A Soldier's Story: Depression, Addiction and Trauma-Treatment for Comorbidities

                                                                   Abstract

This article will present a clinical plan created to treat Major Depressive Disorder, Addiction and Trauma. It will address etiology of the disorders which the client is presenting and explain how depression and addiction are correlated to the life history of the client. I will select a number of formal instruments for use in assessing depression, substance abuse, and suicidal ideation. Further, I will customize treatment strategies and my therapeutic method for the client. Lastly, plans for developing and maintaining a therapeutic relationship with the client will be discussed.

    This is not a simple case of Major Depression, Addictive Disorder, Post-Traumatic Stress Disorder, or Suicidal Ideation. Instead, the following is a description of a soldier-returned-home who is experiencing all of the above, due to the war zone he served in. In order to provide a comprehensive treatment plan for depression, this client’s history, thought patterns, and drinking patterns will need to be assessed. For soldiers returning home,“Depression screening has increased. Treatment often includes administration of SSRI or other classes of anti-depressant” (Konstantinidis, Martiny, Beck, & Kaspar, 2011). When enough stress is placed on an individual who has a generic propensity to develop mental illness, referred to as the Diathesis-Stress-Coping Model (Lazarus & Folkman, 1984), mental illness can be kindled by the stress into a flame of symptoms. When enough unpleasant symptoms are experienced, “self-medicating” with alcohol is a common defense tactic of military personnel, whether active or retired from duty. “Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders” (Heslin, Stein, Dobalian, Simon, Lanto, Yano, & Rubenstein, 2013). In this case, my client is a male, 45, who recently returned from a war zone, and is reporting depression and suicidal ideation, has been drinking heavily to cope, and feels isolated. This is not a safe combination, especially since the client has been trained in combat and likely has a firearm handy. Therefore, I want to intervene immediately with a customized treatment plan.

    The first order of business is to gain rapport with the client, then to conduct a clinical interview, and follow this with formal assessments to ascertain his level of symptomology. I would use the revised version of the Beck Depression Inventory (BDI-11, 1996), as it is aligned closest with the DSM-1V-TR (APA, 2000), and because it is the most recent form of the instrument. I would administer the screening inventory, and then discuss the results of the screening with the client.

    The SAD Person's Scale (Patterson, Dohn, Bird, & Patterson, 1983) suggests the following risk factors for suicide:
1. Depression and hopelessness
2. Men are more likely to commit suicide than women
3. Alcohol and drug abuse increase risk
4. System support loss
5. No significant other.

    A formal suicide assessment tool could aid in determining if this client should be advised to seek immediate hospitalization, or to return for further counseling. I would choose either of the following suicide assessment tools:
1. The Beck Scale for Suicidal Ideation (BSS), (1991-1993). BSS is a 21-item self-report instrument for adults. Due to its time efficacy, this scale is recommended for novice clinicians for detecting suicidal ideation in the psychiatric, psychological, and allied heath fields (Hanes, & Steward, Mental Measurements and Tests, Yearbook 13).
2. Adult Suicidal Ideation Questionnaire, (Reynolds, 1987-1991). This assessment is a self-report for adults comprised of 25 questions, and takes approximately 10 minutes to administer. It measures suicidal ideation to rate the frequency of suicidal thoughts in the past month. This assessment is useful with clients who are reticent to divulge symptoms.

    Further, this client has admitted abuse of alcohol, so an alcohol screening assessment is indicated. I would administer the Substance Abuse Subtle Screening Inventory-3 (SASSI-3, 2013), and also seek to psychoeducate the client on the effects of alcohol abuse including tolerance, withdrawal, and treatment effectiveness and benefits. I would inquire about the client's family: what relationship does he have with them? "Addiction is a family disease because of the seriousness of its effects on family members and family functioning. Just as the person needs support, education, and counseling, so too does the family" (Center For Substance Abuse Treatment, 1995).

