Treatment tips

What to know about OUD + mental health comorbidities

Understand the complex relationship between OUD and mental health disorders like depression, anxiety, personality disorders, bipolar disorder, and OCD.

Ophelia team
Mental health + OUD
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Fact checked by
Mena Soliman, NP

Individually, opioid use disorder (OUD) and mental health disorders are complicated conditions that demand careful treatment to successfully manage. When a patient experiences both, things get even more difficult—and, unfortunately, OUD and mental health conditions, such as PTSD or depression, have high rates of co-occurrence. Understanding the relationship between OUD and mental health is crucial to providing excellent treatment with long-lasting results. In this article, we’ll highlight five major categories of mental health conditions that commonly occur alongside OUD, explore their interactions, and discuss what effective treatment looks like.

How opioid use disorder interacts with common mental health conditions

Depression + opioid use disorder

In the United States, depression is one of the most prevalent mental health disorders. Millions of people—adults and children alike—experience regular feelings of depression each year, and it can be very deadly. This prevalence carries over into populations with opioid use disorders. In fact, as many as 41% of people with OUD also have a mood disorder. This comorbidity is particularly dangerous because OUD and depression have what is known as a bi-directional relationship. This means each condition has the capacity to complicate and exacerbate the other, and the first condition experienced may even lead to the onset of the other. 

For example, people with depression are more likely to experience chronic pain, which can lead to self-medication with opioids, whether prescription or not. Someone with depression may also be attracted to opioids for their euphoric effects since it may temporarily make a person feel happier and less distressed due to the drug’s ability to stimulate the release of dopamine and serotonin. Unfortunately, these relieving effects become harder to achieve as tolerance develops, leaving patients with a new habit of opioid use in addition to their underlying depression.

On the other side of the spectrum, there are opioid users who later develop depression. This is known as opioid-induced depression. OUD is often associated with social isolation, financial hardship, the loss of work and housing, and other stressful material conditions. These can quickly lead to depression. But even without these additional stressors, opioid use can lead to depressive symptoms because it disrupts normal brain function and causes an imbalance of critical neurotransmitters. Opioid use may also disrupt a person’s sleep schedule, which can adversely affect their mental health. 

What makes the presence of both OUD and depression a major problem for many is the overlap in symptoms that the conditions share, including:

  • Fatigue
  • Loss of appetite
  • Excessive sleep or insomnia
  • Mood changes and mood swings
  • Changes in libido
  • Headaches
  • Personality changes 

These commonalities make it difficult for patients and medical professionals to tell which symptoms are coming from which condition, which complicates the treatment process.

Anxiety + OUD

The relationship between OUD and anxiety is a strange one. On the surface, opioids don’t seem like they should exacerbate anxiety. By binding with opioid receptors in the brain, these drugs influence a person’s experience of pain and cause sedation and feelings of relaxation and euphoria. This is the result of a decrease in norepinephrine production that occurs after an opioid is introduced in the brain, which influences a person’s blood pressure, alertness, and responses to fear. As norepinephrine decreases, so do these physical conditions. That would make it seem that opioids have an overall positive impact on a patient’s anxiety.

However, when an opioid begins to wear off, those effects reverse, leading to an increase in epinephrine —and that means higher blood pressure, more alertness, and more intense responses to fear. While the norepinephrine levels in the body may simply be returning to normal, the bodily changes that take place can trigger feelings of anxiety and unrest. This can lead people who are otherwise calm to begin experiencing symptoms of anxiety while using opioids.

Research suggests that about one in three people with an OUD also report anxiety symptoms, making anxiety one of the most common mental health comorbidities with opioid use. Much like depression, it’s possible to develop anxiety due to extended opioid use. Opioid-induced anxiety looks much like regular anxiety, but it may be accompanied by more severe symptoms, like an increase in obsessive-compulsive tendencies, panic attacks, and the development of phobias. People with OUD may also experience heightened anxiety during opioid withdrawal. Withdrawal-related symptoms are typically most severe in people who use short-acting opioids, like heroin and oxycodone. But it’s always a serious matter and should be monitored by a medical professional when possible. 

Dealing with both anxiety and opioid use disorder is particularly difficult because of how these conditions influence one another. Sustained and increased opioid usage can lead to hormonal dysregulation that causes the brain to overproduce norepinephrine as opioids wear off. This then leads to wild fluctuations in the hormone’s concentration in the body, triggering severe anxiety and heightening any underlying anxiety. Meanwhile, the social stresses associated with opioid use—including the stigma faced by people seeking help and treatment for OUD—can also make a person anxious. Likewise, opioid use can emerge as a form of self-medication when anxiety goes improperly treated or untreated entirely.

Personality disorders + opioid use disorder

Of all the mental health comorbidities with OUD, personality disorders are simultaneously some of the most varied and most dangerous. Personality disorders include a wide range of mental health conditions, such as borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, paranoid personality disorder, and avoidant personality disorder. These disorders are typically divided into three categories or clusters:

  • Cluster A personality disorders are also called odd or eccentric, and they relate to schizophrenia and associated conditions.
  • Cluster B categorizes emotional and erratic disorders, which are characterized by emotional and often self-destructive behavior.
  • Cluster C covers anxious and fearful disorders, including obsessive-compulsive disorder (OCD). 

Personality disorders often present themselves by early adulthood and only rarely develop later in life, which sets them apart from many other comorbid mental health conditions, which can manifest at any age.

These disorders come with firm and inflexible patterns of behavior that deviate significantly from what is considered normal or acceptable in the patient’s culture and social environment. Their symptoms are often complex and overlap with those of more common conditions, making them hard to diagnose and treat properly. This also means estimating the prevalence of personality disorders is not an exact science. However, studies have shown that as many as 40% of patients seeking addiction treatment have borderline personality disorder (BPD), which is just one of many disorders in this category. BPD is associated with impulsive, risk-seeking behavior and a tendency to self-medicate, which can increase the likelihood of drug misuse. In fact, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) includes substance misuse as a potential sign of BPD.

