Substance Use and Co-Occurring Mental Disorders

Next Generation Series

By Tom O’Connor and Laurie Engel, Co-Authors

October 3, 2024

#adultchildsyndrome #substanceuse #mentaldisorders #tomoconnor #laurenengel

Co-occurring disorder (COD) refers to having an existing substance use disorder. (SUD) and a mental illness disorder. When faced with these co-occurring disorders, they may differ in severity, and the severity of each disorder can change over time.

Compared to individuals who have a single disorder, those with a combination of disorders may experience more severe medical and mental health challenges and may also require more extended periods of treatment.

CODs require a combination of two diagnoses. One diagnosis is for a SUD and the other is for a mental health disorder, also called mental illness.

Laurie Engel

Laurie Engel is a co-author in this issue. Laurie has over 25 years of experience as a licensed clinical social worker and clinical alcohol and drug counselor. Laurie’s experience includes working with adults in partial care, intensive outpatient, and outpatient levels of care. Laurie is a Licensed Clinical Social Worker (LCSW) and Licensed Clinical Alcohol and Drug Counselor (LCADC). She holds a Master of Science in Clinical Psychology from Philadelphia College of Osteopathic Medicine, where she completed three years of Cognitive-Behavioral Therapy training, and a Master of Social Work from Rutgers University.

Additional Information for You

Laurie Engel on Integrated Treatment

Laurie believes in a holistic and integrative approach to treating Co-occurring disorders (COD) and that one disorder cannot be treated successfully without addressing the other. Until recently, the field was treating mental health disorders and substance disorders either parallel or consecutively. This has finally changed, and integrative treatment is now the gold standard. Because there is a significant link between trauma and Co-occurring disorders, trauma-informed care is essential for the successful treatment of COD. Successful treatment settings use a comprehensive approach that includes evidenced-based therapeutic techniques such as CBT, DBT, EMDR, and family therapy, in addition to holistic treatments like pet therapy, sound therapy, martial arts, and yoga. Holistic Disorder treatment is an approach that considers the whole person rather than just focusing on substance abuse or mental health issues.

Research Statistics

Dual diagnosis is common. According to the Cleveland Clinic, in 2020, 17 million U.S. adults had SUD and mental health disorders.

According to the American Addiction Centers, there are 20.3 million adults diagnosed with SUDs, and more than a third of them also suffer from mental illness. Almost 20% of the 42.1 million people diagnosed with a mental health condition also have SUD.  Unfortunately, more than 50% of those diagnosed with co-occurring disorders never receive treatment for either condition. Costs tend to be the primary barrier to treatment for more than half of those who are diagnosed but do not receive treatment.

The relationship between mental health disorders and substance use disorders is very tightly woven. While concrete statistics are challenging to pin down, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a 2019 National Survey on Drug Use and Health (NSDUH) on the percentage of people suffering from a substance use disorder (SUD) that is concurrent; experiencing a mental health condition is estimated to be close to 50%.

According to the National Institute on Drug Abuse, approximately 50% of individuals who have either a mental illness or SUD will have the other at some point in their lives.

COD Symptoms

If you suspect your family member may have experienced both, or if you are worried about your use of alcohol or drugs, there are symptoms you can watch for that can alert you to the need for a dual diagnosis.

SUD Symptoms 

● Withdrawal from your family and friends.

● Difficulty maintaining focus.

● Sudden changes in your behavior.

● Engaging in risky behaviors.

● Developing a high tolerance for the substance and having withdrawal symptoms.

● Feeling like you need the substance to function.

Mental Health Disorder Symptoms 

● Extreme mood changes.

● Confusion.

● Problems concentrating.

● Unable to function at school or work.

● Avoiding social activities.

● Thoughts of suicide.

According to the National Institute of Mental Health, the symptoms of co-occurring disorders include those associated with a particular substance abuse problem and mental health condition affecting the individual. Mental health conditions that commonly co-occur with SUD include general anxiety disorders (GAD), clinical depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD) in adults, and post-traumatic stress disorder (PTSD).

