What Families Should Know About Co-Occurring Disorders

When you can’t tell what your loved one is struggling with, it’s hard to know how to help!

In many families, alcohol or drug use gets most of the attention, while months of low mood, panic, or sleepless nights go unnoticed. Those symptoms matter because some people turn to alcohol or drugs to cope with distress.

When a mental health condition and a substance use disorder occur together, clinicians call them co-occurring disorders. SAMHSA’s 2025 national survey found that 18.5 million U.S. adults had both a mental illness and a substance use disorder. About 2 in 5 received no treatment for either condition, leaving their mental health and substance use needs unaddressed.

At home, that combination can take very different forms: a daughter may drink to calm panic attacks, while a father may start misusing painkillers after depression sets in. In either case, focusing on only one condition can leave the other unaddressed.

That’s why dual diagnosis treatment focuses on both mental health and substance use, rather than addressing substance use alone.

This guide explains what co-occurring disorders are, why they can occur together, and five signs that your loved one may be struggling with both. It also covers common pairings, how these conditions affect the whole family, and how Cholla Behavioral Health in Phoenix treats both conditions in one plan.

What Are Co-Occurring Disorders?

Co-occurring disorders are conditions in which a person has both a mental health disorder and a substance use disorder. The mental health condition could be depression, anxiety, or bipolar disorder. The substance use disorder would be drinking or drug use, which is difficult to control and/or continues despite the negative consequences.

The two conditions can influence each other over time, which in turn makes diagnosis and treatment more complicated. The NIAAA states that individuals with alcohol use disorder and a co-existing psychiatric disorder are more likely to return to drinking and are more likely to have worse psychiatric symptoms. It can be difficult to identify both conditions as there is some overlap in the symptoms (sleep disturbance and irritability, for instance, can be associated with depression or can be part of the picture during alcohol intoxication and withdrawal). Looking at when symptoms began and whether they persist during extended periods without alcohol can help clinicians distinguish a separate mental health condition from alcohol-related symptoms.

At Cholla Behavioral Health, each client admitted to the program completes a comprehensive biopsychosocial and diagnostic assessment. The assessment considers physical health, mental health, substance use, and life circumstances. If further diagnostic clarity is needed, Cholla’s doctorate-level clinicians can use psychological testing.

Even when two people have co-occurring disorders, their symptoms and treatment needs can look very different. One adult may struggle with depression and weekend drinking that has become difficult to control, while another may have bipolar disorder alongside daily opioid misuse. Based on the assessment, our team recommends a level of care suited to each person’s needs.

Why Can Mental Health Conditions and Substance Use Disorders Occur Together?

NIMH describes three possible pathways that can help explain the co-occurrence of mental health conditions and substance use disorders: common risk factors, using substances as a way of coping with distress, and using substances to cause the mental health symptoms.

Genetic and environmental factors (stress and trauma being two of the most significant) can both increase the risk of the two conditions. Conflict at home and financial problems will add to the stress, and being around friends who are heavy drinkers can make heavy drinking seem perfectly normal.

Trauma can be a shared risk factor, but it can also affect how someone copes with distress afterward. After a car crash, an assault, or childhood abuse, some people turn to alcohol or drugs to cope with painful thoughts and feelings. A drink might take the edge off for a while, so your loved one may reach for it again when the worry returns. Over time, that relief may not last, and repeated drinking can make anxiety harder to manage.

But alcohol and other substances can also contribute to the very symptoms someone is trying to manage. NIAAA notes that heavy drinking can contribute to low mood and anxiety. Mild anxiety or low mood may improve when someone cuts down or stops drinking, but symptoms that persist or worsen need professional assessment.

These pathways can overlap, and the order isn’t the same for everyone. Depression may begin before problematic substance use for some people, while for others, substance use becomes problematic years before mental health symptoms appear. Clinicians consider the timing of symptoms and substance use when working out how the conditions may be related and what care may help.

