Dual Diagnosis

Dual diagnosis is a term used to describe people with mental illness who have coexisting problems with drugs or alcohol. The relationship between the two is complex, and the treatment of people with addiction (or alcoholism) and mental illness is more complicated than the treatment alone. This is unfortunately a common situation—many people with mental illness have ongoing substance abuse problems, and many people who abuse drugs and alcohol also experience mental illness.  When the addiction is very strong, often it’s hard to tell that there’s a second co-existing problem.

Certain groups of people with mental illness (for example  males, military veterans and people with more general medical illnesses) have a higher risk of abusing drugs. Specifically these folks seek out drug like marijuana, opiates (heroin), cocaine meth and alcohol. Recent scientific studies suggest that nearly one-third of people with all mental illnesses and about one-half of people with severe mental illnesses (including bipolar disorder and schizophrenia) also experience alcoholism or addiction problems. On the flip side, more than one-third of all alcohol abusers (alcoholics) and more than one-half of all drug addicts are also losing the battle against mental illness.

What is the relationship between addiction (substance abuse) and mental illness?

The relationship between mental illness and addiction (you might also hear the term dependency) is very confusing. These relationships are often combined in the following ways:

  • Drugs and alcohol can be a form of self-medication. This is very popular. In this scenario, people with mental illness may an have untreated condition (such as anxiety or depression) that may “become more manageable” when the person is high on drugs or alcohol. The bad news is that while drugs and alcohol may feel good in the moment, abuse of the drug doesn’t treat the real problem and—almost without exception—makes it worse.

The Powerful (often overlooked) connection between Mental Health and Addiction.

  • Drugs and alcohol can worsen underlying mental illnesses. This can happen both during acute intoxication (for example a person with depression becomes suicidal while drinking alcohol) and during withdrawal from a substance (in this scenario a person with panic attacks experiences worsening symptoms during heroin withdrawal).
  • Drugs and alcohol can cause a person without mental illness to experience the start of symptoms for the first time. For example, a twenty-year old high-school student begins to hear scary voices (inside his head) and becomes paranoid that his math teacher is poisoning his food. This happens after he smokes some marijuana. This could represent a reaction to the drug (a medical person who probably call this “substance-induced psychosis”) or the first episode of psychosis for this person.

Keep in mind that abuse of drugs and alcohol always results in a worse prognosis for a person with mental illness. People who are actively using are less likely to follow through with the treatment plans they created when they were in recovery.  They are also less likely to take their medication and more likely to miss appointments. This leads to more psychiatric hospitalizations and other bad outcomes. Drug addicts are also less likely to receive adequate medical care for similar reasons and are more likely to experience severe medical complications and early death. People with mental illness who abuse drugs and alcohol are also at increased risk of impulsive and potentially violent acts. Probably the most scary part is that people who abuse drugs and alcohol are more likely to both attempt suicide and to die from their suicide attempts.

People with mental illness and active substance or alcohol abuse are less likely to achieve lasting sobriety. They may be more likely to experience severe complications of their substance abuse, to end up in legal trouble from their substance use and to become physically dependent on their substance of choice. If you have a dual-diagnosis, I hope you are convinced that it is a good idea to get some help.

What treatments are available for individuals with dual diagnosis?

Here comes the good news. Treatment suffering from mental illness and addiction, is complicated, but completely possible. The important thing is to address any life-threatening complications from intoxication. The following situations would require immediate medical care (in a hospital):

  • Severe cases of alcohol intoxication may require emergent medical treatment and can result in death.
  • Use of amphetamines, crack, cocaine and other drugs can result in heart problems (e.g., arrhythmias, heart attacks), stroke and death.
  • Use of benzodiazapines (e.g., diazepam [valium], clonazepam [klonopin]), opiates (e.g., oxycodone, oxycontin) and other “downers” can result in extreme sedation and potentially death in overdose.
  • Drug and alcohol withdrawal can lead to medical emergencies requiring immediate treatment. This can occur when a person who has been regularly using a particular substance has become “addicted” (i.e., the body has become physically dependent on the substance) and abruptly stops using. Here are some examples that may require immediate medical care in the hospital setting:
  • Alcohol withdrawal can result in heart problems (e.g., arrhythmias), seizures or delirium tremens (an acute delirious state), all which can be potentially fatal.
  • Benzodiazapine withdrawal can result in tremors (“shakes”), seizures and potentially death.
  • Opiate withdrawal (heroin or Opioid) is not thought to be life-threatening in most cases, but it can be a very traumatic and painful experience.

Therefore, many people seek assistance in going through the process of stopping their drug and alcohol abuse. This can include inpatient detoxification which can involve admission to a hospital—either a general hospital or a detoxification facility—and treatment with the appropriate medications to avoid serious complications of acute drug and alcohol withdrawal. This is very important. The most complicated withdrawal problem are caused by alcohol and benzodiazapines


It’s called a vicious cycle because self-medicating will always lead to more depression.

Multiple scientific studies have shown that psychiatric treatments are more effective in people who are not actively abusing drugs and alcohol. I suppose this is rather obvious. Once individuals are safely “detoxed” from drugs or alcohol—or stop abusing drugs that they may not necessarily be “addicted” to—treatment of underlying mental illness may be more successful. This is not to say that people with mental illness cannot be treated while they are still using, rather that treatment of mental illness is generally more effective once one is sober and more able to actively participate in treatment.

Many options exist for people who are newly sober or who are trying to avoid relapse on drugs and alcohol. These can include inpatient rehabilitation centers or supportive housing (e.g., sober houses, group homes or residential treatment facilities). Other people may choose to return home to their friends and family who can be helpful in encouraging newly-sober individuals to continue their efforts. This can be critically important as a significant majority of people will relapse into drug and alcohol abuse at some point in their lives, even if they are eventually able to achieve long-lasting sobriety.

Some people find therapy to be a helpful part of maintaining their sobriety. This can include individual therapy (e.g., cognitive behavioral therapy) as well as self-help groups such as Alcoholics Anonymous, Narcotics Anonymous or Smart Recovery.

Some people may also talk with their doctors about certain medications that can be helpful in maintaining sobriety. The following medication treatments have been safely tested in multiple studies including FDA medication trials. For people with alcoholism, available medications include disulfiram (Antabuse), acamprosate (Campral) and naltrexone (Revia). For people with opiate abuse, available medications include naltrexone (Revia, Vivitrol), methadone and buprenorphine (Subutex, Suboxone). Given how complicated these choices may be, it is necessary for any individual with dual diagnosis and their loved ones to discuss medication management strategies with their doctors. Medications that are available to take people off medications is sometimes a controversial topic.

Families, friends and others can be most helpful in providing caring and non-judgmental support of their loved one. With this support, the proper medical treatment and effective treatments, many people with dual diagnosis will be able to actively participate in their journey to recovery. The big trap to avoid is consistency. Many times, we see people take their new medication and start to feel better. Once they feel better, they are convinced they don’t need the medication any longer. This almost always leads to a relapse. Remember, recovery from mental illness, addiction and alcoholism is a lifetime process.

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