Yifrah Kaminer

Patterns of Affective Comorbidity in a Clinical Population of Dually Diagnosed Adolescent Substance Abusers

Patterns of affective comorbidity with substance abuse are examined in a sample of 156 adolescent psychiatric inpatients, ages 13 to 18 years old. Affective disorders, including adjustment disorder with depressed mood, were observed in 51.3% of patients. A total of 30.7% of patients had comorbid major depression. In both males and females, secondary major depressive disorder was more common than its primary form. In this population, the primary-secondary paradigm did not predict either acute remission for depressive symptoms or distinct family history of comorbid disorders. Consistent with previous studies of adults, significantly more females had comorbid affective disorder and significantly more males had conduct disorder.

The Teen-Addiction Severity Index: Rationale and Reliability

There is an urgent need for a reliable method of evaluating the severity of adolescent chemical abuse and problems related to chemical abuse. The lack of an appropriate rating scale to fill this objective hampers the design and the assessment of objective treatment outcome and follow-up of adolescent chemical abusers. The Teen-Addiction Severity Index (T-ASI) is a structured interview which was developed to assess the seven following domains: chemical use, school status, employment-support status, family relationships, peer-social relationships, legal status, and psychiatric status. This paper discusses the rationale for the design of the T-ASI and presents a preliminary study indicating satisfactory interrater reliability of the rating scale.

Psychotherapies for adolescent substance abusers : A pilot study

This study tested the hypothesis that dually diagnosed adolescent substance abusers could be matched to effective treatments on the basis of their comorbid psychopathology. Specifically, patients with externalizing disorders would have better outcomes when treated with cognitive-behavioral group treatment (CBT), and subjects with internalizing disorders without comorbid externalizing disorders would fare better in interactional group treatment (IT). Thirty-two dually diagnosed adolescent substance abusers were randomized into two 12-week manual guided outpatient group psychotherapies: CBT and IT. At 3-month follow-up, no patient-treatment matching effects were identified. Adolescents assigned to CBT demonstrated a significant reduction in severity of substance use compared with those assigned to IT. Improvement in severity of family function showed a trend in favor of CBT. School function, peer-social relationships, legal problems, and psychiatric severity all showed a consistent nonsignificant direction in favor of CBT over IT. CBT appears to be a promising short-term psychosocial intervention for adolescents.

Comparison between Treatment Completers and Noncompleters among Dually Diagnosed Substance-Abusing Adolescents

The psychiatric and demographic characteristics that may distinguish treatment completers from noncompleters among hospitalized adolescents with substance abuse and comorbid psychiatric disorders were examined. Affective and adjustment disorders were more prevalent among treatment completers whereas non-completers were more likely to be assigned a conduct disorder diagnosis. There were no differences between the groups with respect to demographic and legal status, education level and lifetime psychiatric diagnosis in the parents or caretakers, living arrangements, treatment history, and perception of treatment benefits. A higher percentage of treatment completers than noncompleters received psychotropic medications. The factors contributing to treatment termination as well as the clinical and research implications of the findings are discussed.

Efficacy of Outpatient Aftercare for Adolescents With Alcohol Use Disorders : A Randomized Controlled Study

OBJECTIVE Relapse rates for treated adolescents with alcohol use disorders (AUDs) amount to approximately 60% at 3 to 6 months after treatment completion. This randomized controlled study tested the hypothesis that active aftercare may maintain treatment gains better than no active aftercare (NA). METHOD A total of 177 adolescents, 13 to 18 years of age, diagnosed with DSM-IV AUD, participated in nine weekly outpatient cognitive behavioral therapy group sessions. The 144 treatment completers were randomized into a 5-session in-person, brief telephone, or NA condition. Three alcohol use variables were the main outcome measures for 130 aftercare completers. RESULTS At the end of aftercare, the likelihood of relapse increased significantly compared with end of treatment outcomes. The likelihood of relapse for youths in NA, however, increased significantly more for youths in combined active aftercare (AA) conditions (p =.008). This effect was driven primarily by a significant sex x active aftercare interaction: girls showed no significant relapse under AA but relapsed significantly in NA. Youths enrolled in AA also showed significantly fewer drinking days (p =.044) and fewer heavy drinking days (p =.035) per month relative to NA. CONCLUSIONS In general, active aftercare interventions showed certain efficacy in slowing the expected posttreatment relapse process for alcohol use, with maintenance of treatment gains only for girls. Frequency of interventions, dose-response, duration of aftercare phase, and mediators of behavior change should be examined further to optimize aftercare for youths with AUD.

The magnitude of concurrent psychiatric disorders in hospitalized substance abusing adolescents

Data regarding the concomitant occurrence of substance abuse and other psychiatric disorders in an inpatient treatment program for adolescents is presented. Comparison with three other similar studies reveals that conduct and mood disorders appear to be the most prevalent concurrent diagnoses of inpatient adolescent substance abusers.

Measuring treatment process in cognitive-behavioral and interactional group therapies for adolescent substance abusers.

