Youth Substance Use and Co-occurring Mental Health Concerns

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For this podcast, we are joined by Dr. Jillian Halladay, registered nurse, clinical epidemiologist, and winner of ACAMH’s Research Trainee of the Year Award 2021.

Jillian begins by commenting on what it meant to her to have received the ACAMH Research Trainee of the Year Award in 2021, before providing us with an insight into her research examining the co-occurrence of substance use in youth in general and in acute clinical settings.

As principal investigator with the CAMP study, which sought to determine the feasibility of administering a standardized mental health and substance use assessment amongst youth admitted to the inpatient psychiatric unit, Jillian tells us more about the study, its findings, and whether she envisions the standardisation being rolled out.

Having published several papers on student mental health and substance use, Jillian also discusses the importance of schools and teachers on youth mental health and substance use, plus provides insight into what types of schools had high co-occurrence of mental health and drug use based on her research.

Jillian then comments on her involvement in the development, implementation, and evaluation of a mental health literacy program for post-secondary staff, faculty, and graduate teaching assistants called Professor Hippo-on-Campus, plus discusses other recent research projects that she has been involved in.

Furthermore, with Jillian’s clinical and research roles being grounded in identifying, contributing to, and utilizing the best available evidence to improve the lives of youth, Jillian discusses how to go about translating evidence-based research into practice to really make a difference to young people.

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Dr. Jillian Halladay
Dr. Jillian Halladay

Jillian is a Registered Nurse, Clinical Epidemiologist, and current PhD candidate in Health Research Methodology (HRM) at McMaster University, focusing on examining the co-occurrence of substance use and mental health concerns among youth by using diverse epidemiological methods. Through HRM, Jillian is part of Dr. Kathy Georgiades’ research lab at the Offord Centre for Child Studies. Jillian has clinical experience related to inpatient, emergency, and outpatient youth mental health and substance use. Jillian is also a Research Associate at the Peter Boris Centre for Addictions Research leading program development and evaluation for a novel Emerging Adult Substance Use Program. Jillian’s clinical and research roles are all grounded in identifying, contributing to, and utilizing the best available evidence to improve and optimize the lives of youth. (Bio from


[00:00:32.050] Jo Carlowe:  Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I am interviewing Dr. Jillian Halladay, registered nurse, clinical epidemiologist, and winner of ACAMH’s 2021 Research Trainee of the Year Award.

Jillian recently defended her PhD in health research methodology at McMaster University in Canada and will soon begin a postdoctoral fellowship at the Matilda Center for Research in Mental Health and Substance Use with the University of Sydney in Australia.

If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review, and do share with friends and colleagues.

Jillian, thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[00:01:24.255] Dr. Jillian Halladay: Yes, Thanks so much for having me here today. As you mentioned, I’m first trained as a nurse, and I practice as a nurse for 6 and 1/2 years in child and youth mental health. So on an inpatient unit, in psychiatric emergency, and then an outpatient brief substance use counselling. And over time, I’ve transitioned from being predominantly focused on nursing practice with a bit of research sprinkled in to now being entirely focused on research and program development.

So broadly, my research has been focused on co-occurring substance use and mental health concerns among youth, so that includes adolescents and emerging adults or young adults. And I look at co -occurrence from multiple perspectives, including trends of co-occurrence in the general population or in clinical samples, exploring school environments as important context, and then also thinking about the implementation of clinical assessments and actual interventions for youth substance use concerns as well.

[00:02:26.070] Jo Carlowe: Great. Thank you, and how did you come to be interested in child and adolescent mental health?

[00:02:32.100] Dr. Jillian Halladay: Yeah, so I think I got to where I am today due to a series of happy coincidences and connecting with really kind, supportive, and brilliant mentors over the years who have helped me find and create the opportunities that have ultimately led me to a career in youth mental health research. So I always liked working with kids. I worked at camps, I was a gymnastics coach for quite some time, and I had gone into nursing to want to do paediatric oncology.

Through nursing, I liked the theory and the science, but I struggled with connecting to the role of a bedside nurse in a medical setting. It wasn’t until later in my nursing undergrad that I ended up having a placement on an adult psychiatry unit that I really enjoyed and felt like I had found that place where I was going to be able to make the most difference and help the most people.

And from that came two key things. So first, after nursing school, I combined that long standing desire to work with kids with this newfound passion for psychiatric nursing and applied for and got a nursing job on an inpatient youth mental health unit. And then also, this is the coincidental piece. During that placement, I had interviewed the University’s mental health nurse for the end of semester project, and I ended up sending her a thank you card on the day that she was allowed to hire a student for a center depression quality improvement project at the center.

So I ended up being hired for that role and then that kind of launched me into research related to youth mental health. So it’s just been that combo of exploring values, my purpose, practical learning opportunities, and then just really great mentors.

