Alcohol Problem with Bipolar Affective Disorder - Case Study Example

Alcohol Problem with Bipolar Affective Disorder Introduction The case study client is Mary changed), a white Caucasian female thirty-two yearsof age. She presented herself at the out-patient psychiatric clinic complaining of feeling depressed and unable to sleep. She was diagnosed as suffering from bipolar affective disorder with an accompanying alcohol problem. This paper will present the history of the patient and critically evaluate a planned intervention strategy to prevent episode recurrence in the patient and prevent alcohol abuse by the patient. Case History Mary presented herself at the out-patient psychiatric clinic complaining of depression and lack of sleep. She appeared quite depressed and haggard from the lack of proper sleep. In addition she demonstrated pressured speech in her communication and irritability at the questions posed to her to ascertain her case history. Her history was got from her through patient efforts of the nursing professional. Mary was a case with a previous history of bipolar affective disorder. She was diagnosed with history of bipolar affective disorder more than eight years ago. She was put on a maintenance lithium therapy. However her compliance with the planned medication therapy was irregular and for some months now, she had stopped taking her medications loosing confidence in the medication therapy providing permanent relief from her condition. She had married for a second time a year ago impulsively, after a brief courtship of six weeks. The marriage had fallen apart four weeks ago culminating in a divorce. Alcohol consumption had always been a source of comfort for Mary during episodes of depression. The break-up of her marriage had brought on severe depression and Mary had turned to her normal solace of alcohol abuse. She was employed as a part-time solicitor. During periods of alcohol abuse she tended to neglect her work, as the use of alcohol gave her a severe hangover the next day. Currently she was not going to work. Assessment Typically bipolar affective disorder is characterized by wide fluctuations in mood and behaviour stemming from depression and excessive elation or mania (Beckford-Ball, 2008). In the case of Mary however, the acute episode of bipolar affective disorder had led to deep depression, with irritability as the only sign of mania. The current acute episode of depression was brought on by a combination of factors. She had discontinued the medication she was supposed to take and the event of divorce in her personal life. Non-adherence to treatment regimen is common problem with bipolar affective disorder (Baldessarini, Perry & Pike, 2008), and is demonstrated by Mary. Alcohol dependence has only enhanced the non-adherence to the treatment regimen by Mary, as abuse of alcohol causes bipolar affective disorder patients to discontinue their medications (Baldessarini, Perry & Pike, 2008). A detailed investigation by the nursing professional as recommended by Goosens et al, 2008, provided insights into the desired outcomes that Mary expected from her visit to the psychiatric out-patient clinic. The problems that Mary faces are manifold. She is suffering from an acute episode of depression due to her discontinuation of medications for her condition of bipolar affective disorder coupled with the personal tragedy of divorce. She has a problem of alcohol abuse and absence from work. In addition she has a problem of lack of social support. Mary expects that her visit to the psychiatric out patient clinic will help resolve the problems that she faces. Interventions Multi-disciplinary interventions are essential for meeting the expected outcome of Mary. The first intervention is from the psychiatry medical professional, who has to evaluate the therapeutic regimen of lithium that has been prescribed earlier for Mary and decide whether it would be appropriate in the case of Mary to continue with Lithium or a change of drug or a combination of drugs would be more appropriate for Mary. The second intervention required is to target the alcohol abuse and prevent its occurrence. This intervention requires the combined efforts of the psychiatry medical professional, the psychiatry nursing professional, community nursing professional and the social worker. Through discussions between the psychiatry medical professional and the psychiatry nursing professional an appropriate alcohol abuse prevention program for Mary has to be put in place. The alcohol abuse prevention program could consist of a drug supported alcohol abuse prevention program or a an alcohol abuse prevention program without drug support developed in conjunction with Mary and support by the community nursing professional and the social health worker by contacts with Mary in the community and at her residence. The final intervention is to encourage Mary to resume working regularly. The strategy for this intervention results from discussions between the psychiatry nursing professional, the community nursing professional and the social health worker. Though it is initiated by the psychiatry nursing professional in her interaction with Mary, it is essentially implemented by the community nursing professional and the social health worker during the more frequent interactions with Mary. Risks The risk assessment for Mary shows that there are three elements of risk present. The first risk is the possibility of the condition of depression in Mary deteriorating to the extent that she could attempt suicide. The combination of bipolar affective disorder with alcoholism puts Mary at high risk for suicide. Potash et al, 2000, as a result of their study point out that the combination of bipolar affective disorder with alcoholism has a risk of 38.4% life time rate of attempted suicide associated with it in comparison to 21.7% when alcoholism is not present. The second risk is the possibility of Mary becoming an alcoholic through her dependence on alcohol complicating the management of her bipolar affective disorder. The final risk is that her irregularity at her work could lead to her losing her job. The