Juan’s (a pseudonym) eldest son began using cannabis at just 15 years old. At 17, he started his long journey through addiction treatment units. Now 22, he has been treated numerous times in the psychiatric unit of his local hospital for bipolar disorder, dual diagnosis, and suicide attempts, and is currently hospitalized again in serious condition. “Looking back, our son probably had textbook ADHD [Attention Deficit Hyperactivity Disorder], but schools weren’t and still aren’t equipped to detect it, so his journey has likely been ADHD, bullying, cannabis addiction, and bipolar disorder,” he explains.
Over the years, Juan, a member of Asepadual, an association that brings together families of patients with dual diagnoses from all over Spain, has had to hear countless times that his son lacks the willpower to overcome his addiction. “The guilt associated with a lack of willpower in the case of addictions arises because most people think that addiction is a freely chosen risk, at least initially, while mental disorders like depression just happen to you. So, if you started using of your own volition, you must stop that addiction of your own volition, which is impossible without the necessary help,” he reflects.
Scientific evidence has long demonstrated that addiction—with or without substances—is not a matter of willpower, much less a vice, but rather a mental disorder, like depression, bipolar disorder, or schizophrenia. However, the idea that when a person is addicted to a substance, it is by their own free will, remains prevalent. “If they don’t quit, it’s because they don’t want to,” is a common refrain. This is an argument that would be unthinkable to hear applied, for example, to depression.
“That some people are more susceptible to addiction than others is evident in clinical practice. Some people use drugs once, then again, and again without becoming addicted, while others can’t quit from the very first time,” says Celso Arango, head of the Child and Adolescent Psychiatry Service at La Paz University Hospital in Madrid. “Substance use disorder used to be thought of as a behavioral problem or a consequence of bad influences, not a mental illness and therefore a brain disorder, which can begin long before its typical symptoms appear. But scientific evidence is increasingly showing us that addiction isn’t about choice—no one chooses to be an addict—but rather about having a predisposition to develop the disorder,” adds Néstor Szerman, from the Institute of Psychiatry and Mental Health at Gregorio Marañón Hospital in Madrid.
Despite this, the idea that there may be pre-existing brain differences—derived from genetics and early life experiences, especially adverse ones—that predispose a person to early substance use and addiction seems not to have taken hold socially, and even among many medical professionals. However, there is growing evidence pointing in that direction. A study funded by the U.S. National Institutes of Health, using data from nearly 10,000 adolescents, demonstrated through MRI scans that there are neuroanatomical characteristics visible at ages 9-11 that can be associated with early substance use before age 15, which is a marker of greater vulnerability to addiction throughout life.
Among these differences are a thinner prefrontal cortex, which, according to Néstor Szerman, could imply a “lesser development” in key regions for impulse control, emotional regulation, decision-making, or the inhibition of risky behaviors; and a larger overall and subcortical volume, which, for the president of the Dual Pathology Foundation, could be related to personality traits such as sensation seeking, greater emotional reactivity, differences in reward processing or memory, which could also favor the adoption of risky behaviors.
“These differences should be understood as probabilistic markers of risk, and not as deterministic indicators of future substance use problems,” Alex Miller, lead author of the study, explained to EL PAÍS. According to the adjunct professor of psychiatry at Indiana University, the differences in these brain structures would explain “only a fraction” of what distinguishes teens who have used substances from those who have not during this stage, and in no way determine which of these young people will eventually develop substance use problems.
Another study, recently published in Nature Mental Health, has found that children with a family history of substance use disorder already show distinctive patterns of brain activity that could reflect a predisposition to addiction. These patterns, the research also shows, differ between boys and girls, something that, as Arango points out, also coincides with what psychiatrists observe in clinical practice. “These findings could help explain why boys and girls often follow different paths toward substance use and addiction. Girls may find it harder to slow down, while boys may find it easier to accelerate when it comes to risky behaviors and addictions,” said Amy Kuceyeski, one of the study’s authors, in a press release.
Change prevention policies
For Néstor Szerman, the results of these studies support a long-standing demand of the Dual Pathology Foundation: that mental health prevention be based on scientific evidence and “not on opinions, values, morals, or ideology.” “These may be important in family education, but it cannot guide public health prevention,” he maintains. In this regard, he emphasizes the importance of identifying the population at risk of developing addictions and other mental disorders: “While we wait for biological markers of risk, which, given the advances in technology and AI, doesn’t seem too far off, we can try to identify young people with a high density of mental disorders, including, of course, addictions, within their biological families of origin,” he recommends.
Arango shares this opinion, believing it’s currently impossible to perform the same MRI scans used in the aforementioned studies on all children. “These tests remain largely confined to the realm of research, without any practical application in selective primary prevention at the moment,” he argues.
The psychiatrist hopes that these studies will increasingly reduce the stigma faced by people with addiction, and that they will dispel the misconception that addiction is a choice. He also hopes that this research will prompt the relevant authorities to reconsider the medical care offered to people with addiction and other mental disorders. “In all these studies, we see that a high proportion of addictions occur alongside other mental disorders such as depression, anxiety disorders, psychosis, ADHD… However, in many places, these individuals are not being offered integrated treatment for both disorders, which hinders their recovery,” he adds.
Néstor Szerman echoes this opinion, emphasizing the importance of moving towards care models that facilitate coordinated attention and functional integration between mental health and addiction resources. According to the psychiatrist, many patients suffering from addiction symptoms and other mental disorders, as well as their families, “cannot find the appropriate entry point into the healthcare system.” They often face a double entry point (addiction on one hand, mental health on the other), what experts call “the wrong door syndrome,” which, in his view, becomes “a real barrier” to accessing healthcare services and hinders the comprehensive treatment of dual diagnosis.
Juan can attest to this from firsthand experience. “The support system is failing. Let’s not talk about a lack of will, because what these kids really lack is organized and coordinated professional help,” he concludes.
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