The issues of depression and substance abuse have caused schools throughout the globe considerable amount of stress and trouble due to the deleterious effect of the latter upon the youth of today. In this particular study, the possible linkage in regard to depression and substance abuse will be explored.
Purpose of the study:
The aim of this study is to analyze the correlation between substance abuse by teenagers and its possible linkage towards adolescent depression.
Numerous associations have been made pertaining to substance abuse and adolescent depression but this has been severely hampered by the fact that adolescents often succumb to the usage of such substances due to peer pressure and often do not realize the notion that they are depressed (Kaminer, 1994). In this literature review, the link between adolescent depression and substance abuse will be further explored with the causal link being the focal point, alongside the difference in perspective in regard to gender alongside further explanation.
Hence, it can be established that the general research question is:
Is there a significant relationship between substance abuse and adolescent depression?
Research about adolescents suggest that because of low self esteem, drugs were abused which resulted in improved levels of self esteem (Kaplan). The general perception of depressed adolescents is that the use of drugs makes them feel better about their life even if it’s temporarily. The National Survey on Drug Use and Health states that approximately 35% of adolescents who were going through depression consumed an illegal substance, including marijuana as compared to 18 percent of adolescents who were not suffering from depression. Several studies have suggested that the occurrence of a number of behaviors affecting health and psychiatric disorders increase considerably during the period of adolescence (Windle & Davies). The prevalence of these two characteristics, depression and substance abuse/use, has harmful effects in the development, both physically and intellectually, of adolescents.
Explanation of key terms:
Adolescence is a period marked with progressive psychological growth and adaptation to the general norms and practices of society. It is often related to a transitional stage where biological and sexual maturation is increased and experimented with (Kaminer, 1994). Psychological changes involve changes in perception of self as well as the world as the cognition  of the individual begins to mature. Biologically, individuals develop changes in the brain structure involving hormonal activities which is a result of puberty. Social changes involve the change of roles in family, school and community life as adulthood comes with its responsibilities. The definition of adolescents according to the World Health Organization (WHO) consists of individuals ranging from 12 to 19 years of age.
Depression may be experienced as a symptom or a reaction to a stressful life event. For example, the loss of a loved one may cause an individual to go through a period of sadness or grief where he might feel low or decreased energy. This depressed mood, however, does not affect the individual to the extent where it may cause hindrance in everyday life. These symptoms are usually impermanent and weaken as the individual overcomes the period of grieving. In certain instances, depression reaction may have been caused because of the side effects of consuming anabolic steroids which are artificial substances like the male sex hormone, testosterone. Athletes are known to abuse anabolic steroids to develop muscle and improve performance. In females, depression reaction can also happen as a result of Pre-Menstrual Syndrome (PMS), during which the body is experiencing hormonal changes. Depression reaction is usually easy to diagnose as the cause is evident in most cases.
The major concern arises when depression develops as a disorder in an individual’s life. According to the Diagnostic and Statistical Manual  (DSM) VI-TR, the diagnostic criteria for Major Depressive Disorder is includes the occurrence of a minimum of five symptoms which include a depressed mood of lack of interest in activities, significant loss of weight and/or decreasing desire for food day by day, high levels of insomnia almost every day, feeling restless every day, reduced levels of energy usually resulting in fatigue, excessively feeling worthless about one’s own self, lack of concentration and decision-making abilities, persistent thoughts about death or suicide (individual may even attempt to self harm or commit suicide). These symptoms should be present for a duration of two weeks to meet the criteria of depression.
Dysthymia is severe depression with a duration of at least 1 year in adolescents and children. It is marked as depressed mood for most of the day, and along with at least 2 of the following symptoms which include loss of appetite or overeating, insomnia or hypersomnia, decreased energy, low levels of self esteem, lack of concentration and decision making and thoughts of hopelessness.
A further classification of depression falls under Bipolar I and Bipolar II disorders. The essential features in Bipolar disorder are mania, a mixed episode and hypomania. Mania is defined by DSM VI TR as distinct episode of persistently high, expansive, or short-tempered mood lasting at least one week. This period may also involve the individual to have feelings of elevated self esteem or grandiosity, distractibility, flight of ideas, insomnia and excessive participation in risk taking behavior. Mania may also cause the individual to become delusional and perceiving themselves as having special powers or even begin to hallucinate and have a complete detachment with reality.
A mixed episode is distinguished by a phase that lasts for minimum one week in which the criteria for both Manic Episode and Major Depressive Disorder are met almost every day. The individual may experience quickly alternating moods ranging from unhappiness, bad temper to elation.
