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The use of mental health services by adolescent smokers: A nationwide Israeli study
European Psychiatry 28 (2013) 269–275
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Original article
The use of mental health services by adolescent smokers: A nationwide Israeli study G. Shoval a,b, I. Mansbach-Kleinfeld c, I. Farbstein d, R. Kanaaneh d, G. Lubin c, A. Krivoy a,b, A. Apter b,e, A. Weizman a,b,f, G. Zalsman a,*,b,g a
Child and Adolescent Psychiatry Division, Geha Mental Health Center, Tel Aviv University, P.O.Box 102, 49100 Petah Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Mental Health Services, Ministry of Health, Jerusalem, Israel d Child and Adolescent Psychiatry, Ziv Hospital, Safed, Israel e Schneider Center for Children in Israel, Petach Tiqva, Israel f Felsenstein Medical Research Center, Beilinson Campus, Rabin Medical Center, Petah Tiqva, Israel g Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, NY, USA b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2011 Received in revised form 26 January 2012 Accepted 28 January 2012 Available online 27 April 2012
In this study, we aimed to evaluate the utilization of mental health services by adolescent smokers, the presence of untreated mental disorders in this young population and the associated emotional and behavioral difficulties. We performed a nationwide survey study of an Israeli representative sample of 906 adolescents and their mothers. Mental disorders were assessed using the Development and WellBeing Assessment (DAWBA) Inventory. Emotional and behavioral difficulties were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Mental health services use and smoking habits were evaluated by relevant questionnaires. Adolescent smokers were using significantly more mental health services than non-smokers (79% vs. 63%, respectively, P < 0.001), independently of their mental health status or ethnic group. Adolescent smokers also reported more emotional and behavioral difficulties in most areas (P < 0.001), which are consistent with their mothers’ reports, except in the area of peer relationships. The treatment gap for the smoking adolescents was 53% compared to 69% in the nonsmokers (P < 0.001). This is the first study characterizing the use of mental health services and the related emotional and behavioral difficulties in a nationally-representative sample of adolescents. The findings of a wide treatment gap and the rates of the associated emotional and behavioral difficulties are highly relevant to the psychiatric assessment and national treatment plans of adolescent smokers. ß 2012 Elsevier Masson SAS. All rights reserved.
Keywords: Smoking Parents Epidemiology Adolescent Services Substance abuse
1. Introduction Cigarette smoking is associated with five million deaths annually worldwide and is a leading cause of premature death [20]. However, the production and consumption of cigarettes has been on the rise for the past decades [15]. Smoking initiation typically occurs during adolescence, and it is estimated that 3,000 American adolescents initiate smoking every day. Furthermore, there are currently approximately four million smoking adolescents in the USA [38]. A previous epidemiological study demonstrated smoking prevalence of 35% among Israeli youth [25]. Thus, cigarette smoking should be considered as a ‘‘pediatric disease’’. Psychiatric comorbidity is common among adolescent smokers. There have been numerous reports of higher rates of disruptive
* Corresponding author. Tel.: +972 3 9258 205; fax: +972 3 9241041. E-mail address: [email protected] (G. Zalsman). 0924-9338/$ – see front matter ß 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2012.01.003
behavior disorders [31], major depressive disorder [7], anxiety disorders [6] and substance-related disorders [3] in this population. In addition, smoking is associated with other risky behaviors, such as violence, dropping out of school and unplanned pregnancy [12]. Consumption of cigarettes during adolescence appears to be a strong marker for future psychopathology [38], and prior smoking was shown to predict subsequent suicidal behavior in a German cohort of 3,021 subjects aged 14–24 years [2]. Despite these consistent findings, mental health services for adolescents usually do not include treatment for tobacco dependence, and most general health practitioners are not fully aware of the need to screen this at-risk smoking adolescent population for psychopathology. In a recent report, we addressed the issue of the unmet need for mental health services for adolescents and reported a treatment gap (defined as the presence of a mental disorder without corresponding treatment) ranging from 60% to 66% of a nationally-representative sample of 957 adolescents [21]. While adolescent smokers are at high risk for both mental and physical disorders, there is a lack of knowledge regarding their
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utilization of community mental health services and the emotional and behavioral difficulties experienced by this population and their parents. We have utilized the body of data collected in the Israeli Survey of Mental Health among Adolescents (ISMEHA) Study to investigate the particular characteristics of the smoking adolescents in this community-based representative sample and their associated emotional and behavioral difficulties. Our goal was to characterize the relationship between these particular difficulties and the utilization of mental health services by adolescent smokers and to determine the treatment gap for this population considering their untreated mental health disorders. 2. Subjects and methods This study is part of the ISMEHA Study. For further details on the sample and sampling method, see Mansbach-Klienfeld et al. [22]. 2.1. Sample and procedures Briefly, the representative sample included 957 adolescents (age range 14–17 years) and their mothers. The sampling frame used was the Israeli National Population Register (INPR), including the names of all legal residents of Israel-born between July 2, 1987 and June 30, 1990 regardless of whether they were in school (n = 317,604). Mothers and adolescents were interviewed separately at home by two trained lay interviewers in the native language of the participants. Fifty-one adolescents refused to participate, although their mothers agreed. Twenty-two mothers disagreed to be interviewed but consented to their child’s participation. The response rate was 80% in the located sample (n = 1,195) and 68% (n = 957/1,402) in the total sample. No significant differences related to gender or immigration status were noted. The results were weighted back to the total population to compensate for clustering effects and non-responses. The study was approved by the Israeli Ministry of Health Review Board. Written informed consent of the parents and their adolescent children for participation in the study were obtained after the nature of the study was fully explained.
[13]. This tool assesses peer relationships, hyperactivity and inattention, conduct disorders and emotional symptoms. This measure is increasingly being used in both community and clinical settings due to its relative brevity and availability in the public domain (www.sdqinfo.org). The psychometric properties of the Hebrew version of the SDQ (SDQ-H) were shown to be acceptable compared to other translated versions [23]. Assessment of services utilization: Mothers were asked whether during the past 12 months they had consulted a professional or informal service provider about the emotional and/or behavioral problems of their adolescent offspring and provided a list that included a family practitioner or a pediatrician, another medical specialist, an adolescent health clinic, a psychiatrist, psychologist, social worker or psychiatric nurse, a school counselor, any teacher, other school staff, a school nurse, hotline staff, a self-help group, a spiritual leader, an alternative medicine agent, a probation officer or other relevant individuals. The adolescents were asked whether during the past school year they had consulted someone in school regarding problems not connected to the academic material, such as problems with their peers, problems at home and problems with concentration, and, if yes, whom they had consulted. The list of choices included a school counselor, a teacher, a psychologist, a friend, a school nurse or other. In the option for adding other sources, the adolescents indicated that they had notified a school principal and a youth movement guide. Mothers were asked whether their adolescent had visited a primary-care practitioner (PCP) during the past year. In Israel, the concept of a PCP includes general practitioners, pediatricians and internists [37]. 2.2.2. Smoking habits Adolescents were asked whether they had ever smoked and whether they still smoke. For the purpose of this study, we included all past and present smokers in the smoking group (lifetime smoking) because of the evidence that smoking patterns in adolescence are largely inconsistent [16,17]; therefore, referring to current smoking vs. previous smoking may not accurately reflect the smoking behavior over the period of adolescence.
