Welcome, everyone. I am, my name is Dr. Amy Ewell. On behalf of the American Psychiatric Association, I welcome you to today's webinar, Dual Diagnosis of Use, Substance Use Disorders and Depression, the Nature of the Association, and Treatment Implications. Today's activity is presented on behalf of the SAMHSA-funded Provider Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. Please note that today, that following today's presentation, you will receive a follow-up email within one hour of the webinar. This email will contain the instructions on how to claim credit for attending. One CME credit is available for today's presentation. Next slide. Dr. Kaminar, if you can forward to the next slide. Yes. Unfortunately, it's frozen. Frozen. Let me see what is happening here. I guess like the video, it suddenly stopped. I cannot proceed. Maybe we can ask. So if you want to unshare, Ben, are you able to share the slides? Yep. Great. So slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. Select the link to download the PDF. And next slide. At the end of the presentation, we'll reserve 10 to 15 minutes for question and answer. Please feel free to submit your questions throughout the presentation by typing them into the question area. And we're hopeful for the Q and A's to use the Q and A function as opposed to the chat if you can try to use that. That would be great. Next slide. And so with that, I'm really delighted to introduce you and to welcome the faculty for today's webinar, Dr. Yifra Kaminar. Dr. Kaminar is a child and adolescent psychiatrist and a professor emeritus of psychiatry and pediatrics at the University of Connecticut Medical School. His main clinical interests and research lie in the spectrum of adolescent high-risk behaviors. In particular, the assessment and treatment of substance use disorders, psychiatric comorbidity, and suicidal behavior. I welcome you to today's session, Dr. Kaminar, and thank you for leading today's webinar. Thank you very much, Dr. Yule. And Ben, thank you for helping moving the slides forward. And I will just ask you to keep on progressing as we go. These are my disclosures and disclaimers. Next one, please. And target audience, the overarching goal of PCSS is to train healthcare professionals in evidence-based practice for prevention and treatment of opioid use disorders, particularly in discovery medications, as well for the prevention and treatment of substance use disorders. Thank you. These are the educational objectives that we will try to go through in this presentation. So we're going to focus on some theory and practice. The theory will be to understand and apply the five co-occurrence models to diagnosing patients who may be presenting symptoms of both conditions, which also are known as dual diagnosis. Summarize the implications of comorbid major depressive disorder and substance use disorder to patients and families. This, again, focus on adolescents and emerging or young adults up to age 25. And explain how to effectively communicate potential interventions and treatment methods to patients and families. And I will also introduce you to very updated and most recent studies in the field that my team in collaboration with Dr. Carey's team at Duke has been working on for quite some time. Thank you. Next slide. Okay. I'd like to bring to your attention, because, again, we're all interested in dual diagnosis called caring disorder. I'm on the board of Research Society on Marijuana. We've been around for about six days, and now we're going to have a big-time meeting, and I hope that some of you will attend to it. It will take place the weekend of July 22nd and 24th at Boston University. We have a wonderful keynote speaker, Dr. Miranda from Brown, and it's a very nice conference. Great, by the way, for trainees, post-docs, with very competitive low rates, because we are very interested in education and adding more young and promising researchers and clinicians to our ranks. So please check us online, and hopefully we'll see you in Boston. Next one, please. Okay, so this is what our flyer looks like when we've been conducting studies, and this is the way we have been recruiting young people for our studies. Next one, please. Okay, so the age of melancholy, actually, this is a very appropriate term actually coined in the 1990s, and unfortunately, since then, we have seen a considerable increase on an annual basis of major depressive episodes. If in the 90s, the prevalence was less than 10%, as you can see in the mid-to-late teens, we have moved to 20.8% in 2016, 14.4% in 2018, and most recently, the numbers have continued to grow. In addition to that, those who have MDE definitely have been associated with a higher prevalence of substances. Almost one out of three of young people diagnosed with depression have been using substances as compared to non-MDE individuals, and this is based on a very large sample. Next one. You know, if you want to look at it visually, this is a big country, highly populated, roughly speaking 230 million people, so every minor change in the prevalence brings to our attention that there is an increasing need for interventions, which of course we're going to address later, but the resources definitely do not match the needs. Next