Dual Diagnosis: Substance Abuse and Mental Health

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. To make the situation more complicated, the 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.

While substance abuse problems and mental health issues don't get better when they're ignored—in fact, they are likely to get much worse—it's important 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 make depression and anxiety symptoms worse. Also:

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 temporarily change their mood. 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 causes them. However, if you are at risk for a mental health issue, abusing alcohol or drugs may push you over the edge. For example, 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 difficult to identify a dual diagnosis. It takes time to tease out what might be a mental health disorder and what might be a drug or alcohol problem. The signs and symptoms also vary depending upon both 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 the signs of schizophrenia and alcohol abuse. 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, to control pain or the intensity of your moods, to face situations that frighten you, or to 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 substance abuse

Abused substances include prescription medications (such as opioid painkillers, ADHD medications, and sedatives), recreational or street drugs (such as marijuana, methamphetamines, and cocaine), and alcohol (beer, wine, and liquor). A substance abuse problem is not defined by what drug you use or the type of alcohol you drink, though. Rather, it comes down to the effects your drug or alcohol use has on your life and relationships. In short, if your drinking or drug use is causing problems in your life, you have a substance abuse problem.

To help you spot the signs of a substance abuse problem, answering the following questions may help. The more “yes” answers you provide, the more likely your drinking or drug use has become a problem.

• Have you ever felt you should cut down on your drinking or drug use?
• Do you need to use more and more drugs or alcohol to attain the same effects on your mood or outlook?
• Have you tried to cut back, but couldn't?
• Do you lie about how much or how often you drink or use drugs?
• Are you going through prescription medication at a faster-than-expected rate?
• Have your friends or family members expressed concern about your alcohol or drug use?
• Do you ever feel bad, guilty, or ashamed about your drinking or drug use?
• Have you done or said things while drunk or high that you later regretted?
• Has your alcohol or drug use caused problems at work, school, or in your relationships?
• Has your alcohol or drug use gotten you into trouble with the law?

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 (especially 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 sign 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.

Finding the right treatment program 

Make sure that the program is appropriately licensed and accredited, the treatment methods are backed by research, and there is an aftercare program to prevent relapse. Additionally, you should make sure that the program has experience with your particular mental health issue. Some programs, for example, may have experience treating depression or anxiety, but not schizophrenia or bipolar disorder.

There are a variety of approaches that treatment programs may take, but there are some basics of effective treatment that you should look for:

• Treatment addresses both the substance abuse problem and your mental health problem.
• You share in the decision-making process and are actively involved in setting goals and developing strategies for change.
• Treatment includes basic education about your disorder and related problems.
• You are taught healthy coping skills and strategies to minimize substance abuse, strengthen your relationships, and cope with life's stressors, challenges, and upset.

Dual diagnosis programs

Finding the right program can help you to:

• Think about the role that alcohol and/or drugs play in your life. This should be done confidentially, without judgement or any negative consequences. People feel free to discuss these issues when the discussion is confidential and not tied to legal consequences.
• Learn more about alcohol and drugs, such as how they interact with mental illness and medication.
• Become employed and find other services that may help the process of recovery.
• Identify and develop your personal recovery goals. If you decide that your use of alcohol or drugs may be a problem, a counselor trained in dual diagnosis treatment can help you work on your specific recovery goals for both illnesses.
• Experience counseling specifically designed for people with dual diagnosis. This can be done individually, in a group of peers, with your family, or a combination of all these.

Treatment programs for veterans with co-occurring disorders

Veterans deal with additional challenges when it comes to co-occurring disorders. The pressures of deployment or combat can exacerbate underlying mental disorders, and substance abuse is a common way of coping with the unpleasant feelings or memories associated with PTSD in military veterans.

Often, these problems take a while to show up after a vet returns home, and may be initially mistaken for readjustment. Untreated co-occurring disorders can lead to major problems at home and work and in your daily life, so it's important to seek help.

