Pathways of recovery: preventing further episodes of mental illness (monograph)

Harmful alcohol and other drug use

Page last updated: 2006

Harmful alcohol and other drug use is a major risk factor for relapse for people with mental illness (Ries & Comtois 1997). The co-occurrence of mental illness and harmful alcohol and other drug use is common, and can have significant social, emotional, physical and cognitive consequences that impact on treatment and relapse (see Teeson & Proudfoot 2003). People with mental illness are more vulnerable to harmful alcohol and other drug use for many reasons, which include attempts to self-medicate symptoms as well as lifestyle and social changes associated with mental illness (Bellack & DiClemente 1999).

Estimates of the proportion of people with a co-occurring mental illness and substance use disorder range from 50% to 90% (Baigent, Holme & Hafner, 1995). Australian data show that substance use problems are evident for 28% of men and 14% of women with anxiety disorders, and for 34% of men and 16% of women with affective disorders (Teeson, 2000). For people with psychotic disorders, 60% use tobacco, 22% are daily alcohol users, 23% use alcohol weekly, 9% have used psycho-stimulants, and 5% have used opiates in the past year (Degenhardt & Hall, 2000).

While the role of alcohol and other drugs in causing mental illness is unclear, their role in exacerbating current illness and precipitating relapse is evident. For example, while the effect of cannabis on the onset of psychosis has not been established, once mental illness has occurred, the use of cannabis is a major risk factor for relapse (Degenhardt, Hall & Lynskey 2003). Harmful alcohol use also has a marked impact on relapse.

My biggest problem for relapse is alcohol. If I don't drink, I'm fine. If I start drinking it all goes downhill fast. But even though I realise this, sometimes I still want to have a few drinks, but then it goes down a downward spiral. —Consumer
Harmful alcohol and other drug use impacts in many ways to increase the risk of relapse. It can mask or exacerbate symptoms and make diagnosis unreliable; it can also reduce compliance with treatment and reduce the effectiveness of prescribed medications (Bellack & DiClemente 1999). Harmful alcohol and other drug use often results in negative emotional states such as guilt and remorse, self-blame and loss of self-worth, as well as loss of control, negative lifestyle changes, and detrimental effects on sleep and physical health. Serious health and legal consequences can arise from some forms of substance use, including incarceration, and these are additional stressors that further increase the risk of relapse and impede recovery.

Effective interventions to prevent harmful alcohol and other drug use are imperative components of relapse prevention. Yet, co-occurring disorders have serious implications for mental health services. People with substance use problems can be excluded from standard treatments that have been developed for narrowly defined sets of symptoms, and staff rarely have the skills to recognise and treat more complex presentations (Teesson & Proudfoot 2003). The Australian Psychological Society argues that harmful alcohol and drug use is so common for people with mental health problems that all psychologists and other professionals working in mental health should be skilled in assessing and dealing with substance use problems (through treatment or referral), and all professionals working in alcohol and other drug treatment services should be skilled in assessing and dealing with mental health problems (Rickwood et al. 2003, Rickwood et al. 2005).
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The greatest challenge we face in mental health is alcohol and drug use. It is the norm, yet no services know how to effectively deal with it. —Clinician
Special mention of the impact of tobacco smoking is warranted because the rate of tobacco smoking for people with mental illness is two to three times the rate for the general population (McNeill 2001). This high rate of smoking has a number of negative health outcomes for people with mental illness and contributes to lowered life expectancy (Coghlan et al 2001a). The high cost of tobacco smoking adds to poverty and financial disadvantage (Ashton et al 1999), with heavy smokers at times needing to spend their entire disability support pension on their smoking habit. Furthermore, smoking can contribute to social exclusion because social venues are increasingly smoke-free. Importantly, however, interventions to reduce smoking behaviour among people with mental illness have begun to be developed and favourably evaluated (see Ashton & Weston 2002).