Do Psychiatric Medications Prescribed During Adolescence Increase Risk of Substance Abuse Later in Life?

Psychopharmacological Treatment and Substance Use: New Evidence from Long Range Studies

Parents of teenagers diagnosed with mental health disorders know that the contemporary, 21^st century approach to mental health treatment for adolescents – with some variation, of course – has three primary components:

1. Talk therapy, a.k.a. psychotherapy. Depending on the disorder, this includes:
   • Cognitive behavioral therapy (CBT)
   • Dialectical behavior therapy (DBT)
   • Mindfulness-based cognitive behavioral therapy (MBCBT)
   • Motivational interviewing (MI)
   • Behavioral activation (BA)
   • Interpersonal psychotherapy (IP)
2. Depending on the disorder, medications may include:
   • Anxiolytics (anti-anxiety medication)
   • Antidepressants
   • Antipsychotics
   • Mood stabilizers
3. Lifestyle changes. For almost all disorders, lifestyle changes/interventions include:

• Healthy eating
• Regular exercise
• Stress reduction skills, including:
  • Mindfulness
  • Meditation
  • Yoga and/or similar meditative physical practices

Parents of teenagers also know that adolescence is the time of risk-taking, experimentation, and psychological differentiation. Differentiation means teens actively seek experiences that affirm their identity independent of their parents, which is part of the healthy, typical developmental process of growing into an adult. In some cases, risk-taking and differentiation involve trying drugs and alcohol for the first time. This, in turn, creates the risk of developing a drug or alcohol addiction, which we now call a substance use disorder (SUD) or an alcohol use disorder (AUD).

For parents of teens diagnosed with a mental health disorder, the modern approach to treatment we outline above often leads to a simple and relevant question, the answer to which is not fully understood:

Does taking psychiatric medication during adolescence increase risk of developing a substance use disorder during adolescence or later in life?

A meta-analysis published in the Journal of Child and Adolescent Psychopharmacology in May 2022 called “The Impact of Pharmacotherapy of Childhood-Onset Psychiatric Disorders on the Development of Substance Use Disorders” addresses that question, and the results are encouraging. We won’t give away the outcome of the study yet, but we can say with confidence that, thanks to this study, we now have an expanded understanding of the subject, and a simple answer to the question most parents want to ask, but don’t.

Substance Use Disorder and Alcohol Use Disorder Among U.S. Adolescents

We’ll start our discussion of this important new data by addressing drug use among U.S. adolescents and young adults. Parents may be concerned psychiatric medication can lead to drug use – but is there a real problem with drug use among U.S. adolescents?

This section will remind parents of prevalence rates, risks, and long-term negative consequences of adolescent and early adult substance use, which will clarify why parents do, in fact need to be concerned about the effect any medication their teenager takes on subsequent substance use, substance use disorder, or addictive behavior.

Data from the National Survey on Drug Use and Health (NSDUH) published by the Substance Abuse and Mental Health Services Administration (SAMHSA) shows the following rates of addiction in the U.S.

SUD/AUD Prevalence

• 20.4 million people over age 12 had SUD
  • 8.3 million people had an illicit drug use disorder in the past year
  • 20.5 million people had an alcohol use disorder n the past year

In addition, peer-reviewed data on the age of onset of SUD shows the following.

Age of Onset: SUD

• Onset of SUD is highest in people ages 18-25
• The highest rates of SUD occur in the people ages 18-25
• For people who develop SUD, the average age of initial substance use is around age 13
• Close to 50% of people with SUD are diagnosed with SUD before age 18

People who initiate substance use during adolescence are at increased risk of negative complications later in life, inlcuding:

• Developing SUD as adolescents
• Developing SUD as adults
• Poor overall physical health
• Impaired cognition
• Negative social outcomes
• Reduced employment
• Decreased academic achievement
• Increased premature mortality (death)

That’s the big picture, 30,000-foot view of substance use prevalence and substance use disorder prevalence in the in the U.S., and the negative consequences of early onset SUD for people in the U.S and worldwide. The information above is clear: SUD is a problem among adolescents and young adults in the U.S., and creates significant problems in almost all areas of life. Therefore, the answer to the question at the beginning of this section is this:

“Yes, there is a big problem with drug use among U.S. adolescents, and the consequences can be severe.”