A Hypomanic Episode is distinguished by a phase of persistently elevated, expansive, or irritable mood lasting at least 4 days, with additional symptoms experienced in mania. Hypomania can be defined as a milder form of Mania as it does not cause occupational or social functioning impairment. The diagnosis of Bipolar I Disorder requires an individual to experience at least one manic or mixed episode, pertaining for at least a week within his or her lifetime. A depressive episode is not required in order to necessitate a diagnosis of Bipolar I, although most people usually have multiple depressive episodes. On the other hand, the criteria for diagnosis for Bipolar II disorder an individual must have had at least one hypomanic episode and one depressive episode within his or her lifetime.
The period of adolescent is full of challenges as the rapid changes within the body as well as in the surroundings cause the individual to have a difficulty coping up. This is one of the reasons why in most cases, adolescent depression goes undiagnosed. Their depression is usually labeled as being delinquent or rebellious by parents. Depressed adolescents often have a difficult time coping up with studies, may delve into isolation from friends and family or may get involved in antisocial behavior. In the case of girls, several times, depression may result into an eating disorder that can be life-threatening know as Anorexia Nervosa  . There is an established link between depression and eating disorders according to a report by the National Health Association.
Another very common behavior that adolescents adopt is the abuse of drugs. In adolescents, depression is often seen in the form of irritatibility, destructive behavior, and sudden aggressiveness. Depressed adolescents may express certain symptoms such as withdrawal from socializing, bouts of crying, anger, throwing of fits and tantrums for unknown reasons and general anxiety over petty issues (Epanchin & Paul, 1987)
Biologically, depression can be caused due to a genetic predisposition in adolescents, apart from hormonal imbalances within the body. Children of depressed parents are more likely to develop depression. Social factors too, contribute immensely to the development of depression in adolescents. These factors can include residing within a broken family, history of physical or emotional abuse that the individual may have repressed, a major failure in life academically or athletically, a change in environment such as shifting to a new city or country which would require the individual to start his life afresh. Season change too, can contribute to the development of depression.
Substance abuse refers to the misuse of illegal drugs which include prescription drug abuse as well as abuse of other drugs which include substances like marijuana, hashish, cocaine, heroin, Ecstasy etc.
To elaborate further, prescription drugs includes the medicines that are generally purchased by individuals without a prescription. These medicinal drugs include anti-depressants, pain suppressants, sedative, anxiety and attention deficit disorder medications. The 2010 National Survey on Drug Use and Health (NSDUH) states that approximately 2.4 million Americans have been reported to have abused prescription drugs for the first time in the year 2010. Among this sample, one-half were females between the ages of 12 to 17. (Cotto, Davis, et al.)
Depression can affect any race, gender, ethnic group, nationality or age group impacting about 121 million people worldwide (WHO, 2008, Facts). In the United States, about 44 million individuals suffer from a mental disorder (United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration [SAMHSA], 2006, Mood Disorders Section, 1).
In addition, statistics reveal that in the United States, 8% of adults of the age of 18 and older are affected by Major Depression (Donnelly, 2008). Bipolar Disorder, which was previously addressed as manic depression, affects approximately six million adults in the United States and 6% of children between the ages of 9-17 (Donnelly, 2008; Bright Futures, Key Facts section, 1999).
Since early adolescent is characterized by several cognitive, emotional and physical changes, comprehension of the disorder can be a complicated issue. During the period of adolescence, the levels of depression vary in intensity and severity (Blatt, 2004). Loneliness is one trait that is significant in depressed young individuals and it may be persistent and quite destructive to the individual’s personality and overall development (Klerman, 1986). One of the major issues that adolescents face is to manage and understand how to maintain social and intimate relationships. Rejection from a peer or an intimate partner is a sensitive issue that can lead to the development of depression in adolescents. This rejection that turns into depression leads to two types of isolations in individuals which include social isolation and emotional isolation (Klerman, 1986). To elaborate further, social isolation entails reduced social assimilation and poor network of association whereas emotional isolation branches out from loss of attachment from loved ones.
According to a report issues by NIHM in 2008, there is an increased risk of the development of depression in childhood as well as adolescence. It is emphasized by Reynolds and Johnson that adolescent depression is regarded as a severe mental health condition that needs dire attention and concern (1994). According to Oster and Caro (1990) significant research has proven that childhood depression is persistent and may prolong itself or recur back later in adulthood. This is most likely to happen if the depression goes untreated in an earlier period in life. The ignorance of depression in early stages of life could cause it to reappear later in adulthood (NIMH, 2008, Symptoms section, p.5).
