Co-Occurring Disorders: Dual Diagnosis Treatment Models
According to official statistics, 19.3 million adults in the U.S. are struggling with a substance use disorder (SUD) and 51.5 million are struggling with a mental disorder.1 Mental health disorders and substance abuse can contribute to and complicate each other. When a person battles both a mental health disorder and addiction at the same time, the disorders are considered to be co-occurring. The National Survey on Drug Use and Health carried out in 2019 established that there were 9.5 million people in the U.S. with co-occurring disorders,1 which is a situation also often referred to as dual diagnosis or comorbid disorders.2
Dual diagnosis treatment models, i.e. integrated treatment of co-occurring SUD and mental illnesses, are found to be more effective compared to treating these disorders separately.2 Although the number of people who get treatment for co-occurring disorders in the U.S. is still lower than those who get treatment for one of the conditions, steady progress is being made through research and implementation of new options for dual diagnosis addiction treatment.2
What Is the Connection Between Addiction and Mental Health?
Half of those who struggle with serious mental illnesses and one-third of those who battle any form of mental illness abuse substances. The reverse is also true: over half of those who abuse drugs also suffer from a mental illness and one-third of individuals who abuse alcohol do as well.3
Mood and anxiety disorders are some of the most common mental health issues to co-occur with substance abuse and addiction.4 Drug and alcohol use may seem to blunt the symptoms of an anxiety or mood disorder at the time. However, the “crash” from these mind-altering substances can be more significant and result in making side effects worse.
Addiction can also lead to more social, emotional, physical, and behavioral issues, increasing the odds for more physical health problems, higher stress and emotional strain, worsening mental illness, complications with treatment and compliance, higher risk for suicidal thoughts or actions, and a decreased quality of life in general.
What Are the Most Common Co-occurring Disorders?
Highlighted below are specific mental health disorders that may co-occur with substance use and addiction:
Low energy, activity levels, and moods are signs of depression, and using drugs and alcohol may commonly boost these. The National Institute on Drug Abuse (NIDA) reports that around 40% of those suffering from a mood disorder abuse drugs, and that those who are battling a mood disorder are more likely to struggle with addiction than those who are not.5
A severe mood disorder characterized by extreme swings in mood, energy, and activity levels, bipolar disorder is indicated by episodes of mania and depression that may include psychotic symptoms. Individuals battling bipolar disorder abuse drugs and alcohol at very high rates. Research shows that at least 40% of adults battling bipolar I disorder also suffer from addiction.6
Examples include generalized anxiety disorder (GAD) and social anxiety disorder (SAD). Anxiety can induce a person to want to take drugs or drink alcohol to alleviate the symptoms. The Anxiety and Depression Association of America (ADAA) estimates that 20% of those battling an anxiety (or mood) disorder also suffer from addiction and vice versa.7
Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that involves a previous trauma or life-threatening event. PTSD and addiction commonly co-occur, as individuals may use alcohol or drugs to self-medicate. The US Department of Veterans Affairs (VA) publishes that one out of every three veterans who seek out treatment for addiction also suffer from PTSD and 20% of those battling PTSD also struggle with addiction.8
Schizophrenia is a serious and complex mental illness that involves disorganized thoughts, emotional responses, and perceptions. Individuals battling schizophrenia commonly resort to alcohol and drug abuse. For example, those suffering from schizophrenia smoke cigarettes at rates as much as three times those of the general population in the U.S.9
This category includes disorders such as antisocial personality disorder (APD) and borderline personality disorder (BPD). Personality disorders involve difficulties relating to others and behavior patterns that are often extreme and problematic. Drugs and alcohol may seem to help these individuals to fit in socially. Studies found that over half of those who struggled with BPD also battled addiction at some point in their lives.10
Attention deficit hyperactivity disorder (ADHD) is described as impulsivity, inability to focus, having disorganized thoughts, and experiencing restlessness. Adults suffering from ADHD also abuse substances or are dependent on alcohol or drugs three times more than the general population who do not struggle with a mental health disorder.11
Factors That Affect Substance Abuse & Mental Health Disorders
There are several factors that can contribute to the onset of both a mental health disorder and addiction, and many of these aspects are overlapping.12
Environmental factors like chronic stress, trauma, or childhood neglect or abuse can also make a person more likely to struggle with addiction and potentially develop a mental health disorder.13
Using drugs or drinking alcohol before the brain is completely developed (usually in early adulthood) can contribute to both the onset of mental issues as well as potential problems with substance abuse as an adult. Many mental health disorders can be triggered by substance abuse, and drug and alcohol use can definitely exacerbate symptoms of a mental health disorder. Marijuana use at a young age, for instance, may lead to worsening or earlier onset of schizophrenia in individuals who are vulnerable to the disorder.5 Drug use can induce psychotic symptoms, and if there is an underlying mental disorder, drugs may bring it to the surface.
Alcohol and drugs are often used as a form of self-medicating mental health disorder symptoms. This can actually make the side effects of both the substances involved and the mental illness worse.14
How Are Co-Occurring Disorders Diagnosed?
Substance abuse can make it potentially more difficult to diagnose a mental illness, and the reverse is also true.15 Medical and mental health assessments should be thorough and involve both mental health screening and an evaluation of drug and alcohol use in order to properly diagnose co-occurring disorders. A detailed medical and mental health history is needed to paint a clear picture of the individual’s situation, and individuals are also asked about the role alcohol and drugs play in their lives.
