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Table of Contents
CONTINUING EDUCATION SERIES NO. 42
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 29-39

Psychological issues in adolescents


1 Professor, Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, TN MGR Medical University, Tamil Nadu, India
2 Associate Professor, Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, TN MGR Medical University, Tamil Nadu, India
3 Assistant Professor, Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, TN MGR Medical University, Tamil Nadu, India

Date of Submission11-Apr-2022
Date of Decision30-May-2022
Date of Acceptance13-Jun-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Mrs. Santhi Gladston
Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_53_22

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  Abstract 

Adolescence is a critical period of development in a young person's life, marked by important biological, cognitive, emotional and social changes. It is also a period when adolescents become autonomous and independent and try to develop an identity for themselves. This phase involves many psychological challenges and issues. This article reviews the major psychosocial problems during adolescence.

Keywords: Adolescence, critical period, psychosocial problems


How to cite this article:
Nayak R, Manoharan M, Prasad L, Gladston S, Raghuram M, Edwin D, Kanthi E. Psychological issues in adolescents. Indian J Cont Nsg Edn 2022;23:29-39

How to cite this URL:
Nayak R, Manoharan M, Prasad L, Gladston S, Raghuram M, Edwin D, Kanthi E. Psychological issues in adolescents. Indian J Cont Nsg Edn [serial online] 2022 [cited 2022 Dec 7];23:29-39. Available from: https://www.ijcne.org/text.asp?2022/23/1/29/349905


  Introduction Top


Adolescence is the transition period from childhood to adulthood. During this time, they achieve a unique identity. This involves gaining a clear sense of who they are, what they believe and the social and occupational roles they wish to pursue. Characteristics such as trust, autonomy, initiative and industry contribute to the sense of identity which has been evolving through the years of childhood. Adolescents have much potential and if nurtured appropriately, can contribute productively to society. However, as their emotions develop earlier than the thinking ability that generally stems from the prefrontal cortex, they tend to have emotional and physical outbursts and some even can become destructive.[1] Adolescents also tend to have the feeling of being abandoned and isolated and experience situations of being psychologically vulnerable.[2] Health and behavioural issues can occur as they prefer to listen to peers than parents/adults and would like to project their independence. In this article, we discuss selected psychological issues such as substance abuse, suicide, depression and social media addiction.


  Substance Use Disorder Top


The majority of unhealthy behaviours begin in adolescence and develop into habits and addictions, posing major challenges to public health. Substance abuse is one of the most addictive behaviours that can affect individuals, societies and communities and contributes to social, physical and many mental health problems. Substance abuse in adolescents can affect their brain development and cause major ill effects on health, leading to risky behaviours.

The Centre for Disease Control (CDC) reports that the substances commonly used by adolescents include alcohol, marijuana and tobacco.[3] The common drugs of abuse amongst children and adolescents in India are tobacco and alcohol, and they also include other drugs such as cannabis and heroin.[4]

Epidemiology

Globally, the consumption of illicit substances has increased and the age of onset of substance use is progressively falling.[5] The average age of onset for the use of tobacco was as low as 12 years, and another study revealed that 46% of slum-dwelling adolescents started consuming tobacco, alcohol and cannabis in childhood.[6] With easy access to smokeless tobacco, studies in the slums of Delhi have shown the age of initiation to be as low as 6 years.[7] A study found that most of the users had initiated substance abuse between the ages of 15 and 18 years of age.[8]

Risk factors

  • Substance use is influenced by multiple peer, individuals (depression and delinquency), family (poor parenting), school (location) and community.[9] The risk factors include favourable parental attitudes towards the behaviour, poor parental monitoring, substance abuse by parents, family rejection of sexual orientation or gender identity, association with peers who are delinquent or substance users, lack of school connectedness, low academic achievement, childhood sexual abuse, mental health issues and lower socio-economic status.[10] Existing literature also suggests that substance use in university students can be influenced by many risk factors, such as low harm perceptions, peer influences and coping with a difficult transition period.[11]