2.2. Instruments
2.3. Statistical analysis
2.2.1. Diagnostic assessment Mental disorders were assessed using the Development and Well-Being Assessment (DAWBA) Inventory [14]. The DAWBA, a multi-informant interview, combines a structured interview with open-ended questions regarding psychiatric symptoms and their impact on the adolescent’s life and his or her family. The responses to the structured questions generated a computerized diagnosis according to the Diagnostic Statistical Manual IV-Text Revised (DSM-IV-TR) [1] criteria. Senior child psychiatrists (I.F., A.A. and R.K.) relied on the recorded comments to establish the diagnoses [9]. The specific disorders were categorized into internalizing or externalizing disorders. Internalizing disorders included separation anxiety, specific phobias, social phobias, panic disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD) and major depressive disorder (MDD). Externalizing disorders included attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). Emotional and behavioral difficulties, both self- and motherrated, were evaluated using the Hebrew, Arabic and Russian versions of the Strengths and Difficulties Questionnaire (SDQ) [23]. The SDQ is also a multi-informant questionnaire designed to screen for mental health problems in children and adolescents
Statistical analyses were conducted using an SPSS-17 complex sample analysis module (IBM-SPSS Inc, Chicago, IL). Raw numbers and weighted proportions are presented for the characteristics of the study population. Significance is based on the adjusted F and its degrees of freedom; the adjusted F is a variant of the second-order Rao-Scott adjusted x2 statistic. The mean self- and mother-rated SDQ scale scores and standard deviations according to the adolescents’ report of having ever smoked were calculated, and the t values are presented.
3. Results The sample included 957 subjects, but complete data were available for 906 adolescents (age range 14–17 years) and their mothers who were included in the final analysis (50.3% males). A total of 228 adolescents (27.8%) reported having smoked. Of those, 69 (8.8%) still smoked at the time of the study. Thirty-four participants from the smoking group (34/228) were diagnosed as having a mental disorder according to the DAWBA. However, more than half of them (n = 18; 53.3%) did not use mental health services. This treatment gap was significantly smaller than for the non-smoking group (49/68; 68.7%) (x2=11.46, df = 1, P < 0.001).
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Table 1 Socio-demographic and mental health characteristics of adolescents with lifetime smoking history (raw numbers and weighted proportions). Lifetime smoking n/N
%
202/609 26/296
33.5 9.6
Gender Male Female
128/462 100/443
Age 14–15 16 17
OR (95% CI)
Adj. F; df; P
2.0 1.4
4.730 (3.3–6.8) 1.00 [Reference]
81.568; 1; < 0.001***
29.4 26.1
2.2 2.1
1.172 (0.9–1.6) 1.00 [Reference]
1.33; 1; 0.249
55/272 110/417 63/216
20.6 30.7 32.4
2.6 2.3 1.7
1.00 [Reference] 1.714 (1.2–2.5) 1.843 (1.2–2.8)
5.987; 2; 0.003**
Birthplace Israel-born Immigrant
167/781 61/124
22.8 49.4
1.6 5.1
1.00 [Reference] 3.343 (2.1–5.3)
29.085; 1; < 0.001***
Parents marital status Married Divorced/single/widowed
185/773 36/110
26.5 34.5
1.8 4.5
1.00 [Reference] 1.452 (0.9–2.3)
2.768; 1; 0.097
Maternal years of schooling v0–11 12 13+
48/292 66/259 98/299
19.4 25.4 35.2
2.7 2.6 3.1
1.00 [Reference] 1.404 (0.9–2.2) 2.250 (1.5–3.4)
7.798; 2; < 0.001***
Paternal employment status Employed Unemployed
164/623 40/204
27.8 24.5
2.0 3.4
1.180 (0.8–1.3) 1.00 [Reference]
0.727; 1; 0.395
Welfare care Yes No
28/125 190/752
22.6 28.2
4.5 1.9
1.00 [Reference] 1.331 (0.8–2.3)
1.178; 1; 0.279
18/79 210/824
26.8 27.9
5.4 1.8
0.946 (0.5–1.7) 1.00 [Reference]
0.032; 1; 0.859
Externalizing Yes No
20/36 208/868
51.3 26.7
10.3 1.7
2.886 (1.3–6.7) 1.00 [Reference]
6.785; 1; 0.01*
Any mental disorder Yes No
35/106 193/798
35.3 26.8
4.9 1.7
1.483 (0.9–2.4) 1.00 [Reference]
2.795; 1; 0.096
Socio-demographic characteristics Ethnic group Jewish Arab/Druze
Mental health status Internalizing Yes No
*
P < 0.05;
**
P < 0.01;
***
sd
P < 0.001. Adj. F: adjusted F.
Table 1 shows selected socio-demographic and mental health traits of the adolescents who smoked. There was a higher prevalence of smoking among Jewish compared to Arab adolescents (33.5% vs. 9.6%, OR = 4.73, 95%CI = 3.3–6.8, P < 0.001), among older (16 and 17 years) compared to younger (14–15 years) adolescents (32.4% vs. 20.6%, OR = 1.84, 95%CI = 1.2–2.8, P = 0.003), among immigrant compared to Israeli-born adolescents (49.4% vs. 22.8%, OR = 3.34, 95%CI = 2.1–5.3, P < 0.001) and among those whose mother had more education (> 13 years of schooling) rather than less education (35.2% vs. 19.4%, OR = 2.25, 95%CI = 1.5–3.4, P < 0.001). There was a significant higher rate of externalizing disorders among the smokers compared to non-smokers (51.3% vs. 26.7%, OR = 2.89, 95%CI = 1.3–6.7, P = 0.01). In contrast, no significant difference was detected for internalizing disorders. To assess whether these variables were functioning as intervening variables for the other socio-demographic traits associated with lifetime smoking, we included them as independent variables in a logistic regression. The results showed that ethnic group (Jewish vs. non-Jewish) (OR = 3.9, 95%CI = 2.2–6.9, P < 0.001), immigration (OR = 2.3, 95%CI = 1.4–3.8, P = 0.001) and the age of the adolescent (OR = 1.89, 95%CI = 1.2–2.9, P = 0.008) were each independently associated with lifetime smoking, whereas maternal education was not.