General Anxiety Disorders (GAD)

General anxiety disorder is the most common type of anxiety disorder. It is also one of the most co-occurring disorders (CODs). Experiencing anxiety itself is natural in situations that warrant it. It is when a person experiences persistent fear that is unrelenting and disproportionate to the problem at hand that a diagnosis of GAD may be justified. GAD is often found to be the condition most associated with self-medication behavior that drives SUDs.

Clinical Depression

While depression is highly correlated with SUDs, it is a highly complex disease that could have a diverse number of causes. What is known is that depression and alcohol use are powerfully correlated with increased feelings of

depression.

Bipolar Disorder

Severe mood swings characterize bipolar disorder. These swings range from a

high or euphoric state called mania to the lows, which are depressive. As mentioned above, with clinical depression, depressive episodes are strongly linked to alcohol consumption, which in turn can worsen depressive feelings. However, mani is also dangerous in terms of SUDs. People who are experiencing a manic episode are much more likely to engage in risky behaviors. When combining those circumstances with alcohol consumption, which further reduces inhibitions, a person with bipolar disorder can find themselves in life-threatening situations.

ADHD

Attention deficit hyperactivity disorder is often diagnosed at an early age, such as a person’s childhood or teenage years. However, many individuals have ADHD and are unaware of it until their manifested behaviors lead them into addiction and they are formally diagnosed. Those who have ADHD are more likely to become addicted to alcohol or drugs.

PTSD

Post-traumatic stress disorder includes anyone who has experienced a highly

traumatic impact event. Violence, physical or emotional abuse, and sexual assault are a few of the many reasons why a person may develop PTSD. A recurring behavior that occurs in those who have PTSD is the need to suppress the memories or flashbacks they may have by using alcohol and drugs.

COD Causes

Researchers have a few theories about why SUDs and mental health disorders occur together.

Shared Common Risk Factors

These risk factors may include:

● Genetics: Both SUDs and mental health disorders can run in families. Research

shows many genes may contribute to your risk of developing either condition.

● Environmental Factors: Environmental factors such as stress and trauma can be

passed down through generations. These can contribute to the development of

SUD or a mental health disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), an increased risk of alcohol use disorder (AUD), for example, may also be related to certain anxiety and depressive disorders. As in the case of opioid use disorder (OUD) and depressive disorders, it is possible that a substance use problem leads to the development of other mental health challenges or that it worsens a pre-existing disorder.

Dual Diagnosis

According to the Cleveland Clinic research:

Dual diagnosis combines two diagnoses. It can be challenging to make an accurate diagnosis because the symptoms of SUDs and mental health disorders can overlap.

It would be best if you located a seasoned therapist experienced with working with individuals who suffer from addictions and mental health disorders. Your provider needs wide-ranging screening tools to accurately evaluate you or your loved one for both disorders.

When speaking to your therapist, you or your loved one must be honest and vulnerable. Based on your answers, they can determine the most effective treatment.

There are many Screening Tools for CODs, including:

● Structured Clinical Interview for DSM-V (SCID-5) is a semi-structured interview

guide for making the primary DSM-5 diagnosis created by the American

Psychiatric Association. It must be administered by a clinician or trained mental

health professional familiar with the DSM-5.

● The Patient Health Questionnaire (PHQ-9) is a multipurpose instrument for

screening, diagnosing, monitoring, and measuring the severity of clinical

depression.

● Alcohol Use Disorders Identification Test (AUDIT-C) is an alcohol screen that can help identify patients who are hazardous drinkers or have active AUD.

● AC-OK Screen for Co-Occurring Disorders is a rapid-response screen instrument

with 15 questions designed to identify people likely to have co-existing CODs

efficiently.

● TWEAK alcohol test is an anacronym for tolerance detecting alcoholism/heavy

drinking in the clinical and general populations.

● CAGE-AID Assessment is a personal assessment for substance abuse in adults.

● CRAFFT is a well-validated substance use screening tool for adolescents aged

12-21.

● NIDA Quick Screen-ASSIST is a two-part screening tool to assess the use of

alcohol, tobacco products, prescription drugs, and illegal drugs.

● PQH-2 and PHQ-A are components of the longer Patient Health Questionnaire,

offering therapists concise, self-administered tools for assessing depression.

● GAD Screening is an initial screening for generalized anxiety disorder (GAD).

● The Stress Questionnaire is a screening tool to help determine patients'

stress levels.

