The term co-occurring disorders refers to the existence of a mental health and substance abuse disorder simultaneously (Sadock, Sadock, & Ruiz, 2014). Co-occurring disorders often complicate the treatment regimen. The purpose of this paper is to describe two psychiatric conditions that may co-occur in practice, illustrating their causes, prevalence, indications, and DSM-5 criteria used in their diagnosis. This paper also describes a case study of a patient presenting with one of the described psychiatric disorders and a physical health problem. The relevance of normal development, neurobiology, epidemiology, socioeconomic standing, culture, sexual characteristics, and age are also integrated into the case scenario and assessment.
Alcohol Use Disorder
Etiology
Alcohol use disorder (AUD) is a longstanding complication that is attributed to a multifactorial etiology. Factors implicated in the development of AUD include hereditary, societal, emotional, and environmental. About 50% likelihood of developing AUD is influenced by the genetics of an individual (Grant et al., 2015). Family pedigree investigations of alcoholic individuals show that the likelihood of developing alcoholism increases between four and seven times among first-degree relations of an alcoholic compared to the rest of the population. Twin studies reveal that identical twins have a higher concordance rate of alcoholism compared to non-identical twins (Verhulst, Neale, & Kendler, 2015). The incidence of concordance in non-identical twins resembles that of siblings who are not twins (Lee et al., 2017).
Certain mental disorders are linked to AUD, including anxiety complications, affective problems, schizophrenia, and post-traumatic stress disorder (Grant et al., 2015). This connection is attributed to the impact of alcohol on brain neurotransmitters and their receptors. The social upbringing of a child may also influence their development of AUD. Problem behavior and temperament issues during childhood can influence behavior problems, alcohol, and substance abuse during puberty and early adulthood.
Prevalence
AUD is among the most common mental health problems worldwide. It is estimated that 16 million people in the United States are living with AUD. Only about 20% of adults with AUD seek medical help. National epidemiologic information using the DSM-5 criteria for AUD indicates that the twelve-month prevalence of AUD was 13.9%, whereas the lifetime incidence was 29.1% in 2012. Prevalence was higher for men, white, Native Americans, previously married, or never married adults than the general population (Hughes, Wilsnack, & Kantor, 2016). Subjects with the lowest income rates recorded the highest twelve-month and lifetime AUD prevalence rates. AUD was also associated with a high incidence of other substance use complications, depression, antisocial tendencies, bipolar I disorders, and borderline personality disorders throughout all levels of AUD seriousness (Grant et al., 2015).
Signs and Symptoms
For an individual to be diagnosed as having AUD, they need to display two or more signs out of a set of 11 predefined symptoms as established by DSM–5 over a 12-month period (Sadock et al., 2014). The first symptom is taking larger than anticipated quantities of alcohol over a long time, whereas the second symptom is having an unending yearning to reduce alcohol intake without success. As a result, a lot of time is wasted activities that involve looking for alcohol, taking it or attempting to shake off the effects of alcohol. Other symptoms include having a strong yearning to take alcohol, consistent consumption of alcohol resulting in poor performance of responsibilities, and nonstop consumption of alcohol in spite of experiencing its adverse effects.
The seventh symptom is giving up valuable social, vocational, or leisure activities as a result of alcohol use while the eighth indication is using alcohol in situations where it poses physical danger, for example, driving under the influence of alcohol. An individual also continues to take alcohol in the face of consistent physical and mental issues attributed to alcohol. The affected person may experience alcohol tolerance, which is described as requiring higher than usual quantities of alcohol to attain the desired level of inebriation or a substantial reduction in intoxicating effects with sustained intake of a specific amount of alcohol. The final symptom is experiencing withdrawal symptoms when denied alcohol or taking alcohol or a related substance to prevent the symptoms of withdrawal. An individual displaying two or three of these symptoms is considered to have mild AUD (Sadock et al., 2014). Moderate AUD is characterized by the manifestation of four to five symptoms. On the other hand, severe AUD is indicated by the presence of six or more symptoms.
Other Assessment Instruments
Various instruments are available to diagnose AUD in different age groups. The Alcohol Craving Questionnaire (ACQ–NOW) is a diagnostic instrument that estimates acute alcohol craving. It is commonly used in adult patients to evaluate the effectiveness of treatment before and after rehabilitation (Mishra, Praharaj, Katshu, Sarkar, & Nizamie, 2015). The substance abuse module (SAM version 4.1) is used to help in the planning of treatment for adults and adolescents aged 16 years and above. This tool is beneficial for all populations except those with acute retardation or serious organic brain syndrome.
Major Depressive Disorder
Etiology
There is no single cause for depression. A number of factors are attributed to increased susceptibility to major depressive disorder, which may be referred to as clinical depression. Different genetic and stress features interfere with the chemistry of the brain and its capacity to sustain mood stability. Evidence from investigations involving twins indicates that depression has a concordance of 40 to 50%. Having first-degree relations with a depressed individual triples the chances of developing depress.