What Are the Common Types of Co-Occurring Disorders?

Common pairings include depression or anxiety alongside a substance use disorder, as well as PTSD, bipolar disorder, or ADHD alongside alcohol or drug problems.

Here are 5 common combinations and what families should know about them.

1. Depression and alcohol use disorder: These two conditions frequently co-exist. The NIAAA states that 27% to 40% of people with major depressive disorder also have alcohol use disorder at some point in their lives.
2. Anxiety disorders and substance use disorders: Some people will use alcohol, cannabis or sedatives to cope with their anxiety or to feel more at ease in social situations.
3. PTSD and substance use problems go hand in hand: The VA states that 45% of U.S. adults with PTSD have alcohol or drug use problems.
4. Bipolar and alcohol use disorder: Heavy drinking can exacerbate the mood symptoms and make treatment more difficult.
5. ADHD and substance use disorders: ADHD is linked to a greater risk of substance use problems. Impulsivity is one factor which can contribute to risky drinking or drug use, but it’s not the only one.

What Signs of Co-Occurring Disorders Should Families Look For?

Families may be the first to notice that there’s something odd going on with a relative in terms of their mood, their behavior, or their physical well-being. These changes don’t automatically mean someone has a co-occurring disorder, but a noticeable shift from their usual behaviour is worth discussing with a qualified professional.

A tough week can be different from a lasting change, so 3 simple habits can help you keep track of what you’re noticing.

• Compare what you’re noticing now with how your loved one usually behaves.
• Notice how long symptoms last, how often they return, and whether they affect daily life. Two weeks of constant low mood is something you’d want to be aware of, but if the symptoms are quite severe or are having a significant impact on your ability to carry on with normal activities, don’t wait that long to get some help.
• Brief, dated notes with specific examples will give the clinician a far clearer picture of what’s changed and when.

Sign 1: Persistent Mood Changes, Anxiety, or Emotional Distress

What matters is whether these feelings represent a noticeable change from your loved one’s usual mood or responses.

• Sadness or emptiness lasts for much of the day on most days.
• Excessive worry is hard to manage and will persist long after the immediate issue has gone.
• Irritability is more common or worse than normal, which can lead to arguments or rather sharp reactions with family and/or colleagues.
• Unusual mood shifts seem more intense, abrupt, or difficult to explain than your loved one’s usual reactions.
• Social or emotional withdrawal may look like pulling back from conversations, losing interest in usual activities, or seeming unusually detached from things that once mattered.

Over time, these changes can strain relationships and make work and everyday responsibilities harder to manage.

Sign 2: Increasing or Unexplained Substance Use

Increasing or unexplained substance use may show up as drinking or using drugs more often, taking more than intended, or relying on substances for reasons your loved one finds difficult to explain.

These changes can happen gradually: two drinks after work become four, weekend drinking creeps into weeknights, or a prescription runs out early because the medication is being taken more often than directed. Each change may seem easy to explain away, making the bigger pattern harder to spot.

The amount someone uses matters, but so does what they’re trying to cope with. Some people drink to manage stress or fall asleep, while others rely on medication or cannabis to manage anxiety or avoid difficult emotions like grief. When a substance becomes someone’s main way of coping, it can become harder to manage their use over time.

One important warning sign is when your loved one repeatedly struggles to stick to limits they’ve set. They might plan to have one drink but repeatedly end up drinking more than intended, then regret it afterward. If this happens repeatedly, it may signal difficulty controlling alcohol use, although a professional assessment is needed to determine whether a substance use disorder is present.

When these patterns occur alongside anxiety, depression, or other mental health concerns, a professional assessment can help determine whether dual diagnosis treatment is appropriate.

If your loved one is thinking about stopping, safety matters too: people who drink heavily or regularly use certain sedatives should seek medical guidance before stopping, since withdrawal can be dangerous and may cause seizures.

