For Most Transitional Age Youth Experiencing Homelessness, A Complex Overlay of Substance Use Disorders and Psychiatric Illness

In the United States, transitional age youth (between the ages of 16 and 25 years) experience high rates of homelessness, with 10% of youth between the ages of 18 and 25 reporting housing instability during the past year.  Among transitional age youth experiencing homelessness (TAY-EH),  youth of color, young parents, and LGBTQ+ youth are disproportionately represented.  TAY-EH experience elevated rates of medical and psychosocial morbidity and face a ten-fold greater risk of mortality compared with their stably housed peers, largely due to psychiatric and substance use disorders.  

This is a diverse and vulnerable population with unique and complex needs; however, there is limited data on the co-occurrence and interactions between substance use disorders (SUDs) and psychiatric illness in this marginalized group.  A recent study from Colin Burke, MD, Timothy Wilens, MD and colleagues examined the prevalence of single and co-occurring substance use disorders and psychiatric disorders and the associations between psychopathology and prevalence/severity of SUD in a sample of TAY-EH.

The researchers recruited TAY-EH from a low-threshold social service agency in the Boston metropolitan area.  A total of 140 TAY-EH completed psychosocial and diagnostic interviews using the Mini International Neuropsychiatric Interview (MINI) with supplemental ADHD module to assess for SUD and psychiatric illness.   

The majority of the TAY-EH assessed were youth of color (54% Black/African American, 16% Latinx), and 57% identified as male. Rates of single and co-occurring psychiatric disorders and specific SUDs were higher in TAY-EH than estimates from general TAY populations.

• Cannabis use disorder (CUD, 44%) and alcohol use disorder (AUD, 21%) were common, with markedly lower rates of other SUDs.
• The psychiatric diagnoses most commonly reported were major depressive disorder (28%), bipolar disorder (21%), and ADHD (24%).  
• Suicidality was reported in 27% of the participants.
• Co-occurring CUD and/or AUD were present in the majority of youth with antisocial personality disorders (85%), ADHD (67%), anxiety disorders (66%), suicidality (65%), and mood disorders (64%).

Increased severity of SUD was associated with greater risk of psychiatric illness.  Youth with severe CUD and/or AUD had a fourfold greater odds of having a co-occurring mood disorder, anxiety disorder, ADHD, or suicidality, and 14 times greater odds of having co-occurring antisocial personality disorder than youth without SUD.

The current study reveals a complex overlay of substance use disorders and psychopathology in TAY experiencing homelessness, demonstrating a significant association between co-occurring psychopathology and severity of CUD/AUD. 

Further research into the mechanistic and temporal relationships between these conditions is warranted in order to better inform and tailor treatment interventions.  The findings of this study point to the likely limitations of interventions for TAY-EH focused solely on a single domain, such as psychosocial adversity, psychiatric illness, or SUD and underscore the need for multimodal interventions accounting for the co-occurrence of adversity, marginalization, substance use, and psychiatric illness.   

Burke CW,  Firmin ES, Lanni S, Ducharme P, DiSalvo M, Wilens TE.Substance Use Disorders and Psychiatric Illness Among Transitional Age Youth Experiencing Homelessness  JAACAP Open.  Published online: January 17, 2023

Burke CW, Firmin ES, Wilens TE. Systematic review: Rates of psychopathology, substance misuse, and neuropsychological dysfunction among transitional age youth experiencing homelessness. Am J Addict. 2022 Nov;31(6):523-534.