Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder

| September 16, 2008 | 0 Comments

by Yifrah Kaminer, MD, MBA; Daniel F. Connor, MD; and John F. Curry, PhD

Dr. Kaminer is with the Alcohol Research Center and the Division of Child and Adolescent Psychiatry at the University of Connecticut Health Center, Farmington, Connecticut; Dr. Connor is with the Division of Child and Adolescent Psychiatry at the University of Connecticut Health Center, Farmington, Connecticut; and Dr. Curry is with the Department of Psychiatry and Behavioral Science, Duke University Medical Center, Durham, North Carolina.
Psychiatry (Edgemont) 2008;5(9):34–39

Editor’s Note

All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment.


The authors acknowledge the support of grant K24 AA013442-02 from the National Institute on Alcohol Abuse and Alcoholism.


The comorbidity of unipolar depression with substance use disorders (SUD) in adolescents  is well established and accounts for 24 to 50 percent in clinical samples. Very little empirical data exist on the treatment of dually diagnosed youth. The objective of this paper is two-fold: 1) We will review the literature on SUD and unipolar depression; and 2) we will provide guidelines for a combined pharmacological and psychosocial intervention based on a clinical case example.

Key Words

adolescent substance use disorders, psychiatric comorbidity, depression, treatment


In populations of adolescents with substance use disorders (SUD), one of the largest subgroups comprises those with one or more comorbid psychiatric disorders, also known as dual diagnosis (DD). This group accounts for 70 to 80 percent of adolescent substance abusers in clinical samples.[1] In particular, the comorbidity of SUD with depression in adolescents is well established,[2] with comorbid unipolar depression ranging from 24 to 50 percent in clinical samples of SUD adolescents.[3,4] Depression as a comorbidity during SUD treatment raises the risk of treatment dropout, poorer treatment response, and earlier relapse.[5,6] SUDs among depressed youths are a risk factor for suicidal behaviors, including ideation, attempts, and completed suicide. Furthermore, even screened and triaged youth face barriers in finding treatment.[1]

This article aims to enhance practitioner knowledge of evidence-based approaches to treating adolescents with substance use disorder (SUD) and comorbid unipolar depression using a case example of an adolescent with cannabis use disorder and major depressive disorder.

Case Example

Joe was a 15-year-old Caucasian boy who, following an arrest for drug dealing, was referred by a juvenile drug court social worker for psychiatric and substance abuse evaluation and treatment.

Joe started smoking marijuana at age 13 after his older brother introduced the drug to him. Joe gradually escalated his use of marijuana over the past three years and upon presentation smoked 1 to 2 joints daily. He reported a calming effect from the marijuana and frequently went to school “high.” Beginning this year, Joe occasionally worked for a drug dealer distributing marijuana to students on the grounds of his high school where he was a freshman.

Joe started smoking cigarettes at age 11 and upon presentation was smoking half a pack per day. He started drinking alcohol at age 13, and in the last year he would regularly consume one six-pack of beer on Friday and Saturday nights to the point of intoxication. All of Joe’s friends were drug and/or alcohol users. Joe never drove a car, although he was a passenger in a car several times that was driven by a friend who was under the influence of drugs or alcohol.

Joe was not sexually active. Joe was an average student whose grades gradually deteriorated since seventh grade. Despite a full-scale IQ of 106, he had to make considerable effort in order to complete his work in school. At time of presentation, he had a C- average and his attendance was compromised. He was repeating ninth grade.

When Joe was 11 years old, his mother died in a car accident. She was in treatment for unipolar depression. When he was 14 years old, he was diagnosed with depression after he reported intense symptoms dating to the loss of his mother consisting of daily anhedonia and boredom, irritability, and uncontrollable anger, especially when he perceived himself as being provoked. He was referred to an anger management group but did not attend. He was prescribed sertraline but took it only briefly. He did not disclose his substance use at that time.

