Maybe a glass of wine became the only reliable way to quiet anxiety at night. Maybe cannabis started as a way to sleep and now feels necessary just to get through the day. Or maybe someone you love has been treated for depression, then for drinking, and neither treatment seemed to stick. Situations like these are often described as co-occurring disorders, and they are far more common than most people realize.
This article explains what co-occurring disorders are, how often they happen, why mental health conditions and substance use tend to show up together, and what integrated treatment looks like in practice. It also includes guidance for family members. The information here is educational and is not a substitute for an assessment by a qualified professional, but it can help you understand the options and take a well-informed next step.
What Are Co-Occurring Disorders?
Co-occurring disorders are the presence of a mental health condition and a substance use disorder in the same person at the same time. The term is often used interchangeably with "dual diagnosis." The two conditions can develop in either order, and each can influence the course of the other.
The mental health side can include conditions such as depression, anxiety disorders, post-traumatic stress disorder (PTSD), bipolar disorder, ADHD, or schizophrenia and other psychotic disorders. The substance use side can involve alcohol, cannabis, opioids, stimulants, sedatives or other drugs.
A substance use disorder is a medical condition, not a character flaw. It is diagnosed when a pattern of use causes significant problems, such as difficulty cutting down, cravings, or continued use despite harm to health, relationships or responsibilities. Using person-first language, such as "a person with a substance use disorder," reflects this understanding.
How Common Are Co-Occurring Disorders?
Co-occurring disorders are common. According to SAMHSA's 2024 National Survey on Drug Use and Health (NSDUH), about 21.2 million U.S. adults had both a mental illness and a substance use disorder in the past year, which is roughly 8 percent of adults.
The same survey highlights a significant treatment gap:
About 41 percent of adults with co-occurring mental illness and a substance use disorder received no treatment for either condition in the past year.
Among adults who did receive some treatment, most received mental health treatment only. Roughly one in four of those treated received care for both conditions.
Among adults with any mental illness in 2024, a little under a third also met the criteria for a substance use disorder.
In other words, many people are living with both conditions, but relatively few receive care that addresses both. That gap is one of the main reasons public health agencies emphasize integrated treatment.
Common Combinations
Any mental health condition can co-occur with any substance use disorder, but some pairings are frequently seen in clinical practice. The table below lists examples, not predictions about any individual.
Mental health condition
Substances commonly involved
What the overlap can look like
Anxiety disorders
Alcohol, cannabis, sedatives
Using substances to calm worry or sleep, then experiencing rebound anxiety
Depression
Alcohol, opioids, cannabis
Using to numb emotional pain, with substance use deepening low mood over time
PTSD
Alcohol, opioids, sedatives
Using to manage nightmares, hypervigilance or intrusive memories
Bipolar disorder
Alcohol, stimulants, cannabis
Increased use during mood episodes; substances can destabilize mood
ADHD
Nicotine, stimulants, cannabis
Attempting to manage restlessness, focus or impulsivity
Psychotic disorders
Cannabis, stimulants, alcohol
Some substances can worsen or trigger psychotic symptoms in vulnerable people
Why Do Mental Health and Substance Use Disorders Occur Together?
There is no single cause. The National Institute of Mental Health and the National Institute on Drug Abuse describe several overlapping pathways that help explain why the two conditions so often appear together.
Shared risk factors
Genetics, family history, early life stress, trauma and certain brain-related factors can raise the risk of both mental health conditions and substance use disorders. When the same underlying factors are at play, both conditions can emerge in the same person.
Using substances to cope
Many people first turn to alcohol or drugs to ease symptoms they have not yet been able to name or treat, such as anxiety, sleeplessness, emotional numbness or intrusive memories. This is often called self-medication. It can bring short-term relief, but over time it can worsen the original symptoms and lead to dependence.
Substances can cause or worsen symptoms
Heavy or regular substance use can change mood, sleep, motivation and thinking. Withdrawal can produce anxiety, irritability and low mood. Some substances can trigger panic attacks or, in some people, psychotic symptoms. This is one reason careful assessment matters: some symptoms ease once substance use changes, while others reflect an independent condition that needs its own treatment.
Each condition can make the other harder to treat
Untreated depression can sap the motivation needed for recovery. Untreated substance use can undermine therapy and interfere with psychiatric medications. SAMHSA notes that people with co-occurring disorders are more likely to be hospitalized than people with either condition alone, which underscores the value of treating both.
Signs That Mental Health and Substance Use May Be Overlapping
Only a qualified professional can diagnose co-occurring disorders, but certain patterns suggest it may be time for an assessment that looks at both:
Drinking or using drugs specifically to manage stress, anxiety, sadness, anger, sleep or memories.
