Co-occurring Disorders
Substance use disorders often can occur simultaneously with mental health disorders, which is referred to as "co-occurring disorders."
According to the National Institute of Mental Health, although mental health and substance use disorders often co-occur, that does not mean that one causes the other. Either disorder can develop first. Many people who develop substance use disorder are also diagnosed with mental health disorders, and many people with mental health disorders will develop an substance use disorder.
Co-occurring disorders may include any combination of two or more mental health disorders and substance use disorders identified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
About Co-occurring Mental Health and Substance Use Disorders
Millions of people in the United States are affected by mental health and substance use disorders:
- 57.8 million people – one in 5 American adults –experience some form of mental illness in any given year.
- In 2023, 48.5 million people – one in 6 Americans aged 12 or older – had a substance use disorder in the past year.
- In 2023, 20.4 million Americans aged 18 and older had co-occurring mental health and substance use disorders.
Why Do Mental Health and Substance Use Disorders Co-occur?
Research suggests three possible reasons why these disorders often occur together:
- Substance use and mental health disorders have common risk factors. A person’s genes, trauma, emotional distress, and environmental stress can be common risk factors. For example, childhood trauma increases the risk for substance use, other mental health disorders, suicidality, and physical health conditions. Studies estimate that more than 30 percent of adults with SUD experienced childhood trauma including emotional abuse, sexual abuse, emotional neglect, or physical neglect.
- Mental health disorders can contribute to substance use and SUD. Studies found that people with a mental health disorder like anxiety, stress, depression, or post-traumatic stress disorder (PTSD), may use drugs or alcohol to self-medicate, and cope with overwhelming symptoms.
- Substance use can contribute to the development of mental health disorders and make them worse. Substance use can trigger changes in some of the same brain areas that are disrupted in mental health disorders such as schizophrenia, anxiety, mood or impulse-control disorders, making a person more likely to develop a mental health disorder. For example, evidence suggests that cocaine use may worsen the symptoms of bipolar disorder and contribute to progression of this illness.
Diagnosing and Treating Co-occurring Disorders
Because co-occurring mental health and substance use disorders may interact with each other, and some symptoms are the same for both disorders, diagnosis and treatment can be complex. People who have co-occurring disorders often have symptoms that are more persistent, severe, and resistant to treatment compared with patients who have either disorder alone.
Since substance use and mental health disorders frequently co-occur, integrating screening and treatment for both disorders leads to a better quality of care and health outcomes for those living with co-occurring disorders by treating the whole person.
Learn more about integrated diagnosis and treatment for co-occurring disorders at SAMHSA.gov.
About Substance Use Disorder
Substance use disorder occurs when the repeated use or misuse of substances – like legal or illegal drugs, alcohol, or medications – changes a person’s brain and behavior, making it difficult for them to control their use of the substance even when it causes harm.
Substance use disorder is a chronic but treatable medical condition.
What Is a “Substance?"
Substances are chemicals that can change how a person’s body and mind work. According to MedlinePlus.gov, substance use, or misuse, includes:
- Illegal substances, such as anabolic steroids, heroin, cocaine and methamphetamines.
- Prescription medications, such as narcotic pain medicines like opioids. Misuse includes:
- - Taking a medicine that is prescribed for someone else.
- - Taking a larger dose than prescribed.
- - Using the medicine in a different way than it is prescribed. For example, instead of swallowing tablets, they might be crushed and then snorted or injected.
- - Using the medicine for another purpose, such as getting high.
- Over-the-counter medications, such as some painkillers, sleep aids, and cough medicines. Misuse includes using them for another purpose and using them in a different way than they are intended to be used.
- Legal substances, such as alcohol and tobacco.
Who Does Substance Use Disorder Affect?
According to SAMHSA’s National Survey on Drug Use and Health, in 2023:
(age 12 or older) had a substance use disorder in the past year. That's 48.5 million people.
- Of these 48.5 million people:
- 28.9 million had an alcohol use disorder.
- 27.2 million had a drug use disorder.
- 7.5 million people had both alcohol and drug use disorders.
The highest percentage of people with a substance use disorder in the past year:
were young adults age 18 to 25
— 9.2 million people.
were adults age 26 or older
— 37.0 million people.
were adolescents age 12 to 17
— 2.2 million people.
Stages of Substance Use
There are several stages of substance use that may lead to addiction, according to MedlinePlus. Young people seem to move more quickly through the stages than adults do. These stages are:
- Experimental use: Typically involves peers, done for recreational use; the user may enjoy defying parents or other authority figures.
- Regular use: The user misses more and more at school or work; worries about losing substance supplier; uses substances to fix negative feelings; begins to stay away from friends and family; may change friends to those who are regular users; shows increased tolerance and ability to handle the substance.
