In a dual diagnosis, both the mental health issue and the drug or alcohol addiction have their own unique symptoms that may get in the way of your ability to function, handle life’s difficulties, and relate to others. To make the situation more complicated, the co-occurring disorders also affect each other and interact. When a mental health problem goes untreated, the substance abuse problem usually gets worse as well. And when alcohol or drug abuse increases, mental health problems usually increase too.
What comes first: Substance abuse or the mental health problem?
Addiction is common in people with mental health problems. But although substance abuse and mental health disorders like depression and anxiety are closely linked, one does not directly cause the other.
- Alcohol or drugs are often used to self-medicate the symptoms of depression or anxiety. Unfortunately, substance abuse causes side effects and in the long run worsens the very symptoms they initially numbed or relieved.
- Alcohol and drug abuse can increase underlying risk for mental disorders. Mental disorders are caused by a complex interplay of genetics, the environment, and other outside factors. If you are at risk for a mental disorder, drug or alcohol abuse may push you over the edge.
- Alcohol and drug abuse can make symptoms of a mental health problem worse. Substance abuse may sharply increase symptoms of mental illness or trigger new symptoms. Alcohol and drug abuse also interact with medications such as antidepressants, anti-anxiety pills, and mood stabilizers, making them less effective.
Addiction is common in people with mental health problems
According to reports published in the Journal of the American Medical Association:
- Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.
- 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.
- Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.
Source: National Alliance on Mental Illness
It can be difficult to diagnose a substance abuse problem and a co-occurring mental health disorder such as depression, anxiety, or bipolar disorder. It takes time to tease out what might be a mental disorder and what might be a drug or alcohol problem.
Complicating the issue is denial. Denial is common in substance abuse. It’s hard to admit how dependent you are on alcohol or drugs or how much they affect your life. Denial frequently occurs in mental disorders as well. The symptoms of depression or anxiety can be frightening, so you may ignore them and hope they go away. Or you may be ashamed or afraid of being viewed as weak if you admit the problem.
Admitting you have a dual diagnosis or co-occurring disorders
Just remember: substance abuse problems and mental health issues don’t get better when they’re ignored. In fact, they are likely to get much worse. You don’t have to feel this way. Admitting you have a problem is the first step towards conquering your demons and enjoying life again.
- Consider family history. If people in your family have grappled with either a mental disorder such as depression or alcohol abuse or drug addiction, you have a higher risk of developing these problems yourself.
- Consider your sensitivity to alcohol or drugs. Are you highly sensitive to the effects of alcohol or drugs? Have you noticed a relationship between your substance use and your mental health? For example, do you get depressed when you drink?
- Look at symptoms when you’re sober. While some depression or anxiety is normal after you’ve stopped drinking or doing drugs, if the symptoms persist after you’ve achieved sobriety, you may be dealing with a mental health problem.
- Review your treatment history. Have you been treated before for either your addiction or your mental health problem? Did the substance abuse treatment fail because of complications from your mental health issue or vice versa?
If you’re wondering whether you have a substance abuse problem, the following questions may help. The more “yes” answers, the more likely your drinking or drug use is a problem.
- Have you ever felt you should cut down on your drinking or drug use?
- Have you tried to cut back, but couldn’t?
- Do you ever lie about how much or how often you drink or use drugs?
- Have your friends or family members expressed concern about your alcohol or drug use?
- Do you ever felt bad, guilty, or ashamed about your drinking or drug use?
- On more than one occasion, have you done or said something while drunk or high that you later regretted?
- Have you ever blacked out from drinking or drug use?
- Has your alcohol or drug use caused problems in your relationships?
- Has you alcohol or drug use gotten you into trouble at work or with the law?
Common signs and symptoms of depression
- Feelings of helplessness and hopelessness
- Loss of interest in daily activities
- Inability to experience pleasure
- Appetite or weight changes
- Sleep changes
- Loss of energy
- Strong feelings of worthlessness or guilt
- Concentration problems
- Anger, physical pain, and reckless behavior (especially in men)
Common signs and symptoms of mania in bipolar disorder
- Feelings of euphoria or extreme irritability
- Unrealistic, grandiose beliefs
- Decreased need for sleep
- Increased energy
- Rapid speech and racing thoughts
- Impaired judgment and impulsivity
- Anger or rage
Common signs and symptoms of anxiety
- Excessive tension and worry
- Feeling restless or jumpy
- Irritability or feeling “on edge”
- Racing heart or shortness of breath
- Nausea, trembling, or dizziness
- Muscle tension, headaches
- Trouble concentrating
The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously.
