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. The National Survey on Drug Use and Health 2018 found that approximately 9.2 million adults in the United States have a dual diagnosis.

With so many people affected, and after years of under-diagnosis and under-treatment, healthcare providers and government agencies are now focusing on effective treatment programs for dual diagnosis. If you or a loved one has a mental health concern and an addiction, you will find all the information you need here to understand more about the condition and the help that is available.

What Is Dual Diagnosis?

Dual diagnosis is a term used to describe when someone simultaneously has a substance use disorder and mental health condition. 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. With comorbidity, consideration is given to whether one disorder is a consequence of the other. While this can apply to substance use disorder and mental health concerns, it can also apply to other health conditions. These conditions can be psychological, physical, or a mixture.
Co-occurring disorder: The term co-occurring disorders may include any combination of two or more substance use disorders, mental disorders, and physical conditions. Many people with addiction have co-occurring disorders beyond mental health concerns. For example, one in ten new HIV diagnoses in the US is related to injection drug use, meaning that individuals can have co-occurring substance addiction and HIV.
Dual diagnosis: This term relates to just two conditions, hence the name “dual.” Dual diagnosis is often used to describe someone with an alcohol or drug addiction and mental health condition. However, it can also relate to other conditions, such as substance use disorder and diabetes.

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
Eating disorder
ADHD (Attention-deficit hyperactivity disorder)
Bipolar disorder
Borderline personality disorder
Schizophrenia
Psychosis
PTSD

What Can Cause Someone To Have a Dual Diagnosis?

There can be various reasons why someone may receive a dual diagnosis. The National Alliance on Mental Illness (NAMI) states that mental health conditions can cause substance use disorders (and vice versa). For this reason, it can be difficult to identify which came first as, for many people, the conditions are diagnosed at different times. Furthermore, historically, addiction and mental health conditions have been diagnosed and treated in isolation, with little understanding of the link between the two. Environmental, genetic, and childhood influences can also affect the chance of someone receiving a dual diagnosis.

The Impact of Mental Health on Addiction

Individuals with mental health concerns are more likely to abuse substances and develop a substance use disorder, and those with severe mental illnesses are at a higher risk. Studies have concluded that the more severe the mental illness, the greater the likelihood that the person will also use or abuse illicit substances. Reasons why more than half of people with a serious mental health illness also have an addiction include:

Self-medicating

Some people with mental health conditions may choose to self-medicate to cope with or relieve the symptoms of their mental illness. Individuals with mental disorders perceive their symptoms as treatable and act purposefully to mitigate them through the use of substances. As the person becomes used to the medication and tolerance develops, they may use it more frequently or in higher doses to have the same effect. The person can become reliant on the substance to function and may not even realize that they have an addiction.

Shared Triggers

As well as coping with the symptoms of their mental illness, individuals may also seek external coping mechanisms for stressful or triggering situations. If they struggle to manage their thoughts and feelings internally, they may experience a mental health episode or turn to drugs or alcohol to block out their surroundings or numb their emotions.

Impulsive Behavior

Studies have shown that impulsivity leads to a high frequency of comorbidities, such as substance use disorders. Impulsivity is a common trait among those with particular mental illnesses. For example, someone with bipolar disorder experiencing a manic episode may display enhanced cognitive behaviors. These include increased energy and attention span, and the inability to assess risk effectively, which leads to impulsive decision-making.

Certain Mental Illnesses

The chance of developing an addiction is related to the severity of a person’s mental illness as well as their specific diagnosis. Studies have shown that certain personality disorders are linked with chronic substance use. Examples of personality disorders that may increase the likelihood of addiction are:

Narcissistic Personality Disorder
Borderline Personality Disorder
Dependent Personality Disorder
Antisocial Personality Disorder
Paranoid Personality Disorder
Schizoid Personality Disorder

The Impact of Addiction on Mental Health

The use of drugs and alcohol can worsen or even cause mental illness. Addiction is a mental illness in itself, as substance abuse can majorly impact brain function, which encourages drug-seeking behavior.

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health states that there is well-supported scientific evidence that substance use disrupts three areas of the brain. These areas are important in the onset, development, and maintenance of substance use disorders. One 2010 study found that drugs are particularly detrimental to the well-being of individuals whose cognitive performance is already compromised by a mental disorder. In other words, people with a mental illness are more susceptible to the impact of drugs on the brain than those without a mental illness, making them more likely to develop an addiction. The three areas of the brain that are impacted by drug use are:

The triggering of substance-seeking cues: This creates the desire to take the substance repeatedly to achieve feelings of pleasure and reward.
Reduced brain sensitivity: The brain becomes less sensitive to pleasure and reward, meaning taking more of the substance is necessary to have the same effect.
Reduced decision-making abilities: Substance use can make someone unable to regulate their actions and emotions and impairs their ability to make healthy decisions. This can lead to impulsive choices without considering the consequences, which is a common factor in the excessive use of drugs and alcohol.

