The co-occurrence of substance use disorders (SUDs) and anxiety disorders has been now well established. This association is frequent and can be explained by three models: the shared vulnerability factors model, the self-medication model, and the substance-induced model. General population epidemiological studies provide strong evidence of the frequency of the association for the most used substances: tobacco, alcohol, cannabis, and to a lesser extent sedatives, opiates, and cocaine. For substances that are less commonly used in the general population, the frequency of the co-occurrence can more precisely be studied in clinical samples. We provide the most recent literature results on the association of SUDs and anxiety, and evidence for one explicative model or the other when available. For substances with sedative properties (alcohol, benzodiazepines, cannabis, opioids), both evidence for a self-medication and for a toxic effect exist. For substances with psychostimulant properties (tobacco, cocaine, and amphetamines), the literature favors the toxic hypothesis to explain the association with anxiety disorders. We give practical steps for the recognition of these dual diagnoses and present therapeutic issues, although the strategies are rarely evidence based.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Wakefield JC, Schmitz MF. How many people have alcohol use disorders? Using the harmful dysfunction analysis to reconcile prevalence estimates in two community surveys. Front Psychiatry. 2014;5:10.
Kessler RC, Ruscio AM, Shear K, Wittchen HU. Epidemiology of anxiety disorders. Curr Top Behav Neurosci. 2010;2:21–35. Review of studies conducted in the general population, reference work from the most eminent epidemiologists.
Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health. 2009;9:285.
Mykletun A, Overland S, Aaro LE, Liabo HM, Stewart R. Smoking in relation to anxiety and depression: evidence from a large population survey: the HUNT study. Eur Psychiatry. 2008;23:77–84.
Moylan S, Jacka FN, Pasco JA, Berk M. Cigarette smoking, nicotine dependence and anxiety disorders: a systematic review of population-based, epidemiological studies. BMC Med. 2012;10:123. Comprehensive review on smoking and anxiety in the general population.
Goodwin RD, Wall MM, Choo T, Galea S, Horowitz J, Nomura Y, et al. Changes in the prevalence of mood and anxiety disorders among male and female current smokers in the United States: 1990–2001. Ann Epidemiol. 2014;24(7):493–7.
Degenhardt L, Chiu WT, Sampson N, Kessler RC, Anthony JC, Angermeyer M, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med. 2008;5(7):e141. Survey comparing different countries with the same assessment.
Miech R, Koester S. Trends in U.S., past-year marijuana use from 1985 to 2009: an age-period-cohort analysis. Drug Alcohol Depend. 2012;124(3):259–67.
Copeland J, Swift W. Cannabis use disorder: epidemiology and management. Int Rev Psychiatry. 2009;21(2):96–103.
Degenhardt L, Coffey C, Romaniuk H, et al. The persistence of the association between adolescent cannabis use and common mental disorders into young adulthood. Addiction. 2013;108:124–33. Prospective study, demonstrates a toxic effect of heavy cannabis use leading to secondary onset of anxiety disorders.
Kedzior KK, Laeber LT. A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population—a meta-analysis of 31 studies. BMC Psychiatry. 2014;14:136. Recent meta-analysis of several epidemiological studies on this topic.
Cheung JTW, Mann RE, Ialomiteanu A, Stoduto G, Chan V, Ala-Leppilampi K, et al. Anxiety and mood disorders and cannabis use. Am J Drug Alcohol Abuse. 2010;36(2):118–22.
Buckner JD, Heimberg RG, Schneier FR, Liu SM, Wang S, Blanco C. The relationship between cannabis use disorders and social anxiety disorder in the National Epidemiological Study of Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2012;124(1–2):128–34. Prospective study, demonstrates a self-medication effect.
Hayatbakhsh MR, Najman JM, Jamrozik K, Mamun AA, Alati R, Bor W. Cannabis and anxiety and depression in young adults: a large prospective study. J Am Acad Child Adolesc Psychiatry. 2007;46(3):408–17.
Billioti de Gage S, Moride Y, Ducruet T, Kurth T, Verdoux H, Tournier M, et al. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ. 2014;349:g5205. Case control study, adds evidence on the association between benzodiazepine prescription and 5-years later onset of Alzheimer disease.
