What Is a Co-occurring Disorder?

Co-occurring disorder refers to the coexistence of a substance use disorder—alcohol or other drug abuse or addiction—and a mental health disorder. Mental health disorders that may commonly occur with addiction include mood disorder, such as depression or bipolar disorder, and anxiety disorder, such as generalized anxiety disorder, social anxiety, panic disorder, post-traumatic stress disorder, or obsessive-compulsive disorder.

Addiction and mental illness are identified as separate and distinct issues that can—and often do—occur together. When people are diagnosed as having a co-occurring disorder, it means that they have been diagnosed with two or more disorders at the same time during the past year.

What Are Common Indicators of a Co-occurring Disorder?

Having a co-occurring disorder can present with problems such as:

• Use of alcohol or other drugs to reduce problems or pain associated with mental health issues
• A worsening mental health disorder because of alcohol or drug use
• A worsening substance use disorder because of mental health problems
• Difficulty getting treatment for both disorders, or difficulty benefiting from treatment
• Difficulty finding supportive professionals or peers who understand both disorders

What Causes Co-occurring Disorders?

Often times there is a genetic risk factor for both substance use and certain mental health disorders, but genes alone usually don’t explain all causes of co-occurring disorders. Other factors include family, environment, and life stress, including traumatic life events, poverty, and loss. Stressful experiences can also trigger genetic factors that contribute to co-occurring disorders. It is possible that people with mental health disorders may be more biologically sensitive to the effects of mood altering substances. They may use alcohol or other drugs to cope with mental health symptoms or to counter social anxiety. People who have a mental health disorder are at much higher risk of also having a substance use disorder and, conversely, people who have a substance use disorder are at much greater risk of developing a mental health disorder.

What’s Involved in the Treatment of Co-occurring Disorders?

It is important to recognize that both the addiction and the mental health disorder need to be treated. Treating only one of the disorders will result in inadequate treatment and a potential worsening of the other condition. The most common treatment for co-occurring disorders involves an integrated treatment model that can stabilize both the symptoms of the co-occurring disorder and provide the foundation for lasting recovery.

Integrated treatment involves a combination of the following:

• Accurate diagnosis of both disorders
• Education about substance use and psychiatric disorders
• The interaction between both the addiction and mental health concerns and the options for treatment
• Exploration of the individual’s motivation and commitment to address his or her co-occurring disorder
• Therapies, including cognitive behavioral therapy, and Twelve Step facilitation that teach new skills and provide new insights
• Appropriate use of medications—there are many safe and non-addictive medications used to treat mental health disorders that will not interfere with an individual’s recovery
• Involvement in treatment, including opportunities for education and skills development
• Ongoing and frequent monitoring for the return of psychiatric symptoms and substance use
• Participation in peer support groups such as Alcoholics Anonymous and Dual Recovery Groups

What Is the Family’s Role in Treatment and Recovery for Individuals with Co-occurring Disorders?

• Educate yourself about your loved one’s addiction and mental health issues.
• Learn about the impact of addiction and mental health issues on family members and loved ones.
• Participate in family support such as Al-Anon, Families Anonymous, or a support group for families coping with addiction and mental health issues.
• Support your loved one’s involvement in a Twelve Step program and therapy.
• Learn new ways of coping with a loved one’s addiction and mental health issues, including what it means to “detach with love” and why it’s important to develop your own self-care program.
• Encourage participation in peer support groups for your loved one.
• Know the signs of relapse.

Are People with Addiction at Greater Risk of Having a Co-occurring Mental Health Disorder?

As reported in Hazelden’s Research Update, Addiction and Mental Illness, the prevalence of substance use disorders in the general population is about 16 percent and nearly doubles to 29 percent for people with mental health disorders. Additionally, the publication provides the following facts and figures on the prevalence of co-occurring disorders.

Depression

Depression is often found at high levels among alcoholics and addicts seeking substance dependency treatment. As many as 80 percent of alcoholics experience depressive symptoms at some time in their lives, and 30 percent meet diagnostic criteria for major depression.

PTSD

There is a strong correlation between substance use disorders and PTSD, with as many as one-third of patients meeting criteria for PTSD when they enter treatment for their alcohol/drug problems.

Anxiety Disorders

Rates of other anxiety disorders anxiety disorders, such as agoraphobia, panic disorder, social phobias, and general anxiety disorder, are high in treatment populations, ranging from 10 to 60 percent.

Eating Disorders

Most studies find that between 15 and 32 percent of women with alcohol/drug disorders meet diagnostic criteria for an eating disorder, like anorexia nervosa or bulimia nervosa, at some time in their lives.

Why Do these Disorders Occur Together So Frequently?

While answers about co-occurrence aren’t conclusive, there are many theories. The Dartmouth Psychiatric Research Center puts forth several theories, including the following:

• Self-medication. People use alcohol or other drugs to “self-medicate” against disturbing symptoms of mental illness.
• Early onset. Certain drugs of abuse (e.g., methamphetamine, cocaine, alcohol) may precipitate an earlier onset of mental illness in certain vulnerable individuals.
• Genetic and environmental. Genetic predisposition or environmental factors (poverty, social isolation, or lack of structure, for example) may cause both substance use problems and mental illness.
• Susceptibility. People with mental illnesses may be more susceptible to the harmful effects of alcohol and other drugs.

Why Is It Difficult to Diagnose Co-occurring Disorders?

Psychiatry is a complex field with regard to diagnostic assessment. Blood tests and lab procedures don’t provide conclusive diagnoses for psychiatric illness. Co-occurring disorders can be especially problematic to diagnose because the presence of one disorder can interfere with diagnosis of the other. For example, a person with alcohol or other drug dependence is likely to manifest problems with depression or anxiety. Likewise, a person seeking medical care for depression or anxiety may downplay or deny his or her alcohol use. Conducting a comprehensive evaluation is of paramount importance because effective treatment of co-occurring disorders is diagnosis driven.

What Type of Treatment Is Recommended for Co-occurring Disorders?

An integrated treatment approach is key, with a focus on stabilizing symptoms of the co-occurring mental health disorder while providing the patient with a foundation for recovery from addiction.