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Co-occurring disorders are defined as the occurrence of two disorders or illnesses in the same person. Although, this term can refer to any combination of disorders and diseases, it often is used to describe someone who suffers from another psychiatric illness (e.g., major depression) in addition to a substance use disorder.

Symptoms may interact between conditions to influence the course and prognosis of both disorders. Also referred to as having co-occurring conditions or “dual diagnosis.”

Approximately 8.1 million adults in the U.S. have co-occurring disorders. This constitutes more than 40% of those with substance use disorder (2015 NSDUH)

“It is often difficult to disentangle the overlapping symptoms of drug addiction and other mental illnesses, making diagnosis and treatment complex.” – Nora Volkow, Director of the National Institute on Drug Abuse

Individuals diagnosed with a substance use disorder are twice as likely to suffer from a mood or anxiety disorder, antisocial personality disorder or conduct disorder compared to the general population. Other psychiatric disorders commonly seen in combination with substance use disorder include: Schizophrenia, Post-traumatic Stress Disorder (PTSD), Bipolar Disorder, and Attention-Deficit Hyperactive Disorder (ADHD).

NESARC DATA REPORTS CURRENT (within the last 12 months)


Individuals with drug use disorder:

44% have personality disorders

28% have mood disorders

24% have anxiety disorders

Individuals with alcohol use disorder:

25% have personality disorders 16% have mood disorders

16% have anxiety disorders

Individuals with both drug and alcohol use disorders:

51% have personality disorders

35% have mood disorders

27% have anxiety disorders

46% have post-traumatic stress disorder



Substance use may lead to the onset of symptoms of another mental illness. Substance use can also cause symptoms that look like symptoms of mental illness but once abstinent the person no longer suffers from those symptoms (often referred to as “substance-induced” symptoms). Mental illness may also precede and lead to substance use, as a method of self-medication, to alleviate symptoms such as anxiety, depression, and discomfort.


Genetic Factors: Genetic vulnerabilities may increase the likelihood of development of both a substance use disorder and other mental illness. Also, substance exposure may act as an epigenetic factor, in that it may activate and turn on genes associated with mental illness that would not otherwise be turned on were it not for the substance exposure.Environmental Factors:Trauma (e.g., physical or sexual abuse; military combat), other stress, or childhood/adolescent exposure to substance use, may increase susceptibility to both substance use disorder and other mental illness.Developmental Factors:Substance use disorder and other mental illness often surface during adolescence and young adulthood, when the brain experiences dramatic developmental change. Early exposure to substance use may affect brain development, increasing risk for mental illness, and visa-versa.

Findings from a 2009 SAMHSA scientific literature review found that co-occurring disorders are best treated with a comprehensive, long-term, staged (e.g. stages of treatment) approach to recovery; assertive outreach as opposed to more passive clinical approaches; person-centered motivational interventions; help clients acquire skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence.


Lack of healthcare providers trained in treating both substance use disorder and other mental illness in an integrated way.Policy barriers that limit the functional integration of substance use and mental health services (e.g. organizational structure, financing, regulations, and licensing).Lack of clear service models, administrative guidelines, contractual incentives, quality assurance procedures, and outcome measures need for treatment programs to effectively implement co-occurring interventions in treatment programs.Stigma associated with both substance use disorder and mental illness.Basic interventions treating co-occurring conditions are not always incorporated into the mental health programs in which patients receive care (SAMHSA, 2009).


In 2016, according to National Survey of Substance Abuse Treatment Services data, 47% of addiction treatment facilities in the United States reported providing programs and groups specifically tailored towards patients with substance use and co-occurring mental disorders.

Research has found that regular substance use disorder treatment programing, such as cognitive behavioral therapy, is known to improve the psychological functioning of patients with co-occurring disorders at similar rates to psychiatrically-integrated or co-occurring-specific treatment approaches (McGovern et al., 2015; Bergman et al., 2014; Brown et. Al, 1997; Leon & Jainchill, 1982). Some of these co-occurring specific treatment approaches are listed in more detail below.


