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Case Study for Dual Diagnosis Introduction This paper is a report on a case study regarding dual diagnosis. The client, Jane, is a 33 old banker originating from York. She is in the process of a divorce in which she is having coping difficulties. She reports feeling depressed at all times and unmotivated. She is also indicated drinking alcohol to help her deal with her problems. She has been prescribed 20 mg of Fluoxetine. She is seeking treatment in order to become abstinence from alcohol. The epidemiological issues, assessment process, areas of risk (Stein & Wilkinson, 2007), model of intervention, care plan, and related national policies assisted with the case study will be discussed.

Epidemiological Issues Research into the epidemiology issues related to dual diagnosis contributes to the field with regard to risk, consequences, relationships, associations, and the causation of these problems (Phillips, McKeown & Sandford, 2009). Accurate information can lead to improved service provisions, planning, and delivery (Brooker & Repper, 2009). A pan-European project was conducted from November of 2002 until October of 2005 in order to investigate dual diagnosis issues (Thornicroft, 2011). The project was called the Integrated Services Aimed at Dual Diagnosis and Optimal Recovery from Addiction (Isadora). The European commission funded the project as part of its Public Health Services (Stein & Wilkinson, 2007). There were seven sites in Europe, which worked with the project. One of these centres was at Middlesex University, London, England. There was also a centre at Cambridge University, England (Rassool, 2009).

It was discovered that somewhere between 60 percent and 90 percent of the substance abusers who seek treatment in the UK also have other mental-health problems and meet the requirements for dual diagnosis. A relatively high proportion (42 percent) of patients seeking treatment in Community Mental Health Team treatment in London also reported having substance abuse problems. It was discovered that females, such as the patient in the case study, were twice as likely to report depression as males suffering from a substance abuse disorder (Cooper, 2011). Overall, it was found that more information needs to be sought in order to reduce the level of comorbidity in the UK among those were depressed and abusing substances (Phillips, McKeown & Sandford, 2009).

Assessment Process The assessment process for an individual suspected of suffering from a dual diagnosis, such as the female in the case study, can be broken down into 12 general steps (Rassool, 2009). There must first be an engagement of the client in which the individual doing the assessment becomes a trusted confidant. The next step is to identify important people in the patient's life such as friends and family. These people must then be contacted with permission from the client. The next step is to detect and screen for the suspected disorders. In the case study, this would involve screening for depression and alcohol abuse or dependence. After this is accomplished, the locus of responsibility can be established. The next part of the assessment is to determine a diagnosis. In the case study, the client is likely to be suffering from the following: 309.0 Adjustment Disorder with Depressed Mood (Boardman, 2010) 305.00 Alcohol Abuse (Stickley & Basset, 2008)

After an appropriate diagnosis has been determined, the level of functional impairment should be assessed (Stein & Wilkinson, 2007). The strengths and support levels should be determined as well. Any linguistic needs or cultural issue should be addressed. Following this step, the problem domains should be identified. This stage of change must also be assessed (Stein & Wilkinson, 2007). After these tasks are accomplished, a treatment plan can be completed with a summary of the process prepared. Often, a risk assessment form such as the one presented in Appendix-A can be helpful for this process (Stickley & Basset, 2008).

Areas of Risk The client in the case study is likely to be suffering from both depression and alcohol abuse or dependence (Cooper, 2011). The combination of alcohol and depression is especially dangerous one with regard to the risk of suicide. While men more commonly commit suicide with violent means such as guns, women often commit suicide through medications. In the case study, Jane is going through a difficult period in her life and attempting to deal with the changes and stress associated with her divorce. She has been prescribed 20 mg of fluoxetine. This is a Selective Serotonin Reuptake Inhibitor (SSRI) and is not especially dangerous with regard to alcohol (Rassool, 2009). Jane should not be prescribed anything, which is a central nervous system depressant such as a benzodiazepine. These types of medications could prove fatal when combined with alcohol (Phillips, McKeown & Sandford, 2009). Studies have shown that many people contemplating suicide will admit this to a mental health professional (Day, 2007). Therefore, simply asking Jane if she is planning on harming herself is likely to be an effective method of assessing her for this risk. If she indicates that this is the case, she should be confined to an inpatient facility (Boardman, 2010).

