This cross-sectional study reports on the prevalence of and motivation for prescription drug misuse among adolescents and young adults with depression.
Key Points
Question
What are the prevalences of and motivations for prescription psychotherapeutic drug misuse among youths with depression?
Findings
In this cross-sectional study of 22 906 adolescents and 27 723 young adults in the 2023 and 2024 National Survey on Drug Use and Health, youths with depression had significantly higher odds of reporting prescription psychotherapeutic drug misuse and use disorder compared with those without depression, and frequently reported misusing prescription psychotherapeutic drugs to help with feelings and emotions.
Meaning
These findings suggest the need to identify barriers to integrated mental health and substance use treatment for at-risk youths before patterns of self-medication progress to substance use disorders.
Abstract
Importance
The prevalence of youths with mental health conditions has increased in recent years. Youths with mental health conditions are at risk of substance misuse via coping and self-regulation pathways; there is therefore a need to identify and address barriers to integrated mental health and substance use treatment in these youths.
Objective
To examine the prevalence of and motivations for prescription psychotherapeutic drug misuse among youths with and without depression.
Design, Setting, and Participants
A cross-sectional analysis of the 2023 and 2024 National Survey on Drug Use and Health (NSDUH) using a nationally representative survey of noninstitutionalized individuals aged 12 years and older related to drugs of misuse and mental health disorders. Data on adolescents and young adults were analyzed from January to March 2026.
Exposure
Past-year major depressive episode (MDE).
Main Outcomes and Measure
The primary outcome was past-year prescription psychotherapeutic drug misuse and use disorder, and the secondary outcome was motivations for misuse. Survey-weighted prevalence estimates with 95% CIs were calculated and group differences were assessed using χ2 tests. To assess the association between drug misuse and depression, logistic regression models were used.
Results
The 2023 and 2024 NSDUH included 22 906 adolescents (aged 12-17 years) and 27 723 young adults (aged 18-25 years), among whom 24 831 (49.1%) were males, 13 256 (26.2%) were Hispanic, 6923 (13.7%) were non-Hispanic Black, 23 114 (45.6%) were non-Hispanic White, and 7336 (14.5%) were non-Hispanic–all other races. A past-year MDE was reported by 16.3% (95% CI, 15.6%-17.0%) of respondents, corresponding to an estimated 9.8 million individuals nationally. Among youths with a past-year MDE, 6.6% (95% CI, 5.8%-7.5%) reported misuse of psychotherapeutic drugs while 6.0% (95% CI, 5.2%-6.9%) reported use disorder. Youths with a past-year MDE had significantly higher odds of reporting prescription drug misuse (odds ratio [OR], 2.09; 95% CI, 1.75-2.50) and prescription drug use disorder (OR, 4.02; 95% CI, 3.37-4.80) compared with those without a past-year MDE. Compared with youths without a past-year MDE, youths with a past-year MDE were more likely to report misusing opioid analgesics (10.2% [95% CI, 6.4%-15.9%] vs 3.7% [95% CI, 2.2%-6.3%]; P = .01) and tranquilizers (29.8% [95% CI, 21.1%-40.3%] vs 13.2% [95% CI, 5.8%-19.9%]; P = .003) to help with feelings and emotions.
Conclusions and Relevance
This cross-sectional analysis of the 2023 and 2024 NSDUH found that youths with depression were more likely than their peers without depression both to report prescription drug misuse and to meet criteria for prescription drug use disorder. For certain medications, this misuse was more often motivated by a desire to address feelings and emotions. These findings underscore the need to identify and address barriers to integrated mental health and substance use treatment for at-risk youths before patterns of self-medication progress to enduring substance use disorders.
