Concurrent disorders are mental illness and substance use disorders that happen at the same time. Depression and alcohol dependence is one example of a concurrent disorder.

What is a substance use disorder?

Substance use means using alcohol, drugs or other substances. Think of it as a scale that ranges from substance use that doesn't cause problems to use that does cause problems in a persons life.

Problematic substance use means the alcohol or other drug use is linked to problems such as:

• health problems like diabetes or psychosis
• problems with friends, family or people at work
• risky behaviour:
  • taking a lot all at once
  • mixing substances (poly drug use), like drinking alcohol and taking sleeping pills at the same time
  • using substances and driving or operating machinery
  • using substances and going to work or school

Problematic substance use may also include dependence, sometimes called addiction.

Dependence means that a child or youth may:

• Need to take more and more of a substance to get the same result, or the same amount doesn’t affect them the way it used to. This is called tolerance.
• Have troubling symptoms when they stop using a substance and feel they have to use it or another substance to deal with the symptoms. This is called withdrawal.
• Have a hard time cutting back or quitting a substance, even though they want to.
• Spend a lot of time finding, using or recovering from using a substance.
• Give up other parts of life, like family events or work, because of their substance use.
• Keep using a substance even though they know it’s affecting their physical or mental health.

Is any substance use a problem?

How substance use can become a problem

Some youth start to use substances to help them cope with stress, anxiety or depression. There may be conflict at home, school or among their peers. They may be questioning their sexuality. Some children and youth are also more likely to take risks than others. And, sometimes they begin using substances such as nicotine because they think it will lower their appetite.

Age is also important. The younger a person starts experimenting with substances, the more chance they'll develop problems.

When a child or youth use substances, they usually don't understand that it can lead to emotional problems or make problems worse. This is especially true if they are at risk for developing a mental health disorder. 

What is mental illness?

Mental illness is a condition that affects the way you feel, think and act. There are many different kinds of mental illnesses, for example:

• attention-deficit/hyperactivity disorder (ADHD)
• behavioural disorders
• depression

How are substance use problems and mental illnesses connected?

There are four general ways that mental illnesses and substance use problems go together:

1. A mental illness comes first. Example: A young person uses substances like alcohol or other drugs to help them deal with troubling symptoms of a mental illness.
2. A substance use problem comes first. Example: A young person uses a substance that triggers symptoms of a mental illness, like depression or psychosis.
3. Both problems start at the same time. Example: A mental illness and a substance use disorder are triggered by the same event, like a very scary accident or traumatic experience.
4. The problems start separately. Example: A mental illness and substance use problem both start separately, but have the same risk factors, like genes or a difficult environment.

Substance use and mental illness are also connected when they're being treated:

• some substances stop medications from working properly, so symptoms of a mental illness become worse
• some mental illnesses such as psychosis might make it harder to go through some substance use treatments
• some mental illnesses can get worse if a person stops or cuts back their substance use without proper help
• some people don't take their medication when they're using a substance and this makes symptoms of a mental illness worse
• when one problem gets worse it can make the other problem get worse; drinking alcohol can make symptoms of depression worse

For these and other reasons, it's important to take care of both issues at the same time.

It can be hard to tell the difference between a mental illness and substance use problem. Many of the symptoms look the same.

• When you are intoxicated and feeling the effects of alcohol or other drugs, it may look the same as many mental illnesses. Mental illnesses can also look similar to withdrawal from alcohol or other drugs.
• Substances can hide symptoms of a mental illness. For example, cocaine may seem to calm some young people living with attention-deficit/hyperactivity disorder.
• Some substances can make a mental illness worse. For example, alcohol slows down brain activity, which can make depression worse.

It may not be possible for a health professional to make a diagnosis until signs and symptoms of intoxication and withdrawal are gone.

A child or youth may hide their substance use because they know it's illegal for them to buy alcohol and other drugs. They also might not want you or other adults to know what they're using. It's also important to remember that having mental health challenges and using a substance doesn't necessarily mean that a child or youth has a concurrent disorder. If you're concerned, it's best to talk to a doctor or a mental health professional.

