Dual Diagnosis: Understanding Drug Addiction and Mental Health

When someone has a substance use disorder (SUD) and a mental health disorder, they have a dual diagnosis, which is also known as a co-occurring disorder. Anyone with a dual diagnosis can receive integrated treatment at various levels of care.

Inpatient and outpatient programs exist to teach you how to maintain recovery and mental health stability. By asking the right questions, you can find the right team to treat your dual diagnosis.

Key Facts About Dual Diagnosis

This dual diagnosis resource will help you understand:

• How dual diagnosis is defined and how it compares to similar terms
• Common co-occurring disorders and their interactions
• Principles of dual diagnosis treatment
• Types of treatment programs available
• How to choose the right treatment program
• The importance of aftercare

Entering dual diagnosis treatment can feel overwhelming and challenging at times. However, the more you know about dual diagnoses, the better you can make informed decisions for yourself and your family.

What Is Dual Diagnosis (Co-Occurring Disorders)?

A dual diagnosis is a mental health condition and drug or alcohol addiction that occurs at the same time. The Substance Abuse and Mental Health Services Administration (SAMHSA) states that people with a mental illness are more likely to experience a substance use disorder than those who do not have a mental illness. 

With so many people affected, and after years of underdiagnosis and under-treatment, healthcare providers and government agencies are now focusing on effective treatment programs for dual diagnosis.

Other words used to describe this situation are comorbidity and co-occurring disorder. While some people use the terms interchangeably, others recognize a difference between them, as follows:

Comorbidity

This term is used when someone has two conditions, but they do not necessarily have to be present simultaneously. In some cases, one disorder may contribute to or result from the other, and understanding that relationship can guide treatment. These conditions can be psychological, physical, or a combination of both.

Co-Occurring Disorder

Someone who has a combination of two or more substance use disorders, mental health disorders, and physical conditions has a co-occurring disorder. They can have multiple substance use disorders, mental illnesses, and physical ailments. 

Dual Diagnosis

Dual diagnosis refers to having a substance use disorder and a mental illness simultaneously. For example, someone may have an alcohol use disorder and depression. Treatment for dual diagnoses must focus on treating both conditions at the same time to prevent a relapse of either condition.

How Substance Use and Mental Illness Interact

Substance use and mental health are so interconnected that it can be hard to tell which one came first. Did someone use substances to cope with their mental health symptoms? Or did substance misuse trigger a mental illness? The two disorders coexist through a shared neurocircuitry in the brain that creates a feedback loop involving feeling high, feeling low, craving, and relapsing.

Common Mental Health Conditions That Co-Occur with SUD

The National Institute of Mental Health states that a dual diagnosis may be made when someone has a substance use disorder and a mental health illness, such as:

• Anxiety disorder
• Depression
• ADHD
• Bipolar disorder
• Schizophrenia
• OCD
• PTSD
• Conduct disorder

Each of these mental health conditions comes with unique challenges and interactions with the substance use disorder.

Depressive Disorders

Someone with depression may feel sad, lethargic, empty, worthless and many other symptoms unique to their situation. For some, a depressed mood occurs temporarily and fades away over time. An example of this is when someone is grieving the loss of a loved one. For others, symptoms of depression do not go away and may develop into a disorder, like postpartum, psychotic, melancholic or seasonal affective disorders.

Anxiety and Panic Disorders

Anxiety disorders occur when thoughts and feelings related to worry and stress interfere with how someone functions, going beyond what is thought to be normal worry and concern. Anxiety disorders include generalized anxiety, obsessive-compulsive disorder, panic, post traumatic stress, separation anxiety and social anxiety. Someone may also experience specific phobias. 

While benzodiazepines can be a beneficial treatment, they are often misused when hyperarousal heightens craving cues. Exposure-based cognitive behavioral therapy can reduce both anxiety and substance abuse triggers.

Bipolar Spectrum Disorders

Bipolar disorder is a mood disorder that can have mild, moderate or severe cycles of symptoms from mania to depression. Common symptoms include mania-linked hyperactivity and impulsiveness, bingeing on alcohol or drugs, extreme depression and isolation. Treatment may include mood stabilizers, but renal and hepatic effects must be taken into consideration.

PTSD and Trauma-Related Disorders

Post-traumatic stress occurs when someone witnesses or experiences a disturbing event or situation. Physical or sexual abuse, war combat, natural disasters and loss of a loved one are some examples of events that cause PTSD. People often use drugs or alcohol to numb symptoms like hypervigilance and flashbacks. Treatments such as eye movement desensitization and reprocessing (EMDR) and safety seeking tend to reduce both substance abuse and mental health symptoms of PTSD.

Personality Disorders

Personality disorders are a group of mental health conditions that describe the thoughts and behavior patterns of people that deviate from cultural expectations and cause distress or impairment in relationships, work, or other areas of life. 