Integrated Dual Disorder Treatment (IDDT) is a multidisciplinary intervention that combines pharmacological (e.g. medication), psychological, educational, and social mechanisms to promote recovery for individuals with co-occurring disorders.Core treatment components of IDDT includeSeeking Safety is an evidence-based, integrated counseling model for individuals with trauma and substance use disorder that incorporated, but does not require patients to disclose their trauma narrative. Key principles of the model include gaining safety, focusing on ideals, and attention to cognitive, behavioral, interpersonal, and case management.Integrated Group Therapy (IGT) is an evidence-based providing treatment for adults with co-occurring bipolar and substance use disorders. IGT emphasizes abstinence from alcohol and other drugs, and centers on improving symptom recognition for substance use and mood, skill training for relapse prevention and life functioning, and medication adherence.

Guide: 11 Indicators of Quality Addiction Treatment

How to identify high-quality addiction treatment programs.

With thousands of programs and rehabs to choose from, it can be challenging to assess which addiction treatment programs offer the highest quality of care.

Finding the right treatment facility is all too important, given the time, money, and energy that substance use disorder treatment and recovery requires of not only the individual, but the entire family.

Research has identified elements that quality substance use disorder treatment facilities should possess. These range from personalized treatments, to national accreditation, to assertive linkages to continuing care.

The experts at the Recovery Research Institute have compiled a comprehensive list of 11 indicators of effective treatment, as a blueprint to help guide you or your loved one to high-quality addiction treatment, maximizing your recovery success.

The 11 Indicators of Quality Addiction Treatment:

1. Assessment and Treatment Matching (Identify)

Finding effective help for an alcohol or other drug use disorder begins with reliable and valid screening for a range of substance use disorders and related conditions, as well as any physical or mental health conditions. This is followed by more comprehensive assessment of substance use history and related disorders, medical history, psychiatric history, individual’s family and social networks, and assessment of available recovery resources (“recovery capital”). These endeavors help uncover the many interrelated factors affecting the patient’s functioning and life and assess a patient’s readiness to change. This careful and comprehensive assessment can help prevent missing aspects or minimizing important aspects of a person’s life, such as trauma or chronic pain, inattention to which could compromise recovery success.

2. Comprehensive, Integrated Treatment Approach (Treat)

As discussed above, patients in treatment may have co-occurring psychiatric disorders, like depression and anxiety, as well as other medical problems like hepatitis C, alcoholic liver disease, or sexually transmitted diseases. Programs should incorporate comprehensive approaches that directly address these additional concerns, or otherwise assertively link patients to needed services. Treating the whole patient, will improve the likelihood of substance use disorder recovery and remission.

3. Emphasis and assertive linkage to subsequent phases of treatment and recovery support       


Continuing care is defined as the ‘ongoing care of patients suffering from chronic incapacitating illness or disease.’ Ongoing care provides essential recovery-specific social support and necessary recovery support services after the patient leaves or transitions away from the initial phase of treatment. Programs that strongly emphasize this continuing care aspect will provide more than just phone numbers or a list of people to call, but instead, will provide assertive linkages to community resources, on-going health care providers, peer-support groups, and recovery residences. This ‘warm hand-off’ or personalized introduction to potential peers and resources in the recovery community, produces substantially better outcomes.

4. A dignified, Respectful, Environment

The treatment program should possess at least the same type of quality environment as one might see in other medical environments (e.g., oncology or diabetes care). You don’t need palm trees and luxury mattresses, but you should expect a clean, bright, cheerful, and comfortable facility. It is important that the program treats substance use disorders with the same professionalism and allocates similar resources for patient care as other chronic conditions. Creating a respectful and dignified environment may be particularly important for addiction patients, because those suffering from substance use disorders often feel as if they’ve lost their self-respect and dignity. A respectful environment helps them regain it.

5. Significant Other and/or Family Involvement in Treatment

Engaging significant others and loved ones in treatment increases the likelihood that the patient will stay in treatment and that treatment gains will be sustained after treatment has ended. Techniques to clarify family roles, reframe behavior, teach management skills, encourage monitoring and boundary setting, re-intervention plans, and help them access community services all help strengthen the entire family system and help family members cope with, and adapt to, the family system changes that occur in recovery.

6. Employ strategies to Help Engage and Retain Patients in Treatment

Dropout from addiction within the first month of care is around 50% nationally. Dropout leads to worse outcomes, so it is vital to employ strategies to enhance engagement and retention. These include creating an atmosphere of mutual trust through clear communication and transparency of program rules, regulations, and expectations. Treatment programs can also work to retain patients by providing client-centered, empathic, counseling that works to build strong patient-provider relationships. They also can use motivational incentives to reward patients for continued attendance and abstinence.