Table 2 shows that significantly more mothers of the teenage smokers (vs. mothers of non-smokers) consulted a professional or an informal mental health provider (17.6% vs. 7.6%, F = 14.05, df = 1, P < 0.001). More adolescent smokers consulted a school professional regarding problems not related to the school curriculum than non-smokers (28.9% vs. 19.5%, F = 7.55, df = 1, P < 0.001), and more adolescent smokers visited a PCP during the past 12 months compared to their non-smoking peers (79.4% vs. 63.6%, F = 21.21, df = 1, P < 0.001). In our previous study, we reported that in this population, ethnic group and the presence of a mental disorder are highly associated with maternal help-seeking [21]. To assess whether smoking was associated with the use of services independently from ethnic group and mental health status, we included these variables in a multivariate analysis (Table 3). The results show that the adolescents’ lifetime smoking activity was independently associated with a higher likelihood of help-seeking by their mothers (OR = 1.96, 95%CI = 1.1–3.4, P = 0.018). As shown in Table 4, mean maternal-rated SDQ scores for their smoking adolescents were significantly higher on the scales of hyperactivity/inattention (3.2 6.8 vs. 1.7 1.8, t = 5.26, P < 0.001), emotional problems (2.3 6.8 vs. 1.7 1.7, t = 2.26, P = 0.024), conduct problems (2.4 6.7 vs. 1.2 1.3, t = 4.32,
G. Shoval et al. / European Psychiatry 28 (2013) 269–275
272
Table 2 Mental health services use by lifetime smoking history of adolescents. Use of services
Lifetime smoking Yes
No
N
%
sd
N
Mother consulted professional or informal mental health provider
38/218
17.6
2.5
45/644
Adolescent consulted someone at school
68/226
28.9
3.2
The adolescent visited a PCP in past 12 months
171/218
79.4
2.6
***
sd
Adj. F; df; P
7.6
1.2
14.05; 1; < 0.001***
134/667
19.5
1.5
7.55; 1; < 0.001***
387/639
63.6
2.3
21.21; 1; < 0.001***
P < 0.001. PCP: primary-care practitioner; Adj. F: adjusted F.
P < 0.001) and the total difficulties score (8.6 7.9 vs. 6.2 4.4, t = 5.72, P < 0.001). However, there were no significant differences between the smokers and the non-smokers in the maternal-rated SDQ pro-social behavior and peer relationship scales. Finally, adolescents who smoked differed significantly from those who did not in all self-rated SDQ problem scales (Table 4). The adolescents with a lifetime smoking history reported higher levels of hyperactivity/inattention (3.5 2.2 vs. 2.7 2, t = 5.37, P < 0.001), emotional problems (2.9 2.1 vs. 2.5 2.0, t = 2.91, P = 0.004), and conduct problems (2.3 1.6 vs. 1.7 1.4, t = 5.49, P < 0.001), and their total difficulties score was higher (10.3 4.7 vs. 8.7 4.6, t = 4.65, P < 0.001). The self-reported scores of the adolescents with a lifetime smoking history were significantly lower regarding pro-social behavior (8.1 1.6 vs. 8.4 1.5, t = 2.22, P = 0.027) and peer relationship problems (1.6 1.4 vs. 1.9 1.5, t = 2.37, P = 0.018). 4. Discussion This is the first study characterizing the relationship between emotional and behavioral difficulties and the utilization of mental health services in a nationally-representative sample of adolescents. Specifically, this study compared subjects who have smoked cigarettes with those who never have. The use of mental health services was markedly higher among the smoking adolescents than the non-smokers. The mothers of the smoking adolescents were twice as likely to consult a professional or an informal mental health provider compared to the mothers of adolescents with no smoking history independently of their mental health status and ethnic group. Adolescent with a lifetime smoking history also had significantly higher rates of helpseeking by school professionals and visits to a PCP compared to non-smokers. These findings are particularly important because they indicate that cigarette smoking in adolescents is a marker for the increased
Table 3 Multivariate analysis of maternal help-seeking patterns by ethnic group, lifetime smoking and the presence of a mental disorder. Independent variables
*
%
Mother consulted a professional or informal mental health-care provider OR (95% CI)
P
Ethnic group Jews Arabs/Druze
10.42 (3.4–32.1) 1.00 [Reference]
< 0.001***
Ever smoked Yes No
1.96 (1.1–3.4) 1.00 [Reference]
0.018*
Any mental disorder Yes No
7.82 (4.3–14.3) 1.00 [Reference]
< 0.001***
P < 0.05;
***
P < 0.001.
use of mental health services independent of the psychiatric disorders that are associated with smoking and that adolescent smokers are a high-risk group facing emotional and behavioral difficulties that do not necessarily translate into well-defined DSM-IV-TR disorders. As Table 1 shows, there was an increase in the percentage of smokers from aged 14–15 through 16 to 17 year old groups (14–15 yrs: 20.6%; 16 yrs: 30.7%; 32.4%), indicating that some 14–15 yr old adolescents may in the very near future start smoking. Thus, early preventive intervention seems to be of great importance for this age group. The SDQ assessments of this nationally-representative sample identify these particular emotional and behavioral difficulties as experienced by the adolescents and perceived by their mothers. The smoking adolescents reported more hyperactivity/inattention, emotional and conduct difficulties than their non-smoking peers, which is consistent with the maternal reports for the same problem areas. However, the smoking adolescents perceived themselves as having significantly fewer peer relationship problems than their mothers’ reports. Although parent-adolescent agreement among reports of psychopathology has been repeatedly shown to be very low [5,29,32], the SDQ reports of mothers and their adolescents in this study matched in three out of four problem areas. One possible explanation is that the difficulties of the smoking adolescent group are so prominent that neither the adolescent nor the parent deny or ignore them, resulting in more frequent consultations with health-care professionals. This explanation may also underlie the increased rates of utilization of mental health services by smokers, which remain significant after controlling for the adolescents’ mental health status. In our cohort, lifetime smoking history was threefold more prevalent among the adolescents with externalizing disorders than those who had no externalizing disorders, whereas this significant difference did not exist for internalizing disorders (Table 1). These discordant findings may also explain the elevated utilization of mental health services by the smoking adolescent group. Externalizing disorders, but not internalizing disorders, are often associated with overt high-risk and aggressive behaviors and may therefore trigger increased service use as reported in most previous studies [35,40]. However, these findings are not consistent with the findings of one large-scale prospective 10-year follow-up study in a Finnish general population sample [36], indicating the need for further investigations. It is likely that these characteristics of the lifetime smoking adolescents are also responsible for the relatively narrow treatment gap found among the smokers (53.3%) compared to the non-smokers (68.7%). Smoking in adolescence is often explained as an oppositional, rebellious or anti-social behavior [38,19]; therefore, lack of insight and cooperation were suggested to delay self-referral to the necessary psychiatric treatment. Our study demonstrates that this suggestion is not necessarily true and that non-smoking adolescents actually have a wider treatment gap.
