Emerging adult outcomes of adolescent psychiatric and substance use disorders
Introduction
The substantial comorbidity between psychiatric and substance use disorders has prompted increasing research interest in co-occurring disorders (Cerdá et al., 2008, Gonzales and Insel, 2004). The National Comorbidity Survey (Kessler, 2004) reported that 42.7% of participants with a substance use disorder (SUD) also had a psychiatric disorder (other than a substance use disorder); and of those with at least one psychiatric disorder, 14.7% also had at least one SUD. Other studies have reported similarly high overlap between psychiatric and SUDs among adults (de Graaf et al., 2002, Kessler et al., 2005, Regier et al., 1998) and youth (Armstrong & Constello, 2000).
Cross-sectional studies have reported that co-occurring psychiatric disorders and SUDs are associated with more functional impairment than either type of disorder alone, including greater symptom severity, more frequent disability days, higher rates of substance relapse, and additional treatment challenges and greater unmet need for treatment compared with individual psychiatric disorders or SUDs (Beitchman et al., 2001, Bijl and Ravelli, 2000, Clark et al., 2008, Kessler et al., 2005, Urbanoski et al., 2008). These studies point to the importance of addressing co-occurring disorders, however, longitudinal research, particularly prospective studies that follow participants over a period of several years, is needed to trace the outcomes associated with SUDs in combination with psychiatric impairment (Cerdá et al., 2008, Crome and Bloor, 2005).
In this paper, we follow clusters of youth with various combinations of substance use, psychiatric, and co-occurring disorders from late adolescence (age 18/19) to early adulthood (age 25). This age range has recently been conceptualized as a distinct developmental period — emerging adulthood — because the multiple role transitions, and the social contexts and expectations that characterize this period, including an unprecedented degree of autonomy, differentiate it sharply from adolescence and from subsequent years of adulthood (e.g., Arnett, 2004, Tanner, 2006). Emerging adulthood is likewise an important developmental period with respect to co-occurring disorders because it is at the juncture of conflicting hypotheses about the outcomes of psychiatric and substance use disorders. In contrast to the negative sequelae associated with co-occurring disorders is the phenomenon of adolescents ‘maturing out’ of teenage disorders, particularly SUDs (Cunningham et al., 2005, Maggs and Schulenberg, 2004–2005, O'Malley, 2004–2005).
Outcomes of co-occurring disorders vary depending on the specific combination of SUD and psychiatric disorder (Kessler, 2004, Cerdá et al., 2008). A number of longitudinal studies with adolescent and young adult samples have used variable-centred approaches to track the course, order, and potential causal associations between SUDs and other psychiatric disorders (e.g., Goodwin et al., 2004, Pardini et al., 2007). These studies track the relation between symptoms or diagnoses and specific outcomes, but they do not examine the life outcomes of youth with particular combinations of symptoms.
In contrast, person-centred approaches, which are relatively rare in the comorbidity literature, can be used to identify sub-groups that reflect the complexity of diagnostic patterns and can be followed over time (Beitchman et al., 2001, Beitchman et al., 2005, Kessler et al., 2005, Windle and Davies, 1999). Advanced statistical techniques such as latent class analysis and cluster analysis have the advantage of identifying empirically observed patterns among constellations of diagnoses that can be validated against external criteria. In this paper, we use a cluster analytic approach to trace the life outcomes at age 25 of distinct sub-groups of adolescents identified based on their combinations of substance use and other psychiatric disorders.
Previously (Beitchman et al., 2001), we assessed mental health and psychiatric status in a community sample of 19-year-olds. Diagnoses were entered into a hierarchical clustering algorithm; 8 empirically-derived clinical cluster groups emerged: Depressed, Depressed Drug Abusers, Anxious, Anxious Drinkers, Antisocial, Antisocial Drinkers, Drug Abusers, and Problem Drinkers. A ninth cluster with no psychiatric or SUD diagnoses was added. The clusters were labelled based on the predominant diagnostic groups they represented; however, not every member of each cluster is precisely described by the labels.
Here we report the results of assessments of these participants 6 years later at age 25, focusing on symptom severity, substance use and life-outcome variables. We address the following research questions: 1) Do adolescents with various combinations of SUDs and psychiatric disorders have different life outcomes than their non-disordered peers when they reach adulthood? and 2) Does substance-psychiatric comorbidity influences the trajectory of improvement or decline between adolescence and emerging adulthood?, and 3) Which clinical clusters do well and which do poorly?
Section snippets
Participants
Participants were originally part of a 20-year longitudinal study of Canadian schoolchildren. A one-in-three sample of all English-speaking kindergarten children (N = 1655) was screened for possible speech and language (S/L) impairments (Beitchman, Nair, Clegg, & Patel, 1986). Children who failed the screening (N = 301) completed comprehensive speech/language assessments by qualified speech-language pathologists. Of these, 180 children were diagnosed with speech and/or language difficulties.
Life outcomes
Table 1 presents the proportion of age 19 cluster members who had attained key life outcomes at age 25. The table shows statistical significance (from chi-square tests) of comparisons between each cluster and both its co-occurring disorder diagnostic counterpart (e.g. Anxious with Anxious Drinkers), and the No Diagnosis (non-disordered) cluster.
The rate of high school completion was near 90% for all clusters except for Drug Abusers (44.4%), Depressed Drug Abusers (50%) and Antisocial Drinkers
Adult outcomes of substance use and psychiatric disorders
We first asked whether 25-year-olds are distinguishable from one another based on clinical clusters identified in adolescence. These findings strongly suggest that they are. Two of the adolescent clusters with co-occurring disorders, Antisocial Drinkers and Depressed Drug Abusers, showed evidence six years later of vulnerability spanning multiple life domains including school non-completion, early marriage and early parenthood. The third cluster characterized by adolescent co-occurring
Conclusions
It appears that the emerging adult period is often associated with increasing mental health. However, these improvements did not extend to three clusters with co-occurring mental health and substance concerns, or extensive involvement with illicit drugs. These results underscore the need for intervention for youth with co-occurring disorders and/or substantial illicit drug use.
SUD and psychiatric disorders are interrelated in complex ways. In the community, adolescent co-occurring disorders
Acknowledgements
This study was supported by Grant MOP 49512 awarded to Joseph H. Beitchman from the Canadian Institutes for Health Research.
We gratefully acknowledge the contributions of the Ottawa Language Study Team: Brenda Cavanagh, Hope Harris, Karen Irvings, Lisa McAvoy, Laura Ma, Maria Restivo, and Chris Kenaszchuk. We thank the participants and their families for their continued participation in this study.
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