loss of her job besides having an impact on her social-economic status has a direct bearing on the outcome of her planned care. Among the factors that are responsible for relapse in patients with bipolar affective disorder are the lack of employment and the loss of self-respect, when employment is lost (Marzanski, Jainer & Stallard, 2008). Critique of the Planned Care According to Kohn et al, 2004, mental disorders like bipolar affective disorder are widely prevalent around the world and are not adequately treated in spite of the availability of effective treatments, leading to a gap in the treatment of such mental disorders. This forms the basis of the re-evaluation of the existing treatment regimen. Lithium has been the mainstay of maintenance treatment in bipolar affective disorder for many years now. There is controversy on the effectiveness of lithium as a maintenance treatment in the management of bipolar affective disorder. A frequently pointed out advantage of lithium in bipolar affective disorder is the reduction in suicide tendencies in these patients, but this is not supported by adequate evidence (Burgess et al, 2001). Other medications that can be considered as substitutes for lithium are oxcarbazepine and omega-3 fatty acids. There is however inadequate evidence to provide guidance in the use of oxcarbazepine in the maintenance treatment of bipolar affective disorder (Vasudev et al, 2008). A similar situation exists with omega-3 fatty acids with inadequate evidence for any clear cut use in bipolar affective disorder (Montgomery & Richardson, 2009). With alcoholism as an additional problem valproate maintenance may be considered, as it decreases heavy drinking in patients with co-morbid bipolar disorder (Salloum et al, 2005). Alternatively if the decision is to continue lithium, then quetiapin can be considered as an adjuvant therapy for preventing alcoholism (Martinotti et al, 2008). With many treatment options available, the choice of the appropriate maintenance for Mary has been left to the psychiatric professional based on the assessment of the unique care needs of Mary. The nursing professional support at the clinical level targets the risks for alcoholism causing becoming alcohol depended with its consequences, by putting in place an alcoholism prevention program, which is to be supported by the social worker. In a similar vein the other risk factors of suicide and possible loss of job and through that self-respect are targeted for efforts at the community level through efforts of the community psychiatric nurse and the social health worker to increase social networks and encourage regular attendance of work. Additional effort from the psychiatric nursing professional can come in the form of encouraging compliance with the treatment protocol by creating awareness of the need for this compliance and the consequences in case of non-compliance. Conclusion Mary presents at the clinic with the signs and symptoms of bipolar affective disorder and is diagnosed with bipolar affective disorder. Her history confirms the diagnosis and also provides information that the current acute episode of depression has been triggered by the lack of adherence to the earlier therapeutic regime of lithium and the recent divorce event in her life. She has turned to alcohol for relief, which is having the impact of her not going to work. The management plan consists of a multi-disciplinary effort, wherein the therapeutic regimen is decided by the psychiatric medical professional, while the efforts of the clinical psychiatric nursing professional, the community nursing professional and the social health worker are essentially concentrated on ensuring the therapeutic regimen is complied with; creation and implementation of an alcoholism prevention program suited to Mary; ensuring that Mary resumes working and creating social support for Mary. Literary Reference Baldessarini, R. J., Perry, R. & Pike, J. 2008, ‘Factors associated with treatment nonadherence among US bipolar disorder patients, Human psychopharmacology, vol.23, no.2, pp.95-105. Beckford-Ball, J. 2008, ‘An overview of the new NICE guidelines on bipolar disorder, Nursing Times, vol.102, no.34, pp.23-24. Burgess, S. S., Geddes, J., Hawton, K. K., Taylor, M.J., Townsend, E., Jamison, K. & Goodwin, G. 2001, Lithium for maintenance treatment of mood disorders, Cochrane database of Systematic Reviews, vol.3. Goossens, P. J., Beentjes, T. A., Leeuw, J. A. Knoppert-van de Klein, E. A. & van Achterberg, T. 2008, ‘The nursing of outpatients with a bipolar disorder: what nurses actually do’, Archives of psychiatric nursing, vol.22, no.1, pp.3-11. Kohn, R., Saxena, S, Levav, I. & Saraceno, B. 2004, ‘The treatment gap in mental health care’, Bulletin of the World Health Organization, vol.82, pp.858-866. Martinotti, G., Andreoli, S., Di Nicola., Giannantonio, M., Sarchiapone, M. & Janiri, L. 2008, ‘Quetiapine decreases alcohol consumption, craving, and psychiatric symptoms in dually diagnosed alcoholics’, Human psychopharmacology, vol.23, no.5, pp.417-424. Marzanski, M., Jainer, A.K. & Stallard, N. 2008, ‘Naturalistic study of the efficacy of different treatment strategies in relapse prevention in bipolar affective disorders, International Medical Journal, vol.15, no.4, pp.277-285. Montgomery, P. & Richardson, A. J. 2009,’ Omega-3 fatty acids for bipolar disorder’, Cochrane Database of Systematic Reviews, vol. 2, CD005169. Potash, J. B., Kane, H.S., Chiu, Y., Simpson, S. G., MacKinnon, D. F., McInnes, M. G., McMahon, F. J. & DePaulo, J. R. 2000. ‘Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships’, American Journal of Psychiatry, vol.157, no.12, and pp.2048-2050. Salloum, I. M., Cornelius, J. R., Daley, D. C., Kirisci, L., Himmelhoch, J. M. & Thase, M. E. 2005, ‘Efficacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double-blind placebo-controlled study’, Archives of general psychiatry, vol.62, no.1, pp.37-45. Vasudev, a., Macritchie, E., Watson, S., Geddes, J. & Young, A.H. 2008, Oxcarbazepine in the maintenance treatment of bipolar disorder, Cochrane Database of Systematic Reviews, vol. 1, CD005171. Read More