When disorders are undiagnosed, they are also left untreated. Proper assessment by trained professionals can help to determine what disorders are present, so they can then design a specialized treatment for dual diagnosis disorders.15
What Are Dual Diagnosis Addiction Treatment Options?
Over the years, co-occurring disorders have been treated in many ways. They have been treated one disorder at a time: whichever one was considered more severe is attended to first and then the other one addressed second. Today, integrated treatment for dual diagnosis, i.e. the one that manages both disorders simultaneously, is generally thought to be the most effective method.2 Since symptoms and side effects of addiction and mental illness may be difficult to untangle from each other, treating them at the same time within an integrated dual diagnosis treatment model can be extremely beneficial.
It is also helpful to have medical, mental health, and substance abuse treatment providers all working together toward the same goals. This way, medications and treatment protocols can be properly managed to ensure optimal results and fewer potential pitfalls. With oversight from a team of treatment providers, compliance can be closely monitored, and the plan can be adjusted when needed.
Pharmacological management is often necessary to manage symptoms of a mental health disorder, and these medications will need to be carefully supervised and controlled when a history of substance abuse is also present. Certain types of drugs (those that are habit-forming) may need to be replaced with those with less potential for abuse and diversion.2
When someone suffers from significant drug dependence, a medical detox program may be the first stage of a dual diagnosis addiction treatment program.18 Some drugs, such as opioids and benzodiazepines (and also alcohol), should never be stopped suddenly as severe withdrawal side effects can occur. Instead, medical detox programs can help to safely taper these substances out of the body, often with the help of other medications.
Holistic measures, such as balanced nutritional plans, massage therapy, yoga, chiropractic care, mindfulness meditation, and more, can be helpful adjunctive therapies to promote healing during treatment and detox as well.
Group Therapy & Individual Counseling
Most dual diagnosis treatment models include group and individual therapy. As part of an integrated care plan, they may involve:16
- Contingency management (CM), which offers small incentives and rewards for clean drug tests and the achievement of attainable goals.
- Cognitive behavioral therapy (CBT), which addresses negative thinking patterns and works to help people develop new and healthier coping strategies and mechanisms for managing stressors and behaving in more positive ways.
- Motivational interviewing (MI), which is a non-confrontational approach that helps individuals find the motivation within themselves to want to make positive changes.
- Relapse prevention, which consists of learning how to deal with possible triggers, cravings, and stress in order to sustain recovery. Family involvement and peer support groups are also helpful tools in relapse prevention.
A complete dual diagnosis treatment model will assist people in developing new and useful life skills, help them to form better communication and stress management tools, and provide support, encouragement, and hope. Treatment for co-occurring disorders is individual, and no two plans will be exactly the same. Nevertheless, the main goal of any treatment for co-occurring disorders is to help individuals lead healthy, meaningful, and productive lives.
Frequently Asked Questions
Integrated dual diagnosis addiction treatment involves coordinated substance-abuse treatment and mental health services, rather than treating each disorder separately.16 For example, moods are drastically affected by drug withdrawal, and when a mental health disorder is also diagnosed, detox will need to be closely monitored and managed through a specialized around-the-clock program to manage the side effects.
Recommended retention in residential treatment for co-occurring disorders is at least one month.16 This does not mean that treatment ends after one month but extends with other forms of outpatient treatment. It is recommended that substance abuse treatments should generally last at least 90 days for positive outcomes.17
Since people who suffer from both mental health and SUD need treatment for both disorders, they should consider undergoing treatment at specialized inpatient facilities for co-occurring disorders. Generally, such treatment options are somewhat more common among addiction treatment programs than mental health programs that are currently available in the U.S.19
1. Substance Abuse and Mental Health Service Administration. (2020). National Survey on Drug Use and Health.
2. National Institute on Drug Abuse. (2020). What are the treatments for comorbid substance use disorder and mental health conditions?
3. National Alliance on Mental Illness. (2020). Substance Use Disorders.
4. Quello, S. B., Brady, K. T. & Sonne, S. C. (2005). Mood disorders and substance use disorder: a complex comorbidity. Science & practice perspectives, 3(1), 13–21.
5. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
6. Cerullo, M. A., & Strakowski, S. M. (2007). The prevalence and significance of substance use disorders in bipolar type I and II disorder. Substance abuse treatment, prevention, and policy, 2, 29.
7. Anxiety and Depression Association of America. Substance Use Disorders.
8. National Center for PTSD. Substance Abuse in Veterans – PTSD.
9. PsychCentral. (2016). Schizophrenia and Substance Abuse.
10. Trull, T. J., Freeman, L. K., Vebares, T. J., Choate, A. M., Helle, A. C. & Wycoff, A. M. (2018). Borderline personality disorder and substance use disorders: an updated review.
11. Sherman, C. (2020). The Truth About ADHD and Addiction.
12. National Institute on Drug Abuse. (2020). The Connection Between Substance Use Disorders and Mental Illness.
13. Substance Abuse and Mental Health Service Administration. (2016). Facing Addiction in America.
15. National Institute on Drug Abuse. (2020). What are some approaches to diagnosis?
16. Psychology Today. (2019). Co-Occurring Disorders.
17. Choi S., Adams S. M., MacMaster S. A. & Seiters J. (2013). Predictors of residential treatment retention among individuals with co-occurring substance abuse and mental health disorders.J Psychoactive Drugs, 45(2),122–31.
18. National Institute on Drug Abuse. (2018). Principles of Effective Treatment.
19. McGovern, M. P., Lambert-Harris, C., Gotham, H. J., Claus, R. E. & Xie, H. (2014). Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems. Administration and policy in mental health, 41(2), 205–214.