JOURNAL TRANSCRIPT

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Adolescent Substance Use & Mental Health Disentangling the interconnections Dr Bobby Smyth

Topics • Adolescent Development • Interaction between Mental Disorders and Addiction in adolescents – ADHD – Psychosis – Depression / anxiety – Suicide

• Treatment • Implications Dr Bobby Smyth MRCPsych, March 2018

The Adolescent brain – a work in progress Giedd et al, 1999, Nature Neuroscience,

2, 861-863

http://www.nimh.nih.gov/press/prbrainmaturing.cfm

Red indicates more gray matter, blue less gray matter. Gray matter wanes in a back-to-front wave as the brain matures and neural connections are pruned. Areas performing more basic functions mature earlier; areas for higher order functions mature later. The prefrontal cortex, which handles reasoning and other "executive" functions, emerged late in evolution and is among the last to mature.

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Adolescent Development

Confidence

Competence

Dr Bobby Smyth MRCPsych, March 2018

Past Month Drunkenness ESPAD ‘95 to ‘15

Dr Bobby Smyth MRCPsych, March 2018

Past Month Cannabis UseESPAD ‘95 to ‘15

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Cannabis among 16yo _ESPAD 2011

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

• Adolescents 25.3% (C.I. 20.0–31.4%) • Adults 21.0% (C.I. 15.9–27.2%) Dr Bobby Smyth MRCPsych, March 2018

ADHD & Substance use • SUD (22%) common in ADHD teens

• Treated ADHD in childhood reduces risk of later development of SUD

Kollins SH (2008) ADHD, Substance use disorders, and psychostimulant treatment. J Attent Disorders, 12; 115-125 Dr Bobby Smyth MRCPsych, March 2018

Zeigler DW et al (2004) "Underage alcohol is associated with brain damage and neurocognitive deficits, with implication for learning and intellectual development" Casey & Jones (2010)

“Many studies have reported altered brain structure and function in alcohol dependent or abusing adolescents…… smaller frontal & hippocampal volumes……suggesting that early adolescence may be a period of heightened risk to alcohol’s neurotoxic effects” Dr Bobby Smyth MRCPsych, March 2018

Delayed recovery after abstinence

Volkow et al (1992) Synapse, 11, 184-190.

Dr Bobby Smyth MRCPsych, March 2018

American Journal of Psychiatry (2005), 162: 1403-1413

Dr Bobby Smyth MRCPsych, March 2018

Brain Plasticity - Craving

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

“Epidemiological evidence demonstrates that cannabis use is associated with an increased risk of psychotic outcomes, and confirms a dose response relationship between the level of use and the risk of later psychosis.” Dr Bobby Smyth MRCPsych, March 2018

Gene-Environment Interactions?

Dr Bobby Smyth MRCPsych, March 2018

Delayed recovery after abstinence

Volkow et al (1992) Synapse, 11, 184-190.

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

NPS & mental health

Dr Bobby Smyth MRCPsych, March 2018

7 6 5 4 3 2 1 0 Jan to May to Sept to Jan to May to Sept to Jan to May to Sept to Jan to May to Sept to April 2009 Aug 2009 Dec 2009 April 2010 Aug 2010 Dec 2010 April 2011 Aug 2011 Dec 2011 April 2012 Aug 2012 Dec 2012

Dr Bobby Smyth MRCPsych, March 2018

Drug Induced Psychosis • Intoxication mimicking psychosis

-Stimulants, cannabis, XTC, LSD, solvents

• Psychotic reactions

-Stimulants, cannabis

• Flashbacks

-LSD, cannabis, XTC

• Drug induced relapse

-Stimulants, cannabis

• Withdrawal states

-Barbiturates, benzos, alcohol Dr Bobby Smyth MRCPsych, March 2018

“Doctor, I’m terribly paranoid……”

Dr Bobby Smyth MRCPsych, March 2018

Teens, Alcohol and Depression

Dr Bobby Smyth MRCPsych, March 2018

Learning which shoulder to cry on…..

Dr Bobby Smyth MRCPsych, March 2018

“I tried to drown my sorrows, but the bastards learned how to swim”

Dr Bobby Smyth MRCPsych, March 2018

Frida Kahlo 1907-1954

• In NorthEast – 58% of young people who died by suicide were very drunk (i.e. BAC >160mg%) – Bedford et al (2006). Blood alcohol levels in persons who died from accidents and suicide. Irish Medical Journal, 99(3), 80-82.

• In South – 40% of all deaths by hanging revealed alcohol use, with mean BAC=200mg% – Bellis M, Bolster MA & Doyle CT. (2009) The Role of Alcohol in Deaths Presenting to the Coroner’s Service in Cork City & County. Irish Medical Journal, 102, 13-15. Dr Bobby Smyth MRCPsych, March 2018

Action Areas 14 ALCOHOL AND SUBSTANCE ABUSE To challenge permissive, harmful attitudes to alcohol abuse, help to reduce overall consumption rates and raise awareness of the association between alcohol and/ or substance abuse and suicidal Dr Bobby Smyth MRCPsych, behaviour. March 2018

Dr Bobby Smyth MRCPsych, March 2018

Dual Diagnosis in YoDA* 30

27.1 25

20

20.8 18.8

18.1

Total Prior YoDA

15

10.4

9

10

9 5.6 5.6

5

2.1

1.4

0

0

DSH

ADHD

Mood

Anxiety

•Conduct disorder is clearly under-diagnosed in this group. •International research indicates rates of dual diagnosis in 30-80% of adolescents with substance use disorders.

*James PD, Apantaku-Olajide T, Smyth BP. Mental Health and Dr Bobby Smyth MRCPsych, March 2 Substance Use (2012), 1–9, iFirst article

Psychological problems more common in girls (n=88) 30

% 25 Edokpolo et al (2010), Journal of Psychoactive Drugs, 42: 31-36

20 15 10 5 0

An Se x ie lf c ty on ce pt

De p

An g

res sio n

er

Di sru p

Dr Bobby Smyth MRCPsych, March 2018

t iv e

The pros & the cons......

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Adolescents and Substance Use: The handbook for professionals working with young people “This highly practical manual presents an ideal introduction to adolescent substance use. It offers invaluable guidance for all professionals involved with adolescents including social workers, health and social care professionals, family support workers, teachers, counsellors, mental health teams, A&E staff, police and probation officers. The approach these practitioners take in dealing with the problem has considerable influence over outcomes” http://www.radcliffehealth.com/shop/adolescents-andsubstance-use-handbook-professionals-workingyoung-people Dr Bobby Smyth MRCPsych, March 2018

A Vision for Change • “The major responsibility for care of people with addiction lies outside the mental health system”, p146 • This bizarre statement goes against practice & policy throughout the world Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

• Accept referrals from LHO areas Dublin South Central and Dublin South West (Popn 350k) • Staffing – – – – – –

Clinical Nurse Specialist Counsellor Family Therapist Registrar Consultant Administrator

Dr Bobby Smyth MRCPsych, March 2018

Dr Bobby Smyth MRCPsych, March 2018

Improvement in Psychological wellbeing among cannabis users who engaged in Rx 20 Baseline follow-up

15

**

10 5 0

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* Depression

Self Concept Anxiety

Anger

Disruptive

-5 -10

** p