Co-Occurring Disorders

 
Co-occurring disorders are defined simply as two mental health disorders occurring at the same time. For the purposes of this article, it involves a mental health disorder that is experienced at the same time as a substance abuse disorder.

Many people with substance abuse disorders have co-occurring disorders. In fact, experts advise that when a person is looking at a substance abuse disorder diagnosis, the likelihood of one or more co-occurring disorders should be considered the rule rather than the exception.

Co-occurring disorders are a complicating factor of drug and alcohol abuse and addiction treatment. Many of the symptoms of these mental health disorders can influence, result from, and become inextricably entwined in the symptoms of a substance abuse disorder, making it necessary to treat both in order to achieve progress with either.

• According to the most recent research, 7 million adults have co-occurring substance abuse and other mental health disorders; this is just over 3 percent of the adult population. About 1 percent of adults have a serious mental health disorder co-occur with a substance abuse disorder.
• When looking at people who are in substance abuse treatment programs, between 50 and 75 percent of people with an addiction disorder have a co-occurring mental health disorder at some point in life.
• These troubles can start in youth. About 4 percent of adolescents between 12 and 17 years of age have had a major depressive episode co-occur with a substance abuse disorder.
• A survey of addiction treatment centers showed that the most common co-occurring disorders found in addiction treatment settings include mood disorders (40-42 percent of patients), anxiety disorders (24-27 percent), post-traumatic stress disorder (24-27 percent), severe mental illnesses (16-21 percent), antisocial personality disorder (18-20 percent), and borderline personality disorder (17-18 percent).
• Only 4 percent of individuals receive treatment for both conditions, with 55.8 percent receiving no treatment at all.

 
The following are the most common disorders that co-occur with substance abuse and addiction:

• Mood Disorders

  Mood disorders such as depression or bipolar disorder are the most common co-occurring disorders with substance abuse. Compared to people with no mood disorder, people who struggle with depression are twice as likely to have a substance abuse disorder, and those with bipolar disorder are seven times more likely to struggle with addiction or substance abuse. Common substances of abuse for people with mood disorders are alcohol and cocaine.

  Depression may precede or come after a substance abuse disorder. Depression can also be a symptom of withdrawal from many substances, so it can be difficult to tell if the person’s response is based on the addiction or an actual co-occurring disorder. According to some research, signs of depression related to withdrawal taper between 30 and 50 percent from the first day that substance use is stopped to the end of the second week of abstinence. This can help determine whether the depression is co-occurring or related to withdrawal.

  Depression, mania, and bipolar disorder can also be induced by substance use. As a result, it is important to understand the underlying history of the person, the symptoms presented after detox, and continued behavior and responses during treatment.

• Anxiety Disorders

  Nearly half of the people who have a mood disorder also have a form of anxiety disorder, such as panic disorder, simple phobias, or social anxiety. This can further complicate treatment for co-occurring addiction and mood disorders. Common substances of abuse for anxiety disorders include anti-anxiety medications, such as alprazolam (Xanax) and diazepam (Valium), because these addictive substances are often prescribed for these conditions. While people who take benzos as directed for short periods of time do not tend to become addicted, those who use them more often or for longer periods of time are more likely to have an addiction problem. Alcohol abuse is also common for people with anxiety disorders.

  In addition, while there’s little real correlation between when a mood disorder starts and when the co-occurring substance abuse disorder starts, there is a correlation between anxiety and substance abuse, with onset of an anxiety disorder being more likely to precede the onset of a substance disorder.

• Post-Traumatic Stress Disorder

  People who have experienced major trauma and subsequently develop PTSD are highly likely to also have a substance abuse disorder. Some research indicates that this could have something to do with the person’s need to disconnect with the psychological effects of the trauma. Drugs and alcohol use contribute to a person’s ability to avoid the memories and dreams that arise from trauma and PTSD.

  As an example, veterans returning from war have a high incidence of co-occurring PTSD and substance use disorders. One in three veterans who seek treatment for substance abuse also has PTSD, and more than 20 percent of veterans diagnosed with PTSD also have substance abuse disorders. Similarly, for adolescents seeking drug treatment, 70 percent have a history of trauma.

  Some research has shown a high correlation between opiate abuse and PTSD – both for prescription painkillers and for illicit drugs like heroin. Alcohol, again, is common among people with PTSD.

• Antisocial Personality Disorder

  A person who has this disorder habitually manipulates, exploits, or violates the rights of other people. The disorder often includes a tendency toward violence and cruelty, and it affects more men than women. It is more common in people with at least one parent who was alcoholic or who also had the disorder. Antisocial personality disorder (ASPD) has high correlation with heroin or prescription opiate use in young people.

  A large number of people with ASPD also abuse alcohol and there’s a correlation between alcohol use and violent behavior for these people.

• Borderline Personality Disorder

  People with borderline personality disorder (BPD) lack the ability to control their emotions, often experiencing violent mood swings. They also tend to lack impulse control and have unstable relationships with other people.