Sign 3: Withdrawal From Family, Friends, and Everyday Activities

Your loved one may start to skip the family meals, give up their hobbies, and spend most of their evenings on their own.

A dad who used to coach Saturday soccer might simply stop turning up, while his friends might go weeks without hearing a word from him. And losing interest in things you once enjoyed has a name: anhedonia. And it’s a symptom of depression.

That withdrawal can have different causes, even when it looks similar from the outside. Someone who feels ashamed of their drinking may avoid people who might notice it, while depression can leave them with little energy for social plans. Over time, that distance can strain family relationships: arguments may increase, family gatherings may be missed, and relatives may eventually stop reaching out.

Families may well take that distance as a sign of rejection or of laziness, even if the person is actually in distress which they simply can’t articulate. Rather than assume that your loved one is pulling away on purpose, try opening the door to conversation without any blame at all. “I’ve missed you at Sunday dinner” or “I’m worried about you” is a perfectly valid way of expressing your concern without making any assumptions as to why they’ve distanced themselves.

Support doesn’t have to come from family alone. Group therapy at Cholla Behavioral Health gives clients a chance to connect with others facing similar struggles.

Sign 4: Changes in Sleep, Appetite, Energy, or Personal Care

Changes in sleep, appetite, energy, or personal care are worth noting if they are persistent or if they start to interfere with the person’s normal routine.

• Sleep changes may show up in either direction: your loved one might lie awake much of the night or sleep far longer than usual and still wake up tired.
• Appetite changes may involve eating noticeably more or less than usual, and sometimes noticing unintentional weight changes.
• Fatigue can make ordinary errands, such as a short trip to the store, feel exhausting.
• Personal care and daily routines may start to slip, with your loved one skipping showers, neglecting laundry, or struggling to keep up with everyday tasks.

These changes may be due to a mental health condition, substance use or withdrawal, a medical condition, or a combination of all of the above. A professional assessment would be useful in determining what is actually the cause.

Sign 5: Difficulty Managing Responsibilities or Daily Routines

Difficulty managing responsibilities or daily routines may become noticeable when everyday tasks start slipping, especially if your loved one used to manage them without much trouble. You may notice these changes at work or school, with money, or at home:

• At work or school, your loved one misses shifts, arrives late, or starts failing classes.
• With money, bills go unpaid, or your loved one starts borrowing from others without explaining why.
• At home, dishes pile up, trash goes uncollected, and basic chores go undone for days.

Co-occurring symptoms can impact concentration, motivation, and decision making all at the same time which makes it very difficult to keep up with the day to day demands of life.

If these symptoms affect daily life, simply telling someone to ‘try harder’ is unlikely to help. And dual diagnosis treatment helps address the mental health and substance use issues behind these challenges.

How Can Co-Occurring Disorders Affect the Entire Family?

At home, co-occurring disorders can bring emotional stress and uncertainty, strain communication, increase caregiving pressure, and disrupt routines, finances, and relationships. That strain can show up in everyday moments like these:

• Family members may live with constant worry about the next crisis or late-night phone call.
• A parent or spouse may end up arranging appointments, providing rides, managing medications, and stepping in when everyday responsibilities fall behind.
• Conversations turn tense, and children may start avoiding certain topics.
• Siblings may feel overlooked when much of the family’s attention goes to a loved one who is struggling.
• Household routines may change when one family member takes over childcare or cooking, and the family budget may tighten if they also have to cover extra bills.
• Trust can erode after broken promises, even in loving homes.

SAMHSA’s guidance for family caregivers notes that hard conversations, watching a loved one struggle, and constant change can leave relatives feeling worn out and alone. Family members deserve support of their own, too. They can be there for a loved one, but they are not solely responsible for another adult’s recovery.

Through family therapy and its family education and support groups, Cholla helps relatives find ways to respond to a loved one without feeling they have to manage everything themselves.

What Treatment Options Are Available for Co-Occurring Disorders?

