Indeed, Mental Health and Addiction Insurance Health (MHIA) estimate that every one in ten adults in the United States who have substance use addiction has a higher risk of experiencing co-occurring mental disorders such as mood disorders and depression. Mental disorders are in most cases comorbid in substance and alcohol use. Alcohol abuse and physiological dependence can occur with other psychiatric conditions hence said to be comorbid. Comorbidity of substance abuse and mental disorders have the ability to worsen the course of each other. In many cases, drug addiction is considered a mental problem because it has the propensity to change the brain resulting in compulsive behaviors that can weaken a person’s ability to control his impulses, therefore, bearing a similar hallmark to mental disorders (Carrà et al., 2015). Alcohol abuse may bring about symptoms of mental conditions as in the case of alcohol where clinicians suggest that increased risk of psychosis in alcohol users can be as a possible indicator.
Additionally, predisposing genetic vulnerabilities may make certain individuals susceptible to both mental illnesses and substance abuse. Other contributors to comorbidity may include stress, trauma such as sexual and physical abuse, and early exposure to medicines. Comorbidity addiction is more common in men as they tend to suffer antisocial tendencies than in women who tend to experience mood and anxiety disorders and is considered developmental as the earlier the symptoms of mental illness the higher the risk of later drug abuse. One of the most fundamental principles that emerge from comorbid addiction is the need to treat concurrently and in the process evaluate and identify both with an aim of treating both. This essay will highlight some of the decisions that are made on the medication to prescribe to this 53-year old Puerto Rican female with comorbid addiction as well as how ethical considerations will impact on her treatment.
Provision of medication based on the comorbid mood disorder she is experiencing in addition to alcohol use and gambling disorder
The patient in this case study was a 53-year old Puerto Rican female who presented to my office with what she initially considered an embarrassing problem. She reported that she had alcohol use problems since her father died and for the past 25 years she had been on and off as an alcohol user. Mrs. Perez also stated that she had a gambling problem at her casino where she gets “high” and drinks bottles of beer. She stated that the gambling problem often causes her to get a few drinks and even enjoys smoking as well. Additionally, she presented with a sad mood that comes after episodes of getting high from smoking, drinking, and gambling. From the presenting complaints, I diagnosed her with alcohol use and gambling disorder that is comorbid with an unstable mood that fluctuates.
I chose this decision because in many cases of psychiatric disorders for instance bipolar disorders there is an associated risk factor for drug abuse. Conversely, the most severe symptoms of mood fluctuations and bipolar disorders are often observed in the course of alcohol and substance use. Alcohol use and substance abuse may at times affect neurotransmitters in the brain that are involved in psychiatric conditions. Alcohol use and smoking may prompt the symptoms that were observed in her such as sadness and mood changes. Therefore, the best medication to be chosen for this patient was Lithium given in combination with Naltrexone that improves mood and alleviates her drinking addiction. Chaim et al., (2014) point out that lithium is efficacious in women who undergo rapid mood cycles in a year and hence alleviate mood when used with Naltrexone that decreases craving for alcohol. These medications aim to improve mood and sadness and do away with her addiction problem.
However, the difference between desired outcome and the actual treatment outcome was that the patient complained of certain side effects after a period of time such as weight gain and tremors. To address this I switched her medication to Sodium valproate given with disulfiram at bedtime. Tolliver & Anton, (2015) highlight that women with rapid cycles of mood respond more rapidly to Valproate than Lithium and Naltrexone. The patient reported an improved condition in a timely manner upon switching of medication with reduced side effects.
Provision of medication based on the physical condition of the patient at the time of diagnosis
Mrs. Perez reported that she had gained weight from the drinking that she currently weighed 122 lbs. She also reported smoking episodes as she was gambling and drinking. Additionally, her gambling problems were of interest as she was concerned about her husband knowing about her endeavors. I chose this decision because in the treatment of comorbid alcohol addiction weight issues are a concern due to the individual drugs are given to the patient and the side effects of alcohol consumption. Most mood stabilizers and antidepressants used in comorbid bipolar addiction result in weight gain (Di Nicola et al., 2014). On the other hand, alcohol consumption itself result in an increase in cholesterol levels hence weight gain. Therefore the drugs that I chose for Mrs. Perez must be those that have minimal effect on her weight and work to decrease the weight. Lithium medication causes retention of sodium in women resulting in high steroid levels hence weight gain and should be avoided.
