Increased mortality risk for adolescents with substance abuse problems

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Adolescents with serious conduct and substance use problems are five times more likely to die prematurely than their peers, with roughly one in 20 dying by their 30s, according to Colorado University Boulder research. The study also suggests that while drug and alcohol use among adolescents draws more attention, antisocial behaviour – including rule-breaking tendencies – may be a more powerful predictor of early mortality.

“This research makes it clear that youth identified with conduct problems are at extreme risk for premature mortality, beyond that which can be explained by substance use problems, and in critical need of greater resources,” said lead author Richard Border, a graduate student with the Institute for Behavioural Genetics.

For the study, Border and his colleagues looked at death rates among 1,463 adolescents who had been arrested or referred to counselling for substance use problems and/or “conduct disorder,” a mental health disorder characterised by rule-breaking, aggression toward others, property destruction and deceitfulness or thievery.

They also followed 1,399 of their siblings and a control group of 904 adolescents of similar age and demographic background.

The researchers decided to do the study after, while following up with subjects from the ongoing Genetics of Antisocial Drug Dependence study launched in 1993, they made a troubling discovery: Several had already died. They used mortality data from the National Death Index to determine how many.

With an average follow-up age of 32.7 years, they found that 62 of the original study subjects – more than 4% – had died, compared to less than 1% of controls. Siblings of the study subjects also had higher mortality rates, with about 2.4% dying. Substance-related deaths were the most common, along with traffic related deaths, suicides and deaths resulting from assaults.

“To see detailed, hard data from a cohort of adolescents we have been interviewing face-to-face over the years really makes tangible the dangers that these youth are facing as they go into adulthood,” said co-author John Hewitt, IBG director. “It’s a strikingly poor outcome and should be a major public health concern.”

When the researchers further analysed the data, they were surprised to discover that while both conduct disorder and substance use severity were associated with increased mortality risk, conduct disorder was a more powerful independent risk factor.

“We pay a lot of attention to substance use and it is definitely important, but we don’t put as much attention on rule breaking,” said Hewitt. “Perhaps we should.”

Between 6% to 16% of boys and 2% to 9% of girls meet the criteria to be diagnosed with conduct disorder, previous studies show. Previous CU Boulder research suggests that genetic variants may play a role in making a child more prone to risk-taking or anti-social behaviours.

Because the study focused on youth whose conduct was serious enough they had been arrested or referred to therapy, it’s uncertain to what degree the findings apply to the broader population.

But the takeaway is clear, said Hewitt. “If you have an adolescent who is exhibiting extreme conduct problems, seek help. It is not just a matter of stopping them from doing bad things. It could be a matter of keeping them alive.”

Abstract
Background and aims: Adolescents with conduct and substance use problems are at increased risk for premature mortality, but the extent to which these risk factors reflect family‐ or individual‐level differences and account for shared or unique variance is unknown. This study examined common and independent contributions to mortality hazard in adolescents ascertained for conduct disorder (CD) and substance use disorder (SUD), their siblings and community controls, hypothesizing that individual differences in CD and SUD severity would explain unique variation in mortality risk beyond that due to clinical/control status and demographic factors.
Design: Mortality analysis in a prospective study (Genetics of Antisocial Drug Dependence Study) that began in 1993.
Setting: Multi‐site sample recruited in San Diego, California and Denver, Colorado, USA.
Participants: A total of 1463 clinical probands were recruited through the juvenile correctional system, court‐mandated substance abuse treatment programs and correctional schools, along with 1399 of their siblings, and 904 controls.
Measurements: Mortality and cause‐of‐death were assessed via National Death Index search (released October, 2017).
Findings: There were 104 deaths documented among 3766 (1168 female) adolescents and young adults (average age 16.79 years at assessment, 32.69 years at death/censoring). Mortality hazard for clinical probands and their siblings was 4.99 times greater than that of controls (95% confidence interval = 2.40–10.40; P < 0.001). After accounting for demographic characteristics, site, clinical status, familial dependence and shared contributions of CD and SUD, CD independently predicted mortality hazard, whereas SUD severity did not.
Conclusions: In the United States, youth with conduct and substance use disorders and their siblings face far greater risk of premature death than demographically similar community controls. In contrast to substance use disorder severity, conduct disorder is a robust predictor of unique variance in all‐cause mortality hazard beyond other risk factors.

Authors
Richard Border, Robin P Corley, Sandra A Brown, John K Hewitt, Christian J Hopfer, Shannon K McWilliams, Sally Ann Rhea, Christen L Shriver, Michael C Stallings, Tamara L Wall, Kerri E Woodward, Soo Hyun Rhee

University of Colorado at Boulder material
Addiction abstract


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