1.6 The most common concurrent mental health problems

Youth & Drugs and Mental Health: A Resource For Professionals

1.6 The most common concurrent mental health problems

There are a number of mental health problems that often overlap with substance use problems. Some, such as attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, conduct and learning disorders can emerge in childhood and later increase the risk that a young person develops substance use problems. Others, such as bipolar disorder and schizophrenia tend to onset during adolescence and young adulthood, at the same time that substance use problems tend to emerge.

Attention-Deficit/Hyperactivity Disorder (ADHD)

• Symptoms are impulsivity, inattentiveness, hyperactivity and distractibility.
• ADHD starts at an early age and must be evident before age seven to be diagnosed correctly.
• Children with ADHD often do not completely “grow out of it” and go on to develop an ADHD residual syndrome.
• ADHD, conduct disorder and substance use problems often co-occur.
• ADHD frequently goes undiagnosed, sometimes resulting in self -medication through the use of stimulants or depressants depending on the symptoms the youth wants to modify.
• It is frequently misdiagnosed as other disorders or behaviours that mimic the symptoms of ADHD or that coexist with ADHD such as substance use, learning disability or Fetal Alcohol Spectrum Disorder (FASD).
• Substances such as cannabis are used by youth with ADHD to reduce impulsivity, although cannabis can also increase inattentiveness.
• Ritalin, the stimulant commonly prescribed to youth with ADHD, is the most effective treatment for ADHD symptoms, even in youth with substance use problems (Ballon, in press).

Bipolar disorder

• Bipolar disorder manifests in discrete episodes of manic moods, characterized by irritability or euphoria, alternating with depression.
• The age of onset of bipolar disorder is controversial, though most clinicians feel bipolar disorder doesn’t fully manifest until age 12.
• Among youth with bipolar disorder, substance use may begin at an early age.
• Substance use can cause bipolar symptoms to appear mixed or it can create a rapid-cycling effect.
• Substance use is found more often among people in manic episodes than in any other psychiatric disorder. Stimulants can be used to maintain the manic state and avoid or delay the depressive state. The chronic use of stimulants, however, eventually brings on depression (Ballon, in press).
• Bipolar disorder can be difficult to diagnose when there is abuse of cocaine or other major stimulants. Usually, a period of abstinence is needed for a correct diagnosis.

Conduct disorders

• Conduct disorders refer to long-standing problem behaviours such as defiance, impulsivity or anti-social behaviour that may include vandalism, fire-setting, bullying, fighting, drug use or criminal activity and a lack of concern for others (Chaim & Shenfeld, in press).
• Conduct disorders are highly linked with problem substance use and usually precede it. They are also commonly associated with ADHD.
• Youth with conduct disorders are typically risk-takers and heavy users of multiple substances because of the excitement and rush they get from drugs (CAMH, 2002a).

Depression

• Depression manifests as irritable moods, physical complaints (e.g., headaches, stomach cramps), insomnia, decreased academic functioning and/or decreased social activities.
• Depression often precedes problem substance use. It is a common practice for youth to use substances to alleviate negative feelings associated with depression.
• Stimulants can be used to increase energy in clients with depression, but they can also increase anxiety.
• Many of the drugs that depressed youth use (e.g., alcohol, marijuana) can cause greater depression with chronic use (CAMH, 2002a).
• It should be noted that withdrawal from certain substances could induce depression.

Eating disorders

• The likelihood of developing a concurrent substance use problem increases by 12 to 18 per cent among people with anorexia and by 30 to 70 per cent among people with bulimia.
• The onset of eating disorders usually occurs during adolescence.
• Young people with eating disorders tend to use substances such as nicotine, alcohol or stimulants (e.g., diet pills, caffeine pills, speed, cocaine) to suppress their appetites (CAMH, 2002a).

Fetal Alcohol Spectrum Disorder (FASD)

• FASD is a spectrum of neurological, behavioural and cognitive deficits that interfere with growth, learning, and socialization and are caused by maternal alcohol use during pregnancy.
• The symptoms of FASD can mimic many of the symptoms of ADHD, learning disorders and conduct disorders and often coexist with ADHD.
• Learning disorders
• Learning disorders are caused by “conditions of the brain” that affect the ability to take in, process or express information.
• There is a very high rate of substance use among youth with learning disorders, since they are likely to experience many of the symptoms that are high risk for drug use such as low self-esteem, academic difficulties, loneliness and depression (Chaim & Shenfeld, in press).

