Psychologists help patients with serious mental illness kick nicotine and other addictions

About half of U.S. adults living with serious mental illness (SMI) also have a substance use disorder (SUD). But nearly 30% of those with both diagnoses—more than 2 million people—received no treatment for either condition in 2022, the last year with available data. Of those who did get treatment, most received no help for their substance use (National Survey on Drug Use and Health releases, Substance Abuse and Mental Health Services Administration [SAMHSA], 2022opens in new window).

“It can actually be quite a severe problem, but because they don’t look like the rest of substance misuse people, these patients have historically been given a lesser priority,” said David Kavanagh, PhD, an emeritus professor of psychology at Queensland University of Technology in Brisbane, Australia (where rates of SMI and SUD are similar to rates in the United States) who studies interventions for co-occurring SMI and SUD.

SMI, defined as a diagnosis that has a substantial negative impact on functioning, most commonly includes psychotic disorders, bipolar disorder, and major depressive disorder and shares common risk factors with SUD. (SMI may also include posttraumatic stress disorder, obsessive-compulsive disorder, and personality disorders.) Nicotine and commonly misused substances such as alcohol, opioids, and cannabis can also provide a temporary break from distressing symptoms, a boost to mitigate the sedative effects of antipsychotic medications, or an opportunity for social connection (Mental health and substance use co-occurring disorders, SAMHSA, 2023opens in new window).

“The difficulty is it may work for 5 minutes, but then we’re in a worse situation than we were before we started,” said Judy Ashton, a peer specialist who has volunteered for 16 years at Brigham and Women’s Faulkner Hospital in Boston and is in recovery from SMI and alcohol use. “Part of my work is to help people develop other coping mechanisms besides using substances.”

Psychologists have helped build a strong evidence base for interventions to help reduce or stop substance use, including peer support, motivational interviewing, cognitive behavioral therapy (CBT), and incentive-based approaches. These can be used in addition to or in place of addiction-fighting medications, which have high levels of success for addressing alcohol, opioid, and nicotine problems. Changes to service delivery models would provide greater access to care, psychologists say, such as physically integrating care for SMI and SUD and increasing funding for early risk prevention.

“Helping people with these complex problems can sometimes just feel overwhelming, and this is a group that’s easy to give up on,” Kavanagh said. “But we also know that when people are sufficiently motivated to change the behavior of using substances, many can—and that they have a better prognosis if they do.”

People with SMI use substances for many of the same reasons as others do—to enhance positive feelings (get a buzz or high) or reduce negative ones (deal with trouble sleeping, disruptive thoughts, or emotional pain). Drugs that boost dopamine can counter the numbing effects of some antipsychotic medications, while cigarettes and cannabis may have calming or energizing effects. Alcohol, nicotine, and cannabis are the most commonly used substances, partly because they are easiest to obtain.

Using substances can also provide welcome recreation and social connection for people whose lives can be difficult because they have trouble finding employment and maintaining relationships, said Kavanagh.

“For someone with a serious mental disorder, something that lifts you out of all of that is actually very attractive,” he said. “It also gives you an entrée into a group of others who are using the same substance, where you may feel welcome and connected.”

Self-medication alone cannot fully explain the much higher rates of SUD in this group—48% in 2022, compared with 17% of the general population—said clinical psychologist Kim Mueser, PhD, a professor at Boston University’s Center for Psychiatric Rehabilitation who studies SMI and SUD. A theory known as the supersensitivity hypothesis holds that people with SMI are more sensitive to the effects of alcohol, cannabis, and other substances; even moderate use can trigger SUD symptoms (Miller, P. [Ed.], Principles of addiction: Comprehensive addictive behaviors and disorders, Academic Press, 2013opens in new window).

The link between mental illness and substance use is bidirectional and complex. Mental illness can lead people to use substances; substances can worsen or trigger the development of mental illness. The two conditions also share common risk factors, including stress or trauma early in life and certain genetic vulnerabilities (Common comorbidities with substance use disorders research report, National Institute on Drug Abuse, 2020opens in new window).

For example, evidence suggests that cannabis use during adolescence can increase the risk of developing a psychotic disorder or trigger earlier onset in people with other risk factors, such as a family history of schizophrenia. But understanding of the link is incomplete, and research is still insufficient to determine that it is causal, said clinical psychologist Michelle West, PhD, an assistant professor of psychiatry at the University of Colorado Anschutz Medical Campus who has reviewed the scientific literature on cannabis and psychosis (Psychiatric Clinics of North America, Vol. 46, No. 4, 2023opens in new window).

“There’s also a small subset of people with no known risk factors who develop psychosis after using very high potency cannabis,” she said. “Unfortunately, we’re not yet able to predict who this happens to and why.”

