Substance use disorder is, in most cases, never an isolated disorder and occurs together with other mental conditions. Co-occurring disorders are scenarios in which a patient has a dual diagnosis of mental disorders. The duality of the conditions creates a unique set of needs for the patient that requires flexible and integrated methods and services to optimize results. Given specific client needs, both traditional and alternative interventions, can be used. The caregivers are most suited when they are trained in both mental illness management as well as substance use disorder management.
In a co-occurring disorder, there are two distinct and diagnosable mental illnesses. Typical scenarios include the existence of a psychotic illness together with a substance use disorder. Substance use disorder can be diagnosed as a mental illness on its own. Certain elements and behavioral patterns are characteristic of substance use disorders — crucial being the obsessive and compulsive use of the substances coupled with an inability to stop the same. In a co-occurring state, over and above this symptomatology, there will be specific signs associated with the other conditions alongside which the substance use disorder is occurring (Zagorski, 2019) . The Diagnostic and Statistical Manual for mental disorders classifies and specifies the common signs associated with each condition .
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During the patient assessment, the clinician must be on the lookout for signs that are uncommon with a substance use disorder (Salmon & Forester, 2012) . Over the past, it was quickly dismissed that any mental abnormalities in a known addict were a result of the substance being abused, but it should not be assumed so any longer. Further prodding along the line of suspicion of a co-occurring disorder would help eliminate any doubts. The counselor should be keen to figure out which of the two diseases is primary and which is secondary. This becomes helpful in the management plan.
The two disorders can be interrelated. Persons experiencing mental illnesses in most times, struggle with stigma. This can nudge an individual to opt to indulge in substance abuse as a means to ease the societal struggles ( Zagorski, 2019) . On the flip side, a person using drugs can quickly get into substance-induced psychosis or illnesses resulting from chemical imbalances within the brain. A majority of substances of abuse have high blood-brain barrier permeability, which explains the comorbidities of brain disorders and substance abuse. Co-occurring diseases are quite common, and they pose a significant challenge to manage. A holistic and integrated approach is needed in the management of a patient.
Drug-induced psychosis and several other conditions are likely to occur alongside drug and substance abuse disorder. Marijuana abuse is associated with drug-induced psychosis known as cannabis psychosis ( Zagorski, 2019) . The drug causes a high effect through a distortion of the chemicals in the brain's reward center. Cannabis misuse is known to result in acute psychosis, with a classic presentation for schizophrenia. Chronic abusers of marijuana may experience long term psychosis. Causation of psychosis from hemp is, however dependent on a multiplicity of other factors, including familial history of psychosis.
Various conditions can co-occur. Depression is common among people that misuse substances. Receptor downregulation is a possible etiology of the depressive symptoms associated with most of the drugs. Bipolar disorder is shared among co-occurring mental disorders. Drugs and substances are known to result in significant imbalances in the chemical activities of the brain — these results in episodes of mania and depression on the patient. Antidepressants, as well as alcohol, have been known to result in bipolar like episodes. These are mediated through their mode of action, which alters the moods and functioning of the human brain ( Zagorski, 2019) . Post-traumatic stress disorder can lead to substance misuse resulting in a co-occurring confusion. Life-threatening calamities and experiences can be disruptive to the normal flow of life. Persons who have PTSD quickly resort to drug abuse for momentary relief. Unfortunately, research shows that drugs worsen PTSD and lengthen the duration of recovery from the same.
For patient care, a multidisciplinary team of mental health and substance use disorder specialists ought to attend to the patient (Fisher, McCleary, Dimock, & Rohovit, 2014) . Management of mental co-occurrences is intricate due to the multiplicity of indicators that must be consistently monitored (Knight, Becan, Landrum, Joe, & Flynn, 2014) . Primacy is a critical determinant of the treatment path for a patient. During the assessment, counselors ought to pay keen attention to the patient's cultural background and how it influences treatment. This affects the nature of treatment support the client gets from the relatives and those at home with them.
To achieve the best results, assessment is a critical stage in management. A multi-stage assessment is the best in helping obtain maximal data from the patient. Substance use disorder is likely to be underreported, and addictions are underrated by the persons involved. Initial and ongoing counseling helps the counselor build a rapport with the client, and this may yield more information in the subsequent sessions ( Zagorski, 2019) . The counseling process should, at all times, be aware of the unique variations in each client. Best practices must be incorporated in both in-patient and outpatient settings to achieve optimal treatment outcomes. High-risk behaviors must be considered and necessary attempts at mitigating the same employed. Community supports structures such as the double trouble twelve step recovery can be used to aid healing.
While it may be a daunting task, an accurate diagnosis is the beginning point of recovery. The use of standardized tools for diagnosis is best recommended; primarily because it allows the clinicians to compare a client's responses to those of a normative cohort of persons. Various tools are available online and for which clinicians do not need extensive training to be able to use and score their patients.
Integrated management for both conditions must be constituted. This implies that each of the ailments is managed while coordinating with the other. Besides the pharmacological interventions, cognitive behavior therapy and dialectical behavior interventions ought to be applied. A whole-person approach that encompasses all facets of the patient’s life is necessary and ought to be included in the care plan (Godley, Smith, Passetti, & Subramaniam, 2014) . In-patient and outpatient caretakers must be well educated and understanding of what affects the patient and how best to optimize outcomes.
References
Fisher, C. M., McCleary, J. S., Dimock, P., & Rohovit, J. (2014). Provider Preparedness for Treatment of Co-occurring Disorders: Comparison of Social Workers and Alcohol and Drug Counselors. Social Work Education , 33 (5), 626–641. https://doi.org/10.1080/02615479.2014.919074
Godley, S. H., Smith, J. E., Passetti, L. L., & Subramaniam, G. (2014). The Adolescent Community Reinforcement Approach (A-CRA) as a Model Paradigm for the Management of Adolescents With Substance Use Disorders and Co-Occurring Psychiatric Disorders. Substance Abuse , 35 (4), 352–363. https://doi.org/10.1080/08897077.2014.936993
Knight, D. K., Becan, J. E., Landrum, B., Joe, G. W., & Flynn, P. M. (2014). Screening and Assessment Tools for Measuring Adolescent Client Needs and Functioning in Substance Abuse Treatment. Substance Use & Misuse , 49 (7), 902–918. https://doi.org/10.3109/10826084.2014.891617
Salmon, J. M., & Forester, B. (2012). Substance Abuse and Co-occurring Psychiatric Disorders in Older Adults: A Clinical Case and Review of the Relevant Literature. Journal of Dual Diagnosis , 8 (1), 74–84. https://doi.org/10.1080/15504263.2012.648439
Zagorski, N. (2019). Co-Occurring Mental Illnesses May Be More Pervasive Than Previously Thought. Psychiatric News , 54 (6). https://doi.org/10.1176/appi.pn.2019.3a22
