the overarching plan of the COM. Liaisons from the COM diversity committee facilitated the development of the departments diversity plans. By 2011, the efforts resulted in a doubling of the number of underrepresented-in-medicine (URM, defined as African American, Latino, Native American) students (21% of student body); matriculation of 10 African American males as first-year medical students annually for four consecutive years; more than a threefold increase in URM residents/fellows; expansion of pipeline programs; expansion of mentoring programs; almost twice as many URM faculty; integration of cultural competency throughout the medical school curriculum; advancement of women and URM individuals into leadership positions; and enhanced learning for individuals from all backgrounds. This article reports the implementation of an institutional plan to create a more racially representative workforce across the academic continuum. The authors emphasize the role of the stakeholders in promoting diversity, the value of annual assessment to evaluate outcomes, and the positive benefits for individuals of all backgrounds.

Gender Differences in Dependence Symptoms and Psychiatric Severity in Adolescents with Substance Use Disorders

ABSTRACT One hundred adolescent inpatients (42% female) seeking treatment for a substance use disorder (SUD) were compared by gender on several substance use and psychiatric variables. Adolescents were assessed with the Comprehensive Addiction Severity Index (C-ASI) and other standardized assessment instruments. Results showed that females were more likely than males to endorse dependence symptoms and report experiencing dependence symptoms at a younger age. Females also progressed faster to regular use of drugs than males. Females were more likely than males to begin substance use with cigarettes, whereas males typically began substance use with alcohol. Suicidality was more common in females, but groups did not differ on the prevalence of depression diagnoses or on previous psychiatric treatment history. Future studies are needed to investigate possible physiologic/psychologic bases of the greater susceptibility for females to report substance dependence symptoms.

Preventing HIV/AIDS: A Brief Intervention for Adolescent Substance Abusers.

ABSTRACT HIV/AIDS infection has become a serious threat to many adolescents, as reflected by the increase in the number of AIDS cases among adolescents and young adults. Substance abusing adolescents, in particular, tend to engage in high risk HIV behaviors despite their knowledge of HIV/AIDS. To determine the effectiveness of a brief educational motivation intervention, 60 treatment-seeking male and female substance abusing adolescents were randomly assigned to an experimental intervention or to a control group. The results did not demonstrate any group differences at either 3 or 6 months follow-up after hospital discharge. Risky sexual behaviors decreased from baseline in both groups. A longer follow-up period may be required to unmask any treatment impact.

The utility of DSM‐IV criteria in diagnosing substance abuse/dependence in adolescents

The purpose of this study was to explore the utility of DSM‐IV criteria in diagnosing alcohol and marijuana abuse/dependence in adolescents. A modified version of the Structured Clinical Interview for DSM‐IV (SCID) was administered to assess substance abuse/dependence symptoms in 127 inpatient, treatment‐seeking adolescents with substance‐use disorders. The proportion of individuals with clinically relevant symptoms was examined separately for individuals classified with either abuse or dependence. Chi‐square tests of independence between the abusive/dependent classification and the presence/absence of a given symptom were also performed. Rates of DSM‐IV current substance use diagnoses were alcohol abuse 21 (16%), alcohol dependence 44 (35%), marijuana abuse 27 (21%) and marijuana dependence 72 (57%). A diagnosis of marijuana dependence was significantly more likely when tolerance symptoms were present but was not significantly dependent on the presence of withdrawal symptoms. By contrast, the presence of both tolerance and withdrawal symptoms were indicative of alcohol dependence. There was a high degree of heterogeneity of DSM‐IV dependence symptoms for both alcohol and marijuana dependence. Our study suggests that the DSM‐IV criteria have limitations in diagnosing substance‐use disorders in adolescents. A modified version of the SCID may be useful in the adolescent substance use population.

