7 Things You Need to Know About Substance Use and Mental Illness

By Jeremy Galloway 12/07/16

Mental illness and substance misuse touch every demographic group, but there are disturbingly strong correlations between poverty, mental illness, and harmful substance use.

A capsule opening with gears flowing out and into a profile of a head.

My mood began to fluctuate rapidly between manic and depressive episodes when I was sixteen. Looking back, I’m sure I expressed symptoms of other mental health problems, especially anxiety, even earlier. Based on my limited knowledge, I suspected for many years that I had bipolar disorder. It wasn’t until two decades later that I’d be officially diagnosed.

In the time between noticing symptoms and finding treatment, I began using heroin and developed a serious substance use disorder (SUD). It wasn’t until much later that I realized the significant link between mental health disorders (MHDs) and SUDs. If I’d had effective mental health care in my youth, it could have spared me some troubles later in life. Now that I have, it’s helped me find effective coping tools and get on the road to a healthier life.

Here are seven things you need to know about SUDs, MHDs, the multiple, complex ways they intersect, and some ways you can help yourself or a loved one.

1. You’re Not Alone

Mental illness is a larger problem than many of us would care to imagine. The National Institute of Mental Health (NIMH) reports that in 2014 there were 43.6 million adults living with a diagnosable mental, behavioral, or emotional disorder. This doesn’t include SUDs, which pushes that number even higher. This means that almost 1 in 5 U.S. adults is living with mental illness. Of those, 9.8 million have a serious mental illness (SMI) like schizophrenia, major depression, or bipolar-type I disorder.

The Substance Abuse and Mental Health Services Administration (SAMHSA) projects that by 2020, MHDs and SUDs combined will “surpass all physical diseases as a major cause of disability worldwide.” The annual estimated societal cost of substance misuse in the United States is $510.8 billion, with an estimated 23.5 million Americans aged 12 and older needing drug or alcohol treatment.

Serious mental illness costs America $193.2 billion in lost earnings per year.¹

Mood disorders are the third most common cause of hospitalization in the U.S. for youth and adults ages 18 to 44.² Drug overdose is now the leading cause of injury-related death among U.S. adults, with over 47,000 people dying in 2014 according to the Centers for Disease Control and Prevention. These are undeniably widespread problems with significant racial disparities: Black and Hispanic Americans used mental health services at about one-half the rate of whites in the past year.

2. The Importance of Early Intervention

According to the Government Accountability Office, concern for their children's well-being drives many parents to relinquish custody to government agencies; this is the only way these parents can ensure that their children have greater access to mental health and child welfare services. In 2001 this was the case for almost 13,000 children—not in a developing country, but in the 21st century United States.

Interrupting mental health problems at an early age is vital. More than half of adolescent MHDs go undiagnosed and onset of most mental illnesses begins at an early age. If someone had known how to speak with me about the rapid changes in my brain, or if I’d been taught in school where to turn for help, I might have been able to find treatment before my problems grew so severe. Unfortunately, few people find these conversations worthwhile.

According to a report published through the National Institute of Mental Health (NIMH), despite the availability of effective treatment options, there are long delays—sometimes decades—between the onset of symptoms and when people receive help.

3. Many Street Drugs Mimic Effects of Psychiatric Meds

This is critical for understanding why people use drugs, and why they continue using them in the face of repeated (often socially-constructed) negative consequences.

Many people report antidepressant-like effects from opioids like heroin, and buprenorphine (the active medication in Suboxone) has shown success at easing symptoms of treatment-resistant depression. Researchers have recently been excited about the potential of ketamine and MDMA (ecstasy) at treating mental health problems, with ketamine receiving special “fast track” status by the Food and Drug Administration as a potential rapid treatment for depression.

These medications, as well as stimulants like cocaine and methamphetamine (which, as it turns out, is almost pharmacologically identical to Adderall), act on the same neurotransmitters that regulate our mood. Dopamine imbalances are thought to play a central role in bipolar disorder and schizophrenia. Medications for these conditions either inhibit or activate the dopamine system. It’s no coincidence that most recreational drugs, from nicotine to heroin, have some impact on dopamine.

4. Lack of Access to Effective Treatment

In the 1970s and '80s, funding and beds for mental hospitals were slashed, with the country losing over 40,000 hospital beds in a decade. This left many people with SMI little or no access to treatment resources, and contributed to a tidal wave of homelessness and substance use problems that persists today. Even with reforms like the 2008 Mental Health Parity Act, it’s estimated that it will be years before those with insurance will see improvements.

Today, regions facing the highest overdose rates still have limited, if any, access to effective, evidence-based care. And where it does exist, treatment costs can be prohibitive, even with insurance. It’s no coincidence that places like Appalachia, with some of the highest rates of poverty and unemployment, also have the highest rates of mental illness, substance misuse, and overdose deaths in the United States.

A relatively new model called SBIRT (Screening, Brief Intervention, and Referral to Treatment) can be applied to an array of mental health and behavioral problems. Professionals can perform screenings during routine medical checkups, in emergency or crisis situations, or during physical/mental health assessments, giving them the potential to reach traditionally underserved communities. It’s brief, comprehensive, easy to perform, and shows promise for connecting patients to effective treatments, improving short and long-term health, and reducing risky behaviors.

