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 Table of Contents  
Year : 2022  |  Volume : 43  |  Issue : 1  |  Page : 42-47

Psychiatric comorbidities in adolescents with substance-use disorder

1 Psychiatry General Organization of Teaching Hospital and Institute, Suez Canal University, Suez Canal, Egypt
2 Professor of Psychiatry Faculty of Medicine, Suez Canal University, Suez Canal, Egypt

Date of Submission01-Sep-2021
Date of Decision10-Sep-2021
Date of Acceptance06-Oct-2021
Date of Web Publication26-Feb-2022

Correspondence Address:
Mona Elsayed
Assistant Professor of Psychiatry Faculty of Medicine, Suez Canal University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejpsy.ejpsy_30_21

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Introduction Comorbidity between substance abuse and other psychiatric disorders has been excessively documented in adults while rarely been investigated in adolescents.
Aim The study investigated the prevalence of psychiatric comorbidities among adolescent patients with substance-use disorder attending psychiatric health facilities in Suez Canal region.
Patients and methods It was a cross-sectional study conducted on 120 adolescent patients aged 13–19 with substance-use disorder attending psychiatric health facilities in Suez Canal region. Data were collected using comprehensive psychiatric history, Mini-International Neuropsychiatric Interview, complete physical and neurological examination, and urine toxicology screen.
Results Most of the study-sample participants were polysubstance abusers (89.1%). Cannabis was the commonest substance abused (90.8%). More than half of the patients (53.3%) had psychiatric comorbidity with onset before the abuse of the substance, 27.5% had psychiatric comorbidity after abusing the substance, and 19.2% had no psychiatric comorbidity. Major depressive disorder was the most prevalent disorder (40.8%) among the patients, followed by conduct disorder (38.3%).
Conclusion Depression and conduct disorder are the most common psychiatric disorders among adolescent patients with substance-use disorder.

Keywords: adolescents, psychiatric comorbidities, substance abuse

How to cite this article:
El Badry HE, Fahmy MT, El Tantawy AM, Anwar KA, Elsayed M. Psychiatric comorbidities in adolescents with substance-use disorder. Egypt J Psychiatr 2022;43:42-7

How to cite this URL:
El Badry HE, Fahmy MT, El Tantawy AM, Anwar KA, Elsayed M. Psychiatric comorbidities in adolescents with substance-use disorder. Egypt J Psychiatr [serial online] 2022 [cited 2022 Aug 18];43:42-7. Available from: http://new.ejpsy.eg.net/text.asp?2022/43/1/42/338558

  Introduction Top

Adolescence is a vulnerable developmental stage where significant changes occur in youth bodies, brain, and environmental socialization, this may increase vulnerability to substance use and psychiatric comorbidity (Storr et al., 2012).

Multiple studies have shown that the majority of adults who end up with substances and alcohol use have their first contact with these substances as adolescents (Leung et al., 2014).

Alcohol and other substance-abuse disorders are common among adolescents, and have important public health consequences. The 20th century ended with the conviction that drug abuse was a global problem and thus global solutions were required (Negari Namaghi and Perry, 2019).

The onset of substance use, mental, and behavioral disturbance occurs for many reasons during the adolescent’s years. Consequently, it is essential to understand the numerous factors that place adolescents at risk for alcohol and other drug use (Stone et al., 2012).

Comorbidity between drug abuse and other psychiatric disorders has been excessively documented in adults while rarely had been investigated in adolescents Yakovenko and Hodgins (2018). The current study was aiming to investigate the prevalence of psychiatric comorbidities among adolescent patients with substance-use disorder attending psychiatric health facilities in Suez Canal region.

