During the last 20 years, comorbidity has had a growing prevalence in psychiatric disorders. Comorbidity refers to the overlap of more than one psychiatric disorder. Dual-diagnosis is a more specific diagnosis of a substance use, which can be drug or alcohol use, and other psychiatric disorders (Stinson et al., 2006). Such is the case with the subject Ken, who is presented for this paper. Ken’s sleep disturbances and lack of appetite indicate a diagnosis of depression to fulfill the psychiatric end of the dual-diagnosis. Using alcohol, underage, as a tranquilizer warrants the substance abuse diagnosis. His distraction, restlessness, and difficulties interacting with others can be attributed to both parts of the dual-diagnosis (Stinson et al., 2006).
There are many possible treatment settings which would be able to provide Ken and his family with the assistance he needs at this time. These include 12-step programs geared for adolescents, family service agencies, alcohol detoxification facility if needed, inpatient psychiatric treatment if Ken is a danger to himself or others or is deemed in need of intensive therapy, outpatient programs, alcohol rehabilitation facilities, or clergy or other religious counselors. Being seen by a psychology professional was a positive first step in helping to evaluate Ken’s status and determine which of these, or combination of these treatments are needed at this time. The combative nature that Ken has presented with is of special concern in addition to evaluating how much dependence he has on alcohol at this time (Stinson et al., 2006).
Part of the evaluation the initial evaluation of Ken by the psychology professional will need to be an assessment of each part of his dual-diagnosis. The evaluation needs to include both how much, how long, and how frequently Ken has been abusing alcohol to try and mask his problems and also the extent of his depression. As is often the case, adolescents with comorbid disorders are more likely to have a history of academic and behavioral problems. Additionally, these teens also demonstrate issues with behavioral discipline and social problems (Mason, Hawkins, Kosterman, & Catalano, 2010). If Ken’s alcohol issues are his primary issue, it is important that he is detoxed before other treatment begins. After his alcohol dependence is assessed as stable enough to begin treatment, Ken’s level of depression must then be measured. A general scale of classifying depression includes determining if the person has had a depressed mood over the last years for a period of at least two weeks and having “at least four of the following seven symptoms nearly every day during the same two week period: changes in weight or appetite, sleep-related difficulties, moving or talking slowly, fatigue, guilt or worthlessness, poor concentration or indecision, and thoughts of suicide or death (Mason et a., 2010).
Ken’s assessment demonstrates need for an environment where he can be closely monitored at all times. As is frequently seen, and as exhibited by Ken, 37% of people diagnosed with an alcohol disorder also have a comorbid psychiatric disorder. “The interaction between alcohol dependence and psychiatric comorbidity is complex and presents many challenges” (Lehman, Myers, & Corty, 1989). Additionally, Ken’s history of substance abuse with alcohol is an indicator that he is more likely to injure himself. When treating comorbid alcohol misuse, history has demonstrated that it is common to encounter increased aggression, especially in males (Lyne, O’Donoghue, Clancy, and O’Gara, 2011).
Taking the key elements of Ken’s evaluation, the psychology professional recommended the following after his assessment: inpatient hospitalization on a dual-disorders unit targeted to the adolescent age group, psychiatry assessment, individual and group therapy, alateen, and occupational therapy. Additionally, the psychiatrist will consider and evaluate the use of pharmacotherapy to treat Ken’s alcohol disorder. This is becoming an increasingly popular way to manage alcohol dependence for some doctors and treatment facilities (Ralevski, Ball, Nich, Limoncelli, & Petraskis, 2007).
Ken is at risk of causing injury to himself and others. He also has to be monitored to ensure he does not ingest any alcohol. Since he is a minor, just as a flight-risk precaution and for his safety due to his age, he will be placed on a locked, adolescent, dual-diagnosis unit in a psychiatric facility. His initial admission is for 3 days, but that is standard as he has not yet seen the psychiatrist. Medications will also be determined by the psychiatrist after Ken is evaluated.
Also, until changed by the psychiatrist, Ken will be on 15 minute checks by the psychiatric technicians, and, at any signs of agitation or aggression, he has an order to become a patient under constant observation by staff.
Ken’s harm reduction plan will be in stages. Initially, Ken will have to be able to understand and admit that he has been doing harm to himself, through his alcohol use. He also has to be willing to accept help and treatment. When this is accomplished, he is able to benefit from alateen while inpatient, and after his discharge on an outpatient basis. He also will benefit from working with a certified addictions counselor. The counselor, if qualified, can be the same as for his psychiatric issues. In fact, this is encouraged for continuity of care. When Ken is detoxed, he can also begin treating his depression. A safety contract is a need for Ken. He needs to learn to identify feelings that cause him to act out before he does act. He also needs to learn who it is safe to go to and express these feelings. Ideally, when at home, one or both of his parents can be trained in how to assist Ken if he needs help keeping himself safe. He also needs to understand the basic chemistry of depression and why it is important to work with a psychiatrist about the possible need for medication and compliance with treatment. Ken also needs clearly defined consequences about acting in a way that causes injury to himself or others.
Alcohol and drug use disorders are one of the most common psychiatric disorders in the United States. Now that there are detailed dual-diagnosis treatment options which integrate substance use and psychiatric treatment options, it has been realized the tremendous numbers were missing from those counted in the treatment population (Stinson et al., 2006).
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