Introduction
The prevalence of youths with mental health conditions has increased in recent years. According to data from the National Hospital Ambulatory Medical Care Survey, pediatric mental health–related emergency department (ED) visits increased from 4.8 million to 7.5 million between 2011 and 2020.1 The most recent data from 2024 indicate that 11.3% of adolescents reported a past-year major depressive episode (MDE) with severe impairment. Additionally, 18.8% of adolescents reported moderate or severe symptoms of generalized anxiety disorder, 10.1% had serious thoughts of suicide, 4.6% made a suicide plan, and 2.7% attempted suicide that year.2 These trends prompted the American Academy of Pediatrics to declare a National State of Emergency in Children’s Mental Health, advocating for increased federal funding to improve access to mental health treatment across health care settings.3
Complicating the mental health crisis among youths is a lack of sufficient mental health resources. Access to mental and behavioral health care is perceived to be poor by 12.4% of caregivers of children and adolescents, with access to child psychiatrists particularly challenging in areas of the US with lower educational and income levels.4,5 Data from the National Survey of Children’s Health found that half of children with a mental health disorder did not receive required treatment from a mental health professional.6 This is also the case specifically among children following ED visits for a mental health–related complaint, with only 31.2% receiving the necessary psychiatric follow-up 7 days after the ED visit and 55.8% of children receiving the necessary psychiatric follow-up 30 days after the ED visit.7
Studies have found that untreated psychological distress and underlying mental health conditions may lead to high-risk behaviors and substance use via coping and self-regulation pathways.8 According to the 2024 NSDUH, approximately 30% of adolescents with a past-year MDE reported misusing drugs, compared with only 10% of adolescents without an MDE. Additionally, 3% of adolescents who reported a past-year MDE also had a substance use disorder (SUD).2 Further, coexisting mental health disorders are seen in approximately 40% of individuals aged 10 to 19 years who die of a drug overdose.9 Treatment for youths with both a mental health condition and SUD has historically been poor; results from the 2019 NSDUH showed that only 5% of adolescents received treatment for both their mental health condition and SUD, while more than 40% received treatment for their mental health without treatment for their SUD.10
Despite the increasing prevalence of depression among youths, persistent gaps in mental health treatment access, and the established link between untreated psychological distress and substance use, contemporary data on prescription psychotherapeutic drug misuse in this population remain limited. Prescription psychotherapeutic drugs, including stimulants, tranquilizers, sedatives, and opioid analgesics, warrant particular attention because their pharmacologic effects may appeal to youths attempting to self-manage symptoms of depression, anxiety, or sleep disturbance, and because many are readily accessible through household medicine cabinets or peer networks. Understanding not only whether but why youths with depression misuse these medications is critical: motivations stemming from unmet mental health needs would point to different intervention targets (eg, expanded access to psychiatric care and integrated screening in primary care and ED settings) than motivations rooted in recreational or social drivers, which call for prevention and harm-reduction approaches.11,12 Accordingly, the primary aim of this study was to compare the prevalence of prescription psychotherapeutic drug misuse among youths with and without a past-year MDE using the most recent NSDUH data. A secondary aim was to characterize self-reported motivations for prescription psychotherapeutic drug misuse in this population. We hypothesized that youths with depression would be more likely to engage in prescription psychotherapeutic drug misuse than those without depression, and that their motivations would more often reflect unmet mental health needs, such as self-medication for emotional distress or sleep difficulty, than recreational use.
Methods
Data Source
This cross-sectional study used data obtained from the 2023 and 2024 NSDUH. The NSDUH is conducted annually by the Substance Abuse and Mental Health Services Administration and collects information on the use of drugs of misuse, SUDs, mental health issues, and receipt of treatment for substance use and mental health issues among civilian, noninstitutionalized individuals aged 12 years or older in the US.13 We used the publicly available dataset for 2023 and 2024. The Institutional Review Board at Boston Children’s Hospital determined that this study was exempt from review as it used only deidentified patient data and met criteria for waiver of informed consent. Data were analyzed from January to March 2026. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Surveys were conducted both in-home and via web-based interviews, in English or Spanish, and included all 50 states and the District of Columbia. Those who are experiencing homelessness and not actively in a shelter, are active military, or are in institutional group quarters (eg, jails, nursing homes, mental health institutions) were excluded. The NSDUH uses a state-based, multistage area probability sampling strategy where successively smaller geographic areas are selected, dwelling units are identified, and individuals are contacted for participation. Interview respondents who completed the survey received a $30 incentive as a token of appreciation. In 2024, 137 170 individuals were selected for interview with 70 241 individuals representing the final interview cohort. Full details on the survey methodology and sampling strategy can be obtained from the Substance Abuse and Mental Health Services Administration.13
Patient Selection
We analyzed responses from adolescents (aged 12-17 years) and young adults (aged 18-25 years) using the prespecified age breakdowns provided in the NSDUH. Similar to previous years, adolescents aged 12 to 17 years (2023: n = 14 279 [21%]; 2024: n = 13 985 [20%]) and young adults aged 18 to 25 years (2023: n = 16 211 [24%]; 2024: n = 16 744 [24%]) were oversampled to account for higher rates of substance initiation in this group and to increase statistical precision. The weighted response rate for adolescents was 46.09% in 2023 and 45.34% in 2024, and for young adults was 46.69% in 2023 and 47.87% in 2024. Comparatively, the weighted response rate for adults was 51.54% in 2023 and 52.82% in 2024.13
Outcome Measures
Demographic information was collected and included sex, race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic–all other races), health insurance (private, Medicaid/Children’s Health Insurance Program, other, uninsured), and metro (metropolitan area) status (large metro, small metro, nonmetro). Information on race and ethnicity was self-reported by survey participants and classified per survey methods.13 Different racial and ethnic groups experience drug-related harms at differing frequencies, and as such, race and ethnicity were included as a study variable.