Stress and social losses elevate the risk of major depressive disorder. For example, bereavement during childhood may cause depression in later stages of life. Longstanding pain and medical complications can also trigger depressive episodes. The pain connected with chronic illnesses may disturb sleep patterns and other biological cycles leading to depression. Other risk psychosocial risk factors for depression include solitude and bad life events. Substance abuse and pharmacological agents such as steroids can also trigger major depressive disorder.
Prevalence
Depression is a common mental health problem in the United States. Approximately 7.6% of people aged 12 years and older were diagnosed with depression between 2009 and 2012 (Mata et al., 2015). The incidence of depression was higher in females than males and in people aged between 40 and 59 compared to other age groups. However, there is limited information regarding the prevalence of major depressive disorder in children and teenagers. Overall, the occurrence of clinically meaningful depressive indications increases as individuals advance in age, particularly when medical sickness and institutionalization are involved.
Signs and Symptoms
For an individual to be diagnosed with major depressive disorder, they need to display five or more signs out of a set of symptoms outlined by the DSM–5 over a two-week period. These signs include being dejected all the time as described by specific vocabulary in a subjective assessment or other people’s remarks. These terminologies include feeling blue, sad, empty, cranky (in children), and appearing tearful. The second symptom is an obvious disinterest in everyday activities and other things that a person previously enjoyed. A significant reduction or increase in weight without intentional dieting (more than 5% of the body weight within 30 days) or a significant daily increase or decline in appetite are other indications of depression. Alterations in sleep patterns, for instance, lack of sleep or sleeping too much is a useful depressive symptom. Psychomotor agitation, which is characterized by difficulties staying still and pacing up and down, and psychomotor retardation (slow movements and speech), may also be evident in depression. Extreme fatigue even after doing small tasks or taking too long to accomplish light jobs may be indicative of depression. Another useful indication of depression is an emotional state of worthlessness and guilt brought about by thinking about previous failures. Depressed individuals may display a decreased ability to focus or uncertainty on a regular basis. Suicidal ideations without concrete plans of committing suicide are also reported in depressed people.
Social, work-related, learning, or other essential performances are affected negatively by the alteration in temperament. For example, a depressed person may stop going to work or school or start missing their normal social activities such as spending time with friends. A dejected disposition that is attributed to substance abuse, medication, or a general medical problem is not deemed a major depressive disorder. In addition, a diagnosis of depression cannot be made in people with manic, hypomanic, or mixed attacks as well as schizoaffective disorders (Sadock et al., 2014).
Other Assessment Instruments
Other instruments that can be used to screen for depression include self-report screening tools such as Patient Health Questionnaire-9 (PHQ-9), which is a depression scale consisting of 9 items with a maximum score of 3 on each item. A total score of 27 indicates severe depression. A 9-item depression scale; each item is scored from 0-3, providing a 0-27 severity score. The Center for Epidemiologic Studies-Depression Scale (CES-D) is another self-assessment tool made up of 20 items that permit the patient to assess their feelings, actions, and perceptions from the previous week (Cosco, Prina, Stubbs, & Wu, 2017). Another useful assessment tool is the Hamilton Depression Rating Scale (HDRS), which is done by a qualified professional (Bobo et al., 2016). This tool may have 17 or 21 items tot up from 0 to 2 or 0 to 4. An overall score of 0 to 7 is thought to be normal, whereas scores of 20 and above point towards moderate to severe depression.
Co-Occurrence of AUD and Type 2 Diabetes
Diabetes commonly co-occurs with AUD. The prevalence of medical disorders such as diabetes, high blood pressure, and stroke are usually higher in people with alcohol consumption problems than the general population. This observation is attributed to the impact of alcohol use on self-care behaviors that are needed to manage physical illnesses such as diabetes (Rieckmann et al., 2016). Alcohol use in diabetes is associated with hypoglycemia because intoxication impairs the patient’s capacity to identify the early symptoms of hypoglycemia and intervene correctly. AUD can also aggravate diabetic ketoacidosis and increase the likelihood of peripheral neuropathy and retinopathy. Large amounts of alcohol are known to lower the body’s sensitivity to insulin, which is already a problem in type 2 diabetes. Therefore, alcohol consumption complicates glycemic control.
Etiology
The co-occurrence of diabetes and mental problems such as AUD can occur in different patterns. The two problems may occur as separate disorders without any connection. Alcohol use is a known risk factor for type 2 diabetes (Rieckmann et al., 2016). The progression of diabetes may also be confounded by the development of psychiatric disorders such as AUD. For example, some of the drugs used to treat psychiatric disorders can hamper glucose tolerance, leading to the development of diabetes.
Prevalence
The occurrence of alcohol use in diabetic populations is between 50 and 60% of patients who seek treatment. About 17% of diabetic patients who visit healthcare facilities due to hypoglycemia have drinking problems. Engler, Ramsey, and Smith (2013) report that 28% of arbitrarily selected diabetes patients in an outpatient clinic met analytic criteria for a lifetime incidence of alcohol abuse.
Impact of co-occurrence on clinical assessment
The main problem associated with psychiatric problems in diabetes patients is low detection rates. About half of mental problems go undetected because of an intersection between the physical symptoms of diabetes and psychiatric problems. Therefore, it is essential to look out for social and cognitive attributes of psychiatric disorders.
