Dual Diagnosis

Written by BetterHelp Editorial Team
Medically reviewed by Dr. Jennie Stanford, MD, FAAFP, DipABOM, Julie Dodson, MA, and Laura Angers Maddox, NCC, LPC

Overview

A dual diagnosis (also called concurrent disorder, co-occurring disorder, and comorbidity1 ) is not itself a diagnosis but a combination of disorders. Dual diagnoses are common amongst individuals with psychiatric disorders, with an estimated 50% of people with severe psychiatric disorders also experiencing substance use disorders (SUD).2  

A dual diagnosis can be more severe than a single diagnosis, as mental illnesses and substance use can worsen each other, creating a negative feedback loop. For example, someone with major depressive disorder may self-medicate with alcohol to manage their symptoms. Over time, self-medication can worsen depression symptoms and contribute to alcohol use disorder, which may, in turn, lead to more alcohol consumption.

Complex symptom presentation can make receiving accurate diagnoses and effective treatment more difficult. This barrier may lead people with dual diagnoses to experience a heightened risk of relapse, hospitalization, incarceration, homelessness, and serious infections. While dual diagnoses can be more complex than an SUD or other psychiatric disorder alone, effective treatment options are available that can address both conditions concurrently.  

For those struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

Process

The process of making a dual diagnosis can vary. Often, a client will meet with a mental health professional, such as a therapist,3 psychiatrist, social worker, or counselor, to discuss symptoms, history, and challenges. The provider can then consider the client’s symptoms before making a diagnosis. 

In the case of a dual diagnosis, the therapist may create a treatment plan centered around the unique symptoms of each condition and how they may relate to each other. For example, they might use cognitive-behavioral therapy (CBT) to treat symptoms of a condition like depression or anxiety. They may use a different approach, such as motivational interviewing,4 to treat the substance use disorder. In severe cases, medication might be recommended. 

Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis.

Criteria

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is a handbook including descriptions, symptoms, and other criteria that medical professionals use to diagnose psychiatric disorders. 

There are no diagnostic criteria co-occurring mental disorders because they characterize a combination of disorders rather than a specific disorder. The signs and symptoms of dual disorders can vary significantly, depending on the types of SUD and non-SUD disorders present.

Common dual diagnoses

Any combination of a substance use disorder and another mental health disorder is considered a dual diagnosis. Many of these conditions have similar symptoms and risk factors. Common non-SUD psychiatric disorders seen in people with substance use disorders include the following: 

  • Major depressive disorder: Almost one-third of people with MDD also have a substance use disorder. 
  • Anxiety disorders: Anxiety disorders are associated with a heightened risk of SUDs.  
  • Antisocial personality disorder (ASPD): There is a strong association between antisocial personality disorder and SUDs. 
  • Borderline personality disorder (BPD): It’s estimated that 78% of adults with BPD develop a substance use disorder at some point.  
  • Schizophrenia: It’s estimated that nearly 50% of people with schizophrenia have a substance use disorder, and over 70% have nicotine dependence. 
  • Bipolar disorder: Lifetime comorbidity of bipolar disorder and alcohol use disorder is estimated to be 40% to 70%.  
  • Attention deficit hyperactivity disorder (ADHD): Around 15.2% of adults with ADHD also meet diagnostic criteria for a SUD. 
  • Conduct disorder: One study found that, among youth with conduct disorder, 52% also had a substance use disorder. 
  • Post-traumatic stress disorder (PTSD): The National Center for PTSD reported that 46.4% of people with a diagnosis of PTSD also had a substance use disorder at some point. 

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), substances commonly used by people with non-substance-bound disorders include:

  • Alcohol
  • Marijuana
  • Stimulants, such as cocaine and amphetamines
  • Prescription medications, such as painkillers, cold remedies, and sleeping aids
  • Tobacco
  • Opioids, including fentanyl and heroin
  • Hallucinogens like PCP

Amongst individuals with any lifetime non-SUD psychiatric disorder, 28.9% have a substance use disorder at some point, compared with 13.2% of those with no history of psychiatric disorders.  

Note that association does not always indicate causality, meaning that substance use does not necessarily cause a non-SUD disorder, and a non-SUD disorder does not necessarily cause an SUD. For example, alcohol use disorder and another disorder may both be caused by another variable (such as genetics or trauma), or their co-occurrence may be coincidental. 