  Patients and methods Top


This was a cross-sectional study to investigate the prevalence of psychiatric comorbidities among adolescent patients with substance-use disorder aged from 13 to 19 years attending Suez Canal University Hospital, the psychiatry hospitals or clinics of Suez Canal regional area, and the related tertiary centers of the Ministry of Health. It was conducted on 120 adolescent patients. This study is approved by ethical committee in Faculty of medicine Suez Canal University. Patients were diagnosed as having substance-use disorders according to the criteria of the International Classification of Diseases-10. Patients who were selected were at least 1 year using substance for one or more illicit drugs. Permissions for the study were obtained from the authorities (parents) that were concerned, and patients and their guardians were informed about the purpose of the study, and consent from the patient’s legal guardian was signed before the beginning of this study.

Exclusion criteria

Patients with intellectual disability, patients with epilepsy, severe head trauma and neurologic deficits, patients with sensory defects, such as hearing or visual defect, and patients with severe psychotic symptoms or with severe disorganized behavior (as these could affect cooperation of patients).

  Methods Top

Sample size was calculated with power as 80% and level of significance at 0.05 based on a previously published study (Birhanu et al., 2014) patients (n=120).

The study was conducted using two questionnaires. The first one full comprehensive psychiatric sheet, including sociodemographic data such as age, sex, residency, religion, and educational level, membership in sport clubs, hobbies, interests, values, and friendships. It was tested for validity by pilot study on 10 patients before starting the current study.

The second one structured psychiatric interview using The Mini-International Neuropsychiatric Interview v.5 developed by Sheehan et al. (1998)(Sheehan et al., 2017). For the study, we used the Arabic translation developed by Okasha et al. (1999).

The Mini-International Neuropsychiatric Interview v.5 was designed as a brief structured interview for the major axis-I psychiatric disorders in DSM-IV and International Classification of Diseases-10, including major depressive disorder, dysthymia, generalized anxiety disorder, manic or hypomanic episode, panic disorders, social phobia, agoraphobia, obsessive–compulsive disorder, posttraumatic stress disorder, substance-use disorder, eating disorders, and oppositional-defiant disorder.

Validation and reliability studies have been done and the score was highly acceptable. It takes about 15 min to complete the test.

In addition to interviews, complete physical and neurological examination to exclude neurological or organic comorbidities and urine toxicology screen before detoxification and just before interviewing the patients if he/she is an outpatient client were done.

Statistical analysis

Statistical analysis was performed using using SPSS (Statistical Package for Social Sciences; SPSS Inc., Chicago, Illinois, USA), version 17. Numerical values were expressed as mean±SD. Qualitative data were summarized as numbers and percentages. χ2 test was used to compare categorical variables between groups. P value of 0.05 or less was considered statistically significant.

  Results Top

Most of the patients show positive family history of substance abuse, mental disorder, or both ([Table 1],[Table 2],[Table 3]).
Table 1 Baseline characteristics (N=120)

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Table 2 Socioeconomic scale among the study group (N=120)

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Table 3 Pattern and frequency of different substance-use disorders among the study groups

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Cannabis-use disorder and alcohol-use disorder respectively having represented 90.8 and 79.2%. Most of the patients are polysubstance abuse (89.1%) ([Figure 1] and [Table 4]).
Figure 1 Frequency of substance abuse between the studied sample.

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Table 4 Psychiatric comorbidities in the study group (N=120)

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Major depressive disorder was the most prevalent disorder (40.8%) among the patients, followed by conduct disorder (38.3%) ([Table 5] and [Figure 2]).
Table 5 Comparison between comorbid versus noncomorbid as regard substance of use

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Figure 2 Psychiatric comorbidities in the studied group.

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Patients with positive family history of mental health disease are more likely to develop psychiatric comorbidity (P=0.001) ([Table 6] and [Table 7]).
Table 6 Comparison between patients’ employment status and comorbidity

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Table 7 Comparison between family history and comorbidity

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  Discussion Top

Our study sample revealed that cannabis-use disorder, alcohol, and opioid-use disorder respectively represent 90.8, 79.2, and 52%, respectively. Hallucinogens and stimulants were the least prevalent but both present (3.3%). These results are in agreement with WHO 2014 reports Organization and Organization (2014). Our results were not matching with Negm and Fouad (2014), who found that tramadol, cannabis, and alcohol were the most commonly abused substances among adolescent school students in Zagazig (83.3, 27.8, and 16.7%, respectively) (Negm and Fouad, 2014). This variation may be different in sampling in both studies as in Zagazig study, all samples were school students or could be changed in preference of abused drugs.

