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Introduction
Male adolescents with depression are usually reluctant and unwilling to seek help from adults or even healthcare institutions. They tend to associate the act of seeking assistance with their problems as childishness this end up finding different ways of coping with the situation. One of the ways that most of them result into is substance abuse which advances into poly-substance abuse if no one intervenes in their situation. Some of the substances abused by adolescents include marijuana, alcohol, cigarettes, heroin and cocaine among others. The substances not only have adverse health effects on the victims but also have a negative effect on their socioeconomic life even in their adulthood. To prevent all the negative effects of poly-substance abuse in adolescent males, healthcare practitioners need to understand the level of depression of the victim, the cause of the depression and the possible intervention and treatment measures that are suitable for the particular adolescent.
Literature review
Depression as a major cause of poly-substance abuse
Depression is the most crucial aspect that makes young males indulge in poly-substance abuse. There are various ways in which male adolescents express their depression. Winters, Ramafedi, and Chan (1996) aimed at using one of the most valid and reliable clinical instrument (an existing youth drug abuse screening tool) in assessing the level of poly-substance abuse among gay young men (adolescents). The research also sought to establish the relationship between psychological distress, substance abuse and abnormal behaviors in young adolescents. Their study sample was composed of gay-bisexual male adolescents (13-19 years old) who had sex with men or who otherwise considered themselves to be gay or bisexual. The data was obtained via a structured interview. Most of the males reported symptoms of psychological distress. 52% of them revealed that they worried a lot for no good reason, 31% had problems with dealing with some unusual thoughts, 31% felt sad much of the time, 22% suffered frequent headaches or a nervous stomach and 17% reported to have been contemplating suicide. Of all the participants, 94.6% reported to have used at least one drug in the previous year. The most used substances were marijuana (8.4%), alcohol (24.5%) and cocaine (2.4%). It is noteworthy that 4.2% of the males reported to have used an injectable drug in the previous year which exposed them to the risk of getting HIV/AIDS. From their finding, most of the males were using more than one drug-58% of the participants reported that they were using two or more substances while 29.6% were using more than three drugs. It is thus evident that their sample was composed of a significantly high percentage of individuals who were involved in poly-substance abuse.
Just like Winters, Ramafedi, and Chan (1996), Mason and Windle (2002) believe that the depression that the individuals had triggered them to poly-substance abuse. Poly- substance abuse lowers an individual level of judgment making them to indulge in risky behaviors such as premarital sex or even becoming homosexual an aspect that increases their risk to diseases such as HIV/AIDS among others. It is noteworthy that their research results are representative of findings in clinical gay-bisexual adolescents and may not hold for the same group of adolescents in the general societal setting. Additionally, different ethnic groups exhibit varying frequencies of the involvement of depressed adolescent boys in poly-substance abuse. This was established through a study carried out by Winters and Latimer (2004) in their attempt to Alcohol and other drugs abuse in adolescent boys from different ethnic groups in the U.S. The ethnic groups that were studied were Hispanics, Whites, African Americans and the Native Americans.
Poulin et al. (2004) investigated the relationship between depression and poly-substance abuse in adolescents in the four Atlantic provinces of Canada as far as gender is concerned. Their sample consisted of 12,771 students in both junior and high schools of the public schools in the four provinces. They found out that adolescent females were consistently at a higher risk of depressive symptoms, depressive disorders since they tend to internalize their problems more than their male counterparts. According to their study, the prevalence of very elevated symptoms among female adolescents was 8.6% while that of the males was 2.6%. However, male adolescents are at a greater risk of substance use disorders than the adolescent females. Poulin et al. (2004) found out that different substances are used at different rates among male adolescents with depression. The findings were similar to Nolen-Hoeksemas (2001) who carried out a study to describe how the different genders have different experiences as far as stress in adolescents is concerned. They identified most of the abused substances among adolescents. They include alcohol, cigarettes and cannabis.
