COMHAD: Understanding Co-Occurring Mental Health, Alcohol and Drugs (previously: Dual Diagnosis)
Updated: 2 days ago
COMHAD: A Comprehensive Guide to Co-Occurring Mental Health and Substance Use Difficulties
When someone experiences both mental health difficulties and problematic substance use at the same time, this is known in policy and clinical practice as COMHAD (Co-occurring Mental Health, Alcohol and Drugs). COMHAD conditions are common, complex, and often severe, requiring integrated, person-centred care rather than fragmented support systems.
In the UK, the prevalence of co-occurring mental health and substance use problems has been rising. Between 2024 and 2025, 74% of people starting drug and alcohol treatment reported having a mental health treatment need, illustrating that most people in substance use services also face significant psychological distress (Office for Health Improvement and Disparities, 2025).
Recognising this, the Co-occurring Mental Health and Substance Use: Delivery Framework was published on 10 December 2025, outlining how services can work better together to meet the needs of people with COMHAD.
This article presents:
Why COMHAD matters
The difficulties people face
Best practice frameworks and evidence
How treatment services can effectively respond
How Cheshire Sobriety Clinic helps using a combined RTT® and talking therapy approach
What Is COMHAD?
COMHAD refers to when someone has both a mental health condition and a problem with alcohol or other drugs at the same time. These two issues are interlinked, not separate, and can reinforce each other in harmful ways.
The new delivery framework explicitly recognises that people with COMHAD:
Are often excluded from traditional mental health services unless substance use is resolved first
Are excluded from substance use services until mental health issues are addressed
Suffer worse outcomes when services are siloed rather than integrated(Department of Health and Social Care and NHS England, 2025)
Why COMHAD Is a Public Health Priority
People with co-occurring conditions are among the most clinically vulnerable populations. They are more likely to experience:
Crisis episodes and emergency admissions
Higher suicide risk
Poorer physical health outcomes
Greater likelihood of homelessness and social exclusion (Harris et al., 2023; NCISH, 2025)
The Co-occurring Mental Health and Substance Use Delivery Framework was developed precisely because existing services too often force people to “fit the system” rather than adapting care to meet individual needs.
The Difficulties of Living with COMHAD
COMHAD is complex because mental health and substance use problems can:
Trigger each other
Mask symptoms
Create barriers to help seeking
Increase stigma
Increase risk of self-harm, suicide, and accidents
Interlocking symptoms
For example, someone with anxiety or depression may use alcohol or drugs to cope. Unfortunately, substance use can then worsen anxiety, contribute to depressive cycles, and impair judgment and emotional regulation.
Conversely, chronic substance use can disrupt sleep, impair cognition, and cause emotional instability that mimics or worsens psychiatric disorders. Because the problems feed into each other, treating just one aspect without addressing the other often leads to poor outcomes. This is one of the fundamental challenges COMHAD presents in clinical settings.
Barriers to Effective Treatment
Until recently, services were often organised around substance use on one side and mental health on the other. This has created barriers including:
Long waits to access mental health support for people with active substance use
Being told to get “clean” or “stable” before mental health support can begin
Lack of shared screening or treatment pathways across services (Department of Health and Social Care and NHS England, 2025)
The 2025 delivery framework recognises that these barriers contribute to poor engagement, fragmented care planning, and unmet need and that integration and collaboration across services is central to better outcomes.
What the New COMHAD Delivery Framework Says
The Co-occurring Mental Health and Substance Use Delivery Framework sets out actions to improve care for people with COMHAD conditions. It emphasises four priority areas:
Strategic leadership and service model design
Integrated care pathways
Joint responsibility between mental health and substance use services
No “wrong door”, patients are not bounced between services without care
Data and monitoring
Better recording and sharing of needs and outcomes
Use of modern screening tools like ASSIST-Lite to capture substance use alongside mental health factors
Workforce and training
Competency development across both sectors
Trauma-informed care and best practice interventions
Commissioning and incentives
Joint commissioning plans to fund and prioritise integrated care
Incentives that support person-centred outcomes rather than siloed targets (Department of Health and Social Care and NHS England, 2025)
This framework is significant because it sets a national standard for collaborative, integrated care that aligns with the 10 Year Health Plan and aims to reduce inequalities, improve access, and prevent crisis escalation.
Evidence Supporting Integrated COMHAD Treatment
UK guidance recommends integrated care, where mental health and substance use are treated at the same time (NICE, 2016). The research evidence is more mixed than often assumed: a Cochrane review found no high-quality evidence that integrated models do better than standard care (Hunt et al., 2019).
Past practice often made people fit services. The new delivery framework calls for services to fit people, adapting care pathways around the individual rather than forcing them to meet rigid criteria.