- Problem or risky use: The user loses any motivation; does not care about school and work; has obvious behavior changes; thinking about substance use is more important than all other interests, including relationships; the user becomes secretive; may begin dealing substances to help support habit; use of other, harder substances may increase; legal problems may increase.
- Addiction: The user cannot face daily life without the substance; denies problem; physical condition gets worse; loss of control overuse; may become suicidal; financial and legal problems get worse; may have broken ties with family members or friends.
About Addiction
Addiction Is a Complex Disease
Many people mistakenly believe that addiction results from a lack of willpower or moral principles.
In reality, addiction is a complex disease. Repeated substance use alters the brain, making people compulsively seek and use substances despite harmful consequences, and making it hard to quit – even for those who want to stop.
These changes to the brain can persist, which is why addiction is considered a "relapsing" disease – people may return to substance use even after long periods of sobriety.
Relapse is common, but it doesn’t mean treatment failed. Like other chronic illnesses, addiction treatment must be ongoing and adapted to fit a person’s needs.
Why Do Some People Become Addicted While Others Don’t?
Addiction risk varies based on three key factors:
Biology: Genetics account for about half of a person’s risk. Other factors like gender, ethnicity, and mental health also play a role.
Environment: Family, friends, economic conditions, and life experiences, such as peer pressure, abuse, or early exposure to drugs, can influence addiction risk.
Development: Drug use during key stages of life, especially adolescence, increases the risk. Teen brains are still developing in areas that control decision-making and self-control, making them more likely to engage in risky behaviors like drug use.
Learn more about substance use and addiction on SAMHSA.gov.
Symptoms and Behaviors of Substance Use Disorder
Symptoms and behaviors of a substance use disorder may include:
- Withdrawal from friends and family; no longer taking part in usual activities.
- Sudden changes in behavior, engaging in risky behaviors.
- Neglecting to eat, not caring about physical appearance.
- Missing work or school, or a decrease in performance.
- Developing a high tolerance and withdrawal symptoms.
- Feeling the need for daily or regular substance use to function.
- Lack of control over substance use, being unable to stop or reduce use.
- Continuing to use, even when it causes harm to health, work, or family.
- Hostility when confronted about substance dependence.
- Using substances even when alone.
Diagnosing Substance Use Disorder
This information is only an overview, and should not be used as a substitute for professional medical care or advice. If you have concerns about substance use, talk to your health care provider.
The most commonly used system in the United States for diagnosing mental health and substance use disorders is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
A substance use disorder diagnosis is usually made along a continuum — mild, moderate, or severe — based on the number and severity of the symptoms a person has.
According to the DSM-5, the symptoms include:
- Substance is taken in larger amounts or over longer periods than was intended.
- There is a persistent desire or unsuccessful effort to cutdown or control substance use.
- A great deal of time is spent in activities necessary to obtain substance, use substance, or recover from its effects.
- Craving, or a strong desire or urge to use substance.
- Recurrent use of the substance is resulting in a failure to fulfill major role obligations at work, home, or school.
- Continued use of substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
- Important social, occupational, or recreational activities are given up or reduced because of substance use.
- Recurrent substance use in situations in which it is physically hazardous.
- Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance, as defined by either of the following:
- - A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
- - A markedly diminished effect with continued use of the same amount of the substance.
- Withdrawal, as manifested by either of the following: (Withdrawal does not apply for every substance.)
- - The characteristic withdrawal syndrome for that substance.
- - The substance is taken to relieve or avoid withdrawal symptoms.
If you think that you -- or someone you know -- may have a substance use problem, talk to a health care provider.
Treating Substance Use Disorders
Treatment for substance use disorder begins with recognizing and acknowledging the problem.
Treatment plans will be different for everyone, and depend on the needs of the individual and the substance or substances involved. The goal of most SUD treatments is to change thoughts and behaviors, and, if needed, manage physical dependence and withdrawal symptoms.
There are different treatment approaches, and they each work indifferent ways. Effective SUD treatments address the whole person, often combining multiple approaches tailored to each individual. It is important to work with a treatment provider to determine the most effective treatment plan.
Learn more about treatment and recovery at NIDA.gov.
Common Treatment Elements for Substance Use Disorders
Treatment plans will not be the same for everyone, but there are common elements of treatment:
- Detoxification: The first major hurdle that people with a substance use disorder will have to pass is detoxification. Inpatient detoxification is generally more effective than outpatient for initial sobriety and safety. During inpatient detoxification, trained medical staff monitor a person 24/7 for up to seven days. The staff may administer tapering amounts of the substance or its medical alternative to wean a person off and lessen the effects of withdrawal.
