Psychiatry 2008 - September 2008 - (Page 38)

TABLE 3. Adolescent treatment trials for dually diagnosed depressed adolescents AUTHOR/ SUBSTANCE Riggs, et al. 1997, SUD Deas, et al. 2000, AUD Cornelius, et al. 2001, AUD Riggs, et al. 2007, SUD Curry, et al. 2003, SUD STUDY DESIGN N INTERVENTION/ MEDICATION Fluoxetine RESPONSE 7 out of 8 depressive symptoms improved Improved depressive symptoms and reduced drinking in both groups Within group, significant improvement of depression and reduced drinking Depression improved significantly in the fluoxetine-CBT group vs. placebo group among SUD patients Demonstrated feasibility and was associated with improvements in both disorders (SUD and depression) Open-label 8 Placebo-controlled 10 Sertraline Open-label 13 Fluoxetine Double-blind, placebocontrolled 126 Fluoxetine plus CBT Integrated family and cognitive behavioral therapy Pilot 13 KEY: SUD: substance use disorder; AUD: alcohol use disorder; CBT: cognitive behavioral therapy trials for youth depression), a period of “watchful waiting” with ongoing monitoring of his clinical status was indicated.24 During this time, psychoeducation about depression and its treatment were provided to Joe and his father. Suggestions for lifestyle management included increased engagement with non-drug-involved peers, daily exercise, and the creation of a daily activity schedule to increase pleasurable activities were encouraged. Table 3 summarizes four pharmacological trials5,25–27 and one psychosocial study28 for adolescents with alcohol or substance use disorder and concomitant MDD. Two weeks after the onset of treatment for SUD and with the prompting of his father, Joe agreed to an antidepressant trial “to see if it would help.” After a risk/benefit discussion with Joe and his father, fluoxetine was initiated at 10mg/day and increased to 20mg/day after one week. Three weeks after initiating medication, Joe reported a Beck Depression Inventory score of 18 (a 30% improvement over baseline). He requested to continue his combined medication/psychosocial treatment. Joe adhered to his recommended treatment for two months with 38 Psychiatry 2008 [ S E P T E M B E R ] significant improvement in SUD and depression. He then became nonadherent with scheduled visits and medication. Six months later, his father reported that Joe relapsed and was smoking marijuana daily, although he was not depressed. Joe refused to return to treatment. Our clinic continues to maintain contact with Joe’s father in order to enable access to treatment at a future date. CONCLUSIONS AND FUTURE DIRECTIONS Adolescent substance abuse treatment should begin with a comprehensive multidimensional evaluation.29 Failure to recognize or adequately treat comorbid depression may interfere with substance abuse treatment. The present consensus advocates for a simultaneous and coordinated implementation of psychiatric and substance-abuse treatment services for DD patients. Clinical consensus and emerging evidence-based practice suggest that psychotherapy targeting both depression and SUD as well as integration of psychotherapy with a selective serotonin reuptake inhibitor (SSRI) might be efficacious treatments. Further controlled trials are necessary to confirm these findings and expand on issues such as severity of each disorder, dosage and length of treatment courses, how to address poor response, and barriers to treatment. Finally, close clinical monitoring is required because treatment of depression with an SSRI in adolescents has been under scrutiny due to concern over potential adverse effects such as suicide,2 as well as lack of sufficient evidence regarding interactions of abuse drugs with SSRIs.30 While we are not presently aware of cannabis-SSRI drug adverse interactions, concomitant alcohol use increases lethality in SSRI overdose.31 Clinical consensus suggests that in depressed adolescents with polysubstance dependence, binge-alcohol drinking patterns, or severe SUD as with opiates, SSRIs may be contraindicated.31 REFERENCES 1. Kaminer Y, Bukstein OG. Adolescent Substance Abuse: Psychiatric Comorbidity and High Risk Behaviors. New York, NY: Routledge, Taylor & Francis, 2008. Kaminer Y, Connor DF, Curry JF. Comorbid adolescent substance use 2.

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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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