Anxiety and heavy drinking turn up together often enough that treating either one alone tends to disappoint. This page is about treating both at once.
Two questions shape how that goes. Is the anxiety its own disorder, or is the drinking producing it? And does the program treat the two as one problem, or hand them to two people who never speak?
What follows covers why the which-came-first question matters less than it feels like it does, how each condition feeds the other, how a clinician tells withdrawal anxiety from an anxiety disorder, what integrated treatment looks like at each level of care, and what aftercare has to carry. Our hub on co-occurring disorders sets out the wider picture.
Which came first, and why the answer matters less than people think
Usually nobody can tell, and the treatment plan does not wait for an answer.
Mental disorders commonly co-occurring with substance use disorders include anxiety, depression, post-traumatic stress disorder, disorders of psychosis, borderline and antisocial personality disorders, and others [3]. That is a list of the company alcohol keeps. It is not a causal chain.
Three routes lead to the same place, and NIMH describes all three. Certain environmental factors, like stress or trauma, and genetics, can contribute to developing both substance use disorders and other mental disorders [2]. Mental disorders can lead to an increase in risky behaviors, including using substances to cope [2]. And substance use can contribute to brain changes that increase the risk of other mental disorders [2].
So the order is often genuinely unknowable. What is knowable is what is happening now. That is what an assessment is for, and it is a better use of the first appointment than an argument about history.
How anxiety and substance use reinforce each other
Each one makes the other easier to keep doing.
Alcohol is short-acting. It works as self-medication for an evening and stops working over months. NIAAA’s own screening list asks whether a person has continued to drink even though it was making them feel depressed or anxious, or adding to another health problem [1]. That question is on the list because the pattern is common enough to help make a diagnosis.
The other direction is physical. Substance use can lead to changes in some of the same brain areas that are disrupted in other mental disorders, such as schizophrenia, anxiety, mood, or impulse-control disorders [3].
Then there is the end of each drinking cycle. Mild alcohol withdrawal generally consists of anxiety, irritability, difficulty sleeping and decreased appetite [5]. Someone drinking daily to manage anxiety wakes up more anxious than they went to bed, which is a reason to drink again by lunchtime. The loop closes itself.
Why treating one without the other usually fails
Because the untreated half keeps restarting the treated half.
It is usually better to treat these health issues at the same time rather than separately, and research suggests that this can make all the treatments more effective [3]. Research also shows that integrated treatment leads to better health outcomes for people with substance use and other mental disorders [3].
Integrated care combines mental health and substance use treatment so patients can receive more convenient, coordinated care [2]. In practice that means one team, one plan and one record, rather than two appointments that never mention each other.
It matters more here than it would with a simpler presentation. People who have co-occurring disorders often have symptoms that are more persistent, severe, and resistant to treatment [3]. A program treating only the drinking is treating the easier half of a harder problem.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, call or text 988.
Treatment for alcohol use and anxiety in Georgia
Promises Atlanta, in Dacula, Georgia, publishes medical detox, residential rehab and aftercare planning, and describes itself as a place for people with substance use disorders and co-occurring mental health conditions. Its own what-to-expect page says medical detox there is offered on a case-by-case basis, so ask about it on the first call. Say on the first call that anxiety is part of the picture, because it changes what level of care fits.
See treatment options in Georgia
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Promises Atlanta is part of our family of treatment centers. See the Promises Atlanta campus.
Assessment: separating substance-induced symptoms from an independent disorder
History, timeline and measurement. There is no blood test for this.
Accurate diagnosis is key for treating co-occurring substance use and mental disorders, since symptoms may overlap [2]. Anxiety is the clearest case of that overlap. It is a symptom of an anxiety disorder and a symptom of alcohol withdrawal, and from the outside the two look identical.
What a clinician uses instead of a test is the shape of the history. Anxiety disorders involve more than occasional worry or fear, and for people with these disorders, anxiety does not go away, is felt in many situations, and can get worse over time [4]. Symptoms that began years before the drinking, or that persist well past the withdrawal period, point one way. Symptoms that rise and fall with the drinking cycle point the other.
The withdrawal side of that question is also the dangerous side, and it gets measured rather than eyeballed. Severe alcohol withdrawal usually brings visible trembling of the hands and arms, sweating, a raised pulse and blood pressure, and nausea [5]. Seizures and true delirium tremens are the most extreme forms, and those outcomes can lead to fatal consequences [5]. Clinicians score it with a standardized instrument such as the CIWA-Ar, which walks through nausea, tremor, anxiety, agitation, perceptual disturbance, headache and disorientation [5]. People with a history of severe withdrawals, multiple withdrawals, delirium tremens or seizures are not good candidates for social detoxification programs [5].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, call or text 988.
Our explainers on medical detox and withdrawal symptoms describe that stage in more detail.
Integrated dual diagnosis treatment, level by level
The level of care changes. The principle does not.
At the intensive end, a stay begins with a medical assessment and, where the drinking has been heavy and daily, supervised withdrawal management. Anxiety is loudest here, because withdrawal produces it directly [5]. Very little psychological work happens in the first days, and that is not a failure of the program.
Residential care is where the two conditions start being treated as one. The point of integrated care is coordination, so patients get mental health and substance use treatment in one place rather than in two [2]. A reader comparing programs can test that claim with one question: does the same team hold both parts of the plan?
Step-down care is where anxiety usually becomes the harder half. The drinking has stopped, the structure is thinning out, and the symptoms that the drinking used to mask are now unmasked in ordinary life. Our guide to levels of care explains how the rungs relate, and our page on how to get into rehab covers what the first call involves.
