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Integrated Treatment Guide for Dual Diagnosis of Co-Occurring Mental Health and Substance Use Disorders

Disclaimer: This article is not intended as a substitute for the counsel of a qualified physician or licensed therapist. This content should be used for purely informational purposes. Please consult your doctor if you have further inquiries on this subject. We intend to impart the most accurate and recent information but cannot make any guarantees.

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Substance use disorder is not a modern-day disease. Although it has gone by many names over the centuries, addiction has plagued human society for millennia. The so-called opioid crisis of today has its roots in the opium epidemic that swept across China in the 1700s. Alcoholism has been documented in ancient Egyptian writings as far back as 3000 BC. Yet, despite the problems that addiction has caused for humankind, as well as thousands of studies and research initiatives, no cure has yet been discovered for substance use disorder (SUD).

Within the past few decades, however, a definitive link between mental illness and addictive behaviors has been discovered and studied extensively, making new inroads and progress into the treatment of both conditions.

The term "dual diagnosis" was first coined for co-occurring mental health and substance use disorders in the 1980s. Since then, many different approaches have been used to explore the best way to treat co-occurring disorders. After years of trying and failing to make true progress with dual diagnosis care, comprehensive research has revealed that integrated treatment for co-occurring disorders is by far the most effective in helping to free comorbid patients from the numerous symptoms that make their conditions so difficult to treat.

What is Dual Diagnosis?

The most widely accepted dual diagnosis definition is the occurrence of both a mental health disorder and substance use disorder within the same individual. For centuries, this common occurrence was misdiagnosed because the symptoms of mental illness and severe addiction are often very similar. It was only recently that clinicians began to realize just how prevalent co-occurring disorders actually are, although it is still not understood exactly why the two conditions are so interconnected.

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In some cases, psychological disorders clearly attribute to addiction. For example, studies indicate that people with attention deficit/hyperactivity disorder (ADHD) are more likely than the average person to suffer from addiction. Occasionally, this happens because the stimulant medications prescribed for ADHD can lead to dependence, but there are indications that people with ADHD are also predisposed to develop alcohol use disorder. Evidence like this suggests that personality disorders could make people more susceptible to addiction.

On the other hand, long-term or severe addiction can also attribute to the development of mood disorders. Here are three relevant examples:

  • In the book The Neuroscience of Cocaine, Dr. Victor R. Preedy explores the relationship between long-term cocaine addiction and the emergence of anxiety disorders.
  • Smoking weed has been linked in multiple studies with the onset of psychosis and symptoms of schizophrenia.
  • Opioid usage has a marked effect on the pleasure centers of the brain and has been shown to lead to depression in 10% of patients, according to the Annals of Family MedicineJournal.

As you can see, there is plenty of research into the relationship between SUDs and mental illness. Although direct causality has not been proven in either direction, it is exceedingly clear that the these conditions are intricately connected and interrelated. Since the relationship between the two is so intertwined, it makes sense that they should be treated together and not separately.

Is Dual Diagnosis Common?

Due to centuries of misunderstanding and the misdiagnosis of co-occurring disorders, it has only recently come to light just how prevalent comorbid substance use disorder and mental illness actually is. In fact, the National Survey on Drug Use and Health (NSDUH) found that 45% of those suffering with addiction problems were also diagnosed with a mental health disorder. Some other studies show an even higher occurrence of comorbidity, closer to 60%. Whatever the percentage, the proportion is very high, and it is staggering when you put it into terms of population.

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About 8 million people in the United States suffer from co-occurring mental health and substance abuse, a number that continues to grow with each passing year. What makes this truly alarming is the lack of availability of integrated treatment for dual diagnosis patients. Of the 8 million mentioned above, only 14% will receive appropriate integrated treatment at a dual diagnosis treatment center.

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The Problem with Self-Medication

Self-medication describes any practice in which someone seeks to treat their own illness by self-prescribing medication, alcohol, or other substances. With relation to co-occurring disorders, this would include anyone who tries to reduce the symptoms of their psychological disorders by taking drugs or alcohol.

