Psychiatric Annals

CME Article 

Double Trouble: Depression and Alcohol Abuse in the Adolescent Patient

Jodi E. Star, MD; Daniel Bober, DO; Mark S. Gold, MD

Abstract

With the recent debate about the use of psychotropic medications in children and adolescents, there has been a heightened interest in better understanding the psychiatric diagnostic and treatment process in this unique population. While it has long been known that the comorbidity of depression and alcohol use disorders is common in adults, it is only recently that this been confirmed in adolescents. The importance of the recognition of these dual diagnoses cannot be underestimated, as they have been found to have a negative impact on the course, treatment and outcome of both syndromes. With the presentation of symptoms even more difficult to delineate in adolescents, the task of appropriate diagnosis can be quite a challenge.

When an adolescent is brought for treatment, behavioral concerns are the usual presenting problem. School failure, somatic symptoms or conduct problems are often leading to difficulties in all aspects of the adolescent's life. While children are not little adults, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),1 only modifies the diagnosis of major depressive disorder in adolescents by allowing irritability instead of the necessary sadness or anhedonia needed by the general population for diagnosis. When a teenager is depressed, irritability frequently is the presenting symptom. Alcohol and substance use may be the rule rather than the exception in children and adolescents. However, parents and school generally portray the problem in terms of behavior, attitude, and grades.

Alcohol, which frequently is used socially in the adult population without psychiatric consequences, is illegal in adolescents. In adolescents and children, drinking is quite a different manner from drinking in adults. Safe drinking is an oxymoron for them. Binge drinking and drinking to get drunk are commonplace among adolescents. Adolescent alcohol use, like that in adults, varies from non-users to occasional users to compulsive users. The current DSM-IV-TR diagnostic categories for substance abuse and dependence were determined by adult studies, and their validity in adolescents has been questioned.2 Any use is an issue and problem for the adolescent.

Adolescents with a dual diagnosis of a depressive disorder and alcohol use disorder are a particular diagnostic challenge. As the symptoms of the two disorders frequently mirror one another, it is difficult to determine if one, the other, or both are present. A teenager with alcohol use can appear irritable and violent, much like the presentation of depression. Additionally, regular alcohol use and abuse is known to lead to depressed mood, lack of energy, and difficulty sleeping. In the Table, the symptoms of major depressive disorder and alcohol use disorder are contrasted to allow easier comparison.

Identify clinical symptom similarities and differences between adolescent depression and alcohol use.

Discuss the common prevalence of depression and alcohol use, as well as the dual disorders, in the adolescent population.

Describe the available efficacious, tolerable, and safe treatment strategies for comorbid depression and alcohol use in adolescents.…

With the recent debate about the use of psychotropic medications in children and adolescents, there has been a heightened interest in better understanding the psychiatric diagnostic and treatment process in this unique population. While it has long been known that the comorbidity of depression and alcohol use disorders is common in adults, it is only recently that this been confirmed in adolescents. The importance of the recognition of these dual diagnoses cannot be underestimated, as they have been found to have a negative impact on the course, treatment and outcome of both syndromes. With the presentation of symptoms even more difficult to delineate in adolescents, the task of appropriate diagnosis can be quite a challenge.

Diagnostic Dilemma

When an adolescent is brought for treatment, behavioral concerns are the usual presenting problem. School failure, somatic symptoms or conduct problems are often leading to difficulties in all aspects of the adolescent's life. While children are not little adults, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),1 only modifies the diagnosis of major depressive disorder in adolescents by allowing irritability instead of the necessary sadness or anhedonia needed by the general population for diagnosis. When a teenager is depressed, irritability frequently is the presenting symptom. Alcohol and substance use may be the rule rather than the exception in children and adolescents. However, parents and school generally portray the problem in terms of behavior, attitude, and grades.

Alcohol, which frequently is used socially in the adult population without psychiatric consequences, is illegal in adolescents. In adolescents and children, drinking is quite a different manner from drinking in adults. Safe drinking is an oxymoron for them. Binge drinking and drinking to get drunk are commonplace among adolescents. Adolescent alcohol use, like that in adults, varies from non-users to occasional users to compulsive users. The current DSM-IV-TR diagnostic categories for substance abuse and dependence were determined by adult studies, and their validity in adolescents has been questioned.2 Any use is an issue and problem for the adolescent.

Adolescents with a dual diagnosis of a depressive disorder and alcohol use disorder are a particular diagnostic challenge. As the symptoms of the two disorders frequently mirror one another, it is difficult to determine if one, the other, or both are present. A teenager with alcohol use can appear irritable and violent, much like the presentation of depression. Additionally, regular alcohol use and abuse is known to lead to depressed mood, lack of energy, and difficulty sleeping. In the Table, the symptoms of major depressive disorder and alcohol use disorder are contrasted to allow easier comparison.

