Dual Diagnosis: A Guide to Mental Health and Co-Occurring Substance Use Disorders

Table of Contents

  1. Introduction
  2. Co-Occurring Conditions
  3. Dual Diagnosis Therapies
  4. Dual Diagnosis Treatments
  5. Finding Help

Introduction to Dual Diagnosis

A person who has a mental health disorder along with a drug or alcohol problem has a dual diagnosis. The condition is also called a co-occurring disorder.

Either disorder (mental illness or substance use) of a dual diagnosis can develop first.

  1. Individuals with mental health conditions may turn to drugs or alcohol as a way to self-medicate away symptoms. Unfortunately, drugs and alcohol worsen the symptoms of mental illnesses rather than improve them.1
  2. The prolonged use of drugs or alcohol affects the brain and leads to a mental health disorder.

Statistics About Dual Diagnosis

In 2018, the National Survey on Drug Use and Health reported that 9.2 million adults in the United States had a dual diagnosis both a mental illness and a substance use disorders.

Research shows that rates for lifetime dual diagnosis vary greatly according to ethnicity/race:2

  • African American: 5.4%
  • Hispanic: 2.1%
  • Asian American: 2.1%

The same study on dual diagnosis reported that more people with co-occurring mental health issues and substance abuse disorders (SUDs) reported that their mental disorders appeared first.

  • About 20% of people in the United States that currently have a substance use disorder have at least one current mood disorder not caused by drug or alcohol use.
  • 18% had a least one anxiety disorder not caused by drug or alcohol use.

Compared with those who have a mental disorder or a substance abuse disorder (but not both), those with a dual diagnosis have higher rates of:

  • Poor health
  • Unemployment
  • Housing instability
  • Suicide attempts

Conditions and Commonly Co-Occur with Substance Use Disorders

A wide range of mental health conditions are seen together with drug and alcohol abuse in a dual diagnosis.


Having an anxiety and substance use disorder together affects about 5% to 20% of Americans.3 Anxiety symptoms, anxiety disorders and substance use disorders are commonly seen together. This develops in many different ways. Anxiety symptoms often appear when a person is frequently intoxicated. Also, anxiety symptoms often present during withdrawal from substances.

People with anxiety disorders are at a higher risk of developing a SUD and a dual diagnosis. Also, having an anxiety disorder can change the way SUD develops or appears. Similarly, SUD can change the way an anxiety disorder develops or appears.

Bipolar Disorder

Bipolar and substance abuse disorders are seen together in about 30% to 60% of people with a dual diagnosis. People with both bipolar and substance use disorders (SUD) have a harder time when it comes to dealing with bipolar episodes. Episodes may last longer and happen more frequently when SUD is combined with Bipolar Disorder. Also, they experience a lower quality of life. Suicidal behavior can increase as well. Some people develop a mild form of bipolar disorder after using alcohol for long periods of time.

BPD is a type of misunderstood mental health disorder. Since BPD is triggered and occurs within personal relationships, it can cause much damage to sufferers and their loved ones. People with BPD suffer from:

  • Distorted self-image
  • Abandonment fears
  • Intense and unstable relationships
  • Extreme emotions and intense mood shifts
  • Anger problems
  • Impulsive actions

One reason BPD is misunderstood is that it usually exists with other disorders causing a dual diagnosis. Depression, anxiety, and substance abuse disorders can muddle the diagnosis of BPD. Many times, the BPD is missed or ignored.

If BPD is not treated, its symptoms make it difficult to function normally. Research suggests there is a strong connection between prescription drug abuse and BPD. 4


Codependency can play a part in dual diagnosis in two ways. Relationships that are negative or filled with conflict can cause a person to turn to substance abuse. Also, people who have enabled drug use can cause someone to relapse back to drug or alcohol abuse.


Both a depressive and substance use disorder are seen in 5% to 25% of people with a dual diagnosis. People who abuse depressants such as alcohol or tranquilizers are especially at risk for depression.

Clinical depression can’t be treated with alcohol or drugs. People with depression remain that way without proper treatment.

OCD (Obsessive Compulsive Disorder)

OCD is where a person has high levels of anxiety. For relief from intrusive thoughts, they perform repetitive behaviors. Repetitive behaviors may include:

  • Tapping
  • Counting
  • Checking and rechecking things, like stoves and locks
  • Excessive cleaning or hand washing

Many people who suffer from obsessive-compulsive disorder turn to alcohol or drugs to relieve their high levels of anxiety resulting in a dual diagnosis. They may also abuse substances to block out the intrusive thoughts that invade their daily lives.

