What's In This Guide?
You’ve noticed your teen is increasingly moody and anxious. Is this a sign of a mental health disorder? Or substance use? Or could it be both? What might be behind a young person’s change in behavior is often hard to pin down, particularly when substance use and mental health are both factors. But understanding how these challenges can manifest in a child’s life, and sometimes entwine to create new problems or complicate treatment, is essential to keeping kids healthy.
An Introduction to Co-Occurring Disorders
Prevalence of Co-Occurring Disorders
Over 2.3 million adolescents (aged 12-17) and 7.7 million young adults (aged 18-25) used illegal drugs or misused prescription medication in the U.S. in 2014. About 2.9 million adolescents and 20.8 million young adults — more than half of the young adult population — consumed alcohol in the past month.
Mental health disorders are a subject of increasing concern for young adults. One in five adolescents has a mental health disorder. The most common are anxiety disorders, depression and attention-deficit hyperactivity disorder (ADHD). Young people may also struggle with bipolar disorder, schizophrenia and borderline personality disorder.
Mental health disorders and substance use are tightly linked. Often, when a mental health disorder goes undiagnosed or untreated, a young person will attempt to self-medicate or self-treat with drugs or alcohol. Studies show that ADHD, anxiety disorders, post-traumatic stress disorder and depression all increase risk of drug use and dependence in adolescents.
At the same time, substance use poses a serious risk for developing a mental health disorder. Heavy marijuana use is a demonstrated risk factor for triggering episodes of psychosis, particularly in those with a family history of psychotic disorders. Misuse of prescription medications like stimulants or certain antidepressants can lead to manic or unusually irritable mood states.
Happily, research also shows that identifying and treating mental health disorders can reduce substance use. Similarly, reducing substance use can improve treatment outcomes for mental health disorders.
An Overview of Substance Use
What’s the Attraction?
Teens and young adults use substances for a variety of reasons. They may begin because of curiosity and peer pressure. Often, those who become habitual users are trying to “solve a problem.” Substances can help them relax, alleviate boredom, fit in socially, escape emotional or physical pain, deal with traumatic memories, relieve anxiety, go to sleep, get up in the morning, lose weight, etc. Substance use is “reinforcing,” which means that a child is more likely to keep taking them when they seem to help with a given problem or need. It’s important for parents to understand what it is specifically that makes substances appealing to their child in order to address his or her use. And when substance use is severe, it can be difficult for any parent to address these causes and keep a child safe without professional help.
Substance Use Basics
It’s helpful to have a basic understanding of the different kinds of substances, their effects and how to recognize signs of use. Common substances used by adolescents and young adults include alcohol, tobacco (JUUL, cigarettes), marijuana (leaf, THC oils, dabs and vape pens), hallucinogens (LSD and PCP), sedatives (Xanax, Ambien), stimulants (Adderall, cocaine) and opioids (Vicodin, heroin, Percocet).
How do you know if a child is using alcohol and/or drugs? Aside from direct evidence (such as bottles, bags or other paraphernalia), parents often see physical, emotional and behavioral changes. Of course, the specifics of these changes depend directly upon the substance being used. For example, stimulants can cause an irregular heartbeat, insomnia, irritability and unexplained weight loss. Opioids, like Vicodin, Percocet and heroin, can cause a lack of enthusiasm and energy, constipation, slowed breathing, pinpoint pupils and nausea.
Some behavioral changes that may occur with substance use:
- Loss of interest in hobbies or extracurricular activities
- Comments from teachers, classmates or friends
- Changes in friendships
- Mood swings
- Irritability or argumentativeness
- Unusual agitation, restlessness or hyperactivity
- Lethargy or lack of motivation
- Locking doors, demanding more privacy, isolating or missing family events
- Declining grades, skipping school or poor work performance
- Becoming more accident-prone
- Engaging in risky behaviors (such as sex or driving under the influence)
- Borrowing or taking money or valuables
- Missing prescription drugs or missing alcohol
Many of these symptoms overlap with mental health disorders. For example, it can be hard to tell if a child who becomes withdrawn and isolated is depressed, using alcohol, or both. You can learn more about differentiating between substance and mental health disorders in Section 3.
What Is a Substance Use Disorder?
The term “substance use” exists along a spectrum from initial use to greater frequency (and usually more consequences) and eventually to addiction.
Regardless of the substance, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (known as the DSM-5) defines a substance use disorder as a problematic, recurrent use of drugs or alcohol that causes significant distress or impairment in a person’s life. There are four categories of behaviors that are used to determine the severity of the problem: impaired control, social impairment, risky use, and tolerance and withdrawal.
A person needs to meet two or three of these criteria to be diagnosed with a mild substance use disorder. Meeting four or five of the criteria is considered a moderate substance use disorder, and six or more is deemed a severe substance use disorder.
Even if a child’s use of alcohol and/or other drugs doesn’t rise to the level of an “official” substance use disorder, it can interfere with functioning. There is a trend in the field moving away from categorizing severity by dependence or withdrawal criteria and looking instead at the impact on one’s life. A young person does not need to be dependent on drugs or go through withdrawal symptoms for the substance to have a huge impact on academic and/or social functioning.
What’s Causing These Symptoms?
Are your child’s concerning thoughts, emotions and behaviors the result of a mental health disorder or a substance use disorder? Figuring out which symptoms come from which disorder, and which problem started first, is called differential diagnosis. Determining differential diagnosis is important, because treatment for a mental health disorder can be very different from treatment for a substance use disorder.
You may be concerned about mood swings and suspect your child has bipolar disorder, when in fact he or she has been using opioids and cocaine. Similarly, a child could be diagnosed with a cannabis (marijuana) use disorder without considering that there may be something else going on or at the root of the issue, like anxiety or a traumatic experience.
Finding the right treatment becomes complicated when adolescents or young adults don’t report everything that is going on in their lives. When young people are referred for help for a mental health disorder, they often can be reluctant to talk about their substance use. Similarly, young people being evaluated for substance use problems will often avoid discussing emotional or behavioral problems.
This lack of information can make it hard to get an accurate diagnosis. That’s why it is critical for clinicians to get a full picture of what symptoms occurred first and when substance misuse began. You can help encourage your child to talk about what’s truly going on in his or her life, and help fill in the gaps, as well. You can share information about your child’s and family’s history as well as other factors, such as recent problems (e.g., missing school, changes in sleep or eating patterns, etc.).