Case Scenario
Demographic information
JK is a 42-year-old Hispanic male with a self-reported problem with alcohol consumption. More males are reported to have AUD than females (Hughes et al., 2016), which shows that gender is an important indicator of the prevalence of AUD. JK is married with three children. He used to work as an accountant in a learning institution but he was laid off two years ago.
Presenting problem and behaviors
JK complains of frequent thirst, passing of urine, headaches, and fatigue. JK was diagnosed with type 2 diabetes mellitus 4 years ago. He has been using metformin to manage his blood glucose levels but noticed that these symptoms persisted even with the medication. JK was an occasional alcohol consumer and his drinking sessions were limited to social events and weekends. JK’s was forced to work under a new manager following significant changes at work. Unfortunately, he did not get along well with his new boss, which led to immense work pressure. The work environment became so stressful that he resorted to taking one to two bottles of beer every evening. He found that alcohol provided temporary relief and helped him forget the bad days at work. However, with time, he needed to take three to five bottles to attain the desired effect. Consequently, he reported to work late, his productivity decreased gradually until he was finally laid off two years ago. His drinking problem worsened, causing him to spend a significant fraction of his savings on alcohol, which brought conflicts with his wife. This observation corroborates the hypothesis that alcoholism is more prevalent in people of low socioeconomic status (Lee et al., 2015).
JK disclosed that his father was an alcoholic and that his drinking habits led to his parents’ divorce when he was 12 years. JK grew up without a mother (lacked maternal love) and attributed his problems to the absence of his mother, which probably led him to alcoholism. Normality is deemed as patterns of behaviors or personality attributes that are typical or conform to a given yardstick of respectable and appropriate ways of behaving and being. JK’s development was not normal because of his mother’s absence. The cultural upbringing of the subject highlights the importance of family in nurturing a child. His cultural belief was that the presence of both parents was needed for the proper upbringing of children. These events motivated JK to seek help not only to restore his physical wellbeing, but also to restore his family.
Signs and symptoms
JK increased his alcohol consumption from two to five bottles of beer over the last few years (DSM-5 criterion 1). Long-term alcohol exposure triggers alterations in neural circuits that regulate motivational processes such as stimulation, reward, and strain. These alterations affect how the system uses signaling molecules such as opioid peptides, dopamine, γ-aminobutyric acid, glutamate, and the brain’s stress reaction machinery (Tabakoff & Hoffman, 2013). These neuroadaptations alter sensitivity to the effects of alcohol following constant exposure to and discontinuation of alcohol use.
JK also experienced tolerance when two bottles of beet could not satisfy him, thus compelling him to increase his alcohol consumption to five bottles a day (DSM-5 criterion 11). Alcohol use in the patient lowered his productivity at work, which finally cost him his job (DSM-5 criterion 7). JK continued to take alcohol despite its interference with the management of type 2 diabetes (DSM-5 criterion 9). However, JK is yearning to stop taking alcohol because he understands the impact of alcohol on family (DSM-5 criterion 2). The subject’s other symptoms (frequent thirst, the frequent passing of urine, headaches, and fatigue) are because of the effect of alcohol in patients with type 2 diabetes. It is reported that long-term alcohol use in well-fed diabetic patients causes hyperglycemia (Gepner et al., 2015).
Assessment
JK has five out of the 11 symptoms of AUD as outlined by the DSM-5 criteria. Therefore, his case can be considered moderate AUD. The other symptoms presented by the subject are characteristic of hyperglycemia in patients with type 2 diabetes. A blood sugar test needs to be conducted to ascertain the severity of hyperglycemia. It is also important to conduct HbA1c testing to determine the patient’s glycemic control over the last six months.
Appropriate Screening Tools
The CAGE screening tool is recommended for assessing the extent of drinking problems in patients with type 2 diabetes (Knychala, Jorge, Muniz, Faria, & Jorge, 2015). This tool consists of four questions. Two or more yes responses are indications for further assessment. An additional tool that could provide additional insights into JK’s condition given the co-occurrence of AUD with type 2 diabetes is the substance abuse module (SAM version 4.1), which can be used to plan for the treatment of the patient.
Plan of Care
Alcohol interferes with the uptake of oral hypoglycemic agents. For example, metformin should be discontinued in active alcohol users because it triggers lactic acidosis (Kim et al., 2015). Furthermore, the dosage of oral hypoglycemics that are broken down in the liver should be lowered to prevent alcohol-induced hepatopathy. The patient should receive pioglitazone for blood sugar control (Cusi et al., 2016) and naltrexone to help with the management of alcohol dependence (Rieckmann et al., 2016). Disulfiram cannot be used because it is contraindicated in diabetic patients. The patient should receive education on the dangers of alcohol consumption in diabetes and be encouraged to cut down or stop alcohol consumption.
Conclusion
Individuals with co-occurring physical and mental disorders form a substantial fraction of the population. Comorbidity increases the magnitude of presenting symptoms, functional weakening, elevated medical costs, and reduced quality of life and increased costs. Therefore, concerted care models are required for proper assessment and effective treatment of co-occurring mental and physical health problems.
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