The Correlation of Mental Health and Substance Use Disorders

According to the National Survey on Drug Use and Health, 9.5 million adults in the United States experienced both mental illness and a substance use disorder (SUD) in 2019. It’s a well-known correlation, complicating the treatment of the mental health disorder and the SUD.

“Many individuals who develop substance use disorders are also diagnosed with mental disorders, and vice versa,” explains an information page of the National Institute on Drug Abuse (NIDA). “Multiple national population surveys have found that about half of those who experience a mental illness during their lives will also experience a substance use disorder and vice versa.”

Mental health conditions and SUDs are frequently co-occurring because many people with addiction are primarily misusing addictive substances to self-medicate emotional pain caused by serious mental health disorders. 

According to NIDA, “Data show high rates of comorbid substance use disorders and anxiety disorders—which include generalized anxiety disorder, panic disorder, and post-traumatic stress disorder (PTSD). Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder, attention-deficit hyperactivity disorder (ADHD), psychotic illness, borderline personality disorder, and antisocial personality disorder. Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population.”  

Trauma in particular is an important predictor for substance misuse. According to PTSD United, 70 percent of adults in the US have experienced some type of traumatic event at least once in their lives, and 20 percent of those adults suffer from PTSD. Many traumatized people self-medicate with alcohol and drugs. “For many, if not most, people with addiction, trauma is perhaps the critical factor that causes the problem,” writes addiction expert Maia Szalavitz in her influential book Unbroken Brain.

The combination of bipolar disorder and substance misuse may be particularly challenging to diagnose and treat successfully. “Comorbid bipolar disorder and substance use disorder are frequently the rule rather than the exception,” wrote Suzanne Bujara on Psychiatry Advisor. “Bipolar disorder has among the highest rates of comorbidities, including anxiety disorders, obsessive compulsive disorder, impulse control disorders, eating disorders, cardiovascular and respiratory disorders, and sleep apnea. Not only are comorbid bipolar disorder and substance use disorder difficult to manage, but they also increase a patient’s likelihood for chronic infectious diseases, injury, and suicide.” 

Co-occuring mental health and substance use disorders should be addressed concurrently in a comprehensive treatment program addressing all needs of such patients. “Dual diagnosis” is a term used to describe the presence of addiction and other co-occurring mental health conditions. 

Colorado Recovery understands the importance of coordinated and integrative treatment care and provides substance use services to all clients who require them as part of a specialized dual diagnosis track. We recognize that many of our clients have employed non-prescribed substances to control the symptoms of their mental illness, and as a consequence may have exacerbated their health issues. 

The treatment process at Colorado Recovery starts with evidence-based assessment instruments that help a client understand the severity of their substance use disorder. Colorado Recovery uses the Substance Abuse Subtle Screening Inventory (SASSI-4) an empirically tested tool with a high-reliability rate. We also use the Addiction Severity Index (ASI-6) which was introduced in 1980 and it is probably the most widely used instrument to assess the severity of substance use disorders. Colorado Recovery also has the ability to administer screening tools to assist in identifying gambling and internet addiction disorders.

Colorado Recovery provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

Treehouse Planning Session at IOP Level

Colorado Recovery is now expanding services outside our signature continuum of care. We are admitting directly into our intensive outpatient program (IOP) clients who may be ready to begin their recovery at the IOP level of care, or for those in the process of stepping down from another program. Community integration and social engagement continue to be at the heart of the approach, setting the course for a life of engagement, purpose, and connection.

This non-institutional approach created by Colorado Recovery founder Richard Warner is key to outcomes associated with independence and self-respect. One of the offerings now available at the IOP level is our Treehouse Planning Session.

This group gives clients the opportunity to participate in their recovery plan and voice what they seek from the psychosocial program. We review any needs that they have toward connecting and contributing to the community or improving the space. It’s also a time for people to meaningfully get to know each other and develop friendships outside of a strictly therapeutic setting.

Dr. Warner considered schizophrenia and similar conditions bio-psycho-social disorders significantly affected by the environment surrounding the client on multiple levels. The Warner method harnesses the benefits of client empowerment to increase skills and work preparedness and assist them with social integration. 

