Written By: Sarah Williams, PhD in Clinical Psychology
Read Time: 18 mins
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It is fairly common for individuals with substance abuse problems to also exhibit symptoms of one or more psychiatric conditions. The term used to describe this phenomenon of one person developing two disorders or illnesses, either sequentially or simultaneously, is known as comorbidity.
In most cases, when two conditions are comorbid the features of the two conditions are expected to interact in some way. This interaction between disorders can have effects on the course and outcome of each of the conditions individually.
In fact, substance abuse problems and major depressive disorder, in particular, have been found to co-occur so frequently that many have debated whether they are actually separate conditions.
Source: Substance Abuse and Mental Health Services Administration (SAMHSA), 2012
Individuals with substance abuse problems who are also suffering from a comorbid psychiatric condition are at an increased risk for greater functional impairments, including social and occupational impairments. Further, patients with co-occurring substance abuse disorders and psychiatric conditions can be difficult to treat.
This guide will discuss the comorbidity—or dual diagnosis—of substance abuse and both depressive and bipolar disorders.
Information will be provided regarding the:
Prevalence of substance abuse difficulties with comorbid affective disorders.
Hypothesized mechanisms that may explain the high rate of co-occurrence between these conditions.
Various treatments available.
Depressive Disorder Symptoms
It is normal for everyone to have periods of sadness or feeling down from time to time; however, individuals who experience symptoms of worthlessness or hopelessness that don’t seem to go away may be experiencing symptoms characteristic of depression.
Depression is more than just feelings of sadness in response to a setback or other stressful situations. In fact, some individuals with depression do not have sad feelings at all. These individuals may report feelings of emptiness or apathy.
Nonetheless, depression is the experience that feelings of sadness, emptiness, worthlessness, hopelessness, or apathy have taken over your life completely. Individuals with depression tend to have difficulty with motivation to go to work, sleep, eat, or even do things that they have enjoyed in the past.
If you or someone is experience suicidal thoughts, seek help immediately by calling 911.
Symptoms of Typical Depression
Excessive feelings of worthlessness or guilt
Changes in sleeping habits
Losing interest in daily activities
Thoughts of suicide
Reckless behavior (including self-medicating or compulsive behavior)
Unexplained aches and pains (such as muscle aches, stomach ache, headache)
Feelings of hopelessness or helplessness
Changes in appetite or weight
Increased irritability, anger, violence
Loss of energy
Individuals who have experienced a change of more than 5% of their body weight in one month should consult with their doctor.
Bipolar Disorder Symptoms
It is common for everyone to have ups and downs in relation to life’s experiences. However, an individual may be suffering from bipolar disorder if these symptoms of highs and lows are so severe that they begin to have a negative impact on their:
Performance at work or school.
Normal daily functioning.
Bipolar disorder, which can also be referred to as manic depression, is characterized by extreme shifts in an individual’s energy, mood, thinking, and behavior patterns.
Individuals with bipolar disorder will shift from the high feelings of mania to the low feelings of depression. These symptoms of highs and lows are a bit different to how one might experience mood changes throughout the day, however.
Symptoms of mania or depression tend to last several days, or even weeks or months at a time.
Individuals in the manic phase of bipolar disorder tend to:
Experience intensified feelings of euphoria, creativity and overall energy levels.
Talk very rapidly.
Need very little sleep.
Appear to be hyperactive.
Feel as though they are invincible or have a heightened sense of self-importance.
Moods of Bipolar Disorder
Indeed, manic episodes can initially feel very good; however, they have the potential to cause serious consequences for the individual, as they escalate toward being out of control.
Individuals in a state of mania are more likely to:
Engage in risky behaviors such as:
Gambling away all of their money.
Expensive shopping trips.
Inappropriate sexual activity.
Act more aggressively toward others, particularly those who do not agree to their plans.
At the extreme, individuals in a state of mania may report symptoms consistent with psychosis—such as hearing voices, or having delusional thoughts.
How to Recognize the Symptoms of Bipolar Disorder
Classifications of Bipolar Disorders
Bipolar 1 Disorder
Characterized by the presence of at least one manic episode or mixed episode (i.e., individual exhibits symptoms of mania and depression at the same time) and, occasionally, may also involve one episode of depression.
