When someone suffering from a mental illness is also diagnosed with a substance use disorder, the combination is known as co-occurring disorders or a dual diagnosis. Co-occurring disorders are very common, and understanding the link between substance abuse and mental health is crucial for finding the right treatment program and improving the chances of long-term recovery.
Defining Mental Illness
A mental illness is any condition that affects thought processes, feelings or mood, according to the National Alliance on Mental Illness.1 People who have a mental illness may be unable to relate well to others, and the mental condition may affect overall feelings of good health and well-being. This can interfere with healthy social functioning.
Mood disorders like anxiety and depression are the most common mental illnesses that co-occur with substance abuse.
Mood disorders like anxiety and depression are the most common mental illnesses that co-occur with substance abuse.
Anxiety disorders include generalized anxiety disorder, panic disorder, social anxiety disorder and agoraphobia. Obsessive-compulsive disorder and post-traumatic stress disorder are closely related to anxiety disorders and also commonly co-occur with substance use disorders. Around 40 million American adults, or 18 percent of the adult population, suffer from an anxiety disorder, according to the Anxiety Disorders Association of America.2
Depressive disorders include major depression, dysthymic disorder, postpartum depression, seasonal affective disorder and bipolar disorder. Major depression alone affects around 14.8 million adults in a given year, according to the Depression and Bipolar Support Alliance, and nearly six million people are diagnosed with bipolar disorder each year.3
Defining Substance Abuse
The World Health Organization defines substance abuse as the harmful use of a psychoactive substance, including alcohol, prescription medications and both legal and illegal drugs.4 “Harmful” can mean any negative consequence of using drugs or alcohol, including:
- Relationship problems with family, friends or co-workers
- Neglecting responsibilities at home, work or school
- Physical or mental health problems, including hangovers
- Legal troubles, such as charges of possession, DUI, public intoxication or domestic violence
- Financial problems resulting from buying drugs or alcohol, missing work or losing a job due to using them
People who abuse substances may do so once in a while, or they may do it frequently. Chronic substance abuse is a substance use disorder, and it can lead to worse substance use disorders like addiction and dependence.
Addiction is characterized as being unable to stop using a substance despite negative consequences. Dependence is characterized by changes in brain function that lead to the brain operating more “normally” when a substance is present than when it’s not. If dependence has developed, withdrawal symptoms will set in when the substance is withheld.
The Link Between Substance Abuse and Mental Health
According to the National Institute on Drug Abuse, mental illness and substance use disorders commonly co-occur for three reasons:5
- Drug or alcohol abuse can lead to the onset of a mental illness, and it almost always worsens symptoms of an existing mental illness.
- Mental illness can lead to self-medicating with drugs or alcohol, which can lead to addiction and dependence.
- Risk factors for substance use disorders and mental illness may overlap, leaving some people more susceptible to co-occurring disorders.
Overlapping Factors for Mental Illness and Substance Use Disorders
Three important factors influence the development of mental illness and substance use.
Overlapping genetic vulnerabilities. Researchers have identified several regions of the human genome that are linked to an increased risk of developing both a substance use disorder and a mental illness. Genetic factors may be direct, such as controlling how substances are metabolized, or they may have an indirect influence, such as predisposing someone to engage in risky behaviors that may include abusing drugs or alcohol.
Involvement of similar brain regions. Certain regions of the brain are involved in the development of both mental illness and substance use disorders. For instance, the dopamine system is affected by psychoactive substances, and it’s also a factor in depression and other mental illnesses.
Environment. Environmental factors can influence both substance abuse and mental illness. For example, high stress can cause anxiety, and since many people medicate stress with drugs or alcohol, it can also lead to a substance use disorder.
The Prevalence of Co-Occurring Disorders
According to the National Institute on Drug Abuse, people who have a mood or anxiety disorder are two times more likely than those who don’t to develop a substance use disorder, and vice versa.6
People who have a mood or anxiety disorder are two times more likely than those who don’t to develop a substance use disorder, and vice versa.
