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Dual Diagnosis: Substance Abuse and Comorbidity

Updated: Feb 17, 2021

Dealing with co-occurring disorders? Learn how to tackle addiction when you’re also dealing with depression, anxiety, bipolar disorder, or other complications.

The link between substance abuse and mental health

When you have both a substance abuse problem and a mental health issue such as depression, bipolar disorder, or anxiety, it is called a co-occurring disorder or dual diagnosis. Dealing with substance abuse, alcoholism, or drug addiction is never easy, and it’s even more difficult when you’re also struggling with mental health problems.

In co-occurring disorders, both the mental health issue and the drug or alcohol addiction have their own unique symptoms that may get in the way of your ability to function at work or school, maintain a stable home life, handle life’s difficulties, and relate to others. Co-occurring disorders also affect each other. When a mental health problem goes untreated, the substance abuse problem usually gets worse. And when alcohol or drug abuse increases, mental health problems usually increase too.

Co-occurring substance abuse problems and mental health issues are more common than many people realize. According to reports published in the Journal of the American Medical Association:

  • Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.

  • 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.

  • Of all people diagnosed as mentally ill, 29 percent abuse alcohol or drugs.

Substance abuse problems and mental health issues don’t get better when they’re ignored; they are likely to get much worse—it’s essential to know that you don’t have to feel this way. There are things you can do to conquer your demons, repair your relationships, and get on the road to recovery. With the right support, self-help, and treatment, you can overcome a co-occurring disorder, reclaim your sense of self, and get your life back on track.

What comes first: Substance abuse or the mental health problem?

Substance abuse and mental health disorders such as depression and anxiety are closely linked, although one doesn’t necessarily directly cause the other. Abusing substances such as marijuana or methamphetamine can cause prolonged psychotic reactions, while alcohol can worsen depression and anxiety symptoms.

Alcohol and drugs are often used to self-medicate the symptoms of mental health problems.

People often abuse alcohol or drugs to ease the symptoms of an undiagnosed mental disorder, to cope with difficult emotions, or to change their mood temporarily. Unfortunately, self-medicating with drugs or alcohol causes side effects and, in the long run, often worsens the symptoms they initially helped to relieve.

Alcohol and drug abuse can increase the underlying risk for mental disorders.

Since mental health problems are caused by a complex interplay of genetics, the environment, and other factors, it’s difficult to say if abusing substances ever directly cause them. If you are at risk for a mental health issue, abusing alcohol or drugs may push you over the edge. There is some evidence that those who abuse opioid painkillers are at greater risk for depression, and heavy cannabis use has been linked to an increased risk for schizophrenia.

Alcohol and drug abuse can make symptoms of a mental health problem worse.

Substance abuse may sharply increase symptoms of mental illness or even trigger new symptoms. Abuse of alcohol or drugs can also interact with medications such as antidepressants, anxiety medications, and mood stabilizers, making them less effective at managing symptoms and delaying your recovery.

Recognizing a dual diagnosis

It can be challenging to identify a dual diagnosis. It takes time to tease out a mental health disorder and what might be a drug or alcohol problem. The signs and symptoms also vary depending upon the mental health problem and the type of substance being abused, whether it’s alcohol, recreational drugs, or prescription medications. For example, the signs of depression and marijuana abuse could look very different from schizophrenia and alcohol abuse symptoms. However, there are some general warning signs that you may have a co-occurring disorder:

  • Do you use alcohol or drugs to cope with unpleasant memories or feelings, control pain or the intensity of your moods, face situations that frighten you, or stay focused on tasks?

  • Have you noticed a relationship between your substance use and your mental health? For example, do you get depressed when you drink? Or drink when you’re feeling anxious or plagued by unpleasant memories?

  • Has someone in your family grappled with either a mental disorder or alcohol or drug abuse?

  • Do you feel depressed, anxious, or otherwise out of balance even when you’re sober?

  • Have you previously been treated for either your addiction or your mental health problem? Did the substance abuse treatment fail because of complications from your mental health issue or vice versa?

Dual diagnosis and denial

Denial is common in both substance abuse and mental health issues. It’s often hard to admit how dependent you are on alcohol or drugs or how much they affect your life. Similarly, the symptoms of conditions such as depression, anxiety, bipolar disorder, or PTSD can be frightening, so you may try to ignore them and hope they go away. Or you may be ashamed or afraid of being viewed as weak if you admit you have a problem.

But substance abuse and mental health issues can happen to any of us. And admitting you have a problem and seeking help is the first step on the road to recovery.

Signs and symptoms of common co-occurring disorders

The mental health problems that most commonly co-occur with substance abuse are depression, bipolar disorder, and anxiety disorders.

Common signs and symptoms of depression

  • Feelings of helplessness and hopelessness

  • Loss of interest in daily activities

  • Inability to experience pleasure

  • Appetite or weight changes

  • Sleep changes

  • Loss of energy

  • Strong feelings of worthlessness or guilt

  • Concentration problems

  • Anger, physical pain, and reckless behavior (primarily in men)

Common signs and symptoms of anxiety

  • Excessive tension and worry

  • Feeling restless or jumpy

  • Irritability or feeling “on edge”

  • Racing heart or shortness of breath

  • Nausea, trembling, or dizziness

  • Muscle tension, headaches

  • Trouble concentrating

  • Insomnia

Common signs and symptoms of mania in bipolar disorder

  • Feelings of euphoria or extreme irritability

  • Unrealistic, grandiose beliefs

  • Decreased need for sleep

  • Increased energy

  • Rapid speech and racing thoughts

  • Impaired judgment and impulsivity

  • Hyperactivity

  • Anger or rage

Other mental health problems that commonly co-occur with substance abuse or addiction include Schizophrenia, Borderline Personality Disorder, and PTSD.

Treatment for a dual diagnosis

The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously. Whether your mental health or substance abuse problem came first, long-term recovery depends on getting treatment for both disorders by the same treatment provider or team. Depending on your specific issues:

Treatment for your mental health problem may include medication, individual or group counseling, self-help measures, lifestyle changes, and peer support.

Treatment for your substance abuse may include detoxification, managing of withdrawal symptoms, behavioral therapy, and support groups to help maintain your sobriety.

Helping a loved one with a dual diagnosis

Helping someone with both a substance abuse and a mental health problem can be a roller coaster. Resistance to treatment is common and the road to recovery can be long.

The best way to help someone is to accept what you can and cannot do. You cannot force someone to remain sober, nor can you make someone take their medication or keep appointments. What you can do is make positive choices for yourself, encourage your loved one to get help, and offer your support while making sure you don’t lose yourself in the process.

Seek support. Dealing with a loved one’s mental illness and substance abuse can be painful and isolating. Make sure you’re getting the emotional support you need to cope. Talk to someone you trust about what you’re going through. It can also help to get your own therapy or join a support group.

Set boundaries. Be realistic about the amount of care you’re able to provide without feeling overwhelmed and resentful. Set limits on disruptive behaviors and stick to them. Letting the co-occurring disorders take over your life isn’t healthy for you or your loved one.

Educate yourself. Learn all you can about your loved one’s mental health problem, as well as substance abuse treatment and recovery. The more you understand what your loved one is going through, the better able you’ll be to support recovery.

Be patient. Recovering from co-occurring disorders doesn’t happen overnight. Recovery is an ongoing process and relapse is common. Ongoing support for both you and your loved one is crucial as you work toward recovery, but you can get through this difficult time together and regain control of your lives.

Authors: Lawrence Robinson, Melinda Smith, M.A., and Jeanne Segal, Ph.D.


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