Bipolar 2 Disorder
Occurs when the individual does not experience symptoms of a full-blown manic episode. Instead a more diminished elevation—or hypomanic episode—may be periodically experienced in conjunction with symptoms of depression.
Prevalence of Comorbid (Dual Diagnosis) Substance Abuse Disorders and Depression
It is not uncommon for people to drink alcohol after a long day at work or when coping with major life stressors. Alcohol acts as a depressant and can make you feel sleepy, which gives the impression that alcohol helps you relax and feel good. This seemingly harmless routine can turn into a real problem.
While having one or two drinks on occasion when you feel down or overly stressed doesn’t meet the criteria for substance abuse, the psychological need to have a drink every time you feel a little sad or to cope with any small problem is a red flag for potential substance abuse problems.
sub·stance a·buse (ˈsəbstəns əˈbyo͞oz) noun 1. an excessive use of a substance, such as drugs or alcohol, which leads to clinically significant impairments to the individual’s day-to-day functioning.
These impairments could occur in the individual’s professional, interpersonal, or academic areas of functioning.
Moreover, individuals that were leading successful and healthy lives prior to the onset of their substance abuse are more likely to have their symptoms develop over a longer period of time. This means that impairment may not emerge as quickly, thus substance abuse may be more difficult to spot in these individuals.
This poses a challenge in recognizing and diagnosing a problem in this group. The delay could be quite significant, as individuals who receive treatment for their substance abuse problems early are believed to have better outcomes and be less at risk for developing long-term negative effects from years of abusing substances.
The high prevalence of comorbidity between substance abuse and other mental health disorders has been well documented in the literature throughout the years.
In the general population, prevalence rates have suggested that between 8.5% and 21.4% of individuals with major depressive disorder also have substance abuse problems.1
Further, results from a retrospective study found that 19.2% of individuals reporting symptoms of major depressive disorder within a 12-month period also reported some kind of substance abuse disorder within that same period.2
Similarly, other findings indicate that being diagnosed with major depression or dysthymia—a more mild and persistent form of depression—increases the incidence of both alcohol problems (between 16.5% and 21.9% versus 13.5%) and drug problems (between 18% and 18.9% versus 6.1%) during adulthood.
Lifetime prevalence rates of depression and co-occurring substance abuse problems are reported to be between 27% and 40%.3, 4
Higher Rates of Substance Abuse in Depressed Individuals
The likelihood of substance dependency or abuse for those with and without major depression
On the flip side, studies have also demonstrated that individuals suffering from substance abuse problems are at an augmented risk for also suffering from symptoms of depression. In fact, findings from a large epidemiological study have indicated that adults with either alcohol or other drug-related disorders are 1.9 to 4.7 times, respectively, more likely to have been diagnosed with depression or another affective disorder, than that of the general population.5
Prevalence of Comorbid (Dual Diagnosis) Substance Abuse and Bipolar Disorder
Similar to major depression, there is a growing body of literature linking the comorbidity of substance abuse disorders and bipolar disorders. Interestingly, symptoms of mood instability have been reported as among the most commonly reported psychiatric symptoms in a patient population with substance abuse problems.1, 2
Alternatively, studies examining individuals who have been diagnosed with bipolar disorder have found that substance abuse is the single most commonly occurring comorbidity.6
More specifically, it has been estimated that about 60% of individuals who have been diagnosed with bipolar disorder are expected to also struggle with substance abuse at some point during their lifetime.7
Much like depression, individuals with bipolar disorder experience a number of distressing symptoms.
It is not surprising that they would look to drugs or alcohol as a quick and easy way of managing their feelings of distress.
Alcohol has been found to be the most commonly abused substance by individuals with bipolar disorder.
The second most common substance abused by individuals with bipolar disorder is cannabis, followed by amphetamines and cocaine.8
Why Substance Abuse Disorders Co-Occur with Affective Disorders
It is important first to note that just because two disorders are comorbid, does not mean that one caused the other. This holds true even in situations when the onset of one disorder preceded that of the other. In fact, it is quite difficult to establish causality or directionality in terms of these conditions.
For instance, most individuals who are diagnosed with either major depressive disorder or bipolar disorder received their diagnosis once the severity of their symptoms had reached a level of clinical significance. This means that their symptoms had become so severe that they were beginning to interfere with the individual’s functioning in some way.
Thus, identifying when the actual onset of the disorder occurred, in and of itself can become quite complex.
