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Editorial
Looking Back, Moving Forward
Quentin Rae-Grant
(PDF)

Original Research
Intramuscular Olanzapine and Intramuscular Haloperidol in Acute Schizophrenia: Antipsychotic Efficacy and Extrapyramidal Safety During the First 24 Hours of Treatment
Padraig Wright, Stacy R Lindborg, Martin Birkett, Karena Meehan, Barry Jones, Karla Alaka, Iris Ferchland-Howe, Anne Pickard, Cindy C Taylor, John Roth, John Battaglia, István Bitter, Guy Chouinard, Philip LP Morris, Alan Breier
(PDF)

EEG Abnormalities and Outcome in First-Episode Psychosis
Rahul Manchanda, Ashok Malla, Rajendra Harricharan, Leonardo Cortese, Jatinder Takhar
(PDF)

Impact of Antidepressant Side Effects on Adolescent Quality of Life
Amy H Cheung, Anthony J Levitt, John P Szalai
(PDF)

Violence by Psychiatric Patients: The Impact of Archival Measurement Source on Violence Base Rates and Risk Assessment Accuracy
Kevin S Douglas, James R Ogloff
(PDF)

Medicated Anxious Children: Characteristics and Cognitive-Behavioural Treatment Response
Vitaly Liashko, Katharina Manassis
(PDF)

Review Paper
From Chlorpromazine to Clozapine—Antipsychotic Adverse Effects and the Clinician’s Dilemma
Sabina Abidi, Sreenivasa M Bhaskara
(PDF)

Research Methods in Psychiatry
Unicorns Do Exist: A Tutorial on “Proving” the Null Hypothesis
David L Streiner
(PDF)

Brief Communication
Association of Substance Abuse and Depression Among Adolescent Psychiatric Inpatients
Carla Kmett Danielson, James C Overholser, Zeeshan A Butt
(PDF)

Book Reviews
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Drugs and Addictive Behaviour.
Reviewed by
Nady el-Guebaly, MD, FRCPC

Evidence and Experience in Psychiatry. Volume 5. Bipolar Disorder.
Reviewed by
Verinder Sharma, MB, BS, FRCPC

Letters to the Editor
(PDF)

Re: Unfree Associations: Inside Psychoanalytic Institutes

Reply: Unfree Associations: Inside Psychoanalytic Institutes

Improving the Mood Disorder Questionnaire to Detect Bipolar II Disorder

Mnemonic for the Diagnosis of Hypomania Associated with Bipolar II Disorder

Aripiprazole-Induced Improvement in Tardive Dyskinesia

Dependent Personality Disorder as a Marker of “Battered Husband Syndrome”: A Case Exemplar

Visually Enhanced Psychosexual Therapy (VEST) in a Multicultural Community

Brief Communication

Association of Substance Abuse and Depression Among Adolescent Psychiatric Inpatients

Carla Kmett Danielson, PhD¹, James C Overholser, PhD², Zeeshan A Butt, MA³

Depression and substance abuse during adolescence frequently cooccur (1). In addition, substance abuse may play an important role in adolescent suicidal behaviours (2–6). Substance abuse is one factor that differentiates adolescent suicidal ideators from attempters (7) and that may also increase the risk of suicide attempts in adolescent outpatients (8). Further, substance abuse may be a risk factor for future attempts among adolescents who have already attempted suicide (9,10).

Epidemiological samples of adolescents have focused on the relation between depression and substance abuse (for example, 11). One longitudinal study of female high school students found that adolescents with depression were more likely to abuse substances (18.2%) than female students without depression (6.3%), even after a 4-year follow-up. The presence of substance abuse more than doubled the likelihood of developing a major depressive episode within 3 years after high school (12). In another large epidemiological sample of high school students reevaluated after 1 year, the probability of an alcohol use disorder (given that the adolescent had major depressive disorder) was 13% (13). Choquet and colleagues (11) found in their epidemiological study that suicidal ideation was linked to depression and substance use in adolescents aged 15 to 18 years.

