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Medication and Dual-Diagnosis

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The Complicated Relationship between Mental Health and
Substance Use Disorders
Amber M. Paradise
Kaplan University

Abstract
This paper explores four articles about research on the complicated relationship between mental health and substance use disorders. I focused my research on the relationship between depression, including post-partum, and alcoholism. In this paper, I will explain why my client, Rhonda is considered dually diagnosed, I will explain the health problems that can occur from using alcohol and the effects alcohol has on the brain and body, I will explain how alcohol impacts depression, and last, I will explain the specific problems that exist in treating the dually diagnosed individual.
An individual who has any combination of a mental disorder (anxiety, depression, bipolar disorder) and addiction (drugs, alcohol, sex, gambling) is considered to be dual diagnosed. (Foundations Recovery Network, 1995) In one article, Paljärvi (2009) states “experimental studies have found that alcohol intoxication can produce even severe depressive symptoms during heavy drinking episodes.” Becker (2012) states in his article, “Alcohol has anxiety-reducing properties and can relieve stress, while at the same time acting as a stressor and activating the bodies stress response systems.” According to Evans and Sullivan (2001), individuals with a history of alcohol dependence, especially those early in recovery and those who are older, show significant cognitive impairments. Individuals with major depression also have significant cognitive deficits and the two together cause double the difficulties in thinking and learning. The most helpful support for a dually-diagnosed client is family and friends because they provide empathy and are non-judgmental of the client. Along with support from family and friends, it is also important to provide the proper medical and psychosocial treatment in order for the client to be active in their journey to recovery.

