Problematic Substance Use in Depressed Youth: Associations with Suicidal Ideation and Suicide Attempt History

Marino E.N., Jha M.K., Minhajuddin A., Ayvaci E.R., Levinson S., Pipes R., Emslie G.J., Trivedi M.H.

Substance use among adolescents is common and associated with significant consequences, including depression. Adolescents can experience myriad problems related to early onset substance use and depression, making further understanding of this comorbidity necessary. Participants were a subset from a large-scale performance improvement project and consisted of adolescents aged 12–18 who screened positive for depression during their routine medical or psychiatric appointment and who then completed the substance use assessment Car, Relax, Alone, Forget, Friends, Trouble Version 2.1 (CRAFFT). Participants with problematic substance use had a CRAFFT score ≥2. A total of 621 participants were included in this study, and 105 (16.9%) reported problematic substance use. Compared with participants without problematic substance use, those with problematic use were more likely to have moderate to severe depression and anxiety, as well as significantly higher irritability, impulsivity, suicidal propensity, and suicidal thoughts scores. Controlling for age at screening, sex, race, and ethnicity, problematic substance use remained a significant predictor of depression severity, impulsivity, suicidal propensity, and suicidal thoughts. Participants were from a large, metropolitan area of the Southwest United States who must have screened positive for depression, so results may not generalize. Because all participants were underage, they may have been wary in responding to the substance use assessment accurately. By using a large, diverse sample in a real-world clinical setting, findings strengthen the association between problematic substance use and depression and depression-associated symptoms among adolescents, highlighting the need for early detection and universal depression screening.

Trivedi M.H., Minhajuddin A., Slater H., Baronia R., Blader J., Blood J., Brown R., DeFilippis M., Farmer D., Garza C., Hughes J.L., Kennard B.D., Liberzon I., Martin S., Mayes T.L., et. al.

American youth are seriously impacted by depression and suicide. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) Participant Registry Study was initiated in 2020 to develop predictive models for treatment outcomes in youth with depression and/or suicidality. This report presents the study rationale, design and baseline characteristics of the first 1000 participants. TX-YDSRN consists of the Network Hub (coordinating center), 12 medical school “Nodes” (manage/implement study), each with 1–5 primary care, inpatient, and/or outpatient Sub-Sites (recruitment, data collection). Participants are 8–20-year-olds who receive treatment or screen positive for depression and/or suicidality. Baseline data include mood and suicidality symptoms, associated comorbidities, treatment history, services used, and social determinants of health. Subsequent assessments occur every two months for 24 months. Among 1000 participants, 68.7 % were 12–17 years, 24.6 % were ≥ 18 years, and 6.7 % were < 12. Overall, 36.8 % were non-Hispanic Caucasian, 73.4 % were female, and 79.9 % had a primary depressive disorder. Nearly half of the sample reported ≥1 suicide attempt, with rates similar in youth 12–17 years old (49.9 %) and those 18 years and older (45.5 %); 29.9 % of children

Daly M.

Major depression is a leading cause of disability and represents a significant health concern for adolescents. Evidence of temporal trends in adolescent depression stratified by sociodemographic characteristics is needed.This study drew on 11 years of the National Survey on Drug Use and Health (N = 167,783), a nationally representative survey of adolescents aged 12-17 years conducted between 2009 and 2019.The prevalence of past-year major depressive episode (MDE) increased by 7.7 percentage points from 8.1% to 15.8% between 2009 and 2019. MDE increased by 12 percentage points from 11.4% to 23.4% among girls. The gender difference in the prevalence of MDE increased from 6.4% to 14.8% between 2009 and 2019. Black participants experienced a comparatively small increase in depression (4.1%).Since 2009 there has been a sharp and sustained increase in depression among adolescent girls in the U.S. This concerning trend highlights the critical importance of directing prevention and intervention efforts toward this group.

Berny L.M., Tanner-Smith E.E.