Behavioral symptoms that can result from both mental health disorders and substance use include:
- Sleeping more or less than usual
- Avoiding friends and situations
- Erratic behavior
Getting an Evaluation
There are no laboratory tests to diagnose mental health or substance use disorders, so differential diagnosis depends on reports from the patient, his or her family, teachers and other doctors, and the clinician’s observations. This picture of what’s happening is then compared to criteria in the DSM-5, which professionals use to help diagnose.
Here are some examples of questions a clinician tries to answer:
- Is sadness related to a loss, or just out of the blue?
- Is the adolescent using substances as a way of coping?
- Is substance use a response to stressful life events?
- Is impulsivity part of a child’s personality, or tied to hyperactivity, or is it more manic and self-destructive?
- Is the goal of substance use to seek excitement or to escape reality?
Examples of Results
Differential diagnosis may reveal that substance use is a consequence of a mental health disorder. Here are just a few examples of how substance use can grow out of a mental health disorder:
- Alcohol can be a self-treatment for anxiety, depression or bipolar disorder.
- Marijuana use is often tied to psychotic disorders, ADHD and anxiety.
- Opiates (Percocet, Tylenol w/Codeine) and benzodiazepines (Xanax, Ativan) are more likely to be used by young people with oppositional defiant disorder, conduct disorder and borderline personality disorder.
- Amphetamine (Adderall) use can be a response to overwhelming anxiety and stress related to academic performance.
On the other hand, psychiatric mental health symptoms might result from the direct effect of the substance on the brain. Again, here are just a few examples:
- Alcohol use can cause significant mood fluctuations.
- Nicotine use can mimic anxiety symptoms.
- Psychedelic drugs can cause psychotic states.
Even if it turns out that a young person’s substance use and mental health symptoms are not related to each other, they can still make each other worse.
The next few sections introduce adolescent mental health disorders, their symptoms and treatment, and substance issues that commonly co-occur with these disorders.
Depression and Substance Use
Depression is tough enough on its own, but the combination of substance use and depression in teens elevates the risk of self-harm and sometimes suicide. Teens and young adults who are depressed have chronic feelings of worthlessness and lose interest in things they previously enjoyed. While adults with depression may be sad and lethargic, depressed teens tend to be more irritable, restless and negative. The most common kind of depression is called major depressive disorder. This disorder is made of up severe episodes that last at least two weeks. Persistent depressive disorder has milder symptoms, but it may last for years.
Major Depressive Disorder
If your child has been in a consistent depressed or irritable mood or has lost pleasure in daily activities (or both) for at least two weeks, it’s possible he or she could have major depressive disorder. These symptoms must be very different from previous moods or behavior in order to receive a diagnosis. Other signs of a major depressive disorder include:
- Marked weight loss or gain
- Sleeping too much or too little
- Restlessness, lethargy or fatigue
- Feelings of worthlessness or excessive or inappropriate guilt
- Cloudy or indecisive thinking
- A preoccupation with death, plans of suicide or an actual suicide attempt
Persistent Depressive Disorder
Persistent depressive disorder can be diagnosed when a young person is in a depressed mood or very irritable for most of the day for at least a full year. When a person has persistent depressive disorder, the severity of the symptoms may vary, and sometimes can include episodes severe enough to meet the criteria for major depressive disorder.
When a teen or young person has depression, the thing parents tend to notice first is withdrawal, or when the teenager stops doing things he or she usually likes to do. Of course, teens often make radical changes that are completely normal — the key for parents is to notice when the change lasts for more than two weeks. That can be the main difference between normal teen angst and depression.
Treatment for Depression
Depression is sometimes treatable with therapy or medication alone, but experts agree that a combination including therapy and medication is usually the best approach.
Depression in young people is often treated with cognitive behavioral therapy (CBT) and other specialized evidence-based approaches. Interpersonal therapy (IPT) focuses on changing relationships in the child’s life, behavioral activation (BA) focuses on engaging in activities in order to improve one’s mood, and dialectical behavior therapy (DBT) focuses on helping to regulate emotions. As a parent or family member, you could be involved too. Family therapy is used to engage the family in helping to manage difficult symptoms.
Medications may include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). Parents should closely monitor their children when they’ve just begun taking medication, or when their dose has recently been changed. Antidepressants need to be taken daily as prescribed for at least 2-4 weeks to start being effective, and the dosage will likely need to be adjusted by a clinician.
Depression & Interaction With Substance Use
Adolescents with depression often use alcohol or drugs to dull their painful feelings and to cope with constant negative thoughts. It may work at first, but over time substance use makes depression worse.
Depressed teenagers know there’s something wrong with them, and they often turn first to the remedy peers may be offering: alcohol or drugs. But these substances, by affecting the reward centers of the brain — the same areas that are associated with depression — in turn make them more depressed when they’re not using. Because of this, they’re quickly at risk for problematic substance use or addiction. Addressing only one issue will likely result in treatment failure; integrated care treats these co-occurring disorders as intertwined.
Alcohol use is especially damaging to depressed teenagers because it affects adolescents differently than it does adults. Rather than getting sedated with alcohol, as adults tend to be, adolescents get more energetic and are prone to engage in more risky behavior, including trying to harm themselves.
Anxiety Disorders and Substance Use
It’s perfectly normal for young people to have some amount of anxiety. We start calling it an anxiety disorder when anxious feelings escalate to a point that they interfere with a young person’s ability to handle everyday situations, and can prevent them from enjoying “normal” activities.
Here are some types of anxiety in teens and young adults:
- Generalized anxiety is when children worry excessively about everyday things. Youth with generalized anxiety often struggle with perfectionism.
- Separation anxiety causes excessive worry when young adults are separated from their caregivers, including fear of losing parents and fear of being alone. This is more common in younger children, but can also affect tweens and teens.
- Social anxiety causes teens and young adults to be excessively self-conscious in social situations. Often, social anxiety will inhibit their ability to engage with peers.
- Specific phobia is a fear of a particular thing, like dogs, heights, blood or needles.
- Panic disorder is characterized by sudden, unpredictable panic attacks. A young person experiencing a panic attack may have feelings of impending death or doom and symptoms similar to a heart attack.
