Natalie struggled with a methamphetamine use disorder for more than nine years.
She was one of the fortunate few to receive treatment to address her addiction, yet that help felt incomplete. Like many people trying to heal from substance use disorders, she eventually began taking meth again.
Eventually, Natalie was diagnosed with attention-deficit/hyperactivity disorder (ADHD), one of the most common mental disorders in youth. She started ADHD treatment in addition to treatment for her meth addiction, and it made her long-term recovery a reality.
“The addition of Adderall really changed my life,” she said. “Looking back, it makes sense that I was self-medicating ADHD that was undiagnosed. I found it very discouraging that a lot of people got their lives in order while I struggled to function with everyday tasks. In part, that is what led to my relapse.”
Recovering from drug addiction is notoriously difficult. Setbacks are common. Too often, a critical element is overlooked: co-occurring mental health conditions. Treating mental illnesses like depression, anxiety, post-traumatic stress disorder, ADHD, and others with medications or other therapies is crucial to address the addiction and overdose crisis that now claims over 100,000 lives annually.
Substance use disorders often accompany other mental illnesses. Half of people with a substance use disorder have another mental illness at some point, and vice-versa.
For many people, drug and alcohol problems begin as self-medication: using substances to cope with temporary stress or to manage symptoms of chronic mental health problems they may not even know they have. Substance use, particularly alcohol, can be a socially accepted way of dealing with negative emotions.
Surveys show alcohol use rose during the COVID-19 pandemic, including increased use by stressed parents. Research has also tied problem alcohol use in college students to self-treatment of social anxiety. Similarly, people with untreated depression might discover that opioids or stimulants temporarily boost their mood and use them for that purpose.
Fragmented and hard-to-access mental health care means that these conditions and addiction often go untreated. In some communities, it is easier to get illicit drugs than adequate medical mental health care, making co-occurring addiction and other mental illness more likely.
But using substances to treat mental illness can begin a difficult cycle. Substance use to manage mental illness can lead to addiction and can in turn worsen the original mental illness. Regularly taking drugs or alcohol causes the brain to adapt to that substance—known as dependence. Effectively, the brain dials down its own neurotransmitter systems upon which the drugs act. A person trying to relieve anxiety through substance use will feel worse anxiety most of the time, because their brain now depends on the drug for relief.
Racism and other forms of discrimination, isolation, childhood trauma, poverty and lack of access to education and health care can all play a role in increasing risk of developing mental illness and substance use disorders. The stigma that attaches to both substance use disorders and mental illness exacerbates these factors—making the person with mental illness and addiction even more isolated and vulnerable, and less likely to seek treatment.
The entanglement of mental illness and substance use disorders requires urgent action. Efforts to reverse the addiction and overdose crisis need to be multifaceted, taking mental illness into account. We have powerful, proven treatment tools for addiction, especially for opioid use disorder. Harm reduction strategies, when implemented, can staunch overdose deaths. But expanded screening and care for mental illnesses including depression, anxiety, PTSD, and others must be a component to successfully address the current addiction and overdose crises.
Prevention is possible if investments are made. Opportunities to reduce risk can begin early in life, since substance use disorders and other mental illnesses share common risk and protective factors. Interventions starting during the prenatal period and followed through adolescence and young adulthood can help avert a range of adverse outcomes later in life. Moreover, numerous studies of prevention’s return on investment show that communities could not only save lives but also money by investing in prevention programs.
Screening is equally important. Earlier this year, the US Preventive Services Task Force recommended that primary care physicians screen all adult and teenager patients for depression, given its low cost and potential for benefit. Screening for mental health conditions needs to become part of standard practice along with screening for substance use and substance use disorders to personalize interventions to treat patients’ unique needs and increase the likelihood of recovery.
Dr. Nora Volkow is director of the National Institute on Drug Abuse, part of the National Institutes of Health. NIDA is the world’s largest funder of research on the health aspects of drug use and addiction.