Some people may not report issues with substance abuse because they don’t think it’s relevant to their mental health problems.
The exact mechanisms accounting for why substance abuse disorders tend to co-occur with psychiatric conditions, such as depression or bipolar disorder, are not fully understood. The symptoms of one condition can overlap or even mask the symptoms of the other, making even the diagnosis of these comorbidities quite challenging.
Moreover, individuals who are receiving treatment for a psychiatric condition may not even report issues with substance abuse, as it may not occur to them that this is relevant to their mental health problem.
Nonetheless, there are several possible explanations for why substance abuse disorders tend to co-occur so frequently with psychiatric conditions.
It has been suggested that individuals with depression or bipolar disorder may be more likely to use substances as a way to self-medicate.
Individuals with bipolar disorder, for example, often struggle with symptoms of:
Painful physical complaints.
General fatigue and malaise.
The symptoms can be pretty intense and alarming for these individuals, who may seek out drugs or alcohol as a way to numb the distressing symptoms and attempt to achieve relief.
Indeed, the immediate effects of the substance may give the individual a sense of relaxation and relief; however, these effects are only temporary.
Moreover, when an individual uses substances as a way to manage distress, they do not learn important skills in terms of coping nor do they do anything in terms of addressing the underlying problem causing the symptoms in the first place.
As such, these individuals are more likely to continue seeking out substances in the future in order to cope.
Shared Genetic Vulnerabilities
There is a growing body of literature that suggests there may be a shared genetic vulnerability to developing either substance abuse or depression and bipolar disorders.
This may be that there are certain genetic influences that predispose an individual to developing problems with both substances and other psychiatric conditions.
It may also be that a subset of individuals suffering from problems with one condition possesses certain genetically linked traits that predispose them to developing a second condition, subsequent to the onset of the first condition.
The contribution of genetics to an individual’s risk for developing problems with either substance abuse or a psychiatric condition is still being explored.
Given that there is no way to study the outcomes of specific gene expression within an individual as they develop without taking into account his or her environment, nearly all studies that have examined genetic vulnerability are limited or confounded by the factor of environmental influence.
Studies examining both identical and fraternal twins, as well as adoption studies, have the benefit of providing some insight into the unique contribution of hereditability. However, the methodology of these studies may limit the number of conclusions based on the findings.
Nonetheless, estimates have suggested that between 40-60% of an individual’s risk for developing problems with substance abuse is attributable to genetics, as well as interactions between an individual’s genetics and the environment.9
Further, the heritability of depressive disorders is estimated to be approximately 31-42%,10 and between 40-70% for bipolar disorder.11
The specific mechanism linking the co-occurrence of substance abuse disorders and psychiatric conditions is not fully understood. In general, however, it is widely accepted that an individual’s genetics accounts for the:
Ways in which the body responds to stress.
Individual’s propensity to engage in risky behaviors.
Individual’s drive to seek out novel situations.
These are all believed to contribute to the individual’s degree of risk for developing substance abuse problems in conjunction with symptoms of mental health difficulties.
Similar Brain Circuitries
With the advancement of technology in the healthcare industry, we are now able to have a better understanding of the ways in which the different areas of the brain function and interact.
Using advanced, brain-imaging technology, physicians, and researchers have made significant strides in terms of our understanding of the neurobiological processes underlying substance abuse disorders and psychiatric disorders. However, there is still much to be learned about the different systems within the brain and how they play a role in these conditions.
As scientists continue to develop a better understanding of this neurobiology, it is expected that this will also help us better understand the mechanisms behind substance abuse and depressive or bipolar disorder comorbidities.
Nonetheless, what we do know is that the neurotransmitter dopamine—a brain chemical used by several brain circuits to transport messages from one neuron to another—plays a role in both depression and bipolar disorder.
Dopamine plays a role in both depression and bipolar disorder.
In fact, many of the medications used to treat these conditions target (either directly or indirectly) the regulation of dopamine. Moreover, dopamine pathways have been suggested to play an important role in how the individual responds to stress, thereby making the individual more susceptible to substance abuse in response to stress.12
Drugs, Dopamine, and the New Normal
A conceptual demonstration of the parallels between drug use and depressed brain functioning
Complications Associated with Comorbidities
There are a number of complications that arise, in particular, as the result of comorbid substance abuse and depression or bipolar disorder.
