- Mental Health & Substance Abuse in the U.S.
- Statistical Overview of Co-Occurring Disorders & Substance Abuse
- Common Mental Health Conditions That Co-Occur with Addiction
- Common Combinations
- Signs & Symptoms of Substance Abuse
- Underlying Risk Factors
- Which Comes First — Addiction or Mental Health?
- Difficulties with Diagnosis
- Mental Health & Substance Abuse Treatment Options
- Long-Term Recovery
- Key Sources
- Medical Disclaimer
Living with a mental health condition can be scary and debilitating. Individuals who are struggling with psychiatric conditions like depression, anxiety, or post-traumatic stress disorder (PTSD) can find it incredibly difficult to cope with everyday life. The symptoms associated with mental health issues can be so uncomfortable that many people turn to alcohol and drugs to numb out and escape those feelings.
Unfortunately, mental health disorders are a common problem in the U.S. According to the National Institute of Mental Health, nearly 1 in 5 adults (approximately 51 million people) in the U.S. live with a mental health condition. The National Survey on Drug Use and Health also reports that in 2019 alone, over 9 million Americans had a co-occurring mental health and substance use disorder.
However, despite the high prevalence of mental health disorders and substance abuse, there is ample hope for recovery. In this article, we provide a summary of common co-occurring mental health and substance use disorders and what types of treatments are available.
Mental Health & Substance Abuse in the U.S.
Substance use disorder — also known as alcohol or drug addiction — often occurs concurrently in individuals who have a mental health disorder. The combination of these two conditions is referred to as a “dual diagnosis” or “co-occurring disorder” and they are often characterized by more severe symptoms. In some cases, these conditions evolve together, but they can also develop independently of each other. While many people often have one co-occurring psychiatric condition alongside their substance use, individuals can present with multiple illnesses at once.
According to the National Institute on Drug Abuse, of the 20 million adults in the U.S. with substance use disorders, nearly 40% also have a mental illness. Conversely, of the 18 million American adults with mental health disorders, nearly 20% have a substance use disorder.
Symptoms of Co-Occurring Disorders
- Social isolation
- Retreating from relationships with family and friends
- Displaying intense, painful withdrawal symptoms
- Sudden changes in behavior
- Difficulty managing daily tasks
- Risky behaviors
- Neglecting health and hygiene
- Using substances under unsafe conditions
- Losing control over substance use
- Developing a high tolerance to a substance
- Feeling the need to use substances to function normally
Statistical Overview of Co-Occurring Disorders & Substance Abuse
In 2019, it was estimated that over 9 million U.S. adults aged 18 to 25 were diagnosed with co-occurring mental health and substance use disorders.
Other stats include:
- According to the National Institute on Drug Abuse (NIDA), people with severe mental health issues are 4 times more likely to abuse alcohol and 5 times more likely to be heavy smokers.
- NIDA also indicates that multiple population studies show that about 50% of those diagnosed with mental health conditions will also experience substance use disorder and vice versa.
- Reports published in the Journal of the American Medical Association indicate that 37% of people who abuse alcohol and 53% of people who abuse drugs also have at least one serious mental illness.
- The National Bureau of Economic Research reports that people who have been diagnosed with a mental health disorder in their life are also responsible for the consumption of 69% of alcohol, 84% of cocaine, and 68% of cigarettes.
Common Mental Health Conditions That Co-Occur with Addiction
Below are some of the most common mental health conditions that co-occur with substance abuse and addiction.
It is estimated that around 18% of Americans suffer from anxiety. People with this condition often turn to substances to cope with the intense feelings of fear, panic, and worry. For example, social anxiety disorder is associated with high levels of alcohol abuse. Cocaine, nicotine, and cannabis are also widely used amongst people with anxiety disorder, as these drugs can create feelings of euphoria and achieve a numbing of nervous tension.