Clinical manifestations

Research shows that health problems were reported by 25.8% of respondents, followed by social problems (27.7%). The negative impact of substance abuse on academic performance was also high (23.8%).[12] The clinical manifestations of substance abuse include acting withdrawn, feeling tired frequently, depressed, poor grooming, absenteeism of school and family events, alteration in eating and sleeping habits and deterioration in family and peer relationships.[13]

Treatment

The possible modalities of treatment include multisystemic therapy, family therapy, multidimensional family therapy, behavioural therapy, cognitive-behavioural therapies, motivational approaches and pharmacological treatment which include drugs that reduce craving, euphoria and detoxification.[1],[14] The evidence-based principles given by the national institute of drug abuse, NIH[15] are given in [Table 1].
Table 1: Principles of adolescent substance use treatment

Click here to view


Adolescence is a critical phase of the neurodevelopmental process and abuse of drugs can induce brain plasticity such as long-lasting changes in neural circuitry in humans.[21],[22] The complications include overdose, accidental injury, attempted suicide, unemployment, accidents, suicide, mental illness and decreased life expectancy.[23],[24]

Prevention

Adequate parental supervision, monitoring and enhanced child-parent communication act as an important preventive measure against substance use. Efficient parent training with family skill-building and structured family therapy can also prevent illicit drug use among adolescents.[10] Parents, teachers and health-care professionals play a major role in assessing the adolescents' knowledge on substance abuse and providing factual information. Health-care professionals need to emphasise on problem-seeking behaviour and encourage involvement with self-help associations.


  Suicide Top


One of the disheartening truths that is coming to the forefront is suicide among adolescents. Hospital admission of children and adolescents with suicidal attempts is on the rise. During adolescence, individuals are impulsive and usually have a sense of urgency, and sometimes when they do not feel they belong to a social context, the only alternative they envision to solve problems is to put an end to their lives, that is, put an end to their psychological pain.[25]

Prevalence

The suicide of an adolescent affects his/her family, community and country and has significant effects on the people left behind. Suicide is a worldwide epidemic that affects people from all walks of life.[26] Suicide is the third-leading cause of death among 15 to 19 years old; 62,000 adolescents are estimated to die worldwide due to self-inflicted injuries. As per the National Crime Records Bureau 2020 report of India, 11,396 children died by suicide, an 18% increase from 9613 such deaths in 2019 and a 21% increase from 9413 in 2018.[27] According to the World Health Organization (WHO, 2017), suicide is the second cause of death in adolescents and young adults aged 15–29 years.[28]

Risk and protective factors

There are some risk factors that can lead to suicide. More than one cause may be identified often. Suicidal behaviour in adolescents also can be because of the impulsivity associated with immature neurological development that is already seen. However, some protective factors have been identified to be helpful in reducing the incidences of suicide in adolescents[29],[30] [Table 2].
Table 2: Risk and protective factors associated with suicidal behaviour

Click here to view


Adolescents may feel suicidal as a result of certain life circumstances, such as having a psychiatric disorder such as depression, or bipolar disorder, anxiety disorder, a family history of mood disorder, suicide or suicidal behaviour, a history of physical or sexual abuse or exposure to violence or bullying, a substance use disorder, access to means, such as firearms or medications, exposure to a family member or friend's suicide or loss of or conflict with close friends or family.[31] A previous suicide attempt is the most powerful risk factor for suicide. Among individuals who committed suicide, more than 50% of the victims had a diagnosis of depression.[32]Also feeling unheard, unrecognised, verbally expressing feelings were noted.

Research suggests that suicidal ideation was significantly higher among respondents who were boys and enrolled in public schools, had a mental health problem, a family history of suicidal attempts, lower self-esteem and higher depressive symptoms.[33]

Clinical manifestations or warning signs

Adolescents may be vocal about their thoughts and when talking or writing they make assertions such as 'I'm going to kill myself,' or 'I won't be a bother for you much longer.' Withdrawing from social contact, experiencing mood swings, increasing alcohol or drug use, feeling trapped, hopeless or helpless in a situation, altering normal routines such as eating or sleeping patterns, engaging in risky or self-destructive behaviour, giving away belongings, developing personality changes, becoming extremely worried or disturbed or being severely anxious or agitated are some typical warning signs. Joiner identified that a closely related experience, that of 'thwarted belongingness,' and found it to be a key factor in making completion of suicide possible.[34] Thwarted belongingness is a painful mental status when the adolescent's need to belong is perceived as unmet.[35]