Medication considerations when both are present
Two prescriptions, one prescriber, and no decisions made alone.
Medications can effectively treat addictions to opioids and alcohol and lessen the symptoms of many other mental disorders [2]. Three medications are currently approved by the US Food and Drug Administration to help people stop or reduce their drinking and prevent a return to drinking: naltrexone, acamprosate and disulfiram [1]. All of these are nonaddictive, and they may be used alone or combined with behavioral treatments or mutual-support groups [1].
Treatment for the co-occurring side may include medications, psychosocial interventions, or a combination, depending on the needs of the individual and the substances involved [3]. We publish no doses, schedules or comparisons between medications here, because those belong to the prescriber who has examined you.
The practical point is the one people get wrong on their own. Stopping an existing anxiety prescription, or starting one, is a clinical decision made with the person who wrote it. Bring the bottle and the prescriber’s details to the assessment. Our page on medication assisted treatment covers how medication fits alongside the rest.
Therapies with evidence for co-occurring presentations
The named therapies are the same ones used for each condition alone, applied to both at once.
Cognitive behavioral therapy, contingency management, and motivational interviewing can help individuals build coping skills [2]. Family-based interventions, such as Multisystemic Therapy and Functional Family Therapy, can be particularly effective [2]. Behavioral treatments for alcohol use disorder are provided by licensed therapists and are aimed at changing drinking behavior; examples include brief interventions and reinforcement approaches, treatments that build motivation and teach skills for coping and preventing a return to drinking, and mindfulness-based therapies [1].
What makes any of it integrated is not the technique. It is whether the anxiety work and the drinking work are being done by people who share a plan.
Our overviews of substance abuse counseling techniques and dialectical behavior therapy describe what the sessions involve.
Relapse risk and what aftercare needs to cover
Aftercare that covers only the drinking leaves the trigger in place.
People who have co-occurring disorders often have symptoms that are more persistent, severe, and resistant to treatment [3], which is why a discharge plan built on abstinence alone tends not to hold. The anxiety does not leave when the alcohol does. For some people it gets louder for a while, because the thing that was flattening it is gone.
So the plan has to name both. A prescriber for the medication, if there is medication. A therapist who knows about the drinking as well as the anxiety. A first appointment booked before discharge rather than after it. And a worked-out response to the specific situations that used to end in a drink, decided while thinking clearly rather than at 9pm on a bad Tuesday.
Evidence-based treatment with behavioral therapies, mutual-support groups or medications can help people with alcohol use disorder achieve and maintain recovery [1]. A return to drinking is a signal to change the plan, not evidence that treatment was pointless.
Frequently Asked Questions
How do clinicians tell anxiety from alcohol withdrawal? Mostly by timeline, because the symptoms overlap. Anxiety is one of the standard features of mild alcohol withdrawal, alongside irritability, poor sleep and reduced appetite. Anxiety that started years before the drinking, or that is still there well after withdrawal has passed, is treated as its own disorder. Severe withdrawal can also bring seizures and delirium tremens, which can lead to fatal consequences. If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, call or text 988.
Does drinking make anxiety worse over time? It can. Substance use can lead to changes in some of the same brain areas that are disrupted in other mental disorders, including anxiety, and NIAAA’s screening questions ask directly about continuing to drink despite feeling depressed or anxious. People with co-occurring disorders often have symptoms that are more persistent, severe, and resistant to treatment compared with patients who have either disorder alone.
Will my anxiety medication be stopped in treatment? That is a decision for the prescriber who assesses you, and it is not made in advance or by a website. Medications can lessen the symptoms of many mental disorders while other medications treat alcohol addiction, so both prescriptions are usually part of one plan rather than in competition. Bring the medication and the prescriber’s contact details to the assessment so nothing has to be reconstructed from memory.
Do I need a psychiatrist as well as a counselor? Often, and the important part is that they work together. Integrated care combines mental health and substance use treatment so patients get more convenient, coordinated care. Prescribing sits with a medical clinician; the therapy sits with a licensed therapist. When you compare programs, the question worth asking is whether both roles are on the same team and share one plan.
Does insurance cover treatment for both conditions? Usually in some form, though never automatically. Marketplace plans must include mental health and substance use services among the essential health benefits, and they cannot apply yearly or lifetime dollar limits to that care. How much is covered depends on the policy, the employer and the level of care. Marketplace plans must also provide parity protections, so limits on this care cannot be more restrictive than the limits on medical and surgical care. Those limits include care management, such as being required to get authorization of treatment before getting it. We claim no network status with any carrier, so verify benefits against your own member ID.
Sources
- National Institute on Alcohol Abuse and Alcoholism. Understanding Alcohol Use Disorder. National Institutes of Health. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
- National Institute of Mental Health. Finding Help for Co-Occurring Substance Use and Mental Disorders. National Institutes of Health. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
- National Institute on Drug Abuse. Co-Occurring Disorders and Health Conditions. National Institutes of Health. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
- National Institute of Mental Health. Anxiety Disorders. National Institutes of Health. https://www.nimh.nih.gov/health/topics/anxiety-disorders
- Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment, TIP 45, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances. SAMHSA, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- HealthCare.gov. Mental health and substance abuse health coverage options. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
This page is for general information and is not medical advice. Only a licensed clinician who knows your history can tell you what is right for you. If you or someone you know is in immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