The Complicated Relationship between Mental Health and
Substance Use Disorders Diagnosed with depression as a teenager and using self-injury (cutting) to alleviate this mental health disorder, Rhonda received treatment to stop cutting only to replace it with alcohol and smoking. Rhonda’s history of depression, including postpartum depression, alcohol, and a history of self-injury are the reasons for her being dual diagnosed. A Dual Diagnosis can be made up of any combination of a mental disorder (anxiety, depression, bipolar disorder) and addiction (drugs, alcohol, sex, gambling). Dual Diagnoses that include depressive disorders are among the most common forms of the problem; in fact, the Journal of Clinical Psychiatry reports that one in three adults who struggle with alcohol or drug abuse also suffers from depression. (Foundations Recovery Network, 1995) Rhonda suffered from intense periods of postpartum depression after she had both of her children. Postpartum depression (PPD) alone is a major health concern affecting between 10% and 15% of women following delivery. Defined as a major depressive disorder with onset within four weeks of postpartum, PPD not only affects the new mother, but her children and family as well. Women who suffer from postpartum depression are less likely to breast feed, talk or play with her child and do not visit the child often. Postpartum depression in a mother can cause the child to suffer from impaired mental and motor development, low self-esteem, behavioral challenges, and poor self-regulation. (Wilton, Moberg, & Fleming, 2009)
Discussion
Health problems caused by alcohol. The health effects that can occur from using alcohol are: chronic disease, accidents and injuries, as well as short-term and long-term social consequences. The amount of alcohol an individual drinks and how often they drink determine if there will be any biochemical effects on cells and organs in the body, and/or alcohol dependence. Alcohol contributes to a number of conditions such as: alcoholic psychosis, alcohol-dependence syndrome, diseases affecting the nerves, known as alcoholic polyneuropathy, alcoholic cardiomyopathy-affects the heart, alcoholic gastritis-affects the stomach, and alcoholic liver cirrhosis-affects the liver. There are also a number of cancers associated with alcohol: lip, tongue, throat, esophagus, liver cancer, breast cancer and can also contribute to high blood pressure, abnormal heart rhythms, heart failure, and strokes. (World Health Organization, 2004, pp. 35-57) The immune deficits seen in chronic alcohol abusers are associated with at least some increase in the frequency of various infectious diseases, including tuberculosis, pneumonia, yellow fever, cholera, and hepatitis B. (Hart & Ksir, 2013, pp. 210-214). When Rhonda started using alcohol in place of self-injury during her adolescent years, she increased her chances of adult substance dependence. It is during adolescence, when very important neurobiological changes continue to occur due to the maturation processes in the brain, including, but not limited to, developmental changes in the PFC, the cerebellum, and the hippocampus as well as white matter structural alterations. Additionally, many neurotransmitter systems, such as GABA and dopamine, continue to develop and mature during adolescence. The adolescent brain appears to be sensitive to the effects of alcohol, which can in turn influence behavior. In the short-term, these changes in cellular excitability can disrupt glutamatergic paired-pulse plasticity, enhance presynaptic GABA release, and suppress formation of LTP. Chronic exposure to alcohol can result in long-term changes in expression of genes important for memory formation, as well as protein levels that facilitate the neuroanatomical correlates of learning, including neurotrophic factors. (Klintsova, Hamilton, & Boschen, 2012, pp. 8-9)
Alcohol impacts Depression. Alcohol is a central nervous system depressant and this drug alone triggers depression symptoms like sadness and hopelessness. Rhonda has been drinking alcohol in hopes of lifting her spirits or to block out certain things that she does not want to remember. The result of this is that her depression and alcoholism are feeding into each other and therefore taking a risk of one condition making the other condition worse. Depression can weaken an individual’s immune system as well as the body, making that individual more prone to physical and chronic illness. Mixing alcohol with depression only increases the risks of your physical and emotional health becoming weaker. (Foundations Recovery Network, 1995) The relationship between alcohol abuse and depression is a strong one and has been the subject of many studies. A recent study of almost 2,000 suicide attempts in Germany again found that acute alcohol consumption was present in about one-third of the cases, and in about one-sixth of the total cases the person could be diagnosed with an alcohol use disorder (alcohol abuse or dependence). (Hart & Ksir, 2013 p. 210) When an individual is depressed, they either sleep too much or cannot sleep at all. When adding alcohol to the mix only decreases the chance of sleeping, therefore increasing the symptoms of depression such as: depressed mood, difficulty concentrating, difficulty remembering things and exhaustion. Antidepressants, Prozac and Wellbutrin, were prescribed to Rhonda by her therapist. Thinking these antidepressants were not working, Rhonda would often take a double dose of her medication and mix it with a glass of wine. When mixing antidepressants with alcohol, Rhonda is decreasing the beneficial effects of her medication. Prozac and Wellbutrin are both from a group of antidepressants called monoamine oxidase inhibitors (MAOIs). Wine contains tyramine, an amino acid that controls blood pressure and when mixed with these two antidepressants, your blood pressure can skyrocket and cause a stroke. Self-medicating with alcohol can cause Rhonda’s depression to worsen after the alcohol wears off. The prescriptions from her therapist are treating Rhonda’s depression but her alcohol abuse is being left untreated, therefore causing the treatment for depression to be less effective.
Problems in treating the dually diagnosed. When dealing with a client who is dually diagnosed, it is important to remember that both their mental health disorder and substance use disorder have individual symptoms that can get in the way of the client’s ability to function, deal with different issues that life may throw at them, and how to relate and interact with others. If the mental health disorder is not treated then the substance use disorder will only increase causing the mental health disorder to increase as well. Although alcohol and depression are linked, one does not cause the other. In most cases, alcohol is used to self-medicate the depression but it actually makes the symptoms of depression worse. Depression comes from genetics, environmental factors, and other places such as: relationship issues, health issues, family issues, and financial issues, etc.
Society has viewed alcoholism as a moral and legal issue and depression as the result of poor motivation or weak character, therefore increasing the chances of an individual who is dual diagnosed not seeking treatment. There are very few health professionals who have the necessary cross-training to treat a dually diagnosed client. With public and private funding sources widely disparate funding for the two sets of disorders, health professionals are left to decide which disorder is more important. Proper funding for treatment also leaves health professionals facing moral, ethical, and financial issues regarding what is best for their client. A detox center cannot manage a client with psychotic or violent behavior so they will transfer the client to a mental health center where they have problems treating the substance use disorder or cannot find a community program that will take the client due to their mental disorder. (Evans & Sullivan, 2001, p. 2-5) Denial is one of the most common problems that exist when treating a client who is dual-diagnosed. It is extremely difficult for the client to admit they are dependent on alcohol and how much it affects their life. Depression can be frightening so the client will do their best to ignore the symptoms by covering them up with the alcohol, in hopes it will go away. Dual diagnosis is a challenge for health care professionals because the difficulty of the patient, how the mental health system works, lack of experience and training make it hard to accept and work with these patients. A dually diagnosed patient can respond to treatment but will require more flexibility and creativity as part of a health care professionals approach to the patient’s treatment.
A dually diagnosed client will not get the treatment they need in a traditional rehab program. The best treatment for a dually diagnosed client is an integrated Dual Diagnosis program that is equipped to handle psychiatric problems as well as drug/alcohol addiction in order to assist with proper detox, counseling and aftercare planning. (Foundations Recovery Network, 1995) This type of program provides peer support, education, and relapse prevention for both depression and substance abuse as well as, helping the client understand their depression, teach the client that recovery is possible, motivate the client to make changes in their life, provide the client with skills to help them handle negative thoughts and feelings, and help the client to be able to identify addictive behavior patterns as well as change them. (Foundations Recovery Network, 1995)
Conclusion
Depression has always been a health problem for human beings. Historical documents written by healers, philosophers, and writers throughout the ages point to the long-standing existence of depression as a health problem, and the continuous and sometimes ingenious struggles people have made to find effective ways to treat this illness. (Nemade, Reiss, & Dombeck, 2007) While using antidepressants to treat depression, an individual should not drink alcohol because they are not only decreasing the chances of the medication working but also making their depression worse. The treatment of alcohol addiction and depression at the same time is possible and will give a dually diagnosed patient the opportunity to recognize the causes for each disorder.