Feeling unable to relax, sleep or socialize without a substance.
Mood, anxiety or concentration getting noticeably worse after periods of use.
Previous treatment for one condition helped only partly, or symptoms returned quickly.
Needing more of a substance to get the same effect, or feeling unwell when not using.
Pulling away from friends, family, work or activities that used to matter.
Family members expressing concern about both mood and substance use.
Thoughts of self-harm or suicide, especially when combined with substance use.
If you recognize these patterns in yourself, it does not mean something is "wrong with you." It means your mind and body have been working hard to cope, and you may benefit from support that addresses the whole picture.
Why Integrated Treatment Matters
Integrated treatment means addressing mental health and substance use together, in one coordinated plan, rather than in separate systems that do not communicate. SAMHSA states that integrating screening and treatment for mental and substance use disorders leads to better quality of care and better health outcomes for people with co-occurring disorders.
Historically, mental health services and substance use services were delivered separately. People were sometimes told to "get sober first" before mental health treatment, or that their substance use was outside the scope of mental health care. That approach left many people bouncing between programs.
SAMHSA describes three ways care for co-occurring disorders can be delivered:
1. Coordinated care: separate providers communicate and share information with the person's permission.
2. Co-located care: mental health and substance use services are offered in the same location.
3. Fully integrated care: one team plans and delivers treatment for both conditions together.
The closer the integration, the less the person has to manage the system on their own.
What Does Treatment for Co-Occurring Disorders Include?
Treatment for co-occurring disorders typically combines a comprehensive assessment, psychotherapy, psychiatric care, and recovery and family support, tailored to the person's goals and the severity of each condition. No single approach works for everyone, and plans often change as a person progresses.
Comprehensive assessment
Care usually starts with an evaluation that explores mental health symptoms, substance use history, physical health, medications, safety and life circumstances. A psychiatric evaluation may be part of this step. The assessment helps clarify which symptoms may be linked to substance use and which need separate attention, and it helps determine the right level of care.
Psychotherapy
Several evidence-based therapy approaches are commonly used in co-occurring treatment:
Motivational interviewing: a collaborative conversation style that helps people explore their own reasons for change, without pressure or confrontation.
Cognitive behavioral therapy (CBT): helps identify triggers, change unhelpful thought patterns, and build coping skills for cravings, stress and low mood.
Dialectical behavior therapy (DBT) skills: focuses on emotional regulation and distress tolerance, which can reduce reliance on substances during difficult moments.
Trauma-informed therapy: recognizes the role trauma can play and addresses it at a pace that feels safe.
Contingency management: uses structured incentives to reinforce recovery goals and has research support for certain substance use disorders.
Psychiatric care and medication
A psychiatrist or psychiatric nurse practitioner may evaluate whether medication could help with mental health symptoms, substance use, or both. FDA-approved medications exist for alcohol use disorder and opioid use disorder, and they are an evidence-based part of treatment for many people. Prescribers also take substance use into account when choosing other psychiatric medications. Decisions about medication are always individualized and made together with the prescriber.
Group support
Groups can reduce isolation, build skills and connect people with others who understand what they are going through. Some groups focus on specific skills, such as relapse prevention or emotional regulation, while others focus on mutual support.
Family involvement
Substance use and mental health conditions affect the whole family. Family sessions can improve communication, rebuild trust, help relatives understand the conditions and set healthy boundaries. Family members often benefit from their own support as well.
Recovery support
Recovery extends beyond symptom reduction to health, stable housing, purpose and community. Treatment plans may include help with practical needs, connection to peer support and planning for how to handle high-risk situations.
Outpatient Care and Other Levels of Care
Many people with co-occurring disorders can be treated in an outpatient setting, where they attend appointments while continuing to live at home, work or go to school. Others need more intensive support for a period of time.
Level of care
What it generally involves
Who it may suit
Outpatient
Scheduled therapy and psychiatric visits, in person or by telehealth
People who are medically stable and safe at home, with support around them
Intensive outpatient or partial hospitalization
Several hours of structured treatment on multiple days each week
People who need more support than weekly visits but do not need 24-hour care
Medically supervised withdrawal
Medical monitoring while the body adjusts to stopping a substance
People at risk of significant withdrawal
Inpatient or residential
24-hour care in a hospital or residential setting
People whose safety, health or symptoms require round-the-clock support
An important safety note: stopping certain substances suddenly, including alcohol, benzodiazepines and opioids, can cause serious withdrawal. Withdrawal from alcohol and benzodiazepines in particular can be medically dangerous. If you are considering cutting down or stopping, talk with a healthcare professional first so withdrawal can be managed safely.