Until recently, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) were classified as anxiety disorders. Young people with OCD have unwanted thoughts that they try to get rid of by practicing ritualized behaviors, such as obsessive hand-washing, counting, or lining things up. PTSD symptoms develop after a disturbing event and can include detachment, difficulty sleeping, irritability and reliving the event. While not technically considered anxiety disorders, young people with OCD and PTSD do struggle with feelings of anxiety.
Signs of Anxiety Disorders
Some symptoms of anxiety disorders are:
- Trouble sleeping
- Complaining about stomach aches or other physical problems
- Avoiding situations
- Exhibiting clingy behavior around parents or caregivers
- Trouble focusing in class or being very fidgety
- Disruptive behavior and explosive outbursts
- Overly self-conscious behavior
Anxiety disorders are often difficult to spot in young people. Some experts call anxiety the “great masquerader” because the symptoms can seem like something else. Disruptive or antisocial behavior can be a cover for anxiety. Kids who constantly seek reassurance, are overly hard on themselves, or who cope by escaping into social media or video games may be dealing with severe anxiety.
Treatment for Anxiety Disorders
Anxiety disorders can be treated with behavioral therapy, medication, or a combination of the two.
Most often, anxiety disorders are treated with cognitive behavioral therapy (CBT), which addresses a young person’s worries and patterns of distorted thinking. Exposure and response prevention is one type of CBT often used to treat anxiety. In this type of therapy, young people are exposed to anxiety triggers gradually, in a safe setting. As they become accustomed to each of the triggers, the anxiety fades.
Medication can alleviate symptoms of anxiety and may make behavioral therapy more effective. SSRIs, or selective serotonin reuptake inhibitors, have proven effective at managing anxiety. Fast-acting medications called benzodiazepines (e.g. Xanax, Klonopin) are sometimes used to treat acute anxiety, but are not helpful for reducing symptoms in the long-term. They also carry a risk of dependence and are generally not recommended if someone has a co-occurring substance use disorder due to risk of addiction or overdose if used in combination with alcohol or opioids.
Anxiety Disorders & Interaction With Substance Use
Adolescents with anxiety disorders may use drugs and alcohol to temporarily alleviate anxious feelings associated with socializing, having to present in class, or living up to other expectations. When anxious feelings become too much to handle, alcohol and drugs allow them to feel better for a short period of time.
However, using substances can complicate treatment of anxiety. Because the effects of the substance cover up or mask the anxiety symptoms, it becomes that much more difficult to assess the disorder and provide appropriate treatment.
Additionally, adolescents who use alcohol or drugs to alleviate anxiety symptoms may feel their anxiety is more intense when they aren’t using. This can lead to a pattern of increasing use that can lead to dependence and addiction.
Untreated, anxiety disorders also present long-term risks for substance use or misuse. The good news is that identifying and treating anxiety early can help cut risk of future substance use disorder in half.
ADHD and Substance Use
Attention-deficit hyperactivity disorder (ADHD) is diagnosed when a person has difficulty concentrating, paying attention, sitting still, following directions and controlling impulsive behavior. Children with ADHD have a mix of inattentive and hyperactive or impulsive behaviors which make it challenging to learn at school and often create conflict at home.
About 30 percent of youth with ADHD also have oppositional defiant disorder (ODD). These young people are excessively oppositional to authority and rebellious. When a child has ODD, regular daily frustrations may build up over time, damaging the child/parent bond and reinforcing hostile patterns of behavior.
Characteristic signs and symptoms of ADHD include:
- Making careless mistakes
- Being easily distracted and appearing to not listen when spoken to directly
- Having trouble with organization and frequently losing things
- Excessive talking or interrupting, blurting out answers
What does an adolescent with ADHD look like? By the teenage years, the impact of hyperactive symptoms may have decreased for some teens, but they still have problems with attention, which interferes with succeeding in school or at work. They also may have trouble socially — they can be alienated from peers because of poor self-regulation and difficulty paying attention to the needs and desires of friends. Their self-esteem can take a hit because of these repeated difficulties — some young adults with ADHD can even be withdrawn or depressed because of this.
ADHD treatment typically consists of medication, behavioral therapy, or a combination of the two.
Medications for ADHD include psychostimulants like methylphenidate (Ritalin) and amphetamine salts (Adderall). These medications have been shown in numerous studies to be effective in about 80 percent of youth with ADHD. These psychostimulants, which increase the accessibility of certain chemicals in the brain, help children focus and curb impulsivity and hyperactivity.
Behavior therapies do not eliminate the core symptoms of ADHD, but they can be very helpful in teaching children to manage them better. In children and pre-teens, the main focus of behavior therapy involves teaching parents and educators how to develop supportive relationships with children with ADHD or behavior disorders, how to implement effective behavioral strategies to promote positive behaviors, and how to make clear, calm and predictable decisions in giving consequences for misbehavior. Importantly, at young ages, research clearly shows that it is more crucial that adults learn techniques to manage the behavior of a child with ADHD than it is for a child to be in individual therapy. As children progress into adolescence, individual cognitive behavioral therapy can be helpful in engaging a young person in taking more responsibility for managing their ADHD symptoms or playing a role in problem-solving around their behavior. As one example, if a teen has trouble finishing things and staying organized, she or he can learn techniques for completing tasks and keeping track of assignments.
ADHD & Interaction With Substance Use
Teens and young adults with ADHD are impulsive, sensation-seeking and eager to experiment. They tend to be drawn to substances available in their environment, which may involve low-hanging fruit like nicotine and marijuana. These substances are also attractive because they can temporarily help with core symptoms of ADHD. Nicotine can increase focus in the short term, and marijuana can calm hyperactivity.
Structural and chemical brain differences associated with ADHD also make these young people more responsive to a drug’s effects and more likely to take drugs again. They can go quickly from experimentation to habit, and chronic use actually decreases their ability to pay attention long term. Chronic nicotine use can decrease cognitive functioning and attention while increasing impulsivity.
In some, but not all cases, youth may misuse ADHD medications by crushing and snorting them to get high, or they will sell their meds to classmates. For this reason, medication treatment of ADHD should be carefully monitored by a qualified clinician. In some cases, parental monitoring of administration may be required. Immediate release formulations are easier to misuse and should be prescribed with caution in such cases. There are newer formulations specifically designed to deter misuse by crushing and snorting.