They associated the increased use of these substances with an increasing probability of depressive disorder. They also noted that smoking was the least controllable substance among the males. They established that depressive symptoms and disorder are the major predictors of smoking uptake not only in adolescence but also in adulthood. Early onset smoking poses a greater risk for severe depression symptoms than later onset smoking. On the other hand, cannabis abuse was associated with males who had a history of depression disorder. 16% of those who had used cannabis at least once in their life were diagnosed with depression compared to 6% of the adolescents who had never used cannabis. They also found out that most of the students had depression symptoms while others already had depression disorder but they had not received much help form the society. Only 10.3% reported that they had received help for depression. Their findings show that for the different levels of depression only 12% of the students with somewhat elevated depressive symptoms had received help so was 22% of the students who had very elevated depressive symptoms. A large proportion of male students had not received any help-12.8% of the females sought help as opposed to 7.1% of the males.
Major depression is one of the most common and serious disorders among adolescents. The estimated prevalence of the disorder is between 2.8% and 8.2%. Depressed adolescents are highly vulnerable to poly substance abuse among other issues such as engagement in multiple illegal activities. Pruitt (2007) asserts that male adolescents are less likely to report depression due to several reasons. They tend to distract themselves from depression by doing some of the things that seem enjoyable besides thinking too much about other things. They also tend to ignore their problems. Additionally, male adolescents are usually reluctant and unwilling to ask for help form adults due to the fear that they will appear childish.
How advancement of depression increases poly-substance abuse
Deykin, Levy and Well (1986) established the relationship between depression, alcohol and drug abuse in adolescents. Their study was the first one to document the association as well as the sequence of psychiatric disorder, drug and alcohol abuse which is not only rigorously ascertained but also defined in a normal adolescent population. They employed cross sectional study design to identify the manifestations and correlates of major depressive disorder in adolescents. The sample comprised of 271 females and 153 males who were college students ranging between 16 and 19 years old. They obtained the data using the Diagnostic Interview Schedule which has a high reliability with an overall kappa statistic of 0.69. It is a well-structured standardized interview that was developed for epidemiologic purposes. Regarding alcohol abuse and major depressive disorder (MDD), the study showed that the lifetime prevalence of alcohol abuse was 8.2% while that of MDD was 6.8%. On the other hand, the lifetime prevalence of substance abuse was 9.4%. They found out that adolescents who had a history of alcohol abuse were nearly four times as likely to have history of MDD as those who did not have a history of alcohol abuse. As alcohol abuse, drug abuse among adolescents has a very strong association with a lifetime prevalence of MDD. The study also shows that marijuana is one of the most abused substances among adolescent males. Subjects who had a record of drug abuse, irrespective of the drug they abused, were 3.3 times as much as non-abusers to have history of MDD.
Deykin et al. established that alcohol abuse is common disorder in adolescent males as compared to their female counterparts. Additionally, they found that drug abuse in both male and female adolescents is strongly associated with MDD among other psychiatric disorders. According to the study, depressive illness paves way for alcohol/substance abuse among all the male adolescents. The study further defines the two major types of depression (primary and secondary) to assist in understanding the relationship between poly-substance abuse and depression. Deykin et al.s (1986, p. 181) definition for primary depression is the kind of depression that occurs in a patient whose previous psychiatric history is negative or positive only for pre-existing mania or depression . On the other hand, secondary depression is the type of depression exhibited by a patient who has a pre-existing diagnosable disorder (ibid). The classification is based on the onset of the disorders. In their study, 79% of the males involved in poly-substance abuse had primary depression prior to their involvement in substance abuse. This was in line with Silberg et al.s (2003) findings. Silberg et al conducted a study to establish the relationship between substance abuse and depression in adolescent boys and girls.
The initiation of an individual to early substance use e.g. alcohol at an early age (15 years old) doubles ones risk of substance use dependence. According to Mrug, Gaines and Windle (2010, p. 490), adolescent behavior inclusive of substance abuse is affected by proximal social contexts. They include family, peers as well as more distal settings such as neighborhoods and schools. In their study, they examined school wide use of alcohol, marijuana and tobacco among in relation to the involvement of early male adolescents abuse of substances. They also examined whether the relationships varied across degrees of two most important proximal risk factors in male adolescents: deviant peer affiliations and poor parenting practices. Mrug et al.s (2010) study consisted of a sample of 542 middle school students. The study was approved by the Institutional Review board for Human Use at the University of Alabama at Birmingham. They found out that adolescents who were victims of poor parenting practices engaged in poly-substance abuse in an attempt to cope with their depression. Parents who did not show much concern for their children made them to develop depression especially when their peers seemed to be receiving more care and support from their families. For such adolescents, it was easier for them to join others who opted to use drugs in coping with their hardships.
