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Integrative Case Formation: Chemical Dependency Treatment Case Study

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Updated: Apr 27th, 2021

Demographic Data

  • Initials: M. J.
  • Age: 39 years
  • Sex/gender: Female

HPI

Context: stressPa2

Location: mood

Duration: 2 weeks

Severity: moderate

Associated Symptoms:

  • poor concentration and indecisiveness
  • altered eating patterns
  • insomnia and mental fatigue
  • crying often
  • low self-esteem
  • feelings of worthlessness and guilt
  • recurrent suicidal ideation
  • jaundice
  • fatigue
  • dark-colored urine
  • abdominal pain
  • nausea

Modifying Factors:

  • physical and verbal abuse
  • low income
  • drug addiction
  • hepatitis C
  • weight problems
  • delinquent daughter

Subjective

Past Psychiatric History

M. J. has sought inpatient chemical dependency treatment on multiple occasions. The longest episode of addiction recovery was one year when she was in prison. She has abused neuro-chemically addictive drugs. M. J. has had psychotic symptoms, including delusions with incidences of self-cutting. She is a member of a local church support group.

Substance Abuse History

M. J. began drinking alcohol at age five due to family influence. She was introduced to drugs during her elementary years and started abusing cannabis and psychoactive agents in junior high. In high school, she escalated to crack cocaine and heroin before dropping out. Her adult life has been characterized by substance addiction.

Psychosocial/Family History

M. J. experienced childhood neglect and abuse. She was the only adopted child in a family of four and was not treated well like her siblings were. Her parents were alcoholics, exposing her to early alcohol abuse. Once M.J. became addicted, she moved to psychoactive substances and engaged in prostitution and gambling to buy drugs. She has an abusive boyfriend and does not have a close relationship with her 8-year-old daughter. M. J. has a strong Catholic faith and attends church-related support activities.

Medical History

M. J. reports no major medical problems. She, however, indicates that she used to experience menstrual flows and was taking birth control pills before becoming pregnant.

Medications

  1. 50mg Zoloft for depressive symptoms
  2. 40mg Suboxone for addiction

Objective Data

Psychiatric Assessment

  • Hours of Sleep: 4-6 daily
  • Appetite adequate: yes
  • Attending to Hygiene: yes
  • EPS: akathisia and slight tremors
  • Patient reports the following side effects from psychiatric medications: dizziness, insomnia, vomiting, and agitation
  • Patient on more than 1 Antipsychotic: yes
  • Least Restrictive Environment: partial hospitalization

Mental Status Exam

Observational components:

  • Attitude: cooperative
  • Appearance: normal
  • Personal hygiene: appropriately groomed
  • Affect: blunted
  • Speech and language: articulate, soft, and monotonic
  • Thought process: logical
  • Insight and judgment: poor
  • Memory: poor
  • Behavior: makes little eye contact and tremors
  • Motor activity: restless

Direct inquiry components:

  • Mood: depressed and agitated
  • Perception: negative auditory hallucinations – hearing voices
  • Suicidal ideation: none
  • Cognitive exam:
    • Orientation: oriented 3x – time, place, and person
    • Register and recall: fair
    • Attention and concentration: fair
    • Abstraction: poor
    • Current events: fair

Additional Findings

M. J. reports that abstinence from drugs elicits late-night binge eating. She also has difficulty dealing with anger and frustration. She indicates experiencing recurrent low moods and anxiety.

Standardized Assessment Tools

The Beck Depression Inventory (BDI) and the Zung self-rating depression scale (SDS) was utilized to screen for depression severity. The BDI score was 24 while Zung SDS result was 71, indicating that M. J. had clinical depression. The HCV Rapid Antibody diagnostic test was positive for hepatitis C virus.

Differential Diagnoses

The DSM-5 differential diagnosis for this case is major depressive disorder, single episode, severe (Tusaie & Fitzpatrick, 2017). The rationale for this decision is that M. J. has a history of substance abuse and cannot sustain recovery treatment. She also displays more than five symptoms required to make a major depressive disorder diagnosis, i.e., depressed mood, insomnia, mental/physical fatigue, feelings of worthlessness, and recurrent suicidal ideation.

Diagnoses

  1. F15.24 substance/medication-induced depressive disorder, single episode, severe
  2. F43.10 posttraumatic stress disorder (PTSD)

Additional Specific Areas of Concern

  1. The onset is after withdrawal from drug use
  2. Childhood abuse could account for PTSD

Plan

  1. 50mg Zoloft to treat depression and methadone maintenance treatment
  2. Daily individual and group therapy to improve coping mechanisms
  3. Rational emotional behavioral therapy (REBT) to address development-related addictions

Psychiatric Diagnosis

Epidemiology

The etiology of M. J.’s depressive episode could be linked to substance use or PTSD. The primary stressors include failure to sustain recovery, hepatitis C, sleep disorder (insomnia) and inadequate income. Multigenerational trauma related to childhood abuse could also lead to acute stress disorders.

