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NIDA. (2005, May 1). Drug Abuse Treatment in Adolescents Should Address Co-Occurring Mental Health Problems. Retrieved from

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May 01, 2005
Lori Whitten

Adolescent substance abuse patients with co-occurring emotional and behavioral problems are more likely than peers without coexisting psychiatric conditions to relapse in the year following treatment, a NIDA-funded study has found. "We must improve identification of co-occurring psychiatric disorders among substance-abusing teens and move away from a 'one size fits all' approach to therapy, or treatment gains will remain limited for these vulnerable youth and their families," says Dr. Cynthia Rowe of the University of Miami School of Medicine in Florida, who led the study.

Photo of an adolescent

Following 182 adolescents for a year after substance abuse treatment, Dr. Rowe and her colleagues found that those with co-occurring externalizing disorders—a combination of aggressive and delinquent behaviors including persistent lying, stealing, fighting, and destroying property—recovered more slowly than those without psychiatric disorders. Youths with externalizing and internalizing disorders—acting out mixed with anxiety and depression—obtained the least favorable treatment outcomes. Dr. Rowe says this combination of symptoms often relates to multiple problems in life and indicates psychiatric severity—the best predictor of substance abuse treatment outcomes in adults. "Our results mirror those seen in adults: People with more severe psychiatric problems show a significantly diminished response to substance abuse treatments of known effectiveness," says Dr. Rowe.

All the youths had been referred to substance abuse treatment, almost 85 percent by the juvenile justice or child service systems; they ranged in age from 12 to 17 at the beginning of the study. Participants received manualized treatment—cognitive behavioral therapy (CBT) or Multidimensional Family Therapy (MDFT)—in weekly office-based sessions for an average of 10 weeks. At the outset of the study, the participants' reports of substance abuse frequency in the past month averaged 12.7 days; by the end of the treatment, this figure dropped by 2.5 days. Six months after treatment, past-month substance abuse had fallen another 2.5 days; at the 12-month followup, abuse incidence had dropped an additional 2.5 days. The rates and patterns of change, however, varied depending on coexisting psychiatric disorders.

Substance abusers with no cooccurring disorders (12 percent of the study population) showed the best long-term outcomes. Although initially unresponsive to treatment, they markedly and rapidly reduced substance abuse between the 6- and 12-month followups—changing at a rate approximately 1.5 times that of peers with co-occurring externalizing disorders (35 percent of the study population), who also were initially unresponsive to treatment and also recovered. Youth demonstrating mixed externalizing and internalizing symptoms (48 percent of the study population) showed the opposite pattern. Initially improving in response to therapy, they had relapsed to pretreatment levels of substance abuse a year later. The responses did not differ in patients participating in CBT and MDFT. The other 5 percent of substance-abusing adolescents were diagnosed with internalizing disorders only, a group too small to analyze, so the researchers did not include them in the analysis.

Dr. Melissa Racioppo of NIDA's Division of Clinical Neuroscience, Development and Behavioral Treatment says CBT and MDFT are very effective treatments for most adolescent substance abusers (see "Family-Based Treatment Programs Can Reduce Adolescent Drug Abuse"). Poorer treatment outcomes among people with co-occurring psychiatric disorders suggest that therapists may need to tailor substance abuse treatment for the patient's particular psychiatric condition, although the necessary level of specificity is not clear. "To adapt treatments for people with co-occurring psychiatric disorders, researchers must link particular therapeutic processes with outcomes," she adds—something that Dr. Rowe and her colleagues plan to do in future studies.

"Looking within the therapeutic process may help us discover what must happen to realize recovery from substance abuse. Effective components of therapy may vary for adolescents with different co-occurring mental health problems, and identifying such mechanisms of change may help us develop better interventions," says Dr. Rowe.

Girls Had More Severe Problems

Most (82 percent) of the study's participants were boys; however, girls were overrepresented in the group with the least favorable treatment outcomes. More girls (83 percent) than boys (44 percent) displayed externalizing and internalizing disorders. Dr. Rowe says the pattern is familiar to clinicians across the country—there are typically more girls among the substance abuse patients with pronounced problems and disorders.

"By the time a girl with substance abuse problems is referred to treatment, she is usually in considerable distress and experiencing severe psychiatric symptoms and relationship problems. Family, school, and legal problems will continue unabated without better identification, referral, and treatment of these vulnerable girls," says Dr. Rowe.

Dr. Racioppo emphasizes the need for more research on differences in how boys and girls develop and manifest behavior problems. Troubled youth often have experienced family conflict and instability in relationships, but boys and girls may react differently. Studies indicate that females tend to turn their stress inward, developing anxiety and depression, which are often unnoticed by adults. Dr. Racioppo says girls tend to act out in ways that don't necessarily grab the attention of adults—through sexual behavior, for example—whereas boys externalize in ways that are more obvious, such as fighting. "To improve identification and treatment outcomes of adolescents with co-occurring psychiatric disorders, we need to study gender differences in the root causes and expression of behavioral and emotional problems," she says.


  • Rowe, C.L.; Liddle, H.L.; Greenbaum, P.E.; and Henderson, C.E. Impact of psychiatric comorbidity on treatment of adolescent drug abusers. Journal of Substance Abuse Treatment 26(2):129-140, 2003. [Abstract]