The effects of poly-substance abuse to an individual
Involvement in poly-substance abuse, whatever the cause, has some negative effects on the life of the individual. Green and Ensminger (2006) examined the effects of heavy adolescent substance abuse on employment, marriage and family formation. Their study used marijuana use since it of the most abused substance among male adolescents. They obtained data from the Woodlawn survey, a prospective study of African American youths in Chicago. It is a research and intervention program for drug users which is a partnership of several institutions. They include the University of Chicago, the City of Chicago Board of Health and the Woodlawn Mental Health Centre Board. They used longitudinal design to follow the epidemiologically defined population of 1,242 individuals from 1966 to1993. From 1966, they followed the cohort of adolescence (15-16 years old), early adulthood (age 32-33) and midlife (42-43). A high level of marijuana use, which was also associated with the use of other drugs such as cocaine and heroin, predicted a variety of difficulties. They include dropping out of school, being unmarried, unemployed, parenting and outside marriage. Such individuals also continued using marijuana in ones adulthood. Their findings also suggested that effects of heavy marijuana use continue to be manifested in an individual as much as 15 years after initiation of use in key areas of adulthood which include family formation and employment.
Green and Ensminger (2006) also found out that heavy male adolescent drug abuse led to a pseudo maturity. Their explanation posits that a lifestyle of drug use during adolescence leads to not only premature but also out-of-sequence involvement and performance problems in the roles of adulthood e.g. the roles of spouse, parenting and working. They also found out that at least some of the detrimental effects of adolescent drug abuse are due to the high probability that drug use continues into adulthood. They noted that nearly 25% of the individuals under study who used marijuana as adolescents continued to use them in their 30s. This group was also associated with the use of heroin and cocaine as young adults.
Green and Ensmingers (2006) findings highlights that it is important to prevent and in extreme case delay early drug use especially heavy involve in poly-substance abuse. It is also important have intervention programs for the male adolescents who begin poly substance abuse at an early age to prevent the escalation of the disorder. The intervention and prevention programs should encompass a broad scope since early poly substance use appears to relate to later outcomes. According to their research, the association of adolescent use of drugs with high school dropout provides evidence that programs addressing each risk separately may benefit from addressing the other risks simultaneously.
In most cases, it is difficult to treat young males who are involved in poly-substance abuse. Ohlin, Hesse, Fidell and Tatting conducted a study to determine how poly-substance drug abuse affected the retention as well as the abstinence of the patients during their treatment or rather rehabilitation. Their study was based on data that they obtained from a prospective study of the course of buprenorphine in one of the highly structured clinics in Sweden. The treatment period was between August 2004 and November 2009. The target group (sample) for the treatment was people from different age groups who had a record of substance abuse. At intake to treatment, patients were requested to provide a urine specimen which was analyzed to determine the kind of substances that the individual had taken as given by the type of compounds present in their urine. The patients were then seen by a senior consultant psychiatrist who initiated their treatment. The study showed that poly-substance use indicated that the patient would have at intake indicated that the patient in question would have problems staying abstinent over a rather prolonged period. One of the major conclusions was that healthcare systems need to give some special support to patients who had a high degree of poly-substance abuse prior to joining any form of treatment cum rehabilitation program. Their study also asserted that adolescent patients had a higher rate of dropout than other patients who were under the same treatment program.
