Elsevier

Clinical Psychology Review

Volume 31, Issue 1, February 2011, Pages 104-112
Clinical Psychology Review

Internalizing disorders and substance use disorders in youth: Comorbidity, risk, temporal order, and implications for intervention

https://doi.org/10.1016/j.cpr.2010.08.002Get rights and content

Abstract

This review examines the empirical literature on the relationship between internalizing disorders and substance use disorders (SUDs) in youth in terms of (a) comorbidity rates, (b) risk relationships, (c) temporal sequencing, and (d) implications for intervention. Findings from community and clinical samples suggest that comorbidity rates range from 9.0 to 47.9%. The majority of the evidence supports the temporal precedence of internalizing disorders before substance use disorders and a unidirectional risk model in which internalizing disorders increase risk for later substance use disorders. Implications of this relationship for interventions are considered, both in terms of treatment outcome for principal disorders and in terms of the potential “secondary benefit” of treating one disorder for preventing or reducing risk of the other. Finally, recommendations for future research on the relationship between internalizing disorders and SUDs in youth are discussed.

Research highlights

►Internalizing disorders and substance use disorders are frequently comorbid in youth. ►Evidence suggests internalizing disorders temporally precede substance use disorders. ►Internalizing disorders increase risk for later substance use disorders. ►Findings have important implications for interventions.

Section snippets

Comorbidity between internalizing disorders and SUDs in youth

Internalizing disorders, specifically anxiety and depressive disorders, are among the most common psychological disorders of childhood and adolescence (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Age of onset of anxiety disorders varies by specific disorder, but evidence suggests that some anxiety disorders may onset in early to middle childhood (specific phobia) and early to middle adolescence (social phobia; Rapee, Schniering, & Hudson, 2009). Onset of depressive disorders increases

Risk relationships between internalizing disorders and SUDs in youth

As with any type of comorbid psychopathology, there are several plausible explanations for the association between internalizing disorders and substance use disorders in adolescents (Angold et al., 1999, Brook et al., 1998, Cicchetti and Rogosch, 1999). First, either internalizing disorders or substance use disorders could serve as a risk factor for the other disorder. Anxiety and depressive disorders may increase risk of SUDs, possibly through a self-medication of negative affect mechanism

Temporal order of internalizing disorders and SUDs in youth

Temporal sequencing of internalizing disorders and SUDs when they are comorbid in youth is an important question relevant to their risk relationship, as temporal precedence is necessary to establish a risk factor (Cicchetti and Rogosch, 1999, Kazdin, 1999). Answering the “which comes first” question also presents methodological challenges. Prospective studies that begin prior to onset of the disorders are ideal for determining temporal order (Culbertson, 1999), yet retrospective reports from

Implications for intervention

There is a striking paucity of research on how comorbidity, increased risk, and temporal sequencing among internalizing disorders and SUDs in youth may impact interventions for either category of disorders. However, such research is critical to improving outcomes for treatment of both internalizing disorders and substance use disorders as principal disorders. Furthermore, research on the impact of the relationship between internalizing disorders and SUDS on interventions for these disorders in

Recommendations for future research

The mixed findings in the current review indicate that further investigation of the relationship between internalizing disorders and SUDs is necessary. The limitations of the existing research suggest that methodological improvements in the design of future studies will help clarify these relationships and their implications for relevant interventions. The methodological improvements warranted include the use of longitudinal prospective designs, consistency in the operationalization of

Conclusions

The empirical literature indicates a complex relationship between internalizing disorders and SUDs in youth in terms of comorbidity, risk relationships, temporal sequencing, and implications for interventions. Findings in community studies of the comorbidity between the internalizing disorders and SUDs in youth suggest that between 11.1 and 47.9% of adolescents with SUDs may have comorbid depressive or anxiety disorders. In clinical samples of adolescents with SUDs, the rates of comorbid MDD

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