Canadian Journal of Public Health

, Volume 110, Issue 1, pp 85–92 | Cite as

Substance use and internalizing symptoms among high school students and access to health care services: results from a population-based study

  • Amy H. CheungEmail author
  • Steven Cook
  • Nicole Kozloff
  • Justin N. Chee
  • Robert E. Mann
  • Angela Boak
Quantitative Research



To examine co-occurring mental health problems among a population-based sample of high school students in Ontario, Canada, to understand their prevalence, associated risk factors, and relationship with mental health service access and utilization.


The data were derived from the 2013 Ontario Student Drug Use and Health Survey, a biennial survey of students attending publicly funded Ontario schools, from a subsample of students who completed both the internalizing and substance use portions of the survey (n = 2945). Rates of co-occurring problems were calculated for the previous 12 months. Service use for students with co-occurring problems was also calculated for the past 12 months. Odds ratios were estimated using binary logistic regression models correcting for the survey design.


In an adjusted model, youth with internalizing symptoms were 2.40 times more likely and youth with substance use problems were 2.24 times more likely to have accessed mental health services during the past 12 months than youth without these problems. Youth with co-occurring internalizing and substance use problems were 6.74 times more likely (95% CI 4.66–9.76, p < 0.001) to have accessed mental health services during the past year compared with youth without co-occurring problems, but only 52.8% of youth with co-occurring problems (95% CI 45.6–59.9%) used mental health services.


The findings suggest that just over half of Ontario students in grades 9 through 12 who have co-occurring internalizing and substance use problems are utilizing mental health services. Further research should examine the factors related to service use in this population in order to better inform policy and program development.


Adolescents Health services Substance-related disorders Depression 



Examiner les troubles de santé mentale concomitants dans un échantillon populationnel d’élèves du secondaire en Ontario, au Canada, pour comprendre la prévalence de ces troubles, les facteurs de risque associés et leurs liens avec l’accès et le recours aux services de santé mentale.


Nos données sont dérivées du Sondage sur la consommation de drogues et la santé des élèves de l’Ontario de 2013, une enquête bisannuelle auprès des élèves fréquentant l’école publique dans la province; elles proviennent d’un sous-échantillon d’élèves ayant rempli à la fois les parties du sondage sur l’intériorisation et sur la consommation de substances (n = 2 945). Les taux de problèmes concomitants ont été calculés pour les 12 mois antérieurs. L’utilisation des services par les élèves présentant des problèmes concomitants a aussi été calculée pour les 12 mois antérieurs. Les rapports de cotes ont été estimés au moyen de modèles de régression logistique binaires après correction du plan de sondage.


Selon un modèle ajusté, les jeunes présentant des symptômes d’intériorisation étaient 2,40 fois plus susceptibles, et les jeunes présentant des problèmes de consommation de substances, 2,24 fois plus susceptibles, d’avoir eu accès à des services de santé mentale au cours des 12 mois antérieurs que les jeunes ne présentant pas de tels problèmes. Les jeunes ayant des problèmes concomitants d’intériorisation et de consommation de substances étaient 6,74 fois plus susceptibles (IC de 95 % : 4,66-9,76, p < 0,001) d’avoir eu accès à des services de santé mentale au cours de l’année antérieure que les jeunes sans problèmes concomitants, mais seulement 52,8 % des jeunes ayant des problèmes concomitants (IC de 95 % : 45,6 %-59,9 %) avaient utilisé des services de santé mentale.


Ces résultats indiquent qu’un peu plus de la moitié des élèves de l’Ontario de la 9e à la 12e année ayant des problèmes concomitants d’intériorisation et de consommation de substances ont recours aux services de santé mentale. Il faudrait pousser la recherche pour examiner les facteurs liés à l’utilisation des services dans cette population afin d’éclairer l’élaboration des politiques et des programmes.


Adolescents Services de santé Troubles liés à une substance Dépression 



We want to thank the research support from Ms. Lindsay Williams, Alisha Williams, Connor Ostoich, and Geneva Mason.


This work was supported by the Canadian Institutes of Health Research [grant number EKT-121928]. Dr. Cheung is supported by the Bell Canada Chair in Adolescent Mood and Anxiety Disorders and the Ontario Mental Health Foundation New Investigator Fellowship. Dr. Kozloff is supported by a NARSAD Young Investigator Grant from the The Brain and Behaviour Research Foundation.


