Mental Illness and Substance Use
The Challenge of Co-Occurring Disorders
Thanks to greater distribution of and access to naloxone which reverses the effects of opioids, death rates due to drug overdoses fell by over 25% last year (CDC, 2025). You would think this would be a good reason to ensure the programs supporting this effort should be continued. You would be wrong.
Despite promising to continue these effective programs, the Trump Administration proposes to cut them. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) which helps distribute overdose kits and train first responders will be moved in a major reorganization.
A new Administration for a Healthy America (AHA) will consolidate the OASH, HRSA, SAMHSA, ATSDR, and NIOSH, so as to more efficiently coordinate chronic care and disease prevention programs and harmonize health resources to low-income Americans. Divisions of AHA include Primary Care, Maternal and Child Health, Mental Health, Environmental Health, HIV/AIDS, and Workforce, with support of the U.S. Surgeon General and Policy team (April 2, 2025).
HHS Secretary Robert Kennedy, Jr, himself a heroin addict for 14 years, believes in prevention through “faith and community” and gave lip service to SUD treatment. In a speech at the Rx and Illicit Drug Summit in Nashville, he never mentioned how he entered a rehabiltation facility to quit using. He also never mentioned proposed cuts to funding for naloxone and SAMSHA. Instead he focused on God and daily prayer (April 24, 2025). He never mentioned mental illness, either, despite the fact that mental illness and substance use disorder (SUD) can overlap. He calls people who use medications to control their anxiety and other disorders “addicts” and thinks they should be sent to “wellness farms” (Zbikowski, 2025).
Overlap Between Mental Illness and Substance Use Disorder
As you can see from the figures below, the overlap between mental illness and substance use disorder is significant. Per SAMSHA (2023), in 2022, 84.2 million adults had either substance use disorder (SUD) or any mental illness (AMI) with or without serious mental illness (SMI). Of those adults with AMI, 21.5 had both SUD and AMI within the past year.
Treatment of these co-occurring disorders (CODs) can be quite challenging (NIDA, 2018). Not all psychiatric facilities can or will treat substance use disorders (SUD) at the same time as mental illness, and not all drug rehabilitation facilities can or will treat psychiatric conditions at the same time as SUD. Similar to the chicken and the egg question, substance use can cause mental illness and mental illness can cause substance use. Complicating this matter is the fact that research indicates that SUD is a form of self-medication for mental illnesses such as anxiety, depression, and bipolar disorders (Santucci, 2012).
Psychiatric Bed Shortages
As if all the above was not concerning enough, add to it:
a national mental health crisis, triggered in part by COVID-19;
a shortage of in-patient psychiatric beds to treat children and adults with or without substance use disorder;
overcrowded emergency rooms; and,
a psychiatric hospital workforce shortage (APA, 2022; Cushing et al., 2024; Levin et al., 2024; NRI, 2024).
With the current administration’s efforts to gut health care services of any kind, it is unlikely there will be money for more psychiatric hospital beds. What is a family to do? Some experts are suggesting the hospital at home model, or intensive home treatment (IHT), for psychiatric care. Data from a non-randomized clinical trial in Germany are promising, however, that country has a different model of health care from the United States (Bechdolf et al., 2024). While intriguing, I’m not sure that IHT would work for all families, especially those already dealing with other challenges. I’d like to offer a personal example.
Post World War II, my father was a long-term patient at St. Elizabeths in Washington, D.C. He probably had post-traumatic stress disorder (PTSD), but in the 1940s, that diagnosis did not exist. He was labeled as a paranoid schizophrenic and he was an alcoholic. Today, we would say he had a COD. At home, he was violent and beat my mother. My mother had three children, less than a high school education, and her own psychological problems. She was not prepared to care for him at home. It was a blessing that St E’s was right down the street and that they admitted him.