[00:04:17.893] Jo Carlowe: Brilliant. So it all came together really neatly.

[00:04:21.570] Dr. Jillian Halladay: It did, yes. But I wouldn’t have been able to tell you that 10 years ago that I would be here.

[00:04:28.290] Jo Carlowe: Jillian, you won ACAMH’s 2021 Research Trainee of the Year Award. What did it mean to you to have received that recognition?

[00:04:36.147] Dr. Jillian Halladay: Yeah, it was such an honour to receive that award. And it came at a time when I was entering the final year of my PhD, preparing for that transition out of graduate school, and also during COVID, when there’s a lot of disconnection. So it really reaffirmed that I was on the right trajectory to actually be able to make real and meaningful changes in the lives of youth and increase my confidence in my future and in child and adolescent mental health research.

[00:05:08.090] Jo Carlowe: Let’s dig in to some of your research, in your dissertation, you examined the co-occurrence of substance use in youth in general and in acute clinical settings. Can you set the scene for us? What can you share of your research?

[00:05:23.330] Dr. Jillian Halladay: Yeah, so the overarching goal of my dissertation was to deepen our understanding of the patterns of co-occurrence of substance use and mental health symptoms among adolescents, and that was met through three core papers. So the first paper was a systematic review and meta synthesis of 70 cluster-based studies that examined patterns of multiple substance use. The second paper was a multilevel latent profile analysis and regression that used a large representative sample of secondary students in schools across Ontario and Canada to look at those patterns of co-occurrence, at both the student level and at the school level, and then see if there were any school correlates that predicted those certain patterns.

And then the last paper was a pilot study examining the feasibility of a standardized assessment of substance use and mental health symptoms on an adolescent psychiatric inpatient unit.

[00:06:22.907] Jo Carlowe: Tying in with your dissertation, you were the principal investigator with the CAMP study, which sought to determine the feasibility of administering a standardized mental health and substance use assessment amongst youth admitted to the inpatient psychiatric unit. The study also looked at prevalence of substance use in this group compared to the general population. What more can you tell us about the camp study and its findings?

[00:06:49.710] Dr. Jillian Halladay: So that was the third core paper of my dissertation, and the CAMP study had both youth and front-line staff components. So the primary part of the youth components was that standardized electronic self-reported assessment during their hospitalization. And then secondary parts included a six month follow up assessment, as well as clinical chart reviews to get some insights from clinician notes, as well as from administrative visit history data, and then the front-line staff component was a survey with both closed and open-ended questions around youth substance use on the inpatient unit.

So the ultimate key finding given this was a pilot feasibility study was that collecting this standardized self-reported electronic data in an inpatient setting proved feasible and clinically important in this context. So we were able to recruit 100 youth quickly with a good response rate of about 80% of all eligible youth. We had little participant and staff burden with the assessment only taking on average 13 minutes to complete.

It was highly acceptable to the front-line staff who really thought that substance use was important and common among youth who were admitted to the unit, despite this not being a concurrent disorders unit and often youth with substance use disorders aren’t admitted. So that’s not a primary reason why youth would be admitted, and they had suggestions about how to improve assessment and interventions, including adoption of standardized assessments.

And then lastly, and probably most interesting, although it’s in that small sample of 100 are that related to the scientific outcomes, substance use assessments appeared to be clinically important in this context. So first, substance use was the norm and not the exception, so 79% of youth had used at least one substance in their lifetime, with 69% of youth using in the three months prior to their admission, suggesting universal assessments are merited in this context.

There was also really high frequency of use. So, 18% of youth reported daily cannabis use, 14% reported daily cigarette use, which is about eight to nine times greater than what we see in the general population in Ontario. And then also suggest that a non-negligible proportion of youth may be at risk of withdrawal while they’re on the unit. As they’re typically admitted for seven to eight days without access to substances and given that withdrawal symptoms for cannabis and tobacco are mainly emotional and behavioural symptoms, that might cloud or get in the way of accurate diagnostic assessments or treatment on the unit if it’s not considered.

And then substance use was also correlated with a variety of mental health related clinical indicators at their time of admission. So associated with greater symptom severity, greater complexity in terms of the number of different types of symptoms and disorders that youth were presenting with, and then also correlated with repeat mental health-related hospital visits as well.

[00:10:05.003] Jo Carlowe: Do you think mental health staff are aware of some of these issues you’ve brought up? The greater prevalence and the impact of withdrawal, and so on?

[00:10:15.730] Dr. Jillian Halladay: Yeah, so the frontline staff component, it definitely came out a lot that the staff were aware that this was something that a lot of the youth were struggling with when they came and felt like they wanted more standardization and training to be able to assess and address it better. And in this local context, that ended up happening after this study, but it’s not necessarily a widespread standardized approach to really comprehensive substance use assessments or training for these mental health professionals or interventions in this setting either.