Symptoms of Anxiety
- Feeling nervous, irritable, or on edge
- Having a sense of impending danger, panic, or doom
- Having an increased heart rate
- Muscle tension and headaches
- Trouble concentrating
- Nausea and vomiting
- Digestion issues
Mood disorders, such as depression, affect some 15 million adults in the U.S. Other mood disorders, such as bipolar disorder (which consists of both mania and depression), are less common, but the rates of co-occurring substance abuse with this condition are as high as 70%. Alcohol tends to be the most widely abused drug amongst people with mood disorders, and some estimate that as many as 43% of people with bipolar disorder have an alcohol abuse problem.
Symptoms of Mania (Bipolar Disorder)
- Inflated sense of self-confidence
- Decreased need for sleep
- Racing thoughts
- Poor judgment
- Angry outbursts
- Risky behavior
- Spending sprees
Symptoms of Depression
- Feeling depressed or hopeless
- Having a sense of worthlessness
- Weight loss or gain
- Foggy thinking
- Slow speech
- Insomnia or oversleeping
- Loss of interest or pleasure
- Thoughts of death or suicide
Personality disorders are found in roughly 10% – 15% of the U.S. population. The most common of these conditions that co-occur with substance abuse are borderline personality disorder (BPD), avoidant personality disorder (APD), and paranoid personality disorder (PPD).
People with BPD tend to have particularly high rates of substance abuse due to their symptoms of impulsive behavior and extreme mood swings. According to some estimates, individuals with BPD are 1.7 times more likely to have a substance abuse problem in their lifetime.
Symptoms of BPD
- Intense emotional mood swings
- Extreme depression or anxiety
- Impulsive and dangerous behavior
- Paranoid thoughts or feelings
- Intense and unstable relationships
- Distorted and unstable sense of self
- Intense fear of abandonment
Symptoms of APD
- Avoidance of work, social, or school activities due to fear of criticism or rejection
- Low threshold for criticism
- Feelings of inferiority
- Low self-esteem
Symptoms of PPD
- Doubt about the commitment, loyalty, or trustworthiness of others
- Reluctance to confide in others due to a fear the information will be used against them
- Being unforgiving and holding grudges
- Hypersensitivity to criticism
Post-Traumatic Stress Disorder (PTSD)
It is estimated that around 8 million Americans suffer from post-traumatic stress disorder (PTSD). People with PTSD also have very high rates of addiction to drugs and/or alcohol. In some studies, nearly 50% of individuals with lifetime PTSD also have a substance abuse problem. Alcohol, cocaine, and cannabis tend to be the most abused drugs among people with PTSD.
Symptoms of PTSD
- Flashbacks — reliving the trauma over and over with physical symptoms
- Depression and anxiety
- Staying away from places, events, or objects that are reminiscent of the trauma
- Feeling tense or “on edge”
- Bad dreams or nightmares
- Feelings of detachment from others
Attention Deficit/Hyperactivity Disorder (ADHD)
Attention-Deficit Hyperactivity Disorder (ADHD) affects roughly 2.8% of the U.S. adult population and 13% of adolescents aged 12 to 17. ADHD is associated with an earlier age of onset of substance abuse problems, and it is also linked with the use of a variety of substances, due to the impulsivity associated with this condition.
Symptoms of ADHD
- Inability to sit still, especially in calm or quiet surroundings
- Constant fidgeting
- Inability to concentrate on tasks
- Excessive physical movement
- Excessive talking
- Inability to wait their turn
While the above are common conditions that coincide with substance abuse, there are specific pairings that occur frequently together. These include:
People with antisocial personality disorder (ASPD) typically disregard the needs and feelings of others, are consistently deceitful and irresponsible, and lack any sense of remorse for their behavior. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA)ASPD has the closest link with alcohol addiction. They further state that people who abuse alcohol are 21 times more likely to deal with ASPD when compared to people who don’t have an alcohol abuse problem. Like most co-occurring disorders, ASPD and alcohol abuse often develop early in life. Unsurprisingly, alcohol exacerbates symptoms, especially as lowered inhibitions can augment antisocial behaviors, such as impulsivity and hostility.
Cannabis and Schizophrenia
Individuals with schizophrenia have a tendency to abuse alcohol or drugs. According to the American Journal of Psychiatry, it is estimated that about half of those with schizophrenia also have a substance use disorder. There’s also a striking connection between cannabis abuse and this condition. While it’s unclear as to why this drug is so popular with schizophrenics, since it often produces schizophrenic symptoms, research suggests that cannabis use is widespread among those with this condition.
