Men and Women with Addiction Show Distinct Psychiatric Comorbidities

Two people can arrive at treatment with the same substance use diagnosis and very different mental health records — and a new national analysis suggests that sex is consistently tied to what those records contain.

Drawing on 2022 data from state-funded and state-run mental health services across the United States, researchers examined more than 58,000 adults diagnosed with opioid dependence (28,808), alcohol dependence (23,281) or cannabis dependence (5,961). The study, published in the American Journal of Psychiatry by Eduardo Butelman and colleagues, compared the odds of recorded secondary diagnoses — anxiety, bipolar disorder, depression, schizophrenia and other psychotic disorders, and trauma- and stressor-related disorders — adjusting for age, race and ethnicity.

Across all three substance groups, the same pattern held: men had lower adjusted odds of anxiety, bipolar disorder, depression and trauma-related disorders than women. But the pattern reversed for psychosis. Among people with opioid dependence, men had 24% higher odds of schizophrenia or another psychotic disorder (OR 1.24); among those with cannabis dependence, 12% higher (OR 1.12). Alcohol dependence was the exception — there, no significant sex difference in psychotic disorders emerged.

What the records show

The most common comorbidities differed by substance as well. For opioid dependence, anxiety (14.7%) and depression (13.5%) led the list. For alcohol dependence, depression was most common at 21.8%, followed by anxiety at 12%. For cannabis dependence, depression (18.0%) and psychotic disorders (13.4%) topped the records. The sex-based gaps were striking in scale: men with cannabis dependence had 32% lower odds of a trauma- or stressor-related diagnosis than women (OR 0.68).

The authors caution that one sex did not simply show "more" illness — the type of recorded comorbidity differed, and the dataset cannot explain why. Biology, trauma exposure, stigma, help-seeking behavior and how clinicians recognize symptoms could all play a role. The study is cross-sectional, roughly 20% of race and ethnicity data was missing, and only one secondary diagnosis per person was counted.

Why it matters for treatment

The findings land on a system already falling short: recent federal estimates suggest only about 7% of U.S. adults with co-occurring substance use and mental health disorders receive integrated treatment for both. For clinicians, the message is not to predict diagnoses from demographics, but to keep the full range of comorbidities in view during assessment — particularly for people whose primary diagnosis is treated as the whole story.

Comprehensive screening at intake remains the practical takeaway. Programs offering dual diagnosis care are built around exactly this reality: addiction rarely travels alone, and what travels with it may look different from patient to patient.