Dual Diagnosis & Co-occurring Disorder

When people have a substance abuse disorder as well as a mental health problem, they are known as having “co-occurring disorders”, which was previously known as a “dual diagnosis”. According to the National Survey on Drug Use and Health (NSDUH), released by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2014, there were around 7.9 million adults in this country with co-occurring disorders.

Those who have a mental health issue are more likely to also experience a drug or alcohol abuse disorder than people without a co-occurring disorder. Unfortunately, it can be very difficult to appropriately diagnose these conditions because the symptoms of both are highly complex and can vary in severity. Very often, people receive treatment for one of the two disorders, but the other one is left untreated. This can happen due to the fact that both disorders often have social, psychological, and biological components. Alternatively, providers may not be properly trained on how to screen for co-occurring disorders, there may be an overlap of the various symptoms, or the person has a health issue that must first be addressed. Either way, if a co-occurring disorder is left undiagnosed and subsequently under- or untreated, it is more likely that patients become homeless, incarcerated, or medically ill. They are also more likely to commit suicide or otherwise die prematurely.

It is vital that those with a co-occurring disorder are treated through integrated care. When treatment is integrated, both the substance abuse disorder and the mental health disorder can be treated simultaneously. Not only does this lower the costs for the providers, it also creates much improved outcomes. This does mean that service systems must increase their awareness and capacity to help identify co-occurring disorders and treat them. Through early detection and appropriate treatment, outcomes can be greatly improved. Additionally, those who need these types of services have a much improved quality of life.

What Are Co-Occurring Disorders?

Essentially, when people suffer from a mental health issue, as well as a substance abuse disorder, they are classed as having a co-occurring disorder. It is irrelevant whether the mental health issue or the substance abuse disorder came first, and whether or not one caused the other.

Substance abuse disorders can be abuse of alcohol or drugs, dependence on those substances, or full addiction. A substance abuse problem is diagnosed once it becomes clear that using the substance interferes with the way people are able to perform in their professional, educational, and personal relationships. If it creates a medical condition, or worsens it, it is also classed as a substance abuse disorder. Lastly, these disorders are diagnosed when people abuse substances in a dangerous situation.

Dependency on drugs or alcohol is a worse condition than abuse. Besides the fact that people are exposed to increased negative consequences, those who have a dependency have tried to abstain and have found themselves incapable of controlling their use. Sometimes, people become physiologically dependent on the substance, which means that their tolerance to the drug increases (in which case they must increase their dosage), and that they go into withdrawal and experience the associated symptoms if they try to abstain. Once these people lose all control over their ability to use the substance, they are classed as addicted.

Meanwhile, these people can also experience a wealth of mental health issues. Those who have a chemical dependency are most likely to suffer from an anxiety or mood disorder. In even more cases, people with a severe mental health problem will also abuse substance. These mental health problems are classified as severe because of how strong episodes of illness were, and how long they lasted. Some of the more common mental health disorders where this is experienced include schizoaffective disorders and schizophrenia. These are also known as thought disorders due to the fact that people experience delusions and hallucinations.

Some of the most common mood-related disorders include:

  • Bipolar disorder
  • Dysthymia
  • Major depression

Some of the most common anxiety-related disorders include:

  • Panic disorder
  • Post traumatic stress disorder (PTSD)
  • Generalized anxiety disorder
  • Social anxiety
  • Obsessive compulsive disorder (OCD)

Two Problems Become One

It can be very difficult to properly diagnose a co-occurring disorder. This is mainly because the symptoms of one disorder can mask the symptoms of the other, or they can be confused for each other. When people have a mental health problem, they often do not feel that they need to address their substance abuse problem, believing it to be irrelevant to their situation. However, people with co-occurring disorders often go through certain patterns that can be used to recognize the presence of both issues. These patterns are:

    1. Their mental health symptoms become worse, even if they receive treatment. When they have a mental health problem, they often turn to substances in order to feel better, essentially self-medicating. When they are anxious, for instance, they may want to feel more animated. Or, when they are afraid of other people, they may want to feel less inhibited and more relaxed. Or, when they suffer psychological pain, they may want to numb their feelings.
    2. When they use substances, they find that their mental health issues do not go away, and these also stop them from having the right coping skills to live their lives. These start to affect their personal relationships and they become less comfortable in their own lives as well. When people take alcohol as a crutch, this may interfere with any medication they are currently receiving. Effectively, the mental health disorder becomes worse rather than better.
    3. The substance abuse disorder seems to be resistant to treatment. When people have a co-occurring disorder, they may successfully stop using substances for a period of time. However, their mental health symptoms will then continue to be in place. Clinicians, treatment centers, and addiction specialists often do not have the skills to address both issues. Furthermore, a lot of peer recovery groups only offer assistance to those who are 100% abstinent, which includes prescription medication. Hence, those who have a co-occurring disorder are likely to find it very difficult to treat either of their problems.

