Substance Abuse and Mental Health Issues
Dealing with dual diagnosis? Learn how to tackle addiction when you’re
also dealing with depression, anxiety, or another mental health problem.
Understanding 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
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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. But
you’re not alone. 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 either 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, and while some substance abuse can cause prolonged psychotic reactions, one does
not directly cause the other. However:
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, abusing substances 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.
Mental disorders are caused by a complex interplay of genetics, the environment, and other
outside factors. If you are at risk for a mental disorder, abusing alcohol or illegal or
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prescription drugs may push you over the edge. There is some evidence, for example, that
certain abusers of marijuana have an increased risk of psychosis while those who abuse
opioid painkillers are at greater risk for depression.
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, anti-anxiety pills, and mood stabilizers, making them less effective at
managing symptoms.
Do you have a substance abuse and co-occurring
mental health problem?
It can be difficult to diagnose a substance abuse problem and a co-occurring mental health
disorder. It takes time to tease out what might be a mental 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 drug being abused. 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?
Has someone in your family grappled with either a mental disorder or alcohol or
drug abuse?
Do you feel depressed or anxious even when you’re sober?
Do you have unresolved trauma or a history of abuse?
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?
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Dual diagnosis and denial
Complicating a dual diagnosis is denial. Denial is common in substance abuse. It’s often
hard to admit how dependent you are on alcohol or drugs or how much they affect your life.
Denial frequently occurs in mental disorders as well. The symptoms of depression or anxiety
can be frightening, so you may 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
If you’re wondering whether you have a substance abuse problem, the following questions
may help. The more “yes” answers, the more likely your drinking or drug use is a problem.
Have you ever felt you should cut down on your drinking or drug use?
Have you tried to cut back, but couldn’t?
Do you ever 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?
On more than one occasion, have you done or said something while drunk or high
that you later regretted?
Have you ever blacked out from drinking or drug use?
Has your alcohol or drug use caused problems in your relationships?
Has your alcohol or drug use gotten you into trouble at work or with the law?
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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
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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 include
Schizophrenia, Borderline Personality Disorder, and Post-Traumatic Stress Disorder.
Treatment for substance abuse and mental health
problems
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, 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.
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Keep in mind:
There is always hope. Both mood disorders and alcohol and drug abuse problems are
treatable conditions. Recovering from co-occurring disorders takes time, commitment, and
courage, but people with substance abuse and mental health problems can and do get
better.
It’s important to get and stay sober during treatment. If your doctor needs to
prescribe medication for your mental health problem, mixing it with alcohol or drugs could
have serious effects. Similarly, talk therapy is far less effective if you’re under the influence
of drugs or alcohol.
Relapses are part of the recovery process. Don’t get too discouraged if you relapse.
Slips and setbacks happen, but, with hard work, most people can recover from their
relapses and move on with recovery.
Peer support can help. You may benefit from joining a self-help support group such as
Alcoholics Anonymous or Narcotics Anonymous. A support group gives you a chance to
lean on others who know exactly what you’re going through and learn from their
experiences.
How to find the right program for co-occurring disorders
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.
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Treatment for dual diagnosis or co-occurring disorders
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 unpleasant feelings or memories. 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 substance abuse and co-occurring
disorders
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
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depends on learning healthier coping strategies and making better decisions when dealing
with life’s challenges.
Recovery tip 1: Recognize and manage overwhelming 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?
Recovery tip 2: Stay connected to 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.
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Recovery 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.
Recovery tip 4: Make healthy lifestyle changes
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 for substance abuse and co-occurring
disorders
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
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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 substance abuse and mental
health problem
Helping a loved one 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
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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.
Get more help
Co-occurring Disorders – FAQ with advice for both individuals with co-occurring disorders
and their loved ones. (Mental Health America)
Comorbidity: Addiction and Other Mental Illnesses (PDF) – Learn about causes, diagnosis,
and treatment. (National Institute on Drug Abuse)
Support groups
In the U.S.: SAMHSA Substance Abuse Treatment Facility Locator provides a searchable
database of private and public treatment facilities or you can call the helpline at
1-800-662-4357.
Worldwide
Dual Recovery Anonymous offers 12-step meetings in various countries for people who are
chemically dependent and also affected by a mental health disorder. Other peer support
groups, such as Alcoholics Anonymous, Narcotics Anonymous, Secular Organizations for
Sobriety, SMART Recovery, and Women for Sobriety can also be a good source of support as
you go through recovery and most have worldwide chapters.
Authors: Joanna Saisan, M.S.W., Melinda Smith, M.A., Lawrence Robinson, and
Jeanne Segal, Ph.D. Last updated: October 2019
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