Alcoholism and Co-Occurring Disorders

Mental illness and alcohol use disorder (AUD) often go hand-in-hand.¹ When they co-occur, each condition may influence the course of the other, regardless of which may have developed first. Left untreated, these co-occurring disorders could result in both an exacerbation of mental health symptoms or lead to increased drinking or additional substance abuse.

What is Mental Illness?

According to the American Psychiatric Association, mental illnesses are conditions that involve changes in thoughts, emotions, and behaviors; because of such changes, mental illness can result in significant problems with work, family, and social functioning.²

Mental illness is very common in the United States, with the National Institute for Mental Health reporting that roughly 1 in 5 adults struggle with some form of mental illness.² In 2019, around 51.5 million American adults had a mental health disorder, with such conditions being more prevalent in women (25.6%) than men (16.3%).³

The Centers for Disease Control and Prevention reports that factors known to contribute to the development of a mental illness include:⁴

• Biological factors such as genetics and brain chemistry.
• Early adverse life experiences such as abuse, trauma, or witnessing violent events.
• Abusing alcohol or other substances.
• A limited social circle.
• Feeling lonely or isolated.
• Issues that are related to chronic medical illnesses.

A person’s mental health status can change over time depending on their life circumstances and other external (such as stress or family disruption) or internal (such as medical issues) events.⁴ For example, an otherwise mentally healthy person who experiences a high stress load over a prolonged period may have a higher risk of developing a mental health disorder.⁴ Additionally, when a person’s inner resources and ability to cope with life are overwhelmed, they can experience worsened mental health.⁴

What is Alcohol Abuse and Alcoholism?

Alcohol use disorder is characterized by an inability to stop drinking despite the social, occupational, and health problems it causes.⁵ The compulsive patterns of drinking associated with AUD can lead to alcohol dependence, in which a person needs to continue drinking in order to function and feel normal.⁶

Other signs and symptoms used to diagnose an alcohol use disorder include:⁵

• Drinking higher amounts or for longer periods than originally intended.
• Being unable to cut down alcohol use despite intentions to do so.
• Spending a lot of time drinking or recovering from the effects of alcohol use.
• Experiencing cravings or strong urges to drink.
• Being unable to meet responsibilities at work, home, or school because of drinking.
• Continuing to drink despite experiencing troubled relationships with others.
• Cutting back or giving up activities that you once enjoyed in order to drink.
• Engaging in activities that are physically dangerous (such as driving, operating machinery, or having unsafe sex) during or after drinking.
• Continuing to abuse alcohol even though you experience negative mental or physical health consequences.
• Feeling the need to drink more in order to get drunk or to feel other desired effects.
• Experiencing withdrawal when trying to stop drinking. Alcohol withdrawal includes a variety of physical and mental problems, such as insomnia, anxiety, bodily tremors, nausea, a racing heart, or seizures.

Any person who has experienced two or more of these symptoms within the last 12-months may be diagnosed with an alcohol use disorder.⁷ The more symptoms, the more severe the disorder, which may signal a more urgent need for treatment help.⁵

What Are Co-Occurring Disorders?

Within the realm of addiction medicine, the term co-occurring disorders is used to describe someone having both a mental illness and a substance abuse disorder (such as AUD). Co-occurring disorders can be quite serious and present significant challenges to your well-being and ability to function, but recovery is possible with treatment and ongoing aftercare.⁸

The Journal of the American Medical Association reports that approximately 50% of people with severe mental illness also struggle with some type of substance use disorder.^6,9 In past estimates, 37% of people who abused alcohol or had an alcohol dependence also had at least one serious mental health disorder.⁶

The reasons why substance use disorders and mental illness commonly occur simultaneously may not be fully understood. However, the National Institute on Drug Abuse (NIDA) points to 3 theoretical pathways that could contribute to this common comorbidity:¹⁰

• Common risk factors can increase the chances of developing both disorders.
• Substance abuse may begin due to mental illness.
• Substance abuse and addiction can affect mental health.

Public health surveys have indicated that about 50% of people with a mental illness at some point in their lives will also experience a substance use disorder and vice versa.^{11 top} While mental health disorders and substance use disorders frequently co-occur, it’s often hard to distinguish which came first. Even if symptoms of one disorder appeared before symptoms of the other, it is not a telltale sign that one disorder developed before the other.

For example, people may have mild mental health symptoms that may prompt them to start drinking more or using drugs, which in turn can bring out symptoms of both disorders.^{10 top} Similarly, substance abuse may be associated with certain brain changes, including disruptions within certain neurotransmitter systems and other brain circuitry, that are seen in other mental disorders.¹⁰

Common Co-occurring Disorders

Certain mental health disorders are more common among people with substance use disorders. These include generalized anxiety disorder, panic disorder, bipolar disorder, depression, posttraumatic stress disorder, psychotic disorders, borderline personality disorder, and attention-deficit hyperactivity disorder.¹¹

When looking specifically at alcohol use disorders and concurrent mental health issues, some common associations exist. Psychiatric disorders commonly associated with alcoholism include major depression, bipolar, anxiety disorders, and anti-social personality disorder.¹⁵ One study found that among common psychiatric and AUD comorbidities among alcohol dependent persons, approximately 37% had anxiety disorders, 29% had a mood disorder and 28% had a major depressive disorder.¹⁶

Another study examined the presence of mental health disorders among people with 1) drug use disorders, 2) drug and alcohol use disorders, and 3) alcohol use disorders.¹² The results of the study found that:¹²

• The drug-only group had approximately 44% personality, 28% mood, and 24% anxiety disorders.
• Those with combined drug and alcohol problems showed 51%, 35%, and 27% personality, mood, and anxiety disorders respectively.
• Those who only abused alcohol showed 25%, 16%, and 16% personality, mood, and anxiety disorders respectively.

