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.

Cognitive behavioural therapy (CBT) has been used successfully within both mental health and drug treatment programming. Within substance use services, motivational interviewing and relapse prevention interventions are perhaps the best known of the CBT techniques and these approaches work within both a group and individual setting. Such methods are ideal for use with young people who have particularly complex problems and who may be unable to work within a more structured approach, and first need the development of greater trust and a rapport before more formal treatments.

The most effective application of CBT in the youth drug treatment and mental health sectors is not just limited to those times where a formal appointment to see a drug or mental health counsellor has been made. There is the prospect of using what the drug treatment sector calls opportunistic interventions and the mental health sector calls opportunity-led work: incidents or moments in the worker’s day-to-day engagement with the young person where there is an opportunity for the individual to gain a deeper insight or understanding into their life issues. While this approach is a key aspect of work in therapeutic communities, it is always applicable to any worker-young person interaction.

Such strategies reflect an orientation toward social health models and a more integrated approach to treatment. These approaches facilitate access to services by reducing the hurdles required of young people by not setting any preconditions for treatment. They also normalise and de-stigmatise particular behaviours and allow for earlier and more integrated interventions.

In conclusion

Developing effective cross-sector service responses to adolescents presenting with complex, comorbid conditions will take time and commitment. It will be important for both drug treatment and mental health services to identify points of commonality and agreement and points of difference, and for service systems to recognise the diversity of skills both required and available in supporting this marginalised group of young people.

While young people can perceive mental health services as stigmatising and at times unfriendly, this may be because of acute treatment responses related to crisis support and management. Young people value complementary and integrated service responses. Access, engagement and relationship development activities are highlighted as crucial, especially for adolescents who are particularly marginalised, under resourced, and may find comprehension of information more difficult due to the nature of their condition(s).