7. Use of Evidence-based and Evidence-informed Practices

Programs that deliver services founded on scientific research and principles and that are delivering the available “best practices” tend to have better outcomes. In addition to psychological interventions, these should include accessibility to FDA approved medications for addiction (e.g., buprenorphine/naloxone, methadone, naltrexone/depot naltrexone, acomprosate) as well as psychotropic medication for other types of psychiatric conditions (e.g., SSRIs etc.). This is typically combined with qualified staff (see below).

8. Qualified Staff, Ongoing Training, and Adequate Staff Supervision

Having multi-disciplinary staff (e.g., addiction, medicine, psychiatry, spirituality) can help patients uncover and address a broad array of needs that can aid addiction recovery and improve functioning and psychological wellbeing. Staff with graduate degrees, and adequate licensing or board certification in these specialty areas are indicators of higher quality programs. In addition, clinical supervision and team meetings should take place at least once or twice a week for outpatient programs and three to five times a week for residential and inpatient programs.

9. Personalized Approaches that include Specialized Populations, Gender and Cultural Competence

Stemming from individualized comprehensive screening and assessment, programs should treat all patients as individuals attending to their needs accordingly. One size does not fit all, and neither does one treatment approach work for every individual. High-quality treatment programs identify the potentially different needs of men and women, adolescents versus adults, and those from different minority communities (e.g. LGBT) or cultural backgrounds, creating in turn, treatment and recovery plans that address their specific needs and acknowledge their available strengths and recovery resources.

10. Measurement of Program Performance Including During-treatment “Outcomes”

A further indicator of quality treatment is having reliable, valid measurement systems in place to track patients’ response to treatment. Similar to regular assessment of blood pressure at each check-up in treating hypertension, addiction treatment programs should collect “addiction and mental health vital signs” in order to monitor the effectiveness or ineffectiveness of the individualized treatment plan and adjust it accordingly when needed. Without any kind of standardized metrics, it is difficult to document and demonstrate patients’ progress.

11. External Accreditation from Nationally Recognized Quality Monitoring Agencies           


Accreditation from external regulatory organizations such as the Joint Commission on Accreditation of Healthcare organizations (JCAHO; aka “the Joint Commission”), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Council on Accreditation (COA); and other programs licensed by the state are required to offer minimum levels of evidence-based care. These licensing and accreditation requirements serve as quality assurance that the treatment program is incorporating a certain level of evidence-based care in its model and is open to random audit of its clinical care.

November 29, 2019: National director of the Hazelden Betty Ford Children's Program helped the TV show's creators reach out to kids who suffer because of their parents' disease.

Move over, Elmo; Karli has arrived on Sesame Street, and her mom is struggling with addiction.

In another bold stroke for the beloved children’s show, the nonprofit Sesame Workshop launched Karli‘s complicated story online in October. The fuzzy green monster, age 6 1/2, is in foster care as her mother works toward recovery, and wrestles with her own powerful feelings of isolation, fear, shame and guilt, much like the 5.7 million children under age 11 who live with parents struggling with substance abuse disorder.

With the loving support of Elmo, other Muppets and a few humans, Karli learns that she’s not alone, that she’ll be cared for, and that addiction is a sickness where people need help to get better.

Jerry Moe is, in a way, one of Karli’s creators.

Moe is national director of Hazelden Betty Ford Children’s Program, and an advisory board member for the National Association for Children of Alcoholics. Last year, while in the Minneapolis-St. Paul airport, Moe got an unexpected text: “The people at Sesame Street want to talk to you.”

Moe — who spoke this month in Anaheim, at the California Community Opioid Crisis — had one thought: “Who’s scamming me?” Nobody, it turned out. Moe has an expertise that Sesame Street wanted to tap. The author of “Through a Child’s Eyes: Understanding Addiction and Recovery” also is the creator of created the Seven C’s, a healing program for children:

“I didn’t cause addiction. I can’t control addiction. I can’t cure addiction. But I can help take care of myself, by communicating feelings, making healthy choices and celebrating me.”

It’s a mantra for children, like Karli, whose parents are controlled by addiction. And the work clearly struck a chord with the creatives at Sesame Street. Karli’s story incorporates much of Moe’s work.