one, please. Next slide, please. Okay, so what is happening with other disorders? The odds ratio, as you can see, of conduct disorder, which is quite common, is about four. Depression is in the low two, two point something, and the percentage is 20 or 30%, but there are some studies that also talk about close to 50. There's a broad range, of course, based on the methodology of epidemiological studies, and anxiety between eight to 18%, and with odds ratio 1.5. By the way, when we talk about psychotic disorder spectrum, such as schizophrenia and bipolar, the odds ratio is between five and six, meaning that the likelihood that the person with schizophrenia or bipolar disorder will use substances and develop later substance use disorder is quite higher than those of depression. The reason we see so many people with depression who have substance use disorder is because the prevalence of depression in the population is much higher than psychotic disorder spectrum. Next one, please. It's very important to bring back some data from 1999, that's the Angold et al study, that you don't need to meet the full criteria, the DSM criteria for diagnosis, in order to suffer or to need help. For example, to remember in depression, we need to fulfill five criteria for depression. But what happens if a person has four, three, or even two? Does it mean that they do not need help or they do not suffer? It ain't necessarily so, but there are issues of reimbursement because they do not meet the threshold, because the DSM, at least before it became DSM-5, is being very dichotomous and binary. Yes or no, and the DSM-5 made some efforts to be more dimensional. You have 11 criteria for substance use disorders, and you decide if somebody is mild, moderate, or severe substance use disorder based on the number of criteria. So the issue of sub-threshold has been very important, and if I have time, I'll tell you later on about our most recent study, and the idea is that actually the score of depression is more important in terms of severity and even diagnosis, in my opinion, than the number of symptoms. Next one, please. So again, the issue of categorical versus dimensional, it's even mentioned already earlier by Sam McGruder in the early 90s, that we definitely have an issue when we look at arbitrary cutoff point, and this is very problematic. Also, when we talk about dual diagnosis or multiple diagnosis, there's some asymmetry as well as non-specific symptoms that you can find in a variety of disorders, such as inattention, impulsivity, over and under activity, and so forth. So there are definitely several artifacts that sometimes we need to clean in order to understand the diagnosis per se, but the most important aspect is look at the dysfunction and suffering of patients and perhaps look at it differently in terms of reasons for treatment and choice of treatment in terms of dosage, frequency, and specificity. Next one. So the TAD study, the Pivotal Adolescent Depression, was one of the pivotal studies conducted on depression per se, and it was a multi-center study that produced multiple influential publications. The comparison was between fluoxetine, CBT, fluoxetine plus CBT, and placebo, and it has been found that CBT plus fluoxetine was superior to other approaches, although CBT per se also was very effective, and suicidality actually also improved the cost of all of them. And perhaps this is what they wrote in 2006, but we know right now that CBT is definitely an impact on reducing the probability of suicidal behavior. So this was one of the studies. There have been a couple of other studies. One was PRODIA, which is a treatment of adolescent depression that was fully responsive to treatment, and another one called TASA, the Treatment for Adolescent Suicide. And these three pivotal studies really addressed the importance of psychosocial interventions with adolescents with depression and as well as suicidal behavior, and I'm bringing this to your attention because we're going to get to the point of your presentation discussing what do we do when we have both depression and substance abuse as compared to just uni-diagnosis for either depression or substance abuse, although it's the rule rather than the exception, which is a very important statement, that most patients are at least dually diagnosed, if not more than that, and close to 80% of the patients we see with substance use disorder have at least one co-occurring disorder. So this is the rule rather than the exception. Okay, thank you. Next one, please. Also a very recent study published in the Journal of American Academy of Psychiatry looks also at relapse prevention, let's say for depression and anxiety, so you can call it the next generation of TEDS and like, and it shows that even when there is improvement for treatment, we witness very high relapse rates. And relapse prevention strategies, again, include antidepressants, psychosocial intervention, and combinations that do better than compared to control or intervention at all. Next one. So we get to the question of the chicken and the egg. Actually, this is the title of a lovely book that I bought in the friend quarter in New Orleans, and they also were selling books from boxes. And what's nice about it is that the chicken