Bridge Over Troubled Waters

Meeting the needs of youth with concurrent disorders

Erin Toews

Reprinted from "First Responders for Young People" issue of Visions Journal, 2006, 3 (2), pp. 9-11

It is not an unfamiliar story: a 16-year-old student who had previously been doing well in school is now struggling. Once friendly and open with her family, she has become withdrawn. She has been staying away from home, preferring to spend time alone or with friends. Her parents, already frustrated with her slipping grades, are outraged when they find a marijuana cigarette in her coat pocket. They consider this another example of her increasingly bad behaviour. They are angry and disappointed, and their relationship with their daughter deteriorates.

But at the crux of this story is a missing piece of information—this young woman has been experiencing a serious episode of depression for most of the year. She is self-medicating with marijuana and alcohol, which has resulted in spiralling drug use and depression.

Bridging the divide between mental health and addictions is the role of addictions psychiatry, an increasing subspecialty in the field of mental health.

Help for youth with concurrent disorders

BC Children’s Hospital and BC Mental Health and Addiction Services, agencies of the Provincial Health Services Authority, have a program to assist children and youth facing concurrent disorders (the combination of mental health issues and substance use). It is estimated that about half of individuals facing either mental health or substance use issues, actually have both.1 This is especially true of youth.

Dr. Shimi Kang is director of the Provincial Youth Mental Health and Substance Use Program. She started the clinic three years ago after growing tired of watching some patients fall between the cracks in traditional treatment. Initially, the clinic did one patient assessment per week. In October 2005 the program received additional funding from the Provincial Health Services Authority and is now operating as a full-time clinic based at BC Children’s.

Often mental health treatment services are not prepared to treat individuals for substance use, and addiction treatment facilities are often not equipped to address the specific needs of those with mental illness.

“None of that matters at 3 am when you are working in the emergency department and have someone in front of you who desperately needs help,” explains Dr. Kang. “Most programs don’t look at addictions and mental health in an integrated way—even though we know that most often the two are strongly correlated and affect each other’s presentation, treatment and prognosis. I saw these issues coming up again and again. Mental illness and substance use touch so many families, it would be difficult to find someone who hasn’t had their life directly or indirectly affected by one or the other.”

Problematic substance use by youth is a very real problem in BC

Recent research evidence and surveys of drug use by high school students indicate that nicotine, alcohol and marijuana are still the main drugs of choice. However, the use of ecstasy and crystal meth is on the rise, ranging from experimental to more chronic patterns of use.2

For youth with mental health issues, even experimental use of alcohol and drugs can create or exacerbate symptoms. For example, the use of methamphetamines increases the risk of psychosis. Youth with disordered eating can worsen their disorder through stimulant use. Those with anxiety problems may find the intoxicating effects of alcohol and/or marijuana leads them to escalating and eventually dangerous use.

“Studies and clinical practice demonstrate that youth experiencing higher levels of distress will turn to more potent drugs, thus putting the youth with untreated mental health issues at risk,” says Dr. Kang.

Many youth use substances, but some are at increased risk of concurrent disorders. Those with mental illness, learning disabilities or street involvement are at increased risk, along with gay and lesbian youth. Compared to those with either condition alone, youth with concurrent disorders face potentially serious negative outcomes, such as homelessness, hospitalization, trauma, prison or suicide.

First responders face a complex situation

Identifying and treating children and youth with mental health problems becomes much more challenging when they are also using  substances. A distinct change in temperament and behaviour is often the first sign. Other warning signals include irritability, sleep disturbance, lack of interest in school or other activities, and finding drug paraphernalia—such as bottles, pills, needles and pipes—among a youth’s personal items. These signs are usually flagged by a teacher, friend or parent.

Beginning substance use may be the result of peer pressure or an adolescent desire to explore boundaries. After time and depending on underlying reasons, this use may become misuse and may be causing the young person harm—however, they may still not necessarily be self-treating a mental health issue. Beyond understanding the symptoms, it is important for first responders such as parents or teachers to appreciate the complexities at hand when trying to determine the severity of the issue.

The first step for the first responder is to talk to the youth in an open and nonjudgmental manner. The first responder may suggest that the youth see their family doctor or contact a youth addiction team through community health centres. This is the first step required in order to get an appointment with the Provincial Youth Mental Health and Substance Use Program. Given the natural state of denial and resistance to treatment that sometimes occurs with addictions, the first responder may need to contact the doctor or youth addiction team themselves to discuss an appointment and referral for the youth.

Complex conditions need an integrated approach

These are complex conditions that cross over biological, psychological and social issues. Effective treatment requires an integrated approach. The program at BC Children’s works with the entire care continuum—psychologist, psychiatrist, nurse clinician, nurse practitioner, social worker—and consults with teachers, mental health and addiction counsellors, youth care workers, street nurses, probation officers and the family. The program treats youth up to age 24.

The program aims to disseminate as much knowledge as possible. During the past year it has conducted 12 workshops with a variety of professionals, including youth forensics workers, mental health and addiction clinicians, nurses, teachers and social workers.

Dr. Kang’s advice for helping professionals is to communicate that people do get better, but they must be prepared for a rocky road ahead. These are challenging cases, and even if a youth is well motivated, there can be multiple relapses for both substance use and mental illness.

“You need to engage youth as much as possible. This often requires small steps. My goal in the first appointment is often to see the person return for a second appointment. These can be difficult cases to treat, but it is so worthwhile to see a youth turn their life around or reconnect with their family and friends,” says Dr. Kang. She suggests that any time one condition has been identified, the other be asked about in an open, non-judgmental way.

There are no silver bullets when dealing with concurrent disorders and treatment—the cases are much too individualized for a blanket solution. However, if first responders know about symptoms and resources, and if they understand the continuum between use, misuse and self-medication, they will better be able to deal with these issues. The program at Children’s Hospital will be holding special information nights for parents, who so often find themselves in the role of first responder.

 
About the author
Erin is a communications specialist with BC Children's Hospital.
Footnotes:
  1. Bradizza, C.M., Stasiewicz, P.R. & Paas, N.D. (2006). Relapse to alcohol and drug use among individuals diagnosed with co-occurring mental health and substance use disorders: A review. Clinical Psychology Review, 26(2), 162-178.

  2. Lapinen, T.M., McGhee, D. & Martin, I. (2006).Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria. BC Medical Journal, 48(1):22-27.

 

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