A good outpatient practice will help you understand which level of care fits your situation and, when more intensive care is needed, help with a referral and plan follow-up afterward.
How to Support a Family Member With Co-Occurring Disorders
Watching someone you love struggle with both mental health and substance use can be exhausting, frightening and confusing. You cannot control another person's choices, but your approach can make a real difference to how open they are to help.
What tends to help
Lead with care, not blame. Talk about specific behaviors you have noticed and how you feel, using "I" statements, at a calm moment when the person is not intoxicated.
Learn about both conditions. Understanding how mental health and substance use interact can reduce frustration and help you respond with empathy.
Acknowledge positive steps. Notice and reinforce efforts, however small, such as attending an appointment or cutting back.
Set and keep clear boundaries. Boundaries protect your wellbeing and can encourage change without threats.
Offer practical help. Offer to help research options, make a call together or provide a ride to an appointment.
Take care of yourself. Your own support, whether through therapy, family support groups or trusted friends, matters too.
An evidence-based approach called Community Reinforcement and Family Training (CRAFT) teaches family members communication and reinforcement strategies that can increase the likelihood that a loved one enters treatment, while also improving the family member's own wellbeing. Family-focused therapy can be a good place to learn these skills.
What tends to backfire
Lecturing, shaming or labeling the person.
Confrontational "ultimatum" conversations when emotions are running high.
Covering up consequences in ways that keep the pattern going.
Waiting for the person to "hit rock bottom." Help can start at any point.
Recovery Is Rarely a Straight Line
Recovery from co-occurring disorders often involves progress, setbacks and adjustments. A return to substance use or a resurgence of symptoms does not erase earlier progress or mean that treatment has failed. It is a signal that the plan may need to change, for example by adding support, adjusting medication or addressing a new stressor.
There is also real reason for hope. SAMHSA's 2024 survey found that roughly three in four adults who had ever experienced a substance use problem, and about two in three who had ever experienced a mental health problem, considered themselves to be in recovery or recovered.
Where to Find Help Now
988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org, 24 hours a day, for mental health or substance use crises.
SAMHSA's National Helpline: call 1-800-662-HELP (4357) for free, confidential, 24/7 treatment referral and information.
FindTreatment.gov: SAMHSA's locator for mental health and substance use treatment services in the United States.
911: call if there is an immediate threat to life, such as a suspected overdose.
Moving Forward With Integrated Care
Co-occurring disorders are common, understandable and treatable. When mental health and substance use are addressed together, people do not have to choose which part of their struggle to bring to an appointment. Assessment, therapy, psychiatric care, group support and family involvement can all work as part of one plan built around the person's goals.
Mentalogy's services include substance use treatment, psychiatric care, individual therapy, group support and family services, reflecting Mentalogy's whole-person approach. If you are concerned about yourself or someone you love, you can reach out to Mentalogy to speak with a qualified professional about an assessment that looks at mental health and substance use together. If you are still deciding who to see, our guide to therapist vs. psychiatrist can help you choose a starting point.
Frequently Asked Questions
What is the difference between co-occurring disorders and dual diagnosis?
There is no meaningful difference for most readers. Both terms describe having a mental health condition and a substance use disorder at the same time. "Co-occurring disorders" is the term SAMHSA and many clinicians now prefer.
Which usually comes first, the mental health condition or the substance use?
Either can come first. Some people start using substances to cope with existing symptoms, while others develop mental health symptoms after a period of substance use. Shared risk factors can also lead to both. A careful assessment helps clarify the pattern for each person.
Can co-occurring disorders be treated in an outpatient setting?
Often, yes. Many people receive therapy, psychiatric care and group support on an outpatient basis. People who need medically supervised withdrawal or round-the-clock support may start with a higher level of care and step down to outpatient treatment.
Do I have to stop using substances before getting mental health treatment?
Not usually. Integrated care is designed to address both conditions together. However, stopping some substances suddenly can be dangerous, so speak with a healthcare professional before making changes.
Is medication used to treat co-occurring disorders?
Medication can be part of treatment for some people. There are FDA-approved medications for alcohol use disorder and opioid use disorder, and psychiatric medications may help with mental health symptoms. A prescriber decides with the person what is appropriate.
How can I help a loved one who will not accept treatment?
Focus on calm, caring conversations, reinforce positive steps and set clear boundaries. Approaches such as CRAFT can help family members encourage treatment. Getting support for yourself through therapy or family support groups can also help.
Is relapse a sign that treatment has failed?
No. Setbacks are common in recovery from both mental health and substance use conditions. They usually mean the treatment plan needs adjusting, not that recovery is impossible.
