Psychological Distress, Substance Use, and HIV/STI Risk Behaviors Among Youth

"Psychological distress has been inconsistently associated with sexual risk behavior in youth, suggesting [that] additional factors, such as substance use, may explain this relationship."

Researchers studied the relationship between mental health difficulties, substance use, and sexual risk behaviours in adolescents in Flint, Michigan, United States. As stated here: "The association between sexual risk and psychological distress among youth may be related to an attempt to regulate distressful affective states through sexual or intimate behavior." Similarly, substance use may be associated with the alleviation of psychological symptoms. Researchers sought evidence on whether substance use served to moderate (i.e., greater substance use exacerbates the effect of psychological distress on sexual risk) or mediate (i.e., the effect of psychological distress on sexual risk behavior occurs via youth's substance use) the association of psychological distress and sexual risk.

Based on an 8-year longitudinal study, researchers examined data from 850 adolescents beginning in ninth grade in the United States. Participants were interviewed at one-year intervals, whether they were in or out of school. Structured, close-ended, face-to-face interviews were conducted with students in school or in a community setting if the participants could not be found in school. Measures included: frequency of sexual intercourse, consistency of condom use, number of partners, psychological distress, substance use, and demographic characteristics.

Youth's psychological distress increased over time. However, African American and female youth reported greater decreases in psychological symptoms across adolescence than their White (b = -.34, SE = .06; p = .001) and male counterparts (b = -.11, SE = .04; p = .01), respectively. Use of alcohol and/or marijuana was associated with more psychological distress across adolescence (b = .20, SE = .04, p = .001). Youth were more likely to report greater psychological distress over time with every unit increase in substance use.

The researchers found sexual activity among 14-year-olds, which increased in frequency over the study period. "When we entered psychological distress as a time-varying covariate, we found greater psychological distress was associated with increased sexual intercourse frequency across adolescence (Model 1: b = .09, SE = .05; p < .05)....We then entered substance use as a time-varying covariate in the model and found substance use was associated with increased sexual intercourse frequency across adolescence (b = .34, SE = .02; p < .001). Consistent with the mediation argument, we found substance use fully mediated the relationship between psychological distress and sexual intercourse frequency (Sobel = 4.80; p < .0001; see Model 2 in Table 3); that is, the association between psychological distress and sexual intercourse frequency became non-significant once substance use was included in the model."

"To test for moderation, we entered the interaction term for psychological distress and substance use on condom use, yet we found no support for the moderation argument....We found no differences by sex [gender] or race in the association between condom use and the main effects of psychological distress or substance use, respectively, nor on their interaction effect."

Researchers found that sexual risk behaviours increased across adolescence, increasing the risk of HIV/STI transmission. Psychological distress and substance abuse increased as well, but researchers were unable to determine causality without examining the onset of both psychological distress and substance use. Substance use fully mediated the association between psychological distress and both sexual frequency and condom use. "These results suggest that efforts to address urban adolescents' psychological distress or improve their psychological well-being may have the benefit of both helping to reduce substance use and therefore sexual risk behavior."

The study suggests that peer networks may be a factor: "Given the role social norms may play in the onset and enactment of risky behaviors among youth, future research examining the role of youth's social networks (e.g., prevalence of substance use and psychological distress among youth and his/her family and peers) would be useful." Substance use only partially mediated the association between psychological risk and number of partners over time, suggesting that avoidance of isolation via an increased number of partners may be a factor in risk exposure.