Co-Occurring Disorders

Learn about co-occurring disorders (dual diagnosis), the connection between mental health and substance use issues, and evidence-based treatment approaches for comprehensive recovery.

Co-occurring disorders, also known as dual diagnosis or comorbidity, refer to the presence of both a mental health disorder and a substance use disorder (SUD) in the same person. This complex condition affects millions of Americans, with approximately 21.5 million adults experiencing co-occurring disorders according to SAMHSA's 2022 National Survey on Drug Use and Health [1].


Rather than viewing these as separate issues, mental health professionals now recognize the intricate relationship between substance use and mental health conditions. Co-occurring disorders involve a complex interplay where each condition can influence, exacerbate, or even mask the symptoms of the other, creating unique challenges for diagnosis, treatment, and recovery [2].


The relationship between these disorders is not always straightforward. In some cases, mental health symptoms may lead to substance use as a form of self-medication. In others, prolonged substance use may trigger or worsen mental health symptoms. Often, both conditions share common risk factors, making certain individuals more vulnerable to developing both issues [3].


Common Types of Co-Occurring Disorders

Co-occurring disorders can include various combinations of mental health and substance use conditions. Understanding these common pairings can help identify effective treatment approaches.

Depression and Substance Use

Depression frequently co-occurs with alcohol and drug use disorders. People experiencing depression may turn to substances to temporarily relieve feelings of sadness, hopelessness, or emptiness. However, many substances ultimately worsen depressive symptoms, creating a destructive cycle [4].


Signs of this co-occurring condition may include persistent sadness or emptiness alongside substance use, loss of interest in previously enjoyed activities, changes in sleep and appetite, increased substance use to manage emotional pain, withdrawal from social activities and relationships, and thoughts of death or suicide requiring immediate intervention.


Anxiety Disorders and Substance Use

Various anxiety disorders—including generalized anxiety disorder, panic disorder, and social anxiety—commonly co-occur with substance use. Many people use alcohol or drugs to temporarily reduce anxiety symptoms, but this typically leads to increased anxiety when the substance wears off [3].


This co-occurring condition often presents with excessive worry, fear, or nervousness, physical symptoms like racing heart, shortness of breath, or trembling, avoidance of anxiety-provoking situations, using substances specifically before stressful events, increased anxiety during withdrawal periods, and sleep disturbances exacerbated by both conditions.


PTSD and Substance Use

Post-traumatic stress disorder (PTSD) and substance use disorders frequently co-occur, particularly among veterans, survivors of abuse, and those who have experienced other trauma. Substances may temporarily numb intrusive memories, flashbacks, or hyperarousal symptoms [5].


Common signs include intrusive memories, flashbacks, or nightmares, emotional numbness or detachment, hypervigilance and exaggerated startle response, avoidance of trauma reminders, using substances to suppress traumatic memories, and sleep disturbances and irritability from both conditions.


Bipolar Disorder and Substance Use

The mood swings associated with bipolar disorder—cycling between manic and depressive episodes—create a particularly challenging backdrop for substance use. During manic phases, impulsivity and poor judgment may lead to increased substance use, while depressive phases may prompt self-medication [2].


Indicators of this co-occurring condition include cycling between extreme energy and deep depression, impulsive behavior during manic episodes, using stimulants during depression or depressants during mania, sleep disturbances exacerbated by both conditions, financial or legal problems from impulsive decisions, and increased risk-taking behavior when using substances.


Schizophrenia Spectrum Disorders and Substance Use

People with schizophrenia and related disorders have significantly higher rates of substance use disorders than the general population. Certain substances, particularly cannabis and stimulants, may trigger or worsen psychotic symptoms in vulnerable individuals [1].


Signs may include hallucinations (seeing, hearing, or feeling things that aren't there), delusions (fixed, false beliefs), disorganized thinking and speech, using substances that worsen psychotic symptoms, social withdrawal and difficulty functioning, and poor medication adherence when using substances.


Impact on Daily Life and Relationships

Co-occurring disorders can significantly affect multiple aspects of a person's life, creating challenges that extend far beyond the direct symptoms of each condition.

Personal Functioning

Daily tasks and self-care often become difficult for those with co-occurring disorders. The combined effects of mental health symptoms and substance use can lead to disrupted daily routines with difficulty maintaining regular sleep, eating, and activity patterns; poor self-care including neglecting hygiene, nutrition, or medical needs; cognitive difficulties such as problems with memory, concentration, and decision-making; financial strain from employment issues and spending on substances; legal problems from potential arrests for substance-related offenses; and physical health complications including developing chronic conditions related to substance use [4].