Substance abuse has been linked with both depression and suicide in adolescent outpatients as well. Rao and colleagues (14) found that adolescents with depression were more likely to develop substance abuse problems at an earlier age than nondepressed youths (1.5 years vs 3.3 years). Other research has demonstrated that substance abuse increased the risk of suicide attempts in outpatient youths with depressive disorders (8), and adolescent outpatient suicide attempters were significantly more likely to have abused alcohol, prescription drugs, or illicit drugs (7,15).

High levels of suicidal ideation (31% of boys and 75% of girls) and attempts (28% of boys and 61% of girls) also have been identified in adolescents receiving residential treatment for substance abuse (16,17). In addition, Cavaiola and colleagues (18) studied 250 adolescents in a short-term residential treatment program for chemical dependency and found that the adolescents who attempted suicide within the past 2 years had significantly more depression than those who had not attempted suicide.

The relations among depression, suicide, and substance abuse have been investigated in adolescents who have completed suicide. Often conducted by investigating the adolescent’s history and interviewing the family of the victim, this research also emphasizes that substance use and binge drinking are more common in suicide completers than in normal control subjects (19,20).

Although most research has focused on demonstrating that substance abuse plays a central role in suicidal behaviour, few studies have investigated the differences between those suicide attempters who abuse substances and those suicide attempters who do not. Because depression is often a major factor in suicide attempts, it is important to understand how substance abuse affects depression levels. Will adolescents who may have been self-medicating with substances suffer more or less depression than attempters who do not use such a maladaptive coping (or isolating) mechanism? One purpose of the present study is to investigate how substance abuse may impact levels of depression in a population of adolescent suicide attempters.

Most research done with inpatients has focused only on those who have attempted suicide. Adolescents are sometimes hospitalized for depression, nonsuicidal self-injurious behaviours, and substance-related issues. The second purpose of this study is to compare depression levels in non–suicide- attempting adolescent inpatients who do and do not abuse alcohol.

Methods

Participants
Inpatient adolescents (n = 98) were recruited from a psychiatric hospital located in the suburban region of a large metropolitan area. Subjects ranged in age from 13 to 18 years (mean 15.4 years, SD 1.3). Of the 98 subjects, 53 were girls (54%), and 85 were white (87%). Most patients were of middle-class socioeconomic status and possessed insurance that covered inpatient psychiatric treatment. Sixty-seven of these youths were hospitalized for attempting suicide. The remaining 31 subjects were hospitalized for other psychiatric problems, generally severe depression or anxiety. Method of suicide attempts ranged in level of lethality and included overdosing on some type of oral drug, cutting one’s wrists, hanging, playing Russian roulette with a gun, and driving a car off of a bridge.

Measures
Children’s Depression Inventory (CDI). The CDI is a 27-item self-report measure scored on a 3-point (0 to 2) Likert scale, with patients choosing the statement that is most descriptive of their mood over the past 2 weeks (21). High scores reflect greater levels of depression. Reliability and validity of the CDI have been well researched and adequately demonstrated (22,23).

Rutgers Alcohol Problem Index (RAPI). The RAPI is a 23- item self-report measure scored on a 6-point (0 to 5) scale (24). All 23 items focus on negative consequences that the adolescents attribute to their substance, such as “kept drinking when you promised yourself not to.” High scores indicate greater difficulties with alcohol. The RAPI possesses good internal consistency (a = 0.92) and adequate test–retest reliability and validity (that is, it correlates moderately well with other markers of problem drinking) (24).

Procedure
Graduate research assistants reviewed the patients’ medical records when the adolescents were admitted to the inpatient unit over a 2-year period. If a patient was given a preliminary diagnosis of major depression (based on information reported by the attending psychiatrist, psychiatric social worker, and nursing staff), the patient was asked to participate in a study of adolescent suicidality. Upon providing informed consent, participants were interviewed by a trained researcher and then completed the CDI and the RAPI. Some of these patients also participated in another study on suicide risk, which included the completion of other measures. The findings from that study have been published elsewhere (25).