When accounting for the full spectrum of personality disorders, the number of substance use disorder patients with this particular mental health comorbidity may be as high as 90%. Consider that 79% of individuals with BPD report a history of suicide attempts and that 75% exhibit non-suicidal self-harming behaviors, and it quickly becomes clear why OUD and personality disorders are a lethal combination.

Seeking treatment is particularly hard for patients with OUD and a co-occurring personality disorder, largely due to the complexity of treating a personality disorder on its own. Likewise, the worsening of symptoms in these co-occurring disorders may be more drastic, more noticeable, and even more dangerous than in previous examples. Research has also shown that Cluster B personality disorders are associated with lower success rates in OUD treatment. Given this evidence, it’s crucial for people with both OUD and a personality disorder to receive careful and thorough treatment that includes pharmaceutical OUD treatments and proper psychiatric care and social support. 

Bipolar disorder + OUD

Like personality disorders, bipolar disorder is another mental health concern that carries a high risk of suicide and frequently co-occurs with OUD. According to one 2005 study, more than half of people with bipolar disorder also experience a substance use disorder in their lifetime. Luckily, treatment options for this mental health comorbidity are available, and they may be less difficult to navigate than the treatment plans for other personality disorders and OUD. 

Bipolar disorder is considered by the DSM-5 to be in its own class of mental disorders, and it’s characterized by a patient’s alternating experience of two opposed mental states: depression and mania. A depressive episode looks much like the typical experience of depression. Sadness, listlessness, fatigue, problems regulating sleep, and changes in appetite are all common. During manic episodes, the patient feels positive and overly energetic. They may quickly accomplish tasks that would feel impossible during a depressive episode, and they can experience mania for a week or more at a time. In between these episodes, people with bipolar disorder often have a balanced mood, which is known as being “euthymic.” 

The reasons bipolar disorders and OUD overlap are still unknown, but researchers have suggested causes from self-medication to shared risk factors, such as genetic predispositions. Whatever the case may be, it’s clear that the two disorders can overlap in harmful ways and exacerbate one another. Because opioids are a central nervous system depressant, they can deepen and perhaps even extend depressive episodes. Also, the experience of swings between bipolar episodes can be distressing and may strain relationships and a person’s ability to maintain steady work or housing. These conditions may increase a person’s risk of developing OUD.

Conversely, and positively, successfully treating a patient’s underlying bipolar disorder may reduce their cravings for opioids and can lead to a lower desire to continue misusing them. It’s also been shown that Suboxone can have a positive impact on a patient’s mental health, which may make bipolar disorder easier to manage.


As mentioned above, obsessive-compulsive disorder is a type of personality disorder—but it differs greatly enough from the other clusters that it’s often discussed separately. OCD is characterized by two distinct modes of thinking. The first is obsessive, which sees the affected individual experiencing frequent, insistent, and often debilitating intrusive thoughts. These intrusive thoughts, or obsessions, lead the patient to perform compulsive and ritualistic behaviors to mitigate the anxiety caused by the intrusive thoughts. In some cases, OCD may present with one of these symptoms being mostly or entirely absent.

For many patients, OCD is disruptive and stressful. Common obsessions include:

  • Unwanted, disturbing, or taboo thoughts
  • Germophobia
  • The desire for uniformity and order
  • The fear of loss of control

Common compulsions are repetitive and excessive cleaning (such as handwashing), counting, and checking to ensure a task is completed or that things are in the right order. 

Like with other mental health comorbidities, patients may seek to self-medicate their OCD with opioids, leading to a habit and eventual misuse. However, obsessive-compulsive disorder risk factors often overlap with those of substance misuse. Genetic predispositions are common for both conditions, as are excessive stress or trauma in early childhood.

Also, compulsions look like addiction-related behaviors, and they can rely on similar nervous system frameworks. They both create overwhelming urges, can be hard to deny, and lead to distress when not fulfilled. However, addictions are more likely to have a pleasurable reward or feel good during the process, whereas compulsions are usually performed to mitigate stress and achieve minor relief.

Treatment options for OUD + mental health comorbidities

How to treat a patient simultaneously for both OUD and mental health conditions is still a subject of intense scrutiny. The interactions between these disorders are complex, idiosyncratic, and not yet well understood. Likewise, the medications necessary for treating multiple conditions simultaneously need to be carefully balanced.

Suboxone is considered the gold standard of OUD care because it blocks opioid receptors in the brain and reduces cravings. But it has known interactions with many categories of drugs used to treat mental health conditions, including SSRIs, TCAs, and benzodiazepines (important safety information). The good news is that Ophelia clinicians are well-trained and equipped to manage these interactions.

For many mental health comorbidities, medication alone may not be enough for successful treatment. Psychiatric care should be used to support pharmacological treatments to ensure higher rates of success and better patient outcomes. Unfortunately, buprenorphine-based treatment has had some barriers to access in the past, including the common belief that patients also needed to be in mental health counseling. This simply is not true—counseling can be a helpful addition to a medication-first treatment plan, and access to those medications should not depend on participation in counseling.

When Ophelia patients come in with depressive or anxiety disorders, we can help them get medication to address these conditions in addition to a Suboxone prescription for OUD. Our clinical providers make sure each patient’s treatment plan is specific to their support needs for both physical and mental health. Our patients’ long-term success is our top priority, which means addressing both the immediate opioid-related problems and underlying conditions that can cause complications. This comprehensive approach to care improves outcomes and makes a meaningful difference in patients’ lives.


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