Nearly eight million American adults have co-occurring disorders, according to the Substance Abuse and Mental Health Services Administration.7 The National Alliance on Mental Illness points out that around one-third of people who have any type of mental illness and half of those with a serious mental illness like schizophrenia or bipolar disorder also suffer from a substance use disorder.8 Conversely, around one-third of those who abuse alcohol and over half of those who abuse drugs also have a mental illness.
Common Co-Occurring Mental Illnesses
While any mental illness can co-occur with a substance use disorder, some more commonly do so than others.
Anxiety. People who have an anxiety disorder often self-medicate with alcohol and drugs, and while it may seem to help initially, using psychoactive substances nearly always makes the mental illness worse.
Depressive disorders. Major depression and bipolar are associated with a higher risk of substance abuse. People suffering from depression may use drugs and alcohol to feel better, but this usually makes the condition worse in the long run. Those who have bipolar disorder may tend to engage in high-risk behaviors during a manic episode, increasing the risk of substance abuse and developing a substance use disorder.
A study published in the journal Psychiatric Clinics of North America found that around half of all people with bipolar disorder have a lifetime history of a substance use disorder.9
Schizophrenia. People with schizophrenia may experience delusions, hallucinations and psychotic episodes, and many use nicotine to help compensate for cognitive deficits. Marijuana is also commonly used by those suffering from schizophrenia in an attempt to manage stress.
These and other psychoactive substances can lessen the effects of medications that interfere with dopamine production and make it difficult to feel joy, but they almost always worsen schizophrenia in the long-term.
Obsessive-compulsive disorder (OCD). An article published in the Journal of Anxiety Disorders found that 27 percent of people suffering from obsessive-compulsive disorder had a lifetime history of a substance use disorder.10 Those with OCD may use drugs or alcohol to relieve symptoms like intrusive thoughts and repetitive behaviors, but due to the nature of the disorder, substance abuse may also become compulsive and lead to addiction.
Post-Traumatic Stress Disorder (PTSD). Post-traumatic stress disorder develops after being a witness to or victim of a traumatic event. Those with PTSD often use alcohol to combat symptoms like insomnia, nightmares, flashbacks and intrusive memories of the event.
An article published in the journal Alcohol Research & Health cites a study that found that 40 percent of people seeking inpatient treatment for a substance use disorder suffer from PTSD, and another study found that over half of combat veterans with PTSD subsequently developed an alcohol addiction.11
Eating disorders. People with eating disorders often abuse drugs or alcohol in an attempt to control their appetite or alleviate psychological symptoms like depression and low self-esteem. An article in the journal Social Work Today points out that up to 50 percent of those with an eating disorder abuse alcohol or drugs, compared to just nine percent of the general population.12
Diagnosing Co-Occurring Disorders: Integrated Screening and Assessment
Diagnosing co-occurring disorders can be problematic. It’s often difficult to determine which symptoms are associated with substance abuse and which are associated with mental illness. This is particularly true in a treatment detox setting, and it’s typical for healthcare professionals to wait until withdrawal symptoms subside before making a diagnosis.
It’s often difficult to determine which symptoms are associated with substance abuse and which are associated with mental illness.
Due to the high prevalence of co-occurring disorders, a comprehensive and integrated screening and assessment protocol is in place within the mental healthcare and substance abuse treatment communities to ensure a proactive approach to diagnosing co-occurring disorders.
Integrated screenings take place upon admission for those seeking help for a mental illness or treatment for a substance use disorder. In a mental health setting, a patient is screened for a substance use disorder, and vice versa. The screening is short and simple and involves a series of questions that are scored to indicate whether a more comprehensive assessment is in order.
Integrated assessments begin with gathering information from a patient or client. The assessing therapist and the individual form a partnership and move through a defined, 12-step process to evaluate a substance use disorder in the context of a mental illness or vice versa. At the end of the assessment, a diagnosis is made one way or the other.
Integrated Treatment is Essential for Co-Occurring Disorders
Since mental illness often leads to substance abuse and substance abuse can cause or worsen a mental illness, treating both conditions at the same time, each in the context of the other, is absolutely essential for successful long-term recovery.