Objective: Dually diagnosed adolescents are a high-risk population for experiencing suicidal thoughts and behavior. Given that research suggests risk factors for suicidal ideation and suicide attempts may be different, this study examined whether internalizing disorder severity, frequency of substance use, and the interaction between them differentiated adolescents who attempted suicide from those who ideated. Methods: Baseline data from 287 adolescents who received formal substance use disorder (SUD) treatment were used in this analysis. Major depressive disorder (MDD) and generalized anxiety disorder (GAD) severity as well as past-3 month use of alcohol, cannabis, and other illicit drugs were considered. The outcome of interest was a three-category measure of suicide risk: no reported suicidal ideation or attempts, suicidal ideation only, and suicide attempts. Results: Over half of the sample disclosed prior suicidal ideation (30.0%) or attempts (27.9%). Multinomial logistic regression models indicated more severe MDD and GAD symptomology differentiated ideators from non-suicidal adolescents, but internalizing disorder severity did not differ between ideators and attempters. Substance use frequency did not differ between suicide risk groups. MDD severity and frequency of alcohol use interacted to increase the risk of attempts, yet the effects were minimal. Instead, prior weapon violence victimization and sexual abuse were the largest differentiators between attempters and ideators. Conclusions: Findings suggest that internalizing disorder severity and prior traumatic experiences put adolescents with SUD histories at higher risk of suicidal thoughts and behaviors. Thus, integrating evidence-based suicide prevention and intervention efforts into SUD treatment is critical, particularly for dually diagnosed adolescents who meet these risk profiles. Psychotherapy and medication may help curtail the development of ideation by reducing symptoms of MDD and GAD, whereas adolescents with prior traumatic experiences may benefit from additional treatments shown to lower risk of suicide attempts.

Kang C., Zheng Y., Yang L., Wang X., Zhao N., Guan T.F., Qiu S., Shi J., Hu J.

• Suicidal ideation (SI) was assayed in 1635 adolescent patients with depression. • Demographic and clinical data were associated with SI. • Adolescent patients with SI had greater scores on CDI and ASLEC. • The severity of depression, sex, sleep time, and learning pressure is related to SI. Suicidal ideation (SI) has a high risk in adolescents and is now a significant concern due to its problematic outcome. However, few systemic studies of suicidal ideation have been conducted in adolescent patients. Therefore, the current study was aimed to assess the prevalence and its clinical correlate of suicidal ideation among adolescent patients with depression. A total of 1635 adolescent patients (748 males/ 887 females) with depression were recruited in this study. The clinical and demographic data were collected by a self-administered questionnaire. Suicidal ideation was assessed by interview. Children's Depression Inventory (CDI) was used to evaluate depressive symptoms, Adolescent Self-Rating Life Events Check List (ASLEC) was used to assess the stressful life events. The study showed that the prevalence of suicidal ideation in adolescent depression patients was 38.2% (625/1635). Compared to the non-SI patients, SI patients had greater scores on CDI and ASLEC, had inadequate sleeping time, and were more likely to be females. Further logistic regression analysis indicated that suicidal ideation in adolescent patients with depression was significantly associated with females, inadequate sleeping time, the severity of depression, and higher learning pressure. No causal relationship could be drawn due to the cross-sectional design. Our results suggest a high prevalence of suicidal ideation in adolescents with depression. Moreover, the severity of depression, sex, sleep time, and learning pressure are all related to suicidal ideation. Early recognition and treatment of suicidal ideation can effectively prevent the occurrence of suicide among adolescent patients.

Nock M.K., Kessler R.C., Franklin J.C.

May A.M., Klonsky E.D.

Cox S.M., Castellanos-Ryan N., Parent S., Benkelfat C., Vitaro F., Pihl R.O., Boivin M., Tremblay R.E., Leyton M., Séguin J.R.

Objective: Only a minority of drug and alcohol users develops a substance use disorder. Previous studies suggest that this differential vulnerability commonly reflects a developmental trajectory characterized by diverse externalizing behaviors. In this study, we examined the relation between child and adolescent externalizing behaviors and adolescent substance use in a prospectively followed Canadian birth cohort, accounting for the temporal sequence of a wide variety of contributing factors. Methods: Two hundred and forty-two adolescents followed since birth (date range: 1996 to 2012) were assessed on externalizing behavior (age 17 months to 16 years), alcohol and cannabis use at age 16, age of alcohol use onset, family history of substance use problems, family functioning (age 11 to 15), sensation seeking (age 16), prenatal substance exposure, socioeconomic status (age 1 to 9), and sex. Results: Age of alcohol use onset was predicted by a family history of substance use problems, externalizing traits from ages 6 to 10 and 11 to 16, sensation seeking at age 16, prenatal alcohol and tobacco exposure and family functioning at ages 11 to 15. High frequencies of alcohol and cannabis use at age 16 were both predicted by externalizing traits from ages 11 to 16, a family history of substance use problems and sensation seeking after controlling for other individual, environmental and familial variables. The association between familial substance use problems and substance use during adolescence was partially mediated by externalizing traits from age 11 to 16. Conclusions: The present findings provide prospective evidence for a developmental risk pathway for adolescent substance use, potentially identifying those who could benefit from early interventions.