Cocaine and Anxiety
It might seem counterintuitive for people with anxiety to take stimulants; however, many people with this condition abuse cocaine because it makes them feel euphoric and powerful. The stimulating properties of cocaine can also mask the fearful and worrisome symptoms associated with anxiety. However, one of the symptoms that occurs once cocaine wears off is anxiety and paranoia, so frequent use can worsen one’s underlying condition.
Opioids and PTSD
People who are struggling with post-traumatic stress disorder (PTSD) often experience intense physiological symptoms. Therefore, opioids have become a popular drug of choice due to the way they can numb symptoms, especially if there is physical pain. This is especially the case with war veterans or people who have been involved in accidents. While opioids boost the pleasure feelings inside the brain, the withdrawal produces very uncomfortable symptoms, some of which mirror or augment PTSD symptoms.
Heroin and Depression
Heroin is a commonly used drug among people with depression (as is alcohol). While this drug is often chosen because it creates relaxing and pleasurable sensations, long-term use will also lead to depression. Heroin stimulates the production of the pleasure chemical dopamine, which the brain becomes less able to produce after long-term drug use. This leads to ongoing depression that can be even more severe than when the individual first started taking drugs. In more extreme cases, long-term heroin use can lead to anhedonia, an inability to feel pleasure due to the brain’s inability to produce dopamine.
Signs & Symptoms of Substance Abuse
If you’re concerned about your alcohol or drug use, below are some key signs and symptoms to watch out for, as they can be clear indications of addiction.
- Continuing to use substances despite their negative side-effects
- Loss of interest in activities or hobbies
- Worsening performance at school or work
- Hiding or lying about alcohol or drug use
- Difficulties controlling alcohol or drug use
- Running out of prescriptions early
- Legal or financial problems
- Isolation from work, family, and social life
- Spending a great deal of time using, obtaining, or recovering from substances
- Abusing other substances (“poly-substance use”)
- Relationship problems
- A decline in personal hygiene
- Tolerance: occurs when your body is used to the drug and requires larger amounts to achieve the desired effects.
- Withdrawal: these symptoms present as physical and emotional discomfort, such as nausea, tremors, nervousness, cold sweats, or agitation when stopping drug use.
- Remorse: occurs if your drug use has led you to feel guilty or sad, even though you are taking the substance to feel better.
- Relapse: this happens if you try to stop taking the drug but find yourself going back to it due to intense cravings or withdrawal symptoms.
Underlying Risk Factors
It can be difficult to pinpoint definitive causes of a person’s mental health conditions and substance use; however, there are known risk factors that can contribute to these conditions. These include:
Individuals who have witnessed or experienced a traumatic event are at a higher risk of developing mental health conditions, such as anxiety and depression.
Some studies indicate that the brain structure of individuals with mental health disorders may differ from persons without it. For example, some MRI studies have shown that there is a unique appearance to areas responsible for cognition, mood, and metabolic function in people with serious mood disorders.
While studies vary, some research suggests that there may be genetic links to most mental health disorders. For example, people who have siblings or family members with depression or anxiety are 20% to 30% more likely to develop it themselves.
Environmental or Situational Factors
Individuals that grow up in dysfunctional families with abusive or depressed households can be more prone to developing mood disorders, personality disorders, and PTSD through exposure. Other triggers, such as bereavement, loss, or traumatic life events can also lead to conditions like depression.
Which Comes First — Addiction or Mental Health?
It is sometimes difficult to determine which comes first, the addiction or the mental health condition. However, in some cases, a review of a person’s medical history can reveal whether they had a pre-existing condition that led to substance abuse and vice versa. However, there is no standard order in terms of how these appear.
Underlying Mental Illness as a Cause of Addiction
In cases where a person’s mental health disorder has caused or led to addiction, there are a couple of factors involved:
One of the main reasons that people with mental health conditions resort to substances is to self-medicate. Individuals will attempt to mask their physical and emotional symptoms with substances to numb feelings or escape.
