Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder

Abstract

The comorbidity of unipolar depression with substance use disorders (SUD) in adolescents is well established and accounts for 24 to 50 percent in clinical samples. Very little empirical data exist on the treatment of dually diagnosed youth. The objective of this paper is twofold: 1) We will review the literature on SUD and unipolar depression; and 2) we will provide guidelines for a combined pharmacological and psychosocial intervention based on a clinical case example.

Introduction

In populations of adolescents with substance use disorders (SUD), one of the largest subgroups comprises those with one or more comorbid psychiatric disorders, also known as dual diagnosis (DD). This group accounts for 70 to 80 percent of adolescent substance abusers in clinical samples.¹ In particular, the comorbidity of SUD with depression in adolescents is well established,² with comorbid unipolar depression ranging from 24 to 50 percent in clinical samples of SUD adolescents.^3,4 Depression as a comorbidity during SUD treatment raises the risk of treatment dropout, poorer treatment response, and earlier relapse.^5,6 SUDs among depressed youths are a risk factor for suicidal behaviors, including ideation, attempts, and completed suicide. Furthermore, even screened and triaged youth face barriers in finding treatment.¹

This article aims to enhance practitioner knowledge of evidence-based approaches to treating adolescents with substance use disorder (SUD) and comorbid unipolar depression using a case example of an adolescent with cannabis use disorder and major depressive disorder.

Case Example

Joe was a 15-year-old Caucasian boy who, following an arrest for drug dealing, was referred by a juvenile drug court social worker for psychiatric and substance abuse evaluation and treatment.

Joe started smoking marijuana at age 13 after his older brother introduced the drug to him. Joe gradually escalated his use of marijuana over the past three years and upon presentation smoked 1 to 2 joints daily. He reported a calming effect from the marijuana and frequently went to school “high.” Beginning this year, Joe occasionally worked for a drug dealer distributing marijuana to students on the grounds of his high school where he was a freshman.

Joe started smoking cigarettes at age 11 and upon presentation was smoking half a pack per day. He started drinking alcohol at age 13, and in the last year he would regularly consume one six-pack of beer on Friday and Saturday nights to the point of intoxication. All of Joe’s friends were drug and/or alcohol users. Joe never drove a car, although he was a passenger in a car several times that was driven by a friend who was under the influence of drugs or alcohol.

Joe was not sexually active. Joe was an average student whose grades gradually deteriorated since seventh grade. Despite a full-scale IQ of 106, he had to make considerable effort in order to complete his work in school. At time of presentation, he had a C-average and his attendance was compromised. He was repeating ninth grade.

When Joe was 11 years old, his mother died in a car accident. She was in treatment for unipolar depression. When he was 14 years old, he was diagnosed with depression after he reported intense symptoms dating to the loss of his mother consisting of daily anhedonia and boredom, irritability, and uncontrollable anger, especially when he perceived himself as being provoked. He was referred to an anger management group but did not attend. He was prescribed sertraline but took it only briefly. He did not disclose his substance use at that time.

At presentation, Joe lived with his biological father who worked as an electrician, a 13-year-old sister, and his 19-year-old brother. His brother never graduated from high school, was unemployed, and was a heavy cannabis user. Vocal conflicts centered around drug use and discipline were frequent between the father and Joe’s older brother.

Upon evaluation, Joe initially denied feeling depressed, but reported pervasive feelings of boredom, irritability, and not getting “much fun out of things anymore.” Later, he admitted that he might be “a little depressed.” Joe completed a Beck Depression Inventory and obtained a total score of 26 (moderate depression). He believed marijuana to be helpful in calming himself. Joe never tried to cut down or quit substance use nor was he ever involved in treatment for drug use. Upon evaluation, Joe was not motivated to abstain from drug use, but was willing to discuss a treatment option in order to avoid legal consequences and have his pending charges dropped. No suicidal or homicidal ideation was evident, and no symptoms of bipolar illness or psychotic thinking were present on mental status examination.

Development of A Treatment Plan Utilizing Evidence-Based Practice

We conducted a search using PubMed and the search terms substance use disorders and depression using the following limitations: English language only, limited to the past 10 years, and children less than 18 years old. This search yielded 806 relevant articles. Advanced search terms included randomized controlled trial and practice parameters for youth depression and youth SUD, which yielded 43 relevant articles. Abstracts of these articles were reviewed. In addition, pertinent articles and book chapters from the past 20 years known to the authors were also reviewed

There is empirical evidence in the adult literature supporting the simultaneous treatment of SUD and depression rather than treatment approaches that target only one disorder or the sequential treatment of both disorders.¹ However, the treatment of DD in adolescents remains in the realm of clinical consensus.⁷ This consensus advocates for simultaneous intervention for both disorders provided either by the same clinician or by different experts, each responsible for one disorder but who are keeping the other informed.

The variable clinical course of adolescent SUD treatment often leads to premature termination and then later re-entry into the treatment system.⁸ Survival data from a comprehensive and comparative review⁹ and from the Cannabis Youth Treatment Study (CYT)¹⁰ showed sustained abstinence of 38 percent and 24 percent, respectively, one year after treatment completion.