Based on responses to the RAPI, each subject was identified as either a heavy drinker (that is, one who experiences problems because of a drinking habit) or a light drinker– nondrinker (that is, one who does not drink or drinks without experiencing significant problems). A cut-off score of 15 on the RAPI was used to classify the adolescents’ drinking status. Subjects who endorsed more than 15 items on the RAPI were classified as heavy drinkers. Individuals who scored 15 or less on the RAPI were classified as light drinkers and nondrinkers. This cut-off score has been recommended as a relatively conservative approach to identifying “high-consequence” drinkers so as to reduce the number of false positives in a sample (26).

Results

Sixty-two adolescent inpatients were identified as light drinkers and nondrinkers (25 boys, 37 girls), and 36 were identified as heavy drinkers (20 boys, 16 girls). Nineteen adolescent inpatients were identified as both suicide attempters and heavy drinkers (10 boys, 9 girls). The association between the level of depression and degree of problem drinking differed between attempters who were heavy drinkers (r = 0.45, P < 0.05) and attempters who were light drinkers or nondrinkers (r = –0.08, P = 0.60). The correlations between the CDI and the RAPI were similar for male heavy drinkers (r = –0.37, P < 0.05) and for female heavy drinkers (r = –0.39, P < 0.005). A 2-way analysis of variance was conducted to test for main and interaction effects for depression and substance abuse levels, given suicide attempting status and drinking status. Significant differences were found between the depression levels of suicide attempters vs nonattempters (F_1,96 = 22.27, P < 0.001 [with attempters scoring higher]) and of heavy drinkers vs light drinkers and nondrinkers (F_1,96 = 24.39, P < 0.001 [with heavy drinkers scoring higher]). The interaction among the 4 groups was not significant for depression levels (F_1,96 = 0.03, P = 0.867). The means and standard deviations for depression scores and substance abuse scores by group are listed in Table 1.

Discussion

The results support previous findings of a positive relation between depression levels and substance abuse. Adolescent psychiatric inpatients who abuse substances report higher levels of depression than those who do not abuse substances, independent of whether or not they are being hospitalized for attempting suicide. Although adolescents may use alcohol as a coping mechanism, it may increase distress. Future research should determine whether other factors (for example, genetic overlap of the constructs, family history of suicide, spirituality, and hopelessness) mediate the associations of depression and substance abuse with suicide. Further, the present findings highlight the need to carefully assess and treat alcohol- abusing adolescents who suffer from depression, given their heightened risk for suicide.

Acknowledgements

The project was completed when Dr Danielson was a graduate student at Case Western Reserve University. The authors thank the staff and patients of Laurelwood Hospital for their participation. We also thank Farshid Afsarifard, Mark Warren, and Marti Stephan for their administrative assistance with the project.

References

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25. Overholser JC, Freiheit SR, DiFillippo JM. Emotional distress and substance abuse as risk factors for suicide attempts. Can J Psychiatry 1997;42:402–8.

26. Thombs DL, Beck KH. The social context of four adolescent drinking patterns. Health Education Research Theory and Practice 1994;9:13–22.

Author(s)

Manuscript received June 2002, revised, and accepted January 2003.

An earlier version of this paper was presented at the annual meeting of the Association for the Advancement of Behavior Therapy; November 2001; Philadelphia (PA).

1. Postdoctoral Fellow, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, South Carolina.

2. Professor, Department of Psychology, Case Western Reserve University, Cleveland, Ohio.

3. Doctoral Student, Department of Psychology, Case Western Reserve University, Cleveland, Ohio.

Address for correspondence: Dr CK Danielson, National Crime Victims Research and Treatment Center, Medical University of South Carolina, 165 Cannon Street, PO Box 250852, Charleston, SC 29425

e-mail: danielso@musc.edu

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