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Co-Occurring Disorders

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT Meet The Team >

What are Co-Occurring Disorders?

When a person – child, adolescent, or adult – is diagnosed with a mental health disorder and an alcohol/substance use disorder (AUD/SUD) at the same time, they receive a dual diagnosis. A person with a dual diagnosis has what mental health professionals call co-occurring disorders. Mental health disorders that commonly co-occur with alcohol and substance use disorders in adolescents include:

Experts estimate that 60-75 percent of adolescents with an alcohol or substance use disorder also have a co-occurring mental health disorder. Co-occurring disorders present a challenge for the adolescents who have them and the mental health professionals who treat them for several reasons.

First, the symptoms of alcohol/substance use disorders are often difficult to distinguish from the symptoms of mental health disorders, and vice-versa. Second, people with co-occurring disorders often initiate the use of alcohol and/or drugs to alleviate the symptoms of their mental health disorder: this is what’s known as self-medication. Finally, alcohol and drug use can make the symptoms of a mental health disorder worse, which can lead to more alcohol or drug use, which, in turn, can further exacerbate the symptoms of the mental health disorder.

Mutually Reinforcing Cycles

This creates a pattern of symptom/self-medication/symptom/self-medication that’s hard to break – and the entire situation is problematic because arriving at an accurate diagnosis of co-occurring disorders is complicated by the fact that the symptoms of a co-occurring disorder can often mask the symptoms of a mental health disorder, and vice-versa. That may seem like the same thing we said above, but it’s not. The symptoms of alcohol/substance use disorders and mental health disorders are not only similar, which we did say above, but each may also render the other undetectable, which can cause clinicians to miss one while focusing on the other.

This phenomenon begs a question that clinicians and people with co-occurring disorders often have difficulty answering: which came first – the mental health disorder or the alcohol/substance use disorder?

The answer to that question is not always clear. What is clear, however, is the fact that an adolescent with a co-occurring AUD/SUD and mental health disorder can overcome both diagnoses with appropriate treatment and an accurate diagnosis.

We’ll discuss treatment and diagnosis in a moment. We’ll now offer the latest statistics on co-occurring AUD/SUD and mental health disorders published by the National Institutes of Health (NIH).

The Prevalence of Co-Occurring Disorders Among Adolescents

The 2019 National Survey on Drug Use and Health (2019 NSDUH) offers detailed data on the rates of co-occurring alcohol and/or substance use disorder for people age 12-17. Here are the prevalence statistics among adolescents for the year 2019:

Substance Use Disorder (SUD) and Major Depressive Episode (MDE)

  • 18.7% of adolescents had either substance use disorder (SUD) or major depressive episode (MDE)
    • That’s over 4.5 million adolescents
  • 14.1% of adolescents had MDE but not SUD
    • That’s 3.4 million adolescents
  • 2.7% had SUD but not MDE
    • That’s 682,000 adolescents
  • 1.7% of adolescents had SUD and MDE
    • That’s 397,000 adolescents

Now let’s looks at the number of adolescents with SUD and MDE who received treatment.

Treatment for Substance Use Disorder (SUD) and Major Depressive Episode (MDE)

  • 66.3% of adolescents with SUD and MDE received treatment for one or the other, but not both
    • That’s just over 250,000 adolescents
  • 2.4% received treatment for SUD
    • That’s about 9,500 adolescents
  • 62.5% received treatment for MDE but not SUD
    • That’s about 248,000 adolescents
  • 1.3% received treatment for both SUD and MDE
    • That’s just over 5,000 adolescents
  • 33.7% did not receive treatment for SUD or MDE
    • That’s close to 134,000 adolescents

Those statistics situate the phenomenon of co-occurring in the big picture. However, reading percentages like “1.7% of adolescents had SUD and MDE” can be misleading and may indicate to some parents that the problem is not widespread. We’d like to counter that possible impression with one key fact and one more set of statistics.

They key fact is that in 2019, close to half a million adolescents had co-occurring SUD and MDE (397,000). That’s a large number of teenagers who need support for not one, but two disorders that can negatively impact social, emotional, and physical health.