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One conspicuous example of this type of behavior is someone with social anxiety who drinks alcohol or uses substances to feel more comfortable or secure around other people. There is plenty of research that documents the prevalence of self-medication, such as this study by the Drug and Alcohol Dependence Journal that describes how people suffering from post-traumatic stress disorder (PTSD) self-medicate by drinking alcohol and smoking cigarettes in unhealthy quantities. When questioned, those who engage in this type of behavior sometimes don"t even realize that they"re self-medicating.

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The Dangers of Self-Medicating

Whether it"s through the use of drugs or alcohol, or simply someone who takes antibiotics without a doctor"s prescription, self-diagnosing and self-medicating can have long-lasting health implications. Here are some of the risks of self-medication:

  • Forming dangerous addictions
  • Potentially compounding symptoms of mental disorders
  • Concealing symptoms of serious mental health conditions
  • Dangerous interactions and side effects with psychiatric drugs
  • Legal, social, or otherwise negative consequences of abusing illicit substances
  • Possibility of developing suicidal tendencies
  • Overdose

How to Identify the Symptoms of Mood Disorders and Mental Illness

There are hundreds of different types of mental illness, personality disorders, and mood disorders. We can"t cover them all in this article, but we can go over some of the mental disorders that most commonly interact with substance addiction:

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  • Bipolar disorder - interchanging spells of euphoric, energetic mania and sudden shifts to major depression and despondency
  • Anxiety disorder - turbulent stress and physical anxiety in response to incongruous stimuli
  • Depression or depressive disorder - long intervals of despair, fatigue, and/or hopelessness for periods longer than two weeks
  • Dysthymia - major depression that lasts for two years or more
  • Seasonal affective disorder - depression that emerges during the seasons when the days are shorter and the weather is gloomy
  • Mania - a period of hyperactivity, vigorous energy, intensity, and sometimes euphoria or irritability
  • Psychosis - altered awareness or distorted thinking, such as hallucinations or imagined voices
  • Schizophrenia - periods of psychosis, as well as extreme paranoia and complex delusions
  • Paranoid personality disorder - odd or eccentric thinking patterns, such as paranoia and distrust of others
  • Obsessive-compulsive disorder - unusual or unmanageable obsessions and rituals  
  • Post-traumatic stress disorder - develops after a disturbing event; usually involves terrifying memories and flashbacks
  • Antisocial personality disorder - a marked discompassion and lack of respect or regard for other people or their rights and feelings
  • Dissociative disorder - disconnection between memory, thoughts, reality, and consciousness
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Warning Signs of Mental Illness

The signs and symptoms of mental illness vary greatly from one disorder to another, of course; but there are some general warning signs to look for if you are concerned that you or someone you know may have a mental health condition:

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  • Inability to cope with stressful situations
  • Visions or hallucinations
  • Suicidal tendencies
  • Sudden changes in libido
  • Extreme paranoia, fear, or guilt
  • Retreat from family, friends, and social situations
  • Lack of ability or effort to empathize, understand, and relate with other people
  • Unexplained fatigue or insomnia
  • Unusual changes in eating habits
  • Long-lasting feelings of desolation and melancholy
  • Sudden irritability, anger, or violence
  • Confusion and bewilderment
  • Extreme mood swings
  • Regular drug or alcohol abuse

Co-occurring Disorders and Polydrug Abuse

Just as mental health disorders often coincide with addictive behaviors, polydrug abuse is also more likely among people with mental illness. To find out how prevalent these patterns were, researchers at the Mental Health and Substance Use Journal studied 117 patients at various drug rehab facilities and found the following results:

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  • 54% of all patients in the study were polydrug addicts, and 47% of the patients were also diagnosed with a mental health disorder.
  • Mental illness was present in 59% of patients who engaged in polydrug abuse, as opposed to only 33% of single drug users.
  • The rate of treatment program dropout for both patients with polydrug addiction as well as those with mental health conditions were much higher than the average dropout rates for other patients.
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As you can see, a majority of the patients who engaged in polysubstance abuse were diagnosed with comorbid mental disorders, and this fact is shown to be true in other studies and surveys as well. Polydrug abuse, like mental illness, makes drug rehabilitation more difficult for patients to complete. Findings like these demonstrate the importance of developing specialized programs to treat comorbid patients in an integrated and comprehensive fashion.

