Psychiatry 2008 - September 2008 - (Page 35)

depression using a case example of an adolescent with cannabis use disorder and major depressive disorder. CASE EXAMPLE Joe was a 15-year-old Caucasian boy who, following an arrest for drug dealing, was referred by a juvenile drug court social worker for psychiatric and substance abuse evaluation and treatment. Joe started smoking marijuana at age 13 after his older brother introduced the drug to him. Joe gradually escalated his use of marijuana over the past three years and upon presentation smoked 1 to 2 joints daily. He reported a calming effect from the marijuana and frequently went to school “high.” Beginning this year, Joe occasionally worked for a drug dealer distributing marijuana to students on the grounds of his high school where he was a freshman. Joe started smoking cigarettes at age 11 and upon presentation was smoking half a pack per day. He started drinking alcohol at age 13, and in the last year he would regularly consume one six-pack of beer on Friday and Saturday nights to the point of intoxication. All of Joe’s friends were drug and/or alcohol users. Joe never drove a car, although he was a passenger in a car several times that was driven by a friend who was under the influence of drugs or alcohol. Joe was not sexually active. Joe was an average student whose grades gradually deteriorated since seventh grade. Despite a full-scale IQ of 106, he had to make considerable effort in order to complete his work in school. At time of presentation, he had a Caverage and his attendance was compromised. He was repeating ninth grade. When Joe was 11 years old, his mother died in a car accident. She was in treatment for unipolar depression. When he was 14 years old, he was diagnosed with depression after he reported intense symptoms dating to the loss of his mother consisting of daily anhedonia and boredom, irritability, and uncontrollable anger, especially when he perceived himself 35 as being provoked. He was referred to an anger management group but did not attend. He was prescribed sertraline but took it only briefly. He did not disclose his substance use at that time. At presentation, Joe lived with his biological father who worked as an electrician, a 13-year-old sister, and his 19-year-old brother. His brother never graduated from high school, was unemployed, and was a heavy cannabis user. Vocal conflicts centered around drug use and discipline were frequent between the father and Joe’s older brother. Upon evaluation, Joe initially denied feeling depressed, but reported pervasive feelings of boredom, irritability, and not getting “much fun out of things anymore.” Later, he admitted that he might be “a little depressed.” Joe completed a Beck Depression Inventory and obtained a total score of 26 (moderate depression). He believed marijuana to be helpful in calming himself. Joe never tried to cut down or quit substance use nor was he ever involved in treatment for drug use. Upon evaluation, Joe was not motivated to abstain from drug use, but was willing to discuss a treatment option in order to avoid legal consequences and have his pending charges dropped. No suicidal or homicidal ideation was evident, and no symptoms of bipolar illness or psychotic thinking were present on mental status examination. DEVELOPMENT OF A TREATMENT PLAN UTILIZING EVIDENCE-BASED PRACTICE We conducted a search using PubMed and the search terms substance use disorders and depression using the following limitations: English language only, limited to the past 10 years, and children less than 18 years old. This search yielded 806 relevant articles. Advanced search terms included randomized controlled trial and practice parameters for youth depression and youth SUD, which yielded 43 relevant articles. Abstracts of these articles were reviewed. In addition, pertinent articles and book chapters from the past 20 years known to the authors were also reviewed There is empirical evidence in the adult literature supporting the simultaneous treatment of SUD and depression rather than treatment approaches that target only one disorder or the sequential treatment of both disorders.1 However, the treatment of DD in adolescents remains in the realm of clinical consensus.7 This consensus advocates for simultaneous intervention for both disorders provided either by the same clinician or by different experts, each responsible for one disorder but who are keeping the other informed. The variable clinical course of adolescent SUD treatment often leads to premature termination and then later re-entry into the treatment system.8 Survival data from a comprehensive and comparative review9 and from the Cannabis Youth Treatment Study (CYT)10 showed sustained abstinence of 38 percent and 24 percent, respectively, one year after treatment completion. Psychosocial treatment strategies that have shown promise in reducing SUD among adolescents are comprehensively reviewed by Liddle and Rowe,12 and specifically in other references presented in Table 1.3,10,13–19 Cognitive behavioral therapy (CBT) facilitates coping skills for maintaining abstinence in high-risk situations and improves social networking skills with nonusing youth.20 The manualized integrated motivational enhancement therapy (MET)/CBT approach has been found to be the most cost-effective intervention in the largest, prospective, randomized, controlled study for youth with cannabis use disorders.10 In this context “motivational” means “address readiness to behavior change toward abstinence.” MET is guided by four main principles: 1) express empathy utilizing active listening; 2) develop discrepancy (help patient to recognize how his or her life is when he or she is using the drugs versus how his or her life could be without [SEPTEMBER] Psychiatry 2008 35

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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