Contributors: Erin Smith & Dennis C. Daley
Edited by: Amy Wenzel
Book Title: The SAGE Encyclopedia of Abnormal and Clinical Psychology
Chapter Title: "Substance Use Disorders and Co-Occurring Mental Health Disorders"
Pub. Date: 2017
Access Date: April 13, 2017
Publishing Company: SAGE Publications, Inc.
City: Thousand Oaks,
Print ISBN: 9781483365831
Online ISBN: 9781483365817
Print pages: 3374-3377
The SAGE Encyclopedia of Abnormal and Clinical Psychology
Substance Use Disorders and Co-Occurring Mental Health Disorders
Many individuals have co-occurring disorders (CODs)—a combination of a substance use
disorder (SUD) and a mental health disorder. Epidemiological studies of community and
treatment samples and numerous studies of patients in mental health or addiction treatment
programs show high rates of CODs. For example, the Epidemiological Catchment Area Study
found that 37% of individuals with a lifetime alcohol use disorder and 53% with a drug use
disorder met the criteria for a mental health disorder. SUDs were highest among those
meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for antisocial
personality disorder, bipolar illness, schizophrenia, an anxiety disorder, or clinical depression.
Alcohol use disorders were twice as high as drug use disorders in the Epidemiological
Catchment Area Study. The National Comorbidity Study found that 51% of individuals with a
mental health disorder met the criteria for an SU, and 41% to 66% of those with an SUD met
the lifetime criteria for a mental health disorder. Studies of psychiatric populations show even
higher rates of comorbidity. In terms of clinical presentation, patients may show mild,
moderate, or severe forms of an SUD, a mental health disorder, or both.
Compared with individuals with a single disorder, those with CODs are more difficult to
engage and keep in treatment. They have higher rates of the following:
Psychiatric hospitalizations and visits to hospital emergency rooms
Financial problems, unstable housing, and homelessness
Legal problems and incarceration
Sexually transmitted diseases and HIV infection
Violence, suicidality, and homicidality (as victims or perpetrators)
Psychiatric medication noncompliance
Failure to transition from inpatient to outpatient care
Relapse to substance use or mental health disorder
CODs can impede an individual’s ability to sustain employment. Impulsivity, erratic behavior,
and poor emotional regulation cause difficulty with relationships and contribute to loss of
housing, jobs, or relationships. Family systems and individual members are adversely
affected by CODs, and the burden for families is often high. This entry examines the relation
between SUDs and mental health disorders and then discusses treatment and recovery
Relations Between Disorders
Potential relations between substance use and mental health disorder include the following:
(a) an SUD increases the risk of developing a mental health disorder; (b) substance use can
mask, exacerbate, or trigger mental health symptoms; (c) a mental health disorder increases
the risk of developing an SUD; (d) mental health symptoms and disorders can affect the
onset, duration, and response to treatment of an SUD; (e) an SUD has an adverse effect on
adherence and response to psychiatric treatment; (f) mental health symptoms may arise as a
result of substance use, withdrawal from addictive substances, or the consequences of an
SUD; (g) a relapse to one disorder can affect relapse to the other disorder; and (h) the
disorders can develop at different points in time.
Many factors contribute to how individuals cope with their CODs, including premorbid
functioning, social support systems, the environment, and the type and severity of symptoms
of both disorders. Substance use often intensifies mental health symptoms. For example,
cannabis use is a risk factor for mood and anxiety disorders, and prolonged use is associated with amotivational syndrome. Heavy cannabis use during early adolescence may increase the
risk of developing schizophrenia. Dopamine circuits are affected by substance use and are
implicated in a variety of mental health disorders including schizophrenia and depression.
According to researchers, genetics account for 50% to 60% of the risk of developing an SUD
and play a critical role in whether occasional use leads to an SUD. Specific genes are
associated with nicotine, cocaine dependence, and alcohol dependence. Other factors
associated with developing an SUD include early trauma (including in utero exposure to
substances) and physical or sexual abuse.
