Mental disorders such as depression, anxiety, bipolar disorder, dementia, and schizophrenia are relatively common. Yet what many people don’t know is that these mental health conditions often co-occur with substance use disorders—also known as a dual diagnosis. In order to effectively treat both conditions during rehab, an integrated treatment approach should be taken, which may involve an interdisciplinary team of counselors, case managers, psychiatrists, and therapists. However, the complexity of both disorders can pose some challenges in effectively treating each disorder.
Understanding Dual Diagnoses
Though concurrently having both a mental disorder and a substance use disorder is not unusual, the causality behind the onset of each condition isn’t always clear. For example, in some cases, the mental health disorder may be present before a person becomes addicted to substances, and in others, the addiction may trigger the onset of a mental health disorder or further exacerbate its presentation.
As a matter of a quick review, a substance use disorder is a complex disease that is characterized by the ongoing, compulsive use of drugs or alcohol despite harmful personal, social, or medical consequences. People who struggle with addiction are thought to experience several neurochemical changes within their brains that make it more difficult for them to stop using the drug, even though they know it causes problems in their life.
And mental health disorders are usually “characterized by a combination of abnormal thoughts, perceptions, emotions, behavior, and relationships with others.”2
Grappling with both simultaneously takes a toll not only on the person primarily experiencing the issues, but their family and community as well. According to the World Health Organization (WHO), dual diagnoses are the leading cause of disability worldwide, with roughly 23% of all years lost due to disability caused by them.1
Mental health conditions that most commonly co-occur with substance use disorders are:2,3
- Anxiety: The most prevalent mental health disorder in the U.S., anxiety affects almost 40 million adults, or 18.1% of the U.S. population, every year. Nearly 50% of people who are diagnosed with an anxiety disorder are also diagnosed with depression.
- Depression: One of the main causes of disability worldwide, depression affects more than 300 million people across the globe. It can be chronic or recurrent, and at its most severe, depression can lead to suicide. The disorder is characterized by feelings of sadness, low self-worth, change in sleep or appetite, poor concentration, and loss of interest in things they once enjoyed.
- Post-Traumatic Stress Disorder (PTSD): Women are more likely to be affected by PTSD than men. Rape is a common trigger for the disorder; 65% of men and 46% of women who are raped develop PTSD. Childhood sexual abuse, in general, is a strong predictor of developing PTSD. Approximately 3.5% of the U.S. population suffers from the disorder.
- Schizophrenia: This severe psychotic disorder affects nearly 21 million people globally. A person with schizophrenia may experience changes in perception, emotions, language, thinking, and an altered sense of self. Characteristic symptoms include hallucinations, delusions, and diminished capacity for social functioning. This disorder most often begins in adolescence or young adulthood.
- Bipolar Disorder: Perhaps the most widely recognized variant (bipolar I) of the bipolar spectrum disorders is characterized by the occurrence at some point of a full manic episode, with many also experiencing intermittent major depressive episodes. A person with bipolar disorder may experience abnormally high self-esteem, a decreased need for sleep, irritability, over-activity, and elevated mood, followed by periods of severe depression. More than 60 million people around the world are affected by this disorder.
Experiencing any one of these mental health disorders while also abusing drugs or alcohol can complicate the course of both conditions and poses significant challenges up front when it comes to both diagnosis and treatment.
Challenges During Treatment
People who struggle with co-occurring disorders have higher relapse rates, which is, in part, due to the fact that mental health and substance abuse treatment systems are not always integrated. This makes it difficult for a person to navigate being treated for and recovering from both conditions. In recent years, more dual diagnosis services have been created to help bridge this gap and better serve people with both disorders. A successful recovery means that a person learns to manage both of their illnesses so that they can pursue a meaningful life.4
Comprehensive treatment for both co-occurring disorders must take into consideration the following challenges:4
Treatment Approach: To stay abreast of a patient’s progress with regard to each individual disorder and apply the appropriate treatment interventions at each stage of recovery, effective treatment programs incorporate the concept of stages of treatment, which include:
- Build a trusting relationship.
- Help the person become motivated toward recovery.
- Engage in active treatment.
- Encourage them to develop strategies for aftercare or relapse prevention through therapy.
Because a person does not always move linearly through these stages, it’s important that therapists and clinicians respond accordingly and adjust the person’s care plan as needed. There may well be variability between the co-occurring conditions in terms of what treatment interventions and levels of treatment intensity are needed. This type of individualized treatment approach ensures that the specific needs of each patient are considered and addressed appropriately and that both mental health and substance abuse issues are appropriately managed.
Treatment Approach: Because of this, programs that focus on outreach and combine intensive case management with in-home clinical appointments are most effective. For example, establishing a trusting relationship with homeless patients before they enter treatment and helping connect them with housing provides them not only treatment, but much-needed housing security too. Studies show that without outreach, dropout rates are high.
Treatment Approach: Using motivational interventions, clinicians help patients in treatment identify their own goals for stopping alcohol or drug abuse and seeking help. When people feel motivated, they are more likely to stay in treatment and remain sober after leaving treatment. In addition, this approach helps people learn healthy coping mechanisms that do not involve alcohol and drugs.
Treatment Approach: Once someone is ready and willing to learn how to best manage their disorders, they can begin to learn the skills they need to succeed long-term in weekly or daily counseling sessions. Counseling during treatment is offered in a variety of formats, such as group counseling, individual counseling, couples counseling, and family therapy sessions, depending on the facility and the person’s needs. In particular, cognitive behavioral treatment is highly effective in treating dual diagnosis patients when it is integrated into substance use treatment.5
Treatment Approach: People who struggle with co-occurring disorders do not usually stabilize quickly; instead, they tend to improve over a long period while they are regularly engaged in treatment. Programs that use a long-term community-based approach and incorporate activities such as 12-step meetings, volunteering, ongoing counseling, housing assistance, stress management, and linking to other programs or services, are more effective at treating both disorders and helping to prevent relapse.
Despite the increased awareness that people with dual diagnoses benefit from integrated treatment, research studies show that only 18% of addiction treatment and 9% of mental health programs meet criteria for offering capable dual diagnosis services.6 Establishing guidelines for effectively treating co-occurring disorders is important for serving this population.
- World Health Organization. (n.d.). 10 Facts on Mental Health.
- World Health Organization. (2017). Mental Disorders.
- Anxiety and Depression Association of America. (2017). Facts & Statistics.
- Drake, R.E., Essock, S.M., Shaner, A., Carey, K.B., Minkoff, K., Kola, L., & Rickards, L. (2001). Implementing Dual Diagnosis Services for Clients with Severe Mental Illness. Psychiatric Services, 52(4), 469–476.
- Haller, M., Norman, S.B., Cummins, K., Trim, R.S., Xu, X., Cui, R., & Tate, S. R. (2016). Integrated Cognitive Behavioral Therapy Versus Cognitive Processing Therapy for Adults with Depression, Substance Use Disorder, and Trauma. Journal of Substance Abuse Treatment, 62, 38–48.
- McGovern, M.P., Lambert-Harris, C., Gotham, H.J., Claus, R.E., & Xie, H. (2014). Dual Diagnosis Capability in Mental Health and Addiction Treatment Services: An Assessment of Programs Across Multiple State Systems. Administration and Policy in Mental Health, 41(2), 205–214.