  When it comes to substance abuse, BPD correlates strongly with alcohol use. In addition, any substance abuse disorder with which BPD co-occurs is much harder to treat. Because of the mood swings that characterize the disorder, people who struggle with BPD are more likely to drop out of treatment early. Lack of impulse control also makes them more likely to self-harm during substance abuse, which is sometimes difficult to control during treatment.

• Severe Mental Illnesses

  The greater the severity of the co-occurring disorder, the more likely the person is to abuse drugs or alcohol. People who have schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis are more likely to abuse substances. In fact, they are four times more likely to drink alcohol four or more times per day; 3.5 times more likely to engage in heavy marijuana use; 4.6 times more likely to try other drugs often over their lifetimes, and 5.1 times more likely to smoke daily.

  At the same time, demographics that correlate with lower drug use in the general population don’t seem to hold true among those who have severe mental illness. Women and Asian Americans tend to have lower rates of substance abuse in the general population, but among people with severe mental illnesses, women and Asian Americans are just as likely to have a substance abuse problem as other demographics.

Other disorders can co-occur with substance abuse disorders, including eating disorders, behavioral addictions, simple phobias, and other types of personality disorders. In many cases, the more severe the disorder, the more likely that there is a co-occurring substance abuse disorder. However, schizophrenia, mania, obsessive-compulsive disorder, anorexia, and bulimia are less likely to occur with addiction than the disorders described below.

 
There are a few elements that contribute to the co-occurrence of mental health disorders with substance abuse disorders.

• Regular drug and alcohol abuse can sometimes cause a mental health disorder.
• Those with mental health disorders often self-medicate with drugs or alcohol.
• People sometimes have a family history of both, which could indicate a genetic connection.
• Early exposure to stress or trauma can result in higher likelihood of both a mental health disorder and substance abuse.

It can often be challenging to tell which came first: the substance abuse or the co-occurring disorder. For example, there’s an increased risk for psychosis in people who use marijuana regularly, and people who abuse alcohol may develop depression.

On the other hand, a person with a major mental health disorder may try to lessen the severity of mental health symptoms through “self-medication” with drugs or alcohol. This can occur through abuse of a doctor’s prescription, by drinking alcohol, or through trying illicit drugs.

 
As described and demonstrated above, research has shown that people who have co-occurring disorders may have more severe addictions than the general population. In addition, people with co-occurring disorders are more likely to have poor treatment outcomes. In particular, men with depression and antisocial personality disorder had worse treatment outcomes, while women with phobias had better outcomes.

People with dual diagnoses also often experience more severe physical, emotional, and social consequences than those who have substance abuse disorders alone or who are dealing with a mental health disorder only. Along with this, they also are likely to require longer treatment periods, have more treatment and post-treatment crises, and experience more gradual progress toward recovery.

 
There are numerous options for any person undergoing treatment for substance abuse or for mental health disorders. However, in the case of co-occurring disorders, not all of these treatment modalities are going to help in caring for all aspects of the multiple disorders.

The treatment most likely to result in positive outcomes for co-occurring disorders is one that integrates treatment for all the involved disorders. This means that in order for treatment to be more likely to result in recovery, any co-occurring disorder needs to be treated at the same time and in combination with the substance abuse disorder. Because the symptoms and causes of addiction and mental health disorders can become inextricably linked, treatment for them is more likely to have a positive effect if the methods needed for each are linked as well.

In addition, the following conditions are recommended:

• Staff members who treat the person are all aware of the treatment needs for each condition.
• Any medicine prescribed for the mental health disorder(s) is carefully monitored.
• The person is encouraged to understand that a dual diagnosis is not shameful.
• Therapy is more intensive than for single disorders, with a goal of controlling all disorders.

Other options, such as chronic care management or traditional substance abuse and mental health treatments, have not been shown to have increased positive outcomes for people with dual diagnoses. Instead, a model where the individual members of a treatment team work together with awareness of the full treatment plan is more likely to help.

In this integrated model, having various treatment team members working together – a process called assertive community treatment – has shown promise in having a more positive effect on treatment outcomes. This type of treatment program is difficult to manage in an outpatient setting with diverse treatment professionals from different sources. In addition, sending clients offsite for portions of treatment often ends up with the clients leaving treatment altogether. However, this can be managed if the treatment center has an established outpatient program based on the integrated model.

 
The types of treatment programs to look for are those that understand this integrated model, and that can provide the combined therapies that support recovery from co-occurring disorders. Most experts recommend an inpatient or residential treatment program to have the best chance at a positive treatment outcome that allows for long-term recovery. These treatment plans will typically involve the following elements, among others:

• Medical detox
• An understanding that using medicine to support sobriety or ease psychological conditions must be carefully managed and monitored
• Behavioral therapy modalities that support the range of disorder elements; for example, using Dialectical Behavior Therapy for the treatment of borderline personality disorder, which helps people with this disorder stay in treatment for the full time needed to reach recovery
• Social support structures and tools to help manage recovery post treatment

It is important to find a treatment center that relies on research-based approaches to treating co-occurring disorders, and that has experience doing so. With a science-based understanding of how substance abuse disorders and mental health disorders affect each other and are best treated together, these centers are the ones most likely to create the specialized treatment plan for the individual’s specific needs. In this way, they are also most likely to achieve outcomes leading to long-term recovery.