Treatment

If a patient expresses a desire to die, cuts or participates in other types of self-harm, hospitalisation for evaluation/management is frequently the preferred option. The treatments are aimed at measuring and strengthening the adolescent's and the environment's qualities, as well as giving assistance for long-term care. Current literature points out that psychotherapy is beneficial and can help support the patient who is engaging in an internal process that can gradually lead to a changed perspective and greater hope for the future. One aspect of this process is a genuine acceptance of the actual conditions that precipitated the suicidal crisis.[36] When a psychiatric disorder is present, a combination of evidence-based psychotherapy and medication is likely to be useful.

Prevention

'LIVE LIFE' is a powerful phrase. The World Health Organization's approach to suicide prevention suggests the following essential evidence-based interventions:[22]

  • Identify, assess, manage and follow-up with anyone who has been affected by suicidal conduct as soon as possible
  • Restrict access to suicide methods (e.g. pesticides, firearms, certain medications)
  • Work with the media to ensure accurate suicide reporting
  • Adolescents' socio-emotional life skills should be cultivated
  • These must be combined with the core pillars of situation analysis, multisectoral collaboration, public awareness, capacity building, finance, surveillance, monitoring and evaluation
  • When a child is in severe pain or distress, parents can act as 'protective seatbelts' by improving the family's ability to keep the child safe and the child's willingness to accept this protection.



  Depression Top


Depression is a common mental health problem seen in all age groups. Depression/affective disorder is often associated with significant disability and leads to mental and emotional disorders in adolescents. It is considered to be one of the leading contributors of the global disease burden.[37]

Prevalence

Globally, one in seven 10–19 years old experiences a mental disorder. In adolescents, the most common problems such as anxiety and depression affect mental health. Adolescents undergo some degree of stress and anxiety due to their physiological and hormonal changes during this phase of their life. The developmental changes which occur from preadolescent childhood to adulthood clearly are associated with anxiety symptoms and anxiety disorders.[38],[39] In one of the South Indian studies, the prevalence of depression among high school adolescents was reported as 40.8% and anxiety was 54.7%.[39] Depression is recognised as a serious psychiatric illness with extensive acute and chronic morbidity and mortality. Research shows that only 50% of adolescents with depression are diagnosed before reaching adulthood.[40]

Risk and protective factors

It is difficult to identify a single cause of depression in adolescents as many factors may interact and contribute to the occurrence of depression. Serotonin depletion is said to have a biological effect on the occurrence of depression.[41] Genetic and familial factors influence childhood depression. Depression in twin siblings increases the risk of depression.[42] Children of parents with depression have three to four times increased risk of depression compared to those whose parents are normal.[43] Exposure to adverse life events such as personal physical trauma, loss, bullying by peers, strained family relationships and poverty can lead to depression.[44] The risk is higher if there is an associated inherited risk. The onset of depression due to stressful life events is higher in girls[45] than boys and those who have multiple risks.[46] Depression is also highly likely when children go through situations such as war, disaster or displacement.[47] In addition to these factors, a systematic review of studies done in India reported academic and education-related factors such as not performing well at school, parent dissatisfaction of academic performance, teasing at school, school stress, final year at school, high expectations, failure in examinations, etc., and family factors such as punishment, rejection and deprivation of privileges as some factors associated with depression in adolescents.[48]

Individuals with high intelligence, better coping and emotional regulation capacities and thinking styles have shown resilience to depression even within high-risk conditions. Good interpersonal relationships, especially a warm and supportive parent-child relationship has been consistently associated with good mental health. Quality of peer support is yet another predictor of depression resilience in adolescents.[49]

