When Substance Abuse and Psychiatric Issues Collide

Often starting in adolescence or young adulthood, many individuals have both a substance abuse disorder and at least one psychiatric disorder, although which diagnosis came first is frequently unclear. This “double trouble” problem is also called “co-occurring disorders (CODS),” as well as “concurrent disorders” and “dual diagnosis.”

The combination of disorders has been discussed in speculative articles about celebrities like Charlie Sheen, Demi Lovato, Justin Bieber, Jhene Aiko, Britney Spears, and Russell Brand. More in-depth scientific and biographic articles about Ernest Hemingway, Carrie Fisher, and Kurt Cobain have helped explain the complexity of CODs. Some of us were mesmerized and sad watching their struggles. Kurt Cobain’s lyrics, performance, and even some of his songs (like “Lithium” and “All Apologies”) come to my mind as both a fan and a psychiatrist.

But it’s not just celebrities who are suffering from both substance abuse and mental health issues. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2022, 21.5 million people in the United States had both a substance abuse disorder and a mental illness.

In the past, experts believed it was best to treat one disorder (usually the substance issue) and assumed any psychiatric issues would sort themselves out. However, if the psychiatric issue persisted, it was eventually treated.

In contrast, current thinking is both disorders should be treated in about the same time frame, because ignoring either could be problematic for the patient. If someone is severely depressed, anxious, or has another psychiatric disorder, it may be possible for them to detoxify from a substance, but it’s very hard to develop longer-term control over substance dependence and any accompanying mental illnesses when both issues are not addressed.

For adolescents and young adults with underlying psychiatric disorders, abusing substances provides an unfortunate early opportunity for incorporating bad learning. For example, if they struggle with anxiety, teens may discover that alcohol calms their nerves, making them less anxious about meeting new people or engaging in social interactions. Early self-medication of psychiatric symptoms is double trouble, as alcohol causes brain changes and effects that can trigger alcohol use disorder (AUD.) Some people describe the first drink as magical, that first taste feeling like the key to previously locked-out relief.

Individuals diagnosed with co-occurring disorders often need more intense treatment than others due to the complexity of their cases. They also may face greater consequences from their substance abuse compared to patients diagnosed with a mental illness only. Examples of such possible consequences may include a greater exacerbation of their psychiatric symptoms, hallucinations and/or suicidal thinking, an increase in aggressive and violent behaviors, concurrent medical, nutritional, and infectious issues, more emergency room visits than other patients, and a greater number of falls and injuries.

Those with CODs are also more likely to experience head injuries and physical fights with others as well as sexually transmitted infections (STIs). Some have a greater frequency of involuntary inpatient psychiatric placements. These patients need a psychiatric assessment and treatment from experts in both addictions and psychiatry.

One theory to explain CODS, the self-medication theory, was developed by the late Harvard psychiatrist and psychoanalyst Ed Khantzian, M.D. He assumed anhedonia (the inability to experience pleasure) or suffering in general was the driving force behind addiction. This theory hypothesizes that underlying psychological disorders compel individuals to self-medicate their feelings with alcohol and/or drugs. In addition, patients are sometimes distinguished by their drugs of choice. For instance, patients with an alcohol use disorder might have been battling social anxiety and self-medicating with alcohol for performance anxiety, shyness, or nervousness in social settings; stimulants such as cocaine or methamphetamine often are used by those with depression or untreated attentional disorders like attention deficit hyperactivity disorder (ADHD).

The self-medication hypothesis was first put forth in a 1985 cover article in the American Journal of Psychiatry. It focused on how and why individuals are drawn to and become dependent on drugs. The self-medication hypothesis was derived from clinical evaluation and treatment of thousands of patients spanning five decades and remains a credible theory.

As I have stated in the American Journal of Psychiatry, it is one of the most “intuitively appealing theories” about addiction. But drugs of abuse and addiction can also cause psychiatric illnesses by targeting the brain’s mood and pleasure systems and inadvertently undermining them.

Neuroscientist Kenneth Blum developed the theory of reward-deficiency syndrome (RDS) as the cause for co-occurring addictive disorders and psychiatric diagnoses. In many ways, RDS is a natural extension of Khantzian’s theory, but it’s an update, attributing the cause to an underlying dopamine deficiency or neurochemical dysfunction that supports drug-seeking/self-medication.

People with RDS, which may be inherited, are miserably unhappy and their lives may be intolerable due to their inability to gain satisfaction from work, relationships, or their accomplishments.

An emerging, newer approach of “preaddiction” as an early or moderate stage of substance abuse is championed by leaders of the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute of Mental Health (NIMH). Preaddiction is conceptually analogous to prediabetes, a risk factor for type-2 diabetes. Prediabetes has contributed to a quantum leap in early detection of people at risk for type-2 diabetes, shortened delays between symptom onset and treatment entry before the onset of diabetes, and overall been a remarkable success in halting progression to diabetes. Similarly, the earliest possible detection of substance abuse will save more lives as experts develop and focus on the evolving concept of preaddiction.

In the late twentieth century, a large insurance provider in California worked with researchers to identify adverse childhood experiences (ACEs) that later reverberated in the lives of adults. The researchers found that individuals who reported the greatest numbers of ACEs—such as physical abuse, sexual abuse, loss of a biological parent, witnessing physical violence, and other severely traumatic childhood events—were significantly more likely than those with no ACEs to have psychiatric problems and substance abuse issues in adulthood. They were also at greater risk for suicidal behaviors.

Nirvana’s Kurt Cobain was a person with bipolar disorder, substance use and a heroin habit, according to a cousin who described their family history in detail and noted that two uncles had killed themselves with guns. Cobain, who suicided in 1994, purportedly had at least four ACEs, including witnessing domestic violence, experiencing psychological abuse, being neglected, and suffering from his parents’ divorce. Such a score markedly increased Cobain’s risk for suicide as an adult.

Although an extensive description of how CODs should best be treated is beyond the scope of this article, the key point is to not delay treatment of one disorder in favor of the other. Instead, as much of a simultaneous approach as possible is best. This often means a team of experts is needed, including a psychiatrist, psychologist, therapists, and others to assess the problem, determine whether inpatient, residential, or outpatient treatment is best, and develop a cohesive treatment plan for the patient.

In opioid use disorder treatment, the current standard of care is to focus on prevention of overdose and replacement of opioids with medication-assisted treatments (MATs.) However, detoxification from opioids or maintenance on a MAT would provide little symptomatic relief for a person with opioid use disorder, suicidal ideas, and bipolar illness.

It is also recommended to evaluate individuals for past or recent trauma and co-occurring psychiatric and medical illnesses and treat patients accordingly. Often this means psychotherapy is needed as well as psychiatric treatments. Psychotherapy may include cognitive behavioral therapy (CBT), motivation enhancement therapy (MET), dialectical behavior therapy (DBT), and other forms of therapy. Trained and experienced therapists are crucial. Depending on the substance on which patients depend, medication treatment for their detoxification, relapse prevention, and craving may or may not be available. Currently, medication treatments exist for tobacco use disorder, alcohol use disorder, and opioid use disorder.