Psychosocial treatment strategies that have shown promise in reducing SUD among adolescents are comprehensively reviewed by Liddle and Rowe,¹² and specifically in other references presented in Table 1.^3,10,13–19

TABLE 1.

Empirically supported psychosocial treatment for substance-abusing adolescents

AUTHOR	INTERVENTION	STUDY DESIGN	SAMPLE SIZE	OUTCOME
KEY: CBT: cognitive behavioral therapy PET: psychoeducational therapy MDFT: multidimensional family therapy FFT: functional family therapy MST: multisystemic therapy CM: contingency management
Arzin, et al. 1994	Behavioral therapy or supportive therapy	Random assignment	26	Behavioral treatment significantly better at achieving abstinence
Kaminer, et al. 1998	CBT or interactional group treatment	Random assignment	32	Adolescents assigned to CBT showed significant reductions in severity of substance use
Kaminer, et al. 2002	CBT or PET	Random assignment	88	CBT subjects had significantly lower rates of positive urinalysis than did PET subjects
Liddle, et al. 2001	MDFT	Random assignment	182	Significant reduction in adolescent drug use
Waldron, et al. 2001	FFT	Random assignment	114	FFT significantly associated with percentage of youths achieving minimal substance use
Hennegler, et al. 1996	MST or treatment as usual	Random assignment	118	Home-based MST effective in reducing treatment drop-out and recidivism
Kamon, et al. 2005	CM	Intent to treat	19	Urine documented abstinence increased from 37% to 74% by study end
Winters, et al. 2000	Minnesota 12-Step Model	Consecutive referrals to completer, non-completer, or wait list groups	179	Completing treatment significantly associated with improvement in drug use

Cognitive behavioral therapy (CBT) facilitates coping skills for maintaining abstinence in high-risk situations and improves social networking skills with nonusing youth.²⁰ The manualized integrated motivational enhancement therapy (MET)/CBT approach has been found to be the most cost-effective intervention in the largest, prospective, randomized, controlled study for youth with cannabis use disorders.¹⁰ In this context “motivational” means “address readiness to behavior change toward abstinence.” MET is guided by four main principles: 1) express empathy utilizing active listening; 2) develop discrepancy (help patient to recognize how his or her life is when he or she is using the drugs versus how his or her life could be without drugs; 3) roll with resistance; and 4) support self-efficacy.²³

Case Example, Continued: Implementation of A Dual Diagnosis Treatment Plan

The goals for Joe’s treatment were explicit, realistic, obtainable, and shared by his clinicians, himself, and his father. It was emphasized to Joe and his father that realistic expectations from treatment included awareness that although the ultimate goal is abstinence, treatment is a process and not an event. Recovery often involves periods of improvement, followed by relapse, and changes in symptom severity.

Since Joe was not suicidal or dangerous, treatment was able to occur in an outpatient setting. After three years of continuous drug abuse, Joe was at risk of withdrawal once he stopped using cannabis. Withdrawal symptoms from cannabis reported in youth¹¹ include the following three categories: mood (e.g., irritability 47%; increased anger 40%; depressed mood 58%; nervousness/anxiety 33%), behavioral (e.g., craving 71%; restlessness 46%; increased aggression 36%; sleep difficulty 43%; strange dreams 26%), and physical (e.g., headache 32%; shakiness 29%; sweating 19%; stomach pains 18%; nausea in 15%). A treatment duration of 12 weeks was recommended for a first treatment episode of cannabis use disorder.¹⁰

Because Joe demonstrated little motivation for change and the status of his coping skills to resist substance use in high-risk situations was unknown,²⁰ we recommended an integrated intervention of MET/CBT.^21,22 Table 2 provides an example of a transcription of a session with Joe utilizing this therapy compared to a directive approach.

TABLE 2.

A sample transcript with Joe contrasting a directive approach with a motivational enhancement approach

ASSESSMENT USING A DIRECTIVE APPROACH	ASSESSMENT USING ANMET APPROACH	MET TECHNIQUE
Therapist: Tell me about your drug problem.	Therapist: What brings you here today?	Active listening, empathy
Joe: I don’t have a drug problem.	Joe: I’m only here because my dad made me come.
Therapist: What do you mean you do not have a drug problem?	Therapist: Tell me more about that.	Roll with resistance, maintain empathy
Joe: I use drugs; no problem…	Joe: My dad thinks that I have a drug problem.
Therapist: I have reliable information in this chart about your use.	Therapist: Care to tell me why he thinks so?	Begin to develop discrepancy between Joe’s understanding of his SUD and the concerns of others who care for him
Joe: You sound like my dad or a probation officer.	Joe: I’ve been using and it kinda got me in trouble a couple of times.
Therapist: Sounds like you are in denial of your drug use and consequences. We need to work on changing your negative attitude, otherwise you could be in trouble.	Therapist: Sounds as if you went through some difficulties.	Active listening, empathy, further explore discrepancy
Joe: [Goes silent] I don’t want to work with you.	Joe: I got problems in school and with the police. I don’t see how coming to a place like this is gonna be helpful with that.
Therapist: I have a lot of experience working with teenagers like you and I want to help you. However, you have to listen to me so you can make some changes in order not to ruin your life.	Therapist: I appreciate your honesty. I am glad that we have an opportunity to talk. If you want, we can meet several times and work together to solve these problems. Shall we schedule a meeting to continue?	Roll with resistance, support self efficacy, continue to identify opportunities to highlight discrepancy
Joe: I don’t need this lecture. I’m outta here.	Joe: Well, O.K.