Manifestations

The clinical manifestations may vary between adolescents and can be often a combination of many. Sometimes the symptoms may be subtle and therefore may be missed for a long time. The systematic review of the Indian studies presents a comprehensive list of symptom profiles.[48] Adolescents may have emotional symptoms such as feelings of sadness, crying spells without reason, frustration, irritability anger for simple things, hopelessness, guilt, self–dislike, loss of interest in play or activities of interest, feeling worthless, low self-esteem, problems with concentration, thinking, decision-making and death wishes. They may have suicidal thoughts and may vocalise such thoughts or make plans to attempt suicide. They may exhibit loss of appetite, anhedonia, lack of personal hygiene and complain of somatic symptoms such as headache, abdominal pain or chest pain. Behavioural changes include insomnia or too much sleep, tiredness, restless behaviour such as pacing, hand wringing, use of alcohol or drugs, angry outburst and aggressive behaviour.[50] Adolescents who are depressed tend to avoid socialising and have poor interaction with peers and family members and sadness and lack of or loss of interest in regular and meaningful earlier activities are the most highly reported and also the common symptoms that indicate the onset or presence of depression.[48]

Treatment

The treatment of depression in adolescents and children is still being evaluated. Psychological treatments such as behaviour/behavioural activation therapy, cognitive therapy, problem-solving therapy, acceptance and commitment therapy, emotion-focussed therapy and interpersonal psychotherapy are found to have moderate-to-strong evidence of effectiveness in moderate-to-severe depression.[28],[51] Psychosocial interventions such as family interventions, peer support, support with daily activities and support from the community and school are useful in adolescents with mild depression. Much debate concerning the use of standard medications in children and adolescents has led to different choice of medication use as treatment. Tricyclic antidepressants such as imipramine, chlorpromine and amitriptyline are argued not be effective and also have side effects such as cardiotoxicity. Fluoxetine, a serotonergic antidepressant, is preferred as a choice for adolescents with depression as it is found effective.[52] Fluoxetine with cognitive behaviour therapy (CBT) is found to be most useful in moderate-to-severe depression. Medication use had to be judiciously planned for adolescents with depression.[53]

Studies suggest that 12%–13% of children and adolescents receiving ECT have been diagnosed with depressive disorders and that ECT is effective in most of these adolescents, especially those who are resistant to other therapies.[54]

Prevention

Considering the enormity of the problem prevention measures should be set at all levels to protect adolescents from becoming depressed. Both educational and psychological approaches are found useful in the prevention and the schools are suggested as the best context for rolling out these programmes.[55] Educational interventions include creating awareness about depression and risk factors, the importance of seeking help, information on helplines and self-management approaches related to lifestyle. Psychological approaches include courses and training on interpersonal therapy, coping with stress, bibliotherapy and family adjustment and support.[56] Developing social and emotional habits for mental well-being, encouraging healthy sleep patterns; exercising regularly; developing coping, problem-solving and interpersonal skills; and learning to manage emotions within a protective and supportive environment in the family, at school and in the wider community are important.

In addition to these strategies, early identification of depression, early intervention, psychoeducation, appropriate assessment and referral for therapies, planning for suicide risk reduction and guidance in medication/therapy adherence are vital to reducing morbidity and mortality related to depression.[56]


  Social Media Addiction Top


Introduction

The use of social media is a global issue that has been on the rise in recent years. Children and teenagers are heavily exposed to numerous media, including the Internet for learning new knowledge, attending online classes, performing online shopping and online payment. Using social media platforms such as Instagram, Whatsapp and Facebook for communicating with known and unknown friends have become common. Social media has become an important part of children's and young peoples' daily lives, and increased use of media may lead to media addiction and have a negative impact on children's general health. Research suggests that 92% of 13-to17-years old go online daily and have at least one social media account.[57]

Prevalence

According to research from 2020, India had 580 million social media users, with the number predicted to rise to nearly 1.5 billion by 2040. Facebook is the most popular social networking platform among children. In India, psychiatrists see around 10 teenagers under the age of 12 who are addicted to social media every week.[58]

Influencing factors

Some of the risk factors for children's social media addiction include male gender, 1st year of coursework, permanently logged-in status, peer influence, preference for virtual engagement with friends, and use of the Internet for talking, forming new friendships, entering into online partnerships and online buying.[58]