The patients in the current study were using polysubstance than monosubstance from 1 to 6 substances with an average of 3. These results came alongside with a study done by El-Awady et al. (2017) in Mansoura, which revealed that polysubstance use is much prevalent.

In Egypt, substance-use disorders are prevalent and commonly associated with mental disorders, limited data for this association are available from low-income and middle-income countries. The most prevalent psychiatric disorders in our samples were depression and conduct disorder that go alongside with Deas and Brown (2006), in their study about psychiatry comorbidity among adolescents with substance-use disorder, the explanation could be as patients need abusing substance as the type of self-medication from depression or as the type of impulsivity in patients with conduct disorder.

In India, major depressive disorder, psychosis, bipolar mood disorder, attention-deficit hyperactivity disorder, and anxiety disorders are common comorbidities in adolescent patients with substance-use disorder (Shantna et al., 2009).

However, social phobia, agoraphobia, obsessive–compulsive disorder, and bulimia nervosa did not occur among the study sample. This could be explained by Myrick and Brady (2003), in their survey in South Carolina, which revealed that these disorders are falsely less represented among substance drug-abuse patients while they are common, because they are often unrecognized and/or trivialized as just ‘shyness’ (Myrick and Brady, 2003).

There is a reported temporal relationship between psychiatric disorder and substance-use disorder among the comorbid groups (53.3%) that had psychiatric disorder before substance-use disorder, furthermore, 27.5% of the study sample had the psychiatric disorder with onset after using substance. This temporality goes along with Saban et al. (2014) and Chiu et al. (2018), in their study about the temporal relationship between mental health disease and substance-use disorder, this can be explained by using substance abuse as self-medication in depressed adolescents and as type of impulsivity in conduct disorder.

About 60% of the study sample were working students (unstable employment) and those patients were more likely to develop psychiatric comorbidity (P=0.05), this is in agreement with the results of a large study done by Dhawan et al. (2017) about the pattern and profile of children and adolescents using substances in India, which found that 50% of the users were employed and their employment characterized by instability. This could be due to more social and financial stressors in these groups of patients (Dhawan et al., 2017).

Among the study sample, 73.3% of the study sample showed a positive family history of a psychiatric disorder. Those who had a positive family history of psychiatric disorder were more likely to develop psychiatric comorbidity (P=0.001), this goes alongside with Morean et al. (2009), Wilson et al. (2013), and Robinson and Adinoff (2016). In contrast to a study done by Comtois et al. (2005), they found that positive family history of substance use only was related to the development and severity of substance-related consequences like comorbidity, this difference may be related to different age group of this sample that was 14–25 years old and consequently longer duration of substance use.

  Conclusion Top

From the current study, it was concluded that the substance-use disorders are a major health problem among adolescents. Moreover, it is more prevalent in male sex in Egyptian population. Polysubstance, cannabis, and alcohol dependency are at the top of all substances abused and major depressive disorder, conduct disorder, ADHD, ODD, and anxiety disorders are the most prevalent in Egypt.

It is hard to detect the causality between the substance-use disorder and mental health disorders and this refers to the multifactorial reasons of both disorders, which up till now, are not clear.


It is much important to counsel children and adolescents with a psychiatric illness and their parents about the increased risk for substance-use disorder before transitions to adolescence. Discussions and health education about substance abuse should begin during the fifth grade because data suggest that adolescent substance use often starts (6th–9th grade).