Clinicians report that young people with ODD gravitate to more powerful drugs like prescription opioids (Vicodin, OxyContin) or benzodiazepine anxiety medications (Xanax, Valium) that help them numb painful feelings and escape or avoid frustrating peer and family relationships.
Any drugs, even nicotine, can interfere in evaluation and treatment for ADHD. Vaping or Juuling nicotine, for example, delivers very high amounts of the chemical to the brain. The side effects of nicotine (alertness, anxiety, insomnia, loss of appetite) are also associated with stimulant medications, which unfortunately can confuse the picture and potentially lead to poor treatment outcomes. Nicotine, by way of interacting with the enzymes that metabolize the medications in the liver, can lower the effectiveness of some medications. It’s important that mental health professionals have as many details as possible in order to provide the best treatment.
Bipolar Disorder and Substance Use
Bipolar disorder, also known as manic-depressive disorder, involves bouts of major depression and periods of mania or hypomania— euphoria, poor judgment and extreme risk-taking activity — in an often-debilitating cycle. It usually begins in late adolescence or early adulthood.
Teens and young adults with bipolar disorder will show signs of both depression (prolonged sadness, lack of interest in things they previously enjoyed, sleeping too much) and mania (periods of excitability or irritability, exaggerated self-confidence, even recklessness). For many, the onset of bipolar disorder is marked by a depressive episode; in others, it is a manic episode. How long and how often between depressive and manic episodes varies quite a bit, especially in younger people.
Being on the lookout for symptoms of mania is particularly important if someone already has depressive symptoms. Bipolar disorder with an unnoticed manic component can be misdiagnosed as major depressive disorder — but the medications used to treat depression can be dangerous for someone with bipolar disorder, making accurate diagnosis very important.
Signs of Mania in Bipolar Disorder:
- Drastic personality changes
- Excitability and irritability
- Inflated self-confidence
- Grandiose/delusional thinking
- Decreased need for sleep
- Increased talkativeness, racing thoughts and scattered attention
- Psychotic episodes, or breaks from reality
Signs of Depression in Bipolar Disorder:
- Loss of interest or pleasure in things once enjoyed
- Marked weight loss or gain
- Decreased or increased need for sleep
- Lethargy or fatigue
- Feelings of hopelessness, helplessness, worthlessness
- Excessive or inappropriate guilt
- Preoccupation with death, plans of suicide or an actual suicide attempt
Psychotic episodes in young people with bipolar — essentially breaks from reality — can occur during manic episodes and severe depressive episodes. During a manic episode, these can include delusional thinking, such as proclaiming, “I can fly!” Psychosis is often the first outward sign of bipolar disorder.
Bipolar Disorder Treatment
Medication is essential to the treatment of bipolar disorder, as is the involvement of the whole family.
The first-line medication used to treat bipolar disorder is often a mood stabilizer such as lithium and various anticonvulsants (anti-seizure medication), which are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. In children and adolescents, antipsychotic medications can be used as first line treatments for acute manic episodes. Other drugs may be prescribed to treat symptoms like psychosis (antipsychotics) or trouble sleeping (anti-anxiety medicine). Many people with bipolar disorder take more than one medication that requires monitoring by an experienced clinician.
Bipolar disorder is often treated with cognitive behavioral therapy (CBT) in addition to medications. CBT helps children and adolescents with the disorder understand what triggers their episodes, how their thoughts influence their feelings, and how to control and manage them. A specialized form of CBT called social rhythms therapy helps reduce symptoms by encouraging regular and predictable routines. Family therapy is often employed to engage parents and other family members in keeping track of symptoms and managing stress levels to prevent the onset of manic or depressive episodes.
Bipolar Disorder & Interaction With Substance Use
Nearly 60 percent of individuals with bipolar disorder have a co-occurring substance use disorder. Many adolescents and young adults receive a diagnosis of bipolar disorder after seeking help for substance use issues, since drugs can bring on the manic episodes that are the most visible sign of bipolar disorder.
The behavioral symptoms of bipolar disorder also often lead to substance use problems. Impulsivity is a defining symptom of bipolar disorder — not only during a manic episode, but also between episodes. Young people with bipolar disorder are thus more likely to experiment with drugs and alcohol always.
Finally, as with many disorders, drug and alcohol use complicate diagnosis and make treatment difficult. Medications used to manage bipolar disorder have side effects such as weight gain and sluggishness that young people dislike and often decline to take. In addition, during stable stages they may be convinced they don’t need help or prefer to self-medicate. Medication non-compliance is a common consequence of substance use in bipolar disorder, which causes increased frequency and severity of mood episodes.
Drugs commonly used by youth with bipolar disorder, like nicotine and alcohol, also present a real chemical barrier to treatment effectiveness. Nicotine competes with enzymes necessary to make medications work in the body, and the effects of alcohol on the liver also decreases the availability of these enzymes. These drugs literally change the way a person’s body responds to psychiatric medications, leading to a smaller or larger than expected effect. Parents and concerned adults can help explain the importance of medication adherence, and other substance interactions.
Schizophrenia and Substance Use
Schizophrenia is a disorder characterized by distorted perceptions of reality and disorganized thinking and speech. People who have schizophrenia experience periods of time where they lose contact with reality in the form of hallucinations and/or delusions. They may also experience low motivation and poor attention. It begins usually in late adolescence or early adulthood, often starting with a psychotic episode, or break from reality. Hospitalization is often needed for severe symptoms.
Symptoms of Schizophrenia
- Hallucinations: seeing, hearing, feeling or smelling things that are not actually there
- Delusions: false beliefs that others clearly realize are not true
- Disorganized thinking: jumbled speech, making up words, jumping between topics
- Odd or disorganized behavior (sudden agitation, disheveled appearance, inappropriate sexual behavior) or physical activity (bizarre body postures or excessive motor activity)
- “Negative” symptoms: reduced emotional expressiveness, apathy, social withdrawal, loss of pleasure in things that used to be enjoyable, diminished speech
Parents and family members often notice signs of schizophrenia when a young person insists on delusions like that the television is talking specifically to them, or that the government is after them. While many families first discover that a child has schizophrenia only after a psychotic episode, symptoms of psychosis can develop gradually, as a child has fleeting delusions, withdrawal, moodiness, or a reduced range of emotions, or neglecting hygiene. Noticing these “prodromal” symptoms and treating the adolescent with appropriate therapy can reduce the chance of full-blown schizophrenia in the future.