Principles of Effective COMHAD Treatment
The evidence and policy guidance point to several principles that inform best practice:
Holistic Assessment
Assessment should capture mental health symptoms, substance use patterns, trauma, social determinants, physical health, and support networks.
Shared Care Planning
Teams from different disciplines (psychiatry, psychology, addiction specialists, nurses, counsellors) should collaborate on treatment plans to ensure joined-up care.
Trauma-Informed Practice in COMHAD Treatment
A high proportion of people with co-occurring mental health and substance use difficulties have experienced trauma, including childhood adversity, neglect, violence, or loss. Large-scale studies consistently show strong links between trauma exposure and later substance dependence, emotional dysregulation, and mental health disorders (Simpson and Miller, 2002; Harris et al., 2023).
Trauma does not simply affect memory. It can change how the nervous system responds to stress, increase threat sensitivity, and reduce a person’s ability to self-soothe or regulate emotions. Substances are often used as a way to manage these overwhelming internal states, making trauma a central driver in many COMHAD presentations.
For this reason, trauma-informed care is now considered an essential component of integrated treatment. The Co-occurring Mental Health and Substance Use Delivery Framework (2025) explicitly recognises trauma as a key factor in both mental health distress and substance use, and it calls for services to embed trauma-informed principles across all levels of care (Department of Health and Social Care and NHS England, 2025).
What trauma-informed care means
Trauma-informed care is not a specific therapy. It is an approach that ensures services are delivered in ways that avoid re-traumatisation and promote emotional safety, trust, collaboration, and empowerment.
According to SAMHSA (2014), trauma-informed services:
Recognise the widespread impact of trauma
Understand how trauma affects behaviour, emotions, and relationships
Respond by integrating this knowledge into practice
Actively resist re-traumatisation
NICE guidance on co-existing mental health and substance misuse also highlights the importance of trauma-aware assessment and psychological interventions that take account of past adversity (NICE, 2016).
Why trauma-informed approaches improve outcomes
Trauma-informed services are thought to help in several ways, although the evidence is still developing:
Engagement and retention in treatment improve
Dropout rates decrease
Emotional regulation improves
Risk of relapse may reduce (Harris et al., 2023; SAMHSA, 2014)
A realist synthesis by Harris et al. (2023) identified what helps integrated, trauma-aware systems of care work for people with co-occurring conditions.
The new COMHAD Delivery Framework reinforces this evidence, stating that trauma-informed practice is essential to achieving equitable and effective care for people with co-occurring needs (Department of Health and Social Care and NHS England, 2025).
How this informs clinical practice
At Cheshire Sobriety Clinic, trauma-informed principles guide all aspects of care. This includes:
Creating a safe and non-judgemental therapeutic environment
Recognising emotional triggers linked to trauma histories
Working at a pace that feels manageable for you
Avoiding shame-based or punitive approaches
Empowering clients to regain a sense of control and self-efficacy
Taking trauma into account alongside substance use and mental health is intended to make support feel safer and more compassionate.
Recovery-Oriented Support
Rather than focusing purely on symptom reduction, recovery-oriented models prioritise quality of life, functioning, and personal goals.
Cheshire Sobriety Clinic’s Integrated Approach
At Cheshire Sobriety Clinic, the treatment philosophy aligns closely with the national COMHAD framework’s priorities: integrated care, person-centred planning, trauma awareness, workforce capability, and effective data-informed treatment.
Our model combines Rapid Transformational Therapy® (RTT®) with evidence-based talking therapies for alcohol and drug use. We take your mental health into account and, with your consent, work alongside your GP or mental health team; we do not treat mental illness.
Rapid Transformational Therapy® (RTT® )
RTT® aims to identify and reframe deep-seated subconscious beliefs and emotional patterns that may be fuelling addiction and psychological distress. It aims to help clients change unhelpful internal narratives such as feeling not good enough, unworthy of help, or unable to cope without substances.
This approach aims to support COMHAD treatment goals by addressing:
Underlying beliefs linked to substance use
Trauma-related emotional responses
Self-criticism and avoidance patterns
Motivation and self efficacy
There are not yet any controlled trials of RTT® for alcohol or drug problems, so we use it alongside evidence-based talking therapies.
Evidence Based Talking Therapies
Alongside RTT®, talking therapies at the clinic may include:
Cognitive Behavioural Therapy (CBT) - to restructure unhelpful thought patterns (Magill and Ray, 2009)
Motivational Interviewing (MI) - to strengthen readiness for change (Lundahl et al., 2010)
Relapse Prevention Strategies - to build coping skills and resilience (Marlatt and Donovan, 2005)
These therapies help clients build practical tools to manage cravings, stress and difficult feelings in daily life.
