Co-Occurring Disorders/Dual Diagnosis

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Co-Occurring Disorders/Dual Diagnosis









Co-occurring disorders are sets of mental illnesses that appear together in a single individual. They include a substance abuse disorder with at least one other Axis I or Axis II mental illness. The five Axes are standard diagnostic categories established by the American Psychiatric Association (APA). In co-occurring disorders, an Axis I substance abuse disorder is always present simultaneously with at least one other mental health disorder from Axis I or II. Another name for co-occurring disorders is dual diagnosis, although this may include several diagnoses and not only two (dual). Dual diagnosis in this case means “more than one.” Yet another name given this condition is co-morbidity, with morbidity meaning “illness.”


The term substance abuse includes substance-use disorders on a continuum from experimentation, to regular use, to drug dependence and addiction. Substances include prescription drugs, over-the-counter medications, marijuana, cocaine, heroin, mescaline (peyote), glues (sniffing), spray-can aerosols (huffing), and other categories. Substance abuse is the usual co-occurring disorder among adults with severe mental disorders (SMDs) such as bipolar disorder, other psychoses, and depression.

Depression itself is the most common mental illness coexisting with physical disorders. Further, depression often occurs among patients with substance abuse, whereas substance abuse can coexist with anxiety, post-traumatic stress disorder (PTSD), personality disorders, and eating disorders. Co-occurring disorders result in serious problems such as higher rates of illness relapse than in cases of only one mental illness; increased numbers of hospitalizations; and higher risks for violence, incarceration, homelessness, suicide, and exposure to major infections such as HIV and hepatitis.


According to statistics compiled by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), 10 million Americans or more will develop at least one mental illness together with a substance abuse disorder in any one-year period. The APA has learned that 7% of the American population, or 21 million people, have a full-blown psychosis at any given time. Co-occurring disorders affect a full 50% of all individuals that have severe mental disorders such as psychoses. Kessler, et al., recently found in a controlled study that 55% of the general population may experience one mental illness, 22% from two, and 23% from three co-occurring disorders. This translates to 69 million Americans having three co-occurring disorders.

SAMSHA has found that the prevalence of co-occurring disorders has increased during the last three decades. Named in the early 1980s, dual diagnoses considered most likely to occur among either youth and young adults with schizophrenia or people with bipolar disorder, all of whom showed a history of drug abuse and/or alcohol abuse. The medical opinion was that a person’s entrance into the drug culture was the cause of another mental illness. Currently, it is thought that one or more mental disorders occur first, followed by drugs or alcohol used in self-medicating behavior used to cover unwanted mental symptoms.


Children of alcoholics and of drug-addicted individuals are more likely to have co-occurring disorders than America’s general population. In addition, patients with depression are more at risk for substance abuse and alcohol abuse disorders than people having no mental illness. In addition, the U.S. Department of Health and Human Services has found that people who have received public assistance under welfare reform programs experienced an average of three or four SMDs in addition to substance abuse, without receiving adequate treatment. The affected homeless population suffers similar circumstances, while youth and the aged are also affected by co-occurring disorders.

Among youth, disruptive behavior disorders occur more frequently with than without substance abuse disorders. Older adults with depression or anxiety are at higher risk for substance and alcohol abuse than middle-aged adults. Seniors may be grieving losses of family, friends, and employment. They may drink or misuse drugs to rid themselves of pain and the complications of poverty. Co-occurring disorders complicate the management of any memory problems they may have, slowing metabolism, arthritis, hypertension, diabetes, Alzheimer’s disease and other dementias, and various additional health problems. Further, because women generally outlive men, co-occurring disorders and related physical problems are more prevalently becoming the maladies of older women. However, they also affect veterans and people with eating disorders.

Substance or alcohol abuse may co-occur with eating disorders, because such patients self-medicate feelings of shame, anxiety, extreme hunger, and self-hate commonly experienced in eating disorders. This further complicates their recovery. Finally, many military veterans experience anxiety, depression, and/or post-traumatic stress disorder (PTSD) at the same time they have a history of substance abuse or alcoholism. Unfortunately, assessment, treatment, and prevention services for veterans have been inadequate.


Careful assessment by a licensed professional and therapeutic team is necessary to plan effective treatment strategies. This begins with a detailed medical history and clinical interviews of the patient and family members to establish related health and behavioral patterns and substance or alcohol abuse history. Because denial is an inherent aspect of the problem, a battery of psychiatric tests can uncover mental illnesses. These tests include the Minnesota Multiphasic Personality Inventory (MMPI), Rorschach and other inkblot tests, other personality and projective tests, the Wechsler intelligence scales, and others. A number of substance abuse checklists can help determine substance and alcohol-related disorders.


Despite evidence of the high prevalence of dual diagnoses, the U.S. mental health and substance abuse systems have run separate programs, causing confusion. Failure to combine services for coordinated treatment means prolonged suffering and expense for patients, families, insurance companies, the U.S. health care system, and public assistance and disability programs. In light of welfare reform and health care improvements, the 1990s provided many programs for these patients, often more holistic and supported by federal funding for targeting ex-offenders and welfare-to-work populations.

The key factors in an integrated treatment program are (1) treatment must be approached in stages; (2) assertive outreach leads to higher client retention rates; (3) motivational interventions accompanied by education, counseling, and social support; (4) viewing recovery as a long-term, community-based process; (5) effecting a comprehensive strategy; and (6) a successful program must be culturally sensitive and culturally competent.