In fact, even if the dually diagnosed individual is receiving treatment for both the substance abuse and the psychiatric condition, they are more likely to experience symptoms that are more severe in nature.6
Moreover, these individuals are expected to have more detrimental impacts to their social functioning and more frequent rates of comorbid physical conditions, such as liver or kidney disease.
Treating individuals with comorbid substance abuse and depression or bipolar disorder requires special considerations. Some clinicians may falsely believe that with appropriate substance abuse treatment, the symptoms of the co-occurring depression will simultaneously abate the individual’s concurrent symptoms of depression. Unfortunately this is not always the case.
Therefore, it is generally recommended that clinicians treat both the individual’s substance use disorder and depressive disorder—whether it be a major depression or bipolar disorder—at the same time, if possible.
There may be times, however, when the symptoms of one disorder are so severe that the individual requires a higher level of care, which thereby prevents the simultaneous treatment of these conditions.
Common Treatments for Comorbidities
Given that there is a very high rate of comorbidity between substance abuse disorders and other psychiatric conditions, the ideal method of treatment involves a more comprehensive approach.
Indeed, the most appropriate treatment approach requires that the clinician arrive at the most accurate diagnosis. In order to do this, clinicians may rely on a variety of assessment tools, so that they can avoid the possibility of a missed dual diagnosis.
It is difficult to make an accurate dual diagnosis since many drug-related symptoms are similar to comorbid psychiatric conditions.
It is often difficult for clinicians to ensure that they’ve made an accurate dual diagnosis, because many drug-related symptoms are so similar to the symptoms of potential comorbid psychiatric conditions. For instance, many symptoms of withdrawal can resemble the more common symptoms of depression.
Ideally, individuals who have initiated treatment for substance abuse are first observed for a specified period of time where they have been free from using. This allows the clinician to assess between symptoms of drug use or withdrawal and symptoms of a possible comorbid psychiatric disorder.
There are a number of medications available to treat substance addictions—in particular alcohol, nicotine, and opioid addictions—as well as symptoms of depression and bipolar disorder.
However, these medications have been poorly studied in populations exhibiting comorbid conditions.13
Lithium is one medication that has received ample support for its effects in mood stabilization for individuals suffering from symptoms of bipolar disorder; however, there is very little evidence for effects in terms of treating substance abuse.
One study to date has evaluated lithium’s effects in terms of treating symptoms of mood disorders and co-occurring alcohol and cannabis use. It was found that the medication both improved the individual’s psychiatric symptoms and also reduced the amount of positive drug screen results for cannabis use.
A second study, examining the role of lithium in treating symptoms of bipolar disorder and concurrent cocaine use, however, did not produce such favorable results. More specifically, though the individuals included in this study experienced an improvement in terms of their mood, they failed to report statistically significant improvements in terms of their symptoms of drug abuse.
The anticonvulsants are another class of medications that are prescribed for their mood stabilizing effects and have received some support for their beneficial effects in treating concurrent symptoms of substance abuse.
Specifically, one study supported the use of divalproex sodium (Depakote), a specific type of anticonvulsant medication, for reducing alcohol use.
Moreover, several studies have provided support for the role of divalproex sodium, carbamazepine (Tegretol), and lamotrigine (Lamictal) in reducing cocaine cravings, as well as improving mood symptoms.
No studies to date have evaluated topiramate (Topamax) in the treatment of dually diagnosed individuals.
Findings for the use of atypical antipsychotics in treating mood symptoms and substance abuse have remained mixed.
There is some support for the role of quetiapine (Seroquel), risperidone (Risperdal), and aripiprazole (Abilify) in decreasing the use of alcohol and cocaine dependence; however, studies examining quetiapine have also revealed that individuals who received antipsychotics did not significantly differ in terms of their symptoms from that of the placebo group.
As such, more work is necessary to examine the potential benefits of using this medication for individuals with comorbid substance abuse and depression or bipolar disorder.
Either used alone or in conjunction with medication, behavioral therapies can be one of the most effective methods for ensuring a positive outcome for individuals suffering from substance abuse and comorbid depression or bipolar disorder.
Catching and treating substance abuse problems early can reduce the risk of long-term negative impacts.
In many instances, behavioral therapy is the preferred method of treatment, given that the individual may feel uncomfortable taking another medication given their history of problems with substance abuse.
