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SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL...

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SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages to Substance Abuse
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Page 1: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

SUSAN B. WILSON PHD MBALICENSED CLINICAL PSYCHOLOGISTASSISTANT PROFESSOR, PSYCHIATRY

UMKC SCHOOL OF MEDICINE

Depression and Adolescence: Treating Linkages to Substance

Abuse

Page 2: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Today’s objectives

Explore the impact that depression and other disorders play in triggering and maintaining adolescent substance abuse.

Discuss strategies for treating adolescents 

Considerations for culturally-responsive treatment will be offered.

Page 3: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Adolescence: the dilemma

Adolescence is a time of sweeping developmental changes in identity, mood and social adjustment

Intense peer pressure “It’s just a phase” thinkingNeuroscience research and brain developmentTeens without goals , caring adults other

protective factors are at riskSchool problems are both a risk factor and a

consequence

Page 4: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Current status

National Co-morbidity Survey found half of adolescents sampled met criteria for one or more psychiatric disorders in addition to a substance abuse disorder (Co-morbidity rates of 50-90% in later studies)

11 percent of adolescents have a depressive disorder by age 18 .

Girls are more likely than boys to experience depression.

The risk for depression increases as a child gets older.

Page 5: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Most common co-occurring disorders

Mood disordersAttention deficit disordersConduct disordersYet in many substance abuse prevention and

treatment settings for adolescents, these problems are often overlooked!

Working with adolescents with co-occurring disorders is “ a more challenging clinical phenomena that either problem alone.”Rowe et.al Impact of psychiatric co-morbidity on treatment of adolescent drug abusers. Journal of Substance Abuse Treatment, 26,129-140.

Page 6: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Teens with dual diagnoses face…

Earlier onset of substance abuse

More frequent useUse substances over

longer periodsEarly life issuesHave greater rates of

family, school, and legal problems, and

SA Treatment barriers including:

Funding Inadequately trained

staff “Abstinence first”

philosophy

Page 7: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Assessing COD in teens

Adolescent Diagnostic Interview (wps.com)

Diagnostic Interview Schedule for Children (DISC-R)

Depression screening in AOD programs

SA screening in MH settings

Page 8: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Depression: Recognizing the signs

Signs that are slightly different from the typical adult symptoms of depression.

Physical complaints, withdrawal , school problems, sulking , loss of interest/extreme boredom, negativity or feeling misunderstood.

Complicating matters, these same symptoms can be a result of drug use itself

Page 9: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Recognizing the symptoms

Emotional outbursts Acting out behaviorReckless risk-taking

behaviorExquisite sensitivityProblems fitting inExtremely low self

esteem

Page 10: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Common Dilemma

It can be hard to tell the difference between normal teen behavior and when teenagers are on drugs.

However, the combined presence of a few of the above warning signs most likely indicate a problem.

Who’s problem is it?Gateway vs. recreational?Cultural cannabis

Page 11: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Depression and substance abuse linked

 Teens who are depressed and who have probably not been diagnosed are simply seeking a release from the overwhelming hopelessness of depression=self medication

Alcohol can worsen the effects of depression; re-bound affects of stimulant drugs and marijuana can contribute to depression

Page 12: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Depression

Rates of death by suicide have increased in recent years (ages 10-14)

Teens who are bullied at higher risk

Lesbian and gay teens are thought to be 2-6 times more likely to make a suicide attempt

Can trigger attempts to self-medicate with AOD

Page 13: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

A word about …Attention Deficit Disorder

Linked to school failure and peer problems

Failure experiences lead to low self esteem

Difficulty following rules and listening can lead to conduct disorder and depression

All of the above place a teen at higher risk for substance abuse

Page 14: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Race/Ethnicity and Substance abuse

Investigators led by Duke University psychiatrist Dan G. Blazer analyzed data collected between 2005 and 2008 from confidential national surveys of 72,561 adolescents aged 12 to 17

Abuse of alcohol, marijuana, cocaine, and opioids among white, Hispanic, African-American, Native American, Asian, Pacific Islander, and multiple race/ethnicity adolescents. 

37 percent said they had used alcohol or drugs in the past year while 7.9 percent met the criteria for a substance-use disorder -

Page 15: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Race/ethnicity and substance abuse

Native Americans (31.5 percent), multiracial (25.2 percent), white race/ethnicity (25.2 percent), and Hispanics (21 percent) had the highest rates of substance-related disorders

Adolescents of African, Asian, and Pacific Islander descents abused alcohol and drugs the least. 

Marijuana was the most heavily used, followed by stimulants and then alcohol.

Trend: heroin abuse among white teens

Page 16: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

But wait a minute…

Although studies show African American adolescents abused alcohol and drugs the least=> underreporting?