Recovery depends on treating both the addiction and the mental health problem
Whether your mental health or substance abuse problem came first, recovery depends on treating both disorders.
- There is hope. Recovering from co-occurring disorders takes time, commitment, and courage. It may take months or even years b ut people with substance abuse and mental health problems can and do get better.
- Combined treatment is best. Your best chance of recovery is through integrated treatment for both the substance abuse problem and the mental health problem. This means getting combined mental health and addiction treatment from the same treatment provider or team.
- Relapses are part of the recovery process. Don’t get too discouraged if you relapse. Slips and setbacks happen, but, with hard work, most people can recover from their relapses and move on with recovery.
- Peer support can help. You may benefit from joining a self-help support group like Alcoholics Anonymous or Narcotics Anonymous. They give you a chance to lean on others who know what you’re going through and learn from their experiences.
How to find the right program for co-occurring disorders or dual diagnosis
As with a substance abuse program, make sure that the program is appropriately licensed and accredited, the treatment methods are backed by research, and there is an aftercare program to prevent relapse. Additionally, you should make sure that the program has experience with your particular mental health issue. Some programs, for example, may have experience treating depression or anxiety, but not schizophrenia or bipolar disorder.
There are a variety of approaches that treatment programs may take, but there are some basics of effective treatment that you should look for:
- Treatment addresses both the substance abuse problem and your mental health problem.
- You share in the decision-making process and are actively involved in setting goals and developing strategies for change.
- Treatment includes basic education about your disorder and related problems.
- You are taught healthy coping skills and strategies to minimize substance abuse, cope with upset, and strengthen your relationships.
Treatment for dual diagnosis or co-occurring disorders
- Helping you think about the role that alcohol and other drugs play in your life. This should be done confidentially, without any negative consequences. People feel free to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
- Offering you a chance to learn more about alcohol and drugs, to learn about how they interact with mental illnesses and with medications, and to discuss your own use of alcohol and drugs.
- Helping you become involved with supported employment and other services that may help your process of recovery.
- Helping you identify and develop your own recovery goals. If you decide that your use of alcohol or drugs may be a problem, a counselor trained in integrated dual diagnosis treatment can help you identify and develop your own recovery goals. This process includes learning about steps toward recovery from both illnesses.
- Providing special counseling specifically designed for people with dual diagnosis. This can be done individually, with a group of peers, with your family, or with a combination of these.
The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services offers an extensive listing of licensed, certified drug treatment facilities. Similar treatment facilities are also available in other parts of the world. See References and Resources below for links.
Treatment programs for veterans with co-occurring disorders
Veterans deal with additional challenges when it comes to co-occurring disorders. The pressures of deployment or combat can exacerbate underlying mental disorders, and substance abuse is a common way of coping with unpleasant feelings or memories. Often, these problems take a while to show up after a vet returns home, and may be initially mistaken for readjustment. Untreated co-occurring disorders can lead to major problems at home and work and in your daily life, so it’s important to seek help.
Veterans often benefit from treatment and support from specialized programs that address the unique stresses veterans face. To learn more, see References and Resources below.
As with other addictions, groups are very helpful, not only in maintaining sobriety, but also as a safe place to get support and discuss challenges. Sometimes treatment programs for co-occurring disorders provide groups that continue to meet on an aftercare basis. Your doctor or treatment provider may also be able to refer you to a group for people with co-occurring disorders.
While it’s often best to join a group that addresses both substance abuse and your mental health disorder, twelve-step groups for substance abuse can also be helpful—plus they’re more common, so you’re likely to find one in your area. These free programs, facilitated by peers, use group support and a set of guided principles—the twelve steps—to obtain and maintain sobriety.
Just make sure your group is accepting of the idea of co-occurring disorders and psychiatric medication. Some people in these groups, although well meaning, may mistake taking psychiatric medication as another form of addiction. You want a place to feel safe, not pressured.
Getting sober is only the beginning. Your continued recovery depends on continuing mental health treatment, learning healthier coping strategies, and making better decisions when dealing with life’s challenges.
Recovery tip 1: Recognize and manage overwhelming stress and emotions
- Learn how to manage stress. Stress is inevitable, so it’s important to have healthy coping skills so you can deal with stress without turning to alcohol or drugs. Stress management skills go a long way towards preventing relapse and keeping your symptoms at bay.
- Know your triggers and have an action plan. If you’re coping with a mental disorder as well, it’s especially important to know signs that your illness is flaring up. Common causes include stressful events, big life changes, or unhealthy sleeping or eating. At these times, having a plan in place is essential to preventing drug relapse. Who will you talk to? What do you need to do?