The recommended treatment for schizophrenia, called Coordinated Specialty Care, involves a combination of services coordinated by a group of professionals working with the patient and the family. Elements of the treatment include:
- Low doses of antipsychotic medication
- Cognitive behavioral therapy for psychosis (CBTp)
- Family education and support
- Educational and vocational rehabilitation
The most commonly prescribed drugs for schizophrenia are antipsychotic medications like risperidone (Risperdal) and olanzapine (Zyprexa).
Schizophrenia & Interaction With Substance Use
Some experts estimate that 50 percent of the young people seeking help after a psychotic episode report having used drugs or alcohol. Marijuana is the most common substance, but patients also report using alcohol, K2 (synthetic cannabis), LSD, cocaine and opioids.
In fact, multiple studies have shown that marijuana use in adolescence can make individuals who are vulnerable to schizophrenia have an episode earlier and perhaps more severe than they might have had they not used. For those who have had a first psychotic episode, continued substance use will make them more likely to have ongoing psychotic symptoms and more likely to have a relapse into another full-blown psychotic episode.
Conversations about substance use are an important part of treatment for schizophrenia. After a first episode, young people are eager to get back to normal, to resume their old lives, and that may mean returning to substance use. For young people with schizophrenia, it may be hard for them to accept the fact that their friends may be able to use substances, especially marijuana, but that for them, it could interfere with recovery and contribute to a recurrence of symptoms.
Something that works in favor of giving up substances is to focus on the desire to avoid further hospitalizations. It’s also important for parents and clinicians to understand what substance use did for their young adult (asking what need it filled, or why use began in the first place) and encourage him or her to replace it with healthy alternatives.
Borderline Personality Disorder and Substance Use
Borderline personality disorder (BPD) has historically been difficult to understand and cope with for young people and their families. The symptoms are a painful mix of emotional turmoil, and unstable sense of self, volatile relationships and self-destructive behavior, including suicide attempts.
People who develop BPD are by temperament highly emotionally sensitive and reactive. When their very intense feelings are chronically dismissed as an overreaction, they have difficulty managing their emotions, and are often overwhelmed by intense anger and feelings of abandonment, emptiness, shame and self-loathing.
While in the past BPD was not diagnosed before the age of 18, it is now recognized that onset is often in adolescence. The earlier treatment begins, the better the outcome.
Symptoms of Borderline Personality Disorder
These are the criteria used to diagnose borderline personality disorder:
- Frantic efforts to avoid abandonment, real or imagined
- A pattern of unstable and intense relationships
- An unstable self-image or sense of self
- Dangerous impulsivity such as unsafe sexual encounters, substance use
- Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
- Emotional instability due to high reactivity
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoia or severe dissociative symptoms
A young person with BPD might be overly sensitive to how their friends or fellow students think or act, and quick to interpret things negatively. Minor slights are taken as evidence of abandonment, and the reaction can be swift and intense. She or he might go from “I love you” to “I hate you” in a heartbeat.
Young people with BPD often find unhealthy ways to manage their emotions, including substance use, risky sex, reckless thrill-seeking and self-injury like cutting, scratching and opening wounds.
Borderline Personality Disorder Treatment
The gold-standard treatment for borderline personality disorder is dialectical behavioral therapy (DBT). DBT teaches patients skills to regulate their overwhelming emotions and stop self-destructive behaviors. While in the past BPD was considered largely treatment resistant, long-term studies show that those treated with DBT have a good prognosis: In one study 74% of participants had no active symptoms after 6 years.
Medications cannot treat BPD itself but may be used to reduce specific symptoms including aggression and anxiety. Young people with BPD are often misdiagnosed with bipolar disorder, depression or ADHD, and may be given medications that are ineffective or harmful. As with bipolar disorder, early identification by a clinical professional is very important.
Hospitalization may be required for young people who are at risk of self-injury.
Borderline Personality Disorder & Interaction With Substance Use
Substance use is very common in teenagers and young adults with BPD. Alcohol, nicotine and marijuana are the most commonly used substances, and studies show that as many as half of all BPD patients meet criteria for a substance use disorder.
Young people with BPD tend to use drugs or alcohol not to get “high” but to feel less empty or to numb painful feelings, including self-loathing.
Alcohol and other substances worsen the symptoms of BPD, increasing paranoia and impulsivity. Young people with BPD who use are more likely to have risky sexual encounters, contract sexually transmitted diseases and make more serious suicide attempts. Substance use also interferes with treatment for BPD.
Encouraging Your Young Adult to Seek Treatment
Even when adolescents or young adults are willing to consider treatment, it’s not uncommon for them to still feel hesitant or unsure. They may think that the problem “isn’t that bad” or that there’s no need for formal treatment. A child may think that help is needed for only the mental health part, like anxiety, but not substance use problems. In some cases, he or she may be reluctant to try treatment for fear that it will get in the way of school, work, sports or other activities. Stigma related to treatment may be a contributing factor to this resistance, too.
So how do you convince your son or daughter to try treatment? Prepare yourself before you sit down to have this important discussion. The following guidelines may help:
- Make an effort to see matters from your child’s point of view. How will treatment benefit your child? Will he feel healthier? Will she be more successful at school, work or sports? Will he get into the college of his dreams? What will your child see as the downside of treatment? Will he have trouble socializing without substances? Will she have to give up certain friends? Acknowledging both the positive and not-so-positive aspects of engaging in treatment can help the conversation go more smoothly.
- Determine what’s important to your child and frame the conversation. For example, some kids are reluctant to talk about substance use, but may be more comfortable talking about their mental health problem, such as depression or anxiety. If this is the case, talk about getting help for the area that they are willing to work on. Discuss with the treatment team you choose how to include other concerns.
- Do your homework and be ready with treatment options. Research programs to find ones that are a good fit for your child. If possible, it helps to offer options so that young people can make their own decision as opposed to being told what to do. For some kids, starting with a “consultation” with a counselor is less threatening than talking about long-term treatment.
- Use motivational “hooks.” Highlighting what your adolescent or young adult might gain related to treatment (e.g., better sleep, higher self-esteem, less stress) will likely be better received than talking about substances to give up. Some parents use incentives tied to something a child wants as a way to get them to engage in treatment. For instance, you could say something like, “If you complete eight outpatient sessions, we can discuss getting the video game you want.”