We examined the prevalence of prescription psychotherapeutic drug misuse and use disorder among youths with and without an MDE in the past year. The drugs examined included opioid analgesics, tranquilizers (eg, benzodiazepines), stimulants (eg, dextroamphetamine, methylphenidate), and sedatives (eg, Ambien [zolpidem]). To assess drug misuse, respondents were asked if they ever used a specific prescription psychotherapeutic drug “in any way not directed by a doctor” in the past 12 months. Survey questions to estimate prescription drug use disorder were based on diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).13,14 Behaviors that constitute an SUD include taking a substance in larger amounts and over a longer period than intended, a persistent desire or unsuccessful efforts to decrease use, a strong craving or desire to use, or continued use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by substance use.
Criteria for an MDE were also based on the DSM-5. Respondents were first classified as having an MDE in their lifetime if they had at least 5 of the 9 symptoms outlined in the DSM-5 nearly every day in the same 2-week period. Symptoms of an MDE included a depressed mood most of the day, diminished interest or pleasure in all or most activities of the day, substantial weight loss or gain, insomnia or hypersomnia, fatigue or lack of energy, or recurrent thoughts of death or suicidality. Those respondents who reported a lifetime MDE were presented additional questions to assess whether they had a period of depression during the past 12 months lasting 2 weeks or longer.13
To assess motivations for prescription psychotherapeutic drug misuse, the NSDUH asked respondents about reasons for substance use during the last misuse. Individuals were allowed to select multiple reasons but were prompted to identify the “main reason,” which we used for analysis. Respondents were presented with a standard set of reasons with minor changes based on the substance. For example, “relieve physical pain” was an option for pain relievers but not for tranquilizers, while “help with feelings or emotions” was available for opioid pain relievers, tranquilizers, and sedatives but was not for stimulant misuse. We collected data on all responses.
Statistical Analysis
Data for the 2023 and 2024 NSDUH public use files were combined for analysis. All data were analyzed using the NSDUH person-level sample weight, which accounts for the complex, multistage survey design by specifying the primary sampling units and variance strata provided in the public use files. Survey-weighted analyses were conducted to produce nationally representative estimates. Population totals represent average annual estimates across 2023 through 2024. All analyses were conducted in Stata version 19.5 (StataCorp) using the svyset and svy survey estimation procedures. Descriptive statistics were calculated for adolescents and young adults with and without a past-year MDE. Additionally, among individuals who misused a prescription drug (including those with use disorder), we examined the reported reason for misuse. Percentages and corresponding 95% CIs were estimated using survey-weighted proportions. Comparisons between groups were assessed using survey-weighted χ2 tests.
To assess the association between prescription psychotherapeutic drug misuse and use disorder and an MDE, we estimated logistic regression models. The models adjusted for sex, race and ethnicity, and insurance status and reported odds ratios with 95% CIs. Statistical significance was defined as P < .05. All P values were 2-sided.
Results
The NSDUH study samples included 22 906 adolescents and 27 723 young adults, corresponding to an average annual estimate of 25.9 million adolescents and 37.4 million young adults in the US population. Among these, 24 831 (49.1%) were males, 13 256 (26.2%) were Hispanic, 6923 (13.7%) were non-Hispanic Black, 23 114 (45.6%) were non-Hispanic White, and 7336 (14.5%) were non-Hispanic–all other races. Within this cohort, 16.3% (95% CI, 15.6%-17.0%) reported a past-year MDE, corresponding to an estimated 9.8 million individuals nationally.