Hunt G.E., Malhi G.S., Lai H.M., Cleary M.

Background Comorbidity between Substance Use Disorders (SUDs) and major depression is highly prevalent. This systematic review and meta-analysis aimed to estimate the prevalence of SUDs in subjects diagnosed with a major depressive disorder (MDD) in community, inpatient and outpatient settings. Methods A comprehensive literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2019. Prevalence of co-morbid SUDs and MDD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Results There were 48 articles identified by electronic searches with a total sample size of 348,550 subjects that yielded 14 unique epidemiological studies, 2 national case registry studies, 7 large cohort studies and 20 clinical studies using in- or out-patients. The prevalence of any SUD in individuals with MDD was 0.250. Maximum prevalence was found with alcohol use disorder (0.208), followed by illicit drug use disorder (0.118) and cannabis use disorder (0.117). Meta-analysis showed the pooled variance of any AUD in men with MDD was 36%, which was significantly higher than that for females with MDD (19%, OR 2.628 95% CI 2.502, 2.760). Conclusions Few studies were published over the last decade so current prevalence rates of SUD in MDD are needed. Meta-analysis revealed that SUDs in MDD are highly prevalent and rates have not changed over time. The persistently high prevalence suggests there is an urgent need for more informative studies to help develop better prevention and treatment options for reducing prevalence of SUDs in persons with major depression and co-morbid disorders.

Koyama E., Zai C.C., Bryushkova L., Kennedy J.L., Beitchman J.H.

Childhood traumatic experiences and impulsive aggression are strong predictors of suicide ideation in youth. This study examines whether a gene panel previously associated with impulsive aggression, together with a measure of traumatic experience, will predict suicidal ideation in youth. The sample consisted of 158 youth (ages 9-17 years) of European ancestry that participated in a case-control study for childhood aggression. The Massachusetts Youth Screening Instrument (MAYSI-2) was used to examine suicide ideation and traumatic experiences. The impulsive aggression gene panel consists of 5 markers across 5 susceptibility genes (CRH, CRHR2, MC2R, OXTR, BDNF). A multi-gene risk score (MRS) for each individual was calculated by taking the total number of risk genotypes for that person. The covariates for the multiple regression model included sex, age, symptoms of anxiety/depression, MRS, traumatic experiences, and MRS x traumatic experience interaction. Results show the MRS x traumatic experience interaction term and the anxious/depressed symptoms to be significant predictors of suicide ideation in the full model. Importantly, genetic susceptibility to impulsive aggression and traumatic experiences remained a significant predictor for suicide ideation over and above the youth's level of anxiety and depression. This finding may have important implications for early intervention for youth suicide-related behaviors.

Poulton A., Hester R.

AbstractSubstance dependence constitutes a profound societal burden. Although large numbers of individuals use licit or illicit substances, few transition to dependence. The specific factors influencing this transition are not well understood. Substance-dependent individuals tend to be swayed by the immediate rewards of drug taking, but are often insensitive to delayed negative consequences of their behavior. Dependence is consequently associated with impulsivity for reward and atypical learning from feedback. Behavioral impulsivity is indexed using tasks measuring spontaneous decision-making and capacity to control impulses. While evidence indicates drug taking exacerbates behavioral impulsivity for reward, animal and human studies of drug naïve populations demonstrate it might precede any drug-related problems. Research suggests dependent individuals are also more likely to learn from rewarding (relative to punishing) feedback. This may partly explain why substance-dependent individuals fail to modify their behavior in response to negative outcomes. This enhanced learning from reward may constitute a further pre-existing risk factor for substance dependence. Although impulsivity for reward and preferential learning from rewarding feedback are both underpinned by a compromised dopaminergic system, few studies have examined the relationship between these two mechanisms. The interplay of these processes may help enrich understanding of why some individuals transition to substance dependence.

Shenoi R.P., Linakis J.G., Bromberg J.R., Casper T.C., Richards R., Mello M.J., Chun T.H., Spirito A.

