In 2014 approximately 20.2 million American adults (aged 18 and older) suffered from a substance use disorder, and 40.3 million battled some form of mental illness, according to the National Survey on Drug Use and Health (NSDUH). When a mental health disorder and a substance use disorder overlap – that is they occur in the same person at the same time – these disorders are said to be co-occurring. The NSDUH publishes that in 2014 approximately 7.9 million American adults suffered from co-occurring mental health and substance use disorders. Of those who battle severe mental illness, Psychology Today reports that more than half will also suffer from substance use disorder. Additionally, the National Alliance on Mental Illness (NAMI) estimates that half of all of those who abuse drugs and one-third of those who abuse alcohol also suffer from mental illness.
Substance abuse and mental illness are complexly intertwined, and both can make symptoms of the other worse. Substance abuse can lead to worsening mental illness, and mental illness can incite a person to self-medicate with drugs or alcohol. The two disorders can vary in severity, and one may be more extreme than the other. A substance use disorder may develop after a mental health disorder first appears or vice versa.
Treatment for dual diagnosis and co-occurring mental health and substance use disorders is specialized. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), both disorders should be treated at the same time in an integrated fashion for optimal results.
Causes of Co-occurring Disorders
Co-occurring disorders may be caused by a variety of factors, such as:
- Similar genetic vulnerabilities
- Related regions of the brain being affected
- Environmental aspects
- Age at which substance abuse begins
Biology and genetics can play a role in both the onset of a mental health disorder and an addiction, so it would make sense that they would also be involved in the development of co-occurring disorders. A family history of addiction and/or mental illness may make someone more likely to also suffer from the same disorder.
Depending on the drug, addiction to certain substances may be heritable between 39 percent (for hallucinogens) and 72 percent (for cocaine) of the time, averaging out to about half of the risk for developing an addiction to drugs, the journal Clinical Pharmacology & Therapeutics publishes. Similarly, the National Institute of Mental Health (NIMH) published studies on five of the major mental illnesses, showing that genetics may provide between a 17 and 28 percent risk of developing the respective disorder. Many co-occurring disorders may have shared genetic vulnerabilities as well, as the journal Psychiatric Clinics of North America reports that disorders like attention deficit-hyperactivity disorder (ADHD) have a high prediction rate for addiction as well. This means that someone diagnosed with ADHD has a higher likelihood, due to genetic factors, of also developing a substance use disorder.
Many mental illnesses may be due in part to regions of the brain being underdeveloped, underactive or overactive, or from an abnormality in brain chemistry. Abusing substances like drugs or alcohol makes changes to brain chemistry and some of its circuitry that is related to pleasure, motivation, reward, and memory. Levels of dopamine that are disrupted by substance abuse may also be impacted by depression or schizophrenia, for instance, NIDA reports.
Just as genetics and biology play a role in the onset of co-occurring disorders, so do a person’s environment and exposure to stress, early trauma, or substance abuse at a young age. Chronic stress can damage the pathways in the brain, and when this occurs in a developing brain, some of the regions, like the prefrontal cortex, amygdala, and hippocampus, may not develop as they should, the journal Pediatrics publishes. These regions of the brain partially control impulses, motivation, and memory. When damaged, they may predispose someone to issues with anxiety, mood disorders, difficulties with impulse control, and substance abuse. The same can be said for initiating substance abuse before the brain is done fully growing, as similar regions can be damaged, opening up an individual to future mental health concerns or difficulties with substance abuse, NIDA reports.
Common Co-occurring Disorders
Some of the most common disorders to co-occur with a substance use disorder, as published by Psychology Today, include:
- Personality disorders
- Mood disorders
- Psychotic disorders
- Anxiety disorders
Examples of some of the commonly occurring co-occurring disorders and their prevalence are outlined below.
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In 2014, more than 6.5 percent of the American adult (aged 18 and older) population suffered from a major depressive episode (MDE), the NSDUH reports. Fatigue, lack of energy, weight fluctuations, and feelings of hopelessness, worthlessness, and sadness are common when someone suffers from depression. Depression and substance abuse commonly co-occur, as virtually all substances work to elevate moods or distract a person from reality. Alcohol may be a common substance of choice, as a study published in Psychiatric Times found that of those who were surveyed and diagnosed with a current alcohol use disorder, just over 20 percent also suffered from depression at the time. Those who were considered to be dependent on alcohol were more than 3.5 times more likely to also battle depression than those who were not.
Cocaine, and other stimulant drugs, may also be used for self-medication of depressive symptoms, as these drugs can rapidly elevate moods. Unfortunately, when the alcohol and drugs wear off, a “crash” can ensue. The resulting lowered mood may create worsened depression. Alcohol and drug withdrawal can lead to depression as a side effect as well.
Individuals suffering from anxiety or mood disorders also suffer from substance abuse disorders about 20 percent of the time and vice versa, the Anxiety and Depression Association of America (ADAA) reports. Anxiety disorders may be characterized by an inability to escape the fight-or-flight reaction and the body’s response to stress. Heart rate, blood pressure, body temperature, and respiration rates are raised as the body is constantly on high alert. Central nervous system depressants, like alcohol, benzodiazepine sedatives, marijuana, and opioids, may seem to temporarily dispel these symptoms. When these substances are removed after regular use, withdrawal symptoms are likely to include a rebound of anxiety, insomnia, and other symptoms the drugs may have worked to suppress.