Youth Binge Drinking: Progress Made and Remaining Challenges

Despite educational and legal efforts to reduce alcohol use among youths in the United States, binge drinking (consuming five or more drinks in a row) remains a major public health concern. Alcohol-related behaviors are linked to negative psychological, physical, and social consequences, including risky sexual behaviors, suicide, and fatal automobile accidents. Binge drinking is a particularly important measure in assessing alcohol use because its consequenceValmost always intoxicationVhas specific health and psychological risks that may not occur with a single, occasional drink. Children and adolescents, who have less access to a steady supply of alcohol, may be more likely to engage in heavy drinking when they do have access. Thus, Bbinge drinking[ is an important measure of the intensity of alcohol use, although it does not necessarily translate into alcohol abuse or alcohol dependence. In this issue of the Journal, Grucza and colleagues evaluated the 30-day prevalence of binge drinking among youths and young adults in the United States during a 27-year period (1979Y2006), reporting trends of relative risk according to age, sex, and college status. Few studies have explored national trends on binge drinking over such an extended period, and Grucza et al. are to be commended for adding a longitudinal perspective to the evidence base. Their results reveal that the overall relative risk for binge drinking decreased among 12to 20-year-old male subjects but not among female subjects. Binge drinking among college students exceeded that of similarly aged peers who are not attending college. Indeed, during this period, there was no evidence of decreased relative binge drinking among 18to 20-year-old college male subjects, even as their noncollege peers showed reductions. In sum, the trends for the past three decades show progress in reducing the rates in binge drinking among male subjects only, that college-aged students of both sexes continue to drink more than their peers who are not attending college and that there are marked increases in the relative risk for binge drinking in college-attending and minority female subjects. Much progress has been made for sure, but major challenges still remain: this timely study helps us better understand those populations remaining at highest risk. For the past 32 years, the Monitoring the Future (MTF) survey has provided prevalence data on the state of licit and illicit drug use among teens, college students, and young adults. Consistent with Grucza et al., the MTF prevalence of binge drinking among high school seniors seemed to decline since 1979. The 2008 data from the MTF survey reveals significantly greater prevalence of binge drinking among college students when compared with their noncollege age peers (41% versus 34%), regardless of sex. The Bsex gap[ for binge drinking has been closing among college students since 1998, which is likely attributable to the increase in binge drinking among college female subjects and a decline among college male subjects. The Bsex gap[ is also closing for adolescent alcohol use. This may be because of changing social mores and an increasing tendency on the part of girls and young women to engage in risky behaviors that were previously more closely associated with boys and young men. The immediate lesson is that a rigorous assessment of alcohol use and consequences among female subjects is critical, although often overlooked. Driving while under the influence of alcohol, unintentional injury deaths due to alcohol, and alcohol-related sexual assault have increased among college students since 1998. We need to have a greater understanding of why college students seem to be more susceptible to binge drinking despite these worsening outcomes. The college environment may foster excessive or irresponsible drinking through its social systems, such as fraternities and sororities, celebratory postexamination parties, lack of community alternatives, and Brites of passage[ for some college students. It may be an environment where vulnerable students who engaged in binge drinking behaviors before transitioning to college will experience further escalation while in college, and the lack Accepted April 1, 2009. Drs. Deas and Clark are with the Medical University of South Carolina. Correspondence to Deborah Deas, M.D., Department of Psychiatry, College of Medicine, Medical University of South Carolina, 67 President Street, 460 IOP, Charleston, SC 29425; e-mail: deasd@musc.edu. 0890-8567/09/4807-0679 2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181a84751 E D I T O R I A L

Dual Diagnosis and Drinking Behaviors in an Outpatient Treatment Seeking Sample of Adolescents with Alcohol Use Disorders

ABSTRACT Objectives: Co-occurring psychiatric disorders are common in adolescents with substance abuse. While many studies have explored the prevalence of psychiatric disorders in adolescent substance using samples, few have explored the relationship between comorbid psychiatric disorders and drinking behaviors. This study examined this relationship to investigate whether certain psychiatric disorders impact severity of drinking behaviors in adolescents with alcohol use disorders. Methods: We examined 34 outpatient adolescents with alcohol use disorders for comorbid psychiatric disorders using the K-SADS. Their drinking behavior patterns were examined using the Time-Line Follow-Back. The alcohol drinking parameters were (1) drinks per drinking day (DDD), (2) percent heavy drinking days (PHD), (3) percent heavy drinking days when drinking (PHDD), and (4) percent days abstinent (PDA). Results: The diagnoses that afforded sufficient power to examine the effect of that diagnosis on drinking behavior were any mood or anxiety disorder vs. neither; oppositional defiant disorder (ODD) vs. no ODD; and attention-deficit hyperactivity disorder (ADHD) vs. no ADHD. Results revealed no significant effect of either ODD or any mood/anxiety disorder on drinking indices, both p values > .10; MANOVA revealed a significant effect of ADHD diagnosis, p = .04. Univariate analysis showed that for all four drinking indices, the group with ADHD had more severe alcohol use, all p values < .05. Conclusions: Our results suggest that adolescents with ADHD who meet diagnostic criteria for alcohol use disorders have greater drinking severity than those without ADHD.