Trauma or PTSD (Post-Traumatic Stress Disorder)

Research indicates that 50% of individuals who have SUD also have PTSD.5 This high rate may be due to a genetic connection that is common to both disorders.

Studies also show that people who have SUD who then suffer trauma are more likely to develop PTSD than those without a prior SUD. Other studies show that people with PTSD self-medicate to relieve the mental and emotional distress that comes from the disorder. Self-medicating for long periods of time can lead to addiction requiring treatment with a dual diagnosis.

Therapies for Dual Diagnosis

Recovery from a dual diagnosis is possible. Effective dual diagnosis treatment needs an integrated approach. A mix of different therapies helps people recover from mental health and substance use disorders. The choice of the best-suited therapies depends on the mental health disorder(s).

Evidence-based treatments that work well in the treatment of dual diagnosis include:

Cognitive Behavioral Therapy (CBT) for Dual Diagnosis

Cognitive-behavioral therapy is effective for a wide range of SUDs and for a dual diagnosis with mental health disorders. CBT teaches new skills and strategies for dealing with and reducing problem behaviors and thoughts. CBT does this by using behavioral practices and role-playing.

Also, CBT counselors help clients identify the patterns associated with the use of substances. The counselor and client work to identify and use new strategies to avoid or effectively cope better with the things that come before substance use.

CBT is also used to treat certain mood disorders. CBT helps identify and change distorted thoughts that can lead to mood changes.

Group CBT sessions focus on education about:

The relationships between substance use and their mood disorders

How not taking drugs or alcohol can improve mood disorder symptoms

Exploring how manic and depressive moods can affect judgment

Dialectical Behavioral Therapy (DBT) for Dual Diagnosis

Dialectical Behavior Therapy works well for a dual diagnosis with SUD and a borderline personality disorder or a mood disorder. DBT builds on a strong client-therapist relationship where they commit to being a team. The client must also be willing to accept that there is a need to change dysfunction. Behaviors and feelings that need to change are identified and agreed upon. The therapist then supports the client towards positive alternatives, new skills, and ways to change behaviors.

Rational Emotive Behavioral Therapy (REBT) for Dual Diagnosis

REBT helps people change self-defeating thoughts so they can feel better. Changing those thoughts helps with both conditions of a dual diagnosis.  REBT also helps them change their behaviors to be more flexible, given the situation. The goal is to have new behaviors to help clients achieve their identified goals.

REBT assumes people generally have irrational thoughts about how their lives should be. It also assumes people have illogical thoughts about how people should behave. REBT counselors teach their clients how to challenge irrational thoughts and beliefs. The goal is to develop more realistic behaviors and thoughts that are less self-defeating.

Experiential Therapy for Dual Diagnosis

Experiential therapy can take many forms. ET helps clients identify and deal with hidden issues through experiencing. Experiencing can include role-playing, physical activities, or using props. Experiential therapy examples include:

  • Music or art therapy
  • Equine therapy
  • Dance therapy
  • Recreational therapy

Experiential therapy aims to help clients learn ways to take personal responsibility. Sessions also explore personal relationships. People in experiential therapy learn how to tap into their emotions.

Clients also recreate significant parts of their pasts. They work with others to trigger negative emotions that lead to negative or compulsive behaviors. Once revealed, they work to process those emotions and feelings in a secure therapeutic setting.

Eye Movement Desensitization & Reprocessing (EMDR) for Dual Diagnosis

EMDR can be especially effective in treating a dual diagnosis with SUD and PTSD. Stressful events activate our “flight-or-fight” response. Along with that comes stress, rapid heartbeat, sweating, and tenseness. This is a natural response to face a threat. Once the threat passes, so should our defense reactions. People with PTSD are in a constant state of high alert due to a traumatic event they have not fully healed from.

EMDR clients discuss the traumatic events they have experienced. They are asked to describe the sensations they experience as they think and talk about them. As they do so, they are also asked to move their eyes back and forth. This sweeping of the eyes motion can occur by following the counselor’s hand movements or following side-to-side motions on a screen.

The goal is to help individuals explore memories in detail. It’s also to identify all the persistent thoughts that keep coming up in response to trauma. Clients learn to calm their bodies while thinking about the thoughts and images they’ve been avoiding. In time, they find that the memories can’t harm them and that they are in control. They also realize the persistent thoughts about those memories can be challenged and proven incorrect. EMDR turns off that fight-or-flight response. Trauma sufferers can then move on with their lives.

Motivational Interviewing (MI) for Dual Diagnosis

Motivational interviewing is a short-term treatment. MI focuses on creating quick and internally motivated changes in SUDs and dual diagnosis behaviors. MI builds on the foundation that people who want to change go through a series of stages.