At St. Elizabeths, and at similar facilities in the country, psychiatrists employed various therapies with the seriously mentally ill in restrictive settings. These approaches included, but were not limited to: talk therapy, straitjackets, art therapy, psychodrama, occupational therapy, hydrotherapy, and insulin and electric shock therapy (Herriott & Hagan, 1941; Franz, 1946; Overholser, 1953/1956; Richard, 1984). For those non-responsive to these approaches, frontal, or pre-frontal lobotomy also known as leucotomy, the invasive and life-altering brain surgery that severed the white matter connecting the two prefrontal lobes of the cortex, now considered barbaric, was hailed as a miracle cure in the mid-1940s in the U.S. (El-Hai, 2007). Drugs that treated emotional and psychological diseases did not become available until the 1950’s when chlorpromazine, aka, ThorazineTM led the world into the psycho-pharmaceutical era (Frontline, 2005).
Mental illness and substance use disorders are not a moral failing despite what some say. If you have ever seen the 1975 major motion picture, One Flew Over the Cuckoo’s Nest, you will undoubtedly recall the evil Nurse Ratched, played by Louise Fletcher. Con artist R.P. McMurphy, who is played by Jack Nicholson, pretends to be insane so he can be committed to the relative luxury of a mental hospital instead of going to prison (Douglas, Fink, & Zaentz (Producers) & Forman, (Director), 1975). While in the locked facility, McMurphy runs afoul of Nurse Ratched and stirs up trouble with the other patients. Medications and other approaches don’t control the wily McMurphy, so Nurse Ratched gets her revenge by having McMurphy lobotomized. At the end of the film, McMurphy is a drooling, compliant patient, just another one of the obedient regulars under her care. Is this the future we want for our loved ones? We can’t go back to straitjackets and lobotomies. Organizations representing mental health constituencies are responding to these proposed cuts and we can, too.
What can you do?
Stock up on naloxone while you can and get trained on how to administer it. Next Distro has a list of states and how to obtain it. https://nextdistro.org/naloxone
Support the National Alliance for Mental Illness (NAMI), which “provides advocacy, education, support and public awareness so that all individuals and families affected by mental illness can build better lives.”
Likewise, Mental Health America has a strong advocacy role, promotes equity, access, and prevention.
The Drug Policy Alliance (DPA) “addresses the harms of drug use and drug criminalization through policy solutions, organizing, and public education.”
As always, write, call, email, or send carrier pigeons to your senators and and congress people.
With an administration that is intent on turning back the hands of time to the 1950’s we should be outspoken about proposed cuts to proven treatments for mental illness and substance use disorders.
References for this post along with other resources
American Psychiatric Association Presidential Report on the Assessment of Psychiatric Bed Needs in the United States. (2022). The psychiatric bed crisis in the United States: Understanding the problem and moving toward solutions. American Journal of Psychiatry, 179(8), https://psychiatryonline.org/doi/10.1176/appi.ajp.22179004
Bachhuber, M. A., Roberts, C. B., Metraux, S., & Montgomery, A. E. (2015). Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration. Journal of opioid management, 11(6), 459–462. https://doi.org/10.5055/jom.2015.0298
Bechdolf, A., Nikolaidis, K., von Peter. S., et al. (2024). Utilization of psychiatric hospital services following intensive home treatment: A nonrandomized clinical trial. JAMA Netw Open.7(11):e2445042. doi:10.1001/jamanetworkopen.2024.45042
Buchbinder, S.B. & Shanks, N.H. (2016) Introduction to health care management, 3rd Ed. Jones & Bartlett. https://www.amazon.com/dp/128408101X \
Cushing AM, Nash KA, Foster AA, et al. (2024) Pediatric inpatient psychiatric capacity in the US, 2017 to 2020. JAMA Pediatr. 178(10):1080–1082. doi:10.1001/jamapediatrics.2024.2888 https://jamanetwork.com/journals/jamapediatrics/article-abstract/2822492
Douglas, M., Fink, M. & Zaentz, S. (Producers) & Forman, M. (Director). (1975). One flew over the cuckoo's nest. [Motion Picture]. United States: Fantasy Films.
