Clinical Case Study Examples
Dr Mark Brookes, G.P. circulated case studies to consider how these would be managed within the Dual Diagnosis Pathway. The Steering Group discussed each case against the Dual Diagnosis Pathway.
Case 1 - A 39 year old man who has been stable on methadone for several years. He still drinks heavily and has some symptoms of withdrawal. He also smokes cannabis daily and has done for many years. He is being assessed for an alcohol detox but his main issue for many years is anxiety. He says he has seen many doctors since the age of 13 to deal with it and has tried many medications which he cannot tolerate. I wonder whether some cognitive therapy would help. However the IAPT team won’t see him due to his drug use.
Response from Steering Group – The Substance Misuse Service should provide psychological intervention for anxiety.
Case 2 - 55 year old lady with chronic anxiety and pain who would appear to be addicted to benzodiazepines as she has been on a maintenance script for several years. She is also on a
maintenance script of pethidine and oramoroph for her pain. She would benefit from assessment by a psychiatrist and maybe psychological treatment for her anxiety.
Response from Steering Group – The assessment could be by either the Mental Health Team or Substance Misuse Team to understand the best option for this lady. One option may be shared care.
Case 3 - A patient who you think may have a Personality disorder because of their chaotic and attention seeking behaviour but misuses alcohol/drugs intermittently to cope. He does not have any symptoms of addiction but does binge for several days at a time. As a GP you think complex cases may be appropriate for him but it’s a tertiary service so he needs to be seen by intake and treatment.
Response from Steering Group – Refer to the Intake and Treatment Team for assessment.
Case 4 - 35 year old man with a history of heroin abuse in the past but has been clean for several years. Has been buying diazepam to help him cope with anxiety but recently the supply has been drying up so he has been drinking more. He maintains his problem is underlying anxiety but the referral was rejected by the primary care link worker because “Addaction deal with benzo addiction”. However |Addaction are not funded to deal with prescribed drug addiction.
Response from Steering Group – Assessment by Mental Health or Substance Misuse Team to understand the best option. The assessment could be in Primary Care with the Mental Health Link Worker and Substance Misuse Shared Care Worker.
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Case 5 - 49 year old man who has been smoking cannabis for 20 years to help him control anger. He now wants to stop due to a health scare but is concerned his anger will become worse and he may harm someone. He has been seen by addaction who were concerned by the risks of him stopping the cannabis, but the CMHT won’t see him because of his drug misuse.
Response from Steering Group – Substance Misuse Service. It was highlighted that the Mental Health Team does not provide anger management in the absence of mental illness.
Clinical case study examples – people over 65
Case 6 - 72 year old retired engineer presents from Addenbrooke’s with insulin dependent diabetes, raised BMI, two previous MIs, and now neglected severe foot complications putting him at risk of amputation. He has a current alcohol intake of 1-3 bottles of wine per day. Collateral history from his son indicates he has a 40 year history of drinking excess alcohol with little insight. At times, he has had a decreased need for sleep and is now impulsively spending beyond his means in restaurants and upmarket stores. He has plans for several major new engineering projects, designs for new inventions and, on interview describes several new romantic relationships.
He is dismissive of the need for help and of the possibility of being elated.
He needs psychiatric evaluation regarding possible involuntary admission and close liaison with the GP, Endocrinology and foot clinic regarding his Diabetic control.
Older people’s mental health team lead, with substance misuse joint working.
Case 7 - A retired college porter presents after his 3rd recent paracetamol overdose with high lethal potential on a background of worsening marital discord. His wife manages his 40mg of Diazepam per day under lock and key, often refusing him the medication if they are arguing. He says this amount of medication has been necessary since he retired, for sleep and to prevent him having “scary thoughts”. He is obviously anxious and focused on his drugs as a solution. He has no mental disorder other than this. He says “What does it matter if I’m addicted to them, I’m 75 years old?”. He has been referred through ARC to psychology for his anxiety.
Older peoples mental health team lead, jointly working with substance misuse team
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APPENDIX 13 – Guidance Older People
Government safe consumption guidelines in units-per-week are often far greater than that considered suitable for those over 65, who have comorbid physical problems,
polypharmacy, balance and cognitive problems which might put them at greater risk when consuming alcohol at lower levels than would be considered “safe” or “normal” in the 18-65 population. Also arising is the possibility that an older person may have had a long life of excess alcohol consumption, often resulting in physical morbidity.
• Older people with substance use problems may have high levels of unmet need
• General practitioners should screen every person over 65 years of age for
substance misuse as part of a routine health check, using specific tools such as the Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G);
screening should also incorporate cognitive testing using tools such as the Mini-Mental State Examination (MMSE)
• Re-screening should be carried out if certain physical and/or psychological symptoms are present or if the person is experiencing major life events
• Older people can and do benefit from treatment and in some cases have better outcomes than younger people
• Treatment of co-existing physical conditions (including chronic conditions such as hepatitis C and chronic obstructive pulmonary disease) and psychological conditions is a very important part of management
• Although applying the standard diagnostic criteria for substance use disorders is useful, it should be noted that sometimes they may not be appropriate for older people
• Patients who repeatedly do well in hospital and badly at home, those with
unexplained ‘ups & downs’ in health presentation, those with inconsistencies and contradictions in the history and presentation are of particular concern
• Association of substance misuse (particularly alcohol) and conditions such as liver disease, hypertension, diabetes, falls, cognitive problems, depression, self-harm, incontinence (often not a readily apparent association) indicates specific physical investigations
• Close liaison between all professionals, disciplines and agencies involved in the care of the patient is very important
• Current recommended ‘safe limits’ for alcohol consumption are based on work in younger adults. Because of physiological and metabolic changes associated with ageing, these ‘safe limits’ are too high for older people; recent evidence suggests that the upper ‘safe limit’ for older people is 1.5 units per day or 11 units per week
• In older people, binge drinking should be defined as >4.5 units in a single session for men and >3 units for women
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APPENDIX 14 - Useful Contact Numbers
Additional Useful Contact Numbers :
CAMBRIDGESHIRE DRUG AND ALCOHOL ACTION TEAM (CDAAT) 01223 699680
CAMBRIDGESHIRE CONSTABULARY : Creating a Safer Cambridgeshire 101
SAFER PETERBOROUGH : Building Safe and Confident Communities
Terry Prior on 01733 452543 on behalf of Safer Peterborough
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APPENDIX 15 – References & Resources References/Resources.
Cambridgeshire NHS & Health & Social Care Information Community [2002] General protocol for protecting and usoing personal information within Cambridgeshire &
Peterborough. Updated Nov 2009.
Department of Health [2002] Mental health Policy implementation guide: Dual diagnosis good practice guide. London: DH.
Department of Health [2003] Confidentiality NHS Code of Practice. London: DH.
Department of Health [2006] The Caldicott Guardian Manual. London: DH.
Department of Health [2006] Dual diagnosis in mental health inpatient and day hospital settings. London: DH.
Hughes, E [2006]Closing the Gap: a capability framework with combined mental health and substance use [dual diagnosis]. CCAWI. University of Lincoln.
N.I.C.E. [2011] Psychosis with coexisting substance misuse: assessment and management in adults and young people. NICE clinical guideline 120. National Institute for Health and Clinical Excellence.