Self-help for a dual diagnosis

In addition to getting professional treatment, there are plenty of self-help steps you can take to address your substance abuse and mental health issues. Remember: Getting sober is only the beginning. As well as continuing mental health treatment, your sustained recovery depends on learning healthier coping strategies and making better decisions when dealing with life's challenges.

Tip 1: Manage stress and emotions

Learn how to manage stress. Drug and alcohol abuse often stems from misguided attempts to manage stress. Stress is an inevitable part of life, so it's important to have healthy coping skills so you can deal with stress without turning to alcohol or drugs. Stress management skills go a long way towards preventing relapse and keeping your symptoms at bay.

Cope with unpleasant feelings. Many people turn to alcohol or drugs to cover up painful memories and emotions such as loneliness, depression, or anxiety. You may feel like doing drugs is the only way to handle unpleasant feelings, but HelpGuide's free Emotional Intelligence Toolkit can teach you how to cope with difficult emotions without falling back on your addiction.

Know your triggers and have an action plan. When you're coping with a mental disorder as well as a substance abuse problem, it's especially important to know signs that your illness is flaring up. Common causes include stressful events, big life changes, or unhealthy sleeping or eating patterns. At these times, having a plan in place is essential to preventing a drink or drug relapse. Who will you talk to? What do you need to do to avoid slipping?

Tip 2: Connect with others

Make face-to-face connection with friends and family a priority. Positive emotional connection to those around you is the quickest way to calm your nervous system. Try to meet up regularly with people who care about you. If you don't have anyone you feel close to, it's never too late to meet new people and develop meaningful friendships.

Follow doctor's orders. Once you are sober and you feel better, you might think you no longer need medication or treatment. But arbitrarily stopping medication or treatment is a common reason for relapse in people with co-occurring disorders. Always talk with your doctor before making any changes to your medication or treatment routine.

Get therapy or stay involved in a support group. Your chances of staying sober improve if you are participating in a social support group like Alcoholics Anonymous or Narcotics Anonymous or if you are getting therapy.

Tip 3: Make healthy lifestyle changes

Exercise regularly. Exercise is a natural way to bust stress, relieve anxiety, and improve your mood and outlook. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.

Practice relaxation techniques. When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce symptoms of stress, anxiety, and depression, and increase feelings of relaxation and emotional well-being.

Adopt healthy eating habits. Start the day right with breakfast, and continue with frequent small meals throughout the day. Going too long without eating leads to low blood sugar, which can make you feel more stressed or anxious. Getting enough healthy fats in your diet can help to boost your mood.

Get enough sleep. A lack of sleep can exacerbate stress, anxiety, and depression, so try to get 7 to 9 hours of quality sleep a night.

Tip 4: Find new meaning in life

To stay alcohol- or drug-free for the long term, you'll need to build a new, meaningful life where substance abuse no longer has a place.

Develop new activities and interests. Find new hobbies, volunteer activities, or work that gives you a sense of meaning and purpose. When you're doing things you find fulfilling, you'll feel better about yourself and substance use will hold less appeal.

Avoid the things that trigger your urge to use. If certain people, places, or activities trigger a craving for drugs or alcohol, try to avoid them. This may mean making major changes to your social life, such as finding new things to do with your old buddies—or even giving up those friends and making new connections.

Group support 

As with other addictions, groups are very helpful, not only in maintaining sobriety, but also as a safe place to get support and discuss challenges. Sometimes treatment programs for co-occurring disorders provide groups that continue to meet on an aftercare basis. Your doctor or treatment provider may also be able to refer you to a group for people with co-occurring disorders.

While it's often best to join a group that addresses both substance abuse and your mental health disorder, twelve-step groups for substance abuse can also be helpful—plus they're more common, so you're likely to find one in your area. These free programs, facilitated by peers, use group support and a set of guided principles—the twelve steps—to obtain and maintain sobriety.

Just make sure your group is accepting of the idea of co-occurring disorders and psychiatric medication. Some people in these groups, although well meaning, may mistake taking psychiatric medication as another form of addiction. You want a place to feel safe, not pressured.

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.

[Read: Helping Someone with a Drug Addiction]

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.