Future research with larger samples, a long follow-up, and data collection on parent involvement and substance use can provide further insights on how sociodemographic factors influence substance use among at-risk adolescents, and developing comorbidities, which could lead to enhancements to treatment for this population.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


  References Top

Birhanu AM, Bisetegn TA, Woldeyohannes SM (2014). High prevalence of substance use and associated factors among high school adolescents in Woreta Town, Northwest Ethiopia: multi-domain factor analysis. BMC Public Health 14:1186.  Back to cited text no. 1
Chiu ML, Cheng CF, Liang WM, Lin PT, Wu TN, Chen CY (2018). The temporal relationship between selected mental disorders and substance-related disorders: a nationwide population-based cohort study. Psychiatry J 2018:5697103.  Back to cited text no. 2
Comtois KA, Tisdall WA, Holdcraft LC, Simpson T (2005). Dual diagnosis: impact of family history. Am J Addict 14:291–299.  Back to cited text no. 3
Deas D, Brown ES (2006). Adolescent substance abuse and psychiatric comorbidities. J Clin Psychiatry 67:18.  Back to cited text no. 4
Dhawan A, Pattanayak RD, Chopra A, Tikoo V, Kumar R (2017). Pattern and profile of children using substances in India: insights and recommendations. Natl Med J India 30:224.  Back to cited text no. 5
El-Awady SA, Elsheshtawy EA, Elbahaey WA, Elboraie OA (2017). Impact of familial risk factors on the severity of addiction in a sample of Egyptian adolescents. Egypt J Psychiatry 38:70.  Back to cited text no. 6
Leung RK, Toumbourou JW, Hemphill SA (2014). The effect of peer influence and selection processes on adolescent alcohol use: a systematic review of longitudinal studies. Health Psychol Rev 8:426–457.  Back to cited text no. 7
Morean ME, Corbin WR, Sinha R, O’Malley SS (2009). Parental history of anxiety and alcohol-use disorders and alcohol expectancies as predictors of alcohol-related problems. J Stud Alcohol Drugs 70:227–236.  Back to cited text no. 8
Myrick H, Brady K (2003). Current review of the comorbidity of affective, anxiety, and substance use disorders. Curr Opin Psychiatry 16:261–270.  Back to cited text no. 9
Negari Namaghi R, Perry DG (2019). The perception of young adult alcohol consumers regarding alcohol consumption and the risky behaviors of drinking alcohol in Tehran, Iran. J Substance Use 25:1–7.  Back to cited text no. 10
Negm MG, Fouad AA (2014). Prevalence of substance abuse among adolescent school students in Zagazig. Egypt J Psychiatry 35:161.  Back to cited text no. 11
Okasha A, Khalil A, Fahmy M, Ghanem M (1999). Psychological understanding of Egyptian heroin users. Egypt J Psychiatry 13:37–49.  Back to cited text no. 12
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Robinson SM, Adinoff B (2016). The classification of substance use disorders: historical, contextual, and conceptual considerations. Behav Sci 6:18.  Back to cited text no. 14
Saban A, Flisher AJ, Grimsrud A, Morojele N, London L, Williams DR et al. (2014). The association between substance use and common mental disorders in young adults: results from the South African Stress and Health (SASH) Survey. Pan Afr Med J 17(Suppl 1):11.  Back to cited text no. 15
Shantna K, Chaudhury S, Verma A, Singh A (2009). Comorbid psychiatric disorders in substance dependence patients: A control study. Ind Psychiatry J 18:84.  Back to cited text no. 16
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E et al. (1998). The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59:22–33.  Back to cited text no. 17
Sheehan P, Sweeny K, Rasmussen B, Wils A, Friedman HS, Mahon J et al. (2017). Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. Lancet 390:1792–1806.  Back to cited text no. 18
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Storr CL, Pacek LR, Martins SS (2012). Substance use disorders and adolescent psychopathology. Public Health Rev 34:10.  Back to cited text no. 20
Wilson CS, Bennett ME, Bellack AS (2013). Impact of family history in persons with dual diagnosis. J Dual Diagn 9:30–38.  Back to cited text no. 21
Yakovenko I, Hodgins DC (2018). A scoping review of co-morbidity in individuals with disordered gambling. Int Gambling Stud 18:143–172.  Back to cited text no. 22


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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