Common Co-Occurring Disorders

Depression and Addiction

The most common of all co occurring disorders, depression and substance abuse go hand-in-hand. Although heroin and alcohol are often the drugs of choice for people with depressive disorder, many other substances are also used in conjunction with depression. The reason why is simple; the euphoric effects of illicit substances can temporarily relieve the feelings of sadness and despair that are associated with depression. Any substance that provides a pleasurable high may be used to self-medicate the symptoms of depression, but the benefits are both short-lived and disastrous.

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Any type of substance abuse is extremely detrimental to someone suffering from depression since substances tend to make the symptoms of depression markedly worse over time. The combination of drugs and depression is a recipe for failure, leading to addiction, desperation, and sometimes suicide.

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Antidepressants can greatly improve the symptoms of depressive disorder and may also be helpful during addiction recovery, but they should not be mixed with drugs or alcohol.

Anxiety Disorders and Cocaine Abuse

The powerful, energetic high associated with cocaine use can be an intoxicating temptation for people who suffer from the fear and worry of anxiety disorders. Coke is often abused by people with anxiety since it can provide temporary relief from stressful feelings. Once again, this is a vicious cycle that only intensifies the mental condition.

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The sudden and severe come-down after a cocaine binge only increases feelings of anxiety and stress, making the symptoms of anxiety disorders much worse. If the abuse continues, cocaine addiction can have long-term effects on the psyche. This consequence is so common, in fact, that some doctors attribute post-addiction anxiety diagnoses to cocaine abuse.

Alcohol and Antisocial Personality Disorder

Antisocial Personality Disorder (ASPD) is a serious psychological condition that often destroys the social life and relationships of those who suffer from it. Unfortunately, it is also one of the most difficult personality disorders to treat, even more so if the condition coincides with alcohol use disorder.

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It is thought that people with ASPD tend to drink heavily because alcohol seems to improve their social skills and makes them feel temporarily empathetic with those around them. Research shows that as many as 90% of people who suffer from ASPD also suffer from substance use disorder, with the most prevalent substance listed as alcohol.

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One of the most concerning characteristics of comorbid ASPD and SUD is that patients who suffer from both will most likely refuse treatment unless legally obligated. It is also much more difficult for them to finish any type of rehabilitation program successfully. However, certain treatments such as integrated counseling and cognitive behavioral therapy have been shown to be effective in cases such as these.

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Opioids and Post-Traumatic Stress Disorder (PTSD)

PTSD can have a dramatic effect on memory pathways in the brain, affecting how traumatic memories are processed and recalled. For some reason that is not completely clear, these changes to memory pathways also seem to make people with PTSD more susceptible to the pleasurable effects of dopamine. This could be why opioid addiction and PTSD are so commonly diagnosed together.

One challenge to the treatment of PTSD and addiction comorbidity is that the symptoms of each condition are often confused and misdiagnosed. The symptoms of opioid addiction and PTSD are so similar that clinicians often confuse the two and misdiagnose one or the other.

Despite dual diagnosis challenges, opioid replacement therapy (ORT) has been shown to be effective in reducing the symptoms of PTSD while also helping comorbid patients wean themselves off of opioids at the same time.

Benzodiazepines and Panic Disorder

Benzodiazepines (benzos) are the most commonly prescribed medications to treat panic disorder, so it is not hard to see how a daily medication could come to be abused, establishing an addiction over time.

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If a patient begins to abuse a prescription to benzos, tolerance will build up quickly, creating a dangerous dependence that can lead to overdose. Once a patient has become addicted to benzos, they will need to detox from the drugs completely in order to begin recovery. In these cases, clinicians will try alternative medications and integrated treatment plans to improve the symptoms of panic disorder as well as Benzodiazepine use disorder.