Jaussent I, Ancelin ML, Berr C, Pérès K, Scali J, Besset A, et al. Hypnotics and mortality in an elderly general population: a 12-year prospective study. BMC Med. 2013;11:212. Prospective study, shows an effect of benzodiazepine prescription on death.
Esposito E, Barbui C, Patten SB. Patterns of benzodiazepine use in a Canadian population sample. Epidemiol Psichiatr Soc. 2009;18(3):248–54.
Nordfjærn T, Bjerkeset O, Moylan S, Berk M, Gråwe RW. Clusters of personality traits and psychological symptoms associated with later benzodiazepine prescriptions in the general population: The HUNT Cohort Study. Addict Behav. 2013;38(10):2575–80. Prospective study, demonstrates a self-medication effect of benzodiazepine on anxiety disorders.
Olfson M, Wang S, Iza M, Crystal S, Blanco C. National trends in the office-based prescription of schedule II opioids. J Clin Psychiatry. 2013;74(9):932–9. Prospective study, shows the increase of opioids prescriptions in the US.
Blanco C, Rafful C, Wall MM, Jin CJ, Kerridge B, Schwartz RP. The latent structure and predictors of non-medical prescription drug use and prescription drug use disorders: a national study. Drug Alcohol Depend. 2013;133(2):473–9.
Martel MO, Wasan AD, Jamison RN, Edwards RR. Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain. Drug Alcohol Depend. 2013;132(1–2):335–41.
Fischer B, Lusted A, Roerecke M, Taylor B, Rehm J. The prevalence of mental health and pain symptoms in general population samples reporting nonmedical use of prescription opioids: a systematic review and meta-analysis. J Pain. 2012;13(11):1029–44.
Martins SS, Fenton MC, Keyes KM, Blanco C, Zhu H, Storr CL. Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychol Med. 2012;42(6):1261–72. General population study, demonstrates the association between prescription opioids and anxiety disorders.
Sareen J, Chartier M, Paulus MP, Stein MB. Illicit drug use and anxiety disorders: findings from two community surveys. Psychiatry Res. 2006;142:11–7.
Swendsen J, Burstein M, Case B, Conway KP, Dierker L, He J, et al. Use and abuse of alcohol and illicit drugs in US adolescents: results of the National Comorbidity Survey-Adolescent Supplement. Arch Gen Psychiatry. 2012;69(4):390–8. Prospective study, estimates that anxiety disorder treatment would prevent transition from alcohol abuse to dependence in Adolescents.
Piper ME, Cook JW, Schlam TR, Jorenby DE, Baker TB. Anxiety diagnoses in smokers seeking cessation treatment: relations with tobacco dependence, withdrawal, outcome and response to treatment. Addiction. 2011;106(2):418–27. Clinical study, demonstrates that anxiety is associated with less smoking cessation.
Bruijnzeel AW. Tobacco addiction and the dysregulation of brain stress systems. Neurosci Biobehav Rev. 2012;36(5):1418–41. Recent review of the toxic effect of smoking hypothesis.
Schaap MM, Kunst AE. Monitoring of socio-economic inequalities in smoking: learning from the experiences of recent scientific studies. Public Health. 2009;123:103–9.
Tjora T, Hetland J, Aaro LE, Overland S. Distal and proximal family predictors of adolescents’ smoking initiation and development: a longitudinal latent curve model analysis. BMC Public Health. 2011;11:911. Clinical study, favours a shared vulnerability hypothesis.
Ziedonis D, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J, et al. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob Res. 2008;10(12):1691–715.
Minichino A, Bersani FS, Calò WK, Spagnoli F, Francesconi M, Vicinanza R, et al. Smoking behaviour and mental health disorders—mutual influences and implications for therapy. Int J Environ Res Public Health. 2013;10(10):4790–811. Review of therapeutic strategies for smokers with psychiatric diagnoses.
Richards CS, Cohen LM, Morrell HE, Watson NL, Low BE. Treating depressed and anxious smokers in smoking cessation programs. J Consult Clin Psychol. 2013;81(2):263–73. Review of specific anxiety treatment programs and their effect on smoking cessation.