That brings us to the first component of the topic of this article: mental health disorders and their relationship to substance use and substance use disorder.

SUD and Mental Health Disorders: The Connection

Decades of evidence show that one of the primary risk factors for developing SUD is the presence of a mental health disorder. Here’s a brief look at the statistics on two common mental health disorders that occur during adolescents and their relationship to SUD:

• Major depressive disorder (MDD):
  • Children and adolescents diagnosed with MDD are twice as likely to develop SUD than children and adolescents without an MDD diagnosis
• Attention-deficit hyperactivity disorder (ADHD):
  • Children and adolescents diagnosed with ADHD are two to three times as likely to develop SUD than children without an ADHD diagnosis

Now let’s look at the age of onset – i.e. when the symptoms of a mental health disorder first appear – for the most common mental health disorders. We’ll start with general facts about the onset of mental health disorders.

Age of Onset: Mental Health Disorders (General)

• 33% of mental illness appears before age 14
• 48.4% of mental illness appears before age 18
• 62.5% of mental illness appears before age 25
• The average age of onset across all mental health disorders is 14-18 years old

Now let’s look at the age of onset by type of disorder.

Age of Onset: Mental Health Disorders (Specific)

• Depression (MDD): 14
• Anxiety (AD): 15
• Obsessive-compulsive disorder (ODD): 14
• Eating disorders: 15
• Attention-deficit hyperactivity disorder (ADHD):
• Bipolar disorder (BD):
  • Early: 17
  • Middle: 25
  • Late: 42
• Borderline Personality Disorder (BPD):
  • Early: 12
  • Typical: 20
• Oppositional defiance disorder (ODD): 8
• Conduct disorder (CD):
  • Early: 10
  • Late: 10-18
• Schizophrenia/other psychotic disorders:
  • Early: 12-18
  • Typical: 23-28

And now we arrive at the crux of the matter: everything we know about mental health disorders tells us that most appear first – i.e. the age of onset – during adolescence. We also know that the presence of a mental health disorder during adolescence increases risk of SUD, and that SUD during adolescence can lead to significant problems in all areas of life during adulthood.

We said all that at the beginning of the article. Above, we present data in support of these assertions. That means you don’t have to take our word for it: the numbers tell the story. Now – ready with this knowledge and data – we’re ready to take a look at the meta-analysis that has the answers we’re looking for.

Adolescent Psychiatric Medication and SUD: Is There a Connection?

A meta-analysis is a study that collects all the available studies on a given subject, analyzes the results, and reports on statistically verifiable trends in data. For instance, to perform a meta-analysis on the best treatments for teen depression, researchers find all the published information they can on teen depression treatment. Then they use advanced statistical methods to verify what works, what doesn’t, and report their results. This approach gives researchers and the general public a good idea of what works. It also gives researchers and the general public an idea of what has stood the test of time.

To answer the question at the heart of this meta-analysis, researchers identified 1127 articles with relevant data. Through a process of elimination designed to yield the most reliable results, they narrowed those thousand-plus articles down to 26 studies. Those 26 studies included data on over 3.5 million adolescents and young adults, which gives this meta-analysis a sample set that allows us to make reliable generalizations.

The dataset yielded verifiable information on the relationship of psychiatric medication and subsequence substance use disorder for three types of mental health disorders common in adolescence: attention-deficit hyperactivity disorder (ADHD), depressive disorders (MDD), bipolar disorder, and psychotic disorders.

We’ll walk through the results one disorder at a time.

First, ADHD.

Attention-Deficit/Hyperactivity Disorder

• 11 studies showed that adolescents who received medication for ADHD were less likely than non-medicated adolescents with ADHD to develop SUD or experience negative consequences of substance use
• One study showed medication for ADHD had a protective effect for developing adolescent SUD
• The largest study, which included data from 2.9 million adolescents, showed that teens who received ADHD treatment were 50% less likely to develop SUD than untreated teens.
  • This study also showed that teens were 30% less likely to use substances while on ADHD medication, as compared to times when they were not on ADHD medication
• One study showed that for each year a teen was on ADHD medication, their risk of developing SUD declined by 13%.
• Two studies showed that the earlier a teen received medication for an ADHD diagnosis, the less likely they were to develop SUD at any point during adolescence of early adulthood.