Treatment plan

Historically, dual diagnoses have been underreported and undertreated. However, as dual diagnoses have become more widely recognized, treatment plans have become more effective. Currently, integrated treatment is the gold standard for dual diagnoses, meaning that treatment plans address two or more conditions simultaneously, often using a combination of treatment approaches (such as psychotherapy and pharmacotherapy). The combination of early detection and integrated care can:

  • Reduce substance use
  • Improve psychiatric symptoms and ability to carry out daily functions 
  • Increase the likelihood of SUD remission
  • Decrease hospitalization risk 
  • Improve housing stability
  • Reduce the risk of arrest and incarceration

Integrated treatment may necessitate the coordination of multiple mental health and substance use specialists, such as psychiatrists, licensed talk therapists, social workers, and case managers. Treatment plans are individualized, but they typically progress through two distinct phases: 

  1. Acute stabilization: This phase may include detoxification if the substance used causes physical dependence. Additionally, acute stabilization may involve short-term medications to stabilize psychiatric symptoms. 
  2. Longer-term treatment: This phase may include a combination of therapy, medication, and other treatment approaches aimed at managing symptoms and addressing underlying challenges that contribute to substance use and psychiatric symptoms. 

Long-term treatment approaches may include the following. 

Talk therapy

Talk therapy methods that may be beneficial in treating substance use disorders and co-occurring mental health disorders could include the following: 

  • Cognitive-behavioral therapy (CBT): Through CBT, clients are taught how to reframe maladaptive thoughts, which can reduce emotional distress and harmful behaviors. When utilized as part of an integrated approach, CBT can effectively address dual diagnoses. 
  • Dialectical behavioral therapy (DBT): DBT is a subset of CBT that was initially developed to treat borderline personality disorder (BPD). Some studies have found that individuals with co-occurring bipolar disorder and SUDs may benefit from DBT. 

Online therapy platforms like BetterHelp offer cognitive-behavioral therapy and dialectical behavioral therapy, which may be preferred by clients who are more comfortable attending therapy sessions from the comfort of home. Though most online therapy platforms cannot prescribe medications, diagnose mental health conditions, or provide services during crises, some people find that online therapy can be a practical and more readily available part of their long-term care plan.

Medication

Several medications are available to manage substance use disorders. For example, opioid use disorder may be treated with methadone or buprenorphine, alcohol use disorder may be treated with naltrexone, and tobacco use may be treated with a nicotine patch. 

In some cases, medications are prescribed to treat non-SUD psychiatric disorders. For example, antidepressants like SSRIs are frequently prescribed to treat depressive and anxiety disorders, mood stabilizers are often prescribed for bipolar disorders, and stimulants and non-stimulant medications are sometimes prescribed to treat ADHD. Talk to your doctor to discuss your options. Do not start, stop, or change medications without discussing with your physician or other qualified healthcare professional.

The BetterHelp platform is not intended for any information regarding which drugs, medication, or medical treatment may be appropriate for you. The content is providing generalized information, not specific for one individual. You should not take any action without consulting with a qualified medical professional.

Support groups

Support groups are shown to buffer stress, reduce substance use, and improve physical and mental well-being. In addition, being part of a group can allow clients to meet people experiencing similar challenges, which can reduce loneliness. 

Additional services

The most effective treatment options address substance use and non-SUD disorders concurrently. However, some people with dual diagnoses can have difficulty finding appropriate care. For example, some psychiatrists may be uninvolved with substance use management, and substance use disorder providers may not easily diagnose co-occurring disorders. The following services might help get you connected with integrative care providers who can assist with dual diagnosis of co-occurring mental conditions: 

  • Find a Treatment Facility: If you’re looking for help in the United States, you can use the Substance Abuse and Mental Health Services Administration (SAMHSA) Find Treatment tool to find a nearby treatment facility. This tool can connect you to The Substance Abuse and Mental Health Services Administration.
  • Speak With a Helpline: Access the 988 Suicide and Crisis Lifeline 24/7 by calling or texting 988 for crisis counseling and support. The National Helpline provides referrals and information in both English and Spanish. It can be accessed by calling 800-662-4357.

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Updated on June 27, 2024.
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