Symptoms and signs

Children's signs and symptoms of social media addiction can take the form of both physical and emotional manifestations.[59] The symptoms are outlined in [Table 3].
Table 3: Signs and Symptoms of Social Media Addiction

Click here to view


According to a literature review on online social network site addiction, higher or distorted social media use is reported to be linked to many emotional problems such as depression, anxiety and low self-esteem, relational problems such as social withdrawal, poor concentration, conflicts with family members and jealousy health problems such as poor sleep quality, poor exercise and body images issues, performance problems such as poor academic contribution and work-related problems.[60]

Treatment and management

CBT has been effectively used in modifying behaviour of social media use where the person is taught to use alternate thoughts and processes to overcome problem behaviour. Another intervention is motivational interviewing that involves examining the current behaviour status and delineating the optimal behavioural objective and working towards resolving the discrepancy between the two. The main aim of motivational interviewing is to discover the negative aspects of the behaviour and enabling the internal motivation strategies to change.[61]

Self-help therapy such as not logging on to social network at school hours, no phone during study or school hours, allotting specific time for using social media platforms or gadgets and reducing use during sleep may be useful interventions for adolescents.[60]

Prevention

Techniques which need to be employed for adolescents to relieve social media addiction are:[57]

  1. Parents should monitor their children's online activity and set a time restriction for them
  2. Encourage the child to turn off his or her phone's notifications
  3. Encourage the adolescent to interact with people and participate in real-life activities
  4. Involve them in open talks and outside activities
  5. Adults, especially parents and teachers should be role models both online and offline
  6. Healthy online social networking policies and protocols should be implemented in educational institutions and work environments.[60]


The Internet is a widely used tool known to foster addictive behaviour, and Internet addiction threatens to develop into a major public health issue in the near future in a rapidly developing country like India. Majority of the teenagers are addicted to social networking sites and hence, steps should be taken to create awareness to the teenagers and their patents regarding the addictive behaviours and risk factors associated with the usage of social networking sites.[62]


  Conclusion Top


Psychosocial issues not only affect thought and behaviour but also affect the overall health and well-being of the adolescent. Unfortunately, it is challenging for the adolescent and the family to overcome psychological issues and its effects. Therefore, prevention and early identification of risk factors are the keys to combatting the negative effects of the psychological and emotional problems. A non-judgemental empathetic attitude coupled with opportunities for open and supportive communication in the contexts of family and school will assist adolescents in identifying solution options if and when there is a problem. Health-care providers should screen for psychosocial issues on any point of contact with the adolescents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

CE Test No. 42- Questions


  Psychological Issues in Adolescents Top


  1. The commonly abused drugs amongst children and adolescents in India are


    1. Cannabis and Heroin
    2. Heroin and Tobacco
    3. Tobacco and Alcohol
    4. Alcohol and Cannabis


  2. An adolescent is admitted to the psychiatric unit with a diagnosis of major depression. To create a safe environment the nurse most importantly devises a plan of care that deals specifically with the adolescent's


    1. Disturbed thought process
    2. Imbalanced nutrition
    3. Self care deficit
    4. Deficient knowledge


  3. One of the major factors that strongly predict better outcomes in adolescents with psychological problems is


    1. Higher level of intelligence
    2. Good social background
    3. Higher social support
    4. Higher levels of education


  4. When treating adolescents with substance use disorder, they should be assessed for other mental health problems such as suicidal ideation, psychosis and problem behaviours. The important reason for doing such assessment is because


    1. There is a link between drug use and suicides in adolescents
    2. Child abuse at an early age strongly predicts substance abuse
    3. The adolescent and the problem behaviour should be looked at separately
    4. Majority of the adolescents with mental health problems are substance users


  5. The nursing care of an adolescent with substance use includes:


    1. Showing an attitude of acceptance, separating the adolescent from the unacceptable behaviour.
    2. Providing factual information and answering questions honestly
    3. Involving the family in the development of a treatment plan, using their problem-solving process
    4. Administering Antabuse, craving-suppressing opioids, and antipsychotic medications as per order.