Investigators such as Roszak, Sacks, and Watkins have found recently that for many dual diagnosis patients, the criminal justice system is their last stop. Many jailed youth fail to be diagnosed. Their behavior mandated their incarceration and mental health assessment was not considered. The juvenile and adult justice systems have become the treatment provider, but treatment is not always an option. Two-thirds (67%) of incarcerated youth with substance abuse disorders have one or more additional mental illnesses. The coexistence of a conduct disorder and/or attention deficit-type disorders with substance abuse results in a serious disability. However, a dual diagnosis patient in the criminal justice system may never receive psychiatric evaluation or treatment.

A specific problem with treatments for dual diagnoses is that most mental health treatments are designed, tested, and validated through controlled studies of individuals who have only one mental diagnosis. These treatments may not be as effective when there are two or more mental disorders. However, individually prescribed treatment plans have been successful in using these specific components:

  • planned therapeutic interventions: The client is engaged and persuaded to participate in rehabilitation. In planned group and individual therapies, the patients are given coping skills and support toward managing their illnesses.
  • psychological counseling: This includes both cognitive (thinking) and behavioral skills to change negative thinking patterns and unwanted behaviors. It can include role-playing and homework.
  • social counseling: This includes support groups, group therapy, and family therapy facilitated by professionals. It includes diversity and sensitivity training and cultural competency instruction.
  • health-related education: This helps clients commit to managing their illnesses. It requires an acceptance of and commitment to a long-term supervised recovery process.
  • aggressive follow-up: A treatment team provides intensive, frequent patient follow-up with meetings in the patient’s workplace and home as well as in the case manager’s office.
  • comprehensive treatment: This holistic treatment targets education, health, employment, personal behavior patterns, stress management, peer networks, family, housing, financial skills, spiritual life, and other aspects.


Axis —One of five diagnostic categories of the American Psychiatric Association that are used for mental health diagnoses. Axis I describes the clinical syndrome or major diagnosis; Axis II lists developmental disorders or mental retardation and personality disorders; Axis III lists physical disorders; Axis IV includes the severity of psychosocial stressors for the individual; and Axis V describes an individual’s highest level of functioning currently and in the past 12 months.

Co-occurring disorders —Sets of mental illnesses—usually substance abuse and at least one other Axis I or Axis II disorder—that appear together in a single individual. Also called dual diagnosis or co-morbidity disorders.

Intervention —A confrontation of a substance abuser by a group of interested people that propose immediate medical treatment. An intervention is also a method of treatment used in therapy.

Substance abuse —Illicit, inaccurate, or recreational use of either prescription or illegal drugs. Alcohol can also be abused as a substance but has its own category, alcohol abuse.

Welfare-to-Work —Several American public reforms of the late 1990s and early 2000s, designed to move individuals from public assistance to paying jobs.

Additional considerations

Alcoholics Anonymous, Al-Anon, Narcotics Anonymous, and similar 12-step programs frequently supplement treatment for substance abuse and co-occurring disorders. However, their success cannot be quantitatively validated, because they are anonymous. Further, the direct confrontation of an engagement intervention and that of ongoing 12-step programs can be too threatening for mental health patients. The primary care physician or therapist must decide the most appropriate strategies for each patient.

The use of psychiatric drugs to alter mood or behavior is understandably controversial in substance abuse recovery, so treatments such as support groups for co-occurring disorders can be more effective than drug therapies.


The prognosis for co-occurring disorders depends on the prognosis of the separate disorders occurring in a specific patient, along with the combined effects of those disorders. Dual diagnoses usually present a worse overall health outlook than a single mental illness. Early preventative education, screening, assessment, diagnosis, and treatment are vital to the health of a person suffering from or at risk for co-occurring disorders. Appropriate health promotion education is useful and necessary in alerting the general populations to the risks and signs of co-occurring disorders and in helping themselves maintain good mental hygiene.



American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Sacks, Stanley, PhD, and Richard K. Ries, MD. Treatment Improvement Protocol (TIP) Series 42. Substance Abuse Treatment for Persons with Co-occurring Disorders. U.S. Department of Health and Human Service. Public Health Service. Substance Abuse and Mental Health Services Administration, 2005.


Kessler, Ronald C., PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; and Ellen E. Walters, MS. “Prevalence, Severity, and Comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication.” Archive of General Psychiatry 62 (2005): 617–627.

Roszak, Dennis J. “Mental Illness Starts Early in Life, but Treatment Often Begins Decades Later.” Hospitals & Health Networks 79.7 (2005): 130.

Saxena, Shekhar, and Jose Manoel Bertolote. “Co-occurring Depression & Physical Disorders: Need for an Adequate Response from the Health Care System.” Indian Journal of Medical Research. 122.4 (2005): 273–276.

Watkins, Katherine E., Sarah B. Hunter, and others. “Prevalence and Characteristics of Clients with Co-occurring Disorders in Outpatient Substance Abuse Treatment.” American Journal of Drug and Alcohol Abuse 30.4 (2004): 749–764.


American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. <>.

Double Trouble In Recovery. c/o Mental Health Empowerment Project. 271 Central Avenue, Albany, NY 12209. Telephone: (518) 434-1393

Dual Disorders Anonymous. P.O. Box 681264, Schaumburg, IL 60168. Telephone: (847) 781-1553.

Dual Recovery Anonymous. P.O. Box 218232, Nashville, TN 37221. Telephone: (887) 883-2332.

National Alliance for the Mentally Ill (NAMI). 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201. <>.

Mental Health America. 1021 Prince Street, Alexandria, VA 22314. <>.

Patty Inglish, MS