Today, some 18.5 million Americans struggle with a substance use disorder. A further 46.6 million Americans suffer from one or more mental health disorders. Most importantly, while 15.7% of the general population is likely to abuse or rely on substances such as drugs or alcohol, 36.7% of individuals with a pre-existing mental illness are likely to abuse substances. This number goes up to a heartbreaking 49.4% for individuals with severe mental illnesses. What’s the connection between the two? And why are individuals with mental illness so much more likely to become dependent on a substance?
The truth is, there is no easy answer. However, mental illness is a huge risk factor for substance use disorder for several reasons. Individuals who are most vulnerable to mental health disorders are also most vulnerable to substance use disorder. Mental health disorders affect the brain and behavior, changing coping mechanisms and increasing the likelihood of risky behavior. Mental disorders result in self-medication as a coping mechanism. And, individuals with a substance use disorder are more likely to develop mental illnesses. So, the answer is likely incredibly complex, and no case should be diagnosed without a full understanding of the individual, their history, and their mental health. Dual diagnosis, or a coexisting mental health and substance use disorder, is incredibly common and will impact treatment, so it’s important to understand the factors and relevant risks involved.
Overlapping Risks and Vulnerabilities
Most mental health disorders heavily overlap with substance use disorder. Both are behavioral disorders resulting in changes to serotonin, dopamine, and sometimes GABA production and uptake in the brain and central nervous system. Most result in behaviors that reinforce negative patterns, leading to negative feelings, emotional ups and downs, and unsustainable habits. Most importantly, most have the same general risk patterns and vulnerabilities.
These include genetics, epigenetics, social and economic condition, exposure to trauma, existing physical illnesses, and childhood. So, someone who is stressed and struggling with money is more likely to develop a mental health disorder but also more likely to develop a substance use disorder.
For example, the Adverse Childhood Experiences (ACE) tracks the likelihood of adults being vulnerable to substance use disorder, mental illness, and physical illness based on exposure to childhood trauma and adverse childhood experiences such as poverty, stress, parental separation, etc. The study tracks a significant correlation between the two, with ore adverse experiences resulting in a higher vulnerability to addiction, mental health disorders, and physical illness.
Self-Medicating Mental Health Disorders
Self-medication is the process of using a substance to minimize or temporarily reduce the side-effects or symptoms of a disorder. Persons with mental health disorders are very prone to doing so, which may result in their higher exposure to drugs and alcohol, and therefore higher rates of substance abuse and dependence. Here, individuals drink, take a pill, or take a drug outside of a prescription, with the intent of minimizing symptoms. This can start off as innocuously as “I need a drink to unwind” and lead up to heavily relying on a substance every time something slightly goes wrong. It also quickly leads to a pattern of escalation as tolerance and chemical dependence build, so users must increase the dose to reach the same level of effect.
At the same time, using substances to self-medicate often exacerbates those symptoms and causes more stress in the form of hangovers, poor performance, fatigue, lack of concentration, etc. So, self-medication is often self-defeating, in that it makes problems worse.
In most cases, alcohol is the most abused substance, followed by prescription painkillers such as narcotic opioids.
Who Self-Medicates?
Unfortunately, most people self-medicate in one way or another. Most of us have decided to do or not to do something, or to or not to have a drink or a pill because of stress or because things were bad. For those of us who are otherwise healthy, this can remain a “one time” or “occasional” thing. It’s not healthy, but it’s also not problematic. For persons with frequent and recurring problems, such as a mental health disorder or a very stressful life or job, it becomes more frequent and therefore problematic.
People who are very prone to self-medicate include persons with PTSD, ADHD, Anxiety disorders, depression disorders, panic disorders, bipolar disorder, schizophrenia, borderline personality disorder, and obsessive-compulsive disorder. These disorders are linked to intense mood swings, constant stress, feelings of hopelessness, self-esteem issues, anxiety, and panic. Most are linked to social isolation and alienation, leading individuals to situations where they have few healthy outlets to pain.