A child or youth who may have a concurrent disorder needs to see a doctor for an assessment. The doctor can refer them for special treatment and support services. The goal of treatment should be to help the young person take control over their life and to make positive changes. It may not be realistic to stop all substance use, but it's possible to lessen the harms linked to it. A child or youth is more likely to follow a treatment plan when it makes sense to them. When the young person works through both problems together, it's easier to make positive changes and lower the risk of relapses.

In general, there are two basic groups of formal treatment: talk therapy and medication. The exact treatment a child or youth receives will depend on many different things:

• what mental illness and substance use problem they're living with
• how severe each problem is
• how the problems interact with each other
• what else might be adding to the problems 
• what services are available in their community

Therapies

Here are some of the therapies a child or youth might see:

• Motivational interviewing encourages the individual to see how mental illnesses and substance use problems affect their life. It also encourages positive changes.
• Cognitive behaviour therapy or CBT teaches how thoughts, feelings and behaviours are related. It also teaches skills like problem-solving and recognizing triggers.
• Dialectical behaviour therapy or DBT helps with behaviour problems. It teaches how to manage feelings, cope with distress and improve relationships.
• Multisystemic therapy focuses on factors like family, friends, school and the community. It looks at the issues around you that may lead to problem behaviours.
• Family therapy improves relationships by helping family members learn more about the child or youth's problems. It helps them work together, communicate and provide support. 
• Peer support may help some child and youth with the same illnesses share their experiences. They work together to solve problems and support each other. Family members may also find family peer support groups helpful.

Medications

There are many effective medications for mental illnesses. There are fewer for substance use problems. They may include medications that make using a substance less enjoyable, medications that reduce cravings or medications that reduce or prevent withdrawal symptoms.

Well-being and healthy living

Support from family and friends and schools or workplace is important. So are appropriate housing and income. It often helps a child or youth with a concurrent disorder to get involved in community activities like volunteer work or sports. This may be a course of self-esteem and strength. In fact, not having these supports may be a risk factor for concurrent disorders.

Withdrawal management

Some substances, like alcohol or benzodiazepines, can cause serious health problems if you suddenly stop using them. It's important to have a plan to manage withdrawal symptoms and prevent health problems. It usually includes medication and support from health care workers at home, at a treatment centre or in the hospital. The goal of withdrawal management is to prepare the young person for their long-term treatment and recovery plan.

Relapse

A young person's symptoms or substance use problems may come back, even in they're in treatment. This is a normal part of recovery. If there is a relapse, it's a good idea to talk about it. What can be changed to prevent a future relapse? Does the treatment plan need to be reviewed? It's important to remember that a relapse doesn't mean the young person should stop or change treatment without talking to the doctor or mental health professional.

Family members can help by learning about the problems their child or youth is living with. They can learn what might increase the risk of relapse and watch for warning signs so they can get help early. Some youth write an action plan that lists their warning signs and what other people can do to help.

Recovery

It's important to think about what will happen when treatment is finished. The treatment team may plan this, but it may also be up to family members. Families need to talk to the team about what they can provide.

Some things to consider are:

• Will the child or youth live at home?
• Will they have any financial support?
• Are there programs to help find a job, go to school, or learn other skills?
• What other life changes will continue after formal treatment ends?
• How will the child or youth get to support group meetings or doctor's appointments?

Some people define recovery as not using any substances and not experiencing any symptoms. But most people experience recovery in less black-and-white terms. It is a process or journey that moves in all directions - steps forward and steps backwards - and is different for everyone. A child or youth will need hope and encouragement to overcome challenges, take control of their life, and achieve their goals.

Tips for caregivers

It is very challenging to care for a young person living with a concurrent disorder. At times, you may feel overwhelmed and helpless. A self-care plan can help you through a difficult time. It could include strategies to help you relax, do things that you enjoy and reconnect with family and friends. It may also help to talk to a mental health professional. If you take steps to lower your own stress and model healthy ways to cope, it may help both you and your child or youth.

Talk to your family doctor, who can complete an assessment for your child and youth. Your doctor can also refer them for specialized treatment and support services. 

Looking for more information on this topic? Connect with a family peer support worker at the Kelty Centre to discover additional resources, learn more about support and treatment options, or just to find a listening ear.