The Treehouse planning group is an important element of that. On the one hand, it’s “a safe space to take a break and just hang out,” says Treehouse community organizer Elise Alvarez. “At the same time, it’s a great opportunity to build more comfortable relationships.” The Treehouse group highlights the value of social integration, “many people have found roommates and best friends here,” says Alvarez. “Treehouse gives a population that doesn’t have too much opportunity to socialize the chance to do just that.”

People are able to reach a deeper level of knowing one another while engaging in fun activities. “Hiking is always the most popular group,” reveals Alvarez. “Especially people who are not from Boulder appreciate the nature side Colorado Recovery has to offer.”

In Treehouse planning, people work out their budget, another aspect of empowerment. “It’s an important skill to come to a decision yourself and not just defer to the judgment of the coordinator. Often, I keep pushing it back to them, telling them ‘this is your space,’ so they get to make the call.”

It’s important to give clients some measure of control, to let them work out the budget and create the space the way they want it to be. “We typically start with me making announcements, and then open the floor to things they want to talk about,” explains Alvarez. “We’ve had discussions about terminology: should it be mental illness or biopsychosocial disease? Other times, we plan out dinners or days at the beach.”

For more information about direct admission to our intensive outpatient program or our other services, connect with a specialist who can answer your questions at (720) 218-4068.


The Impact of the Environment in Schizophrenia

Colorado Recovery founder Richard Warner considered schizophrenia a bio-psycho-social disorder significantly affected by the environment surrounding the person with the mental health condition on multiple levels.

In his book The Environment of Schizophrenia, Dr. Warner drew upon the “knowledge of the environmental factors that affect schizophrenia in order to suggest changes which could decrease the rate of occurrence of the illness, improve its course, and enhance the quality of life of sufferers and their relatives.”

Warner divided those environmental factors into three levels: individual, domestic, and community. 

The Individual Level

Among the individual factors, Dr. Warner listed the strong correlation between substance misuse and schizophrenia. “It seems to be true that people with schizophrenia use more drugs than others in the population,” he wrote in The Environment of Schizophrenia. Frequently, that behavior has a detrimental effect. Research has shown time and again that “people with serious mental illness who abuse substances have a worse course of illness.” However, Warner was adamant that substance misuse cannot cause schizophrenia although that is often how it seems to family members and other people. 

On the other hand, a mental health condition can be a driver of addiction. “Many in this population feel a need to find relief from chronic affective symptoms and medication side effects,” Warner wrote. Since the reasons for the substance misuse are complex, treatment approaches need to be individualized. 

Stress is another important factor on the individual level. Stress can trigger episodes of schizophrenia. “People with schizophrenia are more likely to report a stressful life event preceding an episode of illness than during a period of remission,” explained Warner. One of the hallmarks of schizophrenia is “a deficit in the regulation of brain activity so that the brain over-responds to environmental stimuli, reducing the person’s ability to regulate his or her response to new stresses.” 

The Domestic Level

Stress also plays a significant role on the domestic level. People with schizophrenia who live with relatives (by birth or marriage), who are “critical or over-involved” have a much higher relapse rate than those living with relatives who are less critical or intrusive. Outcomes can be improved if families are involved in a more supportive way. 

Studies have shown that “family psychoeducational interventions can lead to a change in the level of criticism and over-involvement among relatives of people with schizophrenia and so reduce the relapse rate.” With appropriate support, domestic stress can be mitigated for all parties involved. 

Dr. Warner included “alienating environments” at the domestic level. “Many people with mental illness face lives of aimlessness and boredom,” wrote Warner. While the traditional state hospital incarceration frequently led to an “instituional neurosis,” featuring restless pacing, unpredictable violence, and posturing, more recent treatment approaches may lead to an “existential neurosis,” which similarly stands in the way of recovery.

Open-door, domestic alternatives to hospitalization, on the other hand, offer a number of benefits, Warner wrote in The Environment of Schizophrenia. “They provide care which is much cheaper than hospital treatment, less coercive and less alienating, and they produce a different result.