References
Becker, H. C. (2012). Effects of Alcohol Dependence and Withdrawal on Stress Responsiveness and Alcohol Consumption. Alcohol Research: Current Reviews, 34(4), 448-458. Retrieved from http://eds.b.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?vid=8&sid=9266a22d-17be-43df-97dd-8f1659ac4ea1%40sessionmgr198&hid=113
Evans, K., & Sullivan, J. M. (2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). New York, NY: The Guilford Press.
Foundations Recovery Network. (1995). Depression and Addiction | Dual Diagnosis. Retrieved from http://www.dualdiagnosis.org/depression-and-addiction/
Hart, C. L., & Ksir, C. (2013). Drugs, Society, and Human Behavior (15th ed). New York, NY: McGraw Hill
Klintsova, A. Y., Hamilton, G. F., & Boschen, K. E. (2012). Long-Term Consequences of Developmental Alcohol Exposure on Brain Structure and Function: Therapeutic Benefits of Physical Activity. Brain Sciences, 3(1), 1-38. Retrieved from http://eds.a.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?vid=1&sid=fdca7c9d-20c5-4221-b12f-3119eaec5c29%40sessionmgr4002&hid=4102
Nemade, R., Reiss, N. S., & Dombeck, M. (2007, September 19). Historical Understandings of Depression - Depression Resources, Education about Depression and Unipolar Depression. Retrieved from http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=12995&cn
Paljärvi, T., Koskenvuo, M., Poikolainen, K., Kauhanen, J., Sillanmäki, L., & Mäkel, P. (2009). Binge drinking and depressive symptoms: a 5-year population-based cohort study (104). Retrieved from Academic Search Complete, EBSCO website: http://eds.b.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?vid=1&sid=9266a22d-17be-43df-97dd-8f1659ac4ea1%40sessionmgr198&hid=113
Wilton, G., Moberg, P. D., & Fleming, M. F. (2009). The Effect of Brief Alcohol Intervention on Postpartum Depression. The American Journal of Maternal Child Nursing, 34(5), 297-302. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743918/
World Health Organization. (2004). Consequences of Alcohol Use. Retrieved from GreenFacts Publication website: www.greenfacts.org/en/alcohol/l-2/04-health-effects-alcohol.htm

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