While some have criticized Sesame Street’s effort, saying the show’s viewers — typically ages 3 to 5 — are too young to be exposed to the life and death theme of addiction, Moe believes those kids need the support.

Once, he was one of them.

“One of every three or four kids out there is growing up loving someone who has addiction,” Moe said. “When you think about opioid or meth or alcohol addiction, you don’t think about kids. But children are the first hurt and last helped. It’s a population we don’t give enough attention.”

Soon after the call, Moe became an adviser to Sesame Street. It’s something he calls “bucket-list stuff for me.”

“We really got to guide the process, sit with them and talk about what language to use,” Moe said.

The overall vibe, he added, was thrilling.

“Being on the set of Sesame Street, hanging out with Elmo, trying to be this mature adult who’s a children’s counselor, (was) an unbelievable feeling. Chills.”

Throwing rocks

At the famous Betty Ford Center in Rancho Mirage, Moe runs four-day workshops for kids caught in addiction’s web. It’s open to all kids, he said; they don’t need to have a parent in treatment to attend. And Mrs. Ford set up financial accounts to ensure that no child would be turned away for lack of funds.

They start by playing — tossing a koosh ball on a string, colorfully decorating folders, sticking pins in a map of the United States as a fun way to see how far some of the kids have traveled to be there. Then they talk.

Everyone there has been hurt by a loved one’s drinking and drug use.

Counselors try to help the kids separate the people they love from the disease that consumes them. To do that, they use metaphors that kids can understand: People, even parents, can get hooked like a fish and can’t get away. And being hooked is like getting gum stuck in their hair; now they need help to get it out.

There’s a backpack filled with 41 pounds of small rocks, each painted with a word: “Hurt.” “Guilt.” “Shame.” “Fighting.” “Abuse.” The kids urged to try to lift the backpack to feel its heft. Their parents, the kids are told, are carrying this. Some start drinking and using drugs because they don’t know how to get rid of it. And at first, the drinking or the drugs puts the bag to sleep. But when that feeling wears off, the grownup has to pick up the bag again — only now it weighs more.

The kids are encouraged to talk about how it can hurt to have an addicted parent — the broken promises, fighting, chaos, disappointment.

“Because of the chaos and uncertainty you’ve been living through, you’ve got your own bag of rocks,” they’re told. They’re asked to take the rocks out of their bags, releasing the sadness, anger and fear they’ve been carrying.

The older kids also are warned that addiction runs in families, and the only way to be certain they won’t get trapped is to never smoke, drink, or use drugs.

Parents and grandparents participate the last two days. The kids can say “I love you… I don’t want you to die.”

The program gets referrals from the child welfare system, from the courts, from other treatment programs. Anyone interested can call 760-773-4291 for more information.

Moe puts it simply: “The only difference between the kids and their parents or grandparents is that those adults are yesterday’s kids that nobody helped.”

California reboot

Officials from Hazelden Betty Ford have been pushing California to tighten up its notoriously lax regulation of the addiction treatment industry, where success — and failure — trickles down to kids.

A year ago, in a five-part series of news stories, the Southern California News Group probed the links between addiction and the child welfare system. It found that while California social service agencies see addiction as a contributing factor to just 12 percent of the state’s child welfare cases, the reality is that addiction is key to as much as 80 percent of those cases, according to several studies and child welfare experts.

Moe was hired by the state of South Carolina as a consultant more than 20 years ago. They worked with a Madison Avenue advertising firm that created the public campaign, “Alcohol abuse. Drug abuse. Child abuse. One thing often leads to another.” California, Moe suggested, might do well to follow that example.

“Just as social welfare needs to ask that question — “Is there an issue of substance use disorder in the family?” — we always have to ask the question, ‘What about child maltreatment?’ We know those two things go together,” he said.

The Sesame Street initiative on this topic is an enormous leap forward, he said. In addition to Karli, it includes articles on how can professionals help these children, how parents can start rebuilding trust, as well as storybooks and interactive coloring.

But right now, Karli’s story unfolds on the online version of “Sesame Street,” not on the TV program piped into millions of homes.

“My hope is that, somewhere down the line, the character can be on the air,” Moe said. “That has been a dream of mine from the beginning.”

But as everyone involved with addiction well knows, it’s one step at a time.