The state of the art for treatment efficacy studies now requires manual guided treatments and tests of therapist adherence. This report provides findings regarding adherence assessment of therapists participating in an investigation of treatment matching in adolescent substance abusers. The Group Sessions Rating Scale (GSRS), a group-therapy process measure, was studied to determine its appropriateness for assessing group treatment of adolescents with a) substance use disorders (SUD), b) interrater reliability, c) internal consistency, and d) ability to discriminate the active ingredients of cognitive-behavioral therapy (CBT) from interactional therapy (IT). Interrater reliabilities were moderate to high, with those for CBT generally higher than those for IT. Internal consistency of CBT items was moderate, whereas those of IT were moderately high. Discriminability between the two treatment modalities was high. The frequency of active ingredients was generally therapy-specific: high for the relevant and low for the nonrelevant therapeutic modality items. The GSRS was found to be effective in the measurement of treatment process in adolescents with SUD.

ADDICTIVE DISORDERS IN ADOLESCENTS

Physicians should recognize the importance of individual differences in the etiologic pathway to drug abuse. Drug use in most adolescents subsides or stops by adulthood; however, adolescents with behavioral or affective dysregulation, poor social skills, a limited social network, and substance abuse during late adolescence are at increased risk for substance dependence in adulthood. Research is needed, however, to clarify the developmental emergence and interaction between individual and contextual risk factors. Understanding person-environment processes within a developmental perspective not only yields a better understanding of the causes but also informs about taxonomy, prevention, and readiness to change and compliance in treatment and after-care. Treatment outcome research suggests that (1) relapse is likely to occur within the first 3 months after treatment completion and, to a lesser extent, over the year following treatment completion; (2) relapse is more likely in adolescents who have comorbid psychiatric disorders and other problems, such as high stress, low social skills, lack of involvement in productive activities or active leisure, and no follow-up intervention; (3) continued after-care treatment may maintain treatment gains; (4) the effectiveness of treatment and aftercare is likely to vary by the amount, mode, and the consistency with which it is delivered; (5) gender differences might have an impact on treatment outcome; and (6) adolescents presenting for treatment are likely to respond well to interventions based on family therapy and CBT approaches.

Screening and Assessing Adolescent Substance Use Disorders in Clinical Populations

When faced in a clinical setting with an adolescent suspected of or known to have a substance abuse problem, it is important to integrate the assessment process with treatment decisions. The initial phase involves efficient identification of substance use and related problems, psychiatric comorbidity, and psychosocial maladjustment.1 This objective can be achieved by the use of screening instruments as a brief first step for the assessment of drug use before moving, if necessary, to the second step of comprehensive assessment of problem severity once it becomes clear that the adolescent may meet criteria for a substance use disorder (SUD). The result of this assessment is a diagnostic summary that identifies the adolescent treatment needs.2 Finally, an integrative treatment plan is developed to target multidimensional areas of dysfunction, which includes psychiatric comorbidity,3 as well as potential problems in the school, family, peer, and legal domains. With 6.0% and 5.4% of youths ages 12 to 17 years classified as needing treatment for alcohol use and illicit drug use, respectively,4 and with substance use during adolescence appearing to lead to a much greater rate of a current SUD compared to rates if drug use occurs later in life,5 these are important public health issues. Reports on performance of pediatricians who customarily see youths for periodic checkups and address their medical needs have not been encouraging. Less than half of the pediatricians surveyed reported screening adolescents for use of tobacco, alcohol, and other drugs, and less than one fourth acknowledged feeling comfortable conducting a comprehensive assessment or offering or making referral for treatment.6–8 The reasons for these troubling figures have been summarized as follows: insufficient time, lack of training to manage positive screens, need to triage competing medical problems, lack of treatment resources, unfamiliarity with screening tools, and tenacious parents (who may not readily leave the room).9 There are no similar reports addressing how prepared child and adolescent psychiatrists (CAPs) are to follow the task at hand. Based on our own clinical and teaching experience, the quantity and quality of training devoted to the screening and assessment of youth substance use, abuse, and dependence in medical schools and psychiatric residency/fellowship training are often insufficient. Little, if any, training is given on how to screen and assess for substance involvement and related problems and on what tools are available to assist with this process. Therefore, the objectives of this column are, first, to introduce several established screeners and comprehensive assessments, and, second, to make recommendations as to standards of training and professional proficiency.

Insulin misuse: a review of an overlooked psychiatric problem.

A number of forms of insulin misuse, other than the usual noncompliance, have been reported in the literature on the treatment of diabetes mellitus. These include attempted and completed suicide, factitious hypoglycemia, Munchausen syndrome by proxy, and the use of insulin by substance abusers. Such misuse has involved diabetic patients, their family members and medical staff, as well as others. The reports of suicide attempts reveal an equal distribution of misuse between the sexes (rather than the expected preponderance of females), underrepresentation of adolescents, and a high rate of recurrence. Recommendations for treatment are discussed for clinicians and investigators regarding this overlooked problem.