Part 1 – Case study and treatment plan

Summary

Jacob is a 63 year old man with a history of Major depressive disorder and Alcohol use disorder. He lives alone and has had many failed relationships, leaving him feeling isolated and worthless for the last 10 years or so. He has cycles of binge drinking and his physical health has deteriorated as a result leading to multiple hospital admissions for alcohol related issues. Interventions needed to help Jacob address both his depression and alcohol use revolve around abstinence from alcohol, coping strategies, and social connection within his small community. Jacob’s motivation for change is unclear at present and the keyworker will need to develop a therapeutic relationship in order to engage him to develop a clear sense of motivation for change and desire to make positive changes for his future health and wellbeing.

Circumstances

Jacob is was referred to Community Drug and Alcohol Service (CADs) by CADS Consult Liaison team during an alcohol induced hospital admission for further assessment. Jacob had realised that he needed help with his alcohol consumption and agreed to seek help. This is the first time Jacob has sought help for his alcohol use in many years. The assessment was conducted in a two-hour Comprehensive Assessment session, face to face with Jacob. Jacob did not bring any support people to the assessment.

Jacob agrees to seeking help with his alcohol use, although does not believe it to be overly problematic for him.

Assessment

Background information

Jacob grew up in England and immigrated to New Zealand in his late twenties. He currently lives alone in a small town, in a block of council owned units. His is twice divorced and has three children. He has regular contact with one of his daughters Jane by telephone as she lives in Wellington. He has many failed relationships which leave him depressed when they end.

Jacob is an ex high school teacher and is retired. He likes to help in the Trust gardens in his spare time with the support workers for company. He is an avid reader and likes to go mountain biking when he can. He has not engaged in these activities in the last few months as his alcohol consumption has increased.

Jacob has multiple health issues including Psoriasis, Barrett’s Oesophagus, Gastritis, and history of previous stroke.

Jacob has had 17 hospital admissions since late December (last six months), for alcohol related issues usually around GI bleeds. Hospital stay varies from 2-6 days each time and is progressively becoming more frequent and longer stays.

Jacob recently was charged with Excessive Breath Alcohol and disqualified for driving for 6 months. It was deemed that Jacob was still driving whilst under the influence of alcohol, and CADS submitted a request to the Land Transport Authority to have the licence revoked. This was approved.

A&D assessment

Alcohol

– Jacob reports that his pattern of drinking is binge drinking rather than regular drinking. He is prescribed Disulfurim but will stop taking this when he is planning on drinking. Jacob advises that he has 750mls of spirits (usually Vodka) and once he starts drinking, he cannot stop. He binge drinks 3-4 times a month. This is a pattern that has been going on for years, and increases with various situational stressors.

Indicators of Substance Use disorder (DSM-V, 2013, p.490-1).

-A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects

-There is a persistent desire or unsuccessful efforts to cut down or control alcohol use

-Important social, occupational or recreational activities are given up or reduced because of alcohol use.

-Recurrent alcohol use in situations in which is physically hazardous

-Alcohol use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

-Withdrawal as manifested by the classic withdrawal syndrome

Jacob meets at least six of the criteria for Substance use disorder and can be classed as having a Severe Alcohol use disorder.

Consequences of his drinking include falls, driving under the influence of alcohol charges and hospital admissions for Gastrointestinal (GI) bleeds.

His withdrawal symptoms include tremor, perspiration, sensitivity to noise and light, hallucinations, nausea and anxiety.

Jacob has had 2 arranged medical detoxifications and numerous detoxifications in the Medical Ward when he has a GI bleed. He has not been to residential rehabilitation as yet.

Other Substances

– Jacob denies use of any other substances. Blood and urine screening would substantiate this claim.

Mental health assessment

Jacob has a long history of depression. He has been depressed since his divorce from wife just over 20 years ago. He is prescribed Citalopram 30mg and Zopiclone 7.5mg by his General Practitioner. It could be assumed that his depression was secondary to his alcohol use,  however the depression still remains even in abstinent periods.

