Dual Diagnosis In Young People

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Co-Morbidity.

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Dual Diagnosis In Young People

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1. Dual Diagnosis In Young People Jo Vernon 2009

2. Co-Morbidity ‘Substance misuse in young people is frequently associated with emotional and behavioural disorder not directly attributable to the effects of the substance’ (Zeitlin,1999) Co-existing psychiatric disorder in young problematic users is the rule rather than the exception Young people will often have more than one co-morbid condition Associated with earlier onset of SM and poor ability to cope with misuse

3. How Common is it? Common and significant UK research patchy and restricted to custodial settings US: 90% clinical populations, 50% community samples (comparison problems with UK)

4. Disruptive behaviours 50-80% clinical populations Conduct disorder ADHD ODD 25% lifetime prevalence community samples Males higher rates

5. Mood Disorder 25-60% clinical populations Depressive disorder Dysthymia Bipolar l/ll 50% community samples Females higher rates

6. Anxiety Disorder 15-40% clinical populations GAD Social phobia PTSD OCD Panic disorder 16% community samples

7. Other Associated Disorders Bulimia Nervosa Schizophrenia (emerging) personality disorder Learning disability

8. Aetiology Not systematically researched Psychopathology may precede a SUD May develop as a consequence of a SUD May influence the severity of a SUD May not be related May originate from a common vulnerability

9. Family Risk Factors Association with family difficulties (Grella et al,2001 and Rowe et al,2004) Unstable/unsupportive family environment Parental ill health/violence/drug use Parental tolerance of use/deviant behaviours Attachment difficulties Looked after

10. Individual Risk Factors Early onset of substance use (before 13 major predictor) History of abuse/neglect History of violence History of reactive/impulsive behaviour Poor academic attainment Poor engagement with services Inappropriate sexual activity

11. Conduct Disorder Repetitive and persistent anti-social, aggressive or defiant conduct, which violates age-appropriate social expectations Prevalence 8% Male : Female ratio 3.5 : 1 Males more likely co-morbid SUD rates 50-80% Ingestion of certain substances may worsen aggression (alcohol, stimulants) Poor treatment prognosis (both CD and SUD)

12. ADHD Neuro-developmental disorder Inattention, impulsivity, over activity Prevalence 3-6% (40% persist in adulthood) Untreated more vulnerable to early onset SUD Co-morbid CD (20-40%) increases risk SUD considerably ? Self medication (cannabis and stimulants can improve symptoms) Use of stimulants to treat ADHD not shown to increase SUD (prudence in co-morbid/alternatives) Dual diagnosis can raise treatment issues but an integrated treatment approach is recommended Use of stimulants to treat can be protective Detection is essential (? Adults)

13. Depression Prevalence 8% (increases with age) Relationship to SUD complex (can precede or be consequent to) Females more likely co-morbid Easily missed, especially if co-morbid CD In trials SSRI’s and Lithium have produced significant improvements

14. Anxiety Disorders Increased risk SUD Finish study :Phobic YP 5X as likely to develop SUD when compared to those without, 50% becoming dependant within 3 years of onset of phobic symptoms Highlights need to screen, diagnose and treat early on

15. Psychosis Rates very low Prevalence increases from 0.9/10 000 at 13 years to 17.6/10 000 at 19 years Association with SUD (stimulants, cannabis) Recent research focuses on cannabis use

16. Cannabis and Psychosis Cannabis worsens psychotic symptoms (THC) Cannabis dependant YP increased rates psychosis Studies suggest an association between cannabis use in adolescence and subsequent development of schizophrenia Cannabis is used more widely by schizophrenics (drug of choice) than the population in general (?CBD)

17. Can Cannabis Cause Schizophrenia? Increasing evidence that Schizophrenia is a developmental disorder (disruption of cells responsible for healthy white matter formation) Frontal lobe implicated in core symptoms Frontal areas/connections mature late adolescence White matter abnormalities more severe in schizophrenic adolescents with co-occurring cannabis use Results conflict as to whether cannabis directly contributes towards disturbance of maturation Does predispose to earlier onset of illness and worse prognosis in vulnerable individuals

18. Why is it Important to Detect Co-morbidity in YP with SUD ? Associated with: Increased violence and criminality Increased suicide rates Increased service utilisation Poor prognosis Increased medical illness Increased social deprivation Early death Low detection rates

19. Key Points Dual diagnosis in young people is common Limited research base (especially UK) with respect to detection, illness patterns and effective management/treatment interventions Failure to recognise and treat has major personal, societal and prognostic implications It is estimated that in UK, of those adolescents with SUD in need of help for mental health, only about 9% receive treatment

20. Implications For Practice Consideration is given to the mental health status of all YP presenting for help with their SM Those working with young SM have some ability and experience assessment of the mental health of young people CAMHS professionals should be conversant with SM issues and be proficient at identifying such individuals

21. Mental Health Needs of Young People with SUD (Leicestershire 2006) 40 consecutive presenters (19F, 21M) to tier 3 YPSM services over 6 month period Screened SDQ Supplement questionnaire: Age, sex Whether they have sought or received help from a professional for the issues raised by the SDQ in the last month and year. Details regarding main substance of misuse and additional substances used

22. SDQ Brief behavioural screening questionnaire 11-16-year olds Robert Goodman 1997 (www.sdqinfo.com) Validated for clinical and research use Self report version takes 5 minutes to complete and provides balanced coverage of young people’s behaviours, emotions and relationships. Generates total difficulties scores covering conduct problems, hyperactivity, emotional symptoms and peer problems. Rates normal, borderline, abnormal

23. Results

24. Results Percentages

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