Mental Health Disorders and Teen Substance Use
Why it's especially tempting — and risky — for kids with emotional or behavioral challenges
When teenagers are struggling with emotional problems, they often turn to alcohol or drug use to help them manage painful or difficult feelings. In this they are not different from adults. But because adolescent brains are still developing, the results of teenage “self-medication” can be more immediately problematic.
In the short term, substance use can help alleviate unwanted mental health symptoms like hopelessness, anxiety, irritability and negative thoughts. But in the longer term it exacerbates them, and often ends in abuse or dependence. Substance use escalates from experimentation to a serious disorder much faster in adolescents than it does in adults, and that progression is more likely to happen in kids with mental health disorders than in other kids.
“The rule of thumb is that almost half of kids with mental health disorders, if they’re not treated, will end up having a substance use disorder,” explains Sarper Taskiran, MD, a child and adolescent psychiatrist at the Child Mind Institute. A 2016 study of 10,000 adolescents found that two-thirds of those who developed alcohol or substance use disorders had experienced at least one mental health disorder.
Substance use also interferes with treatment for mental health disorders and worsens the long-term prognosis for a teenager struggling with one. How can we help these young people avoid the substance use trap when the deck seems to be stacked against them?
Why are kids with mental health disorders prone to substance use?
Kids who are anxious or depressed may feel more emotionally “even” if they drink or smoke marijuana. For socially anxious kids, it can quiet the anxiety enough to allow them to function in peer groups. And since their friends do it, it’s not stigmatized the way taking medication is.
“Pre-gaming is a lot about anxiety,” notes Jeannette Friedman, MSW, who works with families of adolescents with substance use problems. “The kids are saying ‘Let’s go have some fun before we go to the real party.’ But in fact, most of them feel like they need it to calm down enough so they can walk into a group where they’re going to feel exposed and criticized.”
A teen with anxiety might start by smoking marijuana to calm down before social events, and soon find himself smoking every morning just to get to school. “I’ve had very stressed-out kids say, ‘I get high before I go to school because I’m so anxious when I think about the start of the school day,’ says Ms. Friedman. “‘If I smoke a little weed, I don’t feel so anxious.’”
Kids who are depressed may use alcohol or marijuana to cheer themselves up, Dr. Taskiran notes, and blunt the irritability that is a symptom of adolescent depression. “They know there’s something wrong with them,” he says. “They’re not taking pleasure in things, they’re not feeling happy. So if their peers are offering a drug that makes you happy, that’s often the first thing they turn to.” Substance use can quiet negative thoughts that plague depressed kids.
It’s also common for children with mental health or learning disorders to develop self-esteem problems, a sense that there’s something wrong with them or that they’re flawed. When these children reach adolescence, with its focus on fitting in, notes Ms. Friedman, “they really want to be normal and they don’t feel normal. And that means they’re more vulnerable to somebody passing around a drug, because they’re just trying to feel better.”
Why is alcohol use riskier for teenagers?
Alcohol affects teens differently from adults. While adults tend to get more subdued and slowed down by alcohol, in adolescents it’s the opposite. They tend to become more energetic, engage in more risky behavior and get more aggressive.
Dr. Taskiran uses the example of driving. “When adults drink and drive you worry about slowing of the reflexes and lapses in attention, like missing a stop sign,” he explains. “But with adolescents, we’re worried that they’re going to get more activated. It’s not that they won’t see the red light, but they might try to run it.”
This is especially dangerous for kids with ADHD, who are already impulsive. And substance use makes depressed teenagers more prone to impulsive suicidal behavior. “The adolescent will still be depressed,” says Dr. Taskiran, “but the things that usually hold him back won’t be there while he’s intoxicated, like love for family or the belief that he’s going to get better.”
Why teenagers get addicted sooner
Adolescent alcohol or drug use accelerates very quickly when an untreated mental health disorder is present. ”Within months we can see problematic use,” says Dr. Taskiran.
Why are they different than adults? In the adolescent brain, pathways between regions are still developing. This is why teens learn new things quickly. This “plasticity” means the brain easily habituates to drugs and alcohol. “If you start drinking at 30, you don’t get addicted nearly as fast as if you start drinking at 15,” adds Ms. Friedman.
Alcohol and drugs also affect the same brain regions that are at play in behavior disorders like ADHD and ODD, says Dr. Taskiran. Teenagers who have those disorders get more satisfaction from the substance — and are more likely to become addicted. “Biologically they get more from the drug,” he adds, “so that’s why they get more hooked on it.”
It’s important to know that substance use can have disrupt a young person’s life even if he is not technically dependent on the drug. This is especially true for youth with mental health disorders. “You might not see withdrawal, you might not see the craving, which are the hallmark symptoms for dependence,” says Dr. Taskiran. “But the impact in his social life and academic life, or in terms of his mental wellbeing, might still be large.”
Why substance use makes depression and anxiety worse
“Self-medicating” with recreational drugs and alcohol works temporarily to alleviate symptoms of anxiety or depression because they affect the same brain regions that the disorders do. But the result is that teens feel even worse when not using. That’s one reason substance use is a risk factor for suicide in kids with depression, Dr. Taskiran notes.
Another negative effect of substance use is that it undermines treatment. First, it diminishes a teenager’s engagement in therapy, and hence its effectiveness. Second, if she is taking prescription medication, it may lower the effectiveness of that medication. “The drugs and the medications target the same areas of the brain,” explains Dr. Taskiran. When meds have to compete with drugs or alcohol, they are less effective. “Also, it’s not uncommon with kids who are using substances to be noncompliant with their meds.”
Psychosis and substance use
Michael Birnbaum, MD, is a psychiatrist who heads an early treatment program for young people who have had a first psychotic episode, usually signaling the onset of schizophrenia. Dr. Birnbaum estimates that at least 50 percent of his patients have at least some history of drug and alcohol use. Getting a handle on substance use is important for the recovery process, he says. “Folks who are still using are more likely to struggle with ongoing psychotic symptoms, and also are more likely to have a relapse.”
Most of the people who come to the early treatment program have just come from a hospitalization, he notes, and they are eager to make sure that doesn’t happen again. “So part of the discussion is how do we prevent a relapse?” he continues. At Dr. Birnbaum’s program, clinicians work to understand what substance use was doing for the patient. “It may seem obvious to us,” he says. “’Okay, you need to stop using now.’ But there may be other reasons for continued use that, to the patient, outweigh the risks.”
Dr. Taskiran echoes that approach. “The last thing I’d say from the get-go to one of my patients is, ‘Marijuana is bad for you,’ because the kid has heard that from teachers, parents, TV, everywhere. So instead what I say is, ‘What is it doing for you? What are you getting out of it?’”
All behavior serves a purpose, even if it’s self-injurious or risky behavior. “If you’re trying to take something away from a teenager, you need to replace it with something,” says Dr. Taskiran. “So instead of just saying, ‘Don’t do that, it’s bad for you,’ we’re trying to replace the need for substance with a coping strategy, with tools for coping without the substances.”