Dependence Following a Prescription
Millions of Americans receive prescriptions for potentially addictive medications including benzodiazepines like Valium and Xanax. Today, we know that these drugs are tolerance and dependence inducing and that people are at risk after only a few weeks of usage. Most of these drugs are habit forming because they cause behavioral reliance. Someone with anxiety takes Xanax to stave off a panic attack, starts taking more than they need, and eventually convinces themselves that the Xanax is the only reason they aren’t having a panic attack. Someone can then have a panic attack because they don’t have Xanax.
Compulsive users constantly think about, talk about, and use a prescription medication, bring it with them “Just in case”, and might show real distress if it is not available.
Today, most benzodiazepine prescriptions are limited to just 5 weeks. However, millions of Americans have already had benzodiazepine prescriptions for years. The damage is already done, and many are still struggling with resulting dependencies.
Substance Abuse Exacerbates Mental Illness Symptoms
People often take drugs and alcohol to temporarily alleviate symptoms of mental illness, but the result is often the opposite effect. Drugs and alcohol cause dehydration, upset serotonin and dopamine secretion, uptake, and reuptake, and impact the central nervous system. A person who is anxious may temporarily feel better when taking a sedative but over time, that sedative will make them feel worse.
This is especially critical where drug and alcohol abuse overlaps with the symptoms of mental illness. Drug and alcohol abuse causes serotonin and dopamine imbalances, resulting in changes in the brain that are remarkably similar to mental illnesses. So, a person who is heavily using a substance might begin to show symptoms of depression, anxiety, bipolar disorder, or PTSD. Most importantly, for persons who are already vulnerable, these symptoms might exacerbate into becoming a disorder and it may become chronic. This means that individuals who start abusing a substance with no history of mental illness may leave rehab with a diagnosis.
It’s easy to say, “The substance caused the disorder” in cases like this, but the truth is often much more complex, because the individual has vulnerabilities for both and developing one condition might be coincidental. While many drugs do cause anxiety, depression, paranoia, and even psychosis, there is no directly linked “cause and effect”. An individual might be using because they are vulnerable to drugs and alcohol and mental disorders. They might develop the mental disorder because the symptoms caused by substance abuse triggered them into a disorder. And, the physical changes to the brain, including changes in dopamine and serotonin production and uptake, might trigger long-term imbalances, resulting in mental illness. Determining which of these, or which combination of these, is the cause of a mental illness after an addition is complex.
Understanding Dual Diagnosis
Dual diagnosis is the state of holding two or more diagnosis at a given time, typically a mental health disorder and a substance use disorder. This condition is sometimes referred to as co-occurring or co-morbid disorders but refers to an individual with a diagnosis for both. Here, the individual will almost always have to go into rehab with an existing mental health diagnosis. Why? The symptoms of addiction and substance abuse typically heavily overlap with mental health disorders. Most DSM-5 guidelines suggest that individuals with an existing substance use disorder should not be officially diagnosed with mental health disorders such as anxiety or depression until after rehab. However, clinicians may still determine that an individual has a dual diagnosis and act accordingly when planning treatment.
Going into treatment as a dual diagnosis patient means treating both the mental health disorder and the substance use disorder, typically in the order of “most pressing symptoms first”. This means that the order and means of treatment will heavily depend on the individual and their mental state. If their state or substance use is causing danger to themselves or others, that becomes a priority. From there, motivational issues, such as problems that might prevent the individual from recovering, are tackled.
Treating someone with a dual diagnosis means helping an individual to overcome substance abuse while offering coping mechanisms and helping individuals to navigate the symptoms of their mental illness.
Mental illnesses have a complex interaction with substance use disorder, and vice versa. Nearly half of individuals with a severe mental illness also have a substance use disorder, and as many as 40% of individuals with a severe substance use disorder have a mental illness. If you or a loved one is struggling with both, it’s important to seek out treatment that takes both into account, offers the right treatment, and works to support the individual and their needs throughout treatment.
The Gooden Center is, first and foremost, a mental health clinic. We specialize in treatment for mental illnesses, which makes us a good choice if you or your loved one are struggling with a dual diagnosis. Our facilities offer a home-like environment where you can recover and learn the skills to live without drugs or alcohol.
Contact us today at 800-931-9884 for a free assessment, or a free tour of our residential mental wellness facility in Pasadena.