Examples include borderline, antisocial, paranoid, avoidant, histrionic, schizoid and obsessive-compulsive personalities. Prevalent symptoms include emotional dysregulation, self-harm and polysubstance abuse. Typically, dual diagnosis treatment involving dialectical behavior therapy skills modules, integrated with relapse prevention, is successful.

ADHD and Neurodevelopmental Disorders

Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder where someone struggles with impulsiveness or hyperactivity. They often struggle with staying organized, focused, and completing tasks. ADHD symptoms can interfere with how a person performs at home, at work, in school or socially.

Early stimulant misuse can lead to later misuse of other substances. When the executive functioning in the brain is altered, it can make aftercare challenging. Someone with ADHD benefits most from proper stimulant pharmacotherapy, so the need for illicit use is eliminated.

Eating and Feeding Disorders

Eating and feeding disorders include anorexia nervosa, bulimia, binge eating disorder, pica, and avoidant restrictive food intake disorder.

These abnormal eating patterns negatively impact a person’s mental and physical health and require intense treatment, especially when people combine drug or alcohol use with their eating disorder. For example, someone may use stimulants or appetite suppressants to help them lose weight. Part of an effective rehab program includes nutrition and SUD meal planning.

Psychotic Disorders

Psychotic disorders occur when someone disconnects from reality, causing hallucinations, delusions, agitation, and incoherence. Examples of disorders include schizophrenia, postpartum psychosis, schizoaffective disorder, and drug-induced psychosis.

Some people use cannabis and stimulants to cope, but they only exacerbate the symptoms. An effective treatment for SUD and mental health symptoms includes clozapine, but it requires metabolic monitoring.

Principles of Integrated Dual Disorder Treatment (IDDT)

SAMHSA recommends integrated treatment for those with a dual diagnosis. Integrated treatment coordinates mental and substance-use interventions through individualized services that treat both conditions’ physical and emotional aspects.

The advantages of integrated dual diagnosis treatment are as follows:

• Abstinence or reduced substance use
• Improvement in mental health and cognitive functioning
• Reduced chance of relapse and increased likelihood of long-term recovery
• Improved quality of life and housing stability
• Less need for hospitalization or law-enforcement involvement
• Continuous, long-term engagement is viewed as chronic care.

SAMHSA also promotes a “No Wrong Door” policy, ensuring that everyone accessing addiction services is routinely screened for mental health issues and vice versa. The Substance Use Disorder Treatment for Persons with Co-Occurring Disorders: Treatment Improvement Protocol (TIP-42) provides best-practice guidelines emphasizing person-centered, trauma-informed, culturally responsive, recovery-oriented, and comprehensive care.

Evidence-Based Psychotherapies

Numerous therapies are available that benefit individuals with mental health and substance use disorders, including:

• CBT or cognitive behavioral therapy. CBT focuses on cognitive restructuring of thought distortions. It teaches individuals how to replace unhealthy, unrealistic thoughts with positive ones, thereby changing their behaviors.
• DBT or dialectical behavior therapy. DBT is a type of CBT that adds a mindfulness aspect to treatment. It teaches distress tolerance and emotion regulation through specific modules.
• MI, or motivational interviewing. This is most effective with individuals who are not yet fully committed to recovery. It helps them resolve ambivalence and boosts readiness to change.

Medication-Assisted Treatment (MAT) & Psychopharmacology

Medication-assisted treatments are supervised by clinicians who administer appropriate medication doses that prevent getting high but also prevent painful withdrawal symptoms that may lead to relapse.

Examples of MAT and psychopharmacology include:

• Buprenorphine
• Methadone
• Naltrexone
• Naltrexone integrated with SSRIs/SNRIs

Since the medicines are overseen by medical providers and dispensed by pharmacies, there is a decreased chance for misuse or abuse. The length of time someone is on MAT can range from several months to several years, depending on the individual’s specific needs. Various types of counseling are provided alongside these prescriptions, to address both the physical and mental aspects of addiction.

Holistic Modalities

Holistic treatments are those that treat the mind, body, and spirit as a whole, with the understanding that any issue left untreated could be a trigger for relapse. Common effective treatments include yoga, mindfulness, and art therapy, which can reduce cortisol levels and cravings. Nutrition, sleep hygiene, and exercise stabilize mood and energy. Other holistic therapies may include music, animal support, acupuncture, massage, tai chi, and journaling.

Levels of Care and Program Types

Levels of care and types of programs are chosen by a dual diagnosis treatment team based on individual needs for mental health and substance abuse recovery. They range from most intense to least restrictive.

Medical Detox and Stabilization

If someone has an addiction to a substance, they may need to undergo detox in an environment where medical professionals can manage withdrawal symptoms before beginning additional treatment. Once stabilized physically and mentally, they can move to the next level of dual diagnosis treatment.