Furthermore, drug use can cause mental health conditions such as depression and anxiety. One study found a progressive increase in depressive mood levels from non-drug users to users of legal drugs such as alcohol and finally to users of illicit substances. Those who used illegal drugs recorded the highest levels of depression. There are many reasons for this, including the impact a substance use disorder has on the overall quality of someone’s life. As addiction progresses, all aspects of the user’s life can become detrimentally affected, which can cause them to become depressed. A further cause is the impact of drugs on hormone levels within the body. Drugs cause dopamine to be released in the brain, and fluctuating levels of this neurotransmitter impact a person’s mood. Studies have concluded that dopamine likely contributes significantly to the pathophysiology of depression.

Genetic and Epigenetic Influences

Alcoholism and drug dependence are common psychiatric disorders with a heritability (able to be transmitted from parent to child) of about 50%. This means that someone’s chance of developing an addiction is equally related to their genes and to their environment. The same situation applies to mental health conditions. The National Institute of Mental Health has been studying the link between a person’s genes and their likelihood of developing a mental illness for the past 25 years.

Genetic Risks

If there is a history of addiction or mental health concerns within the family, an individual has an increased chance of suffering from the same conditions themselves. In addition, someone’s genetic makeup can influence their likelihood of developing a substance use disorder. Studies have detected rare gene variants that have an impact on addiction risk.

Epigenetic Risks

Epigenetics is the study of how your behaviors and environment can cause changes that affect the way your genes work. Unlike genetics, epigenetic modifications are reversible. Substance use can change a person’s epigenetics. The same 2012 study found that this can alter someone’s initial response to a drug, continued response, and tolerance development, leading to addiction, withdrawal, and relapse.

Environmental Factors

Many environmental factors increase the risk of developing substance use disorders and mental illness, including traumatic experiences and stress. This can happen during adulthood or through experiencing stressful situations as a child. Dual diagnosis among young people is particularly concerning. The National Institute on Drug Abuse (NIDA) states that over 60% of adolescents in community-based substance use treatment programs also meet diagnostic criteria for another mental illness.

The Impact of Early Life Stress

Stress as a child is a well-established risk factor for many psychiatric and medical disorders, including substance use disorders (SUDs). During adolescence, the brain is still forming. Using substances at this time as a coping mechanism for stressful experiences can affect how the brain develops and cause permanent changes. The changes that early life stress causes are an underlying pathophysiology associated with stress-related risk of addiction. This increases the chance of becoming addicted to substances or having a mental health disorder in later life.

The Impact of Stress

Exposure to stress increases the risk of developing mental health conditions such as anxiety and depression. Self-medication for these conditions using alcohol or drugs is common, and addiction can develop as a result. Furthermore, studies have found that the stress-related processes in the brain influence addiction relapse, which means that stress also contributes to someone repeatedly returning to substance use after periods of abstinence.

The Impact of Trauma

When someone experiences a traumatic event such as an act of violence, assault, an accident, or the death of a loved one, they become more susceptible to mental health disorders and addiction. Often people self-medicate to cope with the unpleasant feelings, emotions, flashbacks, and nightmares they may experience following a traumatic event. PTSD (post-traumatic stress disorder) is linked to dual diagnosis, with women being more at risk than men. This is particularly relevant following traumatic events, most commonly deriving from a history of repetitive childhood physical and sexual assault.

What Are the Risks Associated With Dual Diagnosis?

Addiction or mental illness can detrimentally affect the individual with the condition or the lives of those around them. Someone with one of these conditions can struggle to maintain relationships, jobs, and a sense of self-worth while also experiencing deteriorating physical health. When someone has a dual diagnosis, they are at risk of the same things, but the combination of both conditions means their risk is heightened in some areas. These increased risks include the following:

Chance of Relapse

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, and the person will return to old habits.

Increase in Suicide Risk

One study of French prisoners found that a dual diagnosis is commonly found in prison and is a major risk factor for suicide. People with a dual diagnosis are at an increased risk of suicide due to the conflicting feelings, thoughts, and emotions that they experience. Furthermore, some withdrawal symptoms associated with substance abuse can exacerbate mental health concerns, such as severe anxiety and depression that can lead to thoughts of suicide.

