If someone you know is struggling with drinking or drug use and also seems to be dealing with depression, anxiety, or something that has never quite been named, you have run into one of the most common situations in addiction treatment – and one of the most frequently mishandled.
It has a name: dual diagnosis, also called co-occurring disorders.
What dual diagnosis means
Dual diagnosis means a person has both a substance use disorder and a mental health condition at the same time. Not one caused by the other, necessarily – both, together, each needing attention.
It is common. According to NIDA, 35% of US adults who have a mental disorder also have a substance use disorder. Looking at it from the other direction, 2017 national survey data found that of the 14.1 million adults with alcohol use disorder, 41.8% also had a mental health condition – around 5.9 million people.
The term describes a situation, not a specific illness. There is no single “dual diagnosis” condition; there are many possible pairings, and which ones are present matters a great deal for treatment.
Common combinations
Some pairings appear repeatedly:
- Depression and alcohol use – perhaps the most common, and the most circular, since alcohol is a depressant that reliably deepens what people use it to relieve
- Anxiety disorders and alcohol or benzodiazepines – short-term relief, worsening baseline anxiety over time
- PTSD and substance use – where substances are often the only thing that has reliably quieted intrusive symptoms
- ADHD and stimulant use
- Bipolar disorder and substance use, particularly during mood episodes
Recognising the pairing matters because the treatment differs. PTSD and substance use is not the same clinical problem as ADHD and stimulant use, and does not respond to the same plan.
Why they occur together
There isn’t one explanation, and the honest answer is that all three of these operate, sometimes in the same person.
Shared risk factors. NIDA points to “inherited characteristics, adverse social environments, trauma, and stress” – influences that raise the likelihood of both conditions independently. Sometimes neither caused the other; both grew from the same ground.
Self-medication. People “may use drugs to try to feel better, especially if they lack access to mental health care.” This is often the most recognisable pattern to families, and the one that carries the least blame once it’s understood: someone found something that worked, until it stopped working.
Substance use altering the brain. Substance use “can lead to changes in some of the same brain areas that are disrupted in other mental disorders, such as schizophrenia, anxiety, mood, or impulse-control disorders.”
Which explanation applies is often impossible to establish, and – importantly – usually does not change what needs to happen next.
Why treating one alone doesn’t work
This is the part with the clearest evidence.
Neither disorder is likely to show sustained improvement if one disorder is treated without acknowledging the presence or influence of the co-occurring disorder.
That is the whole argument in one sentence. Treat the drinking while ignoring untreated PTSD, and you have removed the only thing that was managing the symptoms, without replacing it. Treat the depression while ignoring daily drinking, and the medication is working against a depressant taken every evening.
The consequences show up in the data. Co-occurrence is associated with higher relapse rates and greater use of psychiatric and emergency services, and symptoms that are “more persistent, severe, and resistant to treatment” than either condition alone.
Which is also why the “get sober first, then we’ll look at the mental health” sequence – still common – tends to fail the people it’s applied to.
How integrated treatment works
Integrated treatment means both conditions are addressed by one coordinated team, at the same time, rather than being passed between separate services.
In practice that usually involves an assessment covering both, behavioural therapies used for both – cognitive behavioural therapy, contingency management, and motivational interviewing among them – and medication where appropriate, including medications with strong evidence for opioid and alcohol use disorder alongside those treating the mental health condition.
A note on the evidence, since most articles overstate it. Integrated treatment is the consensus professional recommendation, and compared with usual care it has been associated with “small but clinically significant improvements.” Head-to-head against well-delivered non-integrated specialist care, the evidence is less clear-cut. What is well supported is the narrower and more important claim: ignoring one condition while treating the other doesn’t work. Coordination between the people treating each is what matters most.
Getting an accurate diagnosis
Diagnosis is genuinely difficult here, and it is worth knowing why before you go in.
Heavy substance use produces symptoms that closely mimic mental health conditions – depression in withdrawal, anxiety and paranoia during intoxication, sleep disruption, mood instability. It is often impossible to tell what is a distinct condition and what is a substance effect until there has been a period of stability.
That means diagnosis is frequently provisional at first and revised later, and that is normal practice rather than a mistake. A good assessment will ask about mental health symptoms before substance use began, family history, what happened during previous periods of abstinence, and any trauma history.
What to look for in a provider: both conditions assessed at intake, psychiatric input available rather than referred out, and a willingness to revisit the diagnosis as things stabilise. Our overview of the stages of alcoholism covers how alcohol-related symptoms in particular can complicate the picture.
If you’re dealing with a substance use and mental health condition together, you don’t have to work through it alone. Choice House offers residential treatment and sober living for men, with integrated care for co-occurring conditions. Call 720-577-4422 or reach out through our website to talk it through and find out what options might help. You can also learn more about our dual diagnosis treatment.