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Concurrent Disorders in Youth: When Mental Health and Addictions Collide

In October 2018, Bill C-45 (also known as the Cannabis Act) will come into effect in Canada. Recreational use of marijuana will be legal for those 18 years of age and over. It is unknown at this time what the true impact – positive or negative – will be on the population, and on youth in particular. However, regardless of where one stands on this issue, the passing of this landmark bill has undeniably led to increased discussion about the use of substances among youth, and how to engage youth on the topic.

Societally, we have decreed that 18 years is the age at which one transitions from being a “youth”, to becoming an adult. Increasingly, however, we are recognizing that the period of “youth” can be considered to last well into one’s 20’s. We now know that the brain is not finished growing and developing until about 25 years of age. Late adolescence is still a period of dramatic neurodevelopment, particularly in the realm of executive thinking (e.g., complex reasoning & problem solving). Significantly, it is also during this period that we see the onset of many different types of mental illness, as well as the onset of experimentation with alcohol and drugs. Either one in isolation can be difficult to address, but when substance use and mental health occur in tandem, the issue gets substantially more complex.

What are “concurrent disorders”

When we use the term “concurrent disorders”, we are referring to an individual who is struggling with the presence of a mental health issue (e.g., anxiety, depression, bipolar disorder, ADHD, psychosis, etc.), while also struggling with co-occurring substance use/abuse (nicotine, alcohol, marijuana, cocaine, heroin, etc.). It is important to note that, depending on the area of Canada in which you reside, concurrent disorders are sometimes known by other terms. In some regions, the term “dual diagnosis” is used to refer to co-occurring substance use and mental health. However, this can become unfortunately confusing, since “dual diagnosis” might also refer (in British Columbia and Ontario, for example) to the presence of co-occurring mental illness and developmental disability.

While the term Concurrent Disorders may or may not be immediately familiar, if asked, it is likely most school professionals would intuit that mental illness and substance use frequently go hand in hand. In fact, this is an accurate assumption. A Canadian study found that only about 3.2% of the general population of youth meet the criteria for a concurrent disorder (Cheung, et. al., 2009). However, a review of the literature put together by Adair (2009) found that across studies, 60-80% of youth who were abusing substances were also experiencing mental health symptoms. Similarly, up to 40% of those struggling with mental illness were also abusing substances. By no means will it always be the case that they will co-exist, but when one issue is present, it is not uncommon that the other will be as well. 

Directionality… what comes first?

It can be tempting to look for a simple explanation when considering the directionality of concurrent disorders – in other words, that one of the disorders “causes” the other. The reality of concurrent disorders is generally more nuanced than this, and the etiology is often unique to each person. Some scenarios of concurrent disorders can include:

  • A youth experiencing symptoms of mental illness, who begins to use alcohol or drugs as a way of quelling their emotional distress, increasing their focus, or distracting themselves from painful thoughts;
  • A youth suffering from a mental illness (particularly bipolar disorder, mania, ADHD, oppositional defiance or conduct disorder) who may experience among their symptoms a decrease of their inhibitions, or an increase of risk-taking behaviour, which can then lead to experimentation with drugs or alcohol;
  • A youth who’s substance use triggers the onset of a mental illness (e.g., drug-induced psychosis);
  • Youth who experienced abuse, traumatic events, or difficult family histories are at an increased risk of both mental health and substance use, and therefore both disorders may arise independently from the same risk factors.

Whatever the model or directionality for the onset of concurrent disorders, it is clear that once both substance use and mental illness are present, they can quickly become inter-related, with each illness bolstering and maintaining the other.

Treatment approach – What to tackle first?

Once the presence of concurrent disorders has been identified, the next question is how best to support the youth towards increased health and wellness. Typically, there are three models of treatment when it comes to addressing concurrent disorders:

Sequential: Either the mental illness, or the substance abuse, is targeted first. Then, once the mental health, or substance use, is sufficiently managed, the other area will be addressed. In some circumstances this may be effective, specifically in the case of a youth who is able to clearly identify using a substance to address a mental health symptom, or a youth who’s mental illness has been clearly triggered by their substance use. However, in many cases a sequential model will be ineffective as it does not address the inter-connected dynamic of concurrent disorders.

Parallel: Both the mental illness, and the substance abuse, are treated at the same time, but separately. While this can perhaps be a desired approach, as it appears to address all issues at once, there are a number of drawbacks. Specifically that a parallel approach would require substantial time on the youth’s part to be engaged in two simultaneous treatment programs (likely to decrease their motivation to engage with either), and substantial communication and collaboration between different professionals

Integrated: An integrated approach to treating concurrent disorders is one that typically involves a specialized professional who treats both the substance abuse and the mental illness at the same time. This approach conceptualizes the two issues as two pieces of the same puzzle, which must be treated in tandem if either is to be effectively addressed. Concurrent Disorders programs (or “Dual Diagnosis” programs, in regions that use this term) utilize this approach and will include mental health professionals and addictions professionals who consult together and work in conjunction with each other, or specialized counselling professionals who are trained to address both issues at the simultaneously.

What can school professionals do?

Clearly, school counsellors are not equipped to take on the specialized treatment of youth affected by concurrent disorders. However, school counsellors can play an integral role in supporting youth, in some of the following ways:

  • Education: Initiatives within the school to educate youth on the realities and impact of substance use, the signs of dependence, as well as the symptoms of mental illness;
  • Observation & Identification: Watch for changes in a youth’s presentation, or school functioning, and when you suspect that a youth may be struggling with mental illness and/or substance abuse, connect with them directly, and identify them to additional support services;
  • Collaboration: When a youth in your school is receiving the services of an addictions or mental health counsellor, reach out to the youth, their family, and the other support services to determine how the youth can best be supported in their school environment;
  • Advocacy: Speak up to school management and school districts regarding the need for specialized programs or support workers in schools (e.g., drug and alcohol counsellors);
  • Empathy and a lack of judgement: As with all of our work with youth, often the greatest help we can provide as school professionals is to be present with youth who are struggling, even when they may still be denying that their mental health or substance use is a problem. Provide a safe space for youth to talk, without judgement or fear of stigma, and walk alongside them on a path to recovery.

By: Laura Hamilton


References
Adair C. (2009). Concurrent substance use and mental disorders in adolescents. A review of the literature on current science and practice. The Alberta Centre for Child Family and Community Research. Retrieved from: https://policywise.com/wp-content/uploads/resources/2016/06/Concurrent-Substance-Use-and-Mental-Disorders-in-Adolescents-A-Review-of-the-Literature-on-Current-Science-and-Practice.pdf

Cheung, A., Bennett, K., Bullock, H., Soberman, H., & Kozloff, N. (2010). Evidence on Tap: Understanding service delivery needs for youth with concurrent disorders. A report prepared for the Ontario Ministry of Health and Long-Term Care.

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