Polysubstance Abuse Among Adolescent Males With Depression

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Introduction

Poly-substance abuse as an effect of Depression comes along with conduct disorder and attention deficit hyperactivity. All these are mental illnesses. Of the depression disorders, major depressive disorder (MDD) is a common concomitant of poly-substance abuse that is a result of substance dependence. Substance abuse among adolescents can be caused by depression. In this case, the adolescents down ply the idea of seeking psychological support from their parents or even health practitioners if they are faced with problems. They instead make it a habit to abuse drugs as an alternative.

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This group of people is always at crossroads when it comes to making decisions, as they always feel mature when actually they are still developing. Their indecisive nature makes them the most vulnerable victims of substance abuse. These substances include among others alcohol, cocaine, marijuana, heroin, and cigarettes. The adverse effects of substance abuse go beyond one’s life to affect the family, society and the government. All the above groups are affected in one way or the other. This paper seeks to find out the severity of this problem by understanding depression levels of victims, its relation to poly-substance abuse and analysis of the treatment methods available.

Literature Review

This area covers the analysis of the literature information available on this topic. This includes collecting the details that will help in making comparisons on the ideas that emerge.

The relationship between Depression and Poly-substance Abuse

Studies over time have shown a close link between depression and polysubstance abuse among adolescent males. Research by Winters, Ramafedi, and Chan in the mid-nineties used clinical instruments that screened drug abuse in assessing the level of poly-substance abuse among gays in this age group. The research also sought to establish the relationship between psychological distress, substance abuse, and abnormal behaviors in young adolescents. Their study sample was composed of gay-bisexual male adolescents (13-19 years old) who had sex with men or who otherwise considered themselves gay or bisexual. The data was obtained via a structured interview. Most of the males reported symptoms of psychological distress. Fifty-two percent of them revealed that they worried a lot for no reason, 31% had problems in dealing with some unusual thoughts, 31% felt sad most of the time, 22% suffered frequent headaches, or nervous stomach and 17% reported to be contemplating suicide. Of all the participants, 94.6% accepted to have used at least one drug in the previous year. The most used substances were marijuana (8.4%), alcohol (24.5%), and cocaine (2.4%). It is noteworthy that 4.2% of the males reported having used injections to abuse drugs in the previous year that exposed them to the risk of getting HIV/AIDS.

From their finding, most of the males abused multiple drugs. Fifty-eight percent of the respondents admitted that they were using two or more substances while 29.6% were using more than three drugs. It is thus evident that their sample was composed of a significantly high percentage of people who were involved in poly-substance abuse.

Just like Winters, Ramafedi, and Chan (1996), Mason and Windle (2002) believed that depression in individuals had triggered them to poly-substance abuse. Poly-substance abuse lowers an individual level of judgment making them indulge in risky behaviors such as premarital sex or even becoming homosexual an aspect that increases their risk of diseases such as HIV/AIDS among others. It is noteworthy that their research results are representative of findings in clinical gay-bisexual adolescents and may not hold for the same group of adolescents in the general societal setting. Additionally, different ethnic groups exhibit varying frequencies of the involvement of depressed adolescent boys in poly-substance abuse. This was established through a study carried out by Winters and Latimer (2004) in their attempt to Alcohol and other drugs abuse in adolescent boys from different ethnic groups in the U.S. The ethnic groups that were studied were Hispanics, Whites, African Americans, and Native Americans.