At presentation, Joe lived with his biological father who worked as an electrician, a 13-year-old sister, and his 19-year-old brother. His brother never graduated from high school, was unemployed, and was a heavy cannabis user. Vocal conflicts centered around drug use and discipline were frequent between the father and Joe’s older brother.

Upon evaluation, Joe initially denied feeling depressed, but reported pervasive feelings of boredom, irritability, and not getting “much fun out of things anymore.” Later, he admitted that he might be “a little depressed.” Joe completed a Beck Depression Inventory and obtained a total score of 26 (moderate depression). He believed marijuana to be helpful in calming himself. Joe never tried to cut down or quit substance use nor was he ever involved in treatment for drug use. Upon evaluation, Joe was not motivated to abstain from drug use, but was willing to discuss a treatment option in order to avoid legal consequences and have his pending charges dropped. No suicidal or homicidal ideation was evident, and no symptoms of bipolar illness or psychotic thinking were present on mental status examination.

Development of a Treatment Plan Utilizing Evidence-Based Practice

We conducted a search using PubMed and the search terms substance use disorders and depression using the following limitations: English language only, limited to the past 10 years, and children less than 18 years old. This search yielded 806 relevant articles. Advanced search terms included randomized controlled trial and practice parameters for youth depression and youth SUD, which yielded 43 relevant articles. Abstracts of these articles were reviewed. In addition, pertinent articles and book chapters from the past 20 years known to the authors were also reviewed

There is empirical evidence in the adult literature supporting the simultaneous treatment of SUD and depression rather than treatment approaches that target only one disorder or the sequential treatment of both disorders.[1] However, the treatment of DD in adolescents remains in the realm of clinical consensus.[7] This consensus advocates for simultaneous intervention for both disorders provided either by the same clinician or by different experts, each responsible for one disorder but who are keeping the other informed.

The variable clinical course of adolescent SUD treatment often leads to premature termination and then later re-entry into the treatment system.[8] Survival data from a comprehensive and comparative review[9] and from the Cannabis Youth Treatment Study (CYT)[10] showed sustained abstinence of 38 percent and 24 percent,  respectively, one year after treatment completion.

Psychosocial treatment strategies that have shown promise in reducing SUD among adolescents are comprehensively reviewed by Liddle and Rowe,[12] and specifically in other references presented in
Table 1.[3,10,13–19]

Cognitive behavioral therapy (CBT) facilitates coping skills for maintaining abstinence in high-risk situations and improves social networking skills with nonusing youth.[20] The manualized integrated motivational enhancement therapy (MET)/CBT approach has been found to be the most cost-effective intervention in the largest, prospective, randomized, controlled study for youth with cannabis use disorders.[10] In this context “motivational” means “address readiness to behavior change toward abstinence.” MET is guided by four main principles: 1) express empathy utilizing active listening; 2) develop discrepancy (help patient to recognize how his or her life is when he or she is using the drugs versus how his or her life could be without drugs; 3) roll with resistance; and 4) support self-efficacy.[23]

Case Example, Continued: Implementation of a Dual Diagnosis Treatment Plan

The goals for Joe’s treatment were explicit, realistic, obtainable, and shared by his clinicians, himself, and his father. It was emphasized to Joe and his father that realistic expectations from treatment included awareness that although the ultimate goal is abstinence, treatment is a process and not an event. Recovery often involves periods of improvement, followed by relapse, and changes in symptom severity.

Since Joe was not suicidal or dangerous, treatment was able to occur in an outpatient setting. After three years of continuous drug abuse, Joe was at risk of withdrawal once he stopped using cannabis. Withdrawal symptoms from cannabis reported in youth[11] include the following three categories: mood (e.g., irritability 47%; increased anger 40%; depressed mood 58%; nervousness/anxiety 33%), behavioral (e.g., craving 71%; restlessness 46%; increased aggression 36%; sleep difficulty 43%; strange dreams 26%), and physical (e.g., headache 32%; shakiness 29%; sweating 19%; stomach pains 18%; nausea in 15%). A treatment duration of 12 weeks was recommended for a first treatment episode of cannabis use disorder.[10]

Because Joe demonstrated little motivation for change and the status of his coping skills to resist substance use in high-risk situations was unknown,[20] we recommended an integrated intervention of MET/CBT.[21,22] Table 2 provides an example of a transcription of a session with Joe utilizing this therapy compared to a directive approach.