- Inpatient Rehabilitation: A person experiencing dependent patterns of substance use may benefit from an inpatient rehabilitation center where they can receive medical and mental health care 24/7. These treatment centers provide therapy, support, medication and health services to treat the substance use disorder and its underlying causes.
- Therapy and Counseling: Therapy and counseling are part of most treatment plans. It can help people develop coping skills, address personal challenges, and build skills for managing triggers. Therapy and counseling usually happen with a licensed behavioral health professional, either one-on-one or in a group setting.
- Medication: There are approved prescription medications that can help ease withdrawal symptoms, reduce cravings, and prevent relapse. They are often used in combination with counseling. These medications have to be prescribed by a doctor, nurse practitioner or physician’s assistant.
- Supportive Housing, like group homes or sober houses, are residential treatment centers that help people who are newly sober or trying to avoid relapse.
- Support Groups: Dealing with a substance use disorder can feel challenging and isolating. Connecting with people who have similar experiences can help. Support groups provide places to make connections with others, and find emotional and social support.
NAMI Jacksonville's free Connection Recovery Support Groups, for individuals (18+) living with mental health conditions and co-occurring substance use disorders, provide a safe place that offers respect, understanding, encouragement, and hope.
There are many different kinds of support groups, processes and programs, including:
- Twelve-Step programs, which are based on a set of spiritual principles originally developed by Alcoholics Anonymous, that are used as a model through which to maintain sobriety. These programs are not based in any one religion, but they are spiritual, in that members have an acceptance of a higher power.
- Twelve-Step programs for individuals include:
- Alcoholics Anonymous (AA): a Twelve-Step abstinence-based recovery program for people who are addicted to alcohol.
- AA Home Group hosts online open Alcoholics Anonymous meetings 24 hours a day, 7 days a week.
- Narcotics Anonymous (NA): a Twelve-Step abstinence-based recovery program for people who are addicted to drugs or alcohol.
- Twelve-Step-based support programs for family members and friends affected by someone else’s substance use include:
- Al-Anon Family Groups: a Twelve-Step program for anyone who is affected by someone else’s drinking.
- Nar‑Anon Family Groups: a Twelve-Step program for people affected by a loved one's drug addiction.
- For teens and young adults:
- Alateen – Al-Anon Meetings for Teens: caters to teens and young adults affected by alcoholism in their family.
- Narateen: part of the Nar-Anon program, provides support to teens affected by a family member or friend’s addiction.
- Secular (non-spiritual) programs do not depend on adherence to any religious or spiritual beliefs or practices. People of all religions are welcome, but spirituality and religion do not play a part in secular programs. Secular programs include:
- SMART Recovery (Self-Management and Recovery Training) is an evidenced-informed recovery method grounded in Rational Emotive Behavioral Therapy (REBT) and Cognitive Behavioral Therapy (CBT), that uses a self-empowering, science-informed approach to recovery from addiction.
In addition to support for individuals, SMART provides specialized meetings for a variety of communities, including: Family & Friends; Military, Veterans and First Responders; Teenagers; LGBTQIA+; people currently involved in the criminal justice system, and others.
- Life Ring Secular Recovery is a network of abstinence-based, peer-to-peer support groups that use scientifically based recovery methods, with the key to recovery being the individual's own motivation and effort.
Additionally, there are Life Ring Focus meetings that support specific communities of people, including those with Co-occurring Disorders; Friends & Family; Men in Recovery; Women in Recovery; Veterans in Recovery; LGBTQIA+ and Friends; and others.
Substance Use Disorder Treatment Settings
SUD treatment can take place in different settings, depending on the substance and the severity of the disorder.
- Outpatient, meaning you have an appointment and leave the same day. Outpatient programs can be in-person or using telehealth.
There are two main types of outpatient care: One is like a standard doctor’s visit. It’s best for people who can make and keep regular appointments. Frequency depends on the care needed.
The other is intensive outpatient or partial hospitalization, which helps coordinate care more intensively than standard visits. This can include one-on-one appointments, group sessions, and learning about coping skills, and it usually takes a few hours. - Inpatient, meaning you stay at a hospital or treatment program overnight for a few days or weeks.
This is usually for people needing 24-hour care for their mental health or substance use. Most of these programs are connected to a hospital or clinic. - Residential, meaning you live at a treatment program. Residential care usually lasts for a few weeks to a few months.
Treatment for more serious conditions may mean staying with a program for a year or more. There are different types of residential programs, including those that help people who have severe mental health conditions to get ready to live in their community, and programs that help people stop using drugs or alcohol. - Interim care, when you need care right away but there isn’t an opening.
Many treatment options have long waitlists, but can still help while you wait. Interim care can provide daily medicine and emergency counseling to keep you safe until an outpatient, inpatient, or residential spot is available.
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