Family Relationships

Co-occurring disorders can place tremendous strain on family relationships. Family members may experience:

  • Confusion about how to help their loved one effectively

  • Emotional distress, including anger, grief, guilt, and fear

  • Financial burden from supporting treatment or covering expenses

  • Caregiver fatigue and potential neglect of their own needs

  • Difficulty distinguishing between symptoms of mental illness and effects of substance use

  • Enabling behaviors that unintentionally reinforce the cycle [6]


Social Connections

The social impact of co-occurring disorders often includes:

  • Withdrawal from friendships and social activities

  • Difficulty maintaining healthy boundaries in relationships

  • Loss of social support networks

  • Stigma and misunderstanding from others

  • Replacing healthy relationships with connections centered around substance use

  • Challenges rebuilding a sober social network during recovery [3]


Causes and Risk Factors

Co-occurring disorders develop through complex interactions of biological, psychological, and environmental factors.

Genetic and Biological Factors

Research suggests that genetic vulnerabilities play a significant role in the development of both mental health and substance use disorders. These include shared genetic risk where certain genes may increase susceptibility to both types of disorders; neurobiological pathways where similar brain regions and neurotransmitter systems are involved in both conditions; family history showing that having first-degree relatives with either disorder increases risk; and developmental factors such as early brain development and neurological differences that may create vulnerability [3].


Environmental and Social Influences

External factors that may contribute to co-occurring disorders include:

  • Trauma exposure – childhood abuse, neglect, or other adverse experiences

  • Chronic stress – ongoing life stressors without adequate support or coping skills

  • Early substance exposure – using substances during adolescence when the brain is still developing

  • Peer influences – social groups that normalize substance use

  • Socioeconomic factors – poverty, unstable housing, and limited access to healthcare

  • Cultural and community factors – varying attitudes toward mental health and substance use [5]


Psychological Factors

Individual psychological characteristics that may contribute include:

  • Self-medication – using substances to manage distressing emotions or symptoms

  • Coping mechanisms – limited healthy coping skills for managing stress or emotions

  • Personality traits – impulsivity, sensation-seeking, or high stress sensitivity

  • Previous mental health episodes – prior episodes increasing vulnerability for both conditions

  • Cognitive patterns – thought patterns that maintain both disorders [2]


Evidence-Based Treatment Approaches

Effective treatment for co-occurring disorders requires addressing both conditions simultaneously through integrated care approaches.

Integrated Treatment Models

Integrated treatment, the current gold standard for co-occurring disorders, involves coordination between mental health and substance use treatment providers. This approach includes simultaneous treatment of both disorders by the same treatment team, coordinated care planning addressing all symptoms and recovery goals, cross-trained professionals knowledgeable about both mental health and addiction, a stage-based approach matching interventions to readiness for change, and a long-term perspective recognizing recovery as an ongoing process [1][4].


Therapeutic Approaches

Several evidence-based therapies have proven effective for co-occurring disorders. These include Cognitive Behavioral Therapy (CBT), which helps identify and change unhelpful thought patterns and behaviors related to both disorders; Dialectical Behavior Therapy (DBT), which teaches emotional regulation, distress tolerance, and interpersonal effectiveness; Motivational Interviewing, which enhances motivation to change by exploring ambivalence; Trauma-Focused Therapies, which address underlying trauma that may fuel both conditions; Contingency Management, which provides incentives for positive behaviors like abstinence; and Family Therapy, which involves family members in the recovery process [2][5].


Medication Management

Appropriate medications can be vital components of treatment for co-occurring disorders. These may include psychiatric medications such as antidepressants, mood stabilizers, anti-anxiety medications, or antipsychotics depending on the specific mental health condition; medications for substance use disorders that reduce cravings or block the effects of certain substances; careful monitoring with regular assessment of effectiveness and side effects; medication adherence support with strategies to help maintain consistent use of prescribed medications; and consideration of interactions to avoid harmful interactions between medications and substances [3].


Support Services

Comprehensive treatment often includes additional support services such as case management with coordination of services and resources; housing support with stable housing options for those in need; vocational services including employment assistance and job skills training; peer support groups that connect individuals with others in recovery; recovery coaching with guidance from individuals with lived experience; and community-based services that provide ongoing support in the least restrictive environment [1].


Self-Care and Recovery Strategies

Recovery from co-occurring disorders involves developing skills and practices that support healing and prevent relapse.

Building a Recovery Foundation

Essential components of a strong recovery foundation include education about both disorders with understanding symptoms, triggers, and treatment options; medication adherence by taking prescribed medications consistently as directed; developing structure through creating healthy daily routines that support recovery; attending to physical wellness by addressing nutrition, exercise, and sleep needs; avoiding high-risk situations by identifying and planning for situations that trigger symptoms or substance use; and building a support network by connecting with understanding friends, family, and peers [4][6].


Developing Healthy Coping Skills

Learning alternatives to substance use for managing mental health symptoms is crucial. This involves practicing emotional regulation techniques such as mindfulness, deep breathing, and grounding exercises; implementing stress management practices by identifying stressors and healthy ways to respond; building problem-solving skills to approach challenges systematically rather than avoiding them; improving communication skills to express needs and feelings appropriately; creating relapse prevention plans that identify warning signs and response strategies; and engaging in wellness activities that support overall well-being [5].


