Relationships Between Substance Use and Psychiatric Medication Use in Young Adults with Psychiatric Disorders

Background: Substance use and mental health problems frequently co-occur in young adulthood.  The self-medication hypothesis links the two, noting that use of illegal substances to control mental health symptoms contributes to substance dependence.  Medications are often a central aspect of managing and treating troubling psychiatric symptoms.  But, little is known about how young people use legal and illegal substances together and how they make decisions between them.  Data from a sample of uninsured young adults admitted to a psychiatric crisis unit were used to explore three research questions: How do participants talk about the role of medications in managing symptoms? How do participants talk about the role of illegal substances in managing symptoms?  How do they make decisions about using one or the other?

Methods: Fifty-five young adults (age 18-25) with a Bipolar (47%), Depression (39%) or Schizophrenia (14%) diagnosis were interviewed in a short term inpatient crisis stabilization unit of a large public system. Interviews used a semi-structured qualitative guide to elicit participants’ experiences with their mental health symptoms and the role of psychiatric medications or illegal substances to manage these symptoms.  Interviewers used probes to gain more depth and detail about how participants made decisions between using illegal substances and medications. Interviews were recorded and transcribed, then reviewed by 4 analysts who used a thematic approach to code overarching themes.  A second round of coding was conducted by 2 coders, identifying sub-dimensions within broader themes specifically relevant to medication and substance use.  The sample was gender-balanced and ethnically diverse.  All participants were currently taking psychiatric medication and 94% reported use of illegal substances.

Results: Participants consistently presented parallel narratives to explain their medication and illegal substance use.  Elements included reasons for taking substances, substance effects, consequences, and views on future use.  Legal and illegal substance effects were described in similar terms [i.e. “calms me down”, “helps me focus”].  Some explicitly used the word “self-medicate” or described choosing specific substances to manage symptoms [“when I'm depressive and sleeping all the time …a little bit of cocaine …will speed me up”]. When deciding between illegal vs prescribed substances, youth described the greater availability of illegal substances[“it’s like on every corner”], difficulties getting a medication prescription, the lower cost of illegal substances[“marijuana did the same thing as the medication…instead of costing $900 it cost $20], the ability to control the dosage themselves, and adverse side effects of psychiatric drugs. 

Conclusions: Young adults described rational decision making processes around using illegal substances or psychiatric medications.  To reduce illegal substance use in favor of legal options, systems need to remove access barriers to psychiatric services.  When illegal substances were more available, cheaper, and had less side effects, they were a more attractive option.   Prescribers of medications should be aware that young people may be considering prescription medication as only one option or an option to be used in conjunction with illegal substances, especially in the face of access barriers.