Untreated childhood attention-deficit/hyperactivity disorder symptoms, such as inattention,
hyperactivity, and impulsivity, can predispose a person to substance use. Adolescents are at
increased risk of developing SUDs. An individual’s first use of nicotine, alcohol, or illicit drugs
often occurs during these years, and the environment plays a key role in how and when this
occurs. Early symptoms of mental health disorders may also manifest during this period. The
adolescent brain is not yet fully developed and is uniquely susceptible to structural damage,
whether caused by untreated mental health disorder or substance use. The primary circuits
involved in addiction are also immature, such as reward pathways (nucleus accumbens and
ventral pallidum), motivation and drive (orbitofrontal cortex and subcallosal cortex), learning
and memory (amygdala and hippocampus), and control (prefrontal cortex and anterior
cingulate gyrus). Underdeveloped neural circuitry may affect decisions to try various
substances and often yields increased reward. This, in turn, leads to an increased risk of
Alcohol, nicotine, opioids, sedatives, stimulants, cocaine, marijuana, hallucinogens, and
inhalants are substances associated with SUDs. Methods of use include oral, intravenous,
intramuscular, and intranasal. The most common SUDs involve alcohol, nicotine, cannabis,
and opioids, with prescription drug addiction being higher than heroin addiction. A clinical
interview is used to diagnose a DSM disorder. A temporal relation among morbidities can be
difficult to discern. The fifth edition of the DSM (DSM-5) has reduced its previous emphasis on
the differentiation between substance abuse and dependence and replaced it with the
broader diagnostic category of substance-related disorders, which include SUDs (related to
specific substances), substance intoxication, substance withdrawal, substance/medication-
induced mental health disorders, and unspecified substance-related disorder.
A diagnosis of an SUD requires that at least 2 of the following 11 criteria be met during a 12-
month period, which relate to impaired control, social impairment, risky use, and physiological
manifestation: (1) using larger amounts of the substance than intended; (2) failing to cut
down; (3) spending an excessive amount of time to obtain, use, or recover from a substance;
(4) cravings to use; (5) failing to perform role obligations; (6) continuing to use regardless of
ongoing relationship problems; (7) reducing important activities because of use; (8) using in
dangerous situations; (9) continuing to use regardless of ongoing medical or mental health
problems as a result of use; (10) needing larger amounts to achieve the same effect, or a
diminished effect with continued use of the same amount (i.e., change in tolerance levels);
and (11) experiencing substance-specific withdrawal symptoms when substances are reduced
or stopped, or a substance is used to relieve or avoid withdrawal. Levels of severity of an SUD
include mild (two to three symptoms), moderate (four to five symptoms), and severe (six or
Transient mental health symptoms such as mood lability, anxiety, and paranoid delusions that
arise from either intoxication or withdrawal can be difficult to distinguish from a mental health
disorder. A substance-induced specifier can be applied to most disorders, particularly mood,
anxiety, and psychotic disorders. This implies that symptoms are of recent onset and will be
short-lived; however, symptoms can become permanent with prolonged use. Careful
examination of symptom duration, including the presence or absence of symptoms during
periods of abstinence, is extremely useful in making an accurate diagnosis.
The prevalence of smoking among psychiatric patients is more than 40%, and up to 90%
among patients with schizophrenia. Smoking cigarettes can affect medication levels; notably,
clozapine is reduced by 30% to 40%. Because withdrawal from both alcohol and
benzodiazepines may precipitate seizures, ruling out a state of withdrawal is essential in acute
settings such as medical or psychiatric emergency rooms.
Treating CODs is more complex and difficult than treating a single disorder. When possible,
the patient should be treated in the same treatment system by the same team so that the
professionals involved in care can collaborate and coordinate care in an integrated manner. In
clinical care, it is not unusual for patients to participate in separate addiction treatment and
mental health programs. Both disorders need to be the focus of clinical interventions for
Patients with CODs may use a combination of addiction and mental health services, including
detoxification, psychiatric inpatient, psychiatric rehabilitation, addiction or COD rehabilitation
programs, partial hospital or intensive outpatient programs, and outpatient care and ancillary
services (e.g., vocational or educational testing and counseling, housing, social services). The
biopsychosocial model provides a useful and holistic framework:
Biological factors include medications, nutrition, and physical activity.
