Cover Story

The largest-ever study on adolescent substance abuse treatment offers some promising news: substance abuse treatment appears to help this population. But the data are also replete with indications that teens' psychological problems--so often a part of why they abuse substances to begin with--are not being addressed effectively, opening the door for more abuse and mental health challenges down the road.

The survey indicates, as have others studies, "the persistence of depressive symptoms following drug treatment for adolescents...and underscores the need for concurrent psychiatric treatment of these youths, both during and following treatment," says psychologist Christine Grella, PhD, of the University of California, Los Angeles, Drug Abuse Research Center, and her co-authors in one of the papers on the study.

"We can conclude that 'typical' adolescent treatment programs should assume that co-morbidity among their patients is the norm, rather than the exception," they say.

They further emphasize that "adolescents with both substance abuse and mental health issues will have more problems than other young people in treatment."

The new data

The analyses are based on the one-year outcomes of "DATOS-A," the adolescent portion of the Drug Abuse Treatment Outcome Studies sponsored by the National Institute on Drug Abuse (NIDA). The 1993-95 survey included extensive interviews and random urine samples with 992 young people in one of 23 drug treatment programs--in Pittsburgh, Minneapolis, Chicago or Portland--and again about a year after their last contact with the programs. The programs included three basic types: residential, outpatient drug-free and short-term inpatient.

Overall, the data, which will be analyzed in several journal articles this year, show that the programs effectively reduce problems in young people. For example, Grella's analysis, to be published in the June Journal of Nervous and Mental Disease, shows that weekly marijuana use dropped from 86 percent to 47 percent among youth with co-morbid mental problems and from 74 to 39 percent among those who did not have such problems. There were similar significant decreases in heavy drinking, although cocaine use actually increased somewhat.

And, although there were some exceptions, psychosocial factors for these youths--including measures such as suicidal thoughts, hostility, self-esteem, enrollment in school, arrests and illegal acts--showed improvement that was often impressive. For example, for the group with psychological problems, those with suicidal thoughts dropped from 32 to 17 percent and those enrolled in school rose from 65 to 80 percent.

But, as one of the DATOS-A analyses notes, "The large percentage of patients reporting unmet needs for psychological services warrants special policy attention related to improving access to psychological services."

Two-thirds with mental problems

The study found that most adolescents who enter substance abuse treatment have psychological problems, and that they emerge from treatment with more mental health problems than those who do not have those complications.

Sixty-four percent of the adolescents had at least one mental disorder, with 59 percent diagnosed with conduct disorder, 15 percent with depression and 13 percent with attention-deficit hyperactivity disorder. Youth with those problems were also more likely to have started using alcohol and marijuana at an earlier age and had higher rates of use of most substances. For example, 41 percent engaged in heavy drinking compared to 27 percent of those without mental disorders; 39 percent had taken hallucinogens as compared to 9 percent of those with no mental diagnosis.

A year after leaving treatment, the co-morbid youth had improved more than the non-co-morbid youth, perhaps due to their higher levels of problems at the outset, say the authors. Even so, by several measures, a year later they had significantly more problems than the other young people who had entered treatment.

At follow-up, those with mental health problems fared worse than their peers: 47 percent of the youth with mental health issues used marijuana weekly compared to 39 percent of the other youth, 32 percent used hallucinogens compared to 18 percent of others, and 17 percent had suicidal thoughts compared to 12 percent of the others.

These numbers point to a need to intervene early with the young people with psychological problems, say the authors, given the fact that such severity of drug use has been found to increase the risk of relapse and diminish positive treatment outcomes "over the course of an addiction/treatment career."

The researchers also call for studies to pinpoint the treatment practices and clinical protocols that could do more to help the youth with psychological problems.

Services have dropped

But even as Grella's analysis finds the tremendous need for mental health services at the time of the DATOS-A survey, another DATOS-A analysis shows a dramatic drop in those services in the years just before DATOS-A was done.

Researchers compared DATOS-A information with surveys on adolescents who were in treatment programs designed for adults in the early 1980s (there were not many adolescent programs at that time). They found that the percentage of patients who got psychological services dropped by half, according to the patients' own reports.

Indeed, Rose Etheridge, PhD, and other researchers associated with the National Development and Research Institutes in Raleigh, N.C., found a decline in most of the related services that NIDA and other experts consider important to drug treatment services, including family, legal, financial and medical. But the drop in psychological services was especially striking.

In addition, those authors found that for each of the three types of treatment programs studied by DATOS-A, 35 to 50 percent of young people said they had unmet psychological needs, and mental health services vied with employment services as the need most often not met.

The researchers did say that the adolescents' reports of need for the various auxiliary services, including psychological services, also decreased from the earlier survey to the DATOS-A study. They note, however, that might be because patients had come to expect fewer services.

The finding of higher unmet psychological needs in the 1990s, the authors stress, demands scrutiny to determine whether it's related to lack of resources for care, lack of provider availability or the programs' failure to adequately assess and diagnose mental health problems. The treatment programs may have "mislabeled adolescents' mental health problems as behavior problems and attempted to address them through the legal system and other social control interventions, a strategy that is likely to prove ineffective," the authors say.

Other analyses of the DATOS-A data indicate that:

  • African-American and Hispanic young people were significantly more likely than white youth to be referred to treatment by the legal system.

  • More than half of youths treated said that they had reduced engagement in risky sex behaviors after treatment. However, those who had conduct disorders coupled with another mental health challenge--such as abuse, unmet physical and emotional needs or low commitment to school--were less likely to improve in terms of risky sex behavior.

  • The drug treatment is associated with significant drops in criminal activity: 61 percent of the adolescents were under some kind of criminal justice supervision when they entered treatment. Within that group, the number who reported being arrested dropped from 54 percent upon treatment entry to 24 percent a year later.

Grella's analysis of the DATOS-A findings is scheduled to appear in the June Journal of Nervous and Mental Disease. Analyses by Etheridge and others' papers on the DATOS-A findings will appear in a special issue of the Journal of Adolescent Research later this year.


NOTES: Heavy alcohol use is having four or five drinks nearly every day. Binge drinking is having five or more drinks once a week.
SOURCES: US Substance Abuse and Mental Health Services Administration, Office of Applied Sciences. Summary of Findings from teh 1998 National Household Survey on Drug Abuse, Rockville, MD, 1999. Table 57.

 NOTES: Heavy alcohol use is having four or five drinks nearly every day. Binge drinking is having five or more drinks once a week.
SOURCES: US Substance Abuse and Mental Health Services Administration, Office of Applied Sciences. Summary of Findings from the 1998 National Household Survey on Drug Abuse, Rockville, MD, 1999. Table 57.


Further Reading

Further information on the DATOS-A project and its findings is online at