  1. Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., & Kessler, R. C. (2014). Barriers to mental health treatment: results from the WHO world mental health surveys. Psychological Medicine, 44(6), 1303. Scholar
  2. Boak, A., Hamilton, H., Adlaf, E., & Mann, R. (2013). Drug use among Ontario students, 1977–2013: detailed OSDUHS findings. Toronto, ON: Centre for Addiction and Mental Health. DrugUseReport.pdf.
  3. Brener, N. D., Billy, J. O., & Grady, W. R. (2003). Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. The Journal of Adolescent Health, 33(6), 436–457.CrossRefGoogle Scholar
  4. Cheung, A., Mayes, T., Levitt, A., Schaffer, A., Michalak, E., Kiss, A., & Emslie, G. (2010). Anxiety as a predictor of treatment outcome in children and adolescents with depression. Journal of Child and Adolescent Psychopharmacology, 20(3), 211–216. Scholar
  5. Cummings, C., Caporino, N., & Kendall, P. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychological Bulletin, 140(3), 816–845. Scholar
  6. Deighton, J., Tymms, P., Vostanis, P., Belsky, J., Fonagy, P., Brown, A., Martin, A., Patalay, P., & Wolpert, M. (2013). The development of a school-based measure of child mental health. Journal of Psychoeducational Assessment, 31(3), 247–257. Scholar
  7. Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M., Tiims F, & Ungemack, J. (2006). Psychiatric Syndromes in Adolescents with Marijuana Abuse and Dependency in Outpatient Treatment. Journal of Child & Adolescent Substance Abuse, 15(4), 37–54.Google Scholar
  8. Dirks, H., Scherbaum, N., Kis, B., & Mette, C. (2017). ADHD in adults and comorbid substance use disorder: prevalence, clinical diagnostics and integrated therapy. Fortschritte der Neurologie-Psychiatrie, 85(6), 336–344. Scholar
  9. Essau, C. A., Lewinsohn, P. M., Lim, J. X., Ho, M. R., & Rohde, P. (2018). Incidence, recurrence and comorbidity of anxiety disorders in four major developmental stages. Journal of Affective Disorders, 228, 248–253.CrossRefGoogle Scholar
  10. Galea, S., Brewin, C. R., Gruber, M., Jones, R. T., King, D. W., King, L. A., & Kessler, R. C. (2007). Exposure to hurricane-related stressors and mental illness after Hurricane Katrina. Archives of General Psychiatry, 64(12), 1427–1434.CrossRefGoogle Scholar
  11. Hersh, J., Curry, J. F., & Kaminer, Y. (2014). What is the impact of comorbid depression on adolescent substance abuse treatment? Substance Abuse, 35(4), 364–375. Scholar
  12. Hetrick, S. E., Bailey, A. P., Smith, K. E., Malla, A., Mathias, S., Singh, S. P., & McGorry, P. D. (2017). Integrated (one-stop shop) youth health care: best available evidence and future directions. The Medical Journal of Australia, 207(10), S5–S18.CrossRefGoogle Scholar
  13. Kaminer, Y. (2016). Youth substance abuse and co-occurring disorders. Washington, DC:American Psychiatric Association Publishing.Google Scholar
  14. Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L., & Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959–976.CrossRefGoogle Scholar
  15. Knight, J. R., Shrier, L. A., Bravender, T. D., Farrell, M., Vander Bilt, J., & Shaffer, H. J. (1999). A new brief screen for adolescent substance abuse. Archives of Pedicatrics and Adolescent Medicine, 153(6), 591–596.Google Scholar
  16. Lundkvist-Houndoumadi, I., Thastum, M. (2017). Anxious Children and Adolescents Non-Responding to CBT: Clinical Predictors and Families' Experiences of Therapy. Clinical Psychology & Psychotherapy, 24(1), 82–93.Google Scholar
  17. Long, S., & Freese, J. (2014). Regression models for categorical dependent variables using Stata. (3rd edition ed.). College Station, TX: Stata Press.Google Scholar
  18. Mann, R. E., Paglia-Boak, A., Adlaf, E. M., Beitchman, J., Wolfe, D., Wekerle, C., & Rehm, J. (2011). Estimating the prevalence of anxiety and mood disorders in an adolescent general population: an evaluation of the GHQ12. International Journal of Mental Health and Addiction, 9(4), 410–420. Scholar
  19. Martin, G., Copeland, J., Gates, P., & Gilmour, S. (2006). The Severity of Dependence Scale (SDS) in an adolescent population of cannabis users: Reliability, validity and diagnostic cut-off. Drug and Alcohol Dependence, 83(1), 90–93. Scholar
  20. Mental Health Commission of Canada (2013). Making the case for investing in mental health in Canada. Calgary, AB: Mental Health Commission of Canada, sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf.
  21. Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., & Olfson, M. (2011). Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–45. Scholar
  22. Miranda, A., Colomer, C., Berenguer, C., Roselló, R., & Roselló, B. (2016). Substance use in young adults with ADHD: comorbidity and symptoms of inattention and hyperactivity/impulsivity. International Journal of Clinical and Health Psychology, 16(2), 157–165.CrossRefGoogle Scholar
  23. Ottosen, C., Petersen, L., Larsen, J. T., & Dalsgaard, S. (2016). Gender differences in associations between attention-deficit/hyperactivity disorder and substance use disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 55(3), 227–234. Scholar
  24. Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption--II. Addiction, 88(6), 791–804.CrossRefGoogle Scholar
  25. Sterling, S., Weisner, C., Hinman, A., & Parthasarathy, S. (2010). Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. Journal of the American Academy of Child and Adolescent Psychiatry, 49(7), 637–646; quiz 725-636. Scholar
  26. Urbanoski, K. A., Rush, B. R., Wild, T. C., Bassani, D. G., & Castel, S. (2007). Use of mental health care services by Canadians with co-occurring substance dependence and mental disorders. Psychiatric Services, 58(7), 962–969. Scholar
  27. van Emmerik-van Oortmerssen, K., Van de Glind, G., Koeter, M. W., Allsop, S., Auriacombe, M., Barta, C., et al. (2014). Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. Addiction, 109(2), 262–272.

Copyright information

© The Canadian Public Health Association 2018

Authors and Affiliations

  • Amy H. Cheung
    • 1
    • 2
    Email author
  • Steven Cook
    • 3
  • Nicole Kozloff
    • 2
    • 4
  • Justin N. Chee
    • 1
    • 2
  • Robert E. Mann
    • 2
    • 4
  • Angela Boak
    • 4
  1. 1.Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada
  2. 2.University of TorontoTorontoCanada
  3. 3.School of Social SciencesCardiff UniversityCardiffUK
  4. 4.Centre for Addiction and Mental HealthTorontoCanada

Personalised recommendations