Problematic substance use and co-occurring psychiatric problems in young Clinical patients and in criminal justice clients. Studies of mortalilty, measurements and intervention.

Background: Substance use disorders commonly involve psychiatric co-morbidity in adolescents and young adults, who are at risk of further negative development including criminality. This thesis aims to study intervention for psychiatric symptoms and new techniques for drug detection among adolescents and young adults, and risk factors for psychiatric hospitalization and self-inflicted death among criminal justice clients. Methods: Adolescents and young adults (N=73) recruited at a treatment facility in Malmö, Sweden, participated in a randomized controlled trial during three months, using an automated telephone technique (Interactive Voice Response, IVR), measuring stress and mental health symtoms twice weekly. The intervention group received personlized feed-back on their ratings (improved or not) as an add-on intervention to treatment as ususal (paper III). Effects on these measurements were analyzed with mixed model analysis. In addition, hair samples were obtained to investigate the prevalence of non-medical prescription opioid use (n= 59, paper IV). Psychiatric (MINI) and socio-demographic (Ung-DOK) data were collected. Comparisons were made between patients positive and negative for prescription opioids with reference to socio-demographic and psychiatric background variables. Clients in the criminal justice system interviewed with the Addiction Severity Index (ASI) were followed after release in national Swedish patient registers with respect to psychiatric hospitalization (N=4,081, paper I) and selfinficted death; suicide, accidental intoxication, so called overdose, or death of undetermined intent, using Cox regression analyses including background variables from the ASI interviews (N=6,744, paper II). Results: IVR with personal feed-back, compared to the control condition, significantly improved stress and anxiety symptoms, but not depression or substance use. All but one patients used cannabis. In hair analysis, tramadol was the most prevalent opioid drug, used by almost one third of the sample. This group did not differ from the others regarding psychiatric or socio-demographic problems. Polysubstance use was common. Ten percent of the population of released prisoners were hospitalized for psychiatric in-patient treatment. Significant predictors were previous psychiatric hospitalization, previous suicide attempt, depression, anxiety and use of sedatives. Use of amphetamines negatively predicted hospitalization. Death of undetermined intent was more closely associated with substance-related risk factors, and had more in common with accidental intoxications, whereas psychiatric risk factors predicted suicide. Conclusions: Intervention with IVR shows promising results and merits further development. It is of importance to screen for different kinds of drugs among adolescents. The results point to the importance of paying attention to both psychiatric and substance use problems before and after release form prison, in order to prevent future psychiatric hozpitalization and unnatural deaths.