Decision tree on Comorbid Addiction

Decision tree on Comorbid Addiction
Comorbidity is the term used to describe a state in which an individual has two or more illnesses occurring simultaneously. The National Institute of Health (NIH) reports that the interaction between the two or more illnesses may complicate or worsen the prognosis of both (NIH, 2018). Comorbidity is a topic in which information present is still insufficient, and as reported by the National Institute on Drug Abuse, it remains a research priority. Drug addiction, on the contrary, is not a new concept. It is a mental illness, characterized by compulsive and uncontrolled drug craving and usage, in which the individual is unable to function normally without taking the drug (NIH, 2018). Comorbidity be used in the context of any two illnesses occurring together, but is often used with regards to substance abuse and addiction. This is because millions of cases of substance abuse and addiction frequently present with a co-occurring mental health disorder such as attention deficit hyperactivity disorder (ADHD), depression, bipolar disorder, post-traumatic stress disorder (PTSD), among many others (NIH, 2018).

For this assessment, we take a look at 19-year-old Miss Jane Doe (not her real name), who reported to the emergency department accompanied by a male who was later identified as her brother. She complained ever since their parents died a year ago, she is anxious most of the time; with feelings of worthlessness, guilt, hopelessness and helplessness. She is often irritable and restless, and is having difficulty concentrating while in school. This has majorly affected her grades, which made her teachers and brother worried. Since the incident with her parents, her alcohol consumption increased two-fold to six or more bottles a day. She reports that indulging in alcohol is her way of dealing with the grief. A mental status exam revealed that Miss Doe has depression disorder, as well as alcohol use disorder. Patient-specific factors to consider before putting her on medication include her comorbidities, how willing she is to take treatment, her weight, as well as any allergies she might be having. The final consideration is her willingness to participate in counselling sessions, as this is paramount in deciding her medication options (NIH, 2018).

Decision #1

Options for decision #1:

Put her on Antabuse (Disulfirum) 250mg orally, once every day
Put her on Campral (Acamprosate) delayed-release 666mg orally, three times a day
Put her on Celexa (Citalopram) 20mg once every day

Decision: Put her on Celexa (Citalopram) 20mg once every day.

Miss Doe is newly diagnosed of two conditions, all of which need to be managed. However, management of depression should be prioritized since it often precedes drug abuse. Selective serotonin reuptake inhibitors (SSRIs), a class of citalopram is a part of, are currently the recommended first-line medication for the treatment of depression (Guo et al., 2019). Put Miss Doe on citalopram gives her an option that is convenient given that this is her initial course of treatment. The other two options were dismissed for the initial treatment since they are adjunctive options in the treatment of alcohol abuse. Treatment of Miss Doe’s depression disorder may consequently lead to her reducing her alcohol intake.

It is expected that once Miss Doe commences medicating, her overall demeanor will improve. The major improvement expected is an elevation of her mood and that she will no longer be experience sadness as frequently as she has been. SSRIs act by blocking the reuptake of serotonin, thus increasing its action in the brain and leading to an elevated mood in the individual (Jakovljevic, 2015). Her alcohol intake is also expected to have a slight decrease, as she will have a better way to deal with her grief in the form of counselling. Miss Doe is expected to return for a review after four weeks.

Decision #2

Options for decision #2:

Increase the dose of Celexa (Citalopram) to 40mg once every day
Put her on Campral (Acamprosate) delayed-release 666mg orally, three times a day
Put her on both Celexa (Citalopram) 20mg once every day, and Campral (Acamprosate) delayed-release 666mg orally three times a day

Decision: Increase the dose of Celexa (Citalopram) to 40mg once every day

Opon her return for review, Miss Doe demonstrated good tolerance for citalopram. Her sadness was also slightly diminished and she was in a better mood than during her initial visit; and indicator of how effective the previous dose was. It is for this reason that her dose needed to be increased to 40mg. The other option of acamprosate is still a good one, but the citalopram was also having a positive impact on her alcohol intake hence why it was dismissed. Combining citalopram and acamprosate was a viable option but should only be considered once citalopram has reached its peak of 40mg (Kupferberg et al., 2016).