The set of statistics we need to address is the prevalence of teens with major depressive disorder who used drugs. Here are the prevalence numbers when we look analyze them in that way:

  • 31.9% of adolescents with MDE reported illicit drug use
    • 4% of adolescents without MDE reported illicit drug use
  • 24.6% of adolescents with MDE reported marijuana use
    • 1% of adolescents without MDE reported marijuana use
  • 8.9% of adolescents with MDE reported binge drinking
    • 2% of adolescents without MDE reported binge drinking
  • 4.2% of adolescents with MDE reported opioid use
    • 8% of adolescents without MDE reported opioid use

Those statistics show clearly that adolescents with MDE use illicit drugs such as marijuana and opioids at over twice the rate as adolescents without MDE. In addition, the numbers show that adolescents with MDE also engage in binge drinking – i.e. consuming more than 4-5 alcoholic beverages on one occasion – at over twice the rate as adolescents without MDE.

While some of these adolescents may not develop SUD or AUD in addition to MDE, they’re at increased risk. These statistics also highlight the treatment gap: of the nearly 400,000 adolescents diagnosed with co-occurring SUD and MDE, about two-thirds of them did not receive treatment for both disorders. That means over 250,000 adolescents in the U.S. in 2019 did not get the treatment they needed to manage their co-occurring disorders.

Despite this fact, it’s important for parents of teens diagnosed with co-occurring mental health and alcohol/substance use disorder to understand that treatment works. However, evidence shows that both must be treated: the alcohol/substance use disorder and the mental health disorder.

Treating one without the other results in less favorable outcomes for both, but when an individual with a dual diagnosis receives professional support and treatment for both disorders, favorable outcomes for both disorders improve.

Integrated Treatment for Co-Occurring Disorders

The challenge most adolescents face when they have a co-occurring addiction and mental health disorder is getting the correct diagnosis. Accurately diagnosing the symptoms related to both addiction and co-occurring mental health disorders typically takes time. Here’s why:

  1. When an individual has SUD or AUD, it may take a period of abstinence from alcohol or drugs for the symptoms of the mental health disorder to appear.
  2. When the symptoms of the mental health disorder appear, clinicians, the adolescent client, and the family need to revise the treatment plan.
  3. Clinicians at the treatment center – or treatment provider – need the training, experience, and skill to treat both disorders simultaneously.

Parents of adolescents who receive a dual diagnosis need to understand that treatment works. Evidence shows that the best treatment for co-occurring disorders follows an integrated treatment model that addresses the whole person, as opposed to treating the symptoms of one disorder or the other separately.

What Parents Can Do

If you think your teen has both a mental health issue and an addiction problem, it’s essential to have them evaluated by a psychologist, psychiatrist, or other mental health professional – preferably one who specializes in or has experience in treating addiction and mental health disorders in the adolescent population. You should arrange a full assessment, which is known as a biopsychosocial profile: this will give a mental health professional a complete picture of all the factors that may affect your teen’s challenges.

Once your child receives a full evaluation, you will most likely receive a recommendation for treatment. In some cases, outpatient therapy once or twice a week may be sufficient. However, in the case of dual diagnosis, it’s possible outpatient therapy will not provide the level of support necessary to help your teen heal and move forward.

The assessing therapist may recommend a more intensive level of treatment may be necessary for your child.  More intensive levels of treatment may include:

Here’s a description of these levels of care:

Intensive Outpatient Programs (IOP)

This level of treatment is a step above weekly therapy or weekly drug and alcohol counseling. The amount and timing of treatment depends on the program. Teens typically participate in treatment 3 times a week for 3 hours per session, live at home, and attend school during an intensive outpatient program.

Partial Hospitalization Programs (PHP)

This level of treatment is a is a step up from intensive outpatient treatment. As with IOP treatment, the amount and timing of treatment depends on the specific program. Adolescents go to treatment daily, usually for 4 hours per day, and attend school at least part time. They live at home or, if additional support is needed, in a sober living facility.

Residential Treatment Centers (RTC)

Residential alcohol treatment, also often referred to as inpatient alcohol treatment, involves having your son or daughter live ‘round the clock at a non-hospital treatment facility. This intensive level of treatment may last anywhere from 28 to 120 days, depending on your child’s treatment needs and progress. In addition to receiving full-time alcohol treatment, one of the greatest advantages of residential alcohol rehab is being in an environment that is free from alcohol and drugs. This enables your child to focus on recovery without having to deal with the temptation to drink.

