Alcohol is the drug of choice for adolescents, with cigarettes and marijuana being second and third.1 Contrary to widespread belief, alcohol dependence is most common in 18- to 20-year-olds, with progressively decreasing rates of alcohol dependence in older age groups.2 Similarly, the age at onset of alcohol dependence is typically highest among those in their later teen years and early 20s, with a much lower rate of onset after the age of 25 years.2
Comorbidity, particularly with major depressive disorder (MDD), is the rule rather than the exception in young people.3 Alcohol use disorders (AUDs), including alcohol dependence and alcohol abuse, and MDD co-occur more frequently than would be expected by chance alone. A number of studies have shown an even stronger association between AUDs and comorbid MDD in clinical samples of adolescents and young adults than in community samples.4
AUDs also commonly co-occur with bipolar disorder. Bipolar disorder can present as either depression, mania, or a combination of depression and mania, so care must be taken to distinguish between major depression and bipolar disorder when an adolescent presents with depressive symptoms.
The depressive symptoms of adolescents with comorbid AUD and MDD are similar to those of adults. The acute clinical presentation in adolescents tends to focus on depressive symptoms, while chronic difficulties--including social and health problems--typically result more often from AUDs. Adolescents typically drink less frequently but more heavily than adults.5 Adults with comorbid AUD and MDD demonstrate a much higher rate of suicidal indicators than either single-diagnosis comparison group (AUD or MDD alone).6 Adolescents in whom comorbid disorders have been diagnosed are at a higher risk for attempting suicide.7 Among those with comorbid disorders, suicide attempts are most common following a recent period of very heavy drinking.8
Clinical course and prognosis
Birmaher and colleagues9 concluded that for most children and adolescents, the index episode of MDD is the beginning of a chronic, recurrent, lifelong disorder. They also found that major depression among children and adults is usually accompanied by other disorders, and continued treatment is generally needed to prevent recurrences of major depression. Similarly, Emslie and coauthors10 reported that 40% of the adolescents they studied with MDD (with no comorbid drug use or AUD) suffered a recurrence of major depression within 12 months of successful treatment with fluoxetine, which they concluded was a higher rate of recurrence of depression than is generally noted among adults.
Cornelius and associates11 undertook a follow-up study of adolescents with comorbid AUDs in combination with major depression and found a high rate (80%) of recurrence of depression in the 5 years following acute-phase treatment with fluoxetine. Thus, it appears that adolescents with major depression display a higher rate of recurrence of major depression than do adults and that adolescents with comorbid disorders display a higher risk of recurrent depressive episodes than do adolescents without comorbidities.
Rapid relapse to alcohol and other substance use has been shown to generally occur following treatment for alcohol and other substance use disorders (SUDs) among adolescents, with two thirds of adolescents relapsing to alcohol or drug use within 6 months after treatment.12 Major depression comorbidity has been shown to be associated with earlier relapse to alcohol and other substance use in adolescents.13 However, the level of substance use typically declines somewhat in the year following treatment.14 Preliminary data from a small sample suggest that the long-term prognosis for adolescents with an AUD and a comorbidity may be better than that for adults with an AUD and a comorbidity.11 A high degree of heterogeneity characterizes adolescents' courses after treatment, involving multiple trajectory subgroups.14 Thus, the long-term course of depressive symptoms and alcohol use in adolescents with comorbidities is variable, but often problematic, so longer-term treatment is warranted--particularly for adolescents with significant residual symptoms.
SCREENING AND ASSESSMENT
Adolescents with major depression should be routinely screened for the presence of alcohol and other SUDs, and conversely, adolescents with an AUD should be routinely screened for the presence of major depression because of the high levels of co-occurrence of those disorders. If an SUD or AUD is detected on initial screening, then a follow-up urine drug screening and Breathalyzer or other measure of blood alcohol concentration should also be considered. As noted above, the comorbid presence of an SUD and major depression is often associated with suicidal ideation or suicidal behavior, so assessment of suicidality should be routine clinical practice if an SUD or major depression is noted.6-8 If these conditions are detected during screening, then appropriate referral should be made for further evaluation and subsequent treatment.
1. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2005. Bethesda, Md:National Institute on Drug Abuse; 2006. NIH publication 06-5882.
2. Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002. Drug Alcohol Depend. 2004;74:223-234.
3. Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7:3-14.
4. Clark DB, Pollock N, Bukstein OG, et al. Gender and comorbid psychopathology in adolescents with alcohol dependence. J Am Acad Child Adolesc Psychiatry. 1997;36:1195-1203.
5. Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS) 1994-1999; National Admissions to Substance Abuse Treatment Services. Rockville, Md: Office of Applied Studies; 2001. DHHS publication (SMA) 01-3550.
6. Cornelius JR, Salloum IM, Mezzich J, et al. Disproportionate suicidality in patients with comorbid major depression and alcoholism. Am J Psychiatry. 1995; 152:358-364.
7. Kelly TM, Cornelius JR, Clark DB. Psychiatric disorders and attempted suicide among adolescents with substance use disorders. Drug Alcohol Depend. 2004;73: 87-97.
8. Cornelius JR, Salloum IM, Day NL, et al. Patterns of suicidality and alcohol use in alcoholics with major depression. Alcohol Clin Exp Res. 1996;20:1451-1455.
9. Birmaher B, Arbelaez C, Brent D. Course and outcome of child and adolescent major depressive disorder. Child Adolesc Psychiatr Clin N Am. 2002;11:619-637, x.
10. Emslie GJ, Heilingenstein JH, Wagner KD, et al. Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial. J Am Acad Child Adolesc Psychiatry. 2002;41:1205-1215.
11. Cornelius JR, Clark DB, Bukstein OG, et al. Acute phase and five-year follow-up study of fluoxetine in adolescents with major depression and a comorbid substance use disorder: a review. Addict Behav. 2005;30:1824-1833.
12. Cornelius JR, Maisto SA, Pollock NK, et al. Rapid relapse generally follows treatment for substance use disorders among adolescents. Addict Behav. 2003;28: 381-386.
13. Cornelius JR, Maisto SA, Martin CS, et al. Major depression associated with earlier alcohol relapse in treated teens with AUD. Addict Behav. 2004;29:1035-1038.
14. Chung T, Maisto SA, Cornelius JR, Martin CS. Adolescents' alcohol and drug use trajectories in the year following treatment. J Stud Alcohol. 2004;65:105-114.
15. Deas D, Thomas SE. An overview of controlled studies of adolescent substance abuse treatment. Am J Addict. 2001;10:178-189.
16. Kaminer Y. Adolescent substance abuse treatment: evidence-based practice in outpatient services. Curr Psychiatry Rep. 2002;4:397-401.
17. Riggs PD, Mikulich SK, Coffman LM, Crowley TJ. Fluoxetine in drug-dependent delinquents with major depression: an open trial. J Child Adolesc Psychopharmacol. 1997;7:87-95.
18. Deas D, Randall CL, Roberts JS, Anton RF. A double-blind, placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study. Hum Psychopharmacol. 2000;15:461-469.
19. Riggs PD, Lohan M, Davies R, et al. Random- ized, controlled trial of fluoxetine/placebo and CBT in depressed adolescents with substance use disorders. Presented at: American Academy of Addiction Psychiatry 16th Annual Meeting and Symposium; December 8-11, 2005; Scottsdale, Ariz. Paper Session C, 53-54.
20. Cornelius JR, Salloum IM, Ehler JG, et al. Fluox- etine in depressed alcoholics. A double-blind, pla- cebo-controlled trial. Arch Gen Psychiatry. 1997;54: 700-705.
21. Clark DB, Wood DS, Cornelius JR, et al. Clinical practices in the pharmacological treatment of comorbid psychopathology in adolescents with alcohol use disorders. J Subst Abuse Treat. 2003;25:293-295.