How Are Alcoholism and Co-Occurring Mental Health Disorders Treated?

An integrated approach to treatment for those with co-occurring mental health and substance abuse disorders is necessary to adequately address the symptoms of both.¹³ Research has shown that this approach has better outcomes than treating either disorder alone.¹³ Integrated treatment generally involves a combination of behavioral therapies, with or without medication.¹³ Whether medication is used depends on a person’s specific needs.

Some of the therapies implemented in an integrated approach include:¹³

• Cognitive-behavioral therapy to address a person’s unhelpful or harmful thoughts and behaviors.
• Dialectical behavioral therapy can be incorporated to help reduce the potential for self-harm, including cutting and other self-injurious behaviors, suicide, and continued substance use.
• Assertive community treatment to help people better utilize a variety of community supports to promote recovery.
• Therapeutic communities to help a person learn to “resocialize” while in long-term residential treatment.
• Contingency management to provide incentives for change and to reward positive behaviors.

Despite the benefits of integrated treatment, NIDA points out that that “only about 18% of [substance use disorder] treatment programs and 9% of mental health treatment organizations have the capacity to serve dually diagnosed patients.” The reasons for this are complex, and include factors outlined by NIDA, such as: ¹⁴

• Substance abuse treatment is often isolated from the general health care system. Furthermore, people with severe mental illness are often treated at specialty facilities, while those with substance abuse are usually treated at another; neither of these facilities traditionally have the specific expertise to address both problems.
• Substance abuse facilities may be concerned with using medication in people who are recovering from drug or alcohol abuse, even in those with severe mental illness, although this trend appears to be shifting. In addition, many substance abuse facilities have not typically had qualified staff who are adequately trained to prescribe or provide these medications.
• Some people with co-occurring disorders are in the criminal justice system, and adequate services to address these disorders are not often available or accessible in these settings.

Therefore, anyone seeking help for addiction or a mental health disorder should be evaluated for both and treated accordingly.¹³

Get Help for Co-Occurring Disorders

Alcohol.org is a subsidiary of American Addiction Centers (AAC), a nationwide provider of addiction treatment facilities. Across our portfolio of treatment centers, our facilities are equipped to treat co-occurring disorders such as depression, PTSD, anxiety disorders, and others.

Our team of treatment staff—ranging from nurses to doctors, therapists, psychiatrists, life residential counselors and skills coaches—are knowledgeable in treating alcoholism as well as mental health illnesses. In order to best address the comorbidity, your therapeutic team can tailor your mental health and recovery treatment plans.

To learn more about your treatment options, our facilities, or what rehab entails, call our admissions navigators 24/7. All calls are 100% confidential and there is no obligation to make any decisions upon your first call. Or, fill out the form below to see if your insurance covers treatment within an AAC facility.

Sources

[1]. National Alliance on Mental Illness. (2010). Mental Illness and Substance Abuse.

[2]. American Psychiatric Association. (2018). What Is Mental Illness?

[3]. National Institute of Mental Health. (2021). Mental Illness.

[4]. Centers for Disease Control and Prevention. (2018). Learn About Mental Health.

[5]. National Institute on Alcohol Abuse and Alcoholism. (2020). Understanding Alcohol Use Disorder.

[6]. NAMI Hearts and Minds. (2010). Mental Illness and Substance Abuse.

[7]. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing; 490-491.

[8]. Substance Abuse and Mental Health Services Administration. (2020). Mental Health and Substance Use Disorders.

[9]. Drake, R. E., Mueser, K. T., & Brunette, M. F. (2007). Management of persons with co-occurring severe mental illness and substance use disorder: program implications. World Psychiatry: Journal of the World Psychiatric Association (WPA), 6(3), 131–136.

[10]. National Institute on Drug Abuse. (2020). Research Report: Common Comorbidities with Substance Abuse Disorders Research Report: Why is there comorbidity between substance use disorders and mental illnesses?

[11]. National Institute on Drug Abuse. (2020). Research Report: Common Comorbidities with Substance Use Disorders Research Report Part 1: The Connection Between Substance Use Disorders and Mental Illness.

[12]. Flynn, P. M., & Brown, B. S. (2008). Co-occurring disorders in substance abuse treatment: issues and prospects. Journal of Substance Abuse Treatment, 34(1), 36–47.

[13]. National Institute on Drug Abuse. (2018). Comorbidity: Substance Use Disorders and Other Mental Illnesses DrugFacts.

[14]. National Institute on Drug Abuse. (2020). Research Report: Common Comorbidities with Substance Use Disorders Research Report Part 4: Barriers to Comprehensive Treatment for Individuals with Co-Occurring Disorders.

[15]. National Institute on Alcohol Abuse and Alcoholism. (2002). Alcoholism and Psychiatric Disorders.

[16]. National Institute on Alcohol Abuse and Alcoholism. (2002). Comorbidity of Alcoholism and Psychiatric Disorders.