Double Trouble: Addiction and Co-Occurring Psychiatric Disorders
Individuals who suffer from an addictive disorder – drugs, alcohol or process addictions, such as gambling – frequently also present with a psychiatric diagnosis or symptoms. Of the estimated 20 million adults in the United States with a substance use disorder, nearly 60 percent have a co-occurring mental health disorder, according to the National Institute on Drug Abuse.1
With any dual diagnosis, clinicians know that if they treat only one disease, neither one is likely to improve. Certainly the one left untreated will not improve, and the one treated often does not respond as expected because the unaddressed illness is interfering with its treatment.
The negative effects of addictions may seem so serious that co-occurring diseases may be overlooked in therapy. The patient may minimize their seriousness with thoughts such as “I’m addicted to drugs so of course I feel sad about it” or “I’m anxious because my addiction might cost me my family and career.”
Both statements may be true for patients with an addiction, but comorbid depression or anxiety magnifies the effect and significantly complicates treatment. Loved ones and caregivers may become frustrated because the patient fails to improve even while receiving appropriate care for the addiction. The patient may become so demoralized that he gives up on addiction treatment. Lack of progress can cause a patient’s depression or anxiety disorder to spiral down, prompting more addictive behavior.
The reverse is also true: If a patient suffers from depression and is not responding well to treatment, an addictive behavior such as alcohol abuse could be interfering. Patients with depression and similar problems often use alcohol and other substances, or addictive behavior like overeating, to self-medicate and relieve the pain of another disorder.
A clinician who diagnoses or treats a patient with any addiction disorder should screen for related forms of psychopathology, including mood disorders, anxiety, personality disorders and bipolar disorder, as mental illness may lead to drug abuse, which can then cause a mental illness. Substance use disorder and psychiatric disorders also share a number of risk factors, including overlapping genetic vulnerabilities, common environmental triggers and involvement of similar regions of the brain, according to the National Institute for Drug Abuse.
In addition, both drug use disorders and other mental illnesses are developmental disorders. They often begin in adolescence, or at an even younger age, a time when the brain experiences dramatic developmental changes. Early exposure to drugs of abuse may increase the risk of later mental disorders, just as early symptoms of a mental disorder may increase the risk of substance abuse later in life.
Because both addiction disorders and psychopathology have significant social stigma, few patients will volunteer the information that they have another problem in addition to the one for which they are already receiving treatment. Many patients will say “no” to direct questions, either because they are in denial or because they do not know they have another issue. Questions that probe behaviors or feelings more effectively indicate a second diagnosis. Helpful lines of inquiry include asking about appetite, sleep, interaction with family and friends, use of alcohol and other substances, repetitive thoughts and feelings of frustration, anger or guilt.
Drug-related symptoms can mimic symptoms of mental disorders, making diagnosis of comorbidities challenging when a person enters treatment for substance abuse. After a period of abstinence, a more accurate assessment can be made.
Treatment for both illnesses must proceed simultaneously, rather than waiting for one to resolve before tackling the other. Addressing an addiction cannot be put off while focusing on another issue such as depression. Chances of successfully treating depression or a similar disease while the patient is still using the addictive substance are extremely low. Similarly, the likelihood of successful recovery without treating depression is small.
Ideally, the patient with a dual diagnosis will receive care at a facility that demonstrates expertise in treating both issues and can develop a treatment plan that incorporates both disorders. Attending to all existing diagnoses provides the best foundation for an optimal long-term clinical outcome and is the course most likely to enable a patient to return to his highest level of functioning.
- Co-morbid Drug Abuse and Illness ↩