More juvenile and later incarceration for drugs

Marijuana and alcohol—drugs of choice—linked to music culture

Still may increase risk factors that lead to legal and school problems for AA youth who are already at risk

Page 17: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Impact of COD on treatment Outcomes

Risk factor for relapse

Interferes with treatment engagement=>treatment drop-out=> Relapse

Pre-treatment coping skills improve outcomes

Page 18: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Implications for Treatment

Both disorders must be treated simultaneously with a flexible, behaviorally- based treatment modality +appropriate medications

Parents and teens must be educated about the link between the mood disorder and drugs

Evidence-based treatments that teach affect regulation skills are preferred

Page 19: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Treatment Principles : Depression and SA

Focus: building relationships and motivating teen to attend treatment

Using evidence-based approaches—but modify them based on cultural group

Skill-building is key: impulse control, stress management, problem solving, affect regulation (e.g. DBT methods).

Realistic changes that are sustainableMonitoring medication adherence and SA useParent involvement—especially if parents use

Page 20: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Depression + SA

The Treatment for Adolescents with Depression Study (TADS) found that combination treatment of medication and psychotherapy works best for most teens with depression.

FDA Black box warning Youth and young adults should be closely monitored especially during initial weeks ; advised against alcohol use.

Therapist with experience in SA who can assist teen with skill building and affect regulation

Page 21: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Cognitive Behavioral Therapy (CBT)

Focus is on the link between thoughts, feeling and behaviors

Replacing unhealthy thoughts and behaviors with healthy ones

Found to produce significant results in substance abuse clients

Page 22: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Family Evidenced -based treatments

Multisystemic TherapyFocus is on social and

family behaviorsEngages multiple

systems in teens life4-6 monthsSmall case loads (5-6)Counselors available

24/7Services delivered in

various locations

Other variants:Ecologically Based

Family Therapy (Homebuilders)

Behavioral Family Counseling (BFC)

Page 23: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Multidimensional Family Therapy: Use with teen Cannabis abuse

Principles of Multidimensional Family Therapy1. Adolescent drug abuse is a complex and

multidimensional 2. Problem situations provide information and

opportunity.3. Change is determined by many factors4. Motivation can change.5. Working relationships are critical.6. Interventions are individualized.7. Planning and flexibility are two sides of the same

therapeutic coin.8. Treatment is in phases9. The therapist’s responsibility is emphasized.10. The therapist’s attitude is fundamental to success.

Page 24: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Multidimensional family treatment: Cannabis abuse

The family is a primary for developing a healthy teen.

Family influence can buffer against the deviant peer subculture.

Adolescents need to develop an interdependent rather than an emotionally separated relationship with their parents.

Symptom reduction and increasing positive behaviors is key

Page 25: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Other Evidence -based Approaches

Motivational Enhancement Therapy/Cognitive Behavioral

Adolescent Community Reinforcement Approach (ACRA)—

Family Support Network (FSN)Individual Cognitive Problem Solving (ICPS)

Page 26: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Challenges with evidence-based treatments

Lack of trainingApplicability to all populationsLack of infrastructureNonetheless, utilizing some of the principles

and techniques will likely yield better outcomes than no methods

Page 27: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Applicability to cultural competence

Studies show that skill-based treatments are better accepted by culturally different individuals

Strengths-based approaches are better receivedIncorporating cultural content, values and

music can be effective, with caveatsKeep in mind that the treatment practice on

encouraging a total change in “ people, places and things” may not apply

Allowing for “structured flexibility” is essential in maintaining a treatment alliance

Page 28: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Prevention is still an important focus

Caring families, adults neighborhoodsPro-social activitiesAwareness of family SA risk factorsSchool success and life goalsCoping and problem-solving skill

developmentBreaking the cycle in familiesReducing mental health stigma and

reluctance to address mental health issues

Page 29: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

RESOURCES

Adolescent Substance Abuse: Psychiatric Comorbidity and High Risk Behaviors edited by Yifrah Kaminer, Oscar Bukstein

Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don’t Know  edited by Dwight L. Evans, M.D., Edna B. Foa, Ph.D., Raquel E. Gur, M.D., Ph.D., Herbert Hendin, M.D., Charles P. O'Brien, M.D., Ph.D., Martin E. P. Seligman, Ph.D., B. Timothy Walsh, M.D.

Adolescent Substance Abuse: Evidence-Based Approaches to Prevention and  Treatment edited by Carl Leukefeld, Thomas P. Gullotta, Michelle Staton-Tindal

http://www.nimh.nih.gov/health/publications/depression-in-children-and-adolescents/index.shtml

Page 30: SUSAN B. WILSON PHD MBA LICENSED CLINICAL PSYCHOLOGIST ASSISTANT PROFESSOR, PSYCHIATRY UMKC SCHOOL OF MEDICINE Depression and Adolescence: Treating Linkages.

Thank you for your [email protected]


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