Dual Diagnosis: Treating Co-Occurring Disorders

The Treatment of Co-occurring Disorders

A large number of people are diagnosed with mental health disorders every year, and a significant number of this population will also be diagnosed with substance use disorders. According to several national surveys, approximately 50% of people who experience a mental illness in their lives will also experience a substance use disorder. In contrast, about 50% of those experiencing a substance use disorder will also experience a mental health disorder.

How Do Mental Health Disorders and Substance Use Disorders Co-occur?

Mental health disorders and substance use disorders often co-occur, but that doesn’t mean that one disorder caused the other.

Mental Health Disorders Can Contribute to the Reason That Substance Use Disorders Develop

When people become addicted to illicit substances, it can cause users to develop symptoms of mental health disorders. People experiencing post-traumatic stress disorder, depression, or anxiety may use substances as a way of alleviating their symptoms. This works for people for a period of time, but it ends up causing the symptoms of the mental health disorder to get worse. Also, changes in the brains of people with mental health disorders cause the rewarding effects that substances cause to be even stronger. This increases the likelihood that these people will ingest substances.

Substance Use Disorders Can Contribute to the Reason that Mental Health Disorders Develop

Substance use changes the brain and the way that it functions, and this makes it more likely that the person will develop a mental health disorder.

Common Risk Factors

Both disorders can be hereditary, so genes that parents pass on to their children may cause these disorders. In fact, 40% to 60% of a person’s risk of developing a substance use disorder is associated with the person’s genes.

Environmental Factors

Environmental factors cause genes to mutate, and parents can pass these mutations down to their children. Both mental health disorders and substance use disorders may travel from one generation to the next in this way. Some environmental factors that influence genetic mutations include drug exposure, trauma, and chronic stress.

Negative Experiences in Childhood

If you were physically or emotionally traumatized during childhood, you are much more likely to develop substance use disorders. Instead of getting therapy to deal with trauma, many survivors turn to alcohol or drugs as a way to cope instead.


Stress is a risk factor for developing mental health disorders and may contribute to the person also developing a substance use disorder. Stress during childhood or chronic stress alters the hypothalamic-pituitary-adrenal, or HPA, axis that is in control of the brain circuits that control a person’s motivation. Because of this alteration, people with mental health disorders and substance use disorders have impairments in their learning, ability to adapt, and motivation.

In addition to the above, hyperactivity in the HPA axis alters dopamine’s ability to send signals, and this may increase the drug’s ability to cause the person to crave the drug. Then, the use of substances causes them to alter neurotransmitter systems that have to do with the way that the body responds to stress. These neurobiological alterations may be the reason that stress causes people to seek their drugs of choice or relapse. Research shows that when someone engages in strategies that reduce stress, their substance use, anxiety and depression are also eliminated.

Development in the Brain Region

Several regions in the brain are affected by mental health disorders and substance use. For example, norepinephrine, GABA, glutamate, serotonin, and dopamine are affected by substance use disorders and mental health disorders.

What Are Some Common Co-occurring Disorders?

Co-occurring disorders may be the following:

• Anxiety disorders
• Depression
• Attention deficit hyperactivity disorder
• Bipolar disorder
• Personality disorder
• Schizophrenia

Dual Diagnosis Treatment

The medical community treats co-occurring disorders at the same time. When people appear at drug treatment centers, they must be evaluated for substance use disorders and mental health disorders at that time. Because the symptoms can be indicative of both disorders, it can be challenging to diagnose each disorder. Therefore, treatment providers use a comprehensive analysis so that there is less of a chance of misdiagnosing a condition.

It is often harder to keep people in treatment when they are experiencing a mental health disorder. Treatment takes several things into consideration when addressing a substance use disorder and a mental health disorder. These factors include the specific disorders, the illicit substance, the age of the patient, and the symptoms.

Medications for Addiction Treatment

Methadone is an opioid agonist, and it relieves withdrawal symptoms and cravings for opioid drugs. It works by attaching to the same opioid receptors in the brain that morphine and heroin also activate. Methadone acts slowly within the body, so it doesn’t create the sensations that other opioids cause. Therefore, someone addicted to opioids can ingest methadone and not experience euphoria. In order to receive this treatment, clients must be in a treatment program.

Buprenorphine is another medication that treatment centers administer during the medication-assisted treatment program. It is a partial opioid agonist, so it also attaches to the same opioid receptors as methadone and other opioids. Buprenorphine is a partial agonist because it doesn’t activate the receptors as strongly as full opioid agonists do. This medication also reduces withdrawal symptoms and prevents cravings without causing the client to experience euphoria.

Naltrexone is an opioid antagonist, and it keeps the opioid receptors from being activated. This medication prevents opioids from causing the user to experience euphoria or any other positive effects of taking opioids. It doesn’t relieve withdrawal symptoms or cravings.

Behavioral Therapies

Researchers learned that the behavioral therapies work well for people experiencing mental health disorders and substance use disorders at the same time. A medical professional may prescribe one or more behavioral therapies along with MAT. The following behavioral therapies have been shown to be effective for adults experiencing both mental health disorders and substance use disorders.

