For what length of time have Janelle’s low moods been occurring? Does she experience symptoms of a depressive disorder?

Question

DSM Diagnosis
303.90 Alcohol Use Disorder, Severe
296.2 Major Depressive Disorder, Recurrent, Mild, With Melancholic Features
250.00 Diabetes mellitus, type II/non-insulin-dependent (a medical doctor diagnosed this condition).
531.71 Chronic stomach ulcer

Rationale
While Janelle reports having abstained from drinking alcohol for the past two months, she describes periods in her life of drinking daily and binge drinking. Janelle meets criteria for several symptoms, including tolerance, taking the substance in larger amounts or for longer periods than was intended; and continued substance use despite its negative effects on physical and psychological health. During her nine-month period of heavy drinking, she was using greater amounts of the substance to achieve the desired effect. Withdrawal is evident in her experience of shaking spells when she goes without alcohol. Although she has never lost a job because of her alcohol use disorder, she spends a lot of time recovering from its effects. Because she is in excess of six symptoms, the specifier “severe” was selected.
Major Depressive Disorder was also diagnosed. Janelle’s mental status is characterized by fatigue, loss of energy and interest in certain activities, feelings of guilt, feelings of worthlessness, and problems with sleeping. These symptoms qualify Janelle for the specifier “with melancholic features”. She experiences relief from these symptoms at times, but some of them are continuous, especially her feelings of worthlessness and lack of interest in life activities. The severity of her disorder would be considered “Mild” because the number of symptoms she usually experiences is low. It appears that Janelle has experienced these episodes at several times in her adult life. It must be recognized, however, that there are many significant biological and psychological factors that may have contributed to Janelle’s depressive symptoms, including past alcohol abuse and dependence, her medical condition, and other psychosocial factors.

Additional Information Required
It will be necessary to gather more information in future sessions about Janelle’s history. In particular, the social worker needs to gather a more detailed history of her alcohol use and her experiences of depressive symptoms. Because substance abuse and dependence can cause or contribute to symptoms of comorbid disorders, such as depression and anxiety, it is often difficult to make a clear diagnosis of disorders like major depressive disorder in persons who abuse substances.
With more knowledge of Janelle’s past use and psychological functioning, the social worker will be able to make a more confident diagnosis. It also needs to be further assessed how Type II Diabetes may contribute to Janelle’s psychological functioning and how she feels it has impacted her life. More information about how alcohol use has affected her diabetes is also important. Alcohol has a high sugar content and therefore affects blood sugar levels. The recommendation is that women with diabetes should not take more than one drink per day. In addition, a clearer understanding of Janelle’s stomach condition would help to rule out any connection between the somatic symptoms Janelle experiences and her emotional functioning.

Treatment
Janelle wishes to reach a point where she is completely abstinent from alcohol use, and she has already made strides toward that end on her own. She also experiences depression related to her feelings about herself and her relationship patterns, and providing her with healthier relationship patterns and better stress coping mechanisms will be an essential part of her intervention.
Goal 1: Abstain from alcohol use
? Objective 1: Refer clients to Alcoholics Anonymous group
? Objective 2: Become able to identify through cognitive behavioral methods situations and emotional states that create risk for alcohol use, and utilize alternative means of managing stress in those situations (including situational avoidance)
Goal 2: Increase quality of social supports for abstinence from alcohol
? Objective 1: Refer adult children to Al Anon program
? Objective 2: Attendance at AA groups
Goal 3: Eliminate symptoms of depression through a 12-week course of interpersonal therapy
? Objective 1: Explore alcohol use disorder and its relationship to past and current relationships.
? Objective 2: Develop better interpersonal and social skills by exploring new ways of thinking, feeling, and behaving with significant others.
? Objective 3: Name and discuss grief emotions, identifying how they affect daily psychological and emotional functioning; practice sharing feelings of grief-with therapist, and with children and friends.
Goal 4: Insure physical health
? Objective 1: Educate the client about the risks of alcohol use with diabetes
? Objective 2: Have the client sign a release of information form to find out from her physician the status of her stomach condition and how to best prevent further problems
? By addressing Janelle’s substance abuse/dependence issues and feelings related to grief and loss in individual cognitive therapy and Alcoholics Anonymous, she will be provided with safe places to address feelings before they become overwhelming, explore past substance use and reasons to abstain in future, and develop effective interpersonal skills and personal coping methods.

Critical Perspective
Janelle’s presentation is somewhat confusing because of the interactions among substance abuse, depression, and physical problems. While she qualifies for the alcohol dependence diagnosis, she has not used much in the past several months, and her intervention will focus on strategies to continue controlling her urges to drink. Managing the client’s depression may be the key to restoring her previous level of functioning. For these reasons she should not be “labeled” primarily as a person who abuses substances, as doing so may take attention away from her other psychosocial needs.

Answer 1

This is somewhat difficult to assess. While Janelle’s mood seems to have been low for much of her life, she has been able to mask it through her use of alcohol. It seems reasonable to assume that her low self-esteem and generally negative moods developed during her childhood, due to her abusive upbringing. What is not clear is whether Janelle was dysthymic (having chronic, low grade depression) or experienced major depressive episodes (with the symptoms making it hard for her to attend to her personal responsibilities). It does appear that she has experienced several major depressive episodes as evidenced by her reports of extremely low moods, lack of energy, lack of interest in most life activities, and sleep difficulties.