Recovery tip 2: Stay connected
- Get therapy or stay involved in a support group. Your chances of staying sober improve if you are participating in a social support group like Alcoholics Anonymous or Narcotics Anonymous or if you are getting therapy.
- Follow doctor’s orders. Once you are sober and you feel better, you might think you no longer need medication or treatment. But arbitrarily stopping medication or treatment is a common reason for relapse in people with co-occurring disorders. Always talk with your doctor before making any changes to your medication or treatment routine.
Recovery tip 3: Make healthy lifestyle changes
- Practice relaxation techniques. When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce symptoms of stress, anxiety, and depression, and increase feelings of relaxation and emotional well-being.
- Adopt healthy eating habits. Start the day right with breakfast, and continue with frequent small meals throughout the day. Going too long without eating leads to low blood sugar, which can make you feel more stressed or anxious.
- Exercise regularly. Exercise is a natural way to bust stress, relieve anxiety, and improve your mood and outlook. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.
- Get enough sleep. A lack of sleep can exacerbate stress, anxiety, and depression, so try to get 7 to 9 hours of quality sleep a night.
Helping a loved one with both a substance abuse and a mental health problem can be a roller coaster. Resistance to treatment is common and the road to recovery can be long.
The best way to help someone is to accept what you can and cannot do. You cannot force someone to remain sober, nor can you make someone take their medication or keep appointments. What you can do is make positive choices for yourself, encourage your loved one to get help, and offer your support while making sure you don’t lose yourself in the process.
- Seek support. Dealing with a loved one's dual diagnosis of mental illness and substance abuse can be painful and isolating. Make sure you're getting the emotional support you need to cope. Talk to someone you trust about what you're going through. It can also help to get your own therapy or join a support group.
- Set boundaries. Be realistic about the amount of care you're able to provide without feeling overwhelmed and resentful. Set limits on disruptive behaviors, and stick to them. Letting the co-occurring disorders take over your life isn't healthy for you or your loved one.
- Educate yourself. Learn all you can about your loved one’s mental health problem, as well as substance abuse treatment and recovery. The more you understand what your loved one is going through, the better able you’ll be to support recovery.
- Be patient. Recovering from a dual diagnosis doesn’t happen overnight. Recovery is an ongoing process that can take months or years, and relapse is common. Ongoing support for both you and your loved one is crucial as you work toward recovery.
Common Co-occurring Disorders
Resources & References
Helpguide’s Yellow Pages
Resources for public assistance, social services, and other health and human services.
General information about co-occurring disorders/dual diagnosis
Dual Diagnosis or Co-Occurring Disorders – Overview of dual diagnosis, or co-occurring substance abuse and mental health disorders. Includes common signs and symptoms. (Dual Recovery Anonymous)
Dual Diagnosis and Recovery – Learn about co-occurring substance abuse and mental illness, also called dual diagnosis. Includes common symptoms and treatment tips. (Depression and Bipolar Support Alliance)
Factsheet: Dual Diagnosis – Browse through an FAQ with helpful advice for both individuals with co-occurring disorders and their family members and loved ones. (Mental Health America)
Dual Diagnosis in Adolescence – Fact sheet on dual diagnosis in adolescence, including treatments that help. (National Alliance on Mental Illness)
Treatment for co-occurring substance abuse and mental health disorders
In the U.S.:
SAMHSA Substance Abuse Treatment Facility Locator – Provides a searchable database of private and public substance abuse treatment facilities. SAMHSA also operates a helpline: (800) 662-HELP (4357) with help in English and Spanish, or TDD at (800) 487-4889. (Substance Abuse and Mental Health Services Administration)
Local State Substance Abuse Agency. Many states have their own listings of substance abuse treatment resources, toll-free hotlines, and information about accreditation. (SAMHSA)
Dual Recovery Anonymous – Independent, twelve-step, self-help organization for people who are chemically dependent and also affected by a mental health disorder. (Dual Recovery Anonymous)
Locating a 12-step program in your area
Resources for veterans with co-occurring disorders/dual diagnosis
Specialized programs can address the unique stresses veterans face.
In the U.S.:
Delving deeper into co-occurring substance abuse and mental health disorders
Comorbidity: Addiction and Other Mental Illnesses (PDF) – In-depth report on co-occurring drug use and other mental disorders. Learn about causes, diagnosis, and treatment. (National Institute on Drug Abuse)