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Common Comorbidities with Substance Use Disorders

What are the treatments for comorbid substance use disorder and mental health conditions?

Integrated treatment for comorbid drug use disorder and mental illness has been found to be consistently superior compared with separate treatment of each diagnosis.3,81–83 Integrated treatment of co-occurring disorders often involves using cognitive behavioral therapy strategies to boost interpersonal and coping skills and using approaches that support motivation and functional recovery.81

Patients with comorbid disorders demonstrate poorer treatment adherence84 and higher rates of treatment dropout3,82 than those without mental illness, which negatively affects outcomes. Nevertheless, steady progress is being made through research on new and existing treatment options for comorbidity.74,81–83,85 In addition, research on implementation of appropriate screening and treatment within a variety of settings, including criminal justice systems, can increase access to appropriate treatment for comorbid disorders.86 

Treatment of comorbidity often involves collaboration between clinical providers and organizations that provide supportive services to address issues such as homelessness, physical health, vocational skills, and legal problems.87 Communication is critical for supporting this integration of services. Strategies to facilitate effective communication may include co-location, shared treatment plans and records, and case review meetings.87 Support and incentives for collaboration may be needed, as well as education for staff on co-occurring substance use and mental health disorders.

Treatment for Youth

As mentioned previously, the onset of mental illness and substance use disorders often occurs during adolescence, and people who develop problems earlier typically have a greater risk for severe problems as adults. Given the high prevalence of comorbid mental disorders and their adverse impact on SUD treatment outcomes, SUD programs for adolescents should screen for comorbid mental disorders and provide treatment as appropriate.21,23,88

Research indicates that some mental, emotional, and behavioral problems among youth can be prevented or significantly mitigated by evidence-based prevention interventions.89 These interventions can help reduce the impact of risk factors for substance use disorders and other mental illnesses, including parental unemployment, maternal depression, child abuse and neglect, poor parental supervision, deviant peers, deprivation, poor schools, trauma, limited health care, and unsafe and stressful environ­ments. Implementation of policies, programs, and practices that decrease risk factors and increase resilience can help reduce both substance use disorders and other mental illnesses, potentially saving billions of dollars in associated costs related to health care and incarceration.89

Other evidence-based interventions emphasize strengthening protective factors to enhance young people’s well-being and provide the tools to process emotions and avoid behaviors with negative consequences. Key protective factors include supportive family, school, and community environ­ments.

In addition to the treatment options discussed in this research report, the following treatments have been shown to be effective for children and adolescents:

  • Multisystemic Therapy (MST). MST targets key factors that are associated with serious antisocial behavior in children and adolescents with substance use disorders, such as attitudes, family, peer pressure, school and neighborhood culture.22,24
  • Brief Strategic Family Therapy (BSFT). BSFT targets family interactions that are thought to maintain or exacerbate adolescent substance use disorder and other co-occurring problem behaviors such as conduct problems, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behaviors.90
  • Multidimensional Family Therapy (MDFT). MDFT, a comprehensive intervention for adolescents, focuses on multiple and interacting risk factors for substance use disorders and related comorbid conditions. This therapy addresses adolescents’ interpersonal and relationship issues, parental behaviors, and the family environment. Families receive assistance with navigating school and social service systems, as well as the juvenile justice system if needed. Treatment includes individual and family sessions.91

Medications

Effective medications exist for treating opioid, alcohol, and nicotine use disorders and for alleviating the symptoms of many other disorders.62,74,83 While most have not been well studied in comorbid populations, some medications may help treat multiple problems. For example, bupropion is approved for treating depression and nicotine dependence. For more information, see the table below.

View Table: Pharmacotherapies Used to Treat Alcohol, Nicotine, and Opioid Use Disorders

Behavioral Therapies

Behavioral treatment (alone or in combination with medications) is a cornerstone to successful long-term outcomes for many individuals with drug use disorders or other mental illnesses.3,81–83,85 Several strategies have shown promise for treating specific comorbid conditions.

  • Cognitive Behavioral Therapy (CBT)
    CBT is designed to modify harmful beliefs and maladaptive behaviors and shows strong efficacy for individuals with substance use disorders. CBT is the most effective psychotherapy for children and adolescents with anxiety and mood disorders.22,24,88
  • Dialectical Behavior Therapy (DBT)
    DBT is designed specifically to reduce self-harm behaviors including suicidal attempts, thoughts, or urges; cutting; and drug use. It is one of the few treatments effective for individuals who meet the criteria for borderline personality disorder.92
  • Assertive Community Treatment (ACT)
    ACT programs integrate behavioral treatments for severe mental illnesses such as schizophrenia and co-occurring substance use disorders. ACT is differentiated from other approaches to case management through factors such as a smaller caseload size, team management, outreach emphasis, a highly individualized approach, and an assertive approach to maintaining contact with patients.93
  • Therapeutic Communities (TCs)
    TCs are a common form of long-term residential treatment for substance use disorders. They focus on the “resocialization” of the individual, often using broad-based community programs as active components of treatment. TCs are appropriate for populations with a high prevalence of co-occurring disorders such as criminal justice-involved persons, individuals with vocational deficits, vulnerable or neglected youth, and homeless individuals.86 In addition, some evidence suggests that TCs may be helpful for adolescents who have received treatment for substance use and addiction.94
  • Contingency Management (CM) or Motivational Incentives (MI)
    CM/MI is used as an adjunct to treatment. Voucher or prize-based systems reward patients who practice healthy behaviors and reduce unhealthy behaviors, including smoking and drug use. Incentive-based treatments are effective for improving treatment compliance and reducing tobacco and other drug use, and can be integrated into behavioral health treatment programs for people with co-occurring disorders.95
  • Exposure Therapy
    Exposure therapy is a behavioral treatment for some anxiety disorders (phobias and PTSD) that involves repeated exposure to a feared situation, object, traumatic event, or memory. This exposure can be real, visualized, or simulated, and is always contained in a controlled therapeutic environment. The goal is to desensitize patients to the triggering stimuli and help them develop coping mechanisms, eventually reducing or even eliminating symptoms. Several studies suggest that exposure therapy may be helpful for individuals with comorbid PTSD and cocaine use disorder, although retention in treatment is a challenge.57
  • Integrated Group Therapy (IGT)
    IGT is a treatment developed specifically for patients with bipolar disorder and substance use disorder, designed to address both problems simultaneously.96 This therapy is largely based on CBT principles and is usually an adjunct to medication. The IGT approach emphasizes helping patients understand the relationship between the two disorders, as well as the link between thoughts and behaviors, and how they contribute to recovery and relapse.96
  • Seeking Safety (SS)
    Seeking Safety is a present-focused therapy aimed at treating trauma-related problems (including PTSD) and substance use disorder simultaneously. Patients learn behavioral skills for coping with trauma/post-traumatic stress disorder and substance use disorder.97
  • Mobile Medical Application
    In 2017, the Food and Drug Administration approved the first mobile medical application to help treat substance use disorders. The intention is for patients to use it with outpatient therapy to treat alcohol, cocaine, marijuana, and stimulant use disorders; it is not intended to treat opioid dependence. The device delivers CBT to patients to teach skills that aid in the treatment in substance use disorders and increase retention in outpatient therapy programs.98

This page was last updated February 2018

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NIDA. (2018, February 27). Common Comorbidities with Substance Use Disorders. Retrieved from https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders

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