Contingency Management

Contingency management is when clients receive rewards for engaging in positive behaviors, and research demonstrates that these types of therapies are effective for keeping people involved in their treatment. They also encourage them to remain abstinent from their drugs of choice.

Voucher-based Reinforcement

Voucher-based reinforcement is a type of contingency management that is community-based. It focuses specifically on people addicted to opioids and stimulants. With VBR, a client receives a voucher every time that he or she submits a drug-free urine test. The client exchanges these vouchers for items that promote a drug-free existence. These include movie passes, food, or other goods or services. In the beginning, the monetary value is low, but as the client continues to submit drug-free urine samples, the value of the vouchers increases. If the client’s drug test turns out to be positive, the monetary value returns to the lower amount. Research demonstrated that clients addicted to opioids or cocaine and undergoing the methadone detoxification program were able to abstain from drug use.

Prize Incentives Contingency Management

Prize incentives contingency management is a similar program to VBR, but instead of earning vouchers, clients earn cash. The program lasts for about three months. During that time, clients submit to a drug test every week. With each drug-free test, the client has the chance to win a prize that is worth between $1 and $100. Attending their counseling sessions and meeting their goals entitles them to be in the drawings. The number of draws each client gets is equal to one, and as the client attends counseling sessions and meets his goals, the number of draws increases. If a client misses a counseling session or doesn’t realize a goal, the number of draws resets back to one.

Therapeutic Communities

Therapeutic communities (TC) are a long-term, residential treatment option. In the beginning, TCs did not allow residents to use medications, but as time went by, professionals began to accept the idea that substance use disorders must be treated the same way that medical conditions are treated. Now, residents are encouraged to use the medications that treatment centers provide for their clients in MAT. TCs have changed in another way as well. They are currently offering residents a shorter term in the residential facilities, and some even give people the opportunity to obtain treatment on an outpatient basis.

Those with co-occurring disorders may be treated in TCs. In the beginning, TCs were run by staff members who were in recovery. Now, TCs employ mental health professionals and substance use professionals with the education and the training to treat residents experiencing co-occurring disorders.

Assertive Community Treatment

Assertive community treatment, or ACT, is another treatment designed for those with co-occurring disorders. This approach tackles some of the most serious types of mental health disorders and treats them along with substance use disorders. This treatment is advantageous because therapists have smaller caseloads and can spend a tremendous amount of time with their clients. It is also an approach that focuses on the individual and works to ensure that therapists remain in contact with their clients.

Dialectical Behavior Therapy

Dialectical behavior therapy is a treatment that works exceptionally well for those with mental health conditions; it is also highly recommended to treat substance use disorders. For example, this therapy was created to address serious issues, such as cutting, suicide attempts, and suicidal thoughts. Researchers determined that it effectively treats those with a borderline personality disorder.

DBT encourages clients to be self-aware and within the present moment. They learn to accept the emotions that they are currently experiencing. This therapy also teaches people how they can improve their relationships, how they can refrain from hurting themselves, and how they can stop trying to commit suicide.

Cognitive-behavioral Therapy

Cognitive-behavioral therapy is a treatment that has been proven to work well for those with substance use disorders. It focuses on changing a person’s harmful beliefs and behaviors. It is a psychotherapy that teaches clients to cope with the present situation by changing their behaviors and challenging irrational thoughts.

Exposure Therapy

Exposure therapy was designed to treat anxiety disorders and phobias. Therapists expose their clients to the object of their fear. It doesn’t always need to be real, so it can be simulated. Clients are only exposed to their feared object or situation if they are in a controlled therapeutic environment. As clients are exposed to the object of fear, they become desensitized to it, and they develop coping mechanisms with their therapists to cope with their emotions. The symptoms eventually disappear. Researchers determined that those diagnosed with cocaine use disorder and post-traumatic stress disorder received help from exposure therapy.

Seeking Safety

Seeking safety is a program that treats substance use disorders and mental health disorders at the same time. It focuses on the present time and teaches clients skills that help them cope with both of their disorders at once.

Integrated Group Therapy

Integrated group therapy is a treatment that was exclusively designed to treat both substance use disorder and bipolar disorder. It is based on the principles of CBT and accompanies the use of medications in most cases. Clients learn how their substance use disorders and bipolar disorders are related, and they also learn how their behaviors are related to their thoughts. Lastly, they learn how these relationships can help them or prevent them from relapsing into drug use and recovering from their addictions.

If you are ready to get help for your loved one or you are in need of help, reach out to Addiction Experts to help find a rehab center for you.

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Reviewed By:

Dr. John Elgin Wilkaitis

Dr. John Elgin Wilkaitis completed medical school at The University of Mississippi Medical Center and residency in general psychiatry in 2003. He completed a fellowship in Child and Adolescent Psychiatry at Cincinnati Children’s Hospital in 2005. Following this, he served as Chief Medical Officer for 10 years of Brentwood Behavioral Healthcare a private health system including a 105-bed hospital, residential treatment, and intensive outpatient services.

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