The Community Level

On the community level, people with schizophrenia have to contend with numerous misconceptions and false assumptions about their disorder. “People with mental illness are subject to prejudice, discrimination, and stigma,” Warner wrote. 

Unfortunately, after being exposed to discrimination and stigma for a long time, people with schizophrenia start to accept negative labels about themselves and conform to the stereotype of a mentally ill person as being incapable and worthless. Frequently, they become socially withdrawn and dependent. 

The many harmful misconceptions about schizophrenia include the belief that

  • Nobody recovers from schizophrenia
  • Schizophrenia is untreatable
  • People with schizophrenia are usually violent and dangerous
  • Schizophrenia is contagious
  • Schizophrenia is the result of a certain weakness of willpower
  • People with schizophrenia cannot make rational decisions about their lives
  • People with schizophrenia are unable to work

Not only are most people with schizophrenia able to work, many of them should.  “Work helps people recover from schizophrenia,” Warner found. “Productive activity is basic to a person’s sense of identity and worth. Given training and support, most people with schizophrenia can work.”

At Colorado Recovery, the psychosocial clubhouse offers a rehabilitation model with a vocational focus that harnesses the benefits of client empowerment to increase members’ skills and work preparedness and assist them in obtaining employment.

Colorado Recovery—created by Dr. Warner—approaches care for mental health based on a path of self-reliance through developed practiced skills. This non-institutionalized philosophy offers comprehensive levels of care supported by an expert medical and clinical team, engaging patients in increasing community participation.

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.


The Role of Work and Community in the Treatment of Schizophrenia

Empowering People with Mental Illness at Colorado Recovery

Social Therapies

In the USA in the 1960s, the era of the Civil Rights Movement, the rise of Feminism, and President Kennedy’s Community Care policy, psychoanalysis became a country-wide fad. Much of Woody Allen’s humor was based on poking fun at psychoanalysis. More significantly, a personal analysis was an essential requirement for a chairperson of a Department of Psychiatry. Over the next several decades the pendulum swung away from psychoanalysis towards biological explanations for psychiatric disorders, partly as a result of technological advances in brain imaging and genetics, but also due to the campaigning of the large and powerful pharmaceutical companies. Today psychoanalysis is almost extinct in the USA. The emphasis on an exclusively biological basis for schizophrenia generated a mind-set inimical to the notion of recovery.

There was never such a wholesale commitment to psychoanalysis in the UK, where the number of analysts has not exceeded several hundred for a population of 55 million. Furthermore the majority of analysts live in the major cities, and there is only a handful in the north of England. The dominant ideology in mental health has been a social approach, the pioneers of which were active from the 1930s, establishing community services before the advent of psychotropic medication. The founding of the National Health Service in 1948 provided a basis for social therapies such as rehabilitation, with an emphasis on recovery from psychiatric illnesses including schizophrenia. From the 1950s onwards, successive governments of both the Right and the Left supported a policy of deinstitutionalization, which has been effective in reducing the number of psychiatric hospitals in England and Wales (Scotland has its own Department of Health) from 130 to less than a dozen. The discharged long-stay patients are living in much improved conditions with greater freedom, and there has been almost no homelessness, or victimization.

The emphasis on a social approach in the UK has led to important advances in the non-pharmacological treatment of schizophrenia. These include professionals working co-operatively with family careers and patients, with a reduction in relapse for the most vulnerable patients from 50% over 9 months to 10 %. British psychologists have adapted cognitive behavior therapy, developed in the US for depression, for the treatment of schizophrenia, with a reduction in delusions and the distress due to auditory hallucinations. Recently a computer-assisted therapy has been developed for the treatment of auditory hallucinations resistant to medication, which has been effective in reducing the frequency, volume and malevolence of the voices in many patients. A minority even ceased to hear the voices altogether. These social therapies do not abolish the need for antipsychotic medication, but are free of side effects and produce improvements in the symptoms that enable patients to re-establish productive and satisfying lives.
Julian Leff


People recover from schizophrenia

You won’t hear psychiatrists say this often (and I am a psychiatrist): People recover from schizophrenia.