and the egg decided to stop arguing, who came first and decided to go along together, which is really sweet. But anyway, you know, we still use the term the chicken and the egg, particularly in co-occurring disorders. Next one, please. So I would like to present at least five co-occurring models and see where do they take us because we're trying to understand why we have co-occurring disorders. So the first one, and probably one of the oldest ones is the self-medication one, meaning the secondary substance use model. There is psychopathology and or stress, distress, uncomfortability, and we self-medicate it. Look at it also at why do we have what we call happy hour. It's probably a good example of what is self-medication to some degree. Post-work, that is very stressful, and going back home, which could be also stressful. So we self-medicate socially, and some people can handle it, and it definitely feeds into the development of alcohol use disorders and so forth. The second one is a disease model that actually psychopathology is allegedly the result of having a substance use disorder. According to many studies, including the PCA, the Epidemiological Catchment Area Study, which was conducted by Yale University in the late 80s, following young people 18 to 30, probably three out of four cases, substance use follows mental health issues and not the other way around. We also see, unfortunately, a decrease in the age of first use of drugs, but also in the age of manifestation of psychiatric disorders. Right now, a high percentage of psychiatric disorders have become prominent or known to us before age 15 or 16. It's also important to mention that there is a bi-directional model, which discusses multiple factors that are involved in going back and forth. Some people also address in this perspective a rebound effect that is associated with the allostatic model, which I will elaborate on in the next slide, so please stay tuned. It is provoked by bio-behavioral factors. It's kind of a slippery slope or the disorder is chasing, so to speak, its tail. There is a progression. Let's say people use substances, they get depressed, then they use more substances, allegedly to self-medicate, but that leads again to more depression, so we have a vicious cycle here. Sometimes people also resort to other drugs. In this case, for example, use cannabis, and then people are resorting to cocaine and opioids, for example, and other stimulants to get a better buzz. They put themselves in higher risk, of course. Can we get back to the previous slide, please? There are two more co-occurrence models. One is called the common factor shared liability model that shows that actually certain individuals and also certain families share a liability model for in several disorders, which can be mental health, as well as substance abuse. And of course, we need to say that maybe it's unrelatedness model because it's just the probability of two sheets, you know, sitting in the dark and colliding, but they have nothing in common, but this is probably not very likely, just like to be fair about it. Okay, let's move forward two slides. Okay, so in summary, to make it very simple, or to simplify it, it's not simple, co-occurring disorders may precede the risk factor of, develop as a consequence of, and moderate the severity of, and here I'm mentioning the study that was conducted more than 30 years ago, but it's still very powerful, and addressing also the fact that co-occurring disorders may originate from a common, vulnerable, insured, environmental, and family risk, and this is what I mentioned at the bottom, that the study by Tatar and his group from the University of Pittsburgh, that there is a transmissible liability index that allows you, PLI, they have several publications on this matter if you're interested, and it allows us to predict who might be developing proclivities to develop substance use disorder, and if we are able to identify at a very early age, it might be helpful in terms of prevention. Of course, there are some social issues here in terms of stigmatizing some subpopulation, and if you say, oh, I think that your kids might develop it, and people might be very happy to hear about it, but on the other hand, we are all looking for genetic markers, biological markers of different sorts, because it's so important in terms of prevention, so the transmissible liability index is an important factor, and I refer you to reading more about it in publications of Ralph Tatar's group. Next one. Okay, so what else do we know? There's some recent publications that show, for example, there's a risk factor in adolescence. This is 13 studies on depression that made the criteria for the meta-analysis done by Gronemann, published in the Orange Journal, what we call the Journal of American Academy of General Psychiatry, that the old ratio is around two, and again, obviating the obvious, as I mentioned before, that mental health disorders are a risk factor for substance use disorder, and it goes both ways, and the shared liability, based on the European group genomic study, which to some degree confirms the shared liability index that Dr. Tatar has developed, and also interesting, there are studies that show that children of alcoholics are at