However, the problem with self-medicating is that substances are a double-edged sword. Not only can they exacerbate psychiatric symptoms such as depression and anxiety during use, but drug withdrawal can also increase them. While underlying mental health conditions can be incredibly distressing and debilitating, it is advisable to seek help before turning to substances, as you can worsen your situation and make it more difficult to cope.
Neurological factors also play a role in substance abuse and underlying mental health disorders. Neurotransmitters such as dopamine, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) are thought to be connected to anxiety, depression, and addiction. These chemicals are responsible for regulating mood and various bodily and mental functions. If an individual has an imbalance in these neurotransmitters, it is thought that they are more prone to depression and addictive behaviors.
Effects of Substance Abuse on Mental Health Issues
Due to the way that drugs alter the biochemistry of the brain, substance use can also initiate depression, anxiety, and paranoia. Depressants such as alcohol, for example, can enhance depressive symptoms, even though it initially helps numb those feelings. Stimulants, on the other hand, can cause agitation, restlessness, irritability, and obsessive or irrational fears. Also, stopping long-term drug use can increase psychiatric symptoms, due to the change in brain chemistry during the withdrawal period, creating the potential for worse symptoms prior to drug use.
Difficulties with Diagnosis
Co-occurring substance abuse and mental health disorders can be difficult to diagnose. This is because substances can mask the symptoms of an underlying psychiatric condition, while symptoms of mental health disorders can be confused with addiction. People with mental health disorders may also dismiss their substance use and vice versa, so assessing these individuals can be tricky.
However, there are two key characteristics that can help therapists and clinicians make an accurate assessment.
A Worsening of Mental Health Symptoms During Treatment
This occurs because people with underlying mental health conditions often take substances to address the specific symptoms of their illness. For example, people with depression will often take drugs to feel more animated, individuals with anxiety will want to take substances to relieve their fear and tension. Therefore, if someone is demonstrating worsened mental health symptoms during rehab or drug withdrawal treatment, it can be a sign that they have an underlying condition.
Substance Use Problems That Seem Resistant to Treatment
In cases where a person receives therapy and is having to abstain from alcohol or drugs, there can sometimes be no progress with treatment. This is because treating an alcohol or drug addiction won’t be successful without treating the underlying mental health condition. Resistance to treatment can often be a sign that they are a dual diagnosis patient and require help with co-occurring conditions.
Mental Health & Substance Abuse Treatment Options
The good news is that despite the high rates of co-occurring mental health disorders and substance abuse, treatment is available. While these conditions can be treated separately, they are best managed simultaneously, using multiple levels of care that begin with detox and continue through to inpatient/residential, outpatient, and aftercare programs.
If you need to seek help, many of these treatment programs are found in rehab facilities or drug treatment centers across the country.
Integrated Treatment & Dual Diagnosis
Historically, mental health disorders and addiction were treated separately. However, in recent years, evidence has shown that co-occurring mental health and substance use disorders influence each other and should be treated together. In other words, treating one condition will not automatically improve the other. The most effective way to treat co-occurring disorders is to provide an integrated treatment plan that addresses both conditions at the same time and in the same place.
The best way to receive integrated therapy is through centers that offer dual diagnosis programs, as they are equipped to recognize, diagnose, and treat concurrent mental health and substance abuse conditions. These centers also allow clinicians to safely address multiple conditions while an individual withdraws from alcohol or drugs. Dual diagnosis can be found in both inpatient and outpatient clinics.
Other key treatments to be aware of when it comes to co-occurring conditions and substance abuse are:
Cognitive-Behavioral Therapy (CBT)
One of the most effective therapies for mental health disorders and substance abuse is cognitive-behavioral therapy (CBT). CBT helps individuals change negative cycles of thought and behavior into more positive ones and this has shown to be especially effective for addiction and mental health conditions. Clients receiving CBT for addiction learn how to recognize “automatic thoughts” and dysfunctional thinking patterns, how to understand the behavior and motivation of others, and how to develop a greater sense of self-understanding and confidence. CBT also helps clients find solutions to triggers that might encourage drug use.