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Poulin et al. (2004) investigated the relationship between depression and polysubstance abuse in adolescents in the four Atlantic provinces of Canada as far as gender is concerned. Their sample consisted of 12,771 students in both junior and high schools of the public schools in the four provinces. They found out that adolescent females were consistently at a higher risk of depressive symptoms, depressive disorders since they tend to internalize their problems more than their male counterparts do. According to their study, the prevalence of very elevated symptoms among female adolescents was 8.6% while that of the males was 2.6%. However, male adolescents are at a greater risk of substance use disorders than adolescent females. Poulin et al. (2004) found out that different substances are used at different rates among male adolescents with depression. The findings were similar to Nolen-Hoeksema’s (2001) who carried out a study to describe how the different genders have different experiences as far as stress in adolescents is concerned. They identified most of the abused substances among adolescents. They include alcohol, cigarettes, and cannabis. They associated the increased use of these substances with an increasing probability of depressive disorder. They also noted that smoking was the least controllable substance among the males. They established that depressive symptoms and disorders are the major predictors of smoking uptake not only in adolescence but also in adulthood.

Early-onset smoking poses a greater risk for severe depression symptoms than later-onset smoking. On the other hand, cannabis abuse was associated with males with had a history of depressive disorder. Sixteen percent of those who had used cannabis at least once in their life were diagnosed with depression compared to 6% of the adolescents who had never used cannabis. They also found out that most of the students had depression symptoms while others already had depression disorder but they had not received much help from society. Only 10.3% reported that they had received help for depression. Their findings show that for the different levels of depression only 12% of the students with somewhat elevated depressive symptoms had received help so was 22% of the students who had very elevated depressive symptoms. A large proportion of male students had not received any help-12.8 percent of the females sought help as opposed to 7.1% of the males.

Depressed adolescents are highly vulnerable to poly-substance abuse in addition to engaging in multiple illegal activities. Pruitt (2007) asserts that male adolescents are less likely to report depression due to several reasons. They tend to distract themselves from depression by doing some of the things that seem enjoyable besides thinking too much about other things. They also tend to ignore their problems. Additionally, male adolescents are usually reluctant and unwilling to ask for help from adults due to the fear that they will appear childish.

How advancement of depression increases poly-substance abuse

Deykin, Levy, and Well (1986) established the relationship between depression, alcohol and drug abuse in adolescents. Their study was the first one to document the association as well as the sequence of psychiatric disorder, drug, and alcohol abuse that is not only rigorously ascertained but also defined in a normal adolescent population. They employed a cross-sectional study design to identify the manifestations and correlates of major depressive disorder in adolescents. The sample comprised 271females and 153 males who were college students ranging between 16 and 19 years old. They obtained the data using the Diagnostic Interview Schedule that has high reliability with an overall kappa statistic of 0.69. A well-structured standardized interview was developed for epidemiologic purposes. Regarding alcohol abuse and major depressive disorder (MDD), the study showed that the lifetime prevalence of alcohol abuse was 8.2% while that of MDD was 6.8%. On the other hand, the lifetime prevalence of substance abuse was 9.4%. They found out that adolescents who had a history of alcohol abuse were nearly four times as likely to have a history of MDD as those who did not have a history of alcohol abuse. Like alcohol abuse, drug abuse among adolescents has a very strong association with a lifetime prevalence of MDD. The study also shows that marijuana is one of the most abused substances among adolescent males. Subjects who had a record of drug abuse, irrespective of the drug they abused, were 3.3 times as much as non-abusers to have a history of MDD.

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Deykin et al. established that alcohol abuse is a common disorder in adolescent males as compared to their female counterparts. Additionally, they found that drug abuse in both male and female adolescents is strongly associated with MDD among other psychiatric disorders. According to the study, depressive illness paves way for alcohol/substance abuse among all male adolescents. The study further defines the two major types of depression (primary and secondary) to assist in understanding the relationship between poly-substance abuse and depression. Deykin et al.’s (1986, p. 181) definition for primary depression is the kind of depression that occurs in a patient whose “previous psychiatric history is negative or positive only for pre-existing mania or depression”. On the other hand, secondary depression is the type of depression exhibited by a patient “who has a pre-existing diagnosable disorder” (ibid). The classification is based on the onset of the disorders. In their study, 79% of the males involved in poly-substance abuse had primary depression prior to their involvement in substance abuse.