increased risk for developing other disorders, which means that they are showing close disorder transfer. So definitely, there is a fertile ground here, unfortunately, for crisscrossing of disorders. Next one, please. Another issue is, why is it so important to study? Because we realize that co-occurring disorders are actually more problematic and have poor prognosis on bio, psychosocial, and environmental development of young people, as compared to a single diagnosis, as you can see here, elevated risk for suicide, greater treatment attrition, poor outcomes, and poor overall quality of life, which is unfortunate, not only on individual basis, but because this is like the sin of the parents, if you will, kids who grew up in such environment and a parent or parents have issues with dual diagnosis, and any one of these disorders anyway, are definitely may need high risk to develop these disorders and or not to get the enough nurturing that they deserve, given the resources of the parents in terms of energy, attention, and why they need to address their own mental health and substance use difficulties. Next one, please. So I don't have enough slides here about suicide because time is limited, but I just wanted to share these slides and definitely any additional substance use disorder or substance abuse and combination of both increases the likelihood for suicidal behavior. This is based on U.S. studies, but also on international studies. And as you can see, mood disorder and disruptive disorders, which include ADHD and conduct are relatively highly represented. And almost 40% of suicide cases were diagnosed with two or more disorders. So in most cases, as we know, suicide, even though it could be very impulsive, if you elaborate and dig deeply to understanding the deceased young individual, you're more likely than not to find not just immediate stress, which led to the event, but also chronic exposure to some other high risk mental health conditions. Next one, please. Now, some people say, you know, you hear it sometimes that internalizing disorder actually are a protective factor compared to externalizing disorders. And here are some of the examples why. I guess the narrative is that the behavioral inhibition is a little bit better in terms of prognosis and prevention, because people who manifest internalized disorders are less likely to affiliate with deviant peer-to-peer conduct disorder. They are pretty much more to themselves and they have more anxiety than inhibition in dealing with high risk substances and behavior. But again, this population is highly heterogenic. And even within each and every disorder, so it's difficult just to generalize and mention it. And I don't think we're in a position to ask, well, what is better to have internalizing or externalizing disorder? Now the issue though, is that, you know, female tend to manifest more internalizing disorders such as anxiety, depression, and PTSD than males, who tend to manifest more externalized disorders such as ADHD and conduct disorder and antisocial behavior later on. But we know that percentage of our clients involve internalizing and externalizing disorders as well. So it's difficult a little bit kind of to make very clear statements such as whether it is a protective factor or maybe a relatively protective factor. It's more complex than that, but I thought it's important to bring it to your attention because this is something that we hear quite often. Next one please. So cannabis use in adolescent and risk of depression. A lot of people are pro marijuana legalization. They try to minimize or even basically contradict the fact that marijuana is clearly a negative experience for adolescence, mental health issues. So what we can see is the auto ratio developing depression indeed not very high, but it's a numbers game. So you see the more people are using the more people develop depression. However, the auto ratio for suicidal ideation and particularly suicide attempt is very high. So this is a major risk for concern. And the high prevalence for the lesson using cannabis generates a large number of young adults who could develop depression and suicidality attributed to cannabis. And we also see that cannabis enhances the exacerbation of new bouts of depression. And it goes that way into adolescence and early adulthood as well. So the claim that cannabis is self-medication or self-medicating agent might be true subjectively to some users, but after a while they develop tolerance and does not work that way. That's very important to explain to patients not in a confrontative, controversial way but need to kind of explain to them when they usually say, oh, but cannabis really soothing my depression and anxiety and the response probably should be along the line of, well, this is your personal experience so far but what we have seen and what we have learned and what is the majority of opinions is that for long-term basically it's gonna put you in a greater jeopardy of chronicity, new bouts and suicidal behavior. Next one please. What we know about adults, as you can see here is that 25% of adults with mood and anxiety do report cannabis use to self-medicate and adults with depression now it's increased use of cannabis use. And there was particularly