Model of Intervention and Care Plan The therapeutic approach which will be used with Jane is Cognitive-Behavioural Therapy (CBT) (Brooker & Repper, 2009). This is a psychotherapy approach which focuses on cognitive processes, maladaptive behaviours, and dysfunctional emotions. It has been shown to be useful with substance abuse, depression, and dual diagnosis problems (Thornicroft, 2011). This is both an action oriented and problem-focused approach. The therapist assists the client by helping them choose strategies, which can reduce their difficulties. This approach to treatment was developed as a combination of cognitive psychology and behaviour therapy (Boardman, 2010). There will be two main goals of the therapy. The first goal will be to eliminate Jane's abuse of alcohol. This will be done by her engaging in the following behaviours: 1. Learn triggers for alcohol abuse (Brooker & Repper, 2009). 2. Avoid situations, which could lead to alcohol abuse. 3. Explore the dynamics between divorce-related depression and alcohol abuse. 4. Achieve one week with no alcohol abuse. The second goal will be an improved mood. This will be achieved by the following behaviours and cognitions: 1. Go one week without crying. 2. Complete three tasks every day. 3. Avoid sleeping to escape from negative feelings. 4. Call a crisis hotline if experiencing suicidal thoughts. 5. Celebrate daily success at mood improvement by noting it in a journal.

The process should be monitored and evaluated by the therapist weekly (Winyard, 2005). This can be done each time the client comes for psychotherapy.

National Policies and Guidelines In the United Kingdom, the National Service Framework (NSF) for Mental Health has emphasised that there is a need for advances with regard to dual diagnosis (Day, 2007). Unfortunately, there has been little progress made toward establishing service models and standards for treating many of these patients. During 2002, the NSF attempted to rectify some of these problems by developing a Dual Diagnosis Good Practice Guide. There was also a complementary guide for models of care with these types of problems, which was developed by the National Treatment Agency for Substance Misuse during 2002 (Stickley & Basset, 2008). One of the more striking messages sent by the Dual Diagnosis Good Practice Guide is that individuals suffering from severe mental illness are highly likely to have a substance abuse disorder (Day, 2007). It also describes why there is a need for integrated and comprehensive care of high quality to treat individuals with the dual diagnosis (Thornicroft, 2011). The publication of this guide and the complementary guide provided by the National Treatment Agency for Substance Misuse can be seen as progress in the UK toward assisting individuals suffering from a dual diagnosis such as the one being experienced by Jane in the case study (Winyard, 2005).

Conclusion This paper reported on a case study of a client suffering from alcohol abuse and depression. There was a discussion of the epidemiological issues (Winyard, 2005), assessment

process, areas of risk, model of intervention, care plan, and associated national policies and guidelines in the United Kingdom in relation to this type of dual diagnosis. It was pointed out that the Dual Diagnosis Good Practice Guide, and the complementary guide developed by the National Treatment Agency for Substance Misuse represent progress made in the United Kingdom toward helping individuals with these difficult problems (Thornicroft, 2011).

References Thornicroft, G. (2011). Oxford textbook of community mental health. Oxford: Oxford University Press. Cooper, D. B. (2011). Developing services in mental health-substance use. Oxford: Radcliffe Pub.. Phillips, P., McKeown, O., & Sandford, T. (2009). Dual Diagnosis Practice in Context.. Chichester: John Wiley & Sons. Day, E. (2007). Clinical topics in addiction. London: RCPsych. Boardman, J. (2010). Social inclusion and mental health. London: Royal College of Psychiatrists. Stickley, T., & Basset, T. (2008). Learning about mental health practice. Chichester, England: Wiley. Rassool, G. H. (2009). Alcohol and drug misuse a handbook for students and health professionals. London: Routledge. Brooker, C., & Repper, J. (2009). Mental health: from policy to practice. Edinburgh: Churchill Livingstone Elsevier. Winyard, R. (2005). Substance misuse in primary care: a multi-disciplinary approach. Oxford: Radcliffe Pub. Stein, G., & Wilkinson, G. (2007). Seminars in general adult psychiatry (2nd ed.). London: Gaskell.

APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

Risk Assessment / Substance Misuse

If YES to any of the questions, tick the relevant box(es) below. If NO Insert an X
1. SUICIDE, SELF-HARM & VULNERABILITY HISTORIC RISK?
N

CURRENT RISK?
N

HISTORIC RISK? Misuse of drugs and/or alcohol Living with another substance misuser Exploitation by others (1) Self harm
Y Y

CURRENT RISK?
Y

Suicide attempt/s Suicidal intent/ideation Significant life events Known to SOVA and/or TTS (2)

Y Y

y N

N
Y

Comments: (1) Has some thoughts of not wanting to be here, yet states he does not act on them. (2) Stated he attempted to overdose a few years prior, but nothing since then (3) He received a sentence for common assault, which triggered his addiction to heroin. He used right before he went in to prison for 2 weeks and has been using daily since coming out. This was 3 years ago. (4) He engages in risky behaviour and exploitation via friends in order to use together. His best friend (who uses with him) lives right next door. (5) He uses heroin and cannabis daily. Also buys diazepam and uses this when cannot get cannabis or heroin. He claims this helps his cravings for alcohol.

