Dual Diagnoses: Major Depressive and Alcohol Abuse Disorders

There are 2 cases (Meredith and Richard)
Each case should:
1. be about 4 pages
2. include 6 references per case
3. Integrate material from the DSM5
4. number each answer
Case #1: The Case of Meredith
Meredith is a 17-year-old Latina high school junior who just experienced a school shooting that resulted in the death of 2 classmates. She was referred to you by her family physician. Meredith was diagnosed with major depressive disorder, recurrent (moderate) previous to this recent incident. Meredith has a history of two suicide attempts within the last 3-4 years. Her previous treatment included inpatient, partial hospitalization, and intensive outpatient phases of mental health care. Meredith discloses that over the past few months, she has been drinking alcohol (whiskey, vodka, and beer) and snorting crushed Adderall tablets. She states that both the alcohol and Adderall help her cope with the depression, just in different ways. Meredith says “drunk or high on Adderall beats depressed or dead” and she refuses to cease either substance.
Major Depressive Disorder and Suicide History
Meredith reports that around age 13, she experienced her first serious and long-lasting depressive episode where she recalls nearly one month of increasingly worsening depressed mood, feeling “worthless and ugly,” and an inability to sleep, eat, or do her schoolwork. At age 14, she first attempted suicide by taking a large amount of acetaminophen (Tylenol). Meredith recalled being angry that the Tylenol did not kill her and she stated that she did not inform her parents. The first attempt was made known 18 months later following her second suicide attempt when Meredith was admitted to an inpatient mental health facility after she had swallowed a handful of Zoloft that her family physician had prescribed. The attempt was uncovered by her parents when she was found vomiting and shaking while reporting being dizzy. Again, Meredith reported feeling “overwhelming” depressed mood in the weeks leading up to her second suicide attempt. The attempt was not planned. Meredith stated that she “did not go into the bathroom to kill myself, it just sort of overtook me all of a sudden.”
Meredith currently reports feeling moderate depressive symptoms that can sometimes border on severe. She is currently in a depressive episode that seems to have lasted for approximately the past three weeks. She reports still having suicidal thoughts, but lacks any plan or intent. She is currently under the care of a psychiatrist who has her on a low dose of Lithium daily.

Alcohol Use History
Meredith reports engaging in two “types” of drinking. One drinking “type” is a typical pattern of alcohol use for a high school student where she reports drinking at parties and sometimes getting drunk. It is the second “type” of drinking that has you concerned. She reports using alcohol as a coping mechanism for the depression and suicidal thoughts. Meredith reports drinking alone in her room 3–4 times per week when she is experiencing depressed mood and/or suicidal thoughts. Over the past four months, Meredith is aware that it seems she now needs “a little more” alcohol to achieve her same desired effect. She also states that over the past two weeks, she experienced her first instance of going to school with a “major hangover.”

Adderall Use History
Approximately two months ago, Meredith’s friend introduced her to snorting Adderall. Meredith states that she has snorted Adderall almost once daily (usually in the morning) over the past several weeks. She stated it helps her to “focus” and to do well in school. “The depression makes me drag. I can’t think well. Plus, I get wrapped-up in my own pity party in my head. Then I snort some Adderall, and I feel a buzz in just a few moments. Then I’m up. I see it as a counter to the depression.

Please respond to the following questions:
1. Drinking and snorting Adderall are clearly not healthy coping skills, but their effectiveness of removing her negative affect/mood/thought (even though it is only temporary) are the only coping skills Meredith seems to believe in. Considering her recent exposure to school violence, her poor perception of typical coping skills, and her reluctance to see counseling as a helpful strategy, how would you work with Meredith to engage her in treatment? Please incorporate Motivational Interviewing in the response.
2. Alcohol is a depressant whereas Adderall is a stimulant. How and why do you think each of these substance classes assist Meredith in coping with her depression and life in general? Why do you think her psychiatrist is treating her with Lithium?
3. Based on your thought process in answering question #2, what would be the appropriate level(s) of care for Meredith? Discuss the complexity of Meredith's treatment in consideration of the recent school shooting, her major depressive disorder, and substance use. Please use the Matrix model of Relapse prevention in the discussion
4. How would you use family counseling in your treatment of Meredith? Please use Multi-dimensional Family Therapy (MDFT) in the response.