- Consider past attempts. If previous attempts to suggest treatment haven’t worked as planned, take time to consider why the discussion didn’t go well. What didn’t work? What would you change? Was the discussion too lengthy? Was it bad timing? What got in the way? Try to incorporate what you’ve learned to make this go more smoothly, including the timing of the conversation, a collaborative tone of voice, providing options, and incentives.
- Consider barriers to treatment. Does your insurance cover the cost of co-occurring treatment? Can you pick up costs that aren’t covered? Will transportation to and from treatment be a problem? Will your child be able to keep up with school? Address these matters before you talk to your child.
- Practice what you want to say. Once you have gathered the relevant information suggested above, it can be helpful to write down what you want to say. As you write, think about how your child might respond.
A Note About Required Consent for Treatment
If your child is a minor under the age of 18, you may assume that your consent is sufficient to get treatment started; however, this may not be the case. State laws vary considerably in terms of age of consent, in some instances being as low as 12 years of age. Additionally, who can consent may change depending upon whether the treatment program is for mental health or substance use and whether the facility is outpatient or inpatient. Often there is no guidance in situations where the parent and child disagree, leaving it up to the courts to figure it out.
If your child refuses consent, asking other family members or friends to step in may help, especially if there is someone your child trusts and respects. Some parents look to educational or religious organizations to forcefully encourage young people into treatment, although research shows that outcomes are more likely to be positive if your child voluntarily agrees to treatment.
Alternatives to Treatment
If your child flatly refuses to seek treatment, there may be other healthy alternatives to consider in the meantime. Mindfulness meditation, for instance, is an effective way for many people to decrease their use of drugs and alcohol, and has also been proven to help with depression, anxiety and other mental health disorders.
Exercise is another useful strategy. It may be worthwhile to pay for a gym membership or yoga or dance classes. Is your child interested in music? Guitar or singing lessons may be a great diversion and an excellent way to increase confidence and self-esteem.
There are a number of ways kids can get help and support, even if they aren’t ready to make significant, long-term changes. An agreement to experiment with abstinence or to reduce their substance use by engaging in healthier activities can be considered a big win that often leads to greater changes.
Addressing Crisis Situations
Call 911 immediately if you’re concerned that your child is violent or may be suicidal or overdosing. Tell responders that your child is having a mental health emergency with as many details as possible so they can be prepared when they arrive. You can also call the National Suicide Hotline at 1-800.273.8255. The free hotline is available 24 hours every day.
- Some states offer mobile response services that respond 24 hours a day, seven days a week, providing help at your home to assess your child and help calm the situation. In addition, services include supportive counseling and referrals to community-based mental health, usually provided free of charge.
- You may consider driving your child to the nearest emergency room or crisis center, but only if you can do it safely. If possible, call and let the ER know when you leave, so they can be prepared when you arrive. If you don’t feel you can drive, ask for recommendations on what you should do next. Don’t transport a child against his or her will.
If you think your child isn’t in immediate danger, but is still in need of help, there may be several options to consider depending on available services in your state or community. The following suggestions may help you determine the best course of action:
- If your child has a therapist or treatment team (e.g. psychiatrist, therapist, nurse, etc.), they should be the first point of contact. People who know your child’s history are in a good position to help you figure out the next step.
- Call your local community mental health crisis center, which can be found using an internet search. Specific services vary widely depending on the state or county, but most offer specialized outpatient treatment for youth. Staff usually includes a team of mental health professionals, such as psychologists, psychiatrists, social workers and nurses.
Regardless of whom you call, the first step is an evaluation or screening. Every effort will be made to understand your child’s needs and to consider various alternatives for treatment.
Quality Treatment and How to Get It
If you’re concerned your child has co-occurring substance use and mental health disorders, it will be helpful to consult a professional who is well versed in both mental health and substance use. This can include an evaluation with a qualified addictions professional. This evaluation can help to develop a preliminary diagnosis and a recommendation for the best treatment approach. Your child’s symptoms, age, gender and culture, among other factors, will help determine his or her treatment plan.
Providers can be found using the Substance Abuse and Mental Health Services Administration (SAMHSA) or American Society of Addiction Medicine (ASAM) directories, Psychology Today or through your insurance provider, who may have an online portal to search specifically for addictions professionals. Evaluations usually take place in a private practice or intensive outpatient setting, although some are done in hospital settings. Regardless of the setting, it’s important to talk to a person who is well-versed in both mental health and substance use to get a good read on what problems need to be addressed. For more information refer to Section Three, which covers differential diagnosis.
Depending on your child’s needs and how severe his or her symptoms are, there are several different levels of care. These include counseling, intensive outpatient programs (IOP), partial hospitalization programs (PHP) and rehab or residential care. Generally speaking, your child will be placed in what is considered to be the least restrictive level of care.
The most effective treatment for co-occurring disorders involves integrated care. This means that both mental health and substance use are treated at the same time by knowledgeable providers (for example, a psychiatrist, psychologist, case manager, medical team, etc.) who develop and implement an integrated treatment plan for both.
The treatment plan should include goals, objectives, treatment team members and their qualifications, evidence-based interventions including therapy and medications, and other services (such as vocational skills or academic supports) that will be offered.
Evidence-based interventions can include:
- Cognitive Behavioral Therapy (CBT)
- Trauma-Focused CBT (TF-CBT)
- Contingency Management
- Dialectical Behavioral Therapy (DBT)
- Motivational Interviewing (MI)
- Multisystemic Therapy (MST)
- Acceptance and Commitment Therapy (ACT)
Programs should also address physical health issues, whether offering on-site testing and counseling or referrals to other service providers. This can include issues like asthma, pain management, sleep disturbances, HIV, Hep C and sexual health.
What Should You Look for in a Quality Treatment Programs?
- A comprehensive treatment plan to address mental health and substance use. Parents and/or the child (depending upon age) should be asked to agree to and sign off on the treatment plan. The treatment plan should be periodically reviewed and updated to reflect progress or modifications to the plan and approach.
- Programs that include a family component as part of the treatment plan to provide education, skill building, resources and support. Often there is an opportunity to interact with other families to share what’s working and what can be improved.
- Programs that promote interactions with mentors, healthy activities and the recovery community. Often adolescents and young adults will need help engaging in activities like sports, volunteering and other organized social events; reconnecting with hobbies and interests that have gone by the wayside; and hanging out with healthier peers.