    1. 1, 2, 3 b. 1, 2, 4 c. 1, 3, 4 d. 1, 2, 3, 4


  6. The important factors that predispose an adolescent to commit suicide are the following except


    1. Impulsive nature
    2. Psychiatric illness
    3. Previous suicide attempt
    4. High economic status


  7. A depressed adolescent female verbalizes feelings of low self-esteem and self-worth typified by statements such as “I'm such a failure… I can't do anything right!” The best nursing response would be to:


    1. Tell her this is not true; that we all have a purpose in life
    2. Remain with the her and sit in silence; this will encourage the client to verbalize feelings
    3. Reassure her that you know how she is feeling and that things will get better
    4. To identify recent behaviors or accomplishments that demonstrates skill ability


  8. Which of the following manifestations of an adolescent is suggestive of an upcoming suicidal attempt?


    1. Saying, I won't be a bother for much longer
    2. Changes in sleeping pattern
    3. Giving away belongings
    4. Cessation of alcohol


    1. 1, 2, 3 b. 1, 2, 4 c. 1, 3, 4 d. 1, 2, 3, 4


  9. The core pillars in the prevention of suicide among the adolescents are the following except


    1. Situation analysis
    2. Capacity building
    3. Discipline forming
    4. Surveillance and monitoring


  10. An educational approach used in the prevention of depression among adolescent is


    1. Encouraging healthy sleep pattern
    2. Training on interpersonal therapy
    3. Bibliotherapy
    4. Information on help lines


  11. In conferring with the treatment team in the out patient department, the nurse should make which of the following recommendations for an adolescent who tells the nurse that everyday thoughts of suicide are present?


    1. A no-suicide contract
    2. Weekly outpatient therapy
    3. A second psychiatric opinion
    4. Intensive inpatient treatment


  12. Stressful life events lead to depression more likely in


    1. Boys
    2. Girls
    3. Both are equally affected
    4. None are affected


  13. Which of the following statement about psychological problems in adolescents is true?


    1. Adolescents who have developed ability to regulate their emotions have better resilience to depression
    2. Neuroplasticity of the brain enhances relief from drug addiction
    3. Adolescents who are unwilling for therapy do not benefit from treatment when provided
    4. Higher media use increases self – esteem in adolescents


  14. Symptoms such as anhedonia, poor personal hygiene, insomnia, and loss of appetite in adolescents is suggestive of


    1. Substance use disorder
    2. Suicide
    3. Social media addiction
    4. Depression


  15. The drug of choice for the treatment of depression among adolescents is


    1. Imipramine
    2. Chlorpromine
    3. Fluoxetine
    4. Amitriptyline


  16. Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using?


    1. Compensation
    2. Denial
    3. Suppression
    4. Undoing


  17. The emotional manifestations of an adolescent with social media addiction is


    1. Insomnia
    2. Euphoria
    3. Body image distortion
    4. Carpel tunnel syndrome


  18. The most effective modality of treatment for an adolescent with social media addiction is


    1. Cognitive behavior therapy
    2. Psychotherapy
    3. Mileu therapy
    4. Pharmacotherapy


  19. The techniques that can be used to relieve social media addiction among adolescents include


    1. Parents monitoring their children's online activity and set a time restriction for them
    2. Encouraging the adolescent to interact with people and participate in real life activities
    3. Involving them in open talks and outdoor activities
    4. Parents and teachers being role models both online and offline


    1. 1, 2, 3 b. 1, 2, 4 c. 1, 3, 4 d. 1, 2, 3, 4


  20. The following characteristics of an adult towards adolescents will assist in combating negative effects of psychological problems among adolescents, except


    1. Non-judgmental attitude
    2. Closed communication
    3. Supportive caring
    4. Empathetic attitude


Answers for CE Test no 41

Adolescence: An Overview of Health Problems

1. A

2. B

3. B

4. A

5. C

6. D

7. A

8. D

9. B

10. C

11. D

12. B

13. A

14. D

15. B

16. A

17. C

18. C

19. D

20. B

CE Test No: 42

Psychological Issues in Adolescents

Select the best answer and shade the circle against the suitable alphabet in the answer form provided.

ANSWER FORM





 
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Introduction
Substance Use Di...
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Depression
Social Media Add...
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