Guillem E, Arbabzadeh-Bouchez S, Vorspan F, Bellivier F. Comorbidity in 207 cannabis users in a specific outpatient setting. Encephale. 2014. doi:10.1016/j.encep.2014.06.004.
Benyamina A, Lecacheux M, Blecha L, Reynaud M, Lukasiewcz M. Pharmacotherapy and psychotherapy in cannabis withdrawal and dependence. Expert Rev Neurother. 2008;8(3):479–91.
Allsop DJ, Copeland J, Lintzeris N, Dunlop AJ, Montebello M, Sadler C, et al. Nabiximols as an agonist replacement therapy during cannabis withdrawal: a randomized clinical trial. JAMA Psychiatry. 2014;71(3):281–91.
Levin FR, Mariani JJ, Brooks DJ, Pavlicova M, Cheng W, Nunes EV. Dronabinol for the treatment of cannabis dependence: a randomized, double-blind, placebo-controlled trial. Drug Alcohol Depend. 2011;116(1–3):142–50.
Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890–8. Clinical study, demonstrates the poor efficacy of tapering strategies in benzodiazepine dependent patients.
Fatséas M, Denis C, Lavie E, Auriacombe M. Relationship between anxiety disorders and opiate dependence—a systematic review of the literature: implications for diagnosis and treatment. J Subst Abuse Treat. 2010;38(3):220–30. doi:10.1016/j.jsat.2009.12.003.
Dell’Osso L, Rugani F, Maremmani AG, Bertoni S, Pani PP, Maremmani I. Towards a unitary perspective between post-traumatic stress disorder and substance use disorder. Heroin use disorder as case study. Compr Psychiatry. 2014;55(5):1244–51.
Higgins DM, Kerns RD, Brandt CA, Haskell SG, Bathulapalli H, Gilliam W, et al. Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans. Pain Med. 2014;15(5):782–90.
Meier A, Lambert-Harris C, McGovern MP, Xie H, An M, McLeman B. Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity. Am J Drug Alcohol Abuse. 2014;40(4):304–11. doi:10.3109/00952990.2014.910519.
Rozet I, Nishio I, Robbertze R, Rotter D, Chansky H, Hernandez AV. Prolonged opioid use after knee arthroscopy in military veterans. Anesth Analg. 2014;119(2):454–9.
Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940–7.
Semple SJ, Strathdee SA, Zians J, McQuaid J, Patterson TL. Correlates of obsessive-compulsive disorder in a sample of HIV-positive, methamphetamine-using men who have sex with men. AIDS Behav. 2011;15(6):1153–60.
Vorspan F, Brousse G, Bloch V, Bellais L, Romo L, Guillem E, et al. Cocaine-induced psychotic symptoms in French cocaine addicts. Psychiatry Res. 2012;200(2–3):1074–6.
Wang G, Shi J, Chen N, Xu L, Li J, Li P, et al. Effects of length of abstinence on decision-making and craving in methamphetamine abusers. PLoS One. 2013;8(7):e68791.
Glasner-Edwards S, Mooney LJ, Ang A, Hillhouse M, Rawson R. Does posttraumatic stress disorder (PTSD) affect post-treatment methamphetamine use? J Dual Diagn. 2013;9(2):123–8. Clinical study, demonstrates that the toxic effect of stimulants on anxiety last for one year after cessation.
Compliance with Ethics Guidelines
Conflict of Interest
Gaël Dupuy and Vanessa Bloch declare that they have no conflict of interest.
Florence Vorspan has received a grant from the French Ministry of Health and from the ANR (PHRC 2012, SAMENTA 2013, ERANet Neuron 2014).
Wajdi Mehtelli has received paid travel accommodations from Lundbeck, SA.
Jean-Pierre Lépine has received payment for conferences and paid travel accommodations from Servier, Valoriser votre Recherche.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Anxiety Disorders
About this article
Cite this article
Vorspan, F., Mehtelli, W., Dupuy, G. et al. Anxiety and Substance Use Disorders: Co-occurrence and Clinical Issues. Curr Psychiatry Rep 17, 4 (2015). https://doi.org/10.1007/s11920-014-0544-y
- Substance use disorders