Case #2: The Case of Richard
Richard is a 22-year-old gay college senior who presents with a five-year history of alcohol use disorder and a little over one-year history of sedative, hypnotic, and anxiolytic use disorder (i.e., Xanax). In addition, Richard presents with a long-term history of generalized anxiety disorder and panic disorder. He discloses that he has been in therapy for anxiety, but has never been in any form of substance use treatment before. He was referred by his partner, who grew concerned regarding Richard’s increase in anxiety over the past few days. His partner does not know of Richard’s Xanax use. Richard reports having “anxiety issues” as far back as he can recall. He vividly remembers the phone call he received from his aunt at age 8, informing him that his parents had been killed in a car accident. He was then raised by his aunt and uncle. Relevant to his adulthood (since approximately age 18), Richard can recall numerous instances in college where he experienced anxiety that he could not understand. “I would wake-up and just feel anxious. It was ridiculous. I’m a great student with a 3.7 GPA, but it just took so much work. And not the normal work others do. I would just get so worried.” Richard also discussed having multiple unexpected panic attacks.

Alcohol Use History
Richard reported frequent use of alcohol that started in his latter high school years and progressed throughout college. He noted that at first his drinking was only a “social thing,” but then he slowly realized that his drinking would help him “calm down.” He tells you how alcohol solved his social anxiety, especially when having to speak in front of classmates. “I felt so much better about 30 minutes later when it was my turn to talk. I can still remember doing the talk while thinking to myself, Wow! I’m not anxious!” Richard reported a drinking history in college that consisted of beer and hard liquor consumption approximately 4-5 days per week. Over the past 12 months, he was unable to quantify his exact alcohol usage.

Xanax Use History
Approximately, 14 months ago, Richard started taking Xanax that he obtained illegally. He began when his friend at college, who also experiences anxiety, offered Richard two of his Xanax prescribed by a physician. Richard found the Xanax just as beneficial for his anxiety as the alcohol, but he was able to take these “out in plain sight.” Richard disclosed that he would typically consume the Xanax and drink alcohol within the same 24-hour period.
Richard’s Presentation
Richard reported that he read an online article about the dangers of Xanax. Then approximately three days ago, he stopped taking the Xanax “cold turkey.” He also reports that he stopped drinking as well because he “read about how alcohol is a bad thing mixed with Xanax.” Richard presents in session as very jittery, with rapid speech, an inability to stay on task, and an increased degree of reported anxiety. Richard also reports that over the past 2-3 days he “sometimes hear(s) footsteps or whispering.” He reports difficulty sleeping the past few nights and he demonstrates moderate hand tremors when filling out intake paperwork. Richard reports he feels “overwhelming” anxiety and fears another panic attack is imminent. When pressed regarding any context for his anxiety, Richard cannot clearly identify why he feels such overwhelming anxiety.
Please respond to the following questions:
1. Richard presented to counseling ONLY for anxiety issues. Consequently, how do you educate Richard on his appropriate immediate level of care? Where do you see the levels of care progressing following the initial treatment level?
2. Even though Richard presents with a clear co-occurring non-substance-related history of anxiety disorders, how do you conceptualize his current anxiety symptoms in the context of his rapid “cold-turkey” cessation of Xanax and alcohol?

3. In consideration of Richard’s history of trauma, current clinical and substance-related presentation, what are your diagnostic impressions?
4. Given the models of intervention and levels of care , how might you treat Richard? Please use this level of care: https://americanaddictioncenters(dot)org/rehab-guide/asam-criteria-levels-of-care in the response.
How might couples counseling be a supportive adjunct to Richard’s treatment?