CRAFFT is used to identify patients in the PED with current problematic substance use and SUDs; it has value in predicting SUDs but with limited sensitivity. BACKGROUND The utility of CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) in identifying current and future problematic substance use and substance use disorders (SUDs) in pediatric emergency department (PED) patients is unknown. We conducted a secondary analysis of a study in 16 PEDs to determine the concurrent and predictive validity of CRAFFT with respect to SUD. METHODS: At baseline, 4753 participants aged 12 to 17 years completed an assessment battery (CRAFFT and other measures of alcohol, drug use, and risk behaviors). A subsample was readministered the battery at 1-, 2-, and 3-year follow-up to investigate future SUDs. RESULTS: Of 2175 participants assigned to follow-up, 1493 (68.6%) completed 1-year, 1451 (66.7%) completed 2-year, and 1265 (58.1%) completed the 3-year follow-up. A baseline CRAFFT value of ≥2 was significantly associated with problematic substance use or mild or moderate to severe SUD diagnosis on the Diagnostic Interview Schedule for Children at baseline (P < .001). The results persisted after 1, 2, and 3 years (P < .001). The best combined sensitivity and specificity was achieved with a baseline CRAFFT value of ≥1 as a cutoff for predicting problematic substance use and a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of mild SUD at 1, 2, and 3 years. The baseline CRAFFT score that best predicted a moderate to severe SUD at 1 year was ≥2; but at 2 and 3 years, the cutoff score was ≥1. CONCLUSIONS: CRAFFT has good concurrent validity for problematic substance use and SUD in PED patients and is useful in predicting SUDs at up to 3 years follow-up but with limited sensitivity.

Reiner R.C., Olsen H.E., Ikeda C.T., Echko M.M., Ballestreros K.E., Manguerra H., Martopullo I., Millear A., Shields C., Smith A., Strub B., Abebe M., Abebe Z., Adhena B.M., Adhikari T.B., et. al.

Importance: Understanding causes and correlates of health loss among children and adolescents can identify areas of success, stagnation, and emerging threats and thereby facilitate effective improvement strategies. Objective: To estimate mortality and morbidity in children and adolescents from 1990 to 2017 by age and sex in 195 countries and territories. Design, Setting, and Participants: This study examined levels, trends, and spatiotemporal patterns of cause-specific mortality and nonfatal health outcomes using standardized approaches to data processing and statistical analysis. It also describes epidemiologic transitions by evaluating historical associations between disease indicators and the Socio-Demographic Index (SDI), a composite indicator of income, educational attainment, and fertility. Data collected from 1990 to 2017 on children and adolescents from birth through 19 years of age in 195 countries and territories were assessed. Data analysis occurred from January 2018 to August 2018. Exposures: Being under the age of 20 years between 1990 and 2017. Main Outcomes and Measures: Death and disability. All-cause and cause-specific deaths, disability-adjusted life years, years of life lost, and years of life lived with disability. Results: Child and adolescent deaths decreased 51.7% from 13.77 million (95% uncertainty interval [UI], 13.60-13.93 million) in 1990 to 6.64 million (95% UI, 6.44-6.87 million) in 2017, but in 2017, aggregate disability increased 4.7% to a total of 145 million (95% UI, 107-190 million) years lived with disability globally. Progress was uneven, and inequity increased, with low-SDI and low-middle-SDI locations experiencing 82.2% (95% UI, 81.6%-82.9%) of deaths, up from 70.9% (95% UI, 70.4%-71.4%) in 1990. The leading disaggregated causes of disability-adjusted life years in 2017 in the low-SDI quintile were neonatal disorders, lower respiratory infections, diarrhea, malaria, and congenital birth defects, whereas neonatal disorders, congenital birth defects, headache, dermatitis, and anxiety were highest-ranked in the high-SDI quintile. Conclusions and Relevance: Mortality reductions over this 27-year period mean that children are more likely than ever to reach their 20th birthdays. The concomitant expansion of nonfatal health loss and epidemiological transition in children and adolescents, especially in low-SDI and middle-SDI countries, has the potential to increase already overburdened health systems, will affect the human capital potential of societies, and may influence the trajectory of socioeconomic development. Continued monitoring of child and adolescent health loss is crucial to sustain the progress of the past 27 years.

Högberg C., Billstedt E., Björck C., Björck P., Ehlers S., Gustle L., Hellner C., Höök H., Serlachius E., Svensson M.A., Larsson J.