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Schizophrenia and Cannabis (Marijuana)

It"s established in the medical community that people with schizophrenia enjoy smoking marijuana. Researchers at the Henquet of Maastricht University Medical Center in the Netherlands claim that schizophrenic patients enjoy the effects of marijuana more than the average person, feeling an amplified psychoactive influence after smoking weed.

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Unfortunately, cannabis has also been consistently linked with increased schizophrenic symptoms and psychosis. By smoking or ingesting weed, people with schizophrenia are actually intensifying their own symptoms and mental illness. Doctors generally recommend that anyone with psychotic tendencies or a family history of mental illness should avoid cannabis in any form.

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Cannabis and Obsessive-Compulsive Disorder (OCD)

There is a positive correlation between cannabis use and the severity of obsessive-compulsive symptoms in patients. The more severe the symptoms, the more weed is smoked by the patient, on average.

The use of relaxing drugs like marijuana can temporarily soothe some symptoms of OCD but also presents risk of addiction, as well as a risk of using other more dangerous substances as the addictive behaviors progress.

Cocaine and Alcohol with Bipolar Disorder

Bipolar disorder is already a cycle of extreme ups and downs that can be difficult to manage without the complications presented by substance abuse. Unfortunately, substance abuse is commonly associated with bipolar disorder, since patients try to compensate during a high or low period by self-medicating with different drugs.

For example, during a manic phase, the patient might drink alcohol or consume other "downers" in an attempt to mellow out, while cocaine or "uppers" might be taken during a depressive phase. Although these substances can provide some temporarily relief, drug use also exacerbates the symptoms of bipolar disorder and can prolong or intensify manic or depressive phases.

There are a variety of psychiatric medications that can be used as medically assisted treatment during integrated care for comorbid bipolar and substance use disorders, but they must be carefully monitored by a licensed physician.

Attention Deficit and Hyperactivity Disorder (ADHD) and Stimulants

Similar to benzos and anxiety disorders, the prescription stimulants used to treat symptoms of ADHD also present a possibility of abuse. Although medications like Adderall and Ritalin are not necessarily addictive as prescribed, they are often abused by adolescents and college-aged individuals.

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Whether they are used as "study aids" or as a way for young party-goers to keep the party going all night long, when stimulants are abused they present a marked risk of addiction. In one survey, 60% of college students admitted to abusing their ADHD prescriptions by taking too much of the medications or using them too often. Of those, 30% went on to use harder stimulants like cocaine.

The challenge for clinicians helping ADHD patients to kick their stimulant habit is to treat the symptoms of ADHD with non-stimulant medications. Fortunately, some other types of therapy are also effective in treating both conditions, some of which we"ll go into below.

Why Is Diagnosing a Co-Occuring Disorder so Difficult?

It took centuries for the medical community to recognize the close relationship between addiction and mental health, but not for lack of expertise. The fact is, comorbid disorders can be exceedingly difficult to spot and diagnose.

The symptoms of long-term drug abuse and mental illness are often very similar. Since the two are usually interconnected, they create a complicated latticework within the mind and behaviors of those who have them. It may be hard for doctors to understand where one condition ends and the other begins.

An example of this phenomenon is a patient who has long abused psychoactive or hallucinogenic substances. This patient may exhibit many symptoms of psychosis or schizophrenia. Heavy stimulant use is another example, since it can create many of the same symptoms as anxiety or mood disorders.

The degradations that long-term drug abuse, sleep deprivation, and withdrawal symptoms carry out on the mind and body can make dual diagnosis nearly impossible in some cases. When this happens, clinicians will often wait until the drug detox phase is complete before making a final diagnosis about mental health.

Should Co-Occurring Disorders Be Treated Differently?

One of the most important and consistent findings within dual diagnosis research is the conclusion that traditional drug rehab methods do not work as well for comorbid patients. The symptoms of mental health disorders make the recovery process even more difficult, partly due to the fact that drug withdrawal symptoms are also worse in patients with co-occurring disorders.

