Treatment Trends: Addressing Substance Use Disorder (SUD) and Mental Illness

By Megan Stahly, MSW, LCSW, Clinical Director, Acute Psychiatric Stabilization Unit at Recovery Works Martinsville in Indiana

In early September 2022, Dr. Nora Volkow, the Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, published an editorial in the Washington, D.C. media outlet The Hill called “Addiction Often Goes Hand-In-Hand With Mental Illnesses – Both Must Be Addressed.” Substance use disorder (SUD) is commonly known as addiction. 

The editorial focuses on a phenomenon we’re familiar with: co-occurring disorders. When a person receives a diagnosis for a substance use disorder (SUD) and a mental health disorder at the same time, they receive a dual diagnosis and have co-occurring disorders.

That’s what Dr. Volkow is talking about when she says addiction often goes hand in hand with mental illness: the phenomenon of co-occurring disorders.

Here’s how she describes the situation for people who receive a dual diagnosis:

“Recovering from drug addiction is notoriously difficult. Setbacks are common. Too often, a critical element is overlooked: co-occurring mental health conditions. Treating mental illnesses like depression, anxiety, post-traumatic stress disorder, ADHD, and others with medications or other therapies is crucial to address the addiction and overdose crisis that now claims over 100,000 lives annually.”

We know exactly what she means: we see and support people with co-occurring disorders every day. We understand how they complicate the SUD recovery process, and how important it is to treat them alongside treating SUD. This article will discuss three mental health disorders commonly associated with SUD: depressive disorders, bipolar disorder, and post-traumatic stress disorder. We’ll share prevalence rates, rates of treatment, and the most effective known treatments for each pair of co-occurring disorders.

First, though, we’ll share Dr. Volkow’s insight on a question most people have when they learned about co-occurring disorders: why are they so common?

Understanding Co-Occurring Disorders

Here’s how Dr. Volkow answers that question:

“For many people, drug and alcohol problems begin as self-medication: using substances to cope with temporary stress or to manage symptoms of chronic mental health problems they may not even know they have. Substance use, particularly alcohol, can be a socially accepted way of dealing with negative emotions.”

That’s logical: sometimes people use substances to manage painful or difficult emotions – and in many cases, they don’t know those extreme and difficult emotions are symptoms of a mental health disorder. This leads us to another question: in the 21^st century – especially after all the press about mental health and COVID-19 – almost everyone knows about mental health treatment and treatment for substance use disorder.

They may not know much, but most people do know it’s possible to receive treatment for mental health disorders and for substance use disorders.

Here’s the question:

If they know treatment is available, why don’t they get treatment?

Here’s how Dr. Volkow answers that question:

“Fragmented and hard-to-access mental health care means that these conditions and addiction often go untreated. In some communities, it is easier to get illicit drugs than adequate medical mental health care, making co-occurring addiction and other mental illness more likely.”

If anyone is in a position to know, that person is Dr. Volkow. Her resume means we need to listen to what she says – which is, in a nutshell, that we need to find ways to better support our citizens with co-occurring SUD and mental health disorders.

We’ll help this effort by sharing what we know about co-occurring SUD and mental health disorders. First, we’ll offer the latest data available. Then, as mentioned above, we’ll discuss the relationship between SUD and depressive disorders, bipolar disorder, and post-traumatic stress disorder (PTSD).

Let’s get to that data.

Prevalence and Treatment for Mental Health Disorders and Substance Use Disorders: Facts and Figures

When a substance use disorder goes untreated, the most likely outcome is an escalation of symptoms and severity. In other words, it gets worse, and the negative consequences compound. Mental health disorders are the same. In the absence of treatment, symptoms and severity often escalates. And like untreated SUD, the negative consequences of untreated mental health disorders most often get worse over time.

The 2020 National Survey on Drug Use and Health (2020 NSDUH) shows:

• 74 million adults received a diagnosis for SUD or any mental health disorder (AMI)
  • 17 million adults received a diagnosis for SUD and AMI
• 47 million adults received a diagnosis SUD or a serious mental health disorder (SMI)
  • 5.7 million adults received a diagnosis SUD and SMI

Evidence indicates the integrated treatment model is an effective, whole person approach that can help people with co-occurring SUD and mental health disorders manage their symptoms and take steps toward long-term, sustainable recovery.

That means treatment can work.

But are the people who need treatment getting the treatment they need?