Jacob meets the DSM-V criteria for Major Depressive Disorder (2013, p.160-1). He has more than five of the symptoms,

and

the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning, and the episode is not attributable to the physiological effects of a substance or to another medical condition.

-Depressed mood most of the day, nearly every day, as indicated by either subjective report (ie; feels sad, empty, hopeless).

Jacob reports that he feels hopeless and worthless. He is constantly sad.

-Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or objective observation).

Jacob

-Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% body weight in a month), or a decrease in appetite nearly every day

. Jacob has lost nearly 10kgs in recent months, and has a poor appetite.

-Insomnia or hypersomnia nearly every day.

Jacob finds it very difficult to sleep

-Fatigue or loss of energy nearly every day.

Jacob has no energy to do the usual things he would do – exercise, gardening, reading.

-Diminished ability to think or concentrate, or indecisiveness, nearly every day (either subjective or as observed by others).

Jacob finds it hard to make decisions on both small and big things in his life and is finding it hard to concentrate

– Recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Jacob has recurrent thoughts of stabbing himself although not acted on these. They scare him.

Jacob in the past had thoughts of stabbing himself. At present her has the occasional fleeting thought of self-harm and/or suicidality but has never acted on these thoughts. He seeks help when feeling this way and has had a short inpatient admission in 2016 after the separation from his Malaysian girlfriend.

Impact of substance use on mental health

The impact of alcohol use on Jacob’s mental health has been significant for him. Initially a depressive episode, with poor coping skills has turned into a cyclic pattern of binge drinking for Jacob. His alcohol use helps him cope with his mood and anxiety symptoms for the time he is drinking, and then when sober he can’t cope once more and returns to binge drinking. When he can not remain sober, Jacob becomes more and more depressed as he feels like a failure.

Socio cultural assessment

Jacob grew up in England and immigrated to New Zealand in his late twenties with his wife. His wife was a Nurse and they were granted permanent residency. They had two daughters who are now 29 and 27 years old. He separated from his wife approximately six years after the arrived in New Zealand and then remarried a teacher that he met whilst teaching at a school together. He had a son (now 15 years old, and that relationship lasted seven years). When they separated Jacob got the custody of his son however his ex-wife abducted him from school and that led to much stress for Jacob.

He then had a relationship with a European lady, and this lasted for about ten years. They separated as she was torn between living with Jacob in New Zealand and her family in Europe. This separation led to a major depressive episode for Jacob.

Most recently Jacob has been in a relationship of long distance with a Malaysian lady. She has visited Jacob and he made plans to go and live in Malaysia with her. Unfortunately, his visa application was denied on the basis of poor health. This has led to another depressive episode for Jacob.

Jacob’s children live in Christchurch, Wellington and Te Awamutu and he has regular contact with them. He also has regular contact with his first wife who lives in Hamilton.

Jacob as worked as a Teacher, boat builder, welder and manager of backpacker’s accommodation.

Jacob currently lives in a council owned flat on his own.

Jacob is currently on the sickness benefit. He recently received a large inheritance from his Aunt in England.

Major Problem clusters

Alcohol use disorder

– as indicated by Jacob in his assessment.

Jacob meets the DSM-V criteria (2013) for Alcohol Use Disorder as follows;

–

A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects

Jacob spends much time in hospital recovering from his alcohol use

-There is a persistent desire or unsuccessful efforts to cut down or control alcohol use

Jacob has tried many times to stop his alcohol use and has been unsuccessful. He sabotages each attempt by binge drinking

-Important social, occupational or recreational activities are given up or reduced because of alcohol use.

Jacob has not attended the gardens for some months and does not engage with his support worker when his alcohol consumption increased.

–

recurrent alcohol use in situations in which is physically hazardous

Jacob continues to drive his car after drinking alcohol and was caught for excess breath alcohol and charged.

-Alcohol use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Jacob has had 15 hospital admissions since December and these are all related to the alcohol consumption and his Barrett’s oesophagus

–

Withdrawal as manifested by the classic withdrawal

syndrome Jacob suffered from severe withdrawal symptoms when he was admitted to hospital and had a forced abstinence from alcohol.

