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Depression, Anxiety and Substance Use: Why Treating One Is Not Enough

A person who drinks to sleep, or uses to get through a crowded room, is usually managing something. Treating the drinking without the anxiety, or the depression without the drinking, leaves half of the problem standing and tends to bring the other half back.

A loop and not two separate problems

Clinicians call the combination dual diagnosis or co-occurring disorders. The two conditions feed each other. A symptom such as dread, low mood or a flood of memories prompts use, the substance eases it for a short while, and the aftermath makes the symptom worse. Withdrawal from many substances then imitates anxiety, depression or agitation, which the person reads as proof that they cannot cope without the substance.

Treatment that respects the loop works on both ends at once. Northwoods Haven describes this approach on its page about dual diagnosis treatment at Northwoods Haven, where care begins with an evaluation of both behavioral health and substance use. The center offers flexible outpatient and intensive outpatient programs so that clients can keep working, studying or caring for family, and it notes that continuing prescribed psychiatric medication is often an important part of success.

The center is also candid about its scope. It states that it does not prescribe medication or offer therapy for mental health concerns without a substance use concern, and it coordinates with the prescribers clients already see.

What the research shows

The NIDA research report on common comorbidities puts numbers on the overlap. Multiple national surveys, it says, have found that about half of those who experience a mental illness during their lives will also experience a substance use disorder, and the reverse is true as well. Around one in four people with serious mental illness also have a substance use disorder, and 43 percent of people in treatment for nonmedical use of prescription painkillers have a diagnosis or symptoms of mental health disorders, particularly depression and anxiety.

The report describes three pathways. Common risk factors such as genetics and early stress or trauma can contribute to both conditions, mental illness may contribute to substance use, and substance use may contribute to the development of mental illness. It adds that the overlap does not prove that one caused the other, even when one appeared first.

On treatment, the report states that integrated treatment has been found consistently superior to separate treatment of each diagnosis. People with both kinds of problems often show poorer treatment adherence and higher dropout, which is one reason a coordinated plan matters. The report also states that only about 18 percent of substance use treatment programs and 9 percent of mental health treatment organizations have the capacity to serve dually diagnosed patients, which explains why many people receive care for only one of their conditions.

Why doing one thing at a time fails

For years the standard advice was to get sober first and deal with the mood later, or to stabilize the mood before addressing drinking. Each order has the same flaw. A person who stops using without help for the underlying symptom often faces the return of the symptom at full strength, and a person who starts an antidepressant while drinking heavily may find the alcohol undoing the benefit.

The NIDA report notes another complication. Drug-related symptoms such as withdrawal resemble the symptoms of mental disorders, so assessment sometimes needs a period of observation after abstinence to tell them apart. That makes a thorough, repeated assessment more reliable than a single early label.

There is a practical cost as well. A person treated for one condition at one clinic and the other elsewhere carries two schedules, two sets of records and two sets of advice that may conflict, and each extra obstacle raises the chance that appointments are missed. Coordinated care reduces that load by putting the plan in one place.

What integrated treatment looks like

Integrated care starts with an assessment that screens for both substance use and mental health conditions. At Northwoods Haven, that assessment sets the substance use diagnosis and identifies the right level of care, and the center describes mental health psychoeducation as part of every group.

Day to day, clients attend group therapy several days a week and meet individually with a licensed counselor. The therapies named in the NIDA report as useful for comorbid conditions include cognitive behavioral therapy and dialectical behavior therapy, and the center lists CBT, DBT and acceptance and commitment therapy among its methods. Skills such as challenging an anxious thought or tolerating distress apply to the urge to use as much as to the mood.

A relapse prevention plan in an integrated program names symptoms as well as substances. It lists the situations, thoughts and physical sensations that raise risk for both conditions, and what to do instead of using.

When a different level of care comes first

Outpatient dual diagnosis care suits people who are stable enough to live at home and attend several sessions a week. It does not suit everyone. Acute psychiatric crisis needs a higher level of care, and people whose needs are primarily mental health without a substance use concern are better served by a program built for that.

Anyone in crisis or thinking about suicide can call or text 988 or call 911, and both are available at any hour. Seeking help for substance use and mental health together is a sign of good judgment, and the best programs say honestly when another place would serve a person better.

Families and employers can help by treating the two conditions as one health matter. Asking how the person is sleeping and coping, as well as whether they are using, shows that the whole picture counts, and it makes it easier for the person to describe symptoms honestly.