Treatment options for co-occurring disorders are therapy, psychiatric services, medication (where appropriate) and relapse prevention. Integrated treatment is the approach of bringing all of these together into one cohesive care plan.

Here are the 6 core parts of that plan at Cholla Behavioral Health.

• Individual therapy offers one-on-one sessions, including EMDR for trauma and motivational interviewing for mixed feelings about change.
• Group counseling teaches skills from cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT).
• Family therapy involves bringing the family together in session so that communication and boundaries can improve at home.
• Psychiatric services cover a full evaluation plus ongoing medication management from psychiatrists and psychiatric nurse practitioners on staff.
• Medication, when appropriate, pairs FDA-approved medicines with counseling, and Cholla also runs an opioid treatment program.
• Relapse prevention planning continues into aftercare through ongoing therapy, peer and recovery coaching, and links to community resources.

Treatment intensity depends on your loved one’s clinical needs and safety, including how severe both conditions are and how stable life at home feels.

The table below compares the levels of dual diagnosis treatment that Cholla offers adults 18 and older.

Level of care	What it looks like at Cholla	Who it usually fits
Ambulatory detox	Outpatient withdrawal management with onsite medical professionals	Adults who need safe withdrawal care first
Residential	24/7 care with intensive support, therapy, and stabilization	Adults who need time away from home to get stable
Partial hospitalization (PHP)	2 to 3 individual sessions and 25 hours of group therapy each week, plus medication management	Adults who need daily structure and close clinical support
Intensive outpatient (IOP)	15 to 25 hours of therapy across 3 to 5 days each week	Adults who need strong support while keeping work or family routines
Outpatient (OP)	Continuing therapy with no fixed end date	Adults stepping down from PHP or IOP who still want regular sessions

Learn More About Dual Diagnosis Treatment & See How It Can Help!

The five signs listed above can help you determine if your loved one may benefit from some professional support. An assessment can help determine whether a mental health condition, a substance use disorder, or both may be the reason for the behaviours you’ve observed.

If both are present, treatment should be delivered in combination. Cholla Behavioral Health provides diagnostic assessments and treatment at its Phoenix clinic, as well as aftercare and relapse prevention support.

Concerned about your loved one? Get in touch with the admissions team to find out more about these services and to check your insurance prior to your first visit.

Frequently Asked Questions (FAQs)

Q1. What are some effective coping skills for managing co-occurring disorders?

Effective coping skills include spotting triggers early, using calming techniques when stress builds, keeping regular sleep and meal routines, and reaching out for support when cravings arise.

CBT helps people recognize thoughts and patterns that contribute to substance use, while DBT teaches skills for managing strong emotions. At Cholla, clients can practice these skills in groups. Those in PHP or IOP can also take part in activities such as yoga, art, music, and gym sessions.

Q2. What is the most effective treatment for co-occurring disorders?

Integrated treatment is generally recommended because it coordinates mental health and substance use care within one treatment plan. For people with alcohol use disorder and co-occurring psychiatric conditions, NIAAA reports that integrated treatment tends to lead to better results than fragmented care.

At Cholla, this approach can combine therapies such as CBT or DBT with psychiatric care and medication management when appropriate.

Q3. Why is early identification of co-occurring conditions important?

Early identification matters because untreated symptoms can persist or worsen, and one condition can make the other harder to treat. A clinical assessment can help clarify the severity of both conditions and guide the choice of care. Depending on their needs, some adults may be able to start with Cholla’s IOP or standard outpatient services, while others may need a different level of care.

Q4. What’s the difference between co-occurring disorders and dual diagnosis?

The terms are often used interchangeably when someone has both a mental health disorder and a substance use disorder. Public health agencies such as SAMHSA and NIMH commonly use the term “co-occurring disorders.”

More broadly, the term can refer to combinations of mental health and substance use disorders, including cases where more than two conditions occur together, such as depression, anxiety, and alcohol use disorder.