More research on the link between specific substances and mental illnesses is part of the solution, but psychologists are also advocating for a broader shift in the way health care approaches treatment for SMI and SUD.

In the past, SMI and substance use problems were typically treated by different providers, often leaving patients with both diagnoses in limbo. When treatments are offered in parallel, they are often not coordinated: Some people are expected to quit using substances before receiving SMI treatment; others receive no help for their substance use. For conditions such as alcohol use disorder and opioid use disorder, that lack of support can be life-threatening because patients with severe addiction require medical oversight to quit.

Existing service delivery models are part of the problem, said Lara Coughlin, PhD, an assistant professor of psychiatry at the University of Michigan and a licensed clinical psychologist focused on SUD treatment, which is why psychologists have helped lead efforts to provide integrated mental health and addiction care. But another major issue is the stigma pervading society and the health care system around both SMI and SUD, as well as provider beliefs about their lack of competence to treat addiction.

“The field is trying to address stigma and provider knowledge gaps so we can make sure we’re treating the whole person instead of passing patients to other providers with the hope of them getting better,” Coughlin said.

For that reason, gaining firsthand experience with people in recovery can be just as helpful for providers as it is for patients. Peer specialists such as Ashton can help provide a living example of what effective treatment can do.

“I model recovery for [hospital] staff so that they will see our patients as people who are not just in a static situation. They can do well, and they can find a way in the world,” Ashton said. “They’re seeing folks at their lowest point, and I try to show them that this is not a life sentence.”

For individuals with SMI and tobacco use disorder, treatment has been particularly hard to come by. Tobacco companies targeted people with mental illness by developing promotions and product giveaways for psychiatric facilities (Apollonio, D. E., & Malone, R. E., Tobacco Control, Vol. 14, No. 6, 2005opens in new window). In the 1980s and 1990s, patients also received mixed messages about smoking from health care providers, said Christopher AhnAllen, PhD, an assistant professor of psychiatry at Harvard Medical School and interim director of psychology at Brigham and Women’s Hospital.

“People would smoke cigarettes with their doctors, smoke in the hospital, or receive cigarettes as a reward for participating in research studies,” said AhnAllen, who is board certified in SMI psychology. Providers often defer treatment of tobacco use disorder in favor of treating other substance use disorders, but research suggests that quitting tobacco helps people abstain from other substances (McKelvey, K., et al., Addictive Behaviors, Vol. 65, 2017opens in new window).

Adults with SMI smoke at more than twice the rate of the general population and face a shortened life expectancy because of smoking-related conditions. Contrary to what providers may believe, people with SMI want to quit smoking at the same rates as those without SMI and can do so effectively when offered evidence-based treatments (Implementing tobacco cessation treatment for individuals with serious mental illness, SAMHSA, 2019opens in new window).

“Oftentimes the extremely high rates of tobacco and other nicotine use are undertreated and even underacknowledged by our health care system,” Coughlin said. “There are so many really near-term concerns about things like suicidality and substance overdose. In the effort to address the immediate risks, tobacco use often gets overlooked.”

But using tobacco can cause substantial harm to people with SMI. In addition to shortening the life span, it can interfere with psychiatric treatment by changing how the body metabolizes antipsychotic medications. Many individuals with SMI live on a low income and may spend close to 30% of their funds on cigarettes; those with alcohol use disorder often face a similar financial conundrum (Young-Wolff, K. C., et al., American Journal of Public Health, Vol. 104, No. 8, 2014opens in new window).

“For people with a fixed income, that’s a tremendous amount, and it sometimes means people are choosing cigarettes over food,” AhnAllen said.

Fortunately, a growing body of research supports a range of interventions that work for people with SMI and tobacco use disorder. In addition to medications such as varenicline, which has proven effective for individuals with SMI, CBT and motivational interviewing can help patients “urge surf” through cravings and identify how tobacco use is negatively impacting their life (Evins, A. E., et al., JAMA, Vol. 311, No. 2, 2014opens in new window). AhnAllen said the best practice is to integrate such strategies into existing psychotherapy treatment, for instance by spending 5 to 10 minutes across multiple sessions, which the U.S. Department of Veterans Affairs is now encouraging its providers to do. Psychologists can use codes 99406 or 99407 when smoking and tobacco use cessation counseling services are performed at the same encounter as an individual psychotherapy session (Novotney, A., Monitor on Psychology, October 2022).