Treatment of depression associated with poly-substance abuse
Acceptance and Commitment Therapy (ACT)
One of the major measures that can be employed in reducing depression in adolescents is the Acceptance and Commitment Therapy. Murrell (2011) carried out a research to establish the effectiveness of the mode of treatment. The current ACT interventions have been tailored to address several disorders and risk behaviors that are costly to the life of youth. He used published articles in reputable databases such as the PsychINFO database search engine provided by EBSCO and the contextual Psychology website. ACT holds that for effective elimination of depression, one has to deal with the private events and thoughts that lower his/her self esteem. ACT interventions target personal life events and thoughts to facilitate functioning and living a worthwhile life. It aims to eliminate the constructive nature brought about by private events in order to allow for a better quality of life. Such an approach is essential in the intervention of drug abuse in male adolescents which has shown an increasing trend in the recent past. For instance, according to Murrell (2011, p. 20), approximately 11% adolescent males in the United States admit to be involved in poly-substance abuse. The ACT approach is also helpful to parents whose children are involved in poly-substance abuse. It not only helps them to cope with the adolescents but also provides them with the knowledge of how to talk their children out of the vice.
Family based therapies
Family therapy is another effective treatment approach for depression in adolescent males. Pruitt (2007) posits that healthy parent-child relationships have a positive impact on adolescent development. Research has shown that interpersonal factors, specifically family relations play a pivotal role not only in the development but also in the maintenance of depression in adolescents. Additionally, parental involvement in the treatment of adolescent depression reduces attrition. The study also considered the fact that parental depression can contribute to adolescent depression and that several family factors and adverse life experiences increase the risk of adolescent depression. Families with a depressed adolescent child, irrespective of their gender, report family dysfunction as well as negative life events which include family conflicts. Some of the conflicts include parent-child conflict and marital conflict especially about parenting. In extreme cases, the conflicts result to parental death, separation/divorce, physical child abuse and maltreatment. Pruitt also found that depressed teens have less secure attachment to their parents.
Several studies have been done to establish the relationship between family, depression and peer pressure. Dorius, Bahr, Hoffmann and Harmon (2004) identified family and peer relations as the two most important socializing forces that affect adolescent behavior. Through intensified research work, they found out that parents who monitor their children closely and develop significantly close relations with them have a significant influence on their childrens decision on poly-substance use. Scheer and Unger also had similar findings after carrying out a research involving 159 Russian adolescents in Moscow (1992, p.297). However, there are some different views by other researchers such as Harris (1995) who argued that parenting has little or no effect on the behavior of adolescents. Parents of depressed adolescents tend to be dominant and controlling besides denying the children the opportunity to be actively involved in the family decision-making process. Such parents also exhibit controlling behaviors which include limiting the self expression of the child, dictating the life goals of the child in question and trying to make the child behave like an adult. Consequently, the adolescent develops depression due to their inability to express themselves. He also noted the presence of absent fathers in a family is detrimental to the health of adolescent boys.
There are three family therapy approaches that are effective in treating adolescent depression. They include the structural Family Therapy, Attachment-Based Therapy and The Interpersonal Family Therapy. Diamond and Sequeland (1995) carried a study to establish the key aspects of this approach. The goal of the Structural Family Therapy is to disrupt the negative cycle associated with families that have a depressed child. It brings out the healthy parts of the family members that lack in such families. The therapy sessions bring out the positive or rather competent aspects of each of the family member that enhance the development of positive interactions within the family. The interventions occur in three different phases. The first phase is characterized by joining the both the parent and the child. It also involves the definition of the focus of the therapy as the improvement of interpersonal relationships within the family. The second phase involves addressing of the strained family relationships. In seeks to not only identify but also strengthen the familys social supports. The therapist brings out the empathetic, protective as well as the caring parental behaviors while reviving the adolescents desire for parental love, care, support and protection. The third step seeks to establish the family as a social unit for each of the members. During this phase, the parents get information on how to balance the adolescents need for independence and attachment. This last phase generally aims at increasing the adolescents trust on the parents, improving his/her view on the different parenting practices and improving family cohesion.