Maintaining Long-Term Recovery

Sustaining recovery over time requires ongoing attention and adaptation:

  • Continued engagement in treatment – attending therapy and support groups consistently

  • Regular self-assessment – monitoring symptoms of both disorders

  • Adjusting strategies as needed – modifying approach based on changing circumstances

  • Celebrating successes – acknowledging progress, no matter how small

  • Managing setbacks constructively – viewing lapses as learning opportunities rather than failures

  • Building a meaningful life – developing purpose beyond symptom management [3]


Supporting a Loved One

Family members and friends play a crucial role in supporting recovery from co-occurring disorders.

Understanding Their Experience

Developing insight into the lived experience of co-occurring disorders helps provide effective support:

  • Learning about both conditions – educating yourself about specific symptoms and treatments

  • Recognizing complexity – understanding that recovery isn't linear and setbacks are common

  • Separating the person from the disorders – seeing your loved one as more than their diagnoses

  • Acknowledging pain – recognizing the real suffering experienced with both conditions

  • Understanding behavior in context – seeing substance use as an attempt to cope, not a moral failure

  • Maintaining realistic expectations – recognizing that recovery takes time [6]


Effective Communication Approaches

How you communicate can significantly impact your loved one's recovery:

  • Using non-judgmental language – avoiding blame, criticism, or labels

  • Practicing active listening – truly hearing concerns without immediately offering solutions

  • Expressing concerns constructively – focusing on specific behaviors rather than character

  • Setting clear boundaries – communicating limits while maintaining respect

  • Offering encouragement – acknowledging progress and efforts toward recovery

  • Being patient – allowing time for processing and change [4]


Self-Care for Supporters

Supporting someone with co-occurring disorders can be challenging, making self-care essential:

  • Setting appropriate boundaries – distinguishing between supporting and enabling

  • Seeking your own support – connecting with support groups for family members

  • Maintaining your own life – continuing activities and relationships beyond the support role

  • Managing expectations – accepting what you can and cannot control

  • Processing difficult emotions – finding healthy outlets for frustration, grief, or worry

  • Considering family therapy – participating in treatment to improve family functioning [6]


Finding Professional Help

Accessing appropriate treatment is a crucial step toward recovery from co-occurring disorders.

When to Seek Help

Consider professional help if you or your loved one experience increasing substance use despite negative consequences; worsening mental health symptoms alongside substance use; difficulty functioning in important life areas; failed attempts to cut down or control substance use; withdrawal symptoms when trying to stop using; dangerous behaviors while intoxicated; or suicidal thoughts requiring immediate intervention [2].


Types of Treatment Settings

Various treatment options exist depending on severity and individual needs:


Finding the Right Provider

When seeking treatment, look for providers with integrated treatment experience and specialization in co-occurring disorders; evidence-based approaches proven effective through research; proper credentials including appropriate licensing and specialized training; insurance coverage with providers within your insurance network; personalized treatment planning that offers a tailored approach rather than one-size-fits-all; and ongoing assessment with regular evaluation of progress and adjustment of treatment plans [3].


Browse Our Treatment Directory

Finding the right support for co-occurring disorders can transform your life or the life of someone you care about. Our comprehensive treatment directory allows you to search for mental health and substance use professionals and programs specializing in integrated treatment for co-occurring disorders.

Our directory helps you find providers based on:

  • Location and accessibility – treatment options in your area or offering telehealth

  • Specialization in co-occurring disorders – professionals with specific expertise

  • Treatment approaches and settings – from outpatient therapy to residential programs

  • Insurance acceptance and payment options – find affordable care options

  • Specific mental health and substance use specialties – providers experienced with your particular conditions

  • Additional services and support – family involvement, peer support, and recovery resources


Don't face this journey alone. Browse our treatment directory today to find a provider who can help you or your loved one create a personalized recovery plan that addresses both mental health and substance use challenges.


Related Conditions

The following related pages may provide additional helpful information:


References

[1] SAMHSA. (2024). Co-Occurring Disorders and Other Health Conditions. https://www.samhsa.gov/substance-use/treatment/co-occurring-disorders

[2] Cleveland Clinic. (2022). Dual Diagnosis: Definition & Treatment. https://my.clevelandclinic.org/health/diseases/24426-dual-diagnosis

[3] National Institute on Drug Abuse (NIDA). (2024). Co-Occurring Disorders and Health Conditions. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions

[4] HelpGuide. (2024). Deal with a Dual Diagnosis: Substance Abuse & Mental Health. https://www.helpguide.org/mental-health/addiction/substance-abuse-and-mental-health

[5] American Addiction Centers. (2024). Co-Occurring Disorder Treatment Centers Near Me. https://americanaddictioncenters.org/co-occurring-disorders

[6] Partnership to End Addiction. (2024). Helping with Co-occurring Disorders. https://drugfree.org/article/helping-with-co-occurring-disorders/

[7] SAMHSA. (2024). Managing Life with Co-Occurring Disorders. https://www.samhsa.gov/mental-health/serious-mental-illness/co-occurring-disorders