Other promising approaches include digital health interventions, replacing normal cigarettes with lower-nicotine ones, and behavioral economic approaches (Gowarty, M. A., et al., JMIR Mental Health, Vol. 8, No. 7, 2021opens in new window; DeAtley, T. E., et al., Addictive Behaviors, Vol. 133, 2022opens in new window). In Michigan, Coughlin has partnered with the state Department of Health and Human Services to test the Incentives to Quit program (Frontiers in Digital Health, Vol. 4, 2022opens in new window). The program uses a behavioral economics approach known as contingency management to provide small financial rewards when participants refrain from smoking—a strategy that can also be used to help patients reduce their use of other substances, such as alcohol, stimulants, or cannabis. Pilot studies showed cessation rates well above what is typically seen, she said.

“A lot of our treatments are pretty unpleasant,” Coughlin said. “We need to provide treatments that are not only effective but also appeal to the patient.”

New perspectives on what it means to “recover”—both from a serious mental disorder and a substance addiction—are behind the latest approaches to treatment. Rather than a sole focus on reducing symptoms and preventing relapses, mental health professionals increasingly seek to collaborate with patients about treatment and to foster autonomy and help people engage with work and their community.

“A somewhat different and now much more accepted definition of recovery involves the regaining of a sense of purpose and meaning in one’s life,” Mueser said.

For those with employment struggles, supported programs such as Individual Placement and Supportopens in new window (IPS) place people with SMI in jobs related to their interests, then train and support them so they can stay employed. A strong evidence base shows that IPS helps people with SMI, including those with SUD, stay in competitive jobs. Such programs can also help people with SMI in high-paying jobs overcome common challenges, such as frustration leading to impulsive actions or navigating interpersonal conflict in the workplace. Meaningful and rewarding work can have ripple effects across a patient’s life, including on substance use behaviors.

“Sometimes we make the mistake as therapists of feeling like we have to hit this head-on,” Kavanagh said. “But what’s more important is that we work with a person to help them achieve what they want.”

For example, one of Kavanagh’s patients did not wish to reduce his substance use but had a strong interest in playing golf. In working toward that goal, the patient found that golfing was an expensive hobby, so he reduced his cannabis use to afford it. Other patients may be willing to reduce the amount of a substance they use but not the frequency, or are willing to make their drug use safer, for instance, by getting their supply of opioids through a less dangerous route.

Motivational interviewing, in which patients have a safe environment to explore the benefits and downsides of their substance use, is a mainstay for many therapists treating SUD. The technique helps patients make their own choices, test them, and redirect to a different approach if needed.

“It’s an accepting environment where we’re helping them to come to their own decision, even though sometimes that decision is not the ideal one,” Kavanagh said.

In addition to helping patients navigate cravings, cognitive behavioral approaches can target harmful beliefs (for example: “I can’t get through the day if I don’t get high at the beginning”). Psychoeducation and skills training for families is another effective way to prepare people to manage conflict and problem solve through the ups and downs of recovery. For young patients at risk for SMI, providing families with details about the link between psychosis and substances such as cannabis is especially important, said West, who works in an early prevention program.

“Young folks are absorbing information from all sorts of places, and having information from providers and loved ones is helpful to add to whatever they might be hearing from their peers and the internet,” she said.

For Ashton, living with SMI and staying sober took a combination of medication, supportive therapy, coping skills, and social support. After years of working in the Faulkner Hospital’s inpatient unit, she now leads a weekly support group where outpatients can share skills for recovery and encourage one another.

Through the group, Ashton and other members share strategies that help them manage cravings, including exercise, crafting, cooking, or changing physical locations (even moving from the bed to the couch can help someone who is ruminating). She also encourages doing something for others—even a small act like opening the door for a stranger or baking cookies for a neighbor can help a person shift their focus.

“What’s really important for recovery is feeling like you fit into a community, have a social network, and have some people to live with and live for,” she said.

Research clearly shows that integrating substance use treatment into care for SMI is the best way to help patients with a co-occurring disorder. But in many states, doing so effectively will require substantial systems-level changes, Coughlin said. That may include changes to physical structures as well as changes to payment structures.

SAMHSA’s Treatment Improvement Program 42opens in new window, which focuses on addressing substance use issues in people with co-occurring disorders, is an important step in the right direction. But future advocacy efforts should also seek to eliminate annual and lifetime coverage limits, prior authorization policies, out-of-pocket costs, and restrictions on stepped-care therapy programs, Coughlin said.

More research is needed to determine how standard SUD treatments benefit those with SMI, including specific groups, such as unhoused individuals or people using multiple substances, said AhnAllen. Going forward, training efforts should prepare a broader range of clinicians to deliver SUD treatment, Coughlin said, including continuing education for those already in the field and targeted efforts to address stigma around SMI and substance use.

“All providers working with those who have serious mental illness ought to have skills for managing addiction and the expertise to integrate that into their services in a way that is consistent and supportive over time,” AhnAllen said.