The initiation of an individual to early substance use e.g. alcohol at an early age (15 years old) doubles one’s risk of substance use dependence. According to Mrug, Gaines and Windle (2010, p. 490), adolescent behavior inclusive of substance abuse is affected by proximal social contexts. They include family, peers, as well distal settings such as neighborhoods and schools. In their study, they examined school-wide use of alcohol, marijuana, and tobacco in relation to the involvement of early male adolescents’ abuse of substances. They also examined whether the relationships varied across degrees of two most important proximal risk factors in male adolescents: deviant peer affiliations and poor parenting practices. Mrug et al.’s (2010) study consisted of a sample of 542 middle school students. The Institutional Review Board approved the study for Human Use at the University of Alabama at Birmingham. They found out that adolescents who were victims of poor parenting practices engaged in poly-substance abuse in an attempt to cope with their depression. Parents who did not show much concern for their children made them develop depression especially when their peers seemed to be receiving more care and support from their families. For such adolescents, it was easier for them to join others who opted to use drugs in coping with their hardships.

The effects of poly-substance abuse

Involvement in poly-substance abuse, whatever the cause, has some negative effects on the life of the individual. Green and Ensminger (2006) examined the effects of heavy adolescent substance abuse on employment, marriage, and family formation. Their study used marijuana use since it of the most abused substance among male adolescents. They obtained data from the Woodlawn survey, a prospective study of African American youths in Chicago. It is a research and intervention program for drug users, which is a partnership of several institutions. They include the University of Chicago, the City of Chicago Board of Health, and the Woodlawn Mental Health Centre, Board. They used a longitudinal design to follow the epidemiologically defined population comprised of 1,242 individuals from 1966 to1993. From 1966, they followed the cohort of adolescence (15-16 years old), early adulthood (age 32-33) and midlife (42-43). A high level of marijuana use, which was also associated with the use of other drugs such as cocaine and heroin, predicted a variety of difficulties. They include dropping out of school, being unmarried, unemployed, parenting, and outside marriage. Such individuals also continued using marijuana in one’s adulthood. Their findings also suggested that effects of heavy marijuana use continue to be manifested in an individual as young as 15 years after initiation of use in key areas of adulthood that includes family formation and employment.

Green and Ensminger (2006) also found out that heavy male adolescent drug abuse led to pseudo maturity. Their explanation posits that a lifestyle of drug use during adolescence leads to not only premature but also out-of-sequence involvement and performance problems in the roles of adulthood e.g. the roles of spouse, parenting, and working. They also found out that at least some of the detrimental effects of adolescent drug abuse are due to the high probability that drug use continues into adulthood. They noted that nearly 25% of the individuals under study who used marijuana as adolescents continued to use them in their 30s. This group was also associated with the use of heroin and cocaine as young adults.

Green and Ensminger’s (2006) findings highlight that it is important to prevent and in extreme cases delay early drug use especially heavy involvement in poly-substance abuse. It is also important to have intervention programs for male adolescents who begin polysubstance abuse at an early age to prevent the escalation of the disorder. The intervention and prevention programs should encompass a broad scope since early polysubstance use appears to relate to later outcomes. According to their research, the association of adolescent use of drugs with high school dropout provides evidence that programs addressing each risk separately may benefit from addressing the other risks simultaneously.

In most cases, it is difficult to treat young males who are involved in poly-substance abuse. Ohlin, Hesse, Fidell, and Tatting conducted a study to determine how poly-substance drug abuse affected the retention as well as the abstinence of the patients during their treatment or rather rehabilitation. Their study was based on data that they obtained from a prospective study of the course of buprenorphine in one of the highly structured clinics in Sweden. The treatment period was between August 2004 and November 2009. The target group (sample) for the treatment was people from different age groups who had a record of substance abuse. At the intake to treatment, patients were requested to provide a urine specimen that was analyzed to determine the kind of substances that the individual had taken as given by the type of compounds present in their urine. A senior consultant psychiatrist who initiated their treatment then saw the patients. The study showed that poly-substance abuse indicated that the patient would have indicated that the patient in question would have problems staying abstinent over a rather prolonged period. One of the major conclusions was that healthcare systems need to give some special support to patients who had a high degree of poly-substance abuse prior to joining any form of treatment cum rehabilitation program. Their study also asserted that adolescent patients had a higher rate of dropout than other patients who were under the same treatment program.