Those results are clear. ADHD medication during childhood or adolescence is not associated with increased SUD during adolescence of early adulthood.

Next, we’ll look at what they found with regards to medication for depressive disorders and SUD.

Depressive Disorders (MDD)

• One study showed a combined protocol of cognitive behavioral therapy and antidepressant medication significantly reduced later development of SUD:
  • 11.6% of participants who received medication developed SUD
  • 24. 6% of participants who did not receive medication developed SUD
• One study examined the use of nonmedical prescription pain medication by two groups of teens: one group received pharmacological treatment for diagnosed MDD, and one group did not receive pharmacological treatment for MDD:
  • Participants who received pharmacological treatment for diagnosed MDD showed significantly less frequent use of nonmedical prescription pain medication
• Trends in all studies indicated that pharmacological treatment of depression is associated with a reduction in substance use and substance use disorder.
• No studies showed increases in substance use or substance use disorder for teens on medication for depressive disorders

Those results are also clear. Medication for MDD taken during adolescence is not associated with increased SUD during adolescence of early adulthood.

Now we’ll look at what the data showed about the relationship between medication for bipolar disorder and schizophrenia/psychotic disorders and SUD.

Bipolar Disorder and Psychotic Disorders

• Two studies found that teens with psychotic disorders treated with second-generation antipsychotics showed:
  • Reduced SUD symptoms
  • Reduced days of mandatory hospitalization for SUD-related reasons
• One study showed that adolescents with bipolar disorder treated with the mood stabilizer lithium:
  • Were less likely to develop SUD than teens with bipolar disorder who did not receive lithium
• One study showed the opposite:
  • Teens with severe hypo/manic symptoms treated with antidepressants and mood stabilizers other than lithium had increased risk of developing SUD

Those results are mixed, but straightforward. Teens with psychotic disorders treated with second generation antipsychotics showed a reduction in SUD symptoms. But teens with bipolar disorder with severe hypo/manic episodes treated with anti-depressants and medication aside from lithium showed increased risk of developing SUD.

Good News For Parents: Psychiatric Medication During Adolescence is Unlikely to Increase Risk of SUD

We would liked to have written that heading like this: psychiatric medication during adolescence does not increase risk of SUD. But that last study shows that in the case of adolescents with severe bipolar disorder, the presence of antidepressants and the absence of lithium may increase risk of SUD. That should not deter parents of teens with bipolar disorder from considering medication for their teen: additional studies showed that certain types of treatment can reduce subsequent SUD, including treatment with well-known medications, such as lithium, with a solid evidence base of reducing bipolar symptoms.

Disclaimer: we’re not endorsing lithium – we’re simply reporting the data.

This meta-analysis contains very good news for parents of teens with any mental health disorder for which psychiatric medication may be prescribed. Here’s the how the study authors describe their results:

“Overall, we failed to find consistent data showing an increase in the risk for subsequent SUD associated with medication treatment of psychiatric disorders in childhood. In contrast, the data support that treating ADHD and MDD with medication appear to mitigate the risk of developing SUD.”

They go on to report that the earlier a child with ADHD receives medication for ADHD, the less likely that child is to develop SUD later in life. Specifically, the data showed that ongoing ADHD treatment that began before age nine had the strongest effect on mitigating subsequent substance use disorder in teens with ADHD. And again, in the words of the study authors:

“We think that [this finding] is probably pertinent to other psychiatric disorders.”

We hope to find additional studies that support that last assertion. New data along these in support of early intervention would align with our overall philosophy of treatment for mental health disorders, with or without medication. That philosophy is not unique to us. It’s not new, either. But it is something we want everyone to understand. The earlier a teen with a mental health disorder receives an accurate diagnosis and begins evidence-based treatment for that disorder, the better the long-term outcome. Or, more simply:

Treatment works – the sooner, the better.