G. Shoval et al. / European Psychiatry 28 (2013) 269–275
273
Table 4 Mean SDQ scores by lifetime smoking history of adolescents. SDQ maternal-rated scales
Lifetime smoking Yes
No
(n = 219)
(n = 664)
xˉ (sd)
xˉ (sd)
Pro-social behavior Peer relationship problems Hyperactivity/Inattention Emotional symptoms Conduct problems Total difficulties Score
8.8 2.1 3.2 2.3 2.4 8.6
8.8 1.7 1.7 1.7 1.2 6.2
SDQ self-rated scales
Yes
No
(n = 228)
(n = 674)
xˉ (sd)
xˉ (sd)
Pro-social behavior
8.1 (1.6)
Peer relationship problems Hyperactivity/Inattention Emotional symptoms Conduct problems Total difficulties score SDQ: Strengths and Difficulties Questionnaire. *P < 0.05;
(6.3) (6.7) (6.8) (6.8) (6.7) (7.9)
1.6 3.5 2.9 2.3 10.3 **
(1.4) (2.2) (2.1) (1.6) (4.7)
P < 0.01;
***
t; df; P
(1.5) (1.4) (1.8) (1.7) (1.3) (4.4)
0.11; 878; 0.914 1.4; 878; 0.161 5.26; 881; < 0.001*** 2.26; 880; 0.024* 4.32; 880; < 0.001*** 5.73; 880; < 0.001*** t; df; P
8.4 (1.5)
2.22; 900; 0.027*
1.9 2.7 2.5 1.7 8.7
2.37; 5.37; 2.91; 5.49; 4.65;
(1.5) (2.0) (2.0) (1.4) (4.6)
899; 899; 899; 899; 899;
0.018* < 0.001*** 0.004** < 0.001*** < 0.001***
P < 0.001.
Because adolescents are often reluctant to seek psychiatric help [39], the above findings are particularly essential for prevention and early-detection programs that address the general adolescent population. Despite the high prevalence of adolescent psychiatric disorders, mental health services reach less than half of those in need [18,34]. One policy may be to focus more on screening nonsmoking adolescents for internalizing disorders, which are less prominent and may therefore remain under-diagnosed and undertreated. Moreover, as shown here, difficulties of both smokers and non-smokers may be present in various life domains and not limited to DSM-IV-TR disorders. Multi-informant data collection is vital to ensure maximal accuracy of the diagnosis, especially when parent-child disagreement is expected. The Great Smoky Mountain Study demonstrated that the most common point of entry into mental health services was the education system [10]. Together with other studies showing the pivotal role of school in early detection of psychopathology [36], we believe it would be advisable to develop more integrative evaluation and treatment programs in this field. Because most adolescent emotional and behavioral difficulties (such as hyperactivity/inattention, conduct disorder and peer relationship problems) may be expressed at school more overtly than at home, school-based programs may be successful in targeting these goals. School is a central arena for adolescent social functioning. Interestingly, the peer relationship was the only area of motheradolescent disagreement on the SDQ in this study. Namely, while the smoking adolescents perceived themselves as having significantly less peer-relationship problems than non-smokers, the maternal reports indicated otherwise. The role of social environmental factors in the initiation and continuation of cigarette smoking has been well established. Smoking is frequently associated with belonging to a certain youth social group, including body piercing fans [4], punk music lovers [28], psychoactive substance abusers [33] or delinquents [11]. We suggest that being part of these groups provides the smoking adolescents with a sense of coherence and social identity, and therefore, they experience their peer-relationships as positive. Their parents, however, are more critical of these social groups and are possibly able to identify the social difficulties of their adolescents more realistically. Further studies into this issue are warranted.
In the presence of the relatively small amount of data from community-based nationally-representative samples of adolescents, this study enables a comprehensive view of the general teen population. Many of the published reports are school-based, so they did not include dropouts and absentees whose risk behavior and psychopathology differ from that of those attending school [8,30]. Thus, generalizing their findings beyond a school-based population may be questionable. We did not thoroughly discuss the findings regarding the socio-demographic variables of the cohort in this study because we consider them related to the local health-care system and particular cultural characteristics as observed in previous cohorts in different countries [36], so they do not necessarily represent universal phenomena. There are a few limitations in the current study. Although this study evaluated a representative sample of Israeli youth, two subpopulations were not included: the Jewish Ultra-Orthodox and Palestinian residents of East Jerusalem. These subpopulations comprise 17.8% and 2.8%, respectively, of the adolescents in this age group [24]. After the feasibility stage showed that very few of the Jewish Ultra-Orthodox population and families of Palestinian residents of East Jerusalem would be willing to participate, we decided not to include these populations in the study. The Ultra-Orthodox Jewish population follows the most theologically conservative form of Orthodox Judaism and is unwilling to participate in projects containing secular content. Regarding the Palestinian residents of East Jerusalem, their willingness to participate in a survey organized and conducted by the Ministry of Health, an official Israeli institution, was low presumably due to their lack of confidence and trust regarding the use of the data. Another possible limitation is the 20% non-response rate. This non-responsive and less cooperative population may have different rates of smoking and different rates of parental reporting of the adolescent problems than the respondents. Despite these limitations, the prevalence rates of psychopathology reported in the ISMEHA Study [21,9] are in line with the epidemiological surveys that have been conducted worldwide, strengthening the likelihood that the findings regarding parents’ and adolescents’ reports of difficulties and their use of services may also be generalized [26,27]. Another limitation is that this study is a secondary analysis of a dataset that was originally designed to characterize mental
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health services use and difficulties of adolescents in the community and not specifically among smokers vs. non-smokers.