• What causes a co-occurring disorder?

  Co-occurring disorders are the result of a person having both a substance abuse disorder or addiction alongside a mental health disorder, like major depression or anxiety disorder. While the exact cause of these disorders and the reasons they often occur together is still not fully understood, there are many elements that can affect whether or not a person will have addiction co-occur with another mental health disorder, including:

  • A mental health disorder developing from drug abuse, such as psychosis from regular marijuana use
  • Self-medicating for a mental health disorder by using drugs or alcohol
  • Experiencing trauma that can result in the development of both types of disorders
  • Genetic traits that may make the combination of addiction and mental health disorders more likely

• What comes first: addiction or mental health conditions?

  Addiction can come before mental health conditions or the other way around. They can also occur independently. In some cases, the effects of a substance addiction on the brain can make certain mental health disorders more likely to occur. In other cases, using medication to treat a mental health disorder can lead to overuse and a resulting substance abuse disorder.

  The relationship between substance abuse and mental health conditions is complex and cannot be reduced to a specific chain of events. Each individual is different. For this reason, it is important to take the individual’s experience and history into account when devising that person’s care.

• What therapies work best?

  The most helpful therapies for people with co-occurring disorders include those that treat the range of elements of each particular disorder. For example, for a person who is addicted to alcohol and also struggles with borderline personality disorder, it is important to provide treatment for the alcohol addiction and the BPD. However, because of the impulse control issues that the person may have as a result of BPD, regular Cognitive Behavioral Therapy may not work to help the person control the desire to drink. Dialectical Behavior Therapy, which was developed specifically for people dealing with BPD and has been shown to help people with co-occurring substance abuse disorders and BPD, is the better treatment modality for this specific population.

  Because no single treatment is effective for everyone, a customized treatment plan – using the treatment and therapy modalities most likely to help the specific individual – is what will work best in the long run.

• What medications work best for treatment?

  Using medication for treatment of co-occurring disorders can be a challenge, since the tendency for a return to substance abuse is always present. For that reason, all medications that are prescribed should be carefully monitored to make sure no addiction is developing.

  When it is necessary to prescribe medications – such as anti-anxiety medications – to control the mental health disorder, highly addictive substances like benzodiazepines should be avoided. In the case that such substances are required, the medicines in that class with the lowest potential for addiction should be considered.

• Is there a cure for co-occurring disorders?

  There is no cure for substance abuse disorders or for the co-occurring mental health disorders that may accompany them. In particular, addiction is a chronic disorder, much like diabetes or asthma, that must be cared for throughout the person’s life. This is also true of mental health disorders that may co-occur with addiction.

  However, addiction and co-occurring disorders are treatable. Again, like asthma or diabetes, these conditions can be controlled through continued therapy, support, and even medical treatment, to help the person achieve and maintain recovery from the symptoms of each disorder.

• What is integrated treatment?

  Integrated treatment is the idea that, when treating two or more co-occurring disorders, the treatment modalities for each disorder work best in combination with the treatment modalities for the other disorder(s). This means that the most effective treatment for co-occurring disorders involves getting the treatment providers to work together with an understanding of the full spectrum of therapies and treatments required to help the individual recover from the involved disorders at the same time. This is preferable to treating just one disorder and hoping the other would resolve or treating each disorder separately.

  Integrated treatment takes into account the ways that the co-occurring disorders can affect one another and impede recovery. It is the most recommended treatment type for co-occurring disorders because it is able to treat the multiple aspects of the disorders that might make it more likely to relapse or have continued symptoms.

• Is treatment necessary?

  Treatment for co-occurring disorders is necessary to keep people who struggle with them from developing more severe issues in the future. People who have co-occurring disorders have a higher likelihood of the following:

  • Homelessness
  • Legal problems and jail time or prison
  • Multiple medical illnesses, such as cancer, liver disease, and brain or heart damage
  • Suicide or severe self-harm
  • Death due to disease, injury, or violence

  
  With treatment, people who struggle with the effects of co-occurring disorders can learn to manage their symptoms and the challenges that come with the disorders. Proper care can allow individuals to stay clean and keep on top of their mental health disorders in the long term.

• What are options after inpatient treatment?

  Because of the more intense nature of each disorder involved in co-occurring disorders, and the intense treatment requirements to address them, aftercare following inpatient treatment program is important. Aftercare helps to prevent relapse for each disorder. If relapse for one disorder occurs, it is likely to lead to relapse for the other disorder.

  Aftercare methods include a variety of supports and continuing treatments to help the person manage the conditions and maintain recovery. These include:

  • Continued regular therapy after the treatment program is completed
  • Medical maintenance for the mental health condition and, if necessary, to control cravings
  • Teaching and reinforcing behavior-management and relapse-control techniques
  • Teaching and practicing skills and tools to break the trigger cycle
  • Facilitating the person’s involvement with mutual self-help groups

  
  There are specific mutual self-help groups available for those who have dual diagnoses. These groups can help meet the specific support needs of individuals with co-occurring disorders, giving them a greater chance to remain involved in recovery over time.