strong increase in early cannabis use as well. So I'm calling this pretty much fake news. The public view of cannabis is effective even in the future for depression and it consists relatively recent publication in Java. Next one please. So I guess it goes without saying, but I do have such a slide why we cannot further ignore substance abuse based on mental health. As you can see overlapping developmental, environmental and genetic vulnerabilities, drugs can trigger mental disorders and vice versa to contribute significantly to morbidity and mortality. And as you can see in the last item by Friedel this is like more than 40 years follow-up of comorbidity and it shows really an entire gamut of problems including higher risk of premature mortality. Next one please. Another issue with youth, even though this comes from 2010, but it's not changed much. We don't have enough resources for youth. The percentage of resources for youth, the piece of the pie is the slice is much smaller compared to their percentage in the population. Ironically, youth in the juvenile justice system have more attention and more resources, which of course they need, but other youth are relatively neglected. And then you can see if they comprise a quarter of the population, they hardly get 10% of the resources. Next slide please. And you know, why is it that way? Because we all work in silos. A lot of people do SUD treatment. This is the expertise, but they don't do mental health treatment. Other people do mental health, but they don't do SUD and they keep on sticking to it the same way that we have in our federal system. We have Institute for Prevention, Institute for Treatment. Even though I don't see major difference between the two, it's just that the only difference in my opinion is where is it necessary along a chronological timeline and the differentiate in terms of the dosage, the frequency and the specificity of the intervention. Next one please. This is a very sad slide because you see on the bottom that about 5% to 6% max of people, young people get mental health services or substance use treatment together, combined one. And we definitely need more and more joint integrated intervention for mental health and substance use together. And there's a lot of work and investment of resources that needs to be done. Next one. And okay, this is some of the barriers that I mentioned and we don't have enough healthcare professionals who basically have experience in dual diagnosis and you will see very few centers for dual diagnosis. I can tell you, I'm talking to you from Connecticut and I'm looking at New England, for example, which has a very active group center at Brown University at Bradley Hospital in East Providence, Rhode Island. But unfortunately, dual diagnosis program at McLean Hospital, one of the flagships of Harvard in Vermont next to Boston, it's dual diagnosis program closed. And it's very difficult when you need to find a place for a young person for dual diagnosis, it's almost unheard of. And you need to send them over to mental health or to substance abuse treatment. And this is an important issue that the American Psychiatric Association and other substance use related associations with many to beat up the drums to develop dual diagnosis program. Next one. What are the interventions? Let's get to the third part of why we're here today. So you have cognitive behavioral therapy, you have motivational interviewing, you have family-focused therapy, medications and others, and integrative medical and psychotherapies that are good for depression and they're good for substance abuse. The question is, how do we integrate them together for dually diagnosed patients? And unfortunately, there are not enough studies on this matter as well, which is another barrier, how to set the bar. And hopefully I'll have enough time to present to you what we've been doing and published most recently. Next one. So treatment of co-morbid alcohol use disorder and MDD, there's a meta-analysis here of different studies that show that there is indeed a significant effective improvement, yet it's a relatively small effect size. This is based on different studies on adults, including studies as early as the 1990s, as you can see from the archives. But nevertheless, this is probably the most efficacious way of intervention of motivational interviewing and CBT together. And this is better than treatment as usual or no treatment at all. Next one, please. So we've conducted the review. It was many years ago, 2014. We found then 12 studies, but unfortunately because of different methodologies, we found that several studies showed that treatment makes things better, treatment makes things worse, and it didn't matter. So that's one of the reasons we decided to conduct the study of our own. Next one. So this is also another slide that I mentioned to you that again, people talk about medication and cannabis for everything, the new panacea, that I think this is a very important statement in the Lancet that there's scarce evidence to suggest that cannabinoids improve any of these disorders. So it's very important to take it into consideration. Next one, please. Okay, this is an important slide because although this study is not a large-end study, it showed you