Let’s take a look at the latest data we have on treatment for co-occurring SUD and mental health disorders, as reported in the 2020 NSDUH:

• 17 million adults diagnosed with SUD and AMI:
  • 50% received treatment for one or the other
  • 42% received treatment for AMI only
  • 3% received treatment for SUD only
  • 6% received treatment for AMI and SUD
• 7 million adults with SUD and SMI:
  • 66% received treatment for one or the other
  • 55% received treatment for SMI only
  • 1.5% received treatment for SUD only
  • 9% received treatment for SMI and SUD

These figures tell us we have work to do, with regards to the treatment of co-occurring SUD and mental health disorders. Here’s how these facts look in raw numbers:

• 17 million adults have co-occurring AMI and SUD
  • 4 million didn’t receive any treatment
  • Only 1.0 million received treatment for AMI and SUD
• 7 million adults have co-occurring SMI and SUD
  • 1.9 million didn’t receive any treatment
  • Only 529,000 received treatment for SMI and SUD

That’s not good enough. Those of us who work in SUD treatment call this the treatment gap. We know how to close this treatment gap: offer people with co-occurring SUD and mental disorders evidence-based treatment that follows the integrated model.

To learn more about integrated treatment, please click here.

Those facts and figures give us a big-picture idea of the true scope of the problem. Next, we’ll look at the interplay of mental health disorders and substance use disorders. We’ll look at three different disorders, starting with depressive disorders.

Depressive Disorders and Substance Use Disorder

Two types of depressive disorders most commonly co-occur with SUD:

• Major depressive disorder (MDD):
  • MDD is highly associated with suicide risk:
    • 39% of people with a lifetime MDD diagnosis contemplated suicide
    • 14% had a lifetime history of suicide attempt
  • Persistent depressive disorder (PDD):
    • MDD symptoms on most days for two years or more

Let’s dive into the statistics on depressive disorders and SUD.

Depressive Disorders and SUD: Facts and Figures

• Presence of a 12-month or lifetime DSM-5 SUD is associated with:
  • 70% increased likelihood of any mood disorder
  • 40% increased likelihood of dysthymia
  • 15% increased likelihood of MDD
• Alcohol use disorder (AUD) is associated with:
  • Increased risk of MDD
  • Increased risk of PDD
• Diagnosis of MDD:
  • 58% more likely to occur in individuals with a history of SUD
  • 41% more likely to occur in individuals with a history of AUD

Next, let’s explore what we know about treatment for co-occurring depressive disorders and SUD.

Treatment for MDD and SUD

• Psychotherapy:
  • Integrated individual or group cognitive behavioral therapy (CBT) can:
  • Reduce frequency of substance use and depressive symptoms
  • Improve short term functioning
  • Improve long-term functioning over the long term
  • CBT and Motivational interviewing (MI) for people with AUD can:
    • Improve depressive symptoms
    • Decrease alcohol use

That’s the latest information on prevalence rates and treatment for co-occurring depressive disorders and SUD. Next, we’ll examine the same data on bipolar disorder and SUD.

Bipolar Disorder and Substance Use Disorder

Bipolar disorder commonly co-occurs with SUD.

• Bipolar Disorder is mood disorder wherein mood fluctuates between extreme depressive and extreme manic episodes
• Patients with bipolar disorder and SUD are at elevated risk of suicide

Let’s take a look at the statistics on co-occurring bipolar disorder and SUD.

Bipolar Disorder and SUD: Facts and Figures

• Among people diagnosed with bipolar disorder:
  • 65% report SUD
  • 54% report AUD
• Presence of a 12-month or lifetime DSM-5 SUD is associated with:
  • 45% increased likelihood of bipolar disorder
• Presence of bipolar disorder is associated with:
  • 390% increased likelihood of SUD
• Among people with bipolar disorder and SUD:
  • 30% report alcohol use
  • 20% report cannabis use
  • 17% report illicit drug use

Now let’s look at the known evidence-based treatments for co-occurring bipolar disorder and SUD.

Treatment for Bipolar Disorder and SUD

• Medication:
  • Medication is the first-line treatment for bipolar disorder, with or without SUD. A person with bipolar disorder may have a prescription for:
    • Mood stabilizers
    • Antipsychotics
    • Antidepressants
    • Combination antipsychotic/antidepressants
• Psychotherapy/Counseling:
  • • Cognitive behavioral therapy (CBT), integrated treatment, relapse prevention techniques can:
      • Reduce hospitalization
      • Increase abstinence
      • Improve medication adherence
      • Reduce SUD symptoms
      • Improve mood symptoms

That’s the latest information on prevalence rates and treatment for co-occurring depressive disorders and SUD. Next, we’ll examine the same data on post-traumatic stress disorder and SUD.

Post-Traumatic Stress Disorder (PTSD) and Substance Use Disorder

PTSD commonly co-occurs with SUD.

• PTSD is an extreme fear response that occurs following exposure to one or more traumatic events
  • Events include witnessing or experiencing war, violence, sexual abuse or threatened sexual abuse/violence, disasters, and extreme accidents
    • People with PTSD report the most disturbing trauma is sexual abuse before the age of 18
  • Symptoms of PTSD include:
    • Persistent re-experiencing initial trauma
    • Extreme avoidance of anything related to the initial trauma
    • Negative mood and patterns of thought
    • Extreme reactivity: on edge, irritable, easily startled

For an in-depth analysis of the relationship between PTSD and SUD, please read this article by our Chief Clinical Officer, Dr. Lori Ryland:

Comorbid PTSD and Substance Use Disorder

Now let’s look at the latest statistics on PTSD and SUD.