Conclusion/diagnosis

It is clear from above, that Jacob meets the criteria for both Major depressive order and Severe Alcohol use disorder. An intervention plan needs to be developed to meet the needs of both disorders, and that Jacob sees as a positive plan to make changes for his future health and wellbeing.

Intervention Plan

General Aims

Central areas for change for Jacob include;

-Abstinence form Alcohol

-Deal with past/present grief

-Develop and maintain Social networks

Intervention 1

Therapeutic goal –

Abstinence form Alcohol

• Medical supervision for Alcohol Withdrawal (inpatient admission for detoxification)
• Residential rehabilitation
• Pharmacotherapy for post detoxification support and in an attempt to prevent relapse
• AOD counselling weekly for support
• AA Meetings weekly for peer support in relapse prevention

Rationale

Jacob needs a combined approach to achieving abstinence from alcohol. This should give Jacob a better chance to abstain from alcohol use long term. On admission to Medical Detoxification, Jacob will have a full medical examination and this will give the team a clear picture of likely complications. Residential rehabilitation is appropriate to help Jacob adapt his lifestyle and for long term abstinence. Ongoing AOD counselling will help Jacob to stay focussed on his goals and his values. AA meetings are necessary for peer support. It is beneficial to Jacob as his peers understand and given his isolation, it will benefit him socially also.

Procedures

A referral to Medical detoxification ward needs to be completed by Jacob’s key worker. Jacob will need to have full blood tests with his General practitioner. Medical Detoxification is carried out in an inpatient ward in the hospital setting with access to Doctors and Nursing staff around the clock. This is followed (usually) by Pharmacotherapy of Disulfurim, Naltrexone, Thiamine and Multivitamins. Medications can be dispensed daily under pharmacist supervision for matters of compliance and in Jacobs case, it is important that he is compliant with his medication

Context

The physical examination may show that Jacob is not a candidate for pharmacotherapies. However, if he can take the pharmacotherapies, his current level of motivation may impede his compliance in continuing taking medications to aid his abstinence from alcohol. This could lead to relapse given the medications are only effective if one is compliant with taking them.

Intervention 2

Therapeutic goal –

Deal with past/present grief

• Personal counselling
• Psychology sessions (ie Cognitive Behavioural Therapy (CBT))

Rationale

Personal counselling sessions for both past and present grief will allow Jacob to process these issues more appropriately, and manage his emotions around them long term. Psychology CBT sessions will help change past patterns of thinking for Jacob and aid him to better manage his emotions and anxiety.

Procedures

CADS key worker to refer Jacob to Community based counselling service which is a free service to consumers by the local NGO. CADS key worker to refer Jacob to Adult Mental Health Psychology service.

Context

It is difficult to gage where Jacob sits in the stages of change. He may be on the Contemplative stage of change in terms of his Alcohol use but may be in pre contemplative stage with grief issues. If he does not have the motivation to address past and present grief issues then it is unlikely that he can make any progress in this area. If he is in the Contemplative stage of change however, then the fact that the service is free removes a financial barrier for Jacob, and he can attend sessions to begin to manage his grief issues.

Intervention 3

Therapeutic goal –

Develop and maintain Social networks

Rationale

Jacob is currently living on his own and feeling very lonely. He feels like he is worthless and unwanted. To gain some self-worth, Jacob needs to develop his social networks or rekindle/maintain previous ones. He needs to redevelop support networks between his friends and his family. Adams (2007) stated that Addiction is not really the attribute of an individual, rather than a relationship between other relationships. The extended family (or Taha Wanau) is a vital part of Te Whare Tapa Wha- Mason Durie’s model of wellness (1998). Social and whanau relationships are integral to Jacobs mental health and wellbeing.

Procedures

Jacob needs to identify his key relationships and who he may need to rekindle a relationship with. Maintaining his connection with his family is important, as is his connection with support people in his small town.

Context

Jacob needs to be able to acknowledge the effect of his behaviour and drinking has had on the relationships with his key relationships. He needs to be in the preparation state of change so that he can redevelop these relationships. This may be an issue if he does not acknowledge that his alcohol consumption is problematic (and therefore can not accept responsibility for associated behaviour).