As many as two out of every 10 military veterans who suffer from post-traumatic stress disorder (PTSD) also battle a substance use disorder, the U.S. Department of Veterans Affairs publishes. PTSD is a disorder that stems from a person being the victim of or witness to a violent event or trauma. Flashbacks, nightmares, and a constant state of arousal may be common PTSD symptoms.
Substance abuse may provide temporary respite from difficult memories and may make it easier to sleep. Drinking alcohol may be a common method of self-medication, as individuals who have experienced a traumatic event may attempt to drink to forget. This does not allow the psyche the opportunity to heal from the trauma, however. Regular bouts of binge drinking may cause a dependence on and addiction to alcohol to form.
Bipolar disorder is a mood disorder indicated by extreme moods, from mania so severe as to require hospitalization to depression so intense as to induce suicidal thoughts or actions. The journal Current Psychiatry publishes that up to 60 percent of individuals battling bipolar disorder will also suffer from a substance use disorder at some point. Drugs, and especially alcohol, may be commonly abused in an effort to blunt mood swings and regulate emotions. Of course, alcohol and drugs only serve to make matters worse. Individuals with a dual diagnosis of bipolar disorder and a substance use disorder may actually experience more severe depression or manic episodes and may be at a higher risk for committing suicide.
Individuals who suffer from schizophrenia, a psychotic disorder, have a very high rate of smoking. NIDA reports that as many as 90 percent of those battling depression may smoke cigarettes.
Nicotine may temporarily produce a calming effect that helps to lower anxiety, improve cognitive functions, and dull psychotic episodes. Marijuana may also be heavily abused by individuals suffering from schizophrenia and may even lead to an early onset of the disorder, NIMH publishes. Schizophrenia is closely related to instances of self-harm, which may include drug abuse. Drugs may provide solace at first; however, schizophrenia symptoms, treatment, and outcomes are made worse by substance abuse and addiction.
Personality disorders include disorders like antisocial personality disorder and borderline personality disorder; impulse control disorders include ADHD and conduct disorder, to name a few. These disorders are often recognizable by difficulties socializing and controlling emotions or outbursts.
Someone who suffers from a personality disorder may rely on alcohol to increase self-confidence and lower inhibitions, thereby increasing sociability. Around 40-50 percent of those who abuse drugs or alcohol also suffer from antisocial personality disorder. A staggering 90 percent of those suffering from antisocial personality disorder also battle a substance use disorder, the Graduate Journal of Counseling Psychology reports.
In a related fashion, individuals who have impaired willpower and difficulties controlling impulses, like those battling a disorder such as ADHD, also abuse substances at high rates. The journal Pediatrics publishes that children suffering from ADHD are at a higher risk for developing a substance use disorder than their peers without the disorder.
Integrated Care for Co-Occurring Disorders
Research-based methods that combine treatment methods for both disorders simultaneously are generally considered to be optimal when treating co-occurring mental health and substance use disorders. Medical and mental health professionals can work in tandem with substance abuse treatment providers to assess the individual and then design and implement a care plan. Treatment plans may need to be longer and progress more gradually during co-occurring disorder treatment, Psychology Today reports.
Detox may be the initial stage of a more comprehensive treatment program. Medical detox is the safest method to help an individual process drugs or alcohol from the body while helping to control the difficult withdrawal symptoms and drug cravings that may occur. With medical detox, a person can be closely monitored for self-harming behaviors, as drug withdrawal often brings about a heightening of mental illness symptoms initially.
Medications are often used both during detox and in treatment for co-occurring disorders, as many mental illness symptoms benefit from mood-stabilizing or other pharmaceutical tools. In the case of medications especially, integrated treatment wherein all treatment providers are working together is highly important. There are many medications, for example, that are not recommended for individuals battling substance use disorders or with a history of substance abuse or addiction. If all medical, mental health, and substance use providers share information and work together, they can ensure that the medications will be helpful and have fewer negative interactions or side effects.
Behavioral therapies are a large part of treatment programs for both mental health disorders and addiction, and they are widely used in the treatment of co-occurring disorders. Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), and Dialectical Behavior Therapy (DBT) are some of the commonly used behavioral therapies that help individuals with co-occurring disorders learn how to regulate emotions, control impulses, communicate effectively, bring about positive life changes, and better cope with stress.
NAMI reports that a residential treatment program may provide the best and most comprehensive option for individuals battling co-occurring disorders, as it provides the structure and time to learn new and effective strategies and for the brain to heal from the effects of substance abuse. Habits have time to form, and individuals can also benefit from holistic and complementary techniques, such as nutritional planning, massage therapy, fitness training, mindfulness meditation, yoga, art therapy and more. Relapse prevention programs, support groups, and aftercare methods that may include continuing therapy, counseling, or even a stay at a transitional living environment may follow a residential treatment program. With the right level of care, quality of life can be enhanced and recovery can be sustained on a long-term basis.