Symptoms of Major Depressive Disorder Versus Alcohol Use Disorder

Table.

Symptoms of Major Depressive Disorder Versus Alcohol Use Disorder

Epidemiology

Both depressive illness and alcohol use are common in the adolescent population. Studies have estimated the prevalence of major depressive disorder to be 5%. However, the rates quoted vary significantly depending on the population examined, the diagnostic criteria used, and the method of assessment. Another 3.3% of adolescents meet diagnostic criteria for dysthymia. Of importance, many more youths have depressive symptoms than have full major depression or dysthymia.

Alcohol use in adolescents has been essentially stable since the year 2000. According to the National Survey on Drug Use and Health of 2003, about 10.9 million people ages 12 to 20 reported drinking alcohol in the month prior to the survey.3 This constituted 29% of this age group. Further divided, 19.2% were defined as binge drinkers, while 6.1% were determined to be heavy drinkers.

Another study, the Monitoring the Future Study,4 investigates lifetime, annual, monthly, and daily use of substances of abuse in three adolescent age groups: eighth grade, tenth grade, and twelfth grade students. Overall, the percentage of teenagers who have used alcohol increases with age, with eighth graders always using less than twelfth graders. Lifetime use of alcohol is staggering, with more than 75% of twelfth graders having tried alcohol. Even more concerning is the 18%, 35%, and 48% of students in their respective grades stating use in the last month. Daily use was found in 1.3% of tenth graders and 2.8% of twelfth graders.

Several epidemiologic samples have focused on the relation between adolescent depression and substance use in general. One longitudinal study of female high school students found those with depression were more likely to abuse substances (18.2%) than those without depression (6.3%).5 This was found to be true even after a 4-year follow-up. In this study, the presence of substance abuse more than doubled the likelihood of developing a major depressive episode within three years of graduating high school. Specific information regarding depression and alcohol use has been gathered via a large sample of high school students. It was noted that the students with major depressive disorder who were re-evaluated after 1 year had a 13% higher chance of having an alcohol use disorder.6

Assessment

All adolescents who present with mood symptoms should be screened for alcohol abuse, and all those presenting for alcohol treatment should be screened for a depressive disorder. This is especially important considering that early diagnosis and treatment improves outcomes. One of the most important questions to answer in the assessment process of an adolescent with a suspected dual diagnosis of a depressive illness and alcohol abuse disorder is determining if there are one or two primary illnesses. Almost 25% of adolescents in residential substance abuse treatment were found to meet criteria from the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III),7 for major depressive disorder, with 8% having a primary depressive disorder and the remainder with a secondary depressive illness.8 Unlike adults, however, teenagers seem to continue with depressive symptoms even after a significant period of abstinence.9

While comorbidity is frequent, transient substance-induced symptoms must be differentiated from a mood disorder through observation during a period of abstinence. The recommended duration of abstinence necessary for accurate diagnosis is 30 days. However, in treatment for addiction, psychiatric disorders, or both, the patient should be monitored carefully for mood and suicidal ideation.

Collateral history is integral in the proper assessment of any adolescent patient. Frequently, the teenager will minimize or deny symptoms that are imperative to proper diagnosis and treatment. Often, the adolescent patient cannot provide a complete family history. Both depressive illness and alcoholism have documented genetic vulnerability, with estimates from epidemiological studies indicating at least 40% for addiction and 24% to 58% for depression.10 Thus, this information is a necessary piece of the diagnostic puzzle.

Screening for psychiatric disorders in people with substance use disorders is an underinvestigated area and may be particularly problematic because of symptom overlap during periods of intoxication or withdrawal. A short questionnaire, called CRAFFT (Sidebar), was developed specifically to be used in this population.11 This screening instrument is quick and easy to administer. If two or more questions are answered yes, this suggests a serious problem, with further investigation being warranted.

Sidebar.

The CRAFFT Questions

  • C — Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
  • R — Do you ever use alcohol/drugs to Relax, feel better about yourself, or fit in?
  • A — Do you ever use alcohol/drugs while you are by yourself or Alone?
  • F — Do you ever Forget things that you did while you are using alcohol/drugs?
  • F — Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
  • T — Have you ever gotten into Trouble while you were using drugs or alcohol?