The expectation is that when Miss Doe returns for her check-up after four weeks, her mood will be elevated and her sadness completely diminished. Her initial symptoms such as anxiety, feelings of worthlessness, guilt, hopelessness and helplessness will have diminished if not resolved. Her alcohol intake will have also doubled-down to levels considered appropriate for a social drinker.

Decision #3

Options for decision #3:

Put her on Antabuse (Disulfirum) 250mg orally, once every day
Put her on Remeron (Mirtazapine) 30mg orally, once every day
Put her on both Celexa (Citalopram) 40mg once every day, and Campral (Acamprosate) delayed-release 666mg orally three times a day

Decision: Put her on Antabuse (Disulfirum) 250mg orally, once every day

Miss Doe, on her return for review, had made significant progress towards a full recovery. Upon assessment, she was in a jovial mood, and all her other initial symptoms had resolved. She was attending all her counselling sessions which, combined with the medication she was taking (citalopram), had propelled her towards recovery. However, she was still taking too much alcohol for hers and our liking; which is why we put her on disulfirum. Putting her on mirtazapine would have been of no use as her depression had resolved. The third option of both citalopram and acamprosate was a good option but the client declined owing to the fact that she would be taking a number of tablets.

The expectation is that when she returns for review after four weeks, Miss Doe will have completely ceased indulging in alcohol. This is because disulfirum inhibits the enzyme aldehyde dehydrogenase, resulting in the toxic accumulation of acetaldehyde (Guo et al., 2019). This accumulation discourages alcohol intake through an unpleasant alcohol-disulfiram reaction. Alcohol abstinence is the therapeutic outcome.

Ethical Considerations

In discharging their day-to-day duties, health care practitioners have to ensure they observe ethical practice. This entails following the ethical principles of autonomy, justice, beneficence and non-maleficence. Mental health practitioners often violate some of this principles, specifically autonomy; hiding behind the fact that their clients may not me mentally sound to make some of the decisions that pertain to their health (Haddad &Geiger, 2020). This should not be so. Clients have the right to choose, accept and decline medication that is being given to them. Health care providers, however, have to give them the necessary information needed for them to make an informed decision. In this scenario, Miss Jane doe declined the combination of citalopram and acamprosate after being given the needed information, allowing her to exercise her autonomy.

Conclusion

Comorbid addiction is a condition in which an individual is suffering from two illnesses, often mental health disorders. It is characterized by drug and substance abuse that accompanies a mental disorder such as depression, attention deficit hyperactivity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD), among many others (NIH, 2018). Treating the mental disorder may in some cases, help to resolve the drug abuse without extra interventions. Treatment options include psychotherapy (counselling) and pharmacotherapy. In depression, selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment, and are quite effective in combination with counselling. Mental health practitioners also have to be careful to observe all ethical principles of justice, beneficence, non-maleficence and more importantly autonomy.

References

Guo, S., Chen, L., Cheng, S. & Xu, H. (2019). Comparative cardiovascular safety of selective serotonin reuptake inhibitors (SSRIs) among Chinese senile depression patients: A network meta-analysis of randomized controlled trials. Medicine. Retrieved from https://doi:10.1097/MD/0000000000015786

Haddad, L. M., & Geiger, R. A. (2020). Nursing Ethical Considerations. Treasure Island (FL): StatPearls Publishing.

Jakovljevic M. (2015). Person-centered psychopharmacotherapy: what is it? Each patient is a unique, responsive and responsible subject. Psychiatria Danubina; 27(1), S28–S33.

Kupferberg, A., Bicks, L., & Hasler, G. (2016). Social functioning in major depressive disorder. Neuroscience & Biobehavioral Reviews, 69, 313-332.

National Institute of Health (2018). Comorbidity: Substance Use Disorders and Other Mental Illnesses Drug-Facts. National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/publications/drugfacts/comorbidity-substance-use-disorders-other-mental-illnesses

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