When Depressed Teenagers Abuse Drugs, Take Action

A teenager caught in substance abuse is rarely dealing with only one problem. Among adolescents who enter drug and alcohol rehabilitation, somewhere between 55 and 74 percent arrive with a diagnosed psychiatric disorder. Depression in particular tends to predict substance use, and it tends to get in the way of treating that use.

The cycle feeds itself. A depressed teen is more likely to reach for substances, and heavy substance use tends to blunt the response to any treatment aimed at the depression. Flip the question around and you hit the same wall: depression can also keep a teen from responding well to substance abuse treatment. That last piece is what has kept researchers up at night, because it means neither problem can be handled cleanly while the other sits in the room.

Relapse is the sharper edge of this. Young people who need treatment for substance use and who also carry a psychiatric diagnosis face a higher risk of slipping back. Yet surprisingly little solid research has looked at comorbid depression (depression that runs alongside another illness) in adolescents who are specifically in treatment for substance abuse. A review published in the journal Substance Abuse pointed to exactly this gap, noting how thin the evidence base is for therapies aimed at these dually affected youth. Everyone agrees depression and substance use are linked. The trouble is that the explanations for how and why keep contradicting each other.

The authors of that review laid out several ways to study the role of comorbid depression among adolescents in substance abuse treatment, and the recommendations are worth walking through.

First, pay attention to time. Depression shows up differently depending on whether you are looking at a person's whole life history or their situation right now. Researchers should measure depressive symptoms at the beginning and the end of a given treatment stretch, because watching those readings rise and fall alongside periods of heavier or lighter substance use can tell you something about where the depression actually stands.

Second, track the phases of depression through treatment itself. Screening a patient for depressive symptoms at intake is the starting point, and if a diagnosable depression is present, it matters just as much to keep measuring how it moves as treatment goes on. Even a facility that cannot offer depression therapy would push the science forward simply by documenting how depression and substance abuse treatment interact.

Third, test properly. Clinicians and researchers should lean on validated, standardized assessments, the kind of inventories that rate severity and sort symptoms into categories. Not every common depressive symptom adds up to clinical depression, and someone with mild depression may respond to substance abuse treatment differently, or use at a different rate, than someone with major depression. Good data on that distinction is hard to gather without the right instruments.

Fourth, figure out the timing between the two. The review stressed the value of pinning down when depressive symptoms show up relative to substance use. A substance use disorder can begin at any point in life. Some people experiment and use before any depressive symptoms appear; others start using only after depression has set in. The direction of the relationship stays murky, but mapping the sequence may bring researchers closer to understanding how depression shapes the outcome of substance abuse treatment.

All of which raises the practical question: with the research still incomplete, what should a therapist actually do with a depressed teenager in substance abuse treatment? The answer is not to wait. Providers should respond to both disorders at once rather than hold off until cleaner evidence arrives.

One concrete approach is the Adolescent Community Reinforcement Approach, or A-CRA. It is a behavioral program built on the idea that behavior grows out of environment, and its aim is to help a teenager settle into a clean and healthy lifestyle. Beyond cutting substance use, it works toward better mental and physical health and more social stability.

Dr. Susan H. Godley, lead author of the Substance Abuse special issue, described A-CRA as a well-tested intervention for substance use disorders that has shown promise for comorbid youth, adding that its procedures line up with those used in evidence-supported treatments for the mental health problems that commonly occur alongside substance use.

A-CRA can run almost anywhere and is designed for adolescents roughly ages 12 to 22. It covers current abuse, aftercare and reentry, community awareness, and classroom material, which makes it flexible enough for a range of settings rather than tied to a single clinic model.

- Melissa Lavery, M.S.

Related