Co-occurring Disorders (COD)

When a person is struggling with addiction and they are also diagnosed with another mental health disorder, it is referred to as a co-occurring disorder or dual diagnosis, as it used to be called. In some cases, a co-occurring disorder may also refer to other combinations of disorders, such as mental disorders and intellectual disability.

People with COD typically have one or more disorders related to substance use as well as one or more mental disorders. An individual can be described as having COD when at least one disorder of each type can be established as independent of the other, and not simply a cluster of symptoms from another disorder.

Common examples of CODs include the combinations of alcohol addiction with panic disorder, cocaine addiction with major depression, and episodic poly-drug abuse with borderline personality disorder. There is a large number of combinations of COD that an individual can suffer from.

People with COD usually experience more severe medical, social, and emotional problems than those with a mental health disorder or substance use disorder alone, and they are vulnerable to both relapse and a worsening of their psychiatric disorder. Relapse can lead to psychiatric distress, and a worsening of psychiatric problems often leads to relapse, which is why relapse prevention has to be specifically designed to meet the needs of people with COD. Furthermore, they usually require longer treatment, have more crises, and progress more gradually in treatment. It Is estimated that approximately 7.9 million adults in the US had COD in 2014.


The symptoms of COD include all those associated with the individual’s particular substance use and mental health condition. COD can sometimes be difficult to diagnose, as the symptoms of a mental illness can be masked by those of substance abuse, and vice versa.

People with more severe mental disorders or developmental disabilities and traumatic brain injuries might be more at risk of harm when using substances at lower levels than people without such disorders. People who suffer from COD are at high risk for many additional problems such as symptomatic relapses, financial problems, social isolation, family problems, suicide, early death, and more.


Mental health and substance abuse disorders are greatly influence by several factors, including genetic susceptibility, environment, and pharmacologic influences. Some people have a genetically high risk for these disorders, some can find themselves in environments that evoke or help sustain them, and some can have higher risks of developing psychiatric or substance use disorders because of the drugs they are taking.

People with mental health disorders are more likely to develop substance use disorders because they may be tempted to use alcohol or drugs to temporarily make themselves feel better. In other cases, substance abuse can trigger or lead to severe emotional and mental distress.


The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends an integrated approach to treating COD. Integrated treatment means coordinating substance-abuse and mental health interventions, rather than treating each disorder independently.

Integrated treatment helps people develop hope, knowledge, and skills to manage their issues and to pursue meaningful life goals. It may include the following:

  • Help people think about the roles alcohol and other drugs play in their lives.
  • Offer them the opportunity to learn more about alcohol and drugs.
  • Help people become involved with supportive employment and other services that may help with recovery.
  • Help people identify and develop recovery goals.
  • Provide counseling specifically for people suffering from COD.

Successful strategies for people with COD include interventions based on addiction work in contingency management, cognitive behavioral therapy (CBT), relapse prevention, and motivational interviewing.


Many people with COD require medication to control their psychiatric symptoms and pharmacological advances have produced antipsychotics, antidepressants, anticonvulsants, and a wide variety of other medications with greater effectiveness and fewer side effects. Because of this, many people who would have otherwise been too unstable for substance abuse treatment or would have been institutionalized with a poor prognosis have been able to lead more functional lives.

Psychoeducational classes

An important element in COD programs are psychoeducational classes on mental and substance-use disorders. They typically focus on the signs and symptoms of mental disorders, on medication, and on the effects that mental disorders may have on substance abuse problems. These classes increase a person’s awareness of their specific problems and they do this in a safe and positive context.

Relapse prevention education presents people with strategies designed to help them become aware of certain cues or triggers that make them more likely to abuse substances and helps them develop coping responses to those cues.

Onsite Double Trouble groups

There are certain groups such as “Double Trouble” that provide a forum for discussion on the interrelated problems of mental disorders, thus helping people identify triggers for relapse. They describe their psychiatric symptoms and their urges to use substances and they are encouraged to discuss these impulses, rather than act on them. Double Trouble groups can also monitor medication adherence, psychiatric symptoms, substance use, and adherence to the scheduled activities.

Dual recovery mutual self-help groups

These are offsite self-help groups that exist in many communities and are tailored to the special needs of a variety of people with COD. They provide people with a safe forum for discussion about medication, mental health, and substance abuse in an understanding and supportive environment.

The dual recovery mutual self-help movement emerges from two cultures: the 12-step fellowship recovery movement and the culture of the mental health consumer movement. The primary purpose of dual recovery fellowships is to allow members to help one another achieve and maintain dual recovery, prevent relapse, and spread the message to other people who are suffering from COD.

Outpatient substance abuse treatment programs

Some agencies offer intensive outpatient programs that provide services several hours a day and several days per week. Treatment typically includes individual and group counseling.

People with COD often need a range of other services besides substance abuse treatment and mental health services and it is generally important to include housing and case management services in order to establish access to community health and social services

It is very important that discharge planning for people with COD ensures continuity of psychiatric assessment and medication management, otherwise stability and recovery will be severely compromised.