You Are Not An Unusual Case
~50% — of adults with a substance use disorder also have a co-occurring mental health condition (National Institute on Drug Abuse, 2024)
If you or someone you love is fighting both addiction and a mental health condition at the same time, you are not an unusual case. You are the case we see most. Roughly half of every client who walks through our doors carries a primary substance use disorder and a co-occurring mental health condition — depression, anxiety, post-traumatic stress, bipolar disorder, or attention-deficit/hyperactivity disorder among the most common.
Roanoke Refuge treats substance use disorder; when co-occurring mental health conditions are present, they are addressed through an integrated outpatient model in which both conditions are addressed inside the same program, by the same clinical team, at the same time. We do not treat the substance use disorder this month and refer you out for the depression next month. The clinical evidence is clear that treating both together produces better outcomes for the people who actually carry both diagnoses, and our program is built around that reality.
The Bidirectional Relationship
Mental health and substance use feed each other in both directions. Each condition can drive the other, and the clinical picture in any individual case usually reflects four overlapping pathways. Substances like alcohol, opioids, and stimulants each interact with different mental-health pathways in ways that compound over time.
Self-medication
Most people with undiagnosed or undertreated mental health conditions reach for something that quiets the symptom — alcohol for anxiety, opioids for emotional pain, stimulants for depression. The pattern works in the short run, which is one of the reasons the substance stuck around. Then it stops working, and the substance use becomes a clinical problem sitting on top of the original one.
Substance-induced symptoms
Chronic substance use produces neurobiological changes that cause or worsen psychiatric symptoms. Some of these symptoms resolve with sustained abstinence. Others reveal a primary mental health condition that was present underneath the substance use the entire time.
Shared neurobiology
Addiction and many common mental health conditions share underlying vulnerabilities in the dopamine system, the stress-response system, and the prefrontal cortical circuits governing impulse control. The biology that makes one condition more likely also makes the other more likely.
Shared environment
Adverse childhood experiences, trauma, poverty, and chronic stress are risk factors for both conditions and often appear in the same client’s history. The trauma history that drove the substance use is almost always the same trauma history that shaped the mental health condition.
Integrated Treatment Produces Better Outcomes
Most of the families we meet have already tried sequential treatment. They have been told the depression would lift if the drinking stopped, or the drinking would stop if the depression lifted, and they have watched neither happen. The research on integrated dual-diagnosis treatment versus sequential or parallel treatment is clear about why: integrated treatment, addressing both conditions simultaneously within the same program by the same clinical team, produces significantly better outcomes than treating one condition at a time.
2× — the rate of substance-use reduction in integrated dual-diagnosis programs vs. sequential treatment, across randomized controlled trials (Cochrane Review, 2019)
Our clinical model is built around that evidence rather than around the older sequential approach that has been the historical norm in much of the field.
Common Co-Occurring Combinations
If you have been wondering whether your particular combination is something we have seen before, the short answer is almost certainly yes. The pairings we see most often across the Roanoke Valley involve alcohol use disorder, opioid use disorder, stimulant use disorder, benzodiazepine dependence, and polysubstance use — each typically paired with a specific mental-health partner.
Alcohol use disorder and Depression
One of the most prevalent combinations in treatment settings nationally and across the Roanoke region. Alcohol is a depressant; sustained heavy use lowers mood, disrupts sleep architecture, and depletes the neurotransmitter systems depression treatment is trying to restore. Learn more
Opioid use disorder and PTSD
Especially common among clients with trauma histories, including veterans served by the Salem VA Medical Center who are now seeking civilian treatment. Opioids quiet hyperarousal in a way that almost nothing else does, which is part of why the combination is so sticky. Learn more
Stimulant use disorder and Anxiety or Bipolar
A pattern that has grown alongside the regional rise in methamphetamine use. For people with undiagnosed bipolar disorder, stimulants can mimic the energy and focus of a hypomanic phase, which feels useful before it tips into something worse. Learn more
Benzodiazepine dependence and Generalized Anxiety
Often a case where anxiety treatment itself produced a secondary dependency that now requires careful, supervised tapering alongside continued mental health care. Stopping cold turkey is medically dangerous; staying on indefinitely no longer treats the underlying anxiety. Learn more
Polysubstance use and Borderline Personality Disorder
A presentation for which Dialectical Behavior Therapy is the evidence-based core therapy. Both diagnoses share emotional dysregulation as a central feature, and the same skills work — distress tolerance, emotion regulation, interpersonal effectiveness — applies to both.
How We Treat Co-Occurring Disorders at Roanoke Refuge
Families often ask what makes co-occurring care different in practice, not just on paper. The honest answer is that it shapes everything from the first phone call onward. Below is the operational shape of integrated dual-diagnosis care at Roanoke Refuge — six elements that work together, supported by therapies like CBT and DBT and on-site medication-assisted treatment.
Integrated treatment planning
Both conditions are named in the treatment plan and addressed in coordinated clinical work — not held in separate silos. The goals, the interventions, and the progress markers all account for both diagnoses at once.
Clinical staff trained in both
Our primary therapists carry training in both substance use treatment and mental health treatment. Clients do not have to rebuild rapport with a different clinician every time the conversation shifts from one diagnosis to the other.
Group programming that addresses both
The curriculum explicitly addresses the dual dimension rather than treating mental health as an afterthought to the substance use track. CBT modules, DBT skills work, relapse-prevention groups, and process groups all assume a co-occurring framing.
MAT prescribed on-site
For clients whose substance use disorder has a pharmacological component, FDA-approved MAT medications are prescribed by our medical team inside the same program as your therapy — buprenorphine, naltrexone, acamprosate, and disulfiram. No separate referral required.
Psychiatric coordination
For clients whose mental health conditions require psychiatric medication management, we coordinate with psychiatric providers across the Roanoke Valley and the Salem VA Medical Center so prescribing decisions are made with full visibility into the substance use treatment.
Validated assessment
Intake includes validated tools such as the PHQ-9 for depression, the GAD-7 for anxiety, and the PCL-5 for post-traumatic stress. Early diagnostic impressions are working hypotheses, refined as the clinical picture clarifies through the first weeks of treatment.
Patient, Longitudinal Assessment
One thing we want you to hear up front: a diagnosis given to you in the first week of treatment is not necessarily the diagnosis you will be carrying six months in. Substance use can mask, mimic, or amplify psychiatric symptoms, and the diagnostic picture often clarifies only once a client has accumulated sustained abstinence and the dust settles.
Our clinical team treats early diagnoses as working hypotheses, refined through ongoing assessment rather than locked in. That patience is part of why treating both together produces better outcomes than the sequential model — the diagnostic work and the treatment work happen in the same room, with the same clinicians, over enough time to actually see what is real.
Local, regional, and accessible.
Roanoke Refuge serves clients from across the Roanoke Valley — Roanoke City, Salem, Vinton, and the surrounding counties of Roanoke County, Botetourt County, and Bedford County. Our facility at 1630 Braeburn Drive in Salem sits just off I-81 exit 137, a short drive from downtown Roanoke via I-581 South and accessible from most of the Valley within 20 to 30 minutes. Whether you live near the Mill Mountain Star or out toward the Blue Ridge Parkway, the outpatient model is the same.
If a co-occurring condition alongside a substance use disorder is the picture for you or someone you love, the first step is a conversation, not a commitment. A short call with the Roanoke Refuge admissions team covers fit, level of care, and insurance — before any clinical work begins. Free, confidential insurance verification runs during the same call. Call (540) 900-0353 when you are ready.