Integrated Mental Health Support
Because mental health and substance use are interlinked, Cheshire Sobriety Clinic avoids treating them in isolation. Instead, mental health symptoms (anxiety, depression, trauma responses) are considered in every treatment plan. This approach reflects the integrated model advocated by the 2025 delivery framework and by NICE guidance on coexistent mental health and substance use (NICE, 2016).
Person-Centred and Flexible
Treatment at Cheshire Sobriety Clinic is personalised to each client’s goals, history, and strengths. Sessions can be delivered in person or online, and support can continue as needed to prevent relapse and promote long term wellbeing. This flexibility supports continuity of care, a key factor in reducing dropouts and enhancing outcomes in COMHAD treatment (Drake et al., 2007).
How the Framework and Clinic Model Align
The national Co-occurring Mental Health and Substance Use Delivery Framework encourages:
seamless joint working
screening across services
data driven care
workforce development
collaborative commissioning
Cheshire Sobriety Clinic’s approach mirrors these priorities by:
taking account of mental health in every substance use treatment plan
training clinicians in trauma informed and evidence based methods
encouraging recovery goals that go beyond symptom reduction
using validated psychological tools and monitoring progress
Together, policy guidance and therapy models converge on one core idea: people with COMHAD conditions need care that meets their whole reality, not fragmented services that treat substance use and mental health separately.
Final Thoughts
COMHAD highlights the intertwined nature of mental health and substance use difficulties and underscores the need for integrated, compassionate, and evidence informed care. The 2025 delivery framework sets out collaboration, strategic leadership, data sharing, workforce training, and integrated commissioning, all essential to improving outcomes.
Cheshire Sobriety Clinic’s combined approach using RTT® and therapeutic modalities aims to help clients address subconscious beliefs, build practical coping strategies and create sustainable recovery plans. This reflects the national direction for COMHAD care.
If you or someone you care about is living with co-occurring mental health and substance use needs, help is available. Recovery and lasting wellbeing are possible with the right support.
Cheshire Sobriety Clinic provides private outpatient therapy. We do not provide medically managed detox, crisis care or psychiatric treatment. If you drink heavily every day, don’t stop suddenly without medical advice: speak to your GP or call NHS 111. In an emergency, call 999. RTT® and hypnosis may not be suitable if you have a history of psychosis, and we will talk this through at your consultation. Everyone’s experience of treatment is different, and results can’t be guaranteed.
If you are under the care of a community mental health team or a psychiatrist, we will work alongside them, not replace them.
References
Department of Health and Social Care and NHS England (2025) Co-occurring mental health and substance use: delivery framework. London: DHSC. Available at: https://www.gov.uk/government/publications/co-occurring-mental-health-and-substance-use-delivery-framework (Accessed: 10th December 2025).
Drake, R.E., Mueser, K.T. and Brunette, M.F. (2007) ‘Management of persons with co-occurring severe mental illness and substance use disorder’, World Psychiatry, 6(3), pp. 131–136.
Harris, J., Dalkin, S., Jones, L., Ainscough, T., Maden, M., Bate, A. and others (2023) ‘Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions’, The Lancet Psychiatry, 10(8), pp. 632–643.
Hunt, G.E., Siegfried, N., Morley, K., Brooke-Sumner, C. and Cleary, M. (2019) ‘Psychosocial interventions for people with both severe mental illness and substance misuse’, Cochrane Database of Systematic Reviews, 12, CD001088.
Lundahl, B., Kunz, C., Brownell, C., Tollefson, D. and Burke, B. (2010) ‘A meta-analysis of Motivational Interviewing’, Research on Social Work Practice, 20(2), pp. 137–160.
Magill, M. and Ray, L.A. (2009) ‘Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials’, Journal of Studies on Alcohol and Drugs, 70(4), pp. 516–527.
Marlatt, G.A. and Donovan, D.M. (2005) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours. New York: Guilford Press.
National Institute for Health and Care Excellence (NICE) (2016) Coexisting severe mental illness and substance misuse: community health and social care services (NG58). London: NICE.
National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) (2025) Annual report: UK patient and general population data, 2012–2022. Manchester: University of Manchester.
Office for Health Improvement and Disparities (2025) Adult substance misuse treatment statistics 2024 to 2025: report. London: OHID.
SAMHSA (2014) SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Simpson, T.L. and Miller, W.R. (2002) ‘Concomitance between childhood sexual and physical abuse and substance use problems: a review’, Clinical Psychology Review, 22(1), pp. 27–77.
© 2025 Cheshire Sobriety Clinic. All rights reserved.
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