The prevalence of an MDE was 15.7% (95% CI, 14.9%-16.6%) among adolescents, which was similar to young adults at 16.7% (95% CI, 15.9%-17.6%; P = .07) (Table 1). Females were more likely to report a past-year MDE compared with males (22.0% [95% CI, 21.1%-22.9%] vs 10.7% [95% CI, 9.9%-11.5%]; P < .001). Compared with non-Hispanic White patients (18.4%; 95% CI, 17.6%-19.2%), every other group was less likely to report a past-year MDE (non-Hispanic Black: 11.4%; 95% CI, 10.2%-12.8%; P < .001; non-Hispanic–all other races: 16.2%; 95% CI, 14.7%-17.6%; P = .006; Hispanic: 14.9%; 95% CI, 13.5%-16.2%; P < .001).
Table 1. Demographic Characteristics and Prevalence of Past-Year Major Depressive Episodes.
| Characteristic | % (95% CI) | P value | ||
|---|---|---|---|---|
| Total (n = 60 422 976) | Youths with major depressive episode (n = 9 847 598) | Youths without major depressive episode (n = 50 575 377) | ||
| Age | ||||
| Adolescents, 12-17 y | 42.9 (42.0-43.8) | 15.7 (14.9-16.6) | 84.3 (83.4-85.1) | .07 |
| Young adults, 18-25 y | 57.1 (56.1-58.0) | 16.7 (15.9-17.6) | 83.3 (82.4-84.1) | |
| Sex | ||||
| Male | 50.6 (49.9-51.3) | 10.7 (9.9-11.5) | 89.3 (88.5-90.1) | <.001 |
| Female | 49.4 (48.6-50.1) | 22.0 (21.1-22.9) | 78.0 (77.1-78.9) | |
| Race and ethnicitya | ||||
| Hispanic | 25.4 (24.6-26.3) | 14.9 (13.5-16.2) | 85.1 (83.8-86.5) | <.001 |
| Non-Hispanic Black | 13.5 (12.8-14.4) | 11.4 (10.1-12.7) | 88.6 (87.3-89.9) | |
| Non-Hispanic White | 50.3 (49.4-51.3) | 18.4 (17.6-19.2) | 81.6 (80.8-82.4) | |
| Non-Hispanic–all other races | 10.8 (10.1-11.4) | 16.2 (14.7-17.6) | 83.8 (82.4-85.3) | |
| Health insurance | ||||
| Private | 51.3 (50.2-52.4) | 17.3 (16.4-18.3) | 82.7 (81.7-83.6) | <.001 |
| Medicaid/CHIP | 31.7 (30.7-32.7) | 15.5 (14.6-16.4) | 84.5 (83.6-85.4) | |
| Other | 7.1 (6.8-7.3) | 17.0 (14.8-19.1) | 83.0 (80.9-85.2) | |
| Uninsured | 9.9 (9.4-10.4) | 12.9 (11.6-14.3) | 87.1 (85.7-88.4) | |
| Metro status | ||||
| Large metro | 54.6 (53.1-56.0) | 15.9 (14.9-16.9) | 84.1 (83.1-85.1) | .06 |
| Small metro | 33.3 (32.0-34.6) | 17.3 (16.2-18.3) | 82.7 (81.7-83.8) | |
| Nonmetro | 12.1 (11.3-13.1) | 15.4 (14.3-16.5) | 84.6 (83.5-85.7) | |
Abbreviations: CHIP, Children’s Health Insurance Program; metro, metropolitan area.
Information on race and ethnicity was self-reported by survey participants.
Among youths with a past-year MDE, 6.6% (95% CI, 5.8%-7.5%) reported misuse of prescription psychotherapeutic drugs, while 6.0% (95% CI, 5.2%-6.9%) reported use disorder. By contrast, among youths without a past-year MDE, 3.2% (95% CI, 2.9%-3.4%) reported misuse (P < .001) and 1.5% (95% CI, 1.4%-1.7%) reported use disorder (P < .001). After controlling for sex, race, and insurance, youths with a past-year MDE had significantly higher odds of reporting prescription psychotherapeutic drug misuse (OR, 2.09; 95% CI, 1.75-2.50) and prescription psychotherapeutic drug use disorder (OR, 4.02; 95% CI, 3.37-4.80) compared with those without a past-year MDE.
