PS531 Unit 7 Bipolar and Substance Use Case Study Example

Mania, Cocaine and the Summer Fishing Charters: A PS531 Unit 7 Case Study of Bipolar I Disorder With Substance Use

[Student Name]

Purdue University Global

PS531: Co-Occurring Disorders and Treatments

Unit 7 Bipolar Disorder and Substance Use Case Study

[Instructor Name]

[Date]

The client, his family, the agency and every detail of the case are composite and illustrative; the sources cited are real.

The Client

Jake is 35 and runs a walleye fishing charter out of Escanaba from May through September, then works winters at a sporting goods store. The bipolar I diagnosis came at 24, after a manic stretch in which he stopped sleeping, bought a second boat on credit and was arrested for a bar fight. He has had five manic or mixed episodes and three depressions since, including one with a suicide attempt at 29.

His pattern is seasonal. Each spring, as charter season approaches, he stops taking lithium because, he says, it "slows me down" and he needs to be sharp with customers. He drinks heavily with charter clients and uses cocaine on weekends to keep up with eighteen-hour days. By August he is sleeping three hours a night and spending recklessly. By November he is depressed, drinking alone and unable to work. He came to our agency this October, at the start of a depressive episode, after his sister found him drunk on the boat at the marina.

Diagnoses

Jake meets criteria for bipolar I disorder, with a current major depressive episode, and for alcohol use disorder and cocaine use disorder, both moderate to severe. The disorders are intertwined: substance use deepens his mood episodes and stopping lithium removes his protection against mania, while mania and depression each drive his drinking and drug use in different ways.

Why Treat Both Together

Geddes and Miklowitz (2013) survey bipolar care and give lithium the strongest record of any drug for holding off new episodes over years, along with psychoeducation, attention to early warning signs and family involvement. They note that substance use is common in bipolar disorder and worsens its course. SAMHSA's protocol recommends integrated treatment, in which mood and substance use are addressed together by one team (Substance Abuse and Mental Health Services Administration, 2020).

Weiss et al. (2007) tested a treatment designed for exactly this combination. In a randomized trial with 62 patients who had bipolar disorder and current substance dependence and were taking a mood stabilizer, they compared twenty weeks of integrated group therapy, which addresses both disorders in every session, with group drug counseling that focused on substance use. Patients in integrated group therapy had significantly fewer days of substance use during treatment and follow-up. The two groups had similar numbers of weeks ill with a mood episode.

Jake treats lithium as a winter medicine and cocaine as a summer tool, and integrated care has to change both habits at once.

Treatment Plan

Stabilization comes first. Jake is depressed and drinking daily. Our agency's psychiatrist will restart lithium, monitor his levels and assess withdrawal risk. Because of his past suicide attempt, safety planning begins at the first session, with his sister holding his firearms over the winter.

Integrated group therapy is the core. Our agency runs an integrated group modeled on Weiss and colleagues' approach, meeting weekly for twenty weeks. Each session covers both disorders through a shared theme, such as how alcohol affects mood, recognizing triggers for both mania and use and the decision to take or stop medication. Jake will join the group in November and finish before charter season.

Individual sessions address his medication beliefs. Jake's reason for stopping lithium each spring, feeling slowed, deserves to be taken seriously. Geddes and Miklowitz note that side effects and missing the energy of mild highs are common reasons for stopping. Jake will talk with the psychiatrist about his dose and side effects, and in counseling we will look at what each summer has cost him: two arrests, one lost boat and three falls into depression.

Summer planning is essential because his relapse risk peaks in May. Before the season, Jake will write a plan for charter days: no drinking on the boat, a set bedtime even in July, a hired first mate who can run afternoon trips if he needs rest and early warning signs that he and his sister agree will trigger a call to the psychiatrist, such as sleeping fewer than five hours two nights in a row.

Family involvement will include his sister, who knows his warning signs better than anyone.

The First Mate and the Marina

The charter business both feeds Jake's drinking and offers ways to curb it. Charter clients often bring beer and expect the captain to drink with them, and the marina's summer social life revolves around drinking. With Jake's agreement, his plan includes a written boat policy, no alcohol aboard on his charters, which he will post on his website and booking confirmations so customers know before they arrive. He worried that he would lose business; his sister, who handles his bookings, pointed out that several families had complained about drinking groups on other boats. The first mate he hires will be someone in recovery or someone who does not drink, recruited with help from the peer recovery coach on our team.

Measuring Mood and Use Together

Integrated care needs integrated measures. Each week in group and in individual sessions, Jake will rate his mood on a simple scale, record hours of sleep and log drinking and cocaine days. Seeing mood and use on the same page helps Jake notice how one leads to the other, such as a week of short sleep followed by a weekend of cocaine.

Goals

By December, Jake's depression improves on the PHQ-9 and he takes lithium daily with levels in range. By the end of group in March, he reports no cocaine use and no more than two drinking days a month. Through the summer, he stays on lithium, has no manic episode requiring hospitalization and keeps the boat running without drinking aboard.

Limits

Weiss and colleagues' trial was small and conducted in one setting, and it did not show fewer weeks of mood illness. Jake's seasonal pattern will test the plan in its first summer.

Conclusion

Jake's bipolar disorder and substance use follow the rhythm of his work, and each disorder makes the other worse. Geddes and Miklowitz support lithium and psychoeducation, SAMHSA's protocol supports integrated care and Weiss and colleagues' trial supports integrated group therapy as a way to reduce substance use for people with both conditions. The plan uses the predictability of his seasons to prepare for May before it arrives.

References

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672-1682. https://doi.org/10.1016/S0140-6736(13)60857-0

Substance Abuse and Mental Health Services Administration. (2020). Substance use disorder treatment for persons with co-occurring disorders (Treatment Improvement Protocol Series, No. 42; SAMHSA Publication No. PEP20-02-01-004).

Weiss, R. D., Griffin, M. L., Kolodziej, M. E., Greenfield, S. F., Najavits, L. M., Daley, D. C., Doreau, H. R., & Hennen, J. A. (2007). A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence. American Journal of Psychiatry, 164(1), 100-107. https://doi.org/10.1176/ajp.2007.164.1.100