Something that has long been accepted as a truism by psychiatrists around the world is a belief, promulgated by Emil Kraepelin, the director of a German asylum in the late 1800s, that schizophrenia has an inevitable downhill course. Kraepelin called the illness “dementia praecox” (progressive illness of early life) to hammer home this idea. The concept is reinforced for psychiatrists by the fact that they rarely see people who have recovered from the illness; the recovered patient just stops coming in to see them and returns to a normal life.

Some events transform our professional lives. The first in my career was a conference in Palo Alto in 1977. I was a raw, young psychiatrist when Loren Mosher and his colleagues presented the results of the Soteria study. At that meeting I learned a truth from which my training had protected me – that people can recover from schizophrenia without medication.

Soteria was a therapeutic milieu for young people who met criteria for schizophrenia that was designed as a gentler alternative to the psychiatric hospital. The program, established in a house on a street in San José, California, offered a calming, respectful environment that tolerated individual differences. Staff were encouraged to treat residents as peers and to share household chores, creating an ethos of shared responsibility for running the house and being part of a mutually-supportive community. AnTo post a response to this blog please visit The Recovery Trust.

The Recovery Trust, a Colorado-based nonprofit, has added a new resource for families in need of education and support. It is a free, secure, online forum through which family members can join with others in the same situation.

The forum is moderated by a team of mental health professionals, psychiatrists, family members and people who have experienced mental illness, all of whom have received extensive training in their role as facilitators. Users of the forum can access a large database of information about these illnesses, FAQs and links to other resources.tipsychotic medication was rarely used.

The Soteria project demonstrated that long-term outcome for residents of the therapeutic household was similar to that of patients admitted to standard hospital-based treatment where antipsychotic medication was routinely used. The Soteria approach has since been replicated in California, Alaska, and several countries in Europe.

Coming away from the Soteria conference, I was infused with a passion to understand the true course and outcome from schizophrenia. For months, I ferretted around in the dusty basements of medical libraries unearthing twentieth-century research studies from all over the world. Outcome from schizophrenia has been a popular topic for psychiatrists to study, in the US, Britain, Scandinavia and beyond, since the late 1800s when it was first defined as an illness by Kraepelin. I brought this analysis of over a hundred studies in schizophrenia up-to-date in 2004, incorporating results from the entire century. It demonstrated that optimism about outcome from schizophrenia is justified. Throughout the century around 20% regularly achieved “social recovery” (economic and residential independence and minimal social disruption) and another 20% achieved “complete recovery” (loss of psychotic symptoms and return to the pre-illness level of functioning). This was true for the whole century, except the Great Depression, when recovery rates were halved. Long-term outcome did not improve at all – in fact it got worse – after the introduction of antipsychotic medication in the mid-1950s.

These results aren’t just ancient history. Support for this level of recovery comes from a number of recent studies. A 2007 Chicago-based 15-year follow-up of people with schizophrenia found 19% to be in complete recovery. A 2008 study from Hamburg, Germany, found that 17% of nearly 400 patients with schizophrenia achieved complete recovery after a 3-year follow-up period, and an 8-year study of people with schizophrenia in Dublin, published in 2009, found 39% to be socially recovered. All these results are closely in line with the results of the twentieth-century studies.

It emerges that one of the most robust findings about schizophrenia is that a substantial proportion of those who present with the illness in high-income countries will recover completely or with good functional capacity. Surprisingly, outcome is even better in low- and middle-income countries. Kraepelin’s view that a deteriorating course is a hallmark of the illness proves not to be true; heterogeneity of outcome, both in terms of symptoms and functioning, is the signature feature.

Knowing what I know now, when I see a patient with a first episode of psychosis I don’t start antipsychotic medications right away, especially if the onset is very acute. I wait a few days to see what transpires. If I eventually decide that the person does suffer from schizophrenia, the first thing I tell the family is: This is an illness that generally gets milder as time passes.

Let’s put Emil Kraepelin behind us. We know what we need to know to be able to stop telling patients and families that the outlook from schizophrenia is dismal.

Dick Warner