IOP, PHP, and RTC programs can be beneficial for adolescents who receive a dual diagnosis for co-occurring disorders.

Inpatient Psychiatric Hospitalization

Hospitalization may be necessary if your teen is a danger to themself or others (e.g. suicidal or psychotic), or in need of 24/7 medical monitoring due to excessive alcohol use. Medical monitoring may be recommended in association heavy binge drinking, which is an increasing and dangerous trend amongst adolescents and young adults. Abrupt cessation of alcohol use (going cold turkey) can cause dangerous and potentially life-threatening withdrawal symptoms, which is why medical monitoring may be necessary.

These levels of care – excluding psychiatric hospitalization, during which immediate safety and psychiatric stability are the primary goals – typically involve some combination of the following therapeutic approaches:

  • Individual therapy and counseling
  • Group therapy and counseling
  • Family therapy and counseling
  • Experiential activities such as exercise and mindfulness
  • Community support (Alcoholics Anonymous or SMART Recovery)

The exact combination of treatment depends on the treatment center and the level of care your teen needs.

Supporting and Encouraging Your Child

If your adolescent receives a dual diagnosis and needs intensive treatment, the most important thing you can do is offer genuine and consistent support and encouragement. The road to recovery can be difficult, and may strain your relationship with your teen. Here are some things you can do to help your teen and minimize the challenges of recovery:

  • Keep the lines of communication open
  • Educate yourself about their specific diagnoses
  • Learn about the mental health disorder and the substance use disorder
  • Take an active role in their treatment and recovery
  • Be available and willing to really listen
  • Be patient: if you keep showing up – and you’re genuine, compassionate, and caring – then they’ll eventually open up
  • Create a home environment that supports recovery. If you keep alcohol or drugs in the home, consider removing them from your home altogether.
  • If your teen has an alcohol use disorder, consider the impact alcohol use by family members may have on your teen
  • Be a good role model for your teen: practice what you preach
  • If your teen relapses, be patient and understanding. Avoid judging, ridiculing, or over-reacting
  • Understand that a co-occurring disorder can be very difficult to manage. If your teen struggles, it doesn’t mean there’s something wrong with them. It means they’re having a challenge overcoming not one, but two chronic, relapsing medical conditions
  • Be willing to address issues of your own that may create conflict or stress in your relationship with your teen or negatively impact your overall family dynamic

The foundation of supporting your child during treatment is unconditional love. That’s followed by compassion and empathy, which are followed by open, honest, and direct communication. If your teen receives a dual diagnosis, that means they need you. They need your guidance, your wisdom, and your support. But most of all, what they need is your unconditional love: they need to know you’re on their side and will support them through the highs and lows of the recovery journey. A teenager who knows their parents are on their side and have their back are more likely to make a full recovery than a teenager who lacks that fundamental level of family support.

Parents: Self-Care Matters

You have to take care of yourself during the treatment and recovery process, too. The journey will be challenging. That’s almost certain. Supporting your child is your highest priority, of course, but to do the best for them, you have to ensure that you’re physically, emotionally, and psychologically capable of offering that support. Therefore, do not neglect your own self-care along the way. You’ll be more available and effective if you manage your mental well-being while your teenager is in treatment.

Self-care will help you, and when you take care of yourself, you also model appropriate self-care for your teen. And all parents know that teens are more likely to do what you do than do what you say.

Here are some steps you can take to model appropriate self-care when your teen is in treatment:

  • Surround yourself with support by joining a support group (local or online), seeing a therapist, and reaching out to family and friends., You do not have to go through this alone.
  • Make sure you get to eat three healthy meals a day and get plenty of sleep and rest
  • Find healthy ways to manage your stress, such as yoga, meditation, and exercise
  • Make time for yourself so you can relax, recharge, and restore life balance.

The road to recovery is rarely linear. There will be successes and setbacks. There will be tough days and wonderful days – but whatever you do, don’t lose hope. Teens do, in fact, recover from alcohol and substance use disorders. They also learn to manage the symptoms of co-occurring mental health disorders.

With your love, support, and commitment, your family can restore balance. Your teen can learn to live a life on their own terms, free from alcohol and drugs, and not dominated by a mental health disorder.

The evidence confirms all of this: your teen can recover too!

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