2.

AGGRESSION / VIOLENCE

HISTORIC RISK? N N

CURRENT RISK? N N Uninhibited behaviour

HISTORIC RISK? N N

CURRENT RISK? N N

History of violence Signs of anger and frustration Comments:

RISK ASSESSMENT. VERSION updated May 2011

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APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

3. CHILD PROTECTION AND SAFEGUARDING CHILDREN, YOUNG PEOPLE AND ADULTS Child Protection Issues Comments:

HISTORIC RISK? N

CURRENT RISK? N Vulnerable adults

HISTORIC RISK? N

CURRENT RISK? N

4. MENTAL HEALTH PSYCHOLOGICAL ISSUES Known to Mental Health

HISTORIC RISK? N

CURRENT RISK? Y Psychological health issues? *

HISTORIC RISK? Y

CURRENT RISK? Y

Comments: Expand * (has this changed e.g. become better or worse) Reports no involvement with CMHT. He reports sometimes he has thoughts of whats the point, yet does not act on them. He presented extremely anxious, talking a mile a minute, going off topic. He said he does suffer from anxiety and claims cannabis use keeps it calm.

5. Neglect

HISTORIC RISK?

CURRENT RISK?

HISTORIC RISK?

CURRENT RISK?

Poor nutrition Accommodation Issues

Y N

Y N

Not registered with a GP Financial Issues

N Y

N Y

Comments: can include details regarding personal hygiene 1. Hygiene was okay when presented, yet he is very skinny and says he can only eat very little 2. Stated he has ulcers and has had these since he was a teen ager due to prolonged alcohol use. He sees his GP for this. 3. Lives with his nan, states there are no issues there except he would like to live on his own again. 4. He is waiting for his benefits to be reinstated. 5. He is unemployed, yet supporting a drug habit daily with no money. He says he just gets his gear from his friends or gets money from his dad.

RISK ASSESSMENT. VERSION updated May 2011

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APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

6.

CRIMINAL JUSTICE

CURRENT RISK?

HISTORIC RISK?

CURRENT RISK?

Offences pending Continued offending behaviour Court dates

Y N N

N N n

Conviction for violent or sexual offences Arson/damage to property Drink/drug driving offences

Y N N

N N N

Comments: (prompts please give detail of violent or sexual offences) 1. Charged with common assault 2-3 years ago and served a minimum sentence for this (2 weeks). States this is what started his heroin use.

Sources of Information Face to face meeting

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APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

Persons Potentially at Risk (tick as appropriate) None Child/young person Self Partner/spouse Parent x Staff member General public

Group (specify)

Other (specify)

Detail of Risk to Self or Others:

Risk of unintentional overdose Risk of deterioration in psychological well being Risk of being caught of doing offending behaviour

Warning Signs of Risk and relapse indicators

Increased heroin use Cannabis use

Summary and Management of Risks Identified: Further action recommended/required: Discussion with multi disciplinary team members (please specify) Referred to CDAT 20/02/2013 for assessment and prescribing, as well as drug test and alcohol misuse Referred to GUM clinic for BBV testing
RISK ASSESSMENT. VERSION updated May 2011 Page 10 of 12

APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

Discussed risks of mixing diazepam and heroin, as well as side effects of pro-longed cannabis use. Crisis Team details discussed if feeling suicidal

Further action at this stage and/or Further risk assessment (please specify). Specify review frequency. (discuss with line manager)

Copies must be placed on file and copies provided to all parties involved in care plan. Assessed by: Date. Time. Location of assessment.
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(please print)

RISK ASSESSMENT. VERSION updated May 2011

APPENDIX A
CF RAF 02 D&A Assessment Form Risk Assessment

National Health

Number.. Agency NDTMS Number.

Mark Webb Name: Date of Birth: ......... 04/12/82

20/02/2013

12:00p.m.

CDAT Harlow

Signatory Page must be completed Assessor

Signature: .................................................................... Print Name:Danelle Chambers .................................... Designation: ................................................................ Date: 20/02/2013.........................................................

Seen and agreed by line manager

Signature: .................................................................... Print Name: ................................................................. Designation: ................................................................ Date: ...........................................................................

RISK ASSESSMENT. VERSION updated May 2011

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