that there are three or four different trajectories in every treatment. One size does not fit all, and this is treatment of substance abuse only, but there are different assessment points. And you can see some people do respond, and some people respond partially, and some people don't respond at all. And also among those who respond, we have to deal with relapse. So it's very important to understand each and every patient what is their prognosis, because it's pretty clear that those who are rapid responders do better than non-rapid responders who can be later responders or perhaps even non-responders. But it's important to identify the rapid responders and the non-rapid responders so we can develop adaptive treatment, develop a decision tree of yes, no, yes, no based on response to treatment or what we also know professionally is unproven. Next one. So very quickly, this is a cannabis use treatment study the largest study ever for the treatment of youth cannabis. There were four sites. Our site is the one in DC, in Connecticut. And the idea was, next slide please, to treat adolescents with cannabis disorders in different ways. One was MET-CBT five session, the other one MET-CBT 12 session, the other one was community reinforcement approach called ACRA, and the other one was MDFT which is multidimensional therapy. And actually all interventions were relatively effective with no major differences between them. But what I'd like to bring to your attention in the study that we conducted on this data set and it was led by Albert Arias from VCU is that we wanted to see even though depression was not treated, but it was assessed, how did depression change or being affected by treatment per se of cannabis only? As you can see, we have 80% of people who may be assigned a four criteria for end major depression disorder. And at least 70% of people with at least one symptoms qualifies for the depression inventory. And so in general, there was a significant linear decrease in depressive scores, even though the treatment was not focused on depression, which shows you how powerful actually is any intervention because there's some kind of unspecific aspects that we use both in depression manual treatment and in substance use depression manual. Improvement in both symptoms was not correlated with type of treatment provided. And improvement in cannabis did not influence improvement in depression and vice versa. Next slide, please. So basically what we found based on time like analysis from one point to the other, that what really matters was within subjects in terms of severity of depression, meaning that cannabis use and depressive symptoms as we see in conclusion number one, the decreases concurrently and not in a staggered fashion, but they did not affect each other. So take home message is definitely particularly CBT, cognitive behavioral therapy. It doesn't matter what you use it for, but any kind of the disorders present might get affected, particularly by people who we correlate with this problem. So that's definitely a good take home message. Next one, please. Why this make, what are the proposed mechanisms for symptom change, particularly CBT? One is the dysfunctional reward processing. It might be a feature of comorbid depression and SUV. We don't have time to talk about exactly what's happening in the brain reward system, but what's happening with substance of abuse quickly, behavior that is rewarded by pleasure after a while becomes compulsive and there's a dysfunction in the reward processing because there's not much reward anymore. The pleasure become actually compulsory behavior. The other one is self-efficacy. This is a possible mediator between depression and substance use relapse. Next slide, please. So that's helpful to understand. Also, it's interesting to show this slide because it shows that we can show the Kokaska theory of change, how from pre-contemplation all the way to maintenance and recovery stage of diagnosis, it affects assessment and engagement, abstinence initiation and relapse prevention. Next one, please. So the current intervention, as we mentioned, is pretty much a hodgepodge of interventions that we need kind of to rebuild this treatment approach and not just try to cut and paste from your diagnosis. Next one. So one of the approaches that we use in our study in the next seven slides, I'm gonna show you our recent studies is adaptive treatment design, which is based on some kind of a decision tree approach. We wanted to find who are those who are rapid responders and be later with those who are not rapid responders. And we have found out that within four or five weeks, those who would respond to treatment of CBT will respond. Similarly, by the way, with substance use disorders, those patients who would respond to treatment would respond within five to six weeks when you provide them with CBT. So if they don't, there's no reason to continue another five or six weeks with the same CBT because you get the curve of diminished, efficacy diminished return. You'd rather move to another intervention and or add on additional booster or intervention, again, in terms of decision tree. And the question is when to do it and what to add. And this is what adaptive treatment design is. And those