Evaluation/review plan and periods

When reviewing the intervention plans, in order to have successful outcomes the following anticipated outcomes would be expected

–

Jacob is

living a sober lifestyle

as evidenced by;

• Taking medication as prescribed
• Attending weekly AOD counselling sessions
• Attending weekly AA meetings

Jacob has

begun to process his past and present grief issues

as evidenced by;

• Attending regular counselling
• Attending psychology (CBT) sessions
• Able to indicate some positivity and hope for his future

Jacob has

begun to develop/rekindle/maintain social relationships

as evidenced by;

• Regular attendance at gardens with support worker
• Regular conversations with family members and support people

The intervention plan will have a four-week review of Jacobs progress in meeting goals, and how the interventions are progressing. Given Jacobs past history with various interventions, a shorter timeframe is necessary as he has a tendency to relapse into drinking in a shorter timeframe. This will enable the key worker to keep a close watch on what is or isn’t working for Jacob and make changes as necessary.

Part 2 – Discussion

Clients with co-existing depression and alcohol use disorders typically can be a challenging group of clients to engage with. Each disorder has a significant impact on the other and estimates of co-morbidity of the two disorders are almost two times higher than that of the general population (Regier et al, 1990). As treating clinicians, we need to be aware of this impact and the effect it will have on outcomes for this group of clients.

An important part of an intervention plan is to address co-existing depression and alcohol treatment. Psychology attempts to do this and address both together for more positive long-term outcomes for clients with co-existing disorders. Brown and Ramsey (2000) believe that Cognitive Behavioural Therapy (CBT) is an intervention that can teach co-existing clients coping skills for managing their depression. They go on to say that they believe that CBT “carries little to no risk to the patient” (p.419).

What is CBT?

CBT

is a type of

psychotherapy

that treats problems and increase mood by modifying dysfunctional emotions, behaviours, and thoughts. It is a solution-based approach to challenging distorted cognitions and changing destructive patterns of behaviour delivered by trained professionals (generally psychologists).

CBT operates on the idea that our thoughts and perceptions can directly influence our behaviour. CBT aims to identify harmful thoughts, assess whether they are an accurate depiction of reality, and if they are not, seeks to employ strategies to challenge/overcome them.

CBT is appropriate for people of all ages, including children, adolescents, and adults. CBT can be delivered effectively online, in addition to face-to-face sessions. CBT is tailored to each client individually.

The clinician first has to assess the client – usually by way of a comprehensive assessment, and then develop a treatment plan to target a key problem list. The early focus of CBT usually revolves around behavioural activities and the client functioning getting back to usual , taking into consideration both substance use and mental health domains Baker, Bucci, Kay-Lambkin and Hides in Baker and Velleman (2007).

How might the use of CBT be effective with the client group who have a co-existing substance use and mental health disorder?

Baker, Bucci, Kay-Lambkin and Hides in Baker and Velleman (2007), believe that in the case of a co-existing depression/substance use disorder integrated treatment may result in more substantial treatment outcomes. This is due to the disorders sharing common features like low mood, low self-efficacy, pessimism and other factors they have in common.

There is a close relationship between depression and alcoholism, and co-existing depression has been linked to poor prognosis after having treatment for alcoholism (Brown, et al; 1997). Depression can trigger poor engagement and relapse among co-existing clients. CBT as an intervention to manage coping skills and manage depressive symptoms in clients with co-existing alcoholism can change this in even just a small way. There is no risk to the client in engaging in CBT unlike medications and the risks they may/may not carry. Brown and Ramsey (2000) looked at clinical trials evaluating the effectiveness of antidepressant medications as a treatment option for alcoholics who had co-existing depression, and found that the results were equivocal. Some studies showed that they helped, and others found that there was no significant change for the client.

Tuener & Wehl (1984) study found that co-existing clients with alcoholism and depression who participated in CBT alongside their alcohol treatment had better outcomes for bother their mood and alcohol use than those who had alcohol treatment alone. This has to be a positive result for co-existing clients seeking treatment, to maximise their chances of having successful outcomes and productive lives as a result.