Treatment of depression associated with poly-substance abuse

Acceptance and Commitment Therapy (ACT)

One of the major measures that can be employed in reducing depression in adolescents is Acceptance and Commitment Therapy. Murrell (2011) carried out research to establish the effectiveness of the mode of treatment. The current ACT interventions have been tailored to address several disorders and risk behaviors that are costly to the life of youth. He used published articles in reputable databases such as the PsychINFO database search engine provided by EBSCO and the contextual Psychology website. ACT holds that for effective elimination of depression, one has to deal with the private events and thoughts that lower his/her self-esteem. ACT interventions target personal life events and thoughts to facilitate the functioning and living a worthwhile life. It aims to eliminate the constructive nature brought about by private events in order to allow for a better quality of life. Such an approach is essential in the intervention of drug abuse in male adolescents that has shown an increasing trend in the recent past. For instance, according to Murrell (2011, p. 20), approximately 11% of adolescent males in the United States admit to being involved in poly-substance abuse. The ACT approach is also helpful to parents whose children are involved in poly-substance abuse. It not only helps them to cope with the adolescents but also provides them with the knowledge of how to talk their children out of the vice.

Family-based therapies

Family therapy is another effective treatment approach for depression in adolescent males. Pruitt (2007) posits that healthy parent-child relationships have a positive impact on adolescent development. Research has shown that interpersonal factors specifically family relations play a pivotal role not only in the development but also in the maintenance of depression in adolescents. Additionally, parental involvement in the treatment of adolescent depression reduces attrition. The study also considered the fact that parental depression can contribute to adolescent depression and that several family factors and adverse life experiences increase the risk of adolescent depression. Families with a depressed adolescent child, irrespective of their gender, report family dysfunction as well as negative life events that include family conflicts. Some of the conflicts include parent-child conflict and marital conflict, especially about parenting. In extreme cases, the conflicts result in parental death, separation/divorce, physical child abuse, and maltreatment. Pruitt also found that depressed teens have a less secure attachment to their parents.

Several studies have been done to establish the relationship between family, depression, and peer pressure. Dorius, Bahr, Hoffmann, and Harmon (2004) identified family and peer relations as the two most important socializing forces that affect adolescent behavior. Through intensified research work, they found out that parents who monitor their children closely and develop significantly close relations with them have a significant influence on their children’s decision on poly-substance use. Scheer and Unger also had similar findings after carrying out research involving 159 Russian adolescents in Moscow (1992, p.297). However, there are some different views by other researchers such as Harris (1995) who argued that parenting has little or no effect on the behavior of adolescents. Parents of depressed adolescents tend to be dominant and controlling besides denying the children the opportunity to be actively involved in the family decision-making process. Such parents also exhibit controlling behaviors, which include limiting the self-expression of the child, dictating the life goals of the child in question and trying to make the child behave like an adult. Consequently, adolescent develops depression due to their inability to express themselves. He also noted the presence of ‘absent fathers’ in a family is detrimental to the health of adolescent boys.

Three family therapy approaches are effective in treating adolescent depression. They include structural Family Therapy, Attachment-Based Therapy, and Interpersonal Family Therapy. Diamond and Sequeland (1995) carried out a study to establish the key aspects of this approach. According to him, the goal of Structural Family Therapy was to disrupt the negative cycle associated with families that have a depressed child. It brings out the healthy parts of the family members that lack in such families. The therapy sessions bring out the positive or rather competent aspects of each of the family members that enhance the development of positive interactions within the family. The interventions occur in three different phases. The first phase is characterized by joining both the parent and the child. It also involves the definition of the focus of the therapy as the improvement of interpersonal relationships within the family. The second phase involves addressing the strained family relationships. It seeks to not only identify but also strengthen the family’s social support. The therapist brings out the empathetic, protective as well as caring parental behaviors while reviving the adolescent’s desire for parental love, care, support and protection. The third step seeks to establish the family as a social unit for each of the members. During this phase, the parents get information on how to balance the adolescent’s need for independence and attachment. This last phase generally aims at increasing the adolescent’s trust in the parents, improving his or her view on the different parenting practices, and improving family cohesion.