Periodic urinalyses to monitor abstinence with consequences for negative or positive urines were recommended. A contract negotiated early in treatment between Joe, his father, and the clinician included changes in curfew times, allowance, and other incentives in a form of entertainment items (e.g., CD, DVD, movie tickets) and clothing. Adjustments were made during treatment based upon progress. An effort to engage Joe’s father as an ally in treatment was important in order to encourage Joe to achieve and maintain abstinence as well as contain the drug-using activities of Joe’s older brother at home.

Joe met criteria for major depressive disorder (MDD) on clinical assessment. CBT was recommended for Joe’s depression and focused on increasing positive activities, improving problem-solving skills, and learning how to restructure unrealistic negative thoughts. Given his lack of suicidal ideation and moderate severity of depressive symptoms, it was not mandatory to begin antidepressant medication immediately. Since evidence suggests that depression in adolescents is influenced by psychosocial variables and has a high placebo response rate (between 35 and 60% in clinical antidepressant trials for youth depression), a period of “watchful waiting” with ongoing monitoring of his clinical status was indicated.[24] During this time, psycho-education about depression and its treatment were provided to Joe and his father. Suggestions for lifestyle management included increased engagement with non-drug-involved peers, daily exercise, and the creation of a daily activity schedule to increase pleasurable activities were encouraged. Table 3 summarizes four pharmacological trials[5,25–27] and one psychosocial study[28] for adolescents with alcohol or substance use disorder and concomitant MDD.

Two weeks after the onset of treatment for SUD and with the prompting of his father, Joe agreed to an antidepressant trial “to see if it would help.” After a risk/benefit discussion with Joe and his father, fluoxetine was initiated at 10mg/day and increased to 20mg/day after one week. Three weeks after initiating medication, Joe reported a Beck Depression Inventory score of 18 (a 30% improvement over baseline). He requested to continue his combined medication/psychosocial treatment. Joe adhered to his recommended treatment for two months with significant improvement in SUD and depression. He then became nonadherent with scheduled visits and medication. Six months later, his father reported that Joe relapsed and was smoking marijuana daily, although he was not depressed. Joe refused to return to treatment. Our clinic continues to maintain contact with Joe’s father in order to enable access to treatment at a future date.

Conclusions and Future Direction

Adolescent substance abuse treatment should begin with a comprehensive multidimensional evaluation.[29] Failure to recognize or adequately treat comorbid depression may interfere with substance abuse treatment. The present consensus advocates for a simultaneous and coordinated implementation of psychiatric and substance-abuse treatment services for DD patients. Clinical consensus and emerging evidence-based practice suggest that psychotherapy targeting both depression and SUD as well as integration of psychotherapy with a selective serotonin reuptake inhibitor (SSRI) might be efficacious treatments. Further controlled trials are necessary to confirm these findings and expand on issues such as severity of each disorder, dosage and length of treatment courses, how to address poor response, and barriers to treatment.
Finally, close clinical monitoring is required because treatment of depression with an SSRI in adolescents has been under scrutiny due to concern over potential adverse effects such as suicide,[2] as well as lack of sufficient evidence regarding interactions of abuse drugs with SSRIs.[30] While we are not presently aware of cannabis-SSRI drug adverse interactions, concomitant alcohol use increases lethality in SSRI overdose.[31] Clinical consensus suggests that in depressed adolescents with poly-substance dependence, binge-alcohol drinking patterns, or severe SUD as with opiates, SSRIs may be contraindicated.[31]


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Category: Child Adol Mental Disorders, Mood Disorders, Past Articles, Psychiatry, Psychotherapy Rounds, Substance Use Disorders

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