Substance Use and Marginalization Among Youth Living with Mental Health Conditions in Ontario

Background: Approximately 70% of mental health problems have their onset in childhood or adolescence. In 2019, data from the Canadian population showed that mental and substance use conditions were highest among youth and young adults, where more than half reported poor mental health and one-third reported substance use. Mental health and addiction-related service use among children and youth in Ontario has also increased over time. Concurrent substance use can be particularly problematic for youth with mental health concerns. It interferes with treatment for mental health disorders, worsens outcomes and long-term prognosis, and increases the cost of care. Furthermore, with so many potential causes, many theories and models have attempted to explain the substance use condition and the relationship between substance use and mental disorders. However, social determinants of health are common factors conceptualized as key risk factors for substance use and mental illness. Therefore, there is a need to improve the integration of proactive and timely substance use and mental health care for children and youth. \nPurpose: This study examines the impact of clinical and social circumstances, including the experience of marginalization, on co-occurring mental health and substance use problems among youth across different mental health care facilities in Ontario, Canada. \nMethods: The first part of this research uses a cross-sectional study design to examine the patterns and factors associated with substance use among youth (12–18 years) assessed in the community (n = 47,418) and residential (n = 700) mental health care facilities in Ontario, Canada. The second part uses a cross-sectional study design to examine how the experience and severity of marginalization are associated with substance use among 9,142 youth living with mental health conditions. Lastly, the third part of this research uses a retrospective cohort design to examine if the experience of marginalization precedes substance use among 19,514 youth living with mental health conditions in Ontario. \nResults: The first study found that 22% of youth reported the use of substances in the community settings and 37% in residential settings. Older age group (Youth older than 16 years), being a victim of abuse, having experienced self-injurious ideation/attempt, being at risk of disrupted education, and having a parent/caregiver with addiction or substance use disorder were significantly associated with substance use. Several factors reduced the risk of substance use, including being a female, having anxiety symptoms, and having cognitive problems. \nStudy 2 shows that after controlling for other variables, having no strong/supportive family relationship, being a victim of abuse, being at risk of disrupted education, caregiver distress, and having a parent with SUD significantly increased the relative risk of substance use among the study sample. However, having no friends and living with a cognitive/intellectual disability reduced the risk of substance use. A sex-based analysis shows a similar pattern among males and females, except for caregiver distress which was not significantly associated with substance use among females. About 91% of the entire sample had experienced at least one indicator of marginalization. The average number of MI experienced by youth was 3 (Standard Deviation = 2.0). The risk model for a sum of MI shows that the risk of substance use among youths increased with increasing cumulation of the experience of MI. Those who experienced four marginalization indicators had twice the risk of substance use compared to those who did not experience any of the MI (RR=1.97, 95% CI: [1.64, 2.30]). Those who experienced eight or more MI had two to four times the risk of substance use compared to those who did not experience any MI (RR=3.12, 95% CI: [2.44, 3.98]). \nLastly, using a longitudinal study design, study 3 shows that about 2.0 % of the total youth in the longitudinal data initiated substance use within the two-year follow-up period. Among those that used substances at follow-up, 42% were males, and 58% were females. About 67% of those that initiated substance use at follow-up were within the older age group (14 – 16 years old) at baseline while 33% were 12 – 13 years old. Interestingly, when examining unique indicators of marginalization only victim of abuse was a significant predictor of future substance use (HR: 1.36 [1.10, 1.68]; p-value 0.01). However, the adjusted model of the cumulative effect of MI on future substance use shows that after controlling for age, sex, and severity of clinical symptoms, the probability of reporting substance use within two-year follow-up among youth that experienced 1 - 2 MI compared to those that did not was approximately 1.5 (P-value=0.003). Among those that experienced 3 - 4 MI, the probability of reporting substance use at two-year follow-up compared to those that did not experience any MI was approximately 2.0 (P-value <.0001). \nConclusion: This study reinforces the need for an early, holistic, patient-centered, trauma-informed, family-based, multidisciplinary/integrated care approach that addresses the broader social determinants of health in the management of youth with mental and substance use conditions. This research demonstrates that social determinants, including indicators of marginalization are risk factors that precede substance use among youth. These risk factors (MI) could persist across the life course and in multiple social levels, i.e., at individual, family, school, and the community. This study also establishes that the more indicators of marginalization a youth experiences the higher the risk of future substance use. The findings from this study provides hypotheses that addressing these MI can influence multiple outcomes that are associated or predicted by them. The results of this research have implied that the implementation and evaluation of modeled or promising prevention programs/interventions and broader dissemination would have a substantial impact on the prevalence of substance use and related consequences. \n \nKeywords: youth; co-occurring mental health and substance use conditions; marginalization; social determinants; integrated care; interRAI; assessment; predictors of substance use

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