Post-traumatic stress

• Post-traumatic stress can manifest through symptoms such as anxiety, depression, self-harming, preoccupation with death, suicidal thoughts or gestures, and flashbacks.
• The incidence of post-traumatic stress is much higher when the young person has been emotionally, sexually or physically abused.
• People experiencing post-traumatic stress often use substances to help numb painful emotions and deal with anger (CAMH, 2002a).

Schizophrenia

• Symptoms of schizophrenia, such as psychosis, hallucinations and paranoia, usually first appear in the late teens or early twenties.
• People with schizophrenia use alcohol primarily for its euphoric and relaxing effects. Alcohol can enhance central nervous system (CNS) side effects of antipsychotic drugs, worsen extrapyramidal side effects (EPS) and also accelerate appearance of Tardive Dyskinesia. It can also increase the risk of anxiety, sleep disorders and sexual problems.
• Some research has shown that people with schizophrenia who use cannabis heavily have earlier onset of illness by five to 10 years compared to others who have not used cannabis.
• The rate of tobacco use in this population is much higher than in the general public, partially because nicotine blunts the side effects of antipsychotic medications. The incidence of Tardive Dyskinesia is much higher in smokers than non-smokers with schizophrenia.
• Psychotic symptoms that mimic schizophrenia (hallucinations, delusions, anxiety, depersonalization and paranoia) can be induced by hallucinogens such as cannabis. Hallucinogens usually cause visual effects, and chronic hallucinogen use can result in Hallucinogen Persisting Perception Disorder (HPPD), more commonly known as “flashbacks.” Flashbacks are visual pseudo-hallucinations appearing as trailing effects, halos and shifting movements from out of the corner of one’s eye. Usually people with HPPD know they are experiencing unreal phenomena, unlike those who are suffering from a psychotic illness (Ballon, in press).
• Cocaine can reduce negative symptoms and relieve feelings of depression.

Social anxiety

• Symptoms of social anxiety usually manifest as school-avoidance behaviours, poor self-image and social isolation, fear of humiliation and negative judgment.
• Initially, avoidance behaviour can protect a young person from using a substance. However, when she or he tries alcohol or other drugs, the anxiety-reducing effect of the substance can promote ongoing use (CAMH, 2002a).
• Use of substances can alleviate the symptoms of social anxiety, and youth who self-medicate in this way appear to be functioning reasonably well. However, as tolerance develops, the effects of the drugs diminish and symptoms of the anxiety can be exacerbated.
• Social anxiety can be mistaken for shyness or social skill deficits that are common developmental deficits during adolescence.
• Excessive caffeine or stimulant use by a person with anxiety disorder can mimic symptoms of anxiety and increase insomnia. It can also lead to increased heart rate, nervousness, flushed face, gastrointestinal disturbances, muscle twitching, palpitations and sweating.

Dual Diagnosis

• Young people with developmental disabilities and mental health disorders have what is referred to as a “dual diagnosis.”
• There are some specific characteristics associated with substance use among individuals with developmental disabilities.
• Substance-related disorders, like mental health problems, are linked to the degree of cognitive impairment/potential. The higher the iq, the higher the prevalence of these disorders (Campbell & Malone, 1991; Edgerton, 1986).
• The commonly held belief that people with dual diagnosis and substance-related disorders would be more vulnerable to the intoxicating effect of the substance of use has been, in part, borne out.
• People with developmental disabilities tend to drink alcohol or use illicit drugs in lower amounts compared to the general population. As a result, they are more difficult to identify. Often, caregivers consider this to be part of the individual’s “life pattern.”
• The inherent limitations that people with developmental disabilities face in their lives and the resulting anxiety and depressive disorders (Stavrakaki, 1999; Stavrakaki & Mintsioulis, 1995; 1997) tend to render these individuals more vulnerable to substance use for self-medication or stress relief (Longo, 1997; Ruf, 1999).

Mental disorders that are common in this population, such as bipolar disorder, and schizophrenia, tend to increase the prevalence of substance-related disorders in this group (Longo, 1997; Stavrakaki, 2002; Westermeyer et al., 1988).

• Print