The prevalence of substance use among adolescents at the First Episode Mood and Anxiety Program (FEMAP) in London, Ontario, was compared to a regional sample of adolescents who completed the 2009 Ontario Student Drug Use and Health Survey (OSDUHS). Relative-risk ratios were calculated to assess the comparability between FEMAP and OSDUHS adolescents on parallel substance use items selected from intake measures at FEMAP that matched items on the 2009 OSDUHS. FEMAP adolescents were more likely to use cigarettes, cannabis, hallucinogens, cocaine, and sedatives or sleeping pills. Rates of substance use were relatively similar between FEMAP adolescents and a subpopulation of the normative sample who reported having sought help for mental health problem(s). Adolescents seeking help for mood and/or anxiety problems appear at higher risk for using certain substances than their peers. Early intervention programs should screen adolescents with mood and/or anxiety problems for a wide range of substance use.

• Adolescent

• Substance use

• Mood and anxiety disorders

• Community mental health services

Schraeder K, Vingilis E, Osuch E (2016) Prevalence of Substance use among Adolescents in the First Episode Mood and Anxiety Program (FEMAP) Versus Adolescents in the General Ontario Population. J Subst Abuse Alcohol 4(2): 1046.

FEMAP: First Episode Mood and Anxiety Program; SUD: substance use disorders

Mood and anxiety disorders are among the most common mental health disorders, with lifetime prevalence rates of almost 21% and 29%, respectively, and onset during childhood or adolescence [1-3]. Epidemiological studies consistently report high rates of comorbid mood and anxiety disorders amongst those with substance use disorders (SUD) [4,5]. Adolescents suffering from these forms of comorbidity have worsened clinical courses and outcomes, and are at higher risk of suicide and impaired functioning [1].

Amongsubstance-using adolescents (ages 16 to 22 years) who have received specialized drug treatment services, about half also meet criteria for a current mood or anxiety disorder [6]. Adolescents who have received specialized mental health treatment for primary mood or anxiety disorder may also be at risk for using substances. For example, one study [7] examined the prevalence of SUD among adolescents (ages 15 to 22 years) who received cognitive-behavioural therapy for a primary anxiety disorder during childhood, approximately 7.4 years earlier. Although successful treatment of childhood anxiety was linked to less substance use during adolescence, a substantial proportion of adolescents reported having used substances at long-term follow-up. For example, 57% had smoked cigarettes, 81% had drunk alcohol, 38% had tried marijuana, and 16% had tried hard drugs (e.g., hallucinogens, barbituates, inhalants, cocaine, opiates).A better understanding of the nature of the association between mood and anxiety disorders and SUD has implications for the development of appropriate screening measures and targeted prevention strategies for adolescents. This is especially relevant for mental health systems, such as in Canada, where SUD assessment and treatment approaches are generally not integrated with psychiatric services.

The current study aimed to report the prevalence of substance use among adolescents who sought help at the First Episode Mood and Anxiety Program (FEMAP) in London, Ontario (Canada). FEMAP was developed in 2006 and is one of the first early intervention programs for mood and anxiety disorders available for Canadian adolescents and young adults between the ages of 16 and 25 presenting with anxiety and/or depressive symptoms. A formative program evaluation conducted recently at the clinic revealed that many of the individuals seen at FEMAP presented with symptoms of both anxiety and depression, and that the majority had self-referred [8]. A subsequent study found 49.6% of FEMAP adolescents to be at either moderate or high risk for a SUD [9]. However, it was unclear whether or not the substance use of a clinical sample was similar to a representative population-based sample of adolescents. Hence, differences and similarities in specific substance use were assessed amongst FEMAP adolescents and a regional sample of adolescentswho completed the Ontario Student Drug Use and Health Survey (OSDUHS) .

FEMAP Intake Measures

The FEMAP sample included all adolescents 16 to 19 years of age, and stable enough to complete the assessment. About two thirds of youth who presented to FEMAP agreed to participate in research. Participants presented to FEMAP having either been referred by either traditional means (a physician) or nontraditional means, including self-referral. Adolescents diagnosed with a developmental delay or major medical problems including significant closed head injury, learning disability, Attention Deficit or having a total lifetime psychiatric medication history of greater than 18 months, were not eligible for the program. Participants underwent an in-person clinical evaluation for assessment of their concerns, symptoms, function, substance use, living circumstances, and severity of illness. They completed selfreport questionnaires as described below. Based on the clinical evaluation combined with the assessment instruments, a primary (single) final hypothesized diagnostic category was made prior to the participant being scheduled with a psychiatrist for definitive diagnostic assessment. Youth with longer than 18 months lifetime medication treatment were excluded since that indicated an earlier, significant psychiatric episode and the establishment of prior care within the mental health care system. Youth who presented with mood and/or anxiety symptoms that had their onset only after the significant use of alcohol or illicit drugs, or for whom their primary mental health concerns appeared to stem from substance use, were referred to a community addiction services program. Further, actively suicidal youth in imminent danger were excluded and referred to emergency services until more stable. Approximately 25% of adolescents were referred to other more appropriate service(s) following intake; however, these youth were included in the present analyses given that they were seeking help primarily for emotional concerns.

The current study used data collected as part of the intake procedure at FEMAP. Participants completed: (1) a demographic screening questionnaire (i.e., age, gender, current grade, parental education level), (2) the Youth Risk Behavior Surveillance System Questionnaire [10], which provided information on whether participants had ever had 5 or more drinks of alcohol on the same occasion; and (3) the National Institute on Drug Abuse (NIDA) Modified ASSIST-Prescreen V1.0 (NIDA). The NIDA provided information on lifetime use of substances including: tobacco products, alcohol, cannabis, cocaine, prescription stimulants used without a prescription, methamphetamine, sedatives or sleeping pills, hallucinogens, street opioids, and prescription opioids (Table 2). This study received approval from the Office of Research Ethics for Human Subject Use of the University of Western Ontario.