Lamictal medication given with disulfiram/ Naltrexone orally is dosages of 25mg have a rapid dissolution profile in women with mood disorders and comorbid addiction is effective in this case where the patient is of high weight. This medication decreases weight in such patients. The treatment outcome was met and was not any different from the desired outcome as the patient reported a decreased alcohol craving and weight reduction. The only observed side effect was slow improvement that I countered by increasing the dose by twofold to 50mg orally.
Provision of medication based on patient compliance
I chose this decision because medication compliance is a key parameter to assessing the effectiveness of any medication used in comorbid addiction. The medication to be given to patients with comorbid addiction should have least side effects of weight gain, lethargy, and tremors. These side effects are often observed in Lithium medication given to the patient. Therefore, the non- compliance towards Lithium by Mrs. Perez was due to these side effects. Alcoholic patients are often not compliant with lithium even if it is effective in mood disorders. It was noted in the treatment outcome that the patient recorded increased compliance towards Lamictal and valproate medication may be a key factor in choosing a mood stabilizer for alcoholic patients with comorbid mood changes (Riper et al., 2014). The patient reported improved compliance because there is less risk of weight gain, lethargy and tremors associated with Lamictal.
How ethical considerations impact the treatment plan and communication to the patient
In the United States, there still exists an ethical challenge in addressing comorbid substance and alcohol use with mental disorders. This arises because there are diverse treatment systems that tend to address mental conditions and drug use disorders separately. Most physicians are at the frontline in treatment of mental disorders but when it comes to drug use there are multifarious venues that exist containing an assortment of professionals with mixed backgrounds. This raises a question of whether it creates a conflict of expertise to address the very problems that physicians alone should be at the frontline advocating for. Neither of these systems are in a position to fully address this problem to its conclusive end because men tend to prefer treatment channels while women from mental practitioners. Moreover, many drug abuse centers do not employ treatment programs and qualified personnel to monitor and dispense to alcoholic patients with mood disorders and failure to address this is a risk factor of violence that is associated with comorbidity addiction (Pickard & Fazel 2013).
Truly, patients with both substance abuse problems and mental disorders maybe challenging to treat as they exhibit persistent and sever addiction in addition to comorbid mood problems. Nevertheless, there is a steady progress on emerging and existing treatment options that focuses on patient oriented practice to alleviate both conditions. These treatment options are based upon medications chosen on basis of the physical condition of the patient such as weight, patient compliance with medication and comorbid psychiatric illness such as mood disorders.
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Chaim, C. H., Nazar, B. P., Hollander, E., & Lessa, J. L. M. (2014). Pathological gambling treated with lithium: The role of assessing temperament. Addictive behaviors, 39(12), 1911-1913.
Di Nicola, M., De Risio, L., Pettorruso, M., Caselli, G., De Crescenzo, F., Swierkosz-Lenart, K., … & Janiri, L. (2014). Bipolar disorder and gambling disorder comorbidity: current evidence and implications for pharmacological treatment. Journal of affective disorders, 167, 285-298.
Pickard, H., & Fazel, S. (2013). Substance abuse as a risk factor for violence in mental illness: some implications for forensic psychiatric practice and clinical ethics. Current opinion in psychiatry, 26(4), 349.
Riper, H., Andersson, G., Hunter, S. B., Wit, J., Berking, M., & Cuijpers, P. (2014). Treatment of comorbid alcohol use disorders and depression with cognitive‐behavioural therapy and motivational interviewing: A meta‐analysis. Addiction, 109(3), 394-406.
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of substance abuse. Dialogues in clinical neuroscience, 17(2), 181.