Review of Literature

The criteria for diagnosing substance/medication-induced depressive disorder entail the appearance of symptoms within four weeks of using a drug, a patient history of substance abuse, and when the key features cannot be attributed to any other condition (Stander, Thomsen, & Highfill-McRoy, 2014). Diagnostic lab (blood) tests can also be used to confirm if drug use is the cause of the symptoms. Treatment entails cognitive-behavioral therapy (CBT) activities for addiction recovery and medication (Suboxone).

Health Promotion

Programs for preventing depressive disorder should promote protective factors linked to this condition. Rappeneau and Bérod (2017) recommend group intervention that equips people with problem-solving and coping skills to lower the prevalence of clinical depression. Campaigns against risk factors such as methamphetamine use and referral to psychiatric care may also help treat addiction.

Medical Diagnosis

Epidemiology

The development of depressive symptoms in M. J. may be linked to substance abuse. M. J. was diagnosed with a medical condition related to injection-drug use called hepatitis C. The HCV antibody test (qualitative assay) was positive and a confirmatory quantitative test (HCV RNA results) indicated a detectable value viral load (>800,000 IU/mL). Antiviral treatments for this condition may be related to an elevated risk of depression and delirium. These pharmacological agents affect the mood, resulting in depressive symptoms.

Review of Literature

Psychiatric comorbidity often occurs in injection-drug users. Substance abuse increases the risk of hepatitis C virus (HCV) infection due to the sharing of injection needles. Mental problems are common in patients receiving antiviral treatment for this condition (Schaefer, Sarkar, & Diez-Quevedo, 2013). MDD is a primary mood disorder associated with interferon alpha therapy (Schaefer et al., 2013). Therefore, interdisciplinary treatment is required to treat addiction, HCV, and depressive symptoms in M. J.

Health Promotion

Awareness programs on the association between depression and HCV antiviral treatment are required (Schaefer et al., 2013). Such interventions will ensure that M. J. seeks medical consultation and receives adequate screening and interdisciplinary pretreatment care. Additionally, antiviral treatment may be discontinued if the depressive symptoms intensify.

Integration of Disorders

Substance/medication-induced depressive disorder and posttraumatic stress disorder are characterized by overlapping symptoms. M. J. shows a depressed mood and agitation, which may indicate PTSD. She reports faulty memory related to drug use, sleep interruption, re-experiencing childhood trauma, and problems with forming intimate relationships (Tusaie & Fitzpatrick, 2017). She also has vegetative symptoms of depression, including poor concentration, insomnia, suicidality, low self-esteem, and feelings of worthlessness (Tusaie & Fitzpatrick, 2017). This comorbidity may be attributed to failed attempts to resolve past and current interpersonal stressors. Antiviral treatment for HCV infection in M. J. due to drug addiction may increase the risk of depression along with other stressors.

Discussion

M. J.’s symptoms meet the criteria for a primary diagnosis of substance/medication-induced depressive disorder. She has a substance abuse history that led to addiction-related hepatitis C infection. Therefore, depression may be a psychiatric side effect of HCV treatment. Antiviral therapy is also linked to neuropsychiatric symptoms, such as sleep alterations and cognitive problems (Schaefer et al., 2013).

M. J.’s history of abuse in childhood, her re-experiencing of this trauma, and sleep interruptions are characteristic of PTSD. This comorbidity may be explained by the presence of trigger factors, i.e., an abusive boyfriend, low socioeconomic status, and patriarchal culture (Fory, 2015). An interdisciplinary care approach that includes medical treatment for HCV, addiction therapy, psychotherapy, and social support can improve therapeutic outcomes.

Conclusion

A diagnosis of substance/medication-induced depressive disorder in M. J. during withdrawal may be a psychiatric side effect of drug addiction. Another related comorbidity is PTSD that could be attributed to her history of abuse. Therefore, an optimal treatment approach for this client is one that integrates medical treatments, hepatology, psychiatric care, and psychotherapy.

References

Fory, J. D. (2015). . Dialogues in Clinical Neuroscience, 17(2), 141-150. Web.

Rappeneau, V., & Bérod, A. (2017). Reconsidering depression as a risk factor for substance use disorder: Insights from rodent models. Neuroscience & Biobehavioral Reviews, 77, 303-316. Web.

Schaefer, M., Sarkar, R., & Diez-Quevedo, C. (2013). Management of mental health problems prior to and during treatment of hepatitis C virus infection in patients with drug addiction. Clinical Infectious Diseases, 57(2), 111-117. Web.

Stander, V. A., Thomsen, C. J., & Highfill-McRoy, R. M. (2014). Etiology of depression comorbidity in combat-related PTSD: A review of the literature. Clinical Psychology Review, 34(2), 87-98. Web.

Tusaie, K. R., & Fitzpatrick, J. J. (2017). Advanced practice psychiatric nursing: Integrating psychotherapy, psychopharmacology and complementary and alternative approaches across the lifespan (2nd ed.). New York, NY: Springer Publishing Company.

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