[10]
5. Conclusion
[11]
We demonstrated that in our nationally-representative community sample, the lifetime smoking adolescents reported more emotional and behavioral difficulties and utilized significantly more mental health services than their non-smoking peers. The implications of these findings are important at different levels, including the assessment of the adolescent psychiatric patient, interpretation of information obtained from his parents and implementation of national reaching-out programs for adolescents with unmet mental health needs. In light of the common reluctance of adolescents to seek psychiatric help, the findings of this study are important for prevention and early-detection programs that target the general adolescent population. The particular emotional and behavioral difficulties of the adolescent smokers and non-smokers demonstrated here are often expressed at school more overtly than at home, so school-based programs may be the most successful for targeting these goals and an appropriate point of entry into mental health services. Disclosure of interest
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The authors declare that they have no conflicts of interest concerning this article. Acknowledgments This survey was supported by the Israel National Institute for Health Policy and Health Services Research (No. 25/2000), the Association for Planning and Development of Services for Children and Youth at Risk and Their Families (ASHALIM), the Englander Center for Children and Youth of the Brookdale Institute, and the Rotter Foundation of the Maccabi Health Services, Israel. The authors also wish to acknowledge the contribution of Itzhak Levav, MD, MSc. and Daphna Levinson, PhD, in the planning and execution of this project. The Judie and Marshall Polk Research Fund for Children at Risk (GZ) partially supported the statistical analysis in this paper. The authors thank Michaela Gerchek and Anneke Ifrah for scientific and English editing. References [1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR). IV-TR ed. Washington, DC: American Psychiatric Press; 2000. [2] Bronisch T, Hofler M, Lieb R. Smoking predicts suicidality: findings from a prospective community study. J Affect Disord 2008;108:135–45. [3] Brown RA, Lewinsohn PM, Seeley JR, Wagner EF. Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J Am Acad Child Adolesc Psychiatry 1996;35:1602–10. [4] Bui E, Rodgers R, Cailhol L, Birmes P, Chabrol H, Schmitt L. Body piercing and psychopathology: a review of the literature. Psychother Psychosom 2010;79:125–9. [5] Canavera KE, Wilkins KC, Pincus DB, Ehrenreich-May JT. Parent-child agreement in the assessment of obsessive-compulsive disorder. J Clin Child Adolesc Psychol 2009;38:909–15. [6] Costello EJ, Erkanli A, Federman E, Angold A. Development of psychiatric comorbidity with substance abuse in adolescents: effects of timing and sex. J Clin Child Psychol 1999;28:298–311. [7] Dierker LC, Avenevoli S, Merikangas KR, Flaherty BP, Stolar M. Association between psychiatric disorders and the progression of tobacco use behaviors. J Am Acad Child Adolesc Psychiatry 2001;40:1159–67. [8] Eggert LL, Seyl CD, Nicholas LJ. Effects of a school-based prevention program for potential high school dropouts and drug abusers. Int J Addict 1990;25: 773–801. [9] Farbstein I, Mansbach-Kleinfeld I, Levinson D, Goodman R, Levav I, Vograft I, et al. Prevalence and correlates of mental disorders in Israeli adolescents:
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Available online at
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Original article
The use of mental health services by adolescent smokers: A nationwide Israeli study G. Shoval a,b, I. Mansbach-Kleinfeld c, I. Farbstein d, R. Kanaaneh d, G. Lubin c, A. Krivoy a,b, A. Apter b,e, A. Weizman a,b,f, G. Zalsman a,*,b,g a
Child and Adolescent Psychiatry Division, Geha Mental Health Center, Tel Aviv University, P.O.Box 102, 49100 Petah Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Mental Health Services, Ministry of Health, Jerusalem, Israel d Child and Adolescent Psychiatry, Ziv Hospital, Safed, Israel e Schneider Center for Children in Israel, Petach Tiqva, Israel f Felsenstein Medical Research Center, Beilinson Campus, Rabin Medical Center, Petah Tiqva, Israel g Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, NY, USA b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2011 Received in revised form 26 January 2012 Accepted 28 January 2012 Available online 27 April 2012
In this study, we aimed to evaluate the utilization of mental health services by adolescent smokers, the presence of untreated mental disorders in this young population and the associated emotional and behavioral difficulties. We performed a nationwide survey study of an Israeli representative sample of 906 adolescents and their mothers. Mental disorders were assessed using the Development and WellBeing Assessment (DAWBA) Inventory. Emotional and behavioral difficulties were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Mental health services use and smoking habits were evaluated by relevant questionnaires. Adolescent smokers were using significantly more mental health services than non-smokers (79% vs. 63%, respectively, P < 0.001), independently of their mental health status or ethnic group. Adolescent smokers also reported more emotional and behavioral difficulties in most areas (P < 0.001), which are consistent with their mothers’ reports, except in the area of peer relationships. The treatment gap for the smoking adolescents was 53% compared to 69% in the nonsmokers (P < 0.001). This is the first study characterizing the use of mental health services and the related emotional and behavioral difficulties in a nationally-representative sample of adolescents. The findings of a wide treatment gap and the rates of the associated emotional and behavioral difficulties are highly relevant to the psychiatric assessment and national treatment plans of adolescent smokers. ß 2012 Elsevier Masson SAS. All rights reserved.
Keywords: Smoking Parents Epidemiology Adolescent Services Substance abuse
1. Introduction Cigarette smoking is associated with five million deaths annually worldwide and is a leading cause of premature death [20]. However, the production and consumption of cigarettes has been on the rise for the past decades [15]. Smoking initiation typically occurs during adolescence, and it is estimated that 3,000 American adolescents initiate smoking every day. Furthermore, there are currently approximately four million smoking adolescents in the USA [38]. A previous epidemiological study demonstrated smoking prevalence of 35% among Israeli youth [25]. Thus, cigarette smoking should be considered as a ‘‘pediatric disease’’. Psychiatric comorbidity is common among adolescent smokers. There have been numerous reports of higher rates of disruptive
* Corresponding author. Tel.: +972 3 9258 205; fax: +972 3 9241041. E-mail address: [email protected] (G. Zalsman). 0924-9338/$ – see front matter ß 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2012.01.003
behavior disorders [31], major depressive disorder [7], anxiety disorders [6] and substance-related disorders [3] in this population. In addition, smoking is associated with other risky behaviors, such as violence, dropping out of school and unplanned pregnancy [12]. Consumption of cigarettes during adolescence appears to be a strong marker for future psychopathology [38], and prior smoking was shown to predict subsequent suicidal behavior in a German cohort of 3,021 subjects aged 14–24 years [2]. Despite these consistent findings, mental health services for adolescents usually do not include treatment for tobacco dependence, and most general health practitioners are not fully aware of the need to screen this at-risk smoking adolescent population for psychopathology. In a recent report, we addressed the issue of the unmet need for mental health services for adolescents and reported a treatment gap (defined as the presence of a mental disorder without corresponding treatment) ranging from 60% to 66% of a nationally-representative sample of 957 adolescents [21]. While adolescent smokers are at high risk for both mental and physical disorders, there is a lack of knowledge regarding their
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utilization of community mental health services and the emotional and behavioral difficulties experienced by this population and their parents. We have utilized the body of data collected in the Israeli Survey of Mental Health among Adolescents (ISMEHA) Study to investigate the particular characteristics of the smoking adolescents in this community-based representative sample and their associated emotional and behavioral difficulties. Our goal was to characterize the relationship between these particular difficulties and the utilization of mental health services by adolescent smokers and to determine the treatment gap for this population considering their untreated mental health disorders. 2. Subjects and methods This study is part of the ISMEHA Study. For further details on the sample and sampling method, see Mansbach-Klienfeld et al. [22]. 2.1. Sample and procedures Briefly, the representative sample included 957 adolescents (age range 14–17 years) and their mothers. The sampling frame used was the Israeli National Population Register (INPR), including the names of all legal residents of Israel-born between July 2, 1987 and June 30, 1990 regardless of whether they were in school (n = 317,604). Mothers and adolescents were interviewed separately at home by two trained lay interviewers in the native language of the participants. Fifty-one adolescents refused to participate, although their mothers agreed. Twenty-two mothers disagreed to be interviewed but consented to their child’s participation. The response rate was 80% in the located sample (n = 1,195) and 68% (n = 957/1,402) in the total sample. No significant differences related to gender or immigration status were noted. The results were weighted back to the total population to compensate for clustering effects and non-responses. The study was approved by the Israeli Ministry of Health Review Board. Written informed consent of the parents and their adolescent children for participation in the study were obtained after the nature of the study was fully explained.