Physical Health Problems

A 2008 study found that people with schizophrenia or bipolar disorder and substance use disorder struggle to maintain their physical health. This is because substance use compounds the physical health issues associated with having a severe mental illness. People with a dual diagnosis generally struggle to look after themselves well, resulting in poor hygiene, diet, exercise, unprotected sexual activity, and other behaviors that can impact physical health. They are also more likely to experience cardiovascular and respiratory health complaints and diabetes.

Shortened Life Expectancy

Research has identified that those with a severe mental health illness or substance use disorder have a shorter life expectancy than those without these conditions. For example, one study concluded that schizophrenic men have a life expectancy of 18.7 years less than men without schizophrenia. Having a dual diagnosis increases this further because, for example, an addiction to opioids reduces life expectancy by 14.7 years for men. The combined outcome of a man having a dual diagnosis of schizophrenia and opioid addiction is a severely reduced life expectancy.

Social Isolation and Homelessness

Family members and close friends are often affected by a loved one’s drug or alcohol abuse or mental health illness. A dual diagnosis can make the situation even more challenging to understand, manage and resolve. Breakdown in relationships, financial difficulties, and isolation from family and friends is common when someone has a dual diagnosis. As a result, individuals can find themselves without support or shelter, which is why dual diagnosis is highly prevalent among individuals experiencing homelessness.

Involvement in Violence and Self-harm

Individuals with a dual diagnosis are more prone to violence and self-harm than others. One study into heroin-addicted patients showed a frequent co-occurrence of aggression and bipolar spectrum disorder. This violence was directed toward others; however, the same study found that there is also a strong link with self-harm. Conversely, another study found that patients with a dual diagnosis were more likely to have been a victim of violence, property crime, and vandalism than the general population.

What Are the Signs of Dual Diagnosis?

Many of the signs that someone has a mental health condition and addiction simultaneously are similar to those displayed when someone suffers from just one of the conditions. These signs include isolating oneself from friends and family, being secretive, lacking motivation for work, school, or hobbies, and changes in sleeping and eating habits.

There are, however, some specific signs that you can look out for that may mean that someone is experiencing a mental health illness at the same time as a substance use disorder. A National Institute of Health study published in 2020 stated that dual diagnosis is underestimated, underdiagnosed, and often poorly treated worldwide. Therefore, knowing what to look out for and where to seek help can positively impact someone’s long-term recovery. Signs of dual diagnosis include:

Extreme mood swings: Drug addiction and mental health concerns can invoke mood swings, depression, and anxiety. If someone is particularly suffering from instability in terms of moods and emotions and seems unable to control them, they may simultaneously be experiencing the effects of both conditions.
Requiring substances to retain emotional stability: If your loved one repeatedly resorts to substances to maintain their emotional stability, they may have developed a reliance on the drug to manage their mental health symptoms.
Experiencing trauma: As discussed previously, trauma can significantly impact someone’s mental health or susceptibility to addiction. Signs may appear following an incident that is, or was, traumatic.
Treatment for one of the conditions has not worked: Often, someone with a dual diagnosis will find that therapy for just one of their conditions is ineffective and that the untreated condition triggers a relapse. For example, 12-step programs such as the ones offered by Narcotics Anonymous and Alcoholics Anonymous are designed to target addiction but not mental health disorders.

What Can I Do if Someone I Know Receives a Dual Diagnosis?

If a loved one has received a dual diagnosis, you may be wondering what you can do to support their recovery. The individual may have already received treatment for one of the two conditions and, therefore, should contact their doctor or treatment center for advice. If they do not have a professional to contact, there are many resources available that can provide trusted and confidential information for the person affected or their loved ones. Examples of sources of help include:

Rehab.com offers a free helpline for confidential advice about treatment options for yourself or your loved one. Call (833) 386-0206 to find treatment providers specializing in dual diagnosis.
SAMHSA also has a free, confidential, and bilingual helpline. Advice is available 24/7 at 1-800-662-HELP (1-800-662-4357).
Local medical professionals are a good source of information about the treatment available in the area. Primary care can be the first step on the road to recovery because it is convenient for patients. It can also reduce the stigma associated with treatment for mental disorders and builds on existing provider-patient relationships.
Online searches can provide a wide array of information about dual diagnosis treatment and treatment centers. You can consult online directories such as the Rehab.com map search, where options are narrowed down geographically and by specialty.