Inpatient / Residential Dual Diagnosis Rehab

Inpatient and residential care involve working with mental health and addiction professionals, addressing dual-diagnosis drivers through CBT and holistic modalities such as meditation and yoga. Medication-assisted treatment can continue at this level.

Partial Hospitalization Programs (PHP) & Intensive Outpatient Programs (IOP)

Partial hospitalization is an outpatient program that involves between 20 and 30 hours of treatment weekly, while intensive outpatient programs include between nine and 15 hours of clinical treatment weekly.

Participants can enhance their skills while working from home, pursuing further education or attending to other responsibilities. These outpatient programs often include frequent urine screens and peer feedback loops. Clients can continue to participate in MAT if needed.

Standard Outpatient & Telehealth Options

Outpatient treatment allows a person to remain at home and attend school or work while receiving therapy several times per week. Couples or family therapy can be integrated. Outpatient programs may also include telehealth options which allow participants to access care from anywhere via video calls, chat features, or other care apps.

Specialized Tracks

Specialized tracks or program options focus on specific treatment populations such as adolescents, women, LGBTQ+, veterans or seniors. Programs tailor curricula to the developmental stage, gender and cultural identity of participants. They also address PTSD-MST, hormonal factors and age-specific comorbidities.

Relapse Prevention and Aftercare

Studies have shown that individuals with co-occurring severe mental illness and substance misuse problems have poorer treatment outcomes, including relapse, than those without a substance disorder. Unless both aspects are treated, the re-emergence of one will likely trigger the other. Individuals leaving treatment must connect with community resources to support their ongoing recovery success.

Personalized Continuing-Care Plans

Continuing care is a vital part of aftercare, and a personalized plan should be created to meet each individual’s specific needs. Examples of an effective continuing care plan include a 12-month schedule of therapy, medication management, and drug testing. Additionally, individuals should establish SMART goals with an accountability partner to help them stay on track with their long-term sobriety plan.

Sober Living & Recovery Residences

Aftercare services such as transitional sober-living homes or support groups provide structure and accountability once the initial program is complete. Sober living and recovery residences provide individuals in early recovery with opportunities to practice the skills they’ve learned before returning to their home environment.

Coping Skills, Stress Management & Mindfulness

It’s important to develop specific skills to manage stress and cope with challenges before leaving treatment. These strategies can include the HALT trigger check, which allows a person to check triggers such as hunger, anger, loneliness, and tiredness. Urge surfing is the ability to ride out an urge rather than giving in to it. Box breathing drills help someone alleviate stress. In addition, journaling and gratitude practice tend to sustain motivation.

Alumni Networks & Digital Support Platforms

Today, there is more support available at every stage of the recovery process. There are mobile apps for craving tracking, online support groups, and virtual 12 Step meetings. People leaving a dual diagnosis treatment program can participate in alumni events to reinforce their sense of community and find a mentor. These events, combined with digital platforms, can provide ongoing support for a lifetime.

Choosing a Dual Diagnosis Treatment Center

When selecting a dual diagnosis treatment center, there are specific characteristics to consider to ensure you receive the best possible care.

Accreditation & Licensing

Treatment programs for individuals with dual diagnoses should be accredited, licensed, and in good standing with organizations such as the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF). This means they undergo external audits of safety and utilize evidence-based protocols in treatment. These accrediting bodies also verify that the facility is competent in offering dual diagnosis treatments.

Questions to Ask Providers

Don’t hesitate to ask questions regarding the program and staff. Examples of good questions to ask include:

• What are your staff-to-patient ratios?
• Do you offer 24-hour medical coverage?
• Do you undergo trauma-informed training?
• How do you track progress and outcomes?
• What are the staff credentials?

Insurance, Financing & Cost Transparency

Ask the treatment center to verify whether your insurance is in-network and to confirm the specific coverage benefits and any single-case agreements before you enter treatment. If you do not have insurance, ask the treatment center if they offer scholarships, sliding scale fees, or payment plan options.

Measuring Outcomes & Success Rates

Knowing how progress is measured helps you stay on track and motivated. Ask the provider if they report 30-, 90-, and 180-day abstinence, and if so, how they track and report these periods. Ask about rewards for reaching treatment goals. Additionally, determine which types of mental health symptom scales are used to assess whether improvements are occurring. Finally, question if they share continuous quality-improvement loops publicly.

Dual Diagnosis Frequently Asked Questions (FAQs)

Find Treatment Near You

To make finding the best dual diagnosis treatment program easier, visit Rehab.com and explore their national provider directory. It’s simple, and you can filter by location, level of care, insurance and special programs. You can view top-ranked centers in your city or state, based on our rehabilitation scoring methodology. 

Not sure where to start? You can also call the the number below to speak with someone who can assist you in finding a treatment center, verify your insurance coverage, and answer any questions you may have regarding dual diagnosis treatment.

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