Many facilities advertise that they offer treatment for co-occurring disorders, but it’s important to do your homework and find out exactly what they mean by that. For instance, some providers won’t work on mental health issues until a person is totally abstinent from substance use. Others might say they treat co-occurring disorders, but what they really mean is that there’s a nurse on hand to dispense psychiatric medications, or a psychiatrist who will write a prescription based upon the diagnosis your child was given prior to admission to the program.
Medications selected must take into account both substance use and mental health, as there are some medications that might not be recommended for people who struggle with substance use. For example, many practitioners won’t prescribe Adderall for ADHD or Xanax for anxiety due to their misuse potential.
Programs may offer yoga, meditation classes, art therapy and other activities as supplements to treatment. Some programs may offer 12-step/mutual aid groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) or SMART Recovery on premises, or require that your child attend on days when he or she isn’t in programming at the facility. Other supports that may help include National Alliance on Mental Illness (NAMI)’s OK2Talk Program or the Depression and Bipolar Support Alliance (DBSA) support group.
Quality programs will develop a comprehensive discharge or continuing care plan, including referrals for a step down to a lower level of care (e.g. a PHP to IOP, or IOP to individual counseling and a psychiatrist). One critical component of continuing care is a relapse prevention plan that identifies high-risk situations or circumstances, early warning signs and symptoms, and flags or problems related to medications, providers, relationships, daily structure, transportation or finances. In addition, it may help to identify an “accountability partner” to help keep your child on track with healthy living and to discuss what the next steps will be should a relapse occur.
The Family Role in Supporting Your Child
The family role in supporting a child with co-occurring disorders is critical. This includes everything from recognizing that there is a problem, to motivating a child to get help, to navigating the treatment system to find the best fit for your child and helping him or her sustain gains in recovery. It can be a significant emotional, time and financial commitment, but research shows that family involvement improves outcomes. Families can also help ensure diagnosis is accurate.
In addition to the mechanics of getting treatment and providing information to the treatment team, you can also help in other ways:
Encourage Treatment Participation
Encourage your child to keep appointments and participate in all aspects of his or her treatment plan. This may include individual, group and family therapy, medications and job and life skill-building. If a case manager is working with your child, stay on the same page and provide input on progress made, as well as setbacks. Keeping a calendar of appointments and ensuring transportation is available if needed may be necessary.
Some parents use positive reinforcement to improve chances that their child will stick with a treatment plan. Hearing that their parent is proud of them or receiving a letter from home while in residential treatment to keep them motivated can be very meaningful to young people. As a parent you can also offer incentives for participating in treatment, as mentioned previously in Section Ten.
Provide Emotional Support and Encouragement
Often adolescents and young adults so desperately want to be “normal.” They don’t want to have to deal with treatment. They don’t want to take any medication. They are hyper-aware of stigma and may minimize one or both disorders as a result. Listening to concerns and being empathetic can go a long way toward helping them stay the course, in addition to simply letting your child know that you care.
Some adolescents and young adults have been to multiple treatment programs and may feel demoralized or that “nothing works.” You too may feel hopeless if your child needs treatment yet again. It can help both of you to reflect on any aspect of previous treatment that was useful (such as learning about his mental health challenges, finding a therapist that she liked, feeling better for even a short period of time, learning a new coping skill, meeting someone in treatment that he could relate to, etc.). It helps if you think about every treatment episode as an opportunity to build upon what was already learned.
Participate in Family Education
Many programs offer what is referred to as a psychoeducational group for families. These groups are provided so that families can learn more about mental health symptoms, signs of substance use, treatment options, medications and relapse warning signs. It’s also a place where families can process what has happened since the last session and get advice as to how to respond more effectively if warranted.
A family weekend or four-day educational program is often offered in residential treatment settings. There are also designated times for visits and, in some cases, time off campus.
Attend Individual and Family Counseling
Participate in individual counseling and family counseling if offered, both with and without your child. These sessions can help you address concerns, improve family interactions and problem solve with the support of a counselor in a safe environment. Skilled therapists can help you and your loved ones learn how to relate to each other and respond effectively to build a stronger family.
Assist With Medication Management
In addition to providing input to doctors when prescribing medications to your child, you may need to fill prescriptions and give your child the medication, depending on his or her age. It can help to keep a notebook of the name of the medicine, the prescribed dosage, and what you notice with respect to side effects and symptom reduction. If multiple medications are needed, it can help to get a weekly pillbox from the pharmacy to organize pills rather than counting them out each day.
It isn’t uncommon for young people to be dissatisfied with their medications at first. This may mean that the medication they are taking has side effects they don’t like. It can also mean that the substances they were using did a better job of addressing their anxiety, boredom or other reasons for use. In either case, it can be helpful to discuss this with the treatment team to make adjustments if necessary. Often visits with psychiatrists are very brief — sometimes just 15 minutes — so being prepared to discuss how the medication is working is critical and can make the most of the session.
Alcohol and other drugs can worsen mental health symptoms and interact negatively with medications. Keep all substances out of your home, including household products that can be used as a substitute for alcohol (like hand sanitizers or vanilla extract), as well as products that can be sniffed or huffed (like keyboard dust cleaners). If you do keep alcohol or marijuana in the home for your personal use, keep it secured along with any medications that can be misused.
Help Establish Structure and Meaning
Co-occurring disorders can disrupt your child’s sense of purpose, throwing daily structure into a tailspin as substance use and mental health problems dominate your child’s life. Getting back to meaningful activities is one of the cornerstones of recovery and can help motivate your child to manage their mental health and provide reasons to stay sober. Asking about and encouraging involvement in school, work, volunteer activities, hobbies, sports and other interesting activities is important.
Hopefully, the treatment team will guide you and your child in creating a purposeful, structured day, but if not, try to put a plan together with your child. A weekly planner can be helpful in terms of establishing a schedule for when to wake up, do chores, attend school or work, participate in recreational activities, attend counseling, etc. This is not to suggest that every minute of every day must be scripted, but it can help to set expectations and to identify gaps in your child’s schedule that can be filled with meaningful activities.
