Reviews

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

 

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

 

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Psychosis and negative symptoms are associated with reduced introspective accu­racy and global over-reporting of functional competence.²⁰ Patients who have never worked have no way to comprehend the specific challenges associated with obtain­ing and sustaining employment. Patients who had a job and have not been able to return work may perceive barriers as more substantial than they are.

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

 

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

 

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

 

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Psychosis and negative symptoms are associated with reduced introspective accu­racy and global over-reporting of functional competence.²⁰ Patients who have never worked have no way to comprehend the specific challenges associated with obtain­ing and sustaining employment. Patients who had a job and have not been able to return work may perceive barriers as more substantial than they are.

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

 

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

 

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

 

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Psychosis and negative symptoms are associated with reduced introspective accu­racy and global over-reporting of functional competence.²⁰ Patients who have never worked have no way to comprehend the specific challenges associated with obtain­ing and sustaining employment. Patients who had a job and have not been able to return work may perceive barriers as more substantial than they are.

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

 

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Pharmacologic strategies for treating co-occurring psychiatric illness and SUD include medication to:
   • decrease substance use and promote abstinence
   • alleviate withdrawal symptoms (medi­cation to treat withdrawal symptoms and agonist treatments)
   • block the effect of substance use (antag­onist agents)
   • decrease likelihood of substance use with aversive agents
   • target comorbid psychiatric illness.

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

 

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

 

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Several studies have evaluated the impact of stimulant and nonstimulant treat­ments for attention-deficit/hyperactiv­ity disorder (ADHD) in adolescents with a co-occurring SUD.^34-39 The largest and only multisite study evaluated the efficacy of osmotic (extended) release methylphe­nidate (OROS-MPH) vs placebo for ado­lescents who also were receiving CBT for SUD.³⁶ In this 16-week RCT, the OROS-MPH and placebo groups showed improvement in self-reported ADHD symptoms with no difference between groups. Parent report of ADHD symptoms did indicate a greater reduction in symptoms in the OROS-MPH group compared with placebo. Both groups had a decrease in self-reported days of sub­stance use over the past month with no dif­ferences between groups. Pharmacotherapy trials for ADHD that have included psy­chotherapy highlight the effectiveness of CBT for SUD and co-occurring psychiatric illness.^36,39,40

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

 

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Pharmacologic strategies for treating co-occurring psychiatric illness and SUD include medication to:
   • decrease substance use and promote abstinence
   • alleviate withdrawal symptoms (medi­cation to treat withdrawal symptoms and agonist treatments)
   • block the effect of substance use (antag­onist agents)
   • decrease likelihood of substance use with aversive agents
   • target comorbid psychiatric illness.

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

 

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

 

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Several studies have evaluated the impact of stimulant and nonstimulant treat­ments for attention-deficit/hyperactiv­ity disorder (ADHD) in adolescents with a co-occurring SUD.^34-39 The largest and only multisite study evaluated the efficacy of osmotic (extended) release methylphe­nidate (OROS-MPH) vs placebo for ado­lescents who also were receiving CBT for SUD.³⁶ In this 16-week RCT, the OROS-MPH and placebo groups showed improvement in self-reported ADHD symptoms with no difference between groups. Parent report of ADHD symptoms did indicate a greater reduction in symptoms in the OROS-MPH group compared with placebo. Both groups had a decrease in self-reported days of sub­stance use over the past month with no dif­ferences between groups. Pharmacotherapy trials for ADHD that have included psy­chotherapy highlight the effectiveness of CBT for SUD and co-occurring psychiatric illness.^36,39,40

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

 

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Pharmacologic strategies for treating co-occurring psychiatric illness and SUD include medication to:
   • decrease substance use and promote abstinence
   • alleviate withdrawal symptoms (medi­cation to treat withdrawal symptoms and agonist treatments)
   • block the effect of substance use (antag­onist agents)
   • decrease likelihood of substance use with aversive agents
   • target comorbid psychiatric illness.

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

 

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

 

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Several studies have evaluated the impact of stimulant and nonstimulant treat­ments for attention-deficit/hyperactiv­ity disorder (ADHD) in adolescents with a co-occurring SUD.^34-39 The largest and only multisite study evaluated the efficacy of osmotic (extended) release methylphe­nidate (OROS-MPH) vs placebo for ado­lescents who also were receiving CBT for SUD.³⁶ In this 16-week RCT, the OROS-MPH and placebo groups showed improvement in self-reported ADHD symptoms with no difference between groups. Parent report of ADHD symptoms did indicate a greater reduction in symptoms in the OROS-MPH group compared with placebo. Both groups had a decrease in self-reported days of sub­stance use over the past month with no dif­ferences between groups. Pharmacotherapy trials for ADHD that have included psy­chotherapy highlight the effectiveness of CBT for SUD and co-occurring psychiatric illness.^36,39,40

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

 

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

 

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

 

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

 

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.