Interpersonal Family Therapy is based on four main pillars which are the cognitive-behavioral psychology, developmental psychopathology, objects relation theory and the family systems theory. During the first phase, the therapist seeks to join the family members by demonstrating empathy for the family as well as the childs situation. Kaslow and Racusin (1994) noted that the assessment of all the family members incorporates several elements: life events; psychological symptomatology; interpersonal, affective and adaptive behavior and family domains. During the second phase of the therapy, the therapist addresses all the aspects of family functioning that were identified in the initial phase. He/she helps the family to make some structural changes including restructuring the hierarchy (if necessary) and facilitating changes in the familys rules as well as interaction sequences. The therapist also assists the family members to develop healthier relational patterns. In the last phase, parents are assisted in improving their self esteem and how to include their child in decision making process. They are also informed on how to communicate more clearly to minimize any form of negative or critical interaction in the family.
Attachment-based Family Therapy (ABFT) helps the depressed male adolescent to establish a good relationship with the parents. It helps the boy to not only work through all the attachment failures but also repair the strained parent-child attachment bond. Allen, Moore and Kupermink (1998) carried a research that showed that adolescents with insecure, anxious and ambivalent attachments are associated with higher levels of depression than their more securely attached adolescent counterparts. This increases their risk of involvement in poly-substance abuse. In their study Diamond and Stern (2003) established that adolescents with a strained attachment/relationship with their parents are prone to developing negative self-schema that increases their vulnerability to depression. Some of the attachment failures that male adolescents may experience are caused by issues such as neglect, criticism, sexual abuse, rejection, physical abuse and emotional abandonment. Kobak, Sudler and Gamble (1991) outlined some of the important aspects that health care specialists should consider when treating depression. He noted that in treating adolescent males, one should understand that the link between insecure attachment strategies and depressive symptoms is stronger in boys than girls.
In ABFT, the therapist employs the enactment methodology to interrupt all forms of dysfunctional interaction patterns within the family. This ends up in the promotion of new, friendlier successful conversations and interactions. In working out both past and present conflicts within the family, the therapist encourages direct or rather one-on-one conversations between the family members. Generally, the initial stage in ABFT includes the preparation of the parties to the other relatively fluid stages. The stages are adolescent disclosure, parent disclosure and parent-child dialogue. It is noteworthy that the parents disclosure increases the adolescents desire to be close to them besides boosting understanding between the two parties. In some cases, parents apology frees the adolescent from blaming himself for the attachment failure.
Clinical Questions That Need To Be Addressed
Although there is extensive literature about poly-substance drug abuse in depressed adolescent boys, some areas have not been addressed adequately leaving several questions unanswered. They include:
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What are the measures that clinicians and parents should take to ensure that depressed male adolescents get treatment before it is too late?
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What are the challenges that clinicians might face in helping depressed adolescents?
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What are some of the indicators of the termination of poly-substance abuse in depressed male adolescents?
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What is the view of most parents on placing their depressed male adolescents who have resulted in poly-substance abuse in rehabilitation centers?
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Do healthcare institutions have the sufficient equipment for dealing with such patients?
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Are there adequate clinicians treat depressed male adolescents in the healthcare institutions?
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Do the available clinicians have the knowledge and skills that are required in addressing the problem?
Summary and Conclusion
Poly-substance abuse is one of the behaviors associated with depressed adolescent males. A lot of research has been carried out concerning this subject unveiling some of the most important issues concerning poly-substance abuse in adolescent male suffering from depression. The research has provided data on the prevalence of the disorder in young men which has exhibited an increasing trend in the recent past. Additionally, it has brought to peoples attention the relationship between the two i.e. depression and poly-substance abuse in young-adolescents. Poly-substance abuse has also been found to differ depending on the level and severity of an individuals depression. Researchers have also documented the effects of poly-substance use in adolescent males and the effects may last for a long period of time even in adulthood. Several ways of curbing the phenomenon have also been researched extensively. The treatment/intervention measures include addressing the depression disorder which in turn causes the individual to stop all the behaviors associated with it such as poly-substance abuse. They include Acceptance and Commitment Therapy (ACT) and family based therapies. In conclusion, to prevent all the negative effects of poly-substance abuse in adolescent males, healthcare practitioners need to understand the level of depression of the victim, the cause of the depression and the possible intervention and treatment measures that are suitable for the particular adolescent.
References
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