Periodic urinalyses to monitor abstinence with consequences for negative or positive urines were recommended. A contract negotiated early in treatment between Joe, his father, and the clinician included changes in curfew times, allowance, and other incentives in a form of entertainment items (e.g., CD, DVD, movie tickets) and clothing. Adjustments were made during treatment based upon progress. An effort to engage Joe’s father as an ally in treatment was important in order to encourage Joe to achieve and maintain abstinence as well as contain the drug-using activities of Joe’s older brother at home.

Joe met criteria for major depressive disorder (MDD) on clinical assessment. CBT was recommended for Joe’s depression and focused on increasing positive activities, improving problem-solving skills, and learning how to restructure unrealistic negative thoughts. Given his lack of suicidal ideation and moderate severity of depressive symptoms, it was not mandatory to begin antidepressant medication immediately. Since evidence suggests that depression in adolescents is influenced by psychosocial variables and has a high placebo response rate (between 35 and 60% in clinical antidepressant trials for youth depression), a period of “watchful waiting” with ongoing monitoring of his clinical status was indicated.²⁴ During this time, psycho-education about depression and its treatment were provided to Joe and his father. Suggestions for lifestyle management included increased engagement with non-drug-involved peers, daily exercise, and the creation of a daily activity schedule to increase pleasurable activities were encouraged. Table 3 summarizes four pharmacological trials^5,25–27 and one psychosocial study²⁸ for adolescents with alcohol or substance use disorder and concomitant MDD.

TABLE 3.

Adolescent treatment trials for dually diagnosed depressed adolesoents

AUTHOR/SUBSTANCE	STUDY DESIGN	N	INTERVENTION MEDICATION	RESPONSE
KEY: SUD: substance use disorder AUD: alcohol use disorder CBT: cognitive behavioral therapy
Riggs, et al. 1997, SUD	Open-label	8	Fluoxetine	7 out of 8 depressive symptoms improved
Deas, et al. 2000, AUD	Placebo-controlled	10	Sertraline	Improved depressive symptoms and reduced drinking in both groups
Cornelius, et al. 2001, AUD	Open-label	13	Fluoxetine	Within group, significant improvement of depression and reduced drinking
Riggs, et al. 2007, SUD	Double-blind, placebo-controlled	126	Fluoxetine plus CBT	Depression improved significantly in the fluoxetine-CBT group vs. placebo group among SUD patients
Curry, et al. 2003, SUD	Pilot	13	Integrated family and cognitive behavioral therapy	Demonstrated feasibility and was associated with improvements in both disorders (SUD and depression)

Two weeks after the onset of treatment for SUD and with the prompting of his father, Joe agreed to an antidepressant trial “to see if it would help.” After a risk/benefit discussion with Joe and his father, fluoxetine was initiated at 10mg/day and increased to 20mg/day after one week. Three weeks after initiating medication, Joe reported a Beck Depression Inventory score of 18 (a 30% improvement over baseline). He requested to continue his combined medication/psychosocial treatment. Joe adhered to his recommended treatment for two months with significant improvement in SUD and depression. He then became nonadherent with scheduled visits and medication. Six months later, his father reported that Joe relapsed and was smoking marijuana daily, although he was not depressed. Joe refused to return to treatment. Our clinic continues to maintain contact with Joe’s father in order to enable access to treatment at a future date.

Conclusions And Future Directions

Adolescent substance abuse treatment should begin with a comprehensive multidimensional evaluation.²⁹ Failure to recognize or adequately treat comorbid depression may interfere with substance abuse treatment. The present consensus advocates for a simultaneous and coordinated implementation of psychiatric and substance-abuse treatment services for DD patients. Clinical consensus and emerging evidence-based practice suggest that psychotherapy targeting both depression and SUD as well as integration of psychotherapy with a selective serotonin reuptake inhibitor (SSRI) might be efficacious treatments. Further controlled trials are necessary to confirm these findings and expand on issues such as severity of each disorder, dosage and length of treatment courses, how to address poor response, and barriers to treatment.

Finally, close clinical monitoring is required because treatment of depression with an SSRI in adolescents has been under scrutiny due to concern over potential adverse effects such as suicide,² as well as lack of sufficient evidence regarding interactions of abuse drugs with SSRIs.³⁰ While we are not presently aware of cannabis-SSRI drug adverse interactions, concomitant alcohol use increases lethality in SSRI overdose.³¹ Clinical consensus suggests that in depressed adolescents with poly-substance dependence, binge-alcohol drinking patterns, or severe SUD as with opiates, SSRIs may be contraindicated.³¹