Another factor is that many patients who present for substance abuse rehabilitation have never received a formal diagnosis for their mental health problems and so don"t know to ask for specialized treatment. Yet, in some cases, the mental illness is what caused the addictive behaviors in the first place. It is unreasonable to assume that treating the addiction without treating its cause could ever be effective.

If every drug treatment facility began formally examining and screening patients for dual diagnoses upon admission, less comorbid patients would fall through the cracks and fail treatment because of it. Integrated treatment for co-occurring disorders is vitally important in order to reduce dropout rates and provide each individual with the tools they need to achieve sobriety and mental stability.

How Are Dual Diagnoses Treated?

Integrated treatment for dual diagnosis is an individualized treatment plan that addresses both mental health disorders and addiction at the same time. It is a comprehensive approach that uses a variety of therapy methods to treat all of a comorbid patient"s symptoms, both those symptoms caused by mental health conditions and also those caused by substance abuse. This level of care requires a versatile team of psychiatrists, medical professionals, counselors, and support staff that can meet all of the potential needs of a patient suffering from co-occurring disorders.

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Fortunately, drug rehabilitation centers across the country have been making great progress in developing integrated treatment programs since the Substance Abuse and Mental Health Services Administration (SAMHSA) began sponsoring COSIG grants in 2006. This initiative has been instrumental in helping hundreds of drug treatment facilities make the transition into full-service integrated drug and alcohol treatment centers.

Medications to Treat Co-Occurring Mental Illness and SUD

Medically Assisted Treatment (MAT) is especially important to integrated treatment programs, since controlling the symptoms of mental illness is necessary in order to effectively begin drug rehab therapy. The types of medications used vary greatly according to the kind of mental disorder the patient has and which substances they have abused in the past.

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For example, antidepressants or anti-anxiety medications can help to reduce symptoms of personality or mood disorders while a patient is going through medical detox for drugs or alcohol. Opioid replacement therapy for opioid addiction may also be combined with certain psychiatric medications to help wean a patient off of drugs while helping to balance out psychotic symptoms at the same time.

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Combining different medications is a very tricky process however. MAT during dual-diagnosis treatment must be carefully monitored by a medical doctor in order to detect potentially dangerous drug interactions or side effects.

Cognitive Behavioral Therapy to Treat Mental Health Disorders and Addictions

Cognitive Behavioral Therapy (CBT) is considered a cornerstone of integrated treatment. Effective for both mental health disorders and substance use disorders, CBT is the process of exploring a patient"s thought patterns, behaviors, and conceptions in order to identify harmful, self-destructive, or otherwise unhealthy thinking patterns.

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Once these harmful thought patterns have been identified, therapists can work with the patient to restructure and reorganize their concepts and behaviors into a healthier, more logical way of thinking and behaving. CBT can be used to address both mental illness and addiction at the same time.

Contingency Management

Contingency management is a rewards-based system that lends an extra level of encouragement and enthusiasm to the difficult process of recovery. Basically a grown-up version of a sticker chart, a contingency management program works by providing sought-after rewards to patients for completing each phase of treatment.

When a certain phase of treatment is completed or another week of sobriety accomplished, the patient will be given a gift voucher, cash reward, or other coveted prize. As simple as it sounds, the system works. Contingency management has exhibited great success in drug treatment programs and is now being proven effective during integrated treatment as well. One study even showed dual diagnosis completion rates improving by 50% under a contingency management program.

Motivational Enhancement Therapy

Motivational enhancement therapy is a counseling protocol that helps comorbid patients find their "why". Through guided self-exploration, the patient is given the opportunity to dig deep into their own psyche to discover the wants and needs that truly motivate them to become sober and healthy.

Since completion rates for patients with co-occurring disorders are so low, this type of counseling can be beneficial for those considering dropout. It also helps patients to identify their true priorities and goals outside of achieving sobriety, giving them added determination to succeed.

Holistic Treatment

Holistic therapy is an important tool to promote whole-self healing of the mind, body, and, soul. Relaxation techniques like yoga and meditation can be especially beneficial to dual diagnosis patients since these exercises help to calm the mind as well as the body as they go through treatment.