The motivations for past-year drug misuse among youths with and without a past-year MDE are shown in Table 2. Compared with youths without a past-year MDE, youths with a past-year MDE were more likely to report misusing prescription opioid analgesics (10.2% [95% CI, 6.4%-15.9%] vs 3.7% [95% CI, 2.2%-6.3%]; P = .01) and tranquilizers (29.8% [95% CI, 21.1%-40.3%] vs 13.2% [95% CI, 5.8%-19.9%]; P = .003) to “help with feelings and emotions.” Youths with a past-year MDE were less likely than those without a past-year MDE to report misusing prescription opioid analgesics to “relieve pain” (44.5% [95% CI, 35.7%-53.5%] vs 62.3% [95% CI, 56.8%-67.7%]; P = .001) but were more likely to report misusing these drugs to “feel good or get high” (18.0% [95% CI, 12.0%-26.0%] vs 10.6% [95% CI, 8.0%-13.9%]; P = .02). Similarly, youths with a past-year MDE were more likely to report misusing prescription stimulants to “feel good or get high” (14.2% [95% CI, 9.2%-21.1%] vs 7.9% [95% CI, 5.4%-11.5%]; P = .04) than those without a past-year MDE.
Table 2. Motivations for Prescription Drug Misuse Among Youths With and Without a Past-Year Major Depressive Episode.
| Reason for misuse | % (95% CI) | P value | ||
|---|---|---|---|---|
| Total | Youths with major depressive episode | Youths without major depressive episode | ||
| Opioid analgesics, No. | 1 375 633 | 997 679 | 377 954 | |
| Relieve physical pain | 57.4 (52.5-62.2) | 44.5 (35.7-53.5) | 62.3 (56.8-67.7) | .001 |
| Feel good/get high | 12.6 (9.7-16.3) | 18.0 (12.0-26.0) | 10.6 (8.0-13.9) | .02 |
| Relax/relieve tension | 6.5 (4.4-9.4) | 4.7 (2.4-8.9) | 7.2 (4.4-11.3) | .32 |
| Unknown | 6.3 (4.5-8.9) | 8.2 (4.5-14.5) | 5.7 (3.7-8.6) | .32 |
| Help with feelings/emotions | 5.5 (4.2-7.2) | 10.2 (6.4-15.9) | 3.7 (2.2-6.3) | .01 |
| Experiment/see what it was like | 4.7 (3.1-6.9) | 6.7 (3.3-13.0) | 3.9 (2.5-6.1) | .18 |
| Help with sleep | 3.7 (2.6-5.4) | 3.6 (2.2-5.7) | 3.8 (2.4-5.9) | .83 |
| Some other reason | 2.0 (1.0-3.8) | 2.5 (0.8-7.3) | 1.8 (0.7-4.1) | .60 |
| Hooked | 0.9 (0.6-1.2) | 1.0 (0.4-2.4) | 0.9 (0.5-1.8) | .83 |
| Increase/decrease effects of other drugs | 0.2 (0.07-0.7) | 0.6 (0.1-2.6) | 0.1 (0.0-0.4) | .02 |
| Tranquilizers, No. | 672 283 | 402 828 | 269 455 | |
| Relax/relieve tension | 33.1 (26.9-40.0) | 25.5 (17.3-35.8) | 38.2 (30.7-46.4) | .03 |
| Help with feelings/emotions | 19.9 (15.2-25.5) | 29.8 (21.1-40.3) | 13.2 (5.8-19.9) | .003 |
| Help with sleep | 17.2 (11.6-24.9) | 18.8 (12.1-28.1) | 16.2 (9.5-26.2) | .59 |
| Feel good/get high | 15.1 (11.0-20.3) | 13.1 (7.9-20.7) | 16.4 (10.9-23.8) | .46 |
| Experiment/see what it was like | 7.6 (4.9-11.6) | 7.0 (3.1-14.9) | 8.0 (4.4-14.0) | .80 |
| Unknown | 2.5 (1.4-4.8) | 2.6 (0.8-8.3) | 2.6 (1.0-6.4) | .99 |
| Some other reason | 2.0 (0.9-4.2) | 1.4 (0.5-4.1) | 2.4 (0.9-6.3) | .50 |