Every mental health therapist and addiction counselor should download and study SAMHSA’s “TIP 42: Substance Use Treatment for Persons with Co-Occurring Disorders.” TIP 42 will provide the latest science in screening, assessing, diagnosing, and managing CODs. I read its contents thoroughly and found them most useful and informative for my research for this Vital Voyage Newsletter Special Issue. SAMHSA (www.samsha.gov) is the U.S. Department of Health and Human Services agency that leads public health efforts to reduce the impact of substance abuse and mental health illnesses in America’s communities.

COD Treatment

According to research, SUD and mental illnesses were historically treated separately, without consideration for the other. SUD is defined as the persistent use of drugs despite the substantial harm and adverse consequences to one’s self and others as a result of their use. For example, a treatment center might help an individual diagnosed with an alcohol use disorder (AUD). AUD is defined as a chronic disease caused by uncontrolled drinking and preoccupation with alcohol. A therapist separately might be treating a person who has been diagnosed with depression.

According to SAMHSA, for co-occurring disorders, they recommend dual diagnosis treatment programs.

Dual Diagnosis Treatment Programs

Dual-diagnosis treatment programs focus on treating both the addiction and the underlying mental health disorder, providing individuals with the best chance at a lasting recovery.

Dual diagnosis treatment can help you:

● Understand your disorders

● Learn how to cope with your disorders

● Improve your overall mental health

● Quit using substances

● Avoid relapse

● Improve your overall physical health

SAMHSA has a “No Wrong Door” policy that people presenting for treatment for a mental disorder should be routinely screened for substance use disorder (SUD), and all people presenting for treatment of SUD should be screened for mental disorders.

SAMHSA also has a “Substance Use Disorder Treatment for Persons with Co-Occurring Disorders:

A Treatment Improvement Protocol” that provides newly updated, best-practice guidelines for preventing and treating substance use disorders and mental health disorders.

COD Behavior Therapy

According to the Cleveland Clinic research, behavior therapies that have been shown to treat CODs include:

● Cognitive Behavioral Therapy (CBT) is a structured, goal-oriented talk therapy. It can help manage mental health conditions, such as general anxiety and clinical depression, and emotional concerns, such as coping with grief or stress. CBT can also help manage psychological health conditions, such as insomnia and

chronic pain.

● Dialectical Behavioral Therapy (DBT) is a type of talk therapy for people who experience emotions very intensely. It’s a standard therapy for borderline personality disorder, but therapists provide it for other mental health conditions as well.

● Assertive Community Treatment (ACT) is a form of community-based mental health care that emphasizes outreach to the community and an individualized treatment approach.

● Therapeutic Communities (TC) use active participation in group living and activities to drive individual change and attain therapeutic goals.

● Contingency Management (CM) is an evidence-based treatment that provides motivational incentives to treat individuals living with substance use disorder.

Medication

According to the Cleveland Clinic research, your therapist may prescribe medication for one or both conditions. Some drugs can help alleviate the symptoms of both dual-diagnosis conditions. For instance, the Food and Drug Administration (FDA) has approved bupropion (Wellbutrin) for the treatment of clinical depression and nicotine dependence (Zyban).

According to Laurie Engel, as part of a comprehensive COD treatment program, doctors may also include Medication Assisted Treatment (MAT), which provides medications that can often help lessen cravings for alcohol, such as naltrexone or Vivitrol (a monthly injection) or suboxone helps to reduce cravings and withdrawal symptoms from opiates and helps to prevent misuse of the medication by blocking the effects of other opioids.

Mutual Support Groups

Support groups can be very beneficial by providing you with the social and emotional support you need for sobriety, like Alcoholics Anonymous (AA). AA is designed for individuals who are struggling with AUD.

Support groups such as Dual Diagnosis Anonymous are also tailored for CODs. (DDA) and Narcotics Anonymous (NA), which offers group meetings for people with CODs.

If a loved one has alcoholism, there are groups like Al-Anon and Adult Children of Alcoholics (ACOA) provide family members of an addict support groups. These two groups are designed for family and friends affected by a loved one’s AUD.

As an ACOA, I have attended Al-Anon and ACOA support group meetings.

These support groups have people who have been in your shoes before. Your peers can share their experiences, answer your questions, and offer tips for everyday challenges.

