Adolescent Substance Abuse: Psychiatric Comorbidity and High-Risk Behaviors

Despite the gradual decline of illicit substance use by adolescents, the prevalence of actual substance use disorders among youths has nearly doubled over the past decade. Substance abuse among youths is a particularly complicated clinical issue, with the majority of adolescents who have substance use disorders also exhibiting other psychiatric comorbidities. Unfortunately, such co-occurring psychiatric conditions are typically unrecognized and/or untreated in this population. Even when the comorbid psychiatric conditions are identified, these youths are typically treated in a sequential manner, with some period of abstinence required before the psychiatric condition is addressed. This is of particular significance, given research demonstrating that youths with untreated comorbid psychiatric disorders typically have poorer substance use disorder treatment outcomes (1 , 2) .

Although the National Institute on Drug Abuse has included concurrent treatment for comorbid psychiatric conditions as one of the nine fundamental principles of substance use disorder treatment since 1999, less than one-half of current substance use disorder treatment facilities offer dual diagnosis programs, with the majority of these lacking the necessary components for adequate services (3) .

A variety of barriers exist that impede the effective, wide-spread implementation of truly integrated treatment for substance use disorders and psychiatric comorbidities among adolescents. These barriers include 1) a relative lack of empirical data on treatment modalities for youths with substance use disorders and psychiatric comorbidities; 2) the exclusion of these youths from psychiatric medication trials, leading to a lack of evidence of safety and tolerability of such medications in this population; 3) a lack of widespread training for clinicians in existing empirically based substance use disorder interventions; and 4) the fiscal constraints resulting from different payer sources for substance use disorder and psychiatric treatments. The topic of integrated treatment has typically been relegated to single chapters in texts on adolescent substance use disorder treatment. Adolescent Substance Abuse is the first to specifically address this issue in a direct, comprehensive manner.

Drs. Kaminer and Bukstein have included contributions from some of the top researchers in the field of adolescent substance abuse. The initial chapters of the book are focused primarily on the etiology, phenomenology, assessment, and treatment of adolescent substance use disorder. It is in the second section that the focus turns more specifically to the topic of psychiatric comorbidities. The editors have included chapters not only on the most common psychiatric conditions among youths who abuse substances, such as conduct disorder, attention deficit hyperactivity disorder (ADHD), and depression, but also on less common disorders, such as eating disorders, self-harm, and gambling. The volume ends with several excellent chapters addressing the barriers to integrated treatment and the ethical/policy issues that arise in treating this population.

Given the constraints inherent in a topic for which little empirical evidence exists, the contributors to this text have done an admirable job compiling all the relevant existing research on treatment for both adolescent substance use disorders and adolescent psychiatric conditions. For those areas in which no empirical evidence exists, the various authors also include relevant findings from adult treatment literature. The chapters are most successful when the authors have truly integrated the discussion of adolescent substance use disorder and psychiatric comorbidity, as in the chapters on ADHD, anxiety disorders, and bipolar disorder. In these chapters, you will find comprehensive discussions of the phenomenological interplay between substance abuse and the psychiatric condition, with recommendations and guidelines offered for comprehensive assessment and clinical management. In the chapters in which this does not occur, however, it only serves to underscore the current state of the science and the need for further research in this area.

With this volume, Drs. Kaminer and Bukstein have succeeded in bringing to the fore the issue of psychiatric comorbidity among adolescents with substance use disorders. It should be of interest and particular benefit to addiction researchers, clinicians working with adolescents who abuse substances, and, hopefully, to primary care physicians. What is most clear in reading this book is the imperative need for the field to increase its focus on developing empirically based guidelines for comprehensive screening and evaluation, acute integrated treatment, and ongoing continuing care for this often overlooked and underserved population.