Promote Healthy Social Supports
Support groups can be a great way for your child to meet other people who understand what he or she is going through. Groups are also a potential source of resources and referrals, along with social supports for engaging in activities that promote well-being. Encourage attendance at meetings for substance use such as 12-step (e.g., AA or NA) and SMART Recovery. You can search for mental health peer support groups at association websites (e.g. Anxiety and Depression Association of America (ADAA), Depression and Bipolar Support Alliance (DBSA) or National Eating Disorder Association (NEDA). Dual Recovery Anonymous is a 12-step meeting specifically for people with co-occurring disorders. Many of these organizations have meetings that can be attended online or in person and have other useful content on their websites.
Your child may welcome your participation at a meeting or prefer to go alone or with a friend. Take your child’s lead on this issue, especially if he or she would prefer to attend without you being there. Your child may welcome the opportunity to share with the other members but be reluctant to say anything in front of you. Also, every meeting is different so if your child doesn’t care for one, encourage trying a different one.
One note of caution: Some participants at 12-step meetings believe that medications are a crutch and unnecessary for “true recovery.” This is not the official position of these organizations, with the exception of Narcotics Anonymous. NA has taken a position stating that anyone on medication-assisted treatment (MAT) for opioid use disorder is not abstinent. Despite overwhelming evidence that MAT can save lives, some NA meetings will limit the participation of anyone on MAT. If your child is on MAT, he or she may be better served by a different support group.
You can also help adolescents and young adults find and engage in sober recreational activities. Aside from support groups, recovery centers host outings (such as flag football, 5K runs, coffee houses, movies, game night, cooking classes, picnics, etc.) that may be of interest to your child. Many kids think they will never have fun again if they aren’t using substances, so helping them learn to how to do this is an important part of recovery.
Join Family Support Groups
Support groups for families geared toward a loved one’s substance use include Al-Anon, Nar-Anon, Families Anonymous and SMART Recovery for Friends and Family. In addition, most of the mental health associations mentioned earlier provide supports to families as well. AA and Al-Anon as well as NA and Nar-Anon often host meetings at the same time and location. If the opportunity presents itself, it’s nice to attend and compare notes afterwards over a cup of coffee or ice cream.
Foster Coping Skills
Help your child learn to address stress in a healthy way by developing coping skills. Stressors can be major, such as an unexpected loss, moving, attending a new school or starting a new job, or they can be minor, such as everyday annoyances or worries. Coping skills can help your child deal with these issues and with mental health symptoms related to depression, anxiety, sleep problems and hallucinations, as well as cravings to use substances.
Help your child process stressful experiences by being there as a sounding board to listen. It can help to ask questions like “What do you think you should do under the circumstances?” or “How do you think you want to handle this situation?” rather than jumping in with answers. While it may be tempting to solve problems for your child, it can undermine self-esteem and confidence. Reminding your child of coping strategies for managing stress can also be helpful, like taking deep breaths or learning to meditate. Your child’s treatment team should be able to provide advice about how to support your child in developing healthy coping skills.
Engage in Self-Care
Helping someone with co-occurring disorders is like being in a marathon than a sprint, so self-care is critical. Remember that if you fall apart, you won’t be able to help your child. Coping with your own stress without using substances, eating nutritious meals, exercising, taking medications as prescribed, getting regular sleep, attending support group meetings, etc., can help you feel better while modeling a healthy lifestyle for your child. Engaging in mindfulness practices (like yoga, breathing exercises, meditation, Tai Chi, or guided visualizations) can also be useful and can be done with your child or as a family.
Know the Signs of Relapse
It isn’t unusual for relapses to happen, despite quality treatment and your child and family’s best efforts. Knowing your child’s “vital signs” for both mental health and substance use disorders is important to head off a relapse as well as to address one should it occur.
The symptoms of relapse are often different for mental health and substance use, so it may take some careful thought to identify what to look for. The treatment team and your child can be helpful in figuring out what the early warning signs are and what to do if you spot them. Having a relapse prevention plan in place can help shorten its duration, getting your child back on track to well-being.
Hope that things can be better is a powerful motivator that can strengthen a person’s desire and determination to attend to their health and well-being. You and other family members can play a critical role in helping your son or daughter feel hopeful, recognize that change is possible and that he or she can lead a wonderful, fulfilling life.
Resources for Co-occurring Disorders
It can be a huge help to educate yourself about substance use and mental health disorders. In addition to the Child Mind Institute (childmind.org) and Partnership to End Addiction (drugfree.org), there are many resources available. If your child is already engaged in formal treatment, consider asking your child’s treatment team for resources, too.
The National Institute of Mental Health (NIMH) offers information on disorders as well as clinical trials.
National Institute of Drug Abuse (NIDA) offers research on the state of the science in the occurrence of substance use disorders with mental illness and physical health conditions.
National Alliance for Mental Health (NAMI) offers a free, 12-week course in local communities called Family-to-Family for caregivers living with a loved one with mental health disorders.
Substance Abuse and Mental Health Services Administration (SAMHSA) offers free e-booklets and guides to download on various co-occurring disorders. They also offer a treatment locator service. It’s helpful to watch their short video to learn how to use their search capabilities.
Mental Health First Aid offers an 8-hour course to help participants recognize when a person is having a mental health or substance use challenge and how to help.
Crisis Text Line connects people with Crisis Counselors trained to bring texters from a hot moment to a cool calm through active listening and collaborative problem solving.
Associations and alliances for mental health disorders may have useful resources to consider:
- Anxiety and Depression Association of America (ADAA)
- International OCD Foundation (IOCDF)
- National Eating Disorders Association (NEDA)
- Depression and Bipolar Support Alliance (DBSA)
- International Bipolar Foundation (IBPF)
- Schizophrenia and Related Disorders Alliance of America (SARDAA)
- National Alliance of Mental Illness (NAMI)
- Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
- National Education Alliance for Borderline Personality Disorder (NEABPD)
The American Academy of Child and Adolescent Psychiatry (AACAP) offers a resource center with information on mental health disorders as well as substance use, bullying, suicides, trauma, etc.
The Brain & Behavior Research Foundation engages in cutting-edge research to find cures for mental illnesses. They also offer the Healthy Minds Public Television Series with Dr. Jeffrey Borenstein and webinars that are informative for public viewing.
MindTools.io rates platforms and apps for teens, adolescents and adults related to mindfulness, stress management, insomnia, substance use, mental health and counseling. Some of the apps are free while others have a nominal fee.