of you who are interested in it, I can definitely send you to some publication on this. One of them by Gina K from the University of Pennsylvania and several good studies on adaptive treatment design. It's been relational and also provide you with a manual on how to address it. Next one please. And so when we designed the study that I presented to you, we were expecting at least a quarter of people who have rapid depression respond. And we decided to develop a design of adaptive treatment, meaning those who do not respond well to the first intervention, we will make some changes. Next one please. This was actually also based on a study published many years ago. It shows actually that CBT plus fluoxetine wasn't much better than CBT plus placebo, which basically shows that CBT is very powerful and we also need to take it into consideration. Next one please. This slide actually, it's on paper that yesterday just was accepted for publication in the American Journal of Addiction. And we also show that it's difficult to recruit adolescents with dual diagnosis compared to those with single diagnosis. And you can see how we dropped from 212 to the screening by 35% and another 57% to meet eligibility, meaning that it's kind of very confusing sometimes to recruit those adolescents. And the discussion that hopefully the paper will be out online in a couple of weeks, we'll find out the reasons why is it that way. So it's pretty clear, it shows us that dual diagnosis from beginning to end in terms of recruiting and treatment is definitely more challenging. And we just need to get better expertise and experience in doing this. Next one please. So this is the design of the study that I'm addressing that was just published, Kerry, Kamina and Al in the American Journal Child and Psychiatry in the April issue of 2022. So first of all, for four weeks, we treated this dually diagnosed adolescents with depression and substance use disorder only by treatment of the substance use disorder. And we measured how depression improved and those with depression did not improve, we moved them to a next stage with an additional manual that we treat their depression. And other people, we had a control group of what we call treatment as usual. And next slide please. And this is the way it was composed, what was treatment, two sessions of motivational interview, 10 sessions of CBT and therefore depression, there were seven sessions for CBT based actually on the TED study that I showed you a slide earlier in this presentation, treatment of adolescent depression. And some of them basically are overlapping with substance use disorder because you use similar mechanisms in terms of CBT mechanism for behavioral change. Next one please. So what happened in the first motivational interview session, you work on report, review of problems, reason for quitting. Number two is functional analysis and goal setting. Then you have CBT sessions, which as you can see, address problem solving, refusal skills, social support, et cetera. It's also the risk depression management there and anger management. And the depression management session basically introduces the triangle of thought, behavior, emotion, or the ABC, the cognitive ABC that shows our feelings, behaviors and actions affect each other in the bidirectional if you imagine a triangle. Next one please. And of course we wrote these manuals, but I cannot address them right now. This is kind of the list of what it looks like schematically in terms of number of sessions. Some of them, by the way, you may repeat in a second cycle. If you think that your client needs more specific intervention, let's say on anger management or socialization or problem solving. Next one please. So what have we found? Interestingly enough, more than a third of youths their depression went to subclinic, was reduced to subclinical level just after four sessions of treatment of depression of cognitive behavioral therapy. And what do I mean by reduction? If we use the Children's Depression Rating Scale by Poznanski and the reduction of 50%, the score in order to meet the score of severe depression it needs to be over 40. And if it goes down to about 28, we call it remission. Not cure, but remission. And that's actually very important. And I mentioned earlier when I talked about subsyndromal threshold, we have found actually that the score, the improved score of depression and CDRS was more important than the number of symptoms of depression as necessary by the DSM system. So this is definitely some food for thought how to address this matter and how to measure improvement. Next one please. Okay, earlier we spend those improved. So what I have is just data up to week 12 of treatment. We still need to analyze the long-term effects to see whether these positive outcomes have been sustainable but we also found out that we see on the bottom that conduct disorder and polysubstance use baseline were negative predictors for early depression. Next one please. In all the studies that I was leading years ago, I show actually that even if you do not address suicidal behavior, if you measure it pre and post treatment for substance use only, you see that suicidal ideation has been reduced. So CBT definitely is a very powerful to improve coping