The stages of motivational interviewing are:

  • Not thinking about changing
  • Thinking about changing
  • Deciding to change through different actions and behaviors
  • Making the change
  • Maintaining the positive changes made
  • Motivational interviewing sessions can vary from one to four, so critical changes can be made quickly.

Psychoeducational Groups for Dual Diagnosis

Psychoeducational groups help people with addiction, as well as mental health issues. These groups teach specific details about addiction, recovery, and mental health disorders which helps cope with both conditions of a dual diagnosis. Participants get the information through lectures, movies, and additional materials.

Topics in psychoeducational groups include:

  • Addiction and its consequences
  • Relapse prevention
  • Stress management
  • Benefits of decreasing substance abuse to improve mental health

12-step, SMART Recovery, and other Support Groups for Dual Diagnosis

Support groups in the form of 12-step, SMART Recovery, and other support groups can be an effective part of dual diagnosis recovery plans. Peer support and inspiration are powerful benefits of group therapy.

12-step groups: Alcoholics Anonymous introduced the 12 steps. Since then, many programs have developed groups based on this philosophy. 12-step groups encourage people to become and remain sober from alcohol, drugs, and harmful behaviors.

SMART Recovery: SMART focuses on teaching practical skills and developing a sense of empowerment to deal with addiction. SMART Recovery encourages clients to determine what changes they need to make and the ways to get there.

Other Support Groups: There are other support groups that can be helpful in the treatment of dual diagnosis. Depending on the individual, faith-based, gender-specific and other support groups can be quite effective.

Dual Diagnosis Treatment Programs

Therapies for dual diagnosis can be administered in a variety of treatment settings.

Inpatient Treatment (IP) for Dual Diagnosis

Individuals with serious mental health symptoms or severe substance abuse issues may need a 24/7 level of care. People who need a medical detox that may produce severe withdrawal symptoms could also need residential treatment.

Around-the-clock care can be a first step in treatment or as a way to combat relapse at any stage of treatment. Inpatient rehab stays start at 28 days but can range from several months or longer. Many choose to go away from home for inpatient treatment. It helps them make a fresh start away from the people, places, and things that can trigger urges and cravings.  It also provides an effective place to deal with a dual diagnosis condition, if one is discovered.

Residential treatment isolates individuals from their environments, so they are away from negative influences and temptations. It also provides close supervision in a highly structured setting. The added support inpatient rehab provides can also lessen the chances of relapse.

Partial Hospitalization Programs (PHP) for Dual Diagnosis

Dual diagnosis PHPs are designed to treat SUDs and mental health disorders in an intensive environment that’s one step below an inpatient setting. PHPs can be an entry point for treatment, a step down from inpatient treatment, or a step up from outpatient care.

PHPs schedule treatment for about 6 hours a day for 3 to 5 days a week, but the hours and days may vary. PHPs are sometimes called day programs.

PHPs are designed to:

Maintain an individual’s level of functioning

Prevent relapse

Avoid full hospitalization

Provide needed medical care

Despite its name, most PHPs take place outside of a hospital setting. PHPs are found in treatment centers, clinics, and community health centers.

PHPs typically provide:

  • Group therapy
  • Individual counseling
  • Psychoeducational groups
  • Medication management
  • Substance use monitoring
  • A gateway to community-based support groups
  • Medical treatment
  • Mental health screening and therapy
  • Job training and services

Intensive Outpatient Programs (IOP) for Dual Diagnosis

Dual diagnosis IOPs are a step below PHPs in the level of care. They typically provide the same therapies as a PHP, but for fewer hours per week. IOPs may or may not provide medical treatment. People who are undergoing a medical detox for mild to moderate substance abuse sometimes do it on an outpatient basis via an IOP.

Outpatient Programs (OP) for Dual Diagnosis

Dual diagnosis OPs are a step below IOPs in the level of care. They typically provide the same therapies as a PHP or IOP, but for fewer hours per week than either. OPs may or may not provide medical treatment. OPs are also the way long-term medication maintenance is handled. One example is outpatient methadone services to treat opiate addiction recovery.

Finding Help for a Dual Diagnosis

When you or a loved one is suffering from a dual diagnosis, it’s important to get the right help as soon as possible. Clinical mental health disorders will not heal on their own. Chronic substance use and abuse also needs formal treatment. Recovery is possible with the right help.

Talk with your doctor or any other healthcare professional that you trust. You can also contact reputable treatment centers both locally and farther away. Take the first important step and reach out for help. It’s the cornerstone to rebuilding a healthy and stable life free of substances and severe mental health symptoms.


  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327759/
  2. https://www.ncbi.nlm.nih.gov/books/NBK64105/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196330/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3466083/