The rise and rise of drug-related mental health problems

There is growing anecdotal evidence to support the research suggesting that the prevalence of comorbid mental health and substance use problems are increasing, especially in younger people (for example, Gossop et al, 1998; Kessler, 1995; Rutter and Smith, 1995).

The Youth Substance Abuse Service (YSAS) was established in 1997 in response to the need for accessible, effective and engaging alcohol and drug interventions for young people between the ages of 12 and 21 years who are experiencing significant problems with their alcohol and or drug use. YSAS provides a range of youth-specific outreach, treatment, withdrawal, rehabilitation and support programs in a number of locations in Melbourne and regional Victoria.

Since inception, YSAS staff have observed a steady increase in the number of young people accessing services who present with comorbid conditions. Staff estimate that at any one time, between 50 and 70 per cent of young people also have mental health issues, with most presenting with evidence of anxiety or mood disorders, self-harming behaviours, or some form of psychosis.

Treatment issues

Over 90 per cent of these young people are not linked in to any mental health service. Referrals of young people to mental health services tend to be unsuccessful for a variety of reasons, including:

• the stigma associated with a diagnosis of a mental health condition;
• the young person is using drugs;
• poor integration of drug treatment and mental health services resulting in comorbidity being poorly treated; and
• funding constraints, which give preference to treatment to those who are in crisis rather than those with non-affective mood disorders.

While young people in general tend to be non-compliant with medical treatment regimes, the behaviours of adolescents with co-occurring substance use and mental health problems can often make them difficult to work with.

Decisions around the use of medications by young people with a dual diagnosis will be influenced by a wide variety of factors including current type and severity of substance use, severity of mental health condition, motivation for change or treatment, the developmental age of the young person, current lifestyle and other patient preferences.

While antidepressant medications may assist in reversing negative symptoms and increasing motivation, a range of negative side-effects have also been noted, suggesting the need for a cautious and judicious implementation of such interventions (SAMHSA, 2002).

A way ahead

Separate funding, educational and administrative processes have fostered a silo approach between psychiatric and drug treatment services.

A holistic treatment approach that takes into account an understanding of the role of the individual’s social and familial contexts assists in providing a way forward to responding to the needs of comorbid adolescents. Such an approach fosters realistic and pragmatic interventions to behaviours associated with substance use and can also be used effectively within a comorbid context, highlighting the need for clinicians to work with young people “where they are at”, rather than expect them to be ready or able to change current problematic behaviours.

A harm minimisation approach in working with these adolescents focuses on the immediate likely harms resulting from particular behaviours and works to reduce these potential harms. A holistic consideration of their psychosocial functioning and wellbeing remains the focus, rather than the cessation of substance use or mental health behaviours and symptoms that may be causing problems.

Treatments based on a harm minimisation framework try to actively engage the young person in the treatment planning process. It facilitates education and information provision, and allows tailored, individualised responses. The young person can be viewed as moving along a continuum of harmful consequences, with the aim being to minimise these in any way practically possible.