Adolescents are quite susceptible to developing depression and depressive characteristics and they may experience general sadness and overall despair and hopelessness (Newman & Newman, 2006; Rutter et al., 1986). These symptoms may be demonstrated through hyperactivity, aggressiveness, lack of academic achievement, delinquency and other forms of misbehavior Klerman, 1986; NLM, 2009, symptoms section, 5). Moreover, a small number of adolescents get treatment for their depression. If the depression diagnosed and treated at the right time, 80% of adolescents can recover from it successfully (TD, 2005, Teenage Depression Statistics section, 5).
It is hypothesized that “many disruptive experiences in adolescents as well as in adults may be enactments of the pain and pathos of intense dysphoria and of an underlying depressive state” (Blatt, 2004, p. 174). It is also stated that “antisocial behavior and acting outâ€¦..can serve as a way of avoiding painful dysphoric affect” (Blatt, 2004, p.174) and that individuals “who have a tendency to express their difficulties in behavioral activityâ€¦ may express their dysphoria in various forms of disruptive and destructive activity” (p.174). Blatt (2004) suggests that in some cases depression may be directed inward and seen through suicide attempts “or outwardly, through violations of social norms or attacking others (the latter, of course, can result in self-destruction as well)” (p. 174)
It is common for depressed children to internalize their emotions of depression, despair, guilt and they usually avoid expressing their negative emotions onto others instead suffer from immense misery and sadness themselves (Reynolds and Johnston, 1994).
Adolescents experience increased amount of vulnerability to anxiety during the period of pubery, however, this vulnerability is reported to be higher in females as opposed to male (Rutter, Izard and Read, 1986). This gender difference may be because of the fact that female adolescents have an increased need to be accepted by their peers and tend to internalize emotions more than males (Newman and Newman, 2006).
In the above mentioned context, depression is a more serious mental condition for females than for males. According to Klerman (1986) young women are reported to have the highest rates for depression in the United States. More in particular, Riley (1999) states that female adolescents tend to internalize their emotions more and adopt a disclosed personality and thus it can be trickier to recognize their problems because of this emotional and verbal shutdown. As far as their externalization is concerned, Riley (1999) postulates that emotional distress is expressed though eating disorders, self harm or even suicidal ideation and in some cases attempts, too. Adolescent females tend to be more responsive to problems. This may be expressed as internal attribution or internalized blaming whereas males externalize by placing the blames on others. Blatt (2004) proposes that depression is expressed by males by externalizing their inner feelings in the form of criminal acts, aggressive behaviors and hostility whereas females who suppress their depression by internalizing their emotions tend to experience increased loneliness, a low self esteem and dependence.
Several risk factors for adolescents may consist of former incidents of depression or depressive affect and/or the suffering of some form of trauma or a family record of depression (TD, 2005, Teen Depression Statistics section, 4). According to Matson (1989) rate of adolescent depression is higher than that of pre-pubertal children.
In several cases, depression may be learned for example, if a parent is depressed, child may have learned this coping style from that specific parent (Matson, 1989). Also, genetic predisposition to depression may also impact the child according to Reynolds and Johnston (1994). Lifestyle and behavior of parents affects their children dramatically. The development of depression is higher in a child who has been under the care of a person who suffers from depression as opposed to a child who has been raised by caregiver who does not suffer from depression (Reynolds and Johnston, 1994; Matson, 1989).
According to the diagnostic criteria, there exists a strong correlation between “depression and disruptive behavior, especially in adolescence” (Blatt, 2004, p. 172-173) stating that there is a “frequent occurrence of depression in children and adolescence with Conduct Disorder, Attention Deficit/Hyperactive Disorder, and Oppositional Defiant Disorder” (Blatt, 2004, p. 172-173). Blatt (2004) also stresses that “disruptive behaviors are often along with mood disturbances, even in severe depression, as well as low self-esteem and underachievement” (p. 173). In addition, he also suggests that there appears to be a significant co-occurrence of depression and conduct disorders. Harrington (1993) suggests that the emotional “symptoms distinguishes them from conduct problems which are for the most part defined by the interaction between the individual and his environment” (p. 135).
According to the DSM VI TR, there are different types of depression which may be linked with disruptive behaviors which include vandalism, poor academic achievement, abuse of illegal substamnces, aggressive behaviors, sexual promiscuity and other irresponsible behavior.
With reference to Bipolar Disorder, disruptive behaviors may especially consist of promiscuity, recklessness and hyperactivity.
Antisocial and disruptive behavior may present increased distancing from exposure to depression, from both the patient and the clinician (Blatt, 2004; Spirito & Overholser, 2002). Moreover, clinical depression may be perceived as “a passive yielding to intense underlying dysphoria, whereas destructive behavior, similar to mania, may be a defensive attempt to avoid and forestall experiencing intense dysphoria and a painful clinical depression” (Blatt, 2004, p. 174).