Treating both conditions at the same time, each in the context of the other, is absolutely essential for successful long-term recovery.
The Substance Abuse and Mental Health Services Administration notes that integrated treatment is associated with better outcomes, including:13
- A reduction in substance abuse
- Improved mental illness symptoms
- Improved mental functioning
- Decreased hospitalization
- Increased housing stability
- Fewer legal problems
- A higher overall quality of life
Some recovery programs offer dual diagnosis treatment in addition to standard treatment services, while others specialize solely in treating co-occurring disorders.
Six Principles of Dual Diagnosis Treatment
The Substance Abuse and Mental Health Services Administration has identified a number of principles that should guide treatment for co-occurring disorders.14
Employ a recovery perspective. Recovery is a process of change from the inside out, and change occurs in predictable stages. Everyone’s path of recovery is different, but all high-quality, successful treatment programs will ensure continuity of care by developing and putting into place an individualized aftercare plan to address the post-treatment stages of recovery and improve the outcome of treatment.
Address multiple problems. Treatment for substance use disorders and mental health conditions requires addressing more than root causes and symptoms. Issues like legal, financial and housing problems, physical health conditions, relationship troubles and employment needs must all be addressed for the best possible outcome.
Use a phased approach. Treatment plans should be dynamic and continually assessed and amended based on an individual’s specific needs and issues at each stage of recovery.
Address real-life problems early on. Working through personal and social problems from the start of treatment increases engagement and helps individuals identify and improve on their various roles in life, such as employee, parent or student. Learning the necessary skills to support these roles is central to successful recovery.
Address cognitive and functional impairments. An individual in treatment should fully understand how treatment works and be able to perform the necessary tasks at each stage of recovery. Addressing cognitive and functional impairments ensures that this happens to the best of a person’s ability.
Institute an aftercare plan. Aftercare is a critical component of any quality treatment program. Once treatment ends and an individual returns to the community, various supports and a comprehensive plan for continued recovery should be in place. The aftercare plan typically includes ongoing therapy, monitoring of the mental illness, support group participation and other components based on need, such as vocational therapy or legal services.
Treatments for Co-Occurring Disorders
A high-quality, holistic dual diagnosis treatment program improves the chances of successful recovery and will employ a number of therapies to treat both the mental illness and the substance use disorder.
- Pharmacotherapy, or the administering of medication, is often essential for getting symptoms of mental illness under control. During the detox phase, medications may help reduce the severity of withdrawal symptoms.
- Behavioral therapies, including cognitive-behavioral therapy, help individuals identify harmful ways of thinking and behaving and replace them with healthier thoughts and behaviors.
- Group therapy helps clients work through various issues with the support and input of peers.
- Family therapy helps to restore function to the household and improve communication among family members.
- Psychoeducational classes help those in treatment better understand both their mental illness and their substance use disorder and how each affects the other.
- Alternative therapies are an essential part of a holistic treatment program and include acupuncture, meditation, biofeedback and art and music therapy.
- Didactical therapy, exposure therapy and other specialized therapies help individuals with severe mental illness reduce dangerous behaviors and improve symptoms that are otherwise difficult to treat.
Choosing a Treatment Program for a Dual Diagnosis
For those who have co-occurring disorders, a treatment program that specializes in dual diagnosis is essential for successful long-term recovery. Treating just the substance use disorder but not the mental illness or vice versa is associated with poor outcomes and high relapse rates.
For those who have co-occurring disorders, a treatment program that specializes in dual diagnosis is essential for successful long-term recovery.
A dual diagnosis program is based on integrated treatment as a collaboration among the members of each treatment team. The mental illness is treated in the context of the substance use disorder, and the substance use disorder is treated in the context of the mental illness.
A holistic approach to treatment is essential for addressing the range of highly complex issues that underlie mental health issues and substance use disorders.
According to the Substance Abuse and Mental Health Services Administration, there is no single pathway to recovery.15 Every individual has different issues and needs, and using a range of both traditional and alternative therapies helps to ensure that all of the various issues are addressed in a variety of ways that promote better overall physical and mental health and a higher sense of well-being.