    If the client scored high on the Beck Scale, I may advise he be taken to the hospital for treatment for depression and suicidal thoughts. I would collaboratively create a safety plan for the client to follow. If the client scores high for suicide, I would rather err on the side of too much intervention than too little, as 98% of people who die of suicide were diagnosed with depression (International Association for the Prevention of Suicide, 1999), and because he knows how to use a weapon and likely has a gun at home. If he declines to go to the hospital, I would contract with him to refrain from suicide attempts until our next appointment. I would also give this client the necessary referrals to hospitals as well as a local crisis line, and discuss with him any concerns he might have about gaining support from family and friends, and what type veteran facilities he may use for future psychiatric care.

    In order to customize this depression treatment plan, since the client witnessed trauma while in combat, I would investigate combat-related Post-Traumatic Stress Disorder (PTSD) as a diagnosis. “Forms of cognitive-behavioral therapy (CBT) currently have the most evidence for efficacy” (Veterans Affairs/Dept. of Defense, 2010). Utilizing CBT as the therapeutic modality, I may also elect to apply systematic desensitization therapy, which, “Pairs the implementation of relaxation techniques with hierarchical exposure to the aversive stimulus” (Nolen-Hoeksema, 2011).

     Issues to consider when approaching termination of therapy include: Will the client’s VA Hospital pay for his psychopharmaceuticals and physician visits? Does the VA offer post-service treatment for PTSD? Will the client have adequate social/familial support, and group therapeutic support for his drinking? I would ask if the client feels he needs a monthly check-in with me until he finds the support he needs. Due to the serious nature of his diagnosis and lack of social and other therapeutic support, I am responsible to offer to him follow-up counseling if he feels he could benefit by it. This way he knows there is an open door: he can return to therapy in case his depression worsens, if the PTSD symptoms are not subsiding, and if he is not able to maintain sobriety.

    Last but certainly not least this client may require treatment of major depression and PTSD with psychopharmaceuticals. A referral to his medical doctor or VA Hospital to discuss medical intervention is crucial in order to stop the suicidal thoughts.

References:

Konstantinidis, A., Martiny, K., Beck, P., Kaspar, S. (2011). A comparison of the Major Depression Inventory (MDI) and the Beck depression Inventory (BDI) in severely depressed patients. International Journal of Psychiatry in Clinical Practice, Vol. 15 (1), p. 56-61. Informa Healthcare.   

Lazarus, R. S., Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springhill.

Heslin, K. C., Stein, J.A., Dobalian, A., Simon, B., Lanto, A. B., Yano, E. M., Rubenstein, L.V., (2013). Alcohol problems as a risk factor for post disaster depressed mood among U.S. veterans. Psychology of Addictive Behaviors, Vol 27 (1), pp. 207-213. Publisher: US: American Psychological Association.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR) (2000). American Psychiatric Association, Arlington, VA.

Patterson, W., Dohn, H., Bird, J., & Patterson, G. (1983). Evaluation of suicide patients: The SAD PERSONS scale. Psychosomatics, 24, 343–349.

Beck, A.T., Steer, R.A. (1991-1993). Beck Scale for Suicidal Ideation. Pearson, San Antonio, TX.

Hanes, K.R., Stewart, J.R. (1991-1993). Review. Beck Scale for Suicidal Ideation. Mental Measurements Yearbook and Tests in Print. Yearbook 3, Psychological Assessment Resources, Inc., Lutz, FL.

Reynolds, W.M. (1987-1991). Adult Suicidal Ideation Questionnaire. Mental Measurements Yearbook and Tests in Print, Yearbook 12, Psychological Assessment Resources, Inc., Lutz, FL.

SASSI Institute. (2013). Specialized Populations. Retrieved from: www.sassi.com/news/index.html.

Center for Substance Abuse Treatment. (1995). Detoxification from Alcohol and Other Drugs. Treatment Improvement Protocol (TIP) Series, No. 19. Rockville, MD.

International Association for the Prevention of Suicide. (1999). Retrieved from: http://www.iasp.info/

Veterans Affairs/Department of Defense (VA/DoD). (2010). Clinical practice guideline:

Management of post-traumatic stress. Retrieved from:

http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp

Nolen-Hoeksema, S. (2011). Abnormal Psychology. Fifth Edition. McGraw-Hill, New York, NY.