| Increase/decrease effects of other drugs | 1.9 (0.8-4.6) | 1.5 (0.0-6.2) | 2.3 (0.8-6.6) | .64 |
| Hooked | 0.5 (0.2-1.5) | 0.3 (0.0-1.8) | 0.7 (0.2-2.4) | .33 |
| Stimulants, No. | 1 263 486 | 814 135 | 449 351 | |
| Help concentrate | 35.6 (30.6-40.8) | 36.7 (28.5-45.7) | 34.9 (28.9-41.5) | .74 |
| Help study | 19.5 (15.8-23.9) | 19.9 (12.7-29.8) | 19.3 (15.0-24.7) | .91 |
| Help be alert or stay awake | 14.8 (11.4-18.9) | 10.7 (7.0-16.1) | 17.1 (12.3-23.1) | .09 |
| Feel good/get high | 10.1 (7.6-13.4) | 14.2 (9.2-21.1) | 7.9 (5.4-11.5) | .04 |
| Experiment/see what it was like | 6.6 (4.4-9.7) | 5.9 (3.3-10.3) | 7.0 (4.2-11.4) | .67 |
| Help lose weight | 5.7 (3.4-9.3) | 4.4 (1.8-10.2) | 6.5 (3.5-11.6) | .46 |
| Some other reason | 3.5 (2.0-6.1) | 3.1 (1.3-7.3) | 3.7 (1.8-7.5) | .77 |
| Unknown | 3.1 (2.1-4.7) | 3.9 (1.8-8.1) | 2.8 (1.8-4.3) | .43 |
| Increase/decrease effects of other drugs | 0.5 (0.1-1.6) | 0.2 (0.0-1.4) | 0.7 (0.2-2.5) | .28 |
| Hooked | 0.4 (0.1-1.4) | 1.0 (0.2-3.8) | 0.1 (0.0-0.7) | .04 |
| Sedatives, No. | 152 676 | 82 779 | 69 897 | |
| Help with sleep | 40.7 (27.5-55.4) | 55.4 (33.8-75.2) | 28.3 (13.9-49.0) | .04 |
| Relax/relieve tension | 17.3 (8.5-31.8) | 10.5 (4.6-21.9) | 23.0 (9.1-47.1) | .18 |
| Unknown | 15.2 (6.4-31.9) | 8.5 (2.1-29.0) | 20.9 (6.8-49.0) | .20 |
| Feel good/get high | 9.7 (4.5-19.6) | 4.6 (1.7-11.4) | 14.1 (5.8-30.2) | .13 |
| Help with feelings/emotions | 9.3 (3.9-20.4) | 11.6 (3.3-33.4) | 7.4 (2.0-24.1) | .60 |
| Some other reason | 6.3 (2.9-13.4) | 7.1 (3.7-13.3) | 5.6 (1.6-18.4) | .78 |
| Experiment/see what it was like | 1.3 (0.4-3.9) | 2.3 (0.4-11.6) | 0.4 (0.0-3.1) | .08 |
| Hooked | 0.1 (0.04-0.6) | NA | 0.3 (0.1-1.3) | NA |
Abbreviation: NA, not applicable.
Discussion
In this nationally representative analysis of adolescents and young adults surveyed in 2023 and 2024, youths with depression were approximately twice as likely to report prescription psychotherapeutic drug misuse and 4 times as likely to meet criteria for prescription drug use disorder compared with their peers without depression. Beyond establishing this elevated risk, our examination of self-reported motivations offers insight into why youths with depression are misusing these medications: they were substantially more likely than youths without depression to report misusing opioid analgesics, tranquilizers, and sedatives to “help with feelings and emotions,” and correspondingly less likely to cite pain relief as their reason for opioid misuse. Taken together, these patterns suggest that a meaningful share of prescription psychotherapeutic drug misuse among youths with depression reflects self-medication of underlying psychological distress rather than purely recreational use, although the heightened endorsement of “feeling good or getting high” for opioids and stimulants indicates that recreational motivations also remain important in this group.