[00:10:52.690] Jo Carlowe: Do you envisage that standardization being rolled out?

[00:10:57.310] Dr. Jillian Halladay: So in this local context, it was rolled out in a bit of a different capacity. So it wasn’t– so for the camp study, we ended up doing it on an iPad essentially, where the youth were self-reporting and it happened quite quickly. What’s happened so far in this context is that the nursing assessment just became more comprehensive, so it’s an interview administered standardized approach, but it is a lot more comprehensive than it was at the outset and then has also more standardized response options, and I know that there has been some movement to thinking about how can those more electronic assessments be integrated that’s embedded into clinical care, as opposed to it requiring a research staff to deliver it.

[00:11:44.588] Jo Carlowe: You’ve published several papers on student mental health and substance use as you’ve told us. This includes a paper on teacher student relationships and adolescent mental health help seeking in elementary and secondary school. Using the same data, you’ve also looked at the patterns of co-occurrence of substance use and mental health concerns among school children and adolescents and you’ve co-written a practice guide related to student cannabis use for school mental health providers.

Can you tell us something about the importance of schools and teachers on youth mental health and substance use?

[00:12:20.320] Dr. Jillian Halladay: Schools are such critical context for substance use and mental health prevention and that early identification of who might be struggling or perhaps early intervention, especially given adolescents spend a majority of their time in schools. And we see that school environments can account for up to 20% of the variability in adolescent substance use, and so one of my papers found that the probability of students experiencing substance use and co-occurring mental health symptoms significantly differed depending on the school that they attended.

And we could identify certain types of schools based on those patterns, and then we also looked at aspects of a school’s social environment that might predict certain patterns of co-occurrence, such as positive school climate, school belongingness, school safety, and those were consistently associated with an increased odds that students would be in that low-risk group. So low in substance use and low and mental health, compared to all the other patterns.

So the school environments themselves are really important and powerful things, even if we’re not directly addressing substance use but addressing connection and sense of belongingness and safety. And then at the teacher level, teachers can play that important role of potentially being the first person to notice that a student is struggling and being able to have those conversations with a student if they have that connection and help them get connected to the right services.

So help facilitating those mental health help seeking behaviours. And one of our papers did show that if teachers are responsive to those emotional concerns and have good relationships with students, those students tend to be more likely to seek help for their mental health concerns. And then lastly are the school mental health professionals. So at least in Ontario, school-based mental health services are one of the most common sources of mental health care for adolescents.

So this might be the only mental health provider youth are seeing or perhaps their first. So these school mental health professionals can play that important role in assessing and potentially addressing, depending on their capacity, or referring to the appropriate community services as well.

[00:14:41.350] Jo Carlowe: Just taking a step back to something you said earlier. What types of schools had high co-occurrence of mental health and drug use?

[00:14:50.983] Dr. Jillian Halladay: Yeah, so I think the most striking thing that we’ve found– and this paper is currently under review, but the most striking thing that we found was that rural schools were disproportionately more likely to be in the higher risk types of schools. So, the lower risk schools are the schools that had lower proportions of adolescent substance use and co-occurring symptoms. None of those schools were in rural areas. So, there was a lot higher numbers of rural schools in the other settings as well, and we see that most of our interventions are mainly created for and driven by urban settings and are delivered and evaluated in urban schools, and some things just don’t work in rural settings.

If you have to drive an hour to school, for example, and you don’t have a way home except for the bus, you perhaps can’t stay after to engage in an extracurricular activity to get that sense of belonging. Now, our paper can’t answer the reasons why, but those were some of our hypotheses around why there might be that disproportionate representation of rural schools and more a higher risk environment.

[00:16:01.030] Jo Carlowe: Jillian, you’ve also been heavily involved in the development, implementation, and evaluation of a mental health literacy program for post-secondary staff, faculty, and graduate teaching assistants called Professor Hippo-on-Campus. What can you tell us about this scheme?

[00:16:18.370] Dr. Jillian Halladay: So, the Professor Hippo-on-Campus program is a mental health literacy intervention for post-secondary faculty and staff that was created at McMaster and led by Dr. Catharine Munn. And the program title refers to the hippocampus. It’s our play on words a little bit, and it was also one of the key characters in the module. So, there’s a Professor Hippo who then tells a story or helps kind of deliver that mental health literacy information.

And the program was designed specifically with emerging adults and post-secondary needs and culture in mind and trying to educate about mental health broadly, including how to create a mental health positive educational environment, training on potentially how to triage or support students who are in difficulty and distress, and increasing knowledge of our campus specific resources, as right now it’s just at McMaster.

And we have two ongoing evaluations. One is for our full Professor Hippo program for faculty and staff. It’s a three-hour virtual asynchronous series of modules and then an optional two hour workshop to apply the learning, and then we have a graduate teaching assistant version as well that’s a one hour e-module and then also that two hour practical workshop.