[13]. This tool assesses peer relationships, hyperactivity and inattention, conduct disorders and emotional symptoms. This measure is increasingly being used in both community and clinical settings due to its relative brevity and availability in the public domain (www.sdqinfo.org). The psychometric properties of the Hebrew version of the SDQ (SDQ-H) were shown to be acceptable compared to other translated versions [23]. Assessment of services utilization: Mothers were asked whether during the past 12 months they had consulted a professional or informal service provider about the emotional and/or behavioral problems of their adolescent offspring and provided a list that included a family practitioner or a pediatrician, another medical specialist, an adolescent health clinic, a psychiatrist, psychologist, social worker or psychiatric nurse, a school counselor, any teacher, other school staff, a school nurse, hotline staff, a self-help group, a spiritual leader, an alternative medicine agent, a probation officer or other relevant individuals. The adolescents were asked whether during the past school year they had consulted someone in school regarding problems not connected to the academic material, such as problems with their peers, problems at home and problems with concentration, and, if yes, whom they had consulted. The list of choices included a school counselor, a teacher, a psychologist, a friend, a school nurse or other. In the option for adding other sources, the adolescents indicated that they had notified a school principal and a youth movement guide. Mothers were asked whether their adolescent had visited a primary-care practitioner (PCP) during the past year. In Israel, the concept of a PCP includes general practitioners, pediatricians and internists [37]. 2.2.2. Smoking habits Adolescents were asked whether they had ever smoked and whether they still smoke. For the purpose of this study, we included all past and present smokers in the smoking group (lifetime smoking) because of the evidence that smoking patterns in adolescence are largely inconsistent [16,17]; therefore, referring to current smoking vs. previous smoking may not accurately reflect the smoking behavior over the period of adolescence.
2.2. Instruments
2.3. Statistical analysis
2.2.1. Diagnostic assessment Mental disorders were assessed using the Development and Well-Being Assessment (DAWBA) Inventory [14]. The DAWBA, a multi-informant interview, combines a structured interview with open-ended questions regarding psychiatric symptoms and their impact on the adolescent’s life and his or her family. The responses to the structured questions generated a computerized diagnosis according to the Diagnostic Statistical Manual IV-Text Revised (DSM-IV-TR) [1] criteria. Senior child psychiatrists (I.F., A.A. and R.K.) relied on the recorded comments to establish the diagnoses [9]. The specific disorders were categorized into internalizing or externalizing disorders. Internalizing disorders included separation anxiety, specific phobias, social phobias, panic disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD) and major depressive disorder (MDD). Externalizing disorders included attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). Emotional and behavioral difficulties, both self- and motherrated, were evaluated using the Hebrew, Arabic and Russian versions of the Strengths and Difficulties Questionnaire (SDQ) [23]. The SDQ is also a multi-informant questionnaire designed to screen for mental health problems in children and adolescents
Statistical analyses were conducted using an SPSS-17 complex sample analysis module (IBM-SPSS Inc, Chicago, IL). Raw numbers and weighted proportions are presented for the characteristics of the study population. Significance is based on the adjusted F and its degrees of freedom; the adjusted F is a variant of the second-order Rao-Scott adjusted x2 statistic. The mean self- and mother-rated SDQ scale scores and standard deviations according to the adolescents’ report of having ever smoked were calculated, and the t values are presented.
3. Results The sample included 957 subjects, but complete data were available for 906 adolescents (age range 14–17 years) and their mothers who were included in the final analysis (50.3% males). A total of 228 adolescents (27.8%) reported having smoked. Of those, 69 (8.8%) still smoked at the time of the study. Thirty-four participants from the smoking group (34/228) were diagnosed as having a mental disorder according to the DAWBA. However, more than half of them (n = 18; 53.3%) did not use mental health services. This treatment gap was significantly smaller than for the non-smoking group (49/68; 68.7%) (x2=11.46, df = 1, P < 0.001).
G. Shoval et al. / European Psychiatry 28 (2013) 269–275
271
Table 1 Socio-demographic and mental health characteristics of adolescents with lifetime smoking history (raw numbers and weighted proportions). Lifetime smoking n/N
%
202/609 26/296
33.5 9.6
Gender Male Female
128/462 100/443
Age 14–15 16 17
OR (95% CI)
Adj. F; df; P
2.0 1.4
4.730 (3.3–6.8) 1.00 [Reference]
81.568; 1; < 0.001***
29.4 26.1
2.2 2.1
1.172 (0.9–1.6) 1.00 [Reference]
1.33; 1; 0.249
55/272 110/417 63/216
20.6 30.7 32.4
2.6 2.3 1.7
1.00 [Reference] 1.714 (1.2–2.5) 1.843 (1.2–2.8)
5.987; 2; 0.003**
Birthplace Israel-born Immigrant
167/781 61/124
22.8 49.4
1.6 5.1
1.00 [Reference] 3.343 (2.1–5.3)
29.085; 1; < 0.001***
Parents marital status Married Divorced/single/widowed
185/773 36/110
26.5 34.5
1.8 4.5
1.00 [Reference] 1.452 (0.9–2.3)
2.768; 1; 0.097
Maternal years of schooling v0–11 12 13+
48/292 66/259 98/299
19.4 25.4 35.2
2.7 2.6 3.1
1.00 [Reference] 1.404 (0.9–2.2) 2.250 (1.5–3.4)
7.798; 2; < 0.001***
Paternal employment status Employed Unemployed
164/623 40/204
27.8 24.5
2.0 3.4
1.180 (0.8–1.3) 1.00 [Reference]
0.727; 1; 0.395
Welfare care Yes No
28/125 190/752
22.6 28.2
4.5 1.9
1.00 [Reference] 1.331 (0.8–2.3)
1.178; 1; 0.279
18/79 210/824
26.8 27.9
5.4 1.8
0.946 (0.5–1.7) 1.00 [Reference]
0.032; 1; 0.859
Externalizing Yes No
20/36 208/868
51.3 26.7
10.3 1.7
2.886 (1.3–6.7) 1.00 [Reference]
6.785; 1; 0.01*
Any mental disorder Yes No
35/106 193/798
35.3 26.8
4.9 1.7
1.483 (0.9–2.4) 1.00 [Reference]
2.795; 1; 0.096
Socio-demographic characteristics Ethnic group Jewish Arab/Druze
Mental health status Internalizing Yes No
*
P < 0.05;
**
P < 0.01;
***
sd
P < 0.001. Adj. F: adjusted F.
Table 1 shows selected socio-demographic and mental health traits of the adolescents who smoked. There was a higher prevalence of smoking among Jewish compared to Arab adolescents (33.5% vs. 9.6%, OR = 4.73, 95%CI = 3.3–6.8, P < 0.001), among older (16 and 17 years) compared to younger (14–15 years) adolescents (32.4% vs. 20.6%, OR = 1.84, 95%CI = 1.2–2.8, P = 0.003), among immigrant compared to Israeli-born adolescents (49.4% vs. 22.8%, OR = 3.34, 95%CI = 2.1–5.3, P < 0.001) and among those whose mother had more education (> 13 years of schooling) rather than less education (35.2% vs. 19.4%, OR = 2.25, 95%CI = 1.5–3.4, P < 0.001). There was a significant higher rate of externalizing disorders among the smokers compared to non-smokers (51.3% vs. 26.7%, OR = 2.89, 95%CI = 1.3–6.7, P = 0.01). In contrast, no significant difference was detected for internalizing disorders. To assess whether these variables were functioning as intervening variables for the other socio-demographic traits associated with lifetime smoking, we included them as independent variables in a logistic regression. The results showed that ethnic group (Jewish vs. non-Jewish) (OR = 3.9, 95%CI = 2.2–6.9, P < 0.001), immigration (OR = 2.3, 95%CI = 1.4–3.8, P = 0.001) and the age of the adolescent (OR = 1.89, 95%CI = 1.2–2.9, P = 0.008) were each independently associated with lifetime smoking, whereas maternal education was not.