Ontario Student Drug Use and Health Survey (OSDUHS)

The OSDUHS is a population survey conducted every two years since 1977 by the Centre for Addiction and Mental Health. The OSDUHS questionnaire has two versions (Form A and B) and is offered in both English and French to all students in grades 7-12 enrolled in public and Catholic school systems in Ontario. It is a self-administered, anonymous survey given to adolescents in their classrooms by the Institute for Social Research, York University. The OSDUHS employed a stratified (region and school type) two-stage (school, class), cluster sample design. Although the final sample size in 2009 was 9,112 students in grades 7 to 12, the current study included adolescents aged 16 to 19 enrolled in secondary schools within the Western Ontario stratum (N= 930) in order to best match the demographic of the FEMAP sample. Items from FEMAP intake measures were matched to parallel items on the OSDUHS. In addition, adolescents who completed the OSDUHS and who endorsed having seen a doctor, nurse or counselor about a mental health issue within the past year were examined as a separate sub-population of help-seeking adolescents, similar to the FEMAP sample.

A total of 134 adolescents (68% female; M = 17.3 years, SD=1.08) completed the intake measures at FEMAP. The OSDUHS sample (N = 930; M = 16.8 years, SD = 0.79) was significantly younger, t(1062) = 6.95, p < .001. The proportion of females was significantly lower in the OSDUHS sample (53% female) compared to the FEMAP sample, χ2 (1) = 9.92, p = .002. School attendance significantly differed between samples, χ2 (1) = 9.92, p = .002; about a third (n = 40) of FEMAP youth reported not being in school, χ2 (4) = 488.92, p < .0001. Table 1 provides a summary of demographic information for each sample including parental education (a proxy for socioeconomic status), which did not significantly vary across samples.

Table 1: Comparison of Demographic Information between FEMAP and OSDUHS Adolescents.

About half of the OSDUHS sample (N=461) were asked whether they “had seen a doctor, nurse, or counselor about a mental/emotional health problem” (Form A). About 21% (n=95; 56.8% female; M=16.7 years, SD=0.80) reported having seen a professional about a mental health concern within the past year.

Risk ratios for substance use items were calculated to assess the comparability between FEMAP and OSDUHS adolescents on parallel substance use items, adjusting for age, gender, and current grade level (Table 2).

Table 2: Rates of Substance Use and Crude and Adjusted Relative Risk Estimates of FEMAP Adolescents Compared with 2009 OSDUHS Adolescents.

A “modified Poisson” approach using a robust variance estimator estimated the crude and adjusted relative risks and confidence intervals [11]. Risk values indicating a substantially heightened risk of lifetime substance use (i.e., RR>1) for FEMAP adolescents were found for cigarettes, cannabis, hallucinogens, cocaine, and sedatives. Overall, in their lifetime, FEMAP adolescents were 48% more likely to use cigarettes, 30% more likely to use cannabis, 60% more likely to use hallucinogens, over twice as likely to use cocaine, and about three times as likely to use sedatives and/or sleeping pills than a comparable adolescent population sample assessed by the OSDUHS.

It is noteworthy that FEMAP adolescents were at higher risk for using cigarettes, cannabis, hallucinogens, cocaine, and sedatives than a comparative population sample of high school adolescents. Higher rates of substance use were not uniformly found across all types of substances assessed in the FEMAP sample. This finding might suggest a higher risk, or selective use, of certain substances among adolescents with mood and/or anxiety problems.

Although about 25% of FEMAP adolescents were referred to more specialized treatments (e.g.,SUD) at intake, the fact that these youth were referred (or referred themselves) to the clinic for emotional problems highlights the need to better integrate treatments of SUD with mood/anxiety disorders.

Early intervention programs for mood/anxiety problems could therefore benefit from addictions treatment, even if the delivery model involves referring all adolescents with a primary SUD elsewhere. Whether substance use behaviours represent an earlier point on the continuum to SUD, serve as a marker for other psychological or social problems, or represent areas associated with medical or psychiatric morbidity in their own right, their identification warrants additional evaluation and intervention. For these reasons, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent clinic outpatients with even sub-diagnostic use of substances. Clinicians should screen all adolescents with a mood and/or anxiety concern for a wide range of substance use. Identification of adolescents with substance use may allow for intervention before either the substance use or the psychiatric symptoms progress to severe levels.

Future research could extend the current findings in a number of ways.First, the association between mood and/or anxiety disorders and substance use has been found to differ according to the particular type of mood or anxiety disorder being examined and the number of comorbidities [12]. Diagnostic information about the type of mood and/or anxiety disorder was not collected for the current study.Future research should seek to clarify these associations among adolescent populations . Second, the cross-sectional nature of the current study could not explain directionality between substance use and mood/anxiety problems. Prospective longitudinal studies have great potential to examine whether treatment for mood and/or anxiety disorders could be linked with reduction in adolescent substance use, and vice versa [13]. Such results could change the standard clinical approach foradolescents with SUD or mood and/or anxiety problems in Canada, and in other regions where mental health and addiction services are not well integrated.

Finally, a number of important differences (i.e., age, sex, grade level) were identified between the FEMAP sample and the OSDUHS population and were therefore controlled for in our analyses. Most notably, over a third of the FEMAP sample was not currently attending school. Adolescents with mental health and substance use concerns have been demonstrated to experience educational difficulties and higher rates of school dropout. Since the OSDUHS sample only includes adolescents attending school, our results might underestimate potentially more severe substance use among adolescents in Western Ontario. Further research should examine whether the substance use trends observed in the current study are consistent across diverse geographic locations.

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