Psychological factors refer to different forms of therapy in which the patient learns
cognitive, affective, and behavioral coping skills.
Social factors include the individual’s environment, relationships, social activities, and leisure interests; mutual-support programs; and the effect of CODs on family members as well as their involvement in the treatment. The impact on families is often profound, and wherever possible, help and support for family members should be included in the treatment plan.
Assertive Community Treatment teams are a community-based resource that helps individuals
with more chronic and severe CODs who have high rates of inpatient psychiatric admissions.
Many service coordinators are trained in addictions, and many Assertive Community
Treatment teams include peer specialists who are in recovery from CODs; such individuals
help foster a sense of hope and offer valuable encouragement to continue treatment.
The Patient Placement Criteria, created by the American Society of Addiction Medicine,
provides a useful framework to determine which level of care best addresses a patient’s
needs. Patients are evaluated along a continuum of the following six dimensions of care,
ranging from early-intervention and outpatient services to inpatient admissions to a medical or
psychiatric hospital: (1) acute intoxication and/or withdrawal potential; (2) biomedical
conditions and complications; (3) emotional, behavioral, or cognitive conditions and
complications; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery/living environment.
The use of psychiatric medications is often required in COD treatment, whether for acute
exacerbation of a mental health disorder, reducing symptoms that have not fully responded to
therapy, or treating severe symptoms of long duration. Among the most commonly prescribed
are selective serotonin reuptake inhibitors for depression, a class that includes fluoxetine and
sertraline, and mood stabilizers such as lithium or valproic acid. Individuals with CODs often
experience significant anxiety; however, given the addictive potential of benzodiazepines and
their dangerous side effects, such as sedation, falling, and withdrawal, many clinicians have
reservations about prescribing this class of medication. Nonaddictive alternatives for anxiety
treatment include buspirone.
Medications also assist in safely managing withdrawal and may be used to treat the SUD
itself. For example, methadone and buprenorphine are used to assist recovery from opioid
use disorder. Naltrexone and acamprosate play a similar role in recovery from alcohol use
disorder; in particular, the anticraving effect of naltrexone is helping in preventing relapse
among heavy drinkers. Nicotine replacement options are legion. The costs and insurance
status of these medications must be considered when selecting which medication will most
likely offer long-term benefits.
Common challenges in medication-assisted treatment are an attitude of overreliance on pills
to “fix” the problems or, conversely, a hesitancy to accept treatment because of internal
perceptions of stigma or pressure from others in recovery to comply. It is important for the
prescriber to be mindful of this and address it with the patient in an empathetic way.
Ultimately, these concerns are best addressed in therapy.
Therapy or Counseling
There are many effective therapies for substance use or mental health disorders including,
interpersonal therapy, cognitive behavioral therapy (CBT), and psychodynamic therapy. Other
evidence-based therapies specific to SUDs include individual drug counseling, twelve-step
facilitation therapy, group drug counseling, motivational incentives, community reinforcement
plus vouchers, motivational interviewing (MI), the Matrix model, and couple (behavioral martial
therapy) and family therapies (community reinforcement approach; multisystemic,
multidimensional, and brief strategic family therapy). MI is a person-centered, collaborative
therapy that was developed for use with CODs, and strong evidence supports its
effectiveness in helping individuals change negative health-related behaviors. MI has the
potential to help patients gain insight into the connections between their CODs. A form of CBT known as relapse prevention therapy builds on the interplay between comorbidities and
facilitates collaborative planning of relapse prevention strategies between client and therapist.