Dialectical Behavior Therapy
The goal of dialectical behavior therapy is to reduce the individual’s engagement in behaviors that are self-harming. For instance, this approach might focus on drug abuse and suicidal thoughts or urges that may accompany depression.
Integrated Group Therapy
Integrated group therapy is designed specifically for individuals with bipolar disorder and substance abuse problems. This method uses a group setting to target the symptoms of both bipolar disorder and substance abuse problems simultaneously.
Cognitive-Behavior Therapy (CBT)
The goal of
is to change an individual’s maladaptive beliefs and unhelpful behaviors. This type of therapy, in particular, has received empirical support for its role in treating substance abuse, both among adult and pediatric populations.
Treatments Specifically for Substance Abuse
Substance abuse is one of the most commonly reported reasons for emergency room visits, as well as one of the leading preventable causes of death, making a top major health concern.
Long-term substance abuse can lead to irreversible damage to the major organs of the body, including the liver, kidneys, and even the heart.
for substance abuse can be a difficult matter. In many cases a number of family members have become very intimately involved in the individual’s problem, owing to enabling behaviors.
The best way to ensure successful outcomes from treatment is first to avoid using substances altogether. Secondly, it’s important to recognize symptoms of substance abuse early and seek treatment at the first sign of a substance abuse problem.
Treatment for substance abuse problems will generally involve a number of different approaches. An individual’s particular treatment plan may include one-on-one psychotherapy sessions. Or you may regularly meet with a trained addictions counselor.
In addition, the individual may be encouraged to participate in family counseling services, support groups, or even holistic therapy.
Individuals may then receive relapse prevention education and treatment, in which relapse prevention strategies—including various coping skills to manage feelings of distress without using, or methods to fight the cravings to use—are reviewed with the individual.
Additionally, relapse prevention training includes reviewing skills in managing situations that tend to trigger substance use for that individual, so that the individual may be able to practice avoiding these types of situations.
Barriers to Comprehensive Treatment
While findings from research studies clearly document the necessity of a comprehensive treatment plan for effectively treating individuals with substance abuse problems and comorbid depression or bipolar disorder, there are a number of barriers preventing that from being possible in all areas.
One reason for this is that there are separate systems in existence to address substance abuse and psychiatric illnesses.
For the most part, primary care physicians are more likely to be sought out by individuals for the treatment of their psychiatric symptoms; substance abuse difficulties are generally addressed by other health care professionals, but not primary care physicians.
Moreover, in many cases, neither primary care physicians nor other health care providers are able to offer a sufficiently broad range of expertise needed to address the full range of issues presented by the patient.
There may also be a negative bias against the use of medications among many substance abuse treatment programs. Additionally, some of these programs do not hire well-qualified medical professionals to provide services in terms of prescribing, dispensing, or medication management.
Thus, these facilities are not equipped to provide adequate treatment to individuals suffering from depression or bipolar disorder.
Treatment for Imprisoned Individuals
A final barrier to receiving adequate comprehensive treatment for substance abuse disorders and comorbid depression or bipolar disorder is that many of those needing treatment are in the criminal justice system.
It has been estimated that about 45% of offenders who are in state and local prisons and jails have a psychiatric condition that is comorbid with substance abuse or addiction.
However, adequate treatment services for both drug use disorders and other mental illnesses are greatly lacking within these settings.
While treatment provision may be burdensome for the criminal justice system, it offers an opportunity to positively affect the public’s health and safety. Treatment of comorbid disorders can reduce not only associated medical complications, but also negative social outcomes by mitigating against a return to criminal behavior and re-incarceration.
The Rise of Dual Diagnosis Treatment
When considering effective treatment strategies, it is clear that the co-existence of both substance abuse and mental health issues presents a more challenging clinical picture than one of substance abuse in isolation.
As mentioned, many facilities have been ill equipped for treating this population of patients struggling with distinct, simultaneous substance abuse and mental health issues.
Fortunately though, an increasing number of alcohol and drug treatment programs are being designed or modified to address the common phenomenon of dual diagnosis. This combined with the care and attention of psychiatric clinical staff, results in specialized treatment designs that best address the intricacies of both substance abuse and co-occurring mental health conditions such as depression and bipolar disorder.
Ideally, this increasing trend of available recovery programs that offer appropriate and effective rehabilitation services will continue to progress, as the need for specialized addiction treatment continues to grow.
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