Interpersonal Family Therapy is based on four main pillars that are cognitive-behavioral psychology, developmental psychopathology, objects relation theory and the family systems theory. During the first phase, the therapist seeks to join the family members by demonstrating empathy for the family as well as the child’s situation. Kaslow and Racusin (1994) noted that the assessment of all the family members incorporates several elements: life events; psychological symptomatology; interpersonal, affective, and adaptive behavior and family domains. During the second phase of the therapy, the therapist addresses all the aspects of family functioning that were identified in the initial phase. He/she helps the family to make some structural changes including restructuring the hierarchy (if necessary) and facilitating changes in the family’s rules as well as interaction sequences. The therapist also assists the family members to develop healthier relational patterns. In the last phase, parents are assisted in improving their self-esteem and including their child in the decision-making process. They are also informed on how to communicate more clearly to minimize any form of negative or critical interaction in the family.

Attachment-based Family Therapy (ABFT) helps depressed male adolescents to establish a good relationship with their parents. It helps the boy to not only work through all the attachment failures but also repair the strained parent-child attachment bond. Allen, Moore, and Kupermink (1998) carried a research that showed that adolescents with insecure, anxious, and ambivalent attachments are associated with higher levels of depression than their more securely attached adolescent counterparts. This increases their risk of involvement in poly-substance abuse. In their study, Diamond and Stern (2003) established that adolescents with a strained attachment/relationship with their parents are prone to developing negative self-schema that increases their vulnerability to depression. Issues such as neglect, criticism, sexual abuse, rejection, physical abuse, and emotional abandonment cause some of the attachment failures that male adolescents may experience. Kobak, Sudler, and Gamble (1991) outlined some of the important aspects that health care specialists should consider when treating depression. He noted that in treating adolescent males, one should understand that the link between insecure attachment strategies and depressive symptoms is stronger in boys.

In ABFT, the therapist employs the enactment methodology to interrupt all forms of dysfunctional interaction patterns within the family. This ends up in the promotion of new, friendlier successful conversations and interactions. In working out both past and present conflicts within the family, the therapist encourages direct or rather one-on-one conversations between the family members. Generally, the initial stage in ABFT includes the preparation of the parties to the other relatively fluid stages. The stages are adolescent disclosure, parent disclosure and parent-child dialogue. It is noteworthy that the parents’ disclosure increases the adolescent’s desire to be close to them besides boosting understanding between the two parties. In some cases, parents’ apology frees the adolescent from blaming himself for the attachment failure.

Clinical questions to be addressed

Although there is extensive literature about poly-substance drug abuse in depressed adolescent boys, some areas have not been addressed adequately leaving several questions unanswered. They include:

  1. What are the measures that clinicians and parents should take to ensure that depressed male adolescents get treatment before it is too late?
  2. What are the challenges that clinicians might face in helping depressed adolescents?
  3. What are some of the indicators of the termination of poly-substance abuse in depressed male adolescents?
  4. What is the view of most parents on placing their depressed male adolescents who have resulted in poly-substance abuse in rehabilitation centers?
  5. Do healthcare institutions have sufficient equipment for dealing with such patients?
  6. Are there adequate clinicians who treat depressed male adolescents in healthcare institutions?
  7. Do the available clinicians have the knowledge and skills that are required in addressing the problem?