Eberhart, N.K. (2024, January 29). Solving psychiatric and substance use disorder treatment bed shortages: How many beds to build and where to build them. RAND Research Brief. https://www.rand.org/content/dam/rand/pubs/research_briefs/RBA1800/RBA1824-1/RAND_RBA1824-1.pdf
El-Hai, J. (2007). The lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness. Hoboken, NJ: John Wiley & Sons.
Franz, J.G. (1946). Psychodrama at St. Elizabeths. Sociometry, 9(2/3),169-170.
Frontline. (2005). Deinstitutionalization: A psychiatric Titanic. https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html
Health and Human Services (HHS). (2024, April 2). Fact Sheet: HHS’ transformation to make America healthy again. https://www.hhs.gov/press-room/hhs-restructuring-doge-fact-sheet.html
Herriott, F. & Hagan, M. (1941). The theatre for psychodrama at St. Elizabeths Hospital. Sociometry, 4(2),168-176.
Levin, J.S., McBain, R.K., Cantor, J.H., Ghandi, P., Crowley, C., Estrada-Darely, I., Hawkins, W., Huilgol, S.S., Matthews, S., & Eberhart, N.K. (2024, January 29). Solving psychiatric and substance use disorder treatment bed shortages:How many beds to build and where to build them. https://www.rand.org/pubs/research_briefs/RBA1824-1.html
Loller, T. (2025, Apri 24). RFK Jr. recounts heroin addiction and spiritual awakening, urges focus on prevention and community. https://apnews.com/article/kennedy-rfk-drug-addiction-heroin-92924f4ca4e445610e3e179142d6ebd7
McPhillips, D. & Greene, C. (30 April 2025). Despite pledge to expand naloxone access, Trump administration proposal would cut overdose prevention programs. https://www.cnn.com/2025/04/30/health/naloxone-grant-budget-cut-overdose-prevention
National Center for Health Statistics. (2025, May 14). U.S. overdose deaths decrease almost 27% in 2024. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2025/20250514.htm
National Institute on Drug Abuse (NIDA). (August, 2018). Comorbidity: Substance use disorders and other mental illnesses. https://www.drugabuse.gov/publications/drugfacts/comorbidity-substance-use-disorders-other-mental-illnesses#ref
NRI. (2024, May). State psychiatric hospital workforce shortages and salaries, 2023. NRI’s 2023 state profiles. https://www.nri-inc.org/media/kj0lsgpb/state-hospital-workforce-shortages-and-salaries-2023-may-2024.pdf
NRI. (2024, May). Use of state psychiatric hospitals, 2023. NRI’s 2023 state profiles. https://www.nri-inc.org/media/is0dobjz/smha-use-of-state-psychiatric-hospitals-may-2024-final-w-out-tables.pdf
Overholser, W. (1953/1956). Across the river and among the trees. Records of the Columbia Historical Society, Washington, D.C., 53/56: 265-281. http://www.jstor.org/stable/40067679
Richard, M. P. (1984). Asylums revisited: 1957-1982. International Social Science Review, 59(3),171-178.
Santucci K. (2012). Psychiatric disease and drug abuse. Current opinion in pediatrics, 24(2), 233-237. doi:10.1097/MOP.0b013e3283504fbf
Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report
Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2022 national survey on drug use and health: Graphics from the key findings report, Slide 46. https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nnr-briefing-slides.pdf
Substance Abuse and Mental Health Services Administration. (2021). Substance Use Disorder Treatment for People with Co-Occurring Disorders, Advisory. https://library.samhsa.gov/product/advisory-substance-use-disorder-treatment-people-co-occurring-disorders-based-tip-42/pep20
Zbikowski, C. (2025, April 3). RFK Jr.’s unsound ideas are a threat to my mental and physical health — and yours, too. https://minnesotareformer.com/2025/04/03/rfk-jr-s-unsound-ideas-are-a-threat-to-my-mental-and-physical-health-and-yours-too/
Good piece-again! Why they want to hurt Americans is something I will never understand.