The term “dual diagnosis” has become more prevalent in and around recovery communities in recent years but can often be surrounded by misunderstanding and confusion. Known officially in the medical field as a co-occurring disorder or comorbidity with a substance use disorder, a dual diagnosis refers to the presentation of both a mental disorder and a substance use disorder.

In a 2014 survey on drug use and health, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that nearly eight million people had a co-occurring disorder. Despite its prevalence, co-occurring disorders often go misdiagnosed or untreated.

We spoke with Dr. Jan A. Mayer, a Nashville-based psychiatrist and expert on addiction, to learn more about co-occurring disorders, how they’re diagnosed, and how they’re treated.

What is a co-occurring disorder?

A broad term to include a range of combinations, a co-occurring disorder refers to the joint presentation of a mental disorder as identified by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and a substance use disorder. Anxiety disorders, depression, and post-traumatic stress disorder (PTSD), each coupled with a substance use disorder, are some of the more common co-occurring disorders. Others include, but are not limited to, schizophrenia, bipolar disorder, and anti-social personality disorder.

Of the nearly eight million people estimated to have a co-occurring disorder, more than half are men.

Who has it?

Co-occurring disorders are not uncommon. Of the nearly eight million people estimated to have a co-occurring disorder, more than half are men.

Some studies estimate that about half of all individuals who suffer from a mental disorder will also experience a substance abuse disorder, and vice versa.

“Almost everybody that’s getting into recovery and in early recovery has a co-occurring disorder. It’s close to 100 percent,” says Dr. Mayer. “So the trick is to know what’s going to get better, how to get it better, and when it urgently needs to be addressed.”

For many who go on to abstain from drugs or alcohol, sobriety eliminates or dramatically reduces the co-occurring mental health issue.

Which comes first? Mental illness or addiction?

It can be a bit of a chicken-egg scenario. Does someone begin using substances to self-medicate mental illness symptoms? Or does someone’s addiction lead to other forms of mental illness?

Co-occurring disorders with substance class table
Diagnoses associated with substance class from the DSM-5

“It’s very important to sort out pre-existing ,” says Dr. Mayer. He gives the example of someone addicted to stimulants—cocaine, ecstasy, amphetamines—who experiences a stimulant use disorder-related mood disorder. “In other words, had you never had stimulant use, then you wouldn’t have the disorder.”

In the absence of the stimulant, the individual may experience depression, lack of energy, dysphoria, or hopelessness. “So, that is a function of cocaine withdrawal,” says Dr. Mayer. “It’s important to know all this because if you see somebody like that and you put them on anti-depressants, they didn’t need to be on anti-depressants. On the other hand, if they had a mood disorder well before they ever used , then they might well need medication or other treatments.”

Dr. Mayer stresses the importance of obtaining family medical histories and health histories from previous medical providers whenever possible in order to begin painting a clearer picture of what someone might be experiencing.

Co-occurring disorders can be challenging to identify and treat because the symptoms are complex and broad-ranging.

What are the symptoms of a co-occurring disorder?

Co-occurring disorders can be challenging to identify and treat because the symptoms are complex and broad-ranging. Disorders may have overlapping symptoms making it harder to tease them apart. While one disorder is treated, another may go undiagnosed and untreated.

Some of the signs of addiction to look for can include, but are not limited to:

  • Loss of control
  • Developing a high tolerance
  • Experiencing symptoms of withdrawal
  • Obsessive thoughts or actions around the drug of choice
  • Experiencing consequences as a result of substance use

Some of the signs of mental illness can include, but are not limited to:

  • Changes in mood
  • Changes in sleep, diet, and sex drive
  • Withdrawing from activities once enjoyed
  • Withdrawing from friends and family
  • Unusual or erratic behavior
  • Apathy
  • Feeling excessively sad or low
  • Thoughts of suicide

How are co-occurring disorders treated?

Medication isn't always necessary to treat co-occurring disordersThe complexity of co-occurring disorders often means a more integrated approach is necessary for treatment. This could mean a combination of various kinds of treatment options like:

For Dr. Mayer, competent and knowledgeable mental health professionals are a good place to start. They don’t need to be recovery specialists or able to prescribe medication in order to help either. In fact, sometimes a resource that cannot prescribe medication can be an asset.

“It’s important to recognize that when you’re treating , that doesn’t always mean medication. If at all possible, if you can have a medication-, drug-free period of time it can help evaluate better what’s going on. But there are some cases you can’t do it. It’s too risky,” says Dr. Mayer.

“My experience is that to every extent that you can engage people with non-pharmacological approaches, then that has a better outcome in the long-term. To the extent that you can wait it out and participate in recovery activities, then a lot of this goes away. But it’s important not to miss something that needs to be addressed.”

What comes next?

Whether an individual is seeking help for a mental health issue, addiction, or a combination of the two, it’s essential to:

  • Find a knowledgeable and competent mental health professional
  • Establish, whenever possible, any pre-existing symptoms, e.g. did symptoms exist before substance abuse, only after, or around the same time?
  • Obtain family health histories
  • Obtain past health histories from previous medical providers

Be patient with the recovery process. Treating co-occurring disorders takes time.


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