These findings may raise particular concerns given the ongoing youth mental health crisis and the persistent gaps in access to psychiatric care, which together create conditions in which adolescents and young adults may turn to readily available prescription medications as a substitute for the treatment they cannot obtain. In line with recommendations from the American Academy of Pediatrics, our results support the need for earlier identification of depression in youths, integration of substance use screening into mental health care and vice versa, and expansion of accessible, developmentally appropriate treatment pathways before self-medication patterns escalate into SUDs that persist into adulthood.11,12
The increase in youth mental health disorders has brought increased attention on the relationship between mental health disorders and substance misuse.15 Prior work using the National Comorbidity Survey–Adolescent Supplement showed that, among adolescents, a variety of mental health conditions, including depression and anxiety, were associated with initiation of alcohol and illicit drug use and subsequent development of SUDs.16 A meta-analysis examining whether psychiatric disorders were risk factors for the development of substance use found that childhood attention-deficit/hyperactivity disorder, oppositional defiant disorder or conduct disorder, and depression were all associated with the development of substance-related disorders.17 In another study focused on Medicaid-enrolled youths with newly diagnosed opioid use disorder, more than 60% were found to have a mental health diagnosis at the time of opioid use disorder diagnosis, with existing depression reported in one-quarter of these cases.18
Conversely, there is a growing body of evidence indicating that treatment of underlying depression attenuates the development of SUDs.19 A prospective study of adolescents with depression with no history of SUD found that a positive response to treatment predicted a lower rate of subsequent SUD.20 Additionally, an analysis based on NSDUH data for 2008 to 2014 indicated that youths with depression who received treatment were less likely to subsequently report nonmedical use of prescription pain relievers compared with those who had not received treatment for their depression.21 It is important to acknowledge that the observed association between depression and substance misuse is likely bidirectional; individuals with substance misuse are at higher risk of developing depression, reinforcing the importance of substance use screening among all adolescents.12,22,23,24
In addition to the association between depression and substance misuse, we explored motivations for drug misuse among youths and found that those with depression were more likely to report misusing opioid analgesics, tranquilizers, and sedatives to “help with feelings and emotions” compared with those without depression. This suggests that youths with untreated behavioral and mental health needs may be self-medicating to treat their depression. These findings are consistent with a 2024 report examining motivations for drug use among adolescents under evaluation for SUD, which found that 40% of respondents were using drugs “to help with depression or anxiety.”25
Preventing this form of self-medication will require expanding timely access to mental health care for youths with depression. National US data from 2021 to 2023 indicate that only 16% of adolescents were prescribed medication for mental health condition and 20% received therapy, while 20% reported unmet mental health care needs.26 This shortfall is seen also in the 2024 NSDUH, in which 40% of the 3.8 million adolescents with depression received no treatment at all.2 Access also appears to be deteriorating: according to the National Survey of Children’s Health, 61% of adolescents currently diagnosed with depression, anxiety, or a behavioral or conduct problem had difficulty obtaining treatment, a 35% increase since 2018.27
These barriers are even more pronounced for youths who develop an SUD alongside depression. Between 2011 and 2019, treatment for depression alone increased from 28.5% to 42.5% and treatment for SUD alone decreased from 4.8% to 1.5%, with the proportion of adolescents treated for both conditions fluctuating between 4.5% and 11.6%. This persistent gap indicates that few youths with co-occurring depression and SUD receive integrated care, leaving those who begin misusing prescription medications to manage depressive symptoms at heightened risk of progressing to entrenched, untreated substance use.10
Limitations
This study has several limitations. First, as is the case with all surveys, responses may be subject to reporting bias, which is of particular importance for surveys addressing stigmatizing conditions, such as mental health conditions and substance use, and can lead to both overreporting or underreporting. Second, we focused on individuals with depression and results may not be reflective of substance use among those with other mental health conditions, nor was substance misuse as a means for suicide assessed.28 Third, slight variation in question formatting between years may affect response rates. Fourth, motivations for substance misuse varied between drugs, making direct comparisons challenging. Additionally, respondents were instructed to select the “main reason” for misuse, which may oversimplify complex factors leading to drug misuse. Fifth, the cross-sectional nature of our study prohibits the establishment of a causal pathway. Finally, the NSDUH excludes individuals experiencing homelessness, which may bias results (particularly among the young adult cohort) as prescription drug use is prevalent among youths experiencing homelessness.29
Conclusions
In this cross-sectional analysis of the 2023 and 2024 NSDUH, youths with depression were more likely than their peers without depression both to report prescription drug misuse and to meet criteria for prescription drug use disorder. For certain medications, particularly opioid analgesics and tranquilizers, this misuse was more often motivated by a desire to address feelings and emotions, suggesting that unmet mental health needs may contribute to a meaningful share of misuse. These findings underscore the need to identify and address barriers to integrated mental health and substance use treatment for at-risk youths before patterns of self-medication progress to enduring SUDs.
Data Sharing Statement
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Associated Data
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Supplementary Materials
Data Sharing Statement