Dialectical-Behavior Therapy (DBT)
Dialectical-behavior therapy (DBT) is a type of cognitive-behavioral therapy that focuses on mindfulness, how to live in the moment, cope with stress, and improve relationships. DBT also helps clients better regulate their moods and learn how to develop healthy coping skills. This kind of therapy is useful for people who have co-occurring conditions, especially those who have depression or bipolar symptoms. DBT is also effective for PTSD and for people who exhibit self-destructive behaviors.
Motivational Interviewing (MI)
Motivational Interviewing (MI) is a type of collaborative therapy between a therapist and the client. During these sessions, the client and therapist work together to define sources of motivation and achieve self-defined goals. MI is known for its positive, client-centered approach and has shown to be effective in treating addiction and mood disorders.
Many people with co-occurring conditions have also experienced trauma. Therefore, integrated therapies that use trauma-informed treatment can be especially effective, as it helps them overcome the emotional suffering associated with traumatic events. This includes eye movement desensitization and reprocessing (EMDR), a therapist-led technique that guides an individual through a series of rapid eye movements to help redirect negative or traumatic memories.
Seeking Safety is another effective trauma treatment. This evidence-based counseling model helps individuals attain safety from trauma and/or substance abuse, especially across vulnerable populations like the homeless, victims of domestic violence, and military personnel.
There are many different types of medications that are prescribed to treat co-occurring disorders. Below are a few of the most common.
Anti-depressants that target serotonin and norepinephrine levels in the brain can help reduce depressive symptoms and help individuals who are weaning off substances. Common SNRIs include Pristiq, Cymbalta, Fetzima, and Effexor.
Naltrexone & Suboxone
For individuals with severe mental health conditions, Naltrexone has shown to be effective at reducing substance cravings. Suboxone is also an effective way of treating individuals with severe mental health conditions and opioid addiction.
Mood stabilizers, such as Lamictal, Gabitril, and Depakote are sometimes useful to help individuals who are struggling with depression and mood swings.
Antipsychotics can be useful for people who suffer from agitation, dissociation, hypervigilance, and paranoia. Clozapine, in particular, has been shown to be effective in individuals with co-occurring schizophrenia and substance abuse.
Alternative or Holistic Therapies
Holistic therapies are also effective at treating addiction and mental health issues. The purpose of holistic therapies is to treat the whole person and not just the symptoms. These can be incredibly beneficial for providing calmness, spiritual support, emotional expression, improving physical health, and teaching valuable coping skills. Some of the popular holistic therapies include:
- Relaxation techniques
- Nutritional therapy
- Animal-assisted therapy (e.g., emotional support dogs)
- Adventure therapy (e.g., hiking or rock climbing)
- Mindfulness and meditation
- Art therapy and music therapy
- Yoga and Tai-Chi
- Equine-assisted (horse) therapy
Alongside these treatments, there are other ways to enhance recovery by making personal lifestyle adjustments, like the ones below:
- Exercise: can stimulate endorphins, which can help with anxiety, depression, and low mood. Examples include low- and high-intensity exercises, such as walking, running, swimming, cycling, or yoga.
- Meditation: can help calm anxious or racing thoughts and improve cognitive function, which is useful when recovering from mental illness and addiction.
- Eating well: the right diet can help repair damage incurred following sustained drug use and lead to improved immunity, cognitive function, and energy.
- Avoiding triggers: learning to avoid triggers like certain people, situations, or circumstances can help prevent a desire to take drugs.
- New Hobbies: while cravings can be difficult to manage, hobbies such as sports, art, music, or crafts can be useful distractions.
If you or a loved one are struggling with co-occurring disorders and substance abuse or addiction, you are not alone. Treatment and support are readily available. Contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment.
You can also find a list of treatment centers near you on our website to help get you on the path to recovery.
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National Institute on Drug Abuse. (2018). Comorbidity: Substance Use and Other Mental Disorders. https://www.drugabuse.gov/drug-topics/trends-statistics/infographics/comorbidity-substance-use-other-mental-disorders.
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