Substance Use Disorders: Frequency and Treatment for People with Serious Mental Illness

Throughout its history, America has attempted to punish substance users as a means to encourage their abstinence. These attempts have included imprisonment, fines, and forced rehabilitation programs, often sentenced at a higher rate to people of color (Volkow, 2023). Punishments like these often fail to address the underlying issues that initiated or perpetuated substance use: severe mental illness (SMI).

Woman sitting on the floor living with substance use disorder

It is important to note that while substance use does not always lead to mental health disorders, nor do mental health disorders always lead to substance use disorders, the two are highly correlated and may develop in response to the other. This could look like an individual who is struggling with their mental health turning to substances as a coping mechanism or an individual who has been using substances struggling with their mental health as a byproduct of their substance use. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 25% of individuals diagnosed with a SMI also meet the criteria for a substance use disorder (2021).


The prevalence of substance use disorders as they relate to SMI seems to be increasing, with over 20 million people in the United States having been diagnosed with a substance use disorder in the past year (HHS, 2021). Data collected during the COVID-19 pandemic indicated that the primary catalyst for many young people’s mental health and substance use struggles was loneliness and lack of connection. In a survey of over 1,000 participants, “49% reported a great degree of loneliness, 80% reported significant depressive symptoms, and 61% reported moderate (45%) to severe (17%) anxiety. Participants disclosed harmful or dependent levels of drinking (30%), with 44% reporting binge drinking at least monthly. And while only 22% of the sample reported using drugs, 38% of users reported severe drug use” (Horigan et al., 2021, p.6). While neither COVID-19 nor loneliness can be identified as the sole factor for SMI or substance use disorders, it begs a strong enough correlation to be considered when devising a treatment intervention.

Common Comorbidities and Risk Factors

The most common comorbid diagnoses for individuals with a substance use disorder include generalized anxiety disorder, panic disorder, post-traumatic stress disorder, depression, bipolar disorder, attention-deficit hyperactivity disorder, borderline personality disorder, antisocial personality disorder, and schizophrenia (SAMHSA, 2021). The development of these disorders in duality with substance use can be compounded by the individual’s age. If a young person in their adolescent years begins experimenting with substances before their brain is fully developed, they are at higher risk for substance use and severe mental illness (Kelly & Daley, 2013).

A significant risk factor for the development of dual diagnoses is early traumatic experiences. Early exposure to trauma may result in an increased production of norepinephrine and cortisol, i.e., Stress responses (Bremner, 2022). With an increased state of stress, the individual may develop chronic anxiety, depression, and mood disorders (Bremner, 2022). In addition, the individual may turn to substances as a coping mechanism; using substances as a coping mechanism while the brain is still developing increases the risk of substance use disorders later in life (Kelly & Daley, 2013).


Despite the growing number of individuals diagnosed with a substance use disorder, only about 10 percent receive substance use treatment (HHS, 2021). There are several reasons for this low participation, including a lack of social support/stigma, fear of treatment, concerns regarding privacy, inability to meet the time demands, limited treatment availability, barriers to admission, and belief in the absence of a problem (Rapp et al., 2006). With the disparity of treatment for people of color, there is also concern that self-reporting substance use will result in criminal prosecution (Valkow, 2023). When an individual has an SMI in addition to their substance use, it is even less likely that they will seek and/or complete treatment.

Fortunately, for those who are ready to accept treatment, there are multiple options available for both substance use and SMI. Supportive treatment options include individually tailored therapy (cognitive behavioral therapy, contingency management, motivational interviewing, trauma informed therapy, etc.) with a combination of prescription medications to reduce the effects of withdrawal, along with peer support programs such as group therapy. There are different levels of care depending on the severity of symptoms, ranging from in-patient detox programs, intensive outpatient programs, sober living facilities, community-based meetings, and individual therapeutic support. Preferences for each of these options will depend on the person and their circumstances; for instance, while someone may benefit from an in-patient detox program that collaborates with mental health professionals, their personal life may only allow them the flexibility to attend an intensive outpatient program. Regardless of the program chosen, it is important to note that shame and blame are never, ever conducive to recovery or to positive mental health. Individuals making the decision to seek treatment should be given support and resources to empower them throughout this daunting process. Compassion and empathy are critical.


There are significant risks associated with substance use, including lung and heart disease, stroke, and cancer (NIDA, 2022). There is also an increased risk of infections such as HIV, hepatitis C, endocarditis, and cellulitis (NIDA, 2022). As mentioned before, substance use can precede a SMI or exacerbate the severity of an otherwise manageable disorder; when substance use is compounded with SMI, the outcome can be deadly. In 2019, over 70,000 people succumbed to fatal overdoses and 47,500 lives were lost to suicide (HHS, 2022; Stone et al., 2021). The non-fatal effects are also deleterious and may include physical long-term conditions with poorer outcomes, lower quality of life, and overall shorter life span (Carswell et al., 2022). In its very name, mental illness is considered severe when the symptoms are an impediment to the individual’s abilities to function; however, even less severe mental illness can cause impairment, especially when amplified with substance use disorders.


Given the history of America’s approach towards individuals with substance use disorders, SMI, or both, there is understandable hesitance to seek treatment. With this in mind, the impact of substance use disorders and SMI on an individual’s quality of life cannot go untreated. With a uniquely tailored approach based on the distinctive needs of the patient, interventions can seek to address the impact of substance use on a mental illness, the impact of mental illness as a catalyst for substance use, or the correlated development of both diagnoses. It is critical to note that approaching this topic with disdain towards the patient will not result in recovery. Compassion and empathy are critical attributes when working with this population and great care should be taken to treat the whole person rather than just their diagnosis.

Jeridith Lord, LCPC, BCBA, is Adjunct Professor and Clinical Counselor at Endicott College. For further information on this topic, Jeridith Lord can be reached at


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Stone, D.M., Jones, C.M., Mack, K.A., (2021). Changes in Suicide Rates: United States, 2018–2019. MMWR Morb Mortal Wkly Rep 2021;70:261–268

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One Response

  1. Janis Furnari says:

    That was an amazing article! Very insightful, and true!

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