The CRAFFT Questions

Several other screening methods are appropriate for use in adolescents. The Children's Depression Inventory is a brief self-report test that helps assess cognitive, affective, and behavioral signs of depression in children and adolescents ages 6 to 17.12 It contains 27 items, is quick and easy to complete, and has good reliability and validity in this population. Another screening method that can be used in the adolescent population is The Rutgers Alcohol Problem Index.13 This 23-item self-report measure focuses on negative consequences that the adolescents attribute to their alcohol use. High scores indicate greater difficulties with alcohol. This screening method possesses good internal consistency and correlates well with other markers of problem drinking. The Beck Depression Scale, frequently used in the adult population, has good validity in the adolescent population;14 the CAGE questionnaire, however, is not particularly useful for adolescents.15

Prognosis

An adolescent with depression and alcohol use disorder has many factors that will determine the prognosis. Historically, these patients are described as “double trouble,” suggesting that they have a more difficult time reaching symptom remission.16–19 A recent study demonstrated that major depressive disorder comorbid with alcohol use disorder in adolescents is associated with an earlier relapse to alcohol use.20 These results are consistent with the results of previous studies involving adults with past alcohol use disorders21,22 and extend the results of previous work involving adolescents with alcohol use disorders.23,24

Other factors are known to play a role in the determining prognosis in adolescents with substance use and mood disorders. For example, physical and sexual abuse in childhood have been shown to be associated with continued alcohol use and depression into young adulthood.25

Suicidal ideation and behavior in this population also limit long-term prognosis and survival. Alcohol use alone has been implicated consistently in adolescent suicide. Accumulating evidence supports that substance abuse is an independent risk factor for suicidal ideation, attempted suicide and completed suicide.26–33 Additional data support a specific association between alcohol intoxication and suicide by firearms among adolescents.34 In this dual-diagnosis population, where depression itself is an independent risk factor for suicide, heightened awareness and appropriate interventions are critical.

Treatment

Comorbidity has implications for prevention and treatment. Mood disorders are known to increase the vulnerability for substance abuse, and thus diagnosis and treatment of depression could help prevent drug abuse. To date, no treatment modality has been shown to be more efficacious than any other in treating adolescent substance abuse.35 Therefore, it is the severity of the depressive symptoms that determines level of care. If an adolescent has suicidal or homicidal thoughts, has attempted suicide, or has associated psychotic symptoms, inpatient psychiatric hospitalization is appropriate. Additional factors such as level of functioning and home environment would be crucial pieces of information to help determine level of care.

While antidepressants have been shown to play a role in the treatment of adult dual diagnosis patients, it is incorrect to assume that data from the adult population can be generalized to adolescents. However, fluoxetine has been investigated in the treatment of adolescent dual-diagnosis patients. Cornelius et al.36 conducted a 12-week open-label study of fluoxetine (20 mg) in 13 adolescents with current comorbid major depression and alcohol use disorder. While fluoxetine or any SSRI will not cure alcohol dependence, a significant improvement was found for both depressive symptoms and drinking during the course of the study. Extrapolating on this information, we now believe anti-depressant play an important role in the treatment of adolescents with both mood and alcohol disorders.

Nonpharmacologic Interventions

Nonpharmacologic interventions are imperative to the treatment of any adolescent with a psychiatric disorder. Dual-diagnosis patients are no different, except they should be treated vigorously for both their mood and addictive disorders. Therapy builds skills that can be used while the patient is acutely ill as well as in the future.

Additionally, learning to self-regulate negative feelings can help the adolescent build self-confidence and feelings of mastery. Therapy also may help patients break out of the mindset of using external agents to combat intolerable feelings.

Individual Therapy

In the adolescent population, nonpharmacologic treatments have been found to be effective for the treatment of patients with a psychiatric and substance use disorders. In teenagers with major depressive disorder, cognitive-behavior therapy (CBT) is considered the initial treatment of choice. Numerous studies have confirmed that CBT results in a rapid and moderate to large effect on symptom reduction.37 CBT has also been found to be an effective intervention in the substance abusing adolescent patient. For instance, Azrin and colleagues38,39 compared the effectiveness of a behavioral outpatient treatment program to that of a supportive counseling program. In the behavioral program, the number of adolescents using drugs by the end of treatment decreased by 73%, compared with a decrease of only 9% of those receiving the comparison treatment.

Preliminary studies comparing different psychotherapies have been completed in the dual-diagnosis adolescent patient. The studies have not been specific for alcohol users and have not separated treatment results according to internalizing or externalizing diagnoses. However, CBT appears to be superior to other therapies in the early stages of substance treatment. Kaminer and Burleson40,41 compared CBT to interactional treatment and psychoeducational therapy in two separate studies. While all interventions were effective in reducing rates of substance use, CBT across studies showed an earlier more robust treatment response.

Family Therapy

While family therapy often is included in the comprehensive treatment plan of the depressed adolescent, it is not considered the mainstay of treatment. However, family therapy is used frequently and has been shown to be effective in the treatment of adolescent substance abuse. Redefining substance use as a family problem, reestablishing parental control, and interrupting dysfunctional family behavior are critical to its success.