The Best Treatments For Dual Diagnosis

Treating dual diagnosis can be challenging. In the past, dual-diagnosis conditions were not diagnosed or treated effectively. Treatment providers would focus on mental health or addiction rehabilitation but rarely treat the same patient for both simultaneously. The impact of this was that often those with both conditions would find that treatment was ineffective as their untreated condition would trigger their treated condition, and they would relapse. Studies have since identified that accurate detection and diagnosis of individuals with psychotic illnesses co-occurring with addictive disorders is vital to treat such disorders properly.

SAMHSA acknowledges that having two conditions can complicate diagnosis and treatment. As a result, they offer evidence-based resources to help providers screen, diagnose, and deliver integrated care to patients with co-occurring disorders.

Finding a treatment center specializing in dual diagnosis treatment is important. The staff will be aware of the requirements of patients and familiar with the most effective therapies and techniques. Patients can also meet and bond with other patients in similar situations to them. Examples of some of the treatment approaches proven to be most effective for dual diagnosis include:

Integrated Treatment

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

The advantages of integrated 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 from both disorders
Improved quality of life
Less chance of hospitalization or requiring medical intervention
More stability in terms of housing
Reduced chance of getting into trouble with law enforcement

“No Wrong Door” Policy

To aid in the detection of those with a dual diagnosis, SAMHSA promotes a “No Wrong Door” policy to ensure that everyone accessing health care services for addiction treatment is routinely screened for mental health issues and vice versa. Many individual states have since adopted this policy. The Californian Department of Health Care Services implemented a “no wrong door” policy in July 2022.

SAMHSA Treatment Improvement Protocol (TIP)

The Substance Use Disorder Treatment for Persons with Co-Occurring Disorders: A Treatment Improvement Protocol offers best-practice guidelines for healthcare practitioners about how to treat co-occurring disorders.

The guidelines recognize that dual diagnosis is treatable, but some adaptations may need to be made depending on the treatment center and the individual patient. The essential services required by patients with substance use disorder and addiction are:

Person-centered: Individualized treatment is essential to enhance the chance of recovery.
Trauma-informed: Treatment programs should identify and address personal trauma.
Culturally responsive: The treatment on offer should be mindful of cultural differences in order to achieve the best results for the patient.
Recovery-oriented: The goal of all dual diagnosis treatment should be full recovery from both conditions.
Comprehensive: Everyone’s treatment needs and responses are different, and treatment programs must adapt and work for all patients.
Continuously offered across all levels of care: Those with a dual diagnosis require all aspects of their condition to be addressed at all times in order to enhance the chance of long-term recovery.

The Treatment Options for Dual Diagnosis

The course of dual diagnosis may be chronic and severe, requiring many long-term therapeutic and rehabilitative programs. Therefore you must find the right treatment for you. As with separate mental health or substance abuse treatment programs, help with a dual diagnosis can occur in various treatment facilities and settings. The most appropriate treatment plan will depend on the substance or substances that someone is addicted to, which mental health conditions they have, and whether or not they have received treatment. Furthermore, those with specific needs, such as young adults or veterans, may need help from specialized treatment facilities tailored to their requirements.

Examples of treatment options for dual diagnosis include:

Detox rehab center: If someone has an addiction to a substance, they may need to undergo a detox in an environment where medical professionals can monitor and manage any withdrawal symptoms they have. Often this detoxification is required before someone can embark on other addiction and mental health treatment.
Inpatient treatment: This involves residential treatment with attention from addiction and mental health professionals to address the issues surrounding the person’s dual diagnosis. The goal is to address the causes of the dual diagnosis, assess behavioral health, and develop new coping mechanisms for dealing with triggering situations without resorting to past behaviors. The treatment may include individual counseling using cognitive behavioral therapy (CBT) techniques and holistic treatment such as meditation and yoga.
Outpatient treatment: Outpatient treatment allows a person to remain at home and attend school and work while receiving treatment for their dual diagnosis conditions several times a week. The treatments on offer can include couples or family therapy, where those closest to the person affected are involved in the rehabilitation process.
Aftercare services: A core element of successful rehabilitation is ensuring that the patient has the support they need once they complete their initial treatment program. This can include living at a sober living home for a period or joining support groups.

If you, or a loved one, receive a dual diagnosis, it can be challenging to know what to do next. Online searches may bring up treatment options for one condition or the other, but it is crucial to treat both to maximize your chances of long-term recovery. Full rehabilitation from both conditions is possible with the right treatment program. Rehab.com can help you find the ideal treatment provider and treatment plan to address your mental illness and substance use disorder. Make the call today and take your first step on the road toward recovery.

Dual Diagnosis: A Guide to Co-Occurring Mental Health Disorders & Addiction