Hello – I’m Dr. Grace Chang. I am a psychiatrist at Harvard Medical School and Director of Clinical Research Education at the Brigham and Women’s Hospital in Boston. I will be taking you through this case.
STEPS 1 and 2: Ask and Assess.
Your next patient is Theresa, a 46-year-old accountant who presents with complaints of insomnia, depression, and fatigue. Although she reports a depressed mood, she is not hopeless or suicidal and has no history of depression. The symptoms of fatigue are vague and nonspecific. During the initial screening, the physician has ruled out most specific causes of insomnia. Theresa has no other known medical conditions and a brief review of systems is negative.
As you listen to Theresa’s interview, try to assess which criteria she meets – or does not meet – for an alcohol use disorder. The following link presents a checklist of the criteria for alcohol abuse and dependence.
Click here for a checklist of the criteria for alcohol abuse and dependence.
Click here to play a recording of the interview
Click here to read a text transcript of the interview
In this interview, Theresa reports none of the signs of abuse, and six of the seven symptoms of alcohol dependence.
Remember, when diagnosing dependence, it is important to determine whether the patient meets three or more of the criteria. The patient who reports one or two symptoms certainly has cause for concern, but doesn’t meet the diagnostic criteria for dependence.
Theresa’s situation is not unusual for women who drink. Double standards of drinking that judge excessive alcohol use more harshly for women than for men have been reported in many cultures throughout history. The stigma associated with drinking can result in greater shame and guilt for women and their families. Women with drinking problems are more likely to hide them and may be reluctant to seek treatment.
Theresa also shows signs of depression. In patients with co-occurring disorders, outcomes are much better if both disorders are addressed at the same time. In this case, Theresa’s depression may clear once she stops drinking, since it began after the heavy drinking developed. In other patients who have a primary mood disorder in addition to the alcohol use disorder, you have to treat the primary condition as well as the alcohol use disorder. Using a combination of pharmacological and psychosocial treatments for both disorders can be effective for these patients.
STEP 3: Advise and Assist.
Now let’s get back to Theresa’s case. Once you’ve reached a diagnosis, the next step is to advise and assist the patient using an empathic and nonjudgmental approach. Listen to these three brief scenarios and select the one that you think provides the best support for Theresa.
Click here to play a recording of Choice A
Click here to play a recording of Choice B
Click here to play a recording of Choice C
Click here for a text transcript of the choices
Once it has been established that Theresa is dependent on alcohol, the next step is to “Advise and Assist.”
The objectives for this step include:
- State your conclusion and recommendations clearly
- Negotiate a drinking goal
- Consider evaluation by an addiction specialist, recommending a mutual help group, the need for medically managed withdrawal, or prescribing medication for dependence
- Arrange followup appointments, including medication management
Let’s listen to see how this physician works through the process.
Several medications are now available for treating alcohol dependence. They have been shown to help patients reduce drinking, avoid relapse to heavy drinking, and achieve and maintain abstinence. The effectiveness of these medications will be maximized if you systematically address patient adherence issues, as is true in treating any chronic illness.
More information on these medications is provided in the following links:
Now let's return to Theresa's visit.
STEP 4: At Followup: Continue Support.
Theresa kept her follow-up appointments with the nurse as requested. Let's rejoin the case as she meets with the physician 4 weeks following her initial visit.
Click here to play a recording of the follow-up visit
Click here to read a text transcript of the follow-up visit
Conclusion.
STEP 1 Ask About Alcohol Use
STEP 2 Assess for Alcohol Use Disorders
STEP 3 Advise and Assist
STEP 4 At Followup: Continue Support
Theresa responded very well to treatment. Although she drank on two occasions, she did not relapse to heavy drinking. Building on this successful start, she showed good progress over the next year.
After 6 months, she was provided with medications for nicotine dependence and successfully quit smoking. She stayed on alcohol dependence pharmacotherapy for 12 months, and had just one brief relapse to heavy drinking during the year. She found a women’s AA group that she really liked and continued to be involved with it throughout the year.
Theresa’s story illustrates how the screening, assessment, assistance, and follow-up approach outlined in the Guide can be effective for patients with alcohol dependence who are willing to commit to abstinence.