Youth and Comorbidity: Addiction and Mental Illness

"A report from the Agency for Healthcare Research and Quality (AHRQ) finds 
that almost one in eight of the 95 million visits to hospital 
emergency departments made by adults in the United States in 2007 
were due to a mental health and/or substance abuse problem. The most 
common reason for these visits was a mood disorder (42.7%), 
followed by anxiety disorders (26.1%), 
alcohol-related problems (22.9%), 
and drug disorders (17.6%)." 

(AHRQ-HCUP Statistical Brief 92. Mental Health and Substance Abuse-Related 

Emergency Department Visits Among Adults, 2007. Released July 2010.)

The term “comorbidity” describes two or more disorders or illnesses occurring in the same person. They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both.

It is important to understand comorbidity as it relates to addiction and other mental illnesses.The following information is taken from NIDA InfoFacts: Comorbidity: Addiction and Other Mental Disorders. (National Institute on Drug Abuse, U.S. Department of Health and Human Services, www.drugabuse.gov) Please read the entire report at http://www.drugabuse.gov/infofacts/comorbidity.html.

Drug addiction is a mental illness. Addiction changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that weaken the ability to control impulses, despite the negative consequences, are similar to hallmarks of other mental illnesses.

Many people who are addicted to drugs are also diagnosed with other mental disorders and vice versa. For example, compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true.

Although drug use disorders commonly occur with other mental illnesses, this does not mean that one caused the other, even if one appeared first. In fact, establishing which came first or why can be difficult. However, research suggests the following possibilities for this common co-occurrence:

• Drug abuse may bring about symptoms of another mental illness. Increased risk of psychosis in vulnerable marijuana users suggests this possibility.
  
  
• Mental disorders can lead to drug abuse, possibly as a means of “self-medication.” Patients suffering from anxiety or depression may rely on alcohol, tobacco, and other drugs to temporarily alleviate their symptoms.

These disorders could also be caused by shared risk factors, such as—

• Overlapping genetic vulnerabilities. Predisposing genetic factors may make a person susceptible to both addiction and other mental disorders or to having a greater risk of a second disorder once the first appears.
  
  
• Overlapping environmental triggers. Stress, trauma (such as physical or sexual abuse), and early exposure to drugs are common environmental factors that can lead to addiction and other mental illnesses.
  
  
• Involvement of similar brain regions. Brain systems that respond to reward and stress, for example, are affected by drugs of abuse and may show abnormalities in patients with certain mental disorders.
  
  
• Drug use disorders and other mental illnesses are developmental disorders. That means they often begin in the teen years or even younger—periods when the brain experiences dramatic developmental changes. Early exposure to drugs of abuse may change the brain in ways that increase the risk for mental disorders. Also, early symptoms of a mental disorder may indicate an increased risk for later drug use.

 
Understanding the Implications

Trauma and stress are major environmental triggers of addiction and other mental disorders for so many young people. Consider all the changes faced by youth during adolescence. The transitions that take place during these years are overwhelming for some. In addition, many social problems are likely to surface then; they can create very serious, threatening outcomes.

Some of the major stressors faced by youth (www.troubledteen101.com, 2009) include the following:

• Family problems (divorce, death in family, new sibling, financial problems)
• Moving to a new school
• Difficulty in school (learning difficulties, too much homework, tests)
• Friends (lack of friends, shyness, fights with friends, acceptance/rejection, peer pressure, boyfriend/girlfriend problems)
• Overload (too many extra-curricular activities combined with school work, jobs, etc)
• Illness
• Physical changes in body
• Lack of sleep
• Deciding one's future (college planning, job planning)
• Overachieving (trying to be perfect in many areas)
• High expectations (setting goals too high can come from both parents and the individual themselves) 

All young people face healthy doses of fear, sorrow, and increased responsibility. It is easy to see how stress can overcome them. When a major event causes stress, it is often because it sets off a chain of events that intensifies the on-going, day-to-day stressful conditions of their lives.

Youth can react to a "pileup" of stressful life events by withdrawing, crying, picking fights, losing focus, and seeking fewer accomplishments. They may change their eating or sleeping patterns, become moody or angry, and even entertain thoughts of suicide. There is a disturbing potential for drug use and dependence.

As a high school English teacher, I was always amazed at the lack of response by parents during time set aside for parent/teacher conferences. Many of same parents who would religiously attend their child's grade school conferences year after year took less of an active role once their child began the high school years, and the parents who did attend the conferences were often parents of honor students, not those of at-risk students.

I assume a significant number of parents believed that by the time a youth entered high school, he or she should be responsible for his or her own actions and readily equipped to handle the stressors in life. This is far from the truth. In my opinion, parents should become even more involved during later school years because of the enormous increase of stress faced by their child and the increase in potential for serious mental problems.

A high school student is not equipped to face all decisions alone. The frontal cortex, the area of the brain that controls reasoning and helps people think before they act, develops later than the part of the brain which is responsible for instinctual reactions including fear and aggressive behavior. This part of the brain is still changing in adolescence and maturing well into adulthood.

Other specific changes in the brain during adolescence include a rapid increase in the connections between the brain cells and pruning (refinement) of brain pathways. Nerve cells develop myelin, an insulating layer which helps cells communicate. All these changes are essential for the development of coordinated thought, action, and behavior.

According to American Academy of Child Adolescent Psychiatry, ("The Teen Brain: Behavior, Problem Solving, and Decision Making," September 2008), adolescents are more likely to be prone to the following behaviors:

• act on impulse
• misread or misinterpret social cues and emotions
• get into accidents of all kinds
• get involved in fights
• engage in dangerous or risky behavior

Adolescents are less likely to: 

* think before they act  
* pause to consider the potential consequences of their actions  
* modify their dangerous or inappropriate behaviors

This is not to say that young people can't make good decisions or cannot tell the difference between right and wrong. In most cases, they can. But an awareness of these differences can help parents better manage the behavior of their child. A better understanding just might prevent addiction and mental illness.

The Department of Health and Human Services offers an interesting look into the thinking of young adults. Why does a youth decide to make a poor, hasty decision such as cheating in school; skipping class; using alcohol, tobacco, or illegal drugs; going somewhere or being with someone that they do not approve of; or driving too fast? Just look at some common efforts they use to justify their missteps:

• Because I wanted to. Enough said—this only works if you are alone on an island with no rules and only yourself to consider.
• Everybody does it. People often try to duck responsibility by showing that their actions—drinking alcohol, staying out too late, or sharing test questions—are in line with the values and likings of their social group. 
• What else could I do? This excuse is a sign of failure to see all the available choices, such as leaving the party or not riding with a certain person.
• But I said I would. Once people decide on something, they tend to stick with it—keeping a date, hosting a party, bringing alcohol. No one likes to admit they’re wrong, appear timid, or disappoint others.

 ("Understanding Teen Decision Making," www.education.com, Department of Health 

and Human Services, 2011)