In-Patient Care 

If you or a loved one are experiencing a dependent pattern of substance use along with a mental health condition, you or your loved one may benefit from a dual diagnosis treatment center. There, you or your loved one will receive both medical and mental health care, including medication, therapy, and support.

According to Laurie Engel, individual and family therapy can be extremely helpful for both loved ones and those who have an addiction and mental health issues. This can address family dynamics and improve the family member’s chance of a successful recovery.

Amanda’s Courageous True-Life Story 

I am honored to connect with Amanda through researching families that are suffering from addiction and mental health conditions. We met through “Addiction and Behavioral Health Network Resources.”

According to the National Library of Medicine research, substance use disorders (SUDs) like Amanda’s alcoholism is often described as “chronically relapsing). There is broad support that changing addictive behavior is complex. Those facts are confirmed by SAMHSA, which states the large percentage of people entering addiction treatment with one or more prior treatment admissions and the high rate of post treatment recurrence of alcohol and drugs, most often within 90 days of treatment.

Approximately 15 years ago, Amanda checked herself into her second treatment center. It was the first time she took professional advice and tried an aftercare program in what she calls “My desperate attempt to gain control of my life.” At this point, Amanda was not entirely willing and committed, but she was ready enough to make her second attempt at achieving sobriety.

Amanda was nervous as she hadn’t made it this far on her journey to recovery. She had to let go of everything she cared about for at least 30 days. Relapse was part of Amanda’s story, but without these new tools, she believes she couldn’t have remained sober.

According to Amanda:

● Lavish treatment centers are friendly environments but not always necessary to get sober.

● You don’t always have to be willing. That’s why you surround yourself with a support system of family and friends, recovery coaches, and sponsors. They will be sure to remind you why you should keep going with your addiction treatment.

● Most importantly, Amanda understood what was hurting her enough (alcoholism) to make her hide from everyday life and decided to change the outcome of her story.

● Amanda has started a new position as a staff member professional with a treatment center, juggling being a wife and mom and a full-time student in nursing school. Amanda suffered childhood trauma, depression, anxiety, eating disorders, early use of alcohol, physical, emotional, and mental abuse, ADHD, and homelessness.

According to Amanda:

“YOU are the secret to recovery. LEARNING is the secret to recovery. DRIVE is the secret to recovery.  Accepting help from others is the SECRET to recovery.”

Amanda’s life story inspires me to continue my work helping Adult Children of Alcoholics (ACOA). I admire Amanda's courage on her unrelenting journey to defeat her addiction and mental health disorders and live a happier life with her husband, children, work, and educational pursuits in nursing.

Your Call to Action

Whether you are an addiction professional, mental health professional, addict, or family member or friend of someone with an addiction or someone with a mental health disorder, think carefully and ask yourself the following questions:

Substance Use

When did the person start using possibly addictive substances (drugs, alcohol)?

What was going on in their life at the time?

How does substance use affect their mental health symptoms?

Have they tried to limit or stop their use?

Has anyone in the person’s family struggled with substance abuse?

Mental Health

Have they been diagnosed with a mental health condition in the past?

How do they feel when they are sober?

Do they have any unresolved emotional trauma?

If so, when did the person start feeling any emotional trauma?

Has anyone in the person’s family struggled with a mental disorder?

Integrated Treatment

Don’t try to fight addiction and mental health separately. It would be best if you had a dual-diagnosis treatment center that’s right for you and start on the path to recovery. According to SAMHSA, integrated treatment can improve outcomes and quality of life for people with co-occurring disorders, including:

● Reduced or discontinued substance use

● Improvement in psychiatric symptoms and functioning

● Increased chance of successful treatment and recovery for both disorders

● Improved quality of life

● Decreased hospitalization

● Reduced medication interactions

● Increased housing stability

● Fewer arrests

Helping Loved One with a COD Diagnosis

Helping someone with a COD diagnosis can be very difficult. Your loved one may deny they have a problem and resist treatment. When they do begin treatment, their road to recovery may be extended.

Accept what you can and cannot do. You cannot force your loved one to remain sober, take medication, and go to therapy. But you can make positive choices for yourself, encourage your loved one to get help, and offer unconditional support.