Integrated Treatment

In the past, treatment for addictions and mental health issues were offered separately. It is now understood that both conditions affect each other and that they therefore must be treated together. If only one disorder is treated, the other one will not automatically improve. In fact, it may worsen. When treatment is offered at the same time, but separately of each other, the treatment plan is not generally effective. Instead, they must be treated together, at the same time, as a whole, by a single team. This is known as integrated treatment.

Different Settings Have Different Approaches

SAMHSA has created guidance documents that help practitioners to provide better services to those who have a co-occurring disorder. Specifically, they have released guidelines for those in the criminal justice system, the homeless, those in primary care, and those in the military community and veterans. In so doing, they hope that all individuals are able to receive better care.

The Criminal Justice System

A lot of people who find themselves inside the criminal justice system also have co-occurring disorders. If this is properly addressed through integrated treatment, then positive outcomes are more likely. This includes reduced arrests and reduced substance use. If inmates are not effectively screened and assessed for co-occurring disorders, then the criminal justice system may see increased costs and recidivism. As such, they should set up a full protocol for effective screening, which should include:

  • Screening as standard when people enter the criminal justice systems
  • Using standardized instruments, such as a cut-off point that helps to determine whether or not someone will require a follow up assessment
  • Training staff so that they can administer these standardized screening instruments and know when and how to refer people for further assessment
  • Providing a proper response for inmates who experience a crisis in their behavioral health, such as drug use or intoxication that should be medically addressed, or if they become suicidal
  • Maintaining all health care records properly by the agency that is responsible for the screening of the individual

SAMHSA has released a document that addresses this protocol. They are also engaged in addressing the juvenile and criminal justice system with a focus on violence and trauma.


People who experience homelessness also very commonly have co-occurring disorders. In this population group, various issues are often present that need services beyond just treatment for behavioral health. These includes housing, employment assistance, and life skills development. While it is important that people who are homeless and experience co-occurring disorder are treated through integrated care, the vast majority cannot access this treatment. People who are homeless are usually isolated and they have very little access to behavioral health and medical health services. Hence, it is likely that they remain both undiagnosed and untreated. As a result, they are more likely to become chronically homeless and experience further deterioration of both their behavioral and physical health, as well as being less able to function economically and socially.

SAMHSA recommends that integrated screening and assessment is fully implemented within the homeless care system. Through this screening, services will be better able to determine whether or not a homeless person has a co-occurring disorder, and what the influence of this is on the behavior, symptoms, and signs. Assessment should be about organization and collecting clinical information and interpreting this using professional judgment and diagnostic criteria.

Primary Care

When people receive primary care, they may face a range of different health issues. It is very important, in cases of co-occurring disorders, that primary care and behavioral care are fully integrated to meet their needs. In many cases, someone with a co-occurring disorder will go to a primary care provider before going to a behavioral health service. Hence, primary care practitioners are in a unique situation where they can identify and screen those who have a co-occurring disorder. When properly screened, primary care practitioners can recognize a condition early and immediately start to address it. Furthermore, through screening, clinical progress can be measured.

There are numerous assessment and screening tools available for those within primary care. These tools are vital to determine whether someone has to be assessed more, while at the same time enabling practitioners to measure how severe the mental health issue and substance abuse issue are. They can also measure the effectiveness of any intervention.

The Military Community and Veterans

It is very common for people within the military community to experience co-occurring disorders, mainly due to the high prevalence of post-traumatic stress syndrome or PTSD. The Veterans Affairs (VA) Department has stated that around one third of veterans who seek or are offered substance abuse treatment can also be diagnosed with PTSD. Veterans and active duty military personnel benefit greatly from having integrated care for substance abuse and mental disorders. However, it is common for people to not seek treatment, not in the least because they fear they will be treated differently.

In order to ensure that service members, veterans, and their families are able to experience full wellness, SAMHSA has encouraged practitioners to work closely together with other organizations in order to come up with a training plan that enables everyone to understand integrated care techniques. SAMHSA has highlighted a number of organizations that are able to offer this type of training and best practice examples:

    1. PTSD: National Center for PTSD, where practitioners can take part in a continuing education course called Managing PTSD and Co-occurring Substance Use Disorders
    2. The VA, which offers the VA/DOD Clinical Practice Guidelines for Management of PTSD and Acute Stress Reaction. These include guidelines on screening, assessing, and treating PTSD and substance abuse.
    3. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s Alcohol Research & Health Journal, which follows the recommendations of the Institute of Medicine (IOM) in terms of how to implement high quality care for those with co-occurring disorders
    4. The National Institute on Drug Abuse (NIDA), which has created guidance on the treatment of comorbid disorders.

Required Competencies in Practitioners

Finally, a number of states have come together in an effort to improve treatment and outcomes for those with co-occurring disorders and they have created a number of core competencies that social service employees should have across the board. A checklist is being developed to ensure practitioners can be assessed on their ability to provide integrated services. These are now being incorporated in licensure, credentialing, personal evaluations, supervision meetings, training plans, and job descriptions.

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