Table 2 shows that significantly more mothers of the teenage smokers (vs. mothers of non-smokers) consulted a professional or an informal mental health provider (17.6% vs. 7.6%, F = 14.05, df = 1, P < 0.001). More adolescent smokers consulted a school professional regarding problems not related to the school curriculum than non-smokers (28.9% vs. 19.5%, F = 7.55, df = 1, P < 0.001), and more adolescent smokers visited a PCP during the past 12 months compared to their non-smoking peers (79.4% vs. 63.6%, F = 21.21, df = 1, P < 0.001). In our previous study, we reported that in this population, ethnic group and the presence of a mental disorder are highly associated with maternal help-seeking [21]. To assess whether smoking was associated with the use of services independently from ethnic group and mental health status, we included these variables in a multivariate analysis (Table 3). The results show that the adolescents’ lifetime smoking activity was independently associated with a higher likelihood of help-seeking by their mothers (OR = 1.96, 95%CI = 1.1–3.4, P = 0.018). As shown in Table 4, mean maternal-rated SDQ scores for their smoking adolescents were significantly higher on the scales of hyperactivity/inattention (3.2 6.8 vs. 1.7 1.8, t = 5.26, P < 0.001), emotional problems (2.3 6.8 vs. 1.7 1.7, t = 2.26, P = 0.024), conduct problems (2.4 6.7 vs. 1.2 1.3, t = 4.32,
G. Shoval et al. / European Psychiatry 28 (2013) 269–275
272
Table 2 Mental health services use by lifetime smoking history of adolescents. Use of services
Lifetime smoking Yes
No
N
%
sd
N
Mother consulted professional or informal mental health provider
38/218
17.6
2.5
45/644
Adolescent consulted someone at school
68/226
28.9
3.2
The adolescent visited a PCP in past 12 months
171/218
79.4
2.6
***
sd
Adj. F; df; P
7.6
1.2
14.05; 1; < 0.001***
134/667
19.5
1.5
7.55; 1; < 0.001***
387/639
63.6
2.3
21.21; 1; < 0.001***
P < 0.001. PCP: primary-care practitioner; Adj. F: adjusted F.
P < 0.001) and the total difficulties score (8.6 7.9 vs. 6.2 4.4, t = 5.72, P < 0.001). However, there were no significant differences between the smokers and the non-smokers in the maternal-rated SDQ pro-social behavior and peer relationship scales. Finally, adolescents who smoked differed significantly from those who did not in all self-rated SDQ problem scales (Table 4). The adolescents with a lifetime smoking history reported higher levels of hyperactivity/inattention (3.5 2.2 vs. 2.7 2, t = 5.37, P < 0.001), emotional problems (2.9 2.1 vs. 2.5 2.0, t = 2.91, P = 0.004), and conduct problems (2.3 1.6 vs. 1.7 1.4, t = 5.49, P < 0.001), and their total difficulties score was higher (10.3 4.7 vs. 8.7 4.6, t = 4.65, P < 0.001). The self-reported scores of the adolescents with a lifetime smoking history were significantly lower regarding pro-social behavior (8.1 1.6 vs. 8.4 1.5, t = 2.22, P = 0.027) and peer relationship problems (1.6 1.4 vs. 1.9 1.5, t = 2.37, P = 0.018). 4. Discussion This is the first study characterizing the relationship between emotional and behavioral difficulties and the utilization of mental health services in a nationally-representative sample of adolescents. Specifically, this study compared subjects who have smoked cigarettes with those who never have. The use of mental health services was markedly higher among the smoking adolescents than the non-smokers. The mothers of the smoking adolescents were twice as likely to consult a professional or an informal mental health provider compared to the mothers of adolescents with no smoking history independently of their mental health status and ethnic group. Adolescent with a lifetime smoking history also had significantly higher rates of helpseeking by school professionals and visits to a PCP compared to non-smokers. These findings are particularly important because they indicate that cigarette smoking in adolescents is a marker for the increased
Table 3 Multivariate analysis of maternal help-seeking patterns by ethnic group, lifetime smoking and the presence of a mental disorder. Independent variables
*
%
Mother consulted a professional or informal mental health-care provider OR (95% CI)
P
Ethnic group Jews Arabs/Druze
10.42 (3.4–32.1) 1.00 [Reference]
< 0.001***
Ever smoked Yes No
1.96 (1.1–3.4) 1.00 [Reference]
0.018*
Any mental disorder Yes No
7.82 (4.3–14.3) 1.00 [Reference]
< 0.001***
P < 0.05;
***
P < 0.001.
use of mental health services independent of the psychiatric disorders that are associated with smoking and that adolescent smokers are a high-risk group facing emotional and behavioral difficulties that do not necessarily translate into well-defined DSM-IV-TR disorders. As Table 1 shows, there was an increase in the percentage of smokers from aged 14–15 through 16 to 17 year old groups (14–15 yrs: 20.6%; 16 yrs: 30.7%; 32.4%), indicating that some 14–15 yr old adolescents may in the very near future start smoking. Thus, early preventive intervention seems to be of great importance for this age group. The SDQ assessments of this nationally-representative sample identify these particular emotional and behavioral difficulties as experienced by the adolescents and perceived by their mothers. The smoking adolescents reported more hyperactivity/inattention, emotional and conduct difficulties than their non-smoking peers, which is consistent with the maternal reports for the same problem areas. However, the smoking adolescents perceived themselves as having significantly fewer peer relationship problems than their mothers’ reports. Although parent-adolescent agreement among reports of psychopathology has been repeatedly shown to be very low [5,29,32], the SDQ reports of mothers and their adolescents in this study matched in three out of four problem areas. One possible explanation is that the difficulties of the smoking adolescent group are so prominent that neither the adolescent nor the parent deny or ignore them, resulting in more frequent consultations with health-care professionals. This explanation may also underlie the increased rates of utilization of mental health services by smokers, which remain significant after controlling for the adolescents’ mental health status. In our cohort, lifetime smoking history was threefold more prevalent among the adolescents with externalizing disorders than those who had no externalizing disorders, whereas this significant difference did not exist for internalizing disorders (Table 1). These discordant findings may also explain the elevated utilization of mental health services by the smoking adolescent group. Externalizing disorders, but not internalizing disorders, are often associated with overt high-risk and aggressive behaviors and may therefore trigger increased service use as reported in most previous studies [35,40]. However, these findings are not consistent with the findings of one large-scale prospective 10-year follow-up study in a Finnish general population sample [36], indicating the need for further investigations. It is likely that these characteristics of the lifetime smoking adolescents are also responsible for the relatively narrow treatment gap found among the smokers (53.3%) compared to the non-smokers (68.7%). Smoking in adolescence is often explained as an oppositional, rebellious or anti-social behavior [38,19]; therefore, lack of insight and cooperation were suggested to delay self-referral to the necessary psychiatric treatment. Our study demonstrates that this suggestion is not necessarily true and that non-smoking adolescents actually have a wider treatment gap.