5. It’s Even Worse in the Corrections System

The U.S. Department of Justice estimates that more than 56% of state, 44% of federal, and 64% of local jail inmates meet the criteria for having a mental health problem. Less than half receive any sort of treatment. When we consider the number of people incarcerated for drug-related crimes or with a history of misusing substances, it’s clear that our jails and prisons serve as warehouses for people with health problems for which effective treatments exist—when we’re willing to provide them.

The New York Daily News reported that city inmates at Rikers Island frequently miss mental health appointments. Medical care in general is gravely insufficient in most U.S. jails and prisons, a major contributing factor in the nationwide prison strikes. I spent a brief part of my two-year prison term at a facility that houses mostly prisoners with MHDs. The way they’re treated by staff was sadistic and frightening. Incarcerated people who have even minor psychological problems often refuse to seek treatment for fear of ending up at these facilities.

If we want to get serious about treating mental health and substance use problems, we’re going to need to dramatically shift our approach away from a “War on Drugs” toward something that empowers directly-impacted people and provides immediate treatment on demand.

6. Poverty, Social Isolation, and Abuse

Mental illness and substance misuse touch every demographic group, but there are disturbingly strong correlations between poverty, mental illness, and harmful substance use. Why this correlation exists is an open question, but some experts suspect that despair, social isolation, stress, and poor overall health habits factor in. Another significant factor is the disparity in access to care and treatment.

Appalachia has some of the highest poverty rates and highest rates of harmful substance use and mental illness in the U.S. While Appalachia is largely rural and predominantly white, many urban areas made up primarily of people of color face strikingly similar problems.

These areas are doubly impacted by lack of access to resources. As I wrote earlier this year, some residents of Appalachia drive over two hours each day for drug treatment. Residents of our nation’s cities face even more severe barriers.

These populations are also more likely to end up locked into our mass incarceration system, where access to treatment often exists on paper, but rarely translates to effective care in the real world. The complex interrelationship of poverty, crime, substance use, mental illness, and incarceration conspire to create crippling social conditions which lead to problems which are passed down from generation to generation—and that’s before we even take biology, and what some researchers consider “genetic predispositions," into account.

7. Words Matter: How We Talk About These Conditions

The old elementary school adage about sticks and stones isn’t always true: Words can cause lasting harm. This is especially true for marginalized populations. Calling someone “schizophrenic” or “addict” can be stigmatizing, even when we don’t mean it to be. Nonchalantly proclaiming someone is “bipolar” because they sometimes have mood swings or that you’re “like totally OCD” because you like things to be organized minimizes the daily struggles faced by people who are diagnosed with those conditions.

There’s been a push in recent years to be more conscious of the words we use to refer to people with MHDs and SUDs. Even subtle distinctions, like saying someone is living with bipolar disorder instead of suffering from it are meaningful. While mental illness is a significant part of someone’s life, saying someone suffers from a condition can be disempowering. Acknowledging the complete spectrum of our relationships with these conditions is essential to helping us overcome them. Vocabulary exchanges can help us become more aware of how to approach these conversations in a healthy, conscious, and empowering manner.

On the flipside, some members of marginalized groups have attempted to reclaim oppressive and insulting language. It’s not uncommon to hear people living with mental illness talk about “mad pride” or for people who self-medicate with street drugs to proudly proclaim their right to use drugs. This can open up spaces which place the needs and voices of directly-impacted people at the center of the conversation. It contributes to the notion of “nothing about us without us,” which demands that people whose lives are impacted by public health and drug policies have a say in how they’re shaped.

Empower People to Make “Any Positive Change”

There’s a saying in the harm reduction community that “any positive change” is a move in the right direction. But as mental health and (especially) substance use issues grow more problematic, what can we do to help? We need to consider the role of social relationships, political power, and the desire to control certain people—especially poor people, people of color, LGBTQ people, and members of other marginalized groups.

These are treatable conditions and, when we’re able to address them early enough, the chance for positive outcomes can be high. This translates to improvements in quality of life, not only for those living with these conditions, but for friends, family, and loved ones. The tools and resources already exist, but maybe political priorities and, dare I say attitudes of privilege, prevent them from being implemented effectively.

What can we do to make sure those of mental health care are connected with life-saving services? And perhaps more importantly, how will we ensure the voices of directly-impacted people living with mental health and substance use disorders are included—and respected—in those conversations? The fate of millions of our friends and neighbors rests on how we answer those questions.


1. Insel, T.R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of Psychiatry. 165(6), 663-665

2. Wier, LM (Thompson Reuters), et al. HCUP facts and figures: statistics on hospital-based care in the United States, 2009. Web.. Rockville, Md. Agency for Healthcare Research and Quality, 2011. Retrieved March 5, 2013, from http://www.hcup-us.ahrq.gov/reports.jsp

Please read our comment policy. - The Fix

Jeremy Galloway is a co-founder of Georgia Overdose Prevention, Harm Reduction Coordinator with Families for Sensible Drug Policy, and advocates for the rights of people who actively or formerly used drugs and those impacted by drug criminalization. He's part of a network of advocates, academics, and public health officials from across the South working to combat the recent wave of overdoses and opioid-related problems in the the region. You can find Jeremy on Linkedin and Twitter.