Lack of treatment of depression in adolescents can increase the likelihood of depression. This results in display of risk factors which include indulging in sexual behavior, self harm, suicide attempts, substance abuse, difficulty in academics etc.
Depression can be a biologically inherited trait environmental circumstances that affect the quality of life of an individual such as poverty, lack of a support system according to Matson, (1989). The symptoms of depression may be adopted by learning the actions and behavior of family member who suffer from it. Since adolescent is such a tender age, depression in this age can alter a child’s personality to a great extent in every field of life ranging from personal to social and to educational and professional. The experiencing of severe mood swings, irritability and frustration and may impact an adolescent’s psychomotor or somatic state which result in them losing all interest in any academic as well as social activities.
According to Reynolds and Johnsons, there is a significant link between depression and the abuse of drugs. The consumption of drugs which have a numbing affect is usually seen as a desperate attempt to counter the effects of depression. Adolescents studying in high school display a higher level of consumption with regard to illegal drugs as states by Newman and Newman (2006)
By the age of 17 or 18, more than half of the students in Amercia have been involved in the consumption of a prohibited drug. The adolescents who have a habit of readily engaging in the consumption of drugs do not regard it as a risky or illegal behavior. (Newman and Newman, 2006). In order to get rid of boredom, adolescents usually indulge in thrilling, adventurous behaviors which involve those trying new things and having experiences that they have never before, this need of sensation seeking leads them to experiment with as well as stated by Newman and Newman, 2006. However, this drug consumption that may start of as an experiment may result into addiction and later on dependence on that drug. While adolescents may abuse drugs to relieve their depressive state, what they do not realize is how the temporary relieve can actually result in worsening of the disorder of depression and related disorders since drugs like marijuana are known to actually aggravate depression if consumption increases over time.
The major limitation of the research was the size of the sample of respondents which had to be limited to a specific social class as well as age. The findings only hold value with reference to that class, which in the case of this research were the urban adolescents of Karachi. This limited the validity of the research findings as the results could not be applied to other social classes of Karachi’s society as depression and drug abuse are elements that are common to all classes residing in a society.
Another limitation that was faced was that generally, depression is an abstract term it usually goes undiagnosed in several cases. Individuals who are depressed usually do not seek professional treatment for this disorder even though it is clinically defined through fixed criteria of symptoms. Depressed individuals usually tend to ignore the symptoms of depression and do not seek out medical help for it.
Furthermore, substance abuse is a relative term to decipher. What may qualify as substance abuse for one individual may not hold true for another. Therefore, individuals’ response to the investigation regarding substance abuse may jumble up the findings regarding the frequency of substance abuse in the society. Therefore, it is difficult to obtain a true understanding and clarity of this concept.
In addition, substance abuse is a topic that individuals may not be very comfortable talking about. Even if they have or are abusing any illegal substances, they might not be wholly straightforward about it. This, therefore, affects the findings as lack of honesty from the respondents is a major limitation of any research especially, about a sensitive topic as this.
Significance of the research:
This research highlights the strong relationship between adolescent depression and its factors that can and do lead to abuse of illegal substances. In most cases, what individuals do not realize is that the substances that they consume to counter the effects of depression actually in return end up contributing to the intensity and frequency of their depression. Depression and substance abuse are both very chronic conditions that need to be paid dire attention to. Occasional substance abuse can lead to dependence on the substance that can further lead to other psychological disorders and increase other risk factors including accidents, interpersonal conflicts, suicide ideation etc (Lewinsohn et al., 2005)
It also highlights the easy availability of substances both medicinal and others in today’s society. The fact that individuals have access to such illegal substances so readily is a matter of concern that should be brought to light. The more the opportunity and availability of substances there is, that increases chances of individuals abusing them.
This chapter describes the methodology and sample size that was used to derive findings of adolescent depression and its relationship with substance abuse. The research methods consisted of review of available literatures followed by an empirical investigation.
The sample consisted of 100 students from co-educational, private institutions of Karachi that used the Cambridge system of education. The age bracket of the respondents varied from 16 to 19 years of age.
The instrument used to collect data was a questionnaire with a set of questions, both open and closed ended. The questions were structured to assess if individuals suffered from depression during their course of life, the cause for the depression, how they countered their depression.
The next set of questions focused of drug abuse including what types of drugs they have consumed so far as well as how they got access to those specific drugs. Finally, the questionnaire consisted of a set of questions that were framed in order to find the relationship between depression and drug abuse as well as the perception of individuals regarding these two elements.
In addition, interviews with psychologists and psychiatrists of Karachi were conducted to investigate about the reported cases of adolescents depression and its relation with substance abuse.
Confidentiality regarding identity of the respondents was strictly maintained.