In 1997, a different study by Brown, Evans, Miller, Burgess & Mueller attempted to address the shortcomings of previous studies around the use of CBT in co-existing clients with depression and alcoholism.  The study looked at the efficacy of CBT and relaxation training control (RTC) combined with hospital treatment for alcoholics with increased depression. The first group received CBT and alongside hospital treatment and the second group received only RCT alongside the hospital treatment. The participants in the study had to meet the Diagnostic and Statistical Manual of Mental Disorders (3

^rd

ed.,rev.;DSM-III-R; American Psychiatric Association, 1987) criteria for alcohol dependence

and

score 10 or more on the Beck Depression Inventory.  Exclusion criteria included active suicidal or homicidal risk, acute psychosis, and current opiate abuse or dependence (Brown and Ramsey 2000, p.419-20). The CBT sessions took place over eight 45minute sessions with individual clients. Results from the study shoed

-during sessions clients showed greater reduction of depressive symptoms in the CBT group

-during the first three months the clients had a larger percentage of abstinent days, but overall not any major change in alcohol abstinence or consumption of fewer daily drinks

-during second three months of follow up CBT clients showed significantly better outcomes on total abstinence (47% vs 13%), Percentage of days abstinent (91% vs 68%), and drinks per day 90.46 vs 5.71). (p.420)

The outcomes for these clients were significant, and suggest that if CBT is added to the normal treatment for alcoholism- then the decrease in depressive symptoms, and improvement in abstinence can be beneficial to those with co-existing alcoholism and depression. It shows that over a longer term these outcomes have a better chance of being maintained – which can only improve outcomes in all areas for these co-existing clients.

Brown and Ramsey (2000) do elude to the fact there are limited studies on the treatment outcomes of co-existing clients with depression and alcoholism. Future studies need to be carried out, and with a larger population, to reiterate the importance of integrated treatment such as CBT with treatment for substance abuse for more effective evidence-based practice. This will only benefit the outcomes of future co-existing clients seeking treatment.

Strengths and limitations of CBT

Firstly, the limitations of CBT are based around engagement. Engagement is a key factor to make CBT effective for the client. Motivational Interviewing of the client may help change where their level of motivation sits and is an essential tool to use prior to starting CBT sessions. If the clinician is unable to develop and maintain a therapeutic relationship with the client, then engaging them and working on motivation may not lead to the client engaging meaningfully in their treatment to get to the point where they are able to undertake CBT.

Whilst the research does show that integrated treatment for co-existing clients can undoubtedly create better outcomes in both Substance use and mental health, there are many clinicians that remain firm in their belief that parallel or sequential treatment is more appropriate. Brown et al, (1997) believe that depression is associated with poorer outcome in alcohol treatment” (p.715). It makes sense to use an integrated approach given the outcomes of the research studies done in this area, but quite often clinicians work in the mindset that the client cannot have mental health without being abstinent, without addressing the fact that abstinence alone is likely to increase the depressive symptoms without appropriate treatment alongside alcohol treatment. Clinicians in the field of Mental Health all too often forget that we can remove the substance, but the reasons that the substance is used still remain. It isn’t until effective treatment occurs, that constructive changes can be made within the client themselves. So when offered CBT, often it is expected that a client is first abstinent from alcohol in order to start CBT. This limits the client’s ability to participate, as abstinence is not always achievable – especially in clients with co-existing depression and substance use disorders.

Strengths of CBT include the fact that it is of no real risk to the client. It will either work or it won’t, but there are no long-term side effects of CBT. The clients have nothing to lose for participating in CBT. A significant strength of CBT is that the research (albeit limited to a few studies) shows that whilst in the short-term outcomes are not dramatically different for co-existing clients, the long-term outcomes for depressive symptoms and substance use are extremely positive. That the clients can see the relevance of the skills they have learned in CBT and use these for living their daily lives. And therefore, in giving the co-existing client back their power is certainly a strength of CBT.

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