Many therapies, including CBT, interpersonal therapy, and dialectical behavior therapy, have
incorporated a focus on both mental health disorders and SUDs and thus are effective in
achieving symptom relief, reduced use or abstinence from a substance, and, ultimately,
recovery. The most effective treatment strategy for CODs emphasizes an integrated approach
that addresses both disorders and acknowledges their symbiotic nature. For example, an
antidepressant medication combined with MI forms an integrated treatment approach for an
ambivalent individual with major depressive disorder and alcohol use disorder. Later in the treatment course of this individual, it would be appropriate to incorporate a maintenance
medication like naltrexone to address cravings, in combination with individual long-term
therapy using an integrated therapy approach and family therapy if possible.
Family members are profoundly affected by a loved one’s CODs. A key aspect of both SUDs
and severe mental health disorder is the inability and failure to fulfill major obligations or
roles. Consequently, spouses and children are subjected to neglect, the inconsistent or
unpredictable presence of the affected individual, extremes of intoxication and withdrawal,
and, in some cases, physical violence. Loved ones may experience a plethora of reactions
ranging from anger to helplessness, and risk becoming either enmeshed in the disorders or,
conversely, estranged from their family member. The relapsing and remitting cycle of
addiction damages the structure and quality of relationships within families and impedes an
individual’s ability to maintain meaningful employment. Establishing a safe environment is a
key priority for family members, and gaining knowledge concerning the CODs helps maintain
control in erratic situations. Family members should be provided with resources to support
their own mental health needs and resilience, whether in the form of workbooks; national
websites such as the National Alliance on Mental Illness; local support networks such as Al-
Anon, Nar-Anon, Alateen, or National Alliance on Mental Illness groups; or referrals to family
therapists or counselors.
Recovery and Relapse
Each disorder affects recovery of the other, and awareness of this relationship by both
therapist and patient is essential to collaboratively establish goals and create a treatment
plan. Recovery is not merely abstinence or symptom reduction; instead, recovery
encompasses six domains: (1) physical, (2) emotional, (3) interpersonal/family, (4) social, (5)
lifestyle, and (6) spiritual. Accepting each disorder lays the groundwork for new insights and a
balanced understanding of how CODs affect individual lives. Recognizing one’s attitudes,
behaviors, and emotions plays an important role in recovery; anger, anxiety, boredom,
depression, grief, and shame often underlie the choice to use substances as coping
mechanisms or means of escape. Individual or group therapy facilitates the self-reflection
through which individuals develop awareness of their thoughts and feelings. Another
challenge is the experience of positive emotions such as gratitude, love, and support, which
may be new and unfamiliar. Learning to recognize and appreciate other people’s emotions
also helps create stronger, healthier support systems.
Patients benefit from learning to identify and manage early signs of relapse of either disorder.
They also benefit from identifying their personal high-risk factors and what they can do to limit
the damage if they relapse to either disorder. Participation in both treatment and mutual-
support programs can provide the patient with the opportunity to learn about relapse and the
skills required to reduce relapse risk and improve quality of life. Mutual-support programs for
addiction (Alcoholics Anonymous, Narcotics Anonymous, other twelve-step and non-twelve-
step programs), mental health disorder (Emotions Anonymous, Recovery, Inc.), and CODs
(Dual Recovery Anonymous) can help patients in many ways, especially if they get “active”
and use the “tools of these programs to make changes in themselves and their lifestyle.”
CODs are common in both mental health and addiction treatment programs. Patients show
varying levels of severity of their CODs, which determines the types of treatment interventions needed. Although many effective psychosocial, medication, and combined interventions exist
for substance use or mental health disorders, integrated care is the preferred strategy when
possible. This approach addresses both substance use and mental health issues. In addition,
mutual-support programs are highly recommended for patients with CODs as they expose the
patients to peers in recovery who can mentor them throughout the recovery process. In
addition, the family can provide input for the treatment plan as well as benefit from
participation in family treatment sessions or mutual-support programs. Families can support
the member with the CODs as well as gain help in dealing with their own emotional reactions
to the loved one who has a COD.
Erin SmithDennis C. Daley
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