And preliminary results for both of these are showing at least pre post improvements and knowledge, reductions in negative attitudes, reductions in stigma, and most notably, increases in confidence in people’s knowledge, their ability to respond and support a student in need. And so yeah, we’re hoping to continue that evaluation and hopefully scale it up as well.

[00:18:03.953] Jo Carlowe: What other recent research projects have you been involved with that been important to mention?

[00:18:09.130] Dr. Jillian Halladay: So I have been really heavily involved in the development, implementation, and evaluation of an outpatient program with the Peterborough Center for Addictions Research and St. Joseph’s Healthcare Hamilton called the Young Adult Substance Use Program, or short version of that is YASUP, and this program is for emerging adults who are about 17 to 25 years of age who are looking to make changes in their substance use. And this is a really critically important period given emerging adults experience the highest prevalence and incidence of substance use disorders and co-occurring disorders, and this occurs alongside a lot of neurodevelopmental and psychosocial changes.

And also in Canada, the transition from paediatric to adult health care systems, which often youth fall through the cracks and then the adult services are more geared towards older adults or middle aged adults, and they don’t necessarily feel like they fit in that context. And similarly with research as well. Most of our research is on adolescent interventions or adult interventions, so it’s an expanding field of emerging adults, but we’re definitely a bit behind when we compare to adolescents and adults in terms of what works best for this group, how to best engage them and care and treat it early so it doesn’t necessarily end up being more of a chronic problem.

[00:19:35.890] Jo Carlowe: Your clinical and research roles are all grounded in identifying, contributing to, and utilizing the best available evidence to improve the lives of youth. How do you go about translating evidence-based research into practice to really make a difference to young people?

[00:19:53.880] Dr. Jillian Halladay: That is a great question and the golden ticket question I think all researchers are looking for. So, I do my best to try to mobilize my research in a number of different ways. So, in addition to your typical conferences or research papers, I also aim to do stakeholder-specific presentations or infographics or reports. So, for the camp study, for example, I created a visual report or summary of the findings.

And then also did a couple of lunch and learns that were specifically for the staff and the leadership on the unit where the research was being done, and then the camp study, which I think is a really important part of the camp study is that it was co-developed and co-interpreted alongside frontline clinicians and leadership on that specific unit, which I think really led to how it actually ended up making some changes, at least at the local level.

And I hope that moving forward I can integrate more youth engagement and co-development into those projects and working with teachers from the outset, for example. And then the other way is that I also– as we’ve talked about– try to participate in a number of programs and projects that are action first and research second, or where we’ve combined the two. So, for example, the Professor Hippo program is based on a lot of evidence, but we have implemented it before we have done a randomized controlled trial, for example.

So we are evaluating as we go, but making sure that we’re doing something as opposed to the formal evidence before we go. And then the same with the young adult substance use program. Again, we spent a number of months– I think nine months– in terms of doing literature reviews, looking at best practices, doing a lot of consultations with various stakeholders to create this program, but nobody’s necessarily evaluated the specific program yet and we’ve integrated a measurement system or measurement based care system into the program so that we can both use that to inform the direct patient care but then also inform research more broadly as well.

[00:22:04.383] Jo Carlowe: Jillian, what are your plans for your academic career going forward?

[00:22:08.595] Dr. Jillian Halladay: I hope I can continue to contribute to bridging those silos between youth substance use and mental health research by building a comprehensive program of work that looks at general trends, prevention, and early interventions for co-occurring problems among youth. So, hoping to continue expanding that program.

[00:22:29.755] Jo Carlowe: And is there anything else in the pipeline for you that you’d like to tell us about?

[00:22:34.490] Dr. Jillian Halladay: Yeah, so a couple of papers we chatted about today are currently under review or close to submission. That will hopefully be available soon. So, like the Professor Hippo paper, a couple of YASUP related development and quality of life papers, and then some of those substance use and mental health school papers as well. And then the transition to work in collaborations at the Matilda Center, I’m sure, will bring a lot more in the pipeline.

[00:22:59.480] Jo Carlowe: And finally, Jillian, what is your takeaway message for those listening to our conversation?

[00:23:04.820] Dr. Jillian Halladay: So, I usually and most of my presentations with the comment that youth can’t wait. So given government interest and population need, practice and policy change need to be proceeding concurrent with research regarding youth substance use and co-occurring mental health concerns. We have enough to start, and it needs to evolve and get more comprehensive, but we can’t wait for that to happen before we act.

[00:23:31.513] Jo Carlowe: Thank you. Such an important point to emphasize. Jillian, thank you so much. For more details on Jillian Halladay, please visit the ACAMH website, and Twitter @acamh. ACAMH is spelled A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

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