A high-quality, holistic dual diagnosis treatment program will:
- Employ experienced and licensed healthcare and mental health professionals
- Have state accreditation
- Adhere to research-based protocol and treatment therapies
- Offer medical detox, which involves administering medications to alleviate the severity of withdrawal symptoms
- Offer services in a culturally aware environment that takes into consideration a client’s cultural background, such as age, gender, sexual orientation, gender identity and values
- Adhere to the Principles of Effective Treatment as set forth by the National Institute on Drug Abuse16
- Offer coordinated care across treatment teams
- Offer a comprehensive aftercare plan once treatment is complete
- Provide a wide range of community supports, such as child care, financial counseling, legal services and peer support groups
The Substance Abuse and Mental Health Services Administration has several excellent resources for helping individuals find a high quality and effective treatment program:
- The National Registry of Evidence-Based Programs and Practices offers information and expert ratings for a large number of programs across the country.17
- The Behavioral Health Treatment Services Locator is a searchable database of treatment programs across the country to help individuals find a high-quality program that suits their needs.18
There is Hope
Hope is the foundation of recovery, driving the motivation to recover and keeping people engaged in treatment despite setbacks and difficult challenges. With the right dual diagnosis treatment program, individuals develop the skills, strategies and knowledge upon which successful recovery is based. No matter how dire things may seem to be, recovery from a substance use disorder and a mental health condition is always possible.
Taking the first step and entering treatment is often the most difficult part of treatment for many, but doing so can restore good physical and mental health and lead to a vastly higher quality of life for those with an addiction and the ones who love them.
- Mental Health Conditions. (n.d.). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions
- Facts & Statistics. (2014, September). Retrieved from http://www.adaa.org/about-adaa/press-room/facts-statistics
- Depression Statistics. (n.d.). Retrieved from http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_depression
- Substance Abuse. (n.d.). Retrieved from http://www.who.int/topics/substance_abuse/en/
- Why Do Drug Use Disorders Often Co-Occur with Other Mental Illnesses? (2010, September). Retrieved from https://www.drugabuse.gov/publications/comorbidity-addiction-other-mental-illnesses/why-do-drug-use-disorders-often-co-occur-other-mental-illnesses
- Comorbidity: Addiction and Other Mental Illnesses. (2010, September). Retrieved from https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf
- Mental and Substance Use Disorders. (2016, March 8). Retrieved from http://www.samhsa.gov/disorders
- Dual Diagnosis. (n.d.). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis
- Sonne, S. C. & Brady, K. T. (1999, September). Substance Abuse and Bipolar Comorbidity. Psychiatric Clinics of North America, 22(3), 609-627. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10550858
- Mancebo, M. C., Grant, J. E., Pinto, A., Eisen, J. L., & Rasmussen, S. A. (2009, May). Substance Use Disorders in an Obsessive Compulsive Disorder Clinical Sample. Journal of Anxiety Disorders, 23(4), 429-435. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705178/#R6
- Volpicelli, J., Balaraman, G., Hahn, J., Wallace, H., & Bux, D. (1999). The Role of Uncontrollable Trauma in the Development of PTSD and Alcohol Addiction. Alcohol Research & Health, 23(4), 256-262. Retrieved from http://pubs.niaaa.nih.gov/publications/arh23-4/256-262.pdf
- Ressler, A. (2008, July). Insatiable Hungers: Eating Disorders and Substance Abuse. Social Work Today, 8(4), 30. Retrieved from http://www.socialworktoday.com/archive/070708p30.shtml
- Behavioral Health Treatments and Services. (2015, October 19). Retrieved from http://www.samhsa.gov/treatment
- Overarching Principles to Address the Needs of Persons with Co-Occurring Disorders. (2006). Retrieved from http://store.samhsa.gov/shin/content//PHD1132/PHD1132.pdf
- Recovery and Recovery Support. (2015, October 5). Retrieved from http://www.samhsa.gov/recovery
- Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). (2012, December). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
- Resource: http://www.samhsa.gov/nrepp
- Resource: https://findtreatment.samhsa.gov/