Co-occurring Psychiatric and Substance Disorders

By Norman G. Hoffmann, Ph.D.; Todd W. Estroff, M.D.; Susan D. Wallace, M.S., LCDS Prevalence Concerns


Varying studies addressing prevalence of co-occurring conditions suggest that the majority of adults seeking either mental health services or treatment for substance dependence manifest corresponding co-occurring mental health or substance use disorders (Lehman, Myers, Corty, & Thompson, 1994; Hien, Zimberg, Weisman, First, & Ackerman, 1997; Milling, Faulkner, & Craig, 1994). This estimate is even higher for adolescents entering treatment for substance use disorders. One study of over 4,000 adolescents in treatment noted indications of depression in about 70% of the patients, and signs of anxiety disorders in about a third (Hoffmann, Mee-Lee, Arrowood, 1993). Another study of over 1,400 adolescents using a more stringent criterion for depression noted that about a third of the patients met criteria for a possible affective disorder (Bergman, Smith, & Hoffmann, 1995).

Adolescents in addictions treatment programs also tend to manifest behavioral disorders resulting in contact with either the legal or juvenile justice systems. A recent study of treatment outcomes of over 2,300 adolescent substance abusers found that more than 75% reported some interactions with law enforcement and more than half reported an arrest. The extent of school behavioral problems and legal issues were found to correlate with addictions treatment outcomes at six months after discharge (Hsieh, Hoffmann, & Hollister, 1998).

Depression and behaviors likely to bring the adolescent into contact with the legal system are only some of the conditions associated with substance abuse. Suicide risk, anxiety disorders, ADHD (attention-deficit/hyperactivity disorder) and other conditions are associated with substance abuse (Bukstein, 2001).

Determining which diagnoses are present is critical. Standardized diagnostic assessments that clearly discriminate those individuals who have symptoms from those who meet diagnostic criteria are essential. If symptoms are not carefully and consistently evaluated so that conditions are correctly diagnosed, appropriate and effective treatment plans cannot be developed.

Diagnostic determinations should not be considered a form of ?labeling,? but rather a necessary, appropriate, and critical step toward effective treatment planning.

Pragmatic Detection Toward this end, two of the authors, Drs. Estroff and Hoffmann, developed the PADDI (Practical Adolescent Dual Diagnostic Interview), a structured diagnostic interview compatible with the DSM-IV diagnostic criteria (APA, 1994).

The development criteria were that the instrument 1) had to be easy to administer, 2) did not require expertise in both mental health and substance abuse, 3) was adaptable to a variety of settings and applications, 4) was easy to score, and 5) could be used by the qualified professional as a foundation for making a diagnosis. The intent was to produce a tool that could be used easily and quickly by substance abuse counselors or mental health professionals. The fully structured interview format was chosen to allow technicians, juvenile justice officers, and paraprofessionals to easily administer the instrument and summarize responses on the scoring page. However, making clinical interpretations or confirming diagnoses must be limited to qualified professionals.

The PADDI (Practical Adolescent Dual Diagnostic Interview) was designed to capture key information about substance use disorders and the most important and prevalent mental health conditions associated with substance abuse. The PADDI questions are directly tied to the DSM-IV diagnostic criteria (Hoffmann & Estroff, 2001). The following Axis I diagnostic areas are addressed:

  • Depression
  • Mania
  • Psychotic indications
  • Panic related anxiety disorders
  • Anxiety/phobias
  • Posttraumatic stress disorder (PTSD)
  • Conduct disorder
  • Oppositional defiant disorder
  • Substance use disorders

Axis II indications of paranoid and dependent personality traits are also covered. The interview addresses dangerousness to self and others. Abuse victimizations?physical, sexual, and emotional are also addressed. The PADDI was designed to take between 20 to 40 minutes, depending upon the extent of problems discovered.

Preliminary Statistics This initial sample of the PADDI interviews consisted of 111 adolescents in addiction treatment programs (59%) or addiction treatment programs within the juvenile justice system (41%). The majority (65%) of the adolescents including all of the juvenile justice adolescents were males. The adolescents ranged in age from 14 to 18 years, but over 80% were between the ages of 15 and 17. Caucasians comprised over 75% of the sample, and African-Americans (13%) constituted the largest minority. The remainder of the sample included Hispanic, Native American, or persons of mixed ethnic background. The vast majority of the non-incarcerated adolescents were currently in school, but their academic achievement appeared low as indicated by the highest grade passed relative to their age. Most of the adolescents in the juvenile justice system were required to do school work or pursue a GED. About a third of the adolescents were currently taking some form of medication for either a physical or psychiatric condition at the time of the evaluation.

Internal consistency reliability coefficients for the various diagnostic scales range from about .70 for conduct disorder to over .90 for affective disorders. For substance dependence the coefficient is above .80. These statistics suggest that the diagnostic items define relatively homogenous syndromes. This would be expected if the DSM-IV definitions identify clearly defined conditions with consistent presentation.

Over 90% of the adolescents met criteria for substance dependence and almost as many met criteria for conduct disorder. Approximately a third of the sample met criteria for a current or past diagnosis of major depressive episode or mania. Mixed states, where depression and mania are present at the same time, were indicated for about 15% of the sample. A current diagnosis for major depressive disorder was indicated for about a fourth of the patients and current mania was indicated for under a third. These rates exclude those cases where the depression or mania appeared to be substance induced. The five most prevalent diagnoses identified by the PADDI in this sample were substance dependence, conduct disorder, major depressive episode, mania, and PTSD. The most common combination was for co-occurring substance dependence and conduct disorder; however, 55% of the adolescents manifested at least three of these five conditions. Over a quarter (26%) appear to meet criteria for at least four of the five conditions. Adolescents in these residential programs are indeed multiple problem individuals.

Symptom Profiles for Selected Conditions N=1

Condition (Lifetime) Minimal Criteria Exceeds Criteria Far Exceeds Criteria Major Depressive Episode 35% 25% 15% Manic Episode 36% 24% 15% Posttraumatic Stress Disorder 25% 22% 11% Panic 17% 11% 5% Anxiety/phobias** 22% 12% 4% Conduct Disorder 86% 63% 38% Oppositional Defiant Disorder* 63% 48% 31% Substance Dependence*** 92% 87% 78% ? *This provides the data on oppositional defiant disorder (ODD) symptoms even if conduct disorder criteria are met. According to the DSM-IV, this diagnosis is not given if conduct disorder criteria are met. In this population, all cases meeting criteria for ODD also met criteria for conduct disorder.

**Items in this category do not define a specific anxiety diagnoses, but reflect extent of symptoms.

***If no substance use is reported in the previous 12 months, the symptom count was set to zero.

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