Missing diagnostic information often results poor accuracy of the clinical diagnostic decision process. The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) is a short standardized diagnostic interview and covers a rather broad range of diagnoses applicable to children and adolescents. MINI-KID disorder classifications have shown test-retest reliability and validity comparable to other standardized diagnostic interviews and is claimed to be a useful tool for diagnostic screening in Child and Adolescent Psychiatric care. The concordance between the Swedish language version of the MINI-KID Interview and LEAD (Longitudinal, Expert, All Data) research diagnoses was studied in secondary child and adolescent psychiatric outpatient care. MINI-KID interviews were performed for 101 patients, boys n = 50, girls n = 51, aged 4 to 18 years. The duration of the interview was on average 46 min, the child/adolescent participating together with the parent(s) in most cases. The seven most prevalent diagnoses were included in the analyses. The average overall percent agreement (OPA) between MINI-KID and LEAD was 79.5%, the average percent positive agreement (PPA) 35.4 and the average percent negative agreement (NPA) 92.7. OPA was highest for Obsessive-Compulsive Disorder (OCD) (0.89), Tic disorders (0.88) and Pervasive developmental disorders (0.81). There were similar results in diagnostic agreement comparing the two versions: the standard MINI-KID and MINI-KID for parents. The specific screening questions in MINI-KID resulted in additional preliminary diagnoses compared with the regular initial clinical assessment. Overall, there was an acceptable agreement between MINI-KID disorder classifications and research diagnoses according to LEAD. The standardized interview MINI-KID could be considered as a tool with the possibility to give valuable information in the diagnostic process in child and adolescent care which is similar to the setting in the present study.

López-Goñi J.J., Fernández-Montalvo J., Arteaga A., Haro B.

Patients with addictions have a great risk of suicidal ideation and attempts. Suicidal behaviour is a continuum that begins with ideation and may continue with planning, attempts and suicide completion. Investigating the specific risk characteristics for suicidal attempts in patients with addiction problems who present with suicidal ideation is crucial for developing prevention strategies. The main aims of this study were to determine the prevalence rate of suicide attempts among patients with lifetime suicidal ideation receiving treatment for addiction, and to explore the differential characteristics for suicide ideators with and without suicide attempts. A sample of 149 patients with suicidal ideation (110 male and 39 female) who sought treatment for addiction in a Spanish clinical centre was assessed. Information concerning socio-demographic characteristics, addiction severity, and psychopathological symptoms was obtained. In total, 39.6% of the patients had attempted suicide (95% Confidence Interval: 32.1%–47.6%). Although all patients with suicidal behaviours presented a high severity in their addiction, patients with both suicidal ideation and suicide attempts showed a more severe addiction profile and more maladjustment to everyday life than patients with only suicidal ideation. Specifically, three psychopathological variables were related to suicide attempts: worse psychiatric state, previous hospitalization for psychological problems, and history of delirium. According to the results, a systematic screening of suicidal risk in patients seeking treatment for addiction problems is recommended. Addiction treatment centres should develop treatment strategies to prevent suicidal ideators from attempting suicide, mainly in those cases with a worse lifetime psychiatric condition. • Patients with addiction problems have a great risk of suicidal ideation and attempts. • There are differences in patients in the different stages of suicidal behaviour. • Among suicidal ideators, 39.6% had attempted suicide. • Patients who attempt suicide show a worse clinical profile. • Screening of suicidal risk in patients seeking treatment for addiction is necessary.

Sun N., Liu Z., Sun L., Sun F., Sun L., Zhang J., Yang R., Yao G., Liu Y.

ObjectiveTo explore the prevalence of suicidal ideation (SI) and suicidal attempt (SA) in inpatients with childhood and adolescent depressive disorders and the relationship between triglyceride/high-density lipoprotein cholesterol (TG/HDL-C), total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratios and SI, SA.MethodsA study was conducted involving 515 pediatric patients diagnosed with depressive disorders at the Third People’s Hospital of Fuyang. This research primarily focused on gathering basic demographic and clinical data. Through employing methods such as correlation analysis and logistic regression, the study aimed to identify factors linked to SI and SA among these individuals.ResultsThe prevalence of SI and SA was 20.0% (103/515) and 9.1% (47/515). Binary logistic regression highlighted several independent predictors for SI. A notable increase in the likelihood of SI was observed with an increase in the number of hospitalizations (Odds Ratio [OR]=1.65, P=0.025), a heightened TC/HDL-C ratio (OR=1.72, P=0.002), an escalated antidepressant dosage (OR=1.02, P=0.029), and elevated HAMD scores (OR=1.04, P=0.003). For SA, critical independent associated factors identified were an increased number of hospitalizations (OR=2.71, P&lt;0.001), a higher TC/HDL-C ratio (OR=1.69, P=0.002), and greater HAMD scores (OR=1.06, P=0.003), particularly in children and adolescents diagnosed with depressive disorders.ConclusionThese findings suggest that monitoring lipid profiles, particularly the TC/HDL-C ratio, alongside careful management of antidepressant dosages and close observation of depressive symptoms, could be crucial in mitigating suicidal risks among this vulnerable population.