A study of family therapy with behavioral interventions found it significantly more effective than supportive therapy alone.42 After 6 months, the treatment group had an abstinence rate of 73%, with only a 9% success rate in the supportive group.

12-Step Programs

The 12-step approach, also known as the Minnesota Model or the Alcoholics Anonymous (AA) approach, is the most widely used model in the treatment of adolescent drug abusers. Based on the tenets of AA and basic psychotherapy, the 12-step model views “chemical dependency” as a disease that must be managed throughout one's life, with total abstinence as a goal.43 The backbone of 12-step treatment is step work, a series of treatment and lifestyle goals that are worked in groups and individually. Step work provides the basic structure for treatment and recovery.

Studies show that at 6-month follow-up, program completers had a significantly higher abstinence rate than non-completers.23,43,44 Results at 1- and 2-year follow-ups, however, are mixed. A study by Winters et al.43 found completers' outcomes to be far superior to noncompleters' at the 12-month follow-up. However, Alford et al.44 reported that abstinence rates fell sharply for boys and slightly for girls at 1 year post-treatment. There was no significant difference between completers and noncompleters by 2 years post-treatment.

It is important that dually diagnosed adolescents choose 12-step recovery groups in which they are not likely to receive mixed or negative messages about the use of psychotropic medications under the directions of a physician.

Summary

There is growing interest in the co-occurrence of depression and alcohol use disorders in adolescents. It is now well documented that both diagnoses are quite common in teenagers, even in the same patient. The diagnostic issues of comorbid alcohol use disorders and depressive illnesses are particularly difficult because of the substantial symptom overlap between substance intoxication and withdrawal and depression, especially in adolescents. It is only recently that treatment in the adolescent dual diagnosis population has been investigated specifically.

Currently, psychotherapy, specifically CBT for the identified patient, plus addiction treatment, are indicated. Investigation regarding the use of pharmacologic interventions in adolescents with depressive and alcohol use disorders is still in its infancy. Adolescent suicide prevention often revolves around prevention of alcohol and other illicit substance use, prompt identification of dual disorders, and aggressive treatment for both in a hospital setting. Although current research is beginning to understand the complexity of the dually diagnosed adolescent with major depressive disorder and alcohol use disorder, much work is still to be done in this area.

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Symptoms of Major Depressive Disorder Versus Alcohol Use Disorder

Major Depressive DisorderAlcohol Use Disorder
MoodSad, irritableMay be euphoric or irritable during use; irritability common in withdrawal, depressed mood found in frequent users
SleepDifficulty initiating and maintaining sleep; frequently with hypersomniaLeads to changes in sleep architecture
InterestDecreasedMay lead to apathy
GuiltCommonFrequent, especially after heavy use
ConcentrationDecreasedAltered during intoxication and withdrawal
AppetiteIncreased or decreasedMay increase appetite; high caloric intake associated with alcohol can lead to weight gain
Pleasurable activitiesLess involvedFrequently, time is spent acquiring alcohol; patient may be too intoxicated to participate in prior enjoyed activities
SuicideCommonIncreases risk independent of depression

Educational Objectives

  1. Identify clinical symptom similarities and differences between adolescent depression and alcohol use.

  2. Discuss the common prevalence of depression and alcohol use, as well as the dual disorders, in the adolescent population.

  3. Describe the available efficacious, tolerable, and safe treatment strategies for comorbid depression and alcohol use in adolescents.

Sidebar.

The CRAFFT Questions

  • C — Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
  • R — Do you ever use alcohol/drugs to Relax, feel better about yourself, or fit in?
  • A — Do you ever use alcohol/drugs while you are by yourself or Alone?
  • F — Do you ever Forget things that you did while you are using alcohol/drugs?
  • F — Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
  • T — Have you ever gotten into Trouble while you were using drugs or alcohol?

The CRAFFT Questions

Authors

Dr. Star is assistant professor, Department of Biomedical Sciences, Florida Atlantic University, Boca Raton, FL. Dr. Bober is a fellow in child and adolescent psychiatry, Yale Child Study Center, New Haven, CT. Dr. Gold is distinguished professor, Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health, and Family Medicine, University of Florida College of Medicine, Gainesville, FL.

Address reprint requests to: Mark S. Gold, MD, University of Florida College of Medicine, PO Box 100183, Gainesville, FL 32610; or e-mail msgold@psychiatry.ufl.edu.

Dr. Star is on the Speakers' Bureaus for AstraZeneca, Janssen, and Pfizer. Dr. Bober and Dr. Gold-have no industry relationships to disclose.

10.3928/00485713-20050601-06

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