PTSD and SUD: Facts and Figures

• Diagnosis of PTSD is strongly associated with:
• • Substance misuse
  • DSM-5 diagnosis of SUD
  • DSM-5 diagnosis of AUD
• Among people with SUD:
  • Prevalence of lifetime PTSD:
    • 34%
  • Prevalence of current PTSD:
    • 5%
  • Among people with PTSD:
    • Prevalence of lifetime SUD:
      • 44%
    • Presence of a 12-month or lifetime DSM-5 SUD is associated with:
      • 55% increased likelihood PTSD
    • Presence of a 12-month or lifetime DSM-5 PTSD is associated with:
      • 40% increased likelihood of lifetime SUD

Next, we’ll review the most common evidence-based treatments for co-occurring PTSD and SUD.

Treatment for PTSD and SUD

Traditionally, therapists treated PTSD and SUD separately. In recent years, however, research showed that treating PTSD and SUD simultaneously improves outcomes. Simultaneous treatment requires skilled and knowledgeable therapists trained in treating people with PTSD and SUD without triggering re-traumatization or re-experiencing of initial trauma.

When administered or facilitated by mental health professionals experienced in treating co-occurring PTSD and SUD, the following treatment modalities are effective:

• Prolonged Exposure Therapy (PE)
• Cognitive Behavioral Therapy (CBT)
• Individual
• Group
• Family
• Cognitive Processing Therapy (CPT)
• Eye Movement Desensitization Reprocessing (EMDR)
• Dialectical Behavior Therapy (DBT)
• Seeking Safety Therapy
• Pharmacotherapy (medication)

That’s a solid overview of the current state of knowledge about the relationship between depressive disorders, bipolar disorder, post-traumatic stress disorder, and substance use disorder. There are other mental health disorders that frequently co-occur with SUD, including:

• Anxiety disorders like general anxiety disorder (GAD) and social anxiety disorder (SAD)
• Personality disorders
• Eating disorders

We focused on three – depressive disorders, bipolar disorder, and PTSD – because we support people with these disorders every day. We also support many individuals with anxiety disorders, which includes PTSD.

We’ll end this article with a brief discussion of integrated treatment. We almost explain integrated treatment, above, when we talk about the various methods used to treat the co-occurring SUD and mental health disorders – but we’ll fill in the blanks below.

What is Integrated Treatment?

Integrated treatment is a therapeutic approach that prioritizes a whole-person perspective to recovery from mental health and substance use disorders. In the past, clinicians focused on one disorder or condition at a time. A person would receive substance use counseling or treatment from a different person and in a different location than they would receive mental health treatment. And in some cases, they would receive mental health treatment from several sources: one clinician may have functioned as a therapist or counselor, another may have managed medication, and yet another may have arrived at their initial diagnosis.

As Dr. Volkow mentions in the quote in the beginning of this article, individuals who needed care often fell through the cracks of this fragmented, complicated system.

Now, at an integrated treatment center, and individual can receive all the types of treatment they need in one location and from one treatment team. That’s crucial: the treatment team communicates with one another weekly or daily, and in many cases, a member of the treatment team also makes the initial diagnosis of co-occurring disorders.

After a full biological, psychological, and social assessment – called a biopsychosocial – an integrated treatment team creates a treatment plan that includes a custom-tailored combination of cutting-edge therapeutic techniques.

Components of Integrated Treatment

• Psychotherapy:
  • Individual
  • Group
  • Family
• Counseling:
  • Individual
  • Group
  • Family
• Medication (if needed)
• Lifestyle changes:
  • Diet
  • Exercise
  • Stress management
• Education:
  • Classes and workshops on the science of addiction and recovery
• Complementary supports:
  • Yoga
  • Meditation
  • Mindfulness
• Community/Peer support:
  • Alcoholics Anonymous (AA)
  • Narcotics Anonymous (NA)
  • SMART Recovery
• Aftercare/Case Management/Ongoing Support
  • Peer support Groups (see above)
  • Relapse prevention
  • Connections to:
    • Physicians
    • Therapists
    • Social services

In short, integrated treatment is a holistic, all of the above approach. But clinicians don’t try the latest fad treatments simply because they’re new. They use innovative treatments because they’re backed by data and evidence – and specific techniques stay on a treatment plan only if they work. That’s what integrated, evidence-based really treatment means: the best approaches applied in combination to give each individual in treatment the best possible chance at achieving lifelong, sustainable recovery.