skill mechanism that might affect also suicidal ideation. Next one please. Pharmacotherapy, a quick one, actually there's not much to talk about. This was one study published by Kevin Gray from NUSC about N-acetylcysteine. It was improved treatment of cannabis among youth. However, it has not done the same for adults. Repeated studies, including one on dual diagnosis and depression as you can see by Tomko have not resulted in anything positive. So I know that most studies have been done on N-acetylcysteine in other agents as well. So stay tuned. Next one please. And this is actually my next slide in terms of data, just a study that I found among adults about computerized intervention that has been found to be useful for dual diagnosis. Next slide. So this is actually the end. This is my email address if people would like to ask questions or refer some other aspects. And I believe that there's several more slides that are more like housekeeping slides. So I'll let Dr. Juul take it from here and or Ben, whomever is responsible for that and then we take some questions over here. And I think we have probably time for one question and then we can go through the kind of last housekeeping slides. One question that came up in the Q&A was, it sounds like Dr. Kamir, when you talked about some of the recent research, these were people who were presenting for treatment for their, or had some willingness to address their substance use disorder. And I guess one of the questions was with adolescents with a co-occurring mental health condition and a substance use disorder, who are not, who are kind of presenting motivated to address their mental health condition, but not motivated to change their substance use disorder. How would you approach them or how do you think about approaching them for treatment? I wish I could answer it in 30 seconds, but I think that we should use a multiversal interviewing or intervention approach and do it step-by-step. Those of you familiar with multiversal interviewing and those who get curious about it, one of the aspects of multiversal interviewing is showing discrepancy, discrepancy between where you are now and where you would like to be. And once we address this issue with adolescents, then we explore with them together in a patient-centered approach how to make this change. So for example, if you ask an adolescent, do you have a problem? He said, no, you're my problem. I don't want to be in treatment. But this is too general. So you, for example, using my teen addiction severity index if you're interested in a certain rating scale. So you look at different domains of how things in school. And again, this is recorded, so I cannot use any adjectives, but they tell you what they think about school, how things at home, what they think about the parents, how things with your probation officer and so forth. And then you say, well, would you like to change it? And they probably say, of course. And I said, what do you have in mind? And then you get into a dialogue. So you get into this transactional paradigm of the theory of change, a la Procasca and DiClemente, and you're able to move from pre-contemplation to contemplation. And there are some manuals of how to do it. And some of these manuals are available from a CYP study if you want to read them any deeper or send me an email and I may be able to send you a paper that we published and also a manual that we've developed. So this is as much as I can say right now. But yeah, don't lose hope. It's a bit of technique and strategy as compared to, well, they don't want to work with us. That's a raison d'etre of being an adolescent, not wanting to work with you. Yeah, I think you capture kind of, it takes time. So, and then I think you were mentioning when you said this CYT, the Cannabis Youth Treatment Trial, and for people that are less familiar with this, they had several different protocols and different types of therapies and those are available for free online or Dr. Kamir also kind of generously offered his email address if you're interested in being in touch with him. So with that, Ben, if you can go to the next slide, please. And next slide after that. So just briefly wanted to touch up on the PCSS Mentoring Program. Please visit PCSSnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorders. Next slide. If you have a clinical question, PCSS mentors have expertise in medication for substance use treatment and clinical education. You can use the PCSS discussion forum, which is a simple and direct way to receive an answer related to medication for substance use treatment. Next slide. And today's activity was presented on behalf of the SAMHSA-funded Provider Clinical Support System, which is a program operated collaboratively by 19 medical specialty organizations, including the APA and the other organizations you see on the slide. Next slide. And so with that, really thank you for joining us today and thank you, Dr. Kamir for this very helpful and educational presentation. And we hope to see you for the next PCSS webinar.

dual diagnosis

substance use disorders

depression

webinar

Dr. Amy Ewell

American Psychiatric Association

SAMHSA-funded Provider Clinical Support System

co-occurring disorders

integrated treatment approaches