G. Shoval et al. / European Psychiatry 28 (2013) 269–275
273
Table 4 Mean SDQ scores by lifetime smoking history of adolescents. SDQ maternal-rated scales
Lifetime smoking Yes
No
(n = 219)
(n = 664)
xˉ (sd)
xˉ (sd)
Pro-social behavior Peer relationship problems Hyperactivity/Inattention Emotional symptoms Conduct problems Total difficulties Score
8.8 2.1 3.2 2.3 2.4 8.6
8.8 1.7 1.7 1.7 1.2 6.2
SDQ self-rated scales
Yes
No
(n = 228)
(n = 674)
xˉ (sd)
xˉ (sd)
Pro-social behavior
8.1 (1.6)
Peer relationship problems Hyperactivity/Inattention Emotional symptoms Conduct problems Total difficulties score SDQ: Strengths and Difficulties Questionnaire. *P < 0.05;
(6.3) (6.7) (6.8) (6.8) (6.7) (7.9)
1.6 3.5 2.9 2.3 10.3 **
(1.4) (2.2) (2.1) (1.6) (4.7)
P < 0.01;
***
t; df; P
(1.5) (1.4) (1.8) (1.7) (1.3) (4.4)
0.11; 878; 0.914 1.4; 878; 0.161 5.26; 881; < 0.001*** 2.26; 880; 0.024* 4.32; 880; < 0.001*** 5.73; 880; < 0.001*** t; df; P
8.4 (1.5)
2.22; 900; 0.027*
1.9 2.7 2.5 1.7 8.7
2.37; 5.37; 2.91; 5.49; 4.65;
(1.5) (2.0) (2.0) (1.4) (4.6)
899; 899; 899; 899; 899;
0.018* < 0.001*** 0.004** < 0.001*** < 0.001***
P < 0.001.
Because adolescents are often reluctant to seek psychiatric help [39], the above findings are particularly essential for prevention and early-detection programs that address the general adolescent population. Despite the high prevalence of adolescent psychiatric disorders, mental health services reach less than half of those in need [18,34]. One policy may be to focus more on screening nonsmoking adolescents for internalizing disorders, which are less prominent and may therefore remain under-diagnosed and undertreated. Moreover, as shown here, difficulties of both smokers and non-smokers may be present in various life domains and not limited to DSM-IV-TR disorders. Multi-informant data collection is vital to ensure maximal accuracy of the diagnosis, especially when parent-child disagreement is expected. The Great Smoky Mountain Study demonstrated that the most common point of entry into mental health services was the education system [10]. Together with other studies showing the pivotal role of school in early detection of psychopathology [36], we believe it would be advisable to develop more integrative evaluation and treatment programs in this field. Because most adolescent emotional and behavioral difficulties (such as hyperactivity/inattention, conduct disorder and peer relationship problems) may be expressed at school more overtly than at home, school-based programs may be successful in targeting these goals. School is a central arena for adolescent social functioning. Interestingly, the peer relationship was the only area of motheradolescent disagreement on the SDQ in this study. Namely, while the smoking adolescents perceived themselves as having significantly less peer-relationship problems than non-smokers, the maternal reports indicated otherwise. The role of social environmental factors in the initiation and continuation of cigarette smoking has been well established. Smoking is frequently associated with belonging to a certain youth social group, including body piercing fans [4], punk music lovers [28], psychoactive substance abusers [33] or delinquents [11]. We suggest that being part of these groups provides the smoking adolescents with a sense of coherence and social identity, and therefore, they experience their peer-relationships as positive. Their parents, however, are more critical of these social groups and are possibly able to identify the social difficulties of their adolescents more realistically. Further studies into this issue are warranted.
In the presence of the relatively small amount of data from community-based nationally-representative samples of adolescents, this study enables a comprehensive view of the general teen population. Many of the published reports are school-based, so they did not include dropouts and absentees whose risk behavior and psychopathology differ from that of those attending school [8,30]. Thus, generalizing their findings beyond a school-based population may be questionable. We did not thoroughly discuss the findings regarding the socio-demographic variables of the cohort in this study because we consider them related to the local health-care system and particular cultural characteristics as observed in previous cohorts in different countries [36], so they do not necessarily represent universal phenomena. There are a few limitations in the current study. Although this study evaluated a representative sample of Israeli youth, two subpopulations were not included: the Jewish Ultra-Orthodox and Palestinian residents of East Jerusalem. These subpopulations comprise 17.8% and 2.8%, respectively, of the adolescents in this age group [24]. After the feasibility stage showed that very few of the Jewish Ultra-Orthodox population and families of Palestinian residents of East Jerusalem would be willing to participate, we decided not to include these populations in the study. The Ultra-Orthodox Jewish population follows the most theologically conservative form of Orthodox Judaism and is unwilling to participate in projects containing secular content. Regarding the Palestinian residents of East Jerusalem, their willingness to participate in a survey organized and conducted by the Ministry of Health, an official Israeli institution, was low presumably due to their lack of confidence and trust regarding the use of the data. Another possible limitation is the 20% non-response rate. This non-responsive and less cooperative population may have different rates of smoking and different rates of parental reporting of the adolescent problems than the respondents. Despite these limitations, the prevalence rates of psychopathology reported in the ISMEHA Study [21,9] are in line with the epidemiological surveys that have been conducted worldwide, strengthening the likelihood that the findings regarding parents’ and adolescents’ reports of difficulties and their use of services may also be generalized [26,27]. Another limitation is that this study is a secondary analysis of a dataset that was originally designed to characterize mental
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health services use and difficulties of adolescents in the community and not specifically among smokers vs. non-smokers.
[10]
5. Conclusion
[11]
We demonstrated that in our nationally-representative community sample, the lifetime smoking adolescents reported more emotional and behavioral difficulties and utilized significantly more mental health services than their non-smoking peers. The implications of these findings are important at different levels, including the assessment of the adolescent psychiatric patient, interpretation of information obtained from his parents and implementation of national reaching-out programs for adolescents with unmet mental health needs. In light of the common reluctance of adolescents to seek psychiatric help, the findings of this study are important for prevention and early-detection programs that target the general adolescent population. The particular emotional and behavioral difficulties of the adolescent smokers and non-smokers demonstrated here are often expressed at school more overtly than at home, so school-based programs may be the most successful for targeting these goals and an appropriate point of entry into mental health services. Disclosure of interest
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