Co-occurring Disorders in Drug and Alcohol Dependency
Drug and alcohol dependency are often accompanied by co-occurring mental health disorders, which usually manifest before the substance use but may appear afterward as well. These co-occurring conditions are so common that people diagnosing addiction know to look for them and have developed procedures to screen for their presence.
Likewise, people who seek evaluation and/or treatment for mental health symptoms are normally screened for substance use. Mental health professionals are aware that men and women with psychological and emotional issues may turn to drugs and alcohol as a way of coping with their symptoms.
When co-occurring conditions are uncovered, treatment must prioritize the substance use disorder and the mental health disorder equally. While detox must take place before any type of treatment can begin, once it does all symptoms and disorders should be addressed simultaneously.
Facts about Addiction and Co-occurring Disorders
In 2016, the most recent year for which comprehensive statistics are available, 44.7 million American adults had some form of a mental illness, while 19 million showed symptoms consistent with a substance use disorder[1].
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These groups included 8.2 million people who had both a substance use disorder and mental health disorder, which means 43 percent of those with an alcohol or drug problem had a co-occurring mental health condition[2]. Among the general population, less than 20 percent had a mental health condition while less than 10 percent had a substance use disorder, which highlights how significantly each type of illness can influence the other[3].
The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), represents the most extensive study of the incidence of specific co-occurring conditions. Over 43,000 adults were surveyed, and among those who reported substance use disorders 20 percent had co-occurring mood disorders while 18 percent were diagnosed with co-occurring anxiety disorders[4].
With personality disorders, the percentages of co-occurrence were even higher: 29 percent of NESARC participants with alcohol use disorders were judged to have at least one personality disorder, and 48 percent of people with a drug use disorder also had one or more personality disorders[5].
Regardless of the specific cause-and-effect relationship, it is clear that having a substance use disorder puts a person at elevated risk for mental health problems, and vice versa.
Reasons Why Co-occurring Conditions are Common
Mental health disorders can be difficult to recognize, and many who experience the symptoms of these conditions fail to understand what is happening to them.
But their impact remains profound and life-altering. Many people choose to self-medicate by using drugs and alcohol to control their anxiety and improve their mood. Unfortunately, this type of behavior can quickly become compulsive, since any changes in mood following drug and alcohol consumption will be temporary and harder to achieve as tolerance builds.
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In some instances, prolonged substance abuse can trigger changes in the brain that evolve into mental illness or other types of disabling health problems, such as sleeping or sexual dysfunction disorders. These are known as substance-induced disorders, and in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) there are six conditions listed that fit the category of substance-induced mental health disorders[6]. They include:
- Substance-induced psychosis
- Substance-induced delirium
- Substance-induced bipolar disorder
- Substance-induced anxiety disorder
- Substance-induced depressive disorder
- Substance-induced obsessive-compulsive disorder
In each of these conditions the symptoms experienced are directly related to substance use, and tend not to recur when drug and alcohol are no longer being consumed. Strictly speaking, substance-induced disorders do not co-occur with substance use disorders but are a consequence of their severity.
While issues of cause-and-effect are not always clear when disturbing mental health symptoms and substance use symptoms are experienced together, in some instances they may be impossible to uncover. It is possible for mental health and substance use disorders to develop independently but nearly at the same time, based on shared risk factors that make a person vulnerable to both.
Specifically, exposure to trauma or abuse, especially (but not necessarily) in childhood, is a known risk factor for a number of life problems, including addiction and ongoing mental health issues. Having a family history of mental health troubles is another risk factor that increases the likelihood of mental illness and/or substance abuse developing, with genetic and environmental components both likely involved.
Diagnosing Co-occurring Disorders
Substance use disorders are diagnosed based on the continuing presence of disabling and life-altering symptoms. When addiction develops, substance use becomes a powerful compulsion rather than a choice, and that reveals itself clearly on a daily basis.
To diagnose drug or alcohol dependency, at least two of these symptoms must be reported during an evaluation (six or more symptoms would indicate a severe addiction)[7]:
- Compulsive and uncontrollable usage
- All previous attempts at abstinence have ended in failure
- Drugs or alcohol use and related factors occupy a significant amount of time
- Physical and psychological cravings are persistent
- Substance use continues despite neglect of work, educational or family responsibilities
- Substance use continues despite its negative impact on important relationships
- Drug and alcohol abuse has replaced old hobbies or activities
- Hazardous behaviors related to substance use has become common
- Substance use continues despite physical or psychological health problems
- Growing tolerance leading to escalating usage
- Withdrawal symptoms that accompany attempts to achieve sobriety
Diagnosing co-occurring mental health disorders can be complicated, since each condition has its own specific markers. In general, mental health symptoms must be experienced independently of any substance use, must manifest consistently over a period of a few weeks or a few months, and must be debilitating enough to make daily functioning difficult if not impossible.
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Treating Co-occurring Substance Use and Mental Health Disorders
Dual diagnosis treatment programs are specifically designed for people with co-occurring mental health and substance use issues. Treatment is comprehensive and carefully targeted at all symptoms, with none being given priority (except during detox, which should be completed before the client transitions into inpatient or intensive outpatient programs).
Unfortunately, dual diagnosis treatment programs are a badly underused resource. Among the 8.2 million people who suffered from both a substance use disorder and a mental health disorder in 2016, only 6.9 percent received specialized (dual diagnosis) care appropriate for co-occurring conditions[8]. Nearly half (48.1 percent) did receive some type of treatment, but 38.2 percent sought mental health services only while 2.9 percent were treated only for a substance use disorder[9].
Ultimately, men and women with co-occurring disorders need treatment for each condition that causes them hardship, and as long as treatment remains partial true recovery will remain elusive. Mental health professionals or addiction specialists who uncover co-occurring conditions should strongly recommend—and the loved ones of people with substance use disorders should insist on—dual diagnosis treatment, preferably in residential treatment programs at licensed rehabilitation facilities with extensive experience in these areas.
[1] Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#adults
[2] Ibid.
[3] Ibid.
[4]Grant, Bridget F., et al. Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders.
[5]Grant, Bridget F., et al. Co-occurrence of 12-month Alcohol and Drug Use Disorders and Personality Disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. https://www.ncbi.nlm.nih.gov/pubmed/15066894
6 Gorski, Terry. DSM 5 Substance Use Disorders. A Concise Summary.
https://terrygorski.com/2013/10/15/dsm-5-substance-use-disorders-a-concise-summary/
[6] Ibid.
[7] Schuckit, Marc, MD, et al. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale.
https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2013.12060782
[8]Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#adults
[9]Ibid.