Summary and Conclusion

Depression has been linked to poly-substance abuse among adolescent males for a long time. A lot of research has been carried out concerning this subject unveiling some of the most important issues concerning poly-substance abuse in adolescent males suffering from depression. The research has provided data on the prevalence of the disorder in young men that has exhibited an increasing trend in the recent past. Additionally, it has brought to people’s attention the relationship between the two (i.e. depression and polysubstance abuse in young adolescents). Poly-substance abuse has also been found to differ depending on the level and severity of an individual’s depression. Researchers have also documented the effects of poly-substance use in adolescent males and the effects may last for a long period even in adulthood. Several ways of curbing the phenomenon have also been researched extensively. The treatment/intervention measures include addressing the depression disorder that in turn causes the individual to stop all the behaviors associated with it such as poly-substance abuse. They include Acceptance and Commitment Therapy (ACT) and family-based therapies. In conclusion, to prevent all the negative effects of poly-substance abuse in adolescent males, healthcare practitioners need to understand the level of depression of the victim, the cause of the depression and the possible intervention and treatment measures that are suitable for the particular adolescent.

References

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Deykin, E. Y., Levy, J.C., & Well, V. (1986). Adolescent Depression, Alcohol and Drug Abuse. Journal of Public Health, 76, 178-182.

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Diamond, G.S., & Stern, R.S. (2003). Attachment-Based Family Therapy for Treatment of Depressed Adolescents: Repairing Attachment Failures. In S.M Johnson & V.E. Whiffen (Eds). Attachment Processes in Couple and Family Therapy. New York: Guilford Press. 191-212.

Dorius, C.J., Bahr, J.S., Hoffmann, J.P., & Harmon, E.L. (2004).Parenting Practices As Moderators of the Relationship between Peers and Adolescent Marijuana Use. Journal of Family and Marriage, 66(1), 163-178.

Green, M.K. & Ensminger, M.E. (2006). Adult Social Behavioral Effects of Heavy Adolescent Marijuana Use among African Americans. Developmental Psychology, 42(6), 1168-1178.

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Kaslow, N.J., & Racusin, G.R. (1994). Family Therapy for Depression in Young People. In W.M. Reynolds & H.E. Johnston (Eds). Handbook of Depression in Children and Adolescents: Issues in Clinical Child Psychology. New York: Plenum Press. 345-363.

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Nolen-Hoeksema, S. (2001). Gender Differences in Depression. Current Directions in Psychological Science, 10(5), 173-176.

Ohlin, L., Hesse, M., Fidell, M., &Tatting, P. (2011). Poly-Substance use and antisocial personality traits at admission predict cumulative retention in a buprenorphine compliance profile. BMC Psychiatry, 11(8), 1-8. doi 10.1186/1471-244x-11-8.

Poulin, C., Hand, D., Boudreau, B., & Santor, D. (2004). Gender Differences in the Association between Substance Use and Elevated Depressive Symptoms in General Adolescent Population. Addiction, 100, 525-535.

Pruitt, I.T. (2007). Family Treatment Approaches for Depression in Adolescent Males. The American Journal of Family Therapy, 35, 69-81.

Scheer, S.D., & Unger, D.G. (1998). Russian Adolescents in the Era of Emergent Democracy: The Role of Family Environment in Substance Use and Depression. Family Relations, 47(3), 297-303.

Silberg, J., Rutter, M., D’Onofrio, B., & Eaves, L. (2003). Genetic and Environmental Risk Factors in Adolescent Substance Use. Journal of Child Psychology and Psychiatry, 44(5), 664-676.

Winters, K.C., & Latimer, W.W. (2004). Measuring Adolescent Drug Abuse and Psychosocial Factors in Four Ethnic Groups of Drug-Abusing Boys. Experimental and Clinical Psychopharmacology, 12(4), 227-236.

Winters, K.C., Ramafedi, G., & Chan, B.Y. (1996). Assessing Drug Abuse among Gay-Bisexual Young Men. Psychology of Addictive Behaviors, 10(4), 228-236.

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