Holistic solutions are also an important building block for the future, focusing on health and wellness while promoting healthy lifestyle choices for moving forward.

How Can You Tell if You Have a Problem with Drugs or Alcohol?

This is a common question about recreational substance use. In most cases, if you have to ask the question, it could be a problem. If you"re wondering whether or not you or a friend is abusing drugs or alcohol, use the indicators below as an example. Someone with a serious substance abuse problem may:

  • Lie to people about their substance use habits
  • Neglect responsibilities or social outings because of alcohol or drugs
  • Use or drink to the point that they "black out" or suffer short-term memory losses
  • Experience guilt or shame in regards to drug or alcohol use
  • Have legal problems or fines associated with drug or alcohol use
  • Use during dangerous situations, such as before driving or swimming
  • Drink or use more than they intended to
  • Seem to lose control of how much of a substance they consume
  • Feel the need to use or drink in order to "wind down" or feel relaxed

To put it simply, if you notice that alcohol or drugs are causing problems within your daily life, substance use has gone too far. If you have tried to quit or cut back your drug abuse only to find that you were unable to, it is definitely time to ask for help. Substance abuse is a dangerous cycle that has ruined millions of lives. Find the help you need before it ruins yours.

How Do You Quit Using Drugs and Drinking?

Once you"ve reached the point where you mind and body are dependent on drugs or alcohol, quitting will be no easy undertaking. Dependence is another word for addiction, and it means that your brain has reached the point that it can no longer function normally and naturally without the influence of outside substances. Once addiction sets in, you will not be able to quit using without feeling the effects of alcohol or drug withdrawal.

Drug withdrawal is a difficult and dangerous process in and of itself, and it"s one of the main reasons for relapse. The problem with trying and failing to get through the detox stage is that relapse presents a high risk of overdose. Other risks associated with drug withdrawal are dehydration, delirium tremens (for alcoholics), and suicide, to name a few. All of these factors can attribute to high relapse rates and failure to achieve sobriety. This is where drug treatment comes in.

Alcohol and drug rehab facilities offer a wide range of services, therapies, and activities to ease and facilitate the withdrawal process and improve long-term recovery rates. Even after drug detox is over, learning to live a healthy, sober lifestyle will require hard work, counseling, and constant dedication. A professional drug rehab center can provide all those tools and more to help you recover and stay sober for the long-term.

Indicators of a Co-Occurring Disorder

If you"re still reading, it"s likely that you or a loved one is showing symptoms of a co-occurring mental health and substance use disorder. Although the symptoms will vary widely from one person to another and between different types of mood disorders, there are some general warning signs to look for if you suspect a co-occurring disorder:

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  • Disregarding hygiene and healthy habits
  • Deteriorating performance at school or work
  • Extreme changes in behavior and moods
  • Alarming or erratic behavior
  • An inability to keep up with daily responsibilities and everyday tasks
  • Difficulty managing money and finances
  • An inability to comply with drug treatment, counseling, or other therapeutic programs
  • Suicidal thoughts or tendencies
  • Apparent cognitive changes or deficits
  • A sudden or unexpected aversion to social situations and planned activities

How Much Does Integrated Treatment Cost?

The first question most patients ask when calling an integrated drug and alcohol treatment center is "How much does it cost?" This is not always a simple question to answer, however. The cost of integrated treatment is rarely free, but it is sometimes covered by health insurance. Always contact your health insurance provider first to find out what kind of coverage they offer for drug and alcohol treatment.

Other factors that influence the cost of dual diagnosis drug rehab are type of treatment, length of program, and the cost of medications. Since an integrated treatment program will be adapted and individualized according to which type of comorbidity you suffer from, the best way to investigate the final out-of-pocket cost is to call the facility"s addiction hotline for an initial consultation.

How to Find Help for Dual Diagnosis

Comorbid mental illness and drug addiction is a troubling dual diagnosis. If you or someone you know is suffering from comorbid disorders, you will likely need professional help to balance out the symptoms and establish a stable, healthy lifestyle. This type of condition will usually deteriorate with time, so don"t wait any longer.

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