Clinical Decision-Making in Treating Mrs. Perez’s Gambling Disorder and Alcohol Use Disorder

QUESTION

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One that was made:

Antabuse (disulfiram) 250 mg orally daily
Choices Not used were as follows :

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

Campral (acamprosate) 666 mg orally three times/day

Results: 

• Client returns to clinic in four weeks
• Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”
• Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing

Decision Point Two that was made:

Continue current dose of Antabuse and refer to counseling for ongoing gambling issues

Choices Not used were as follows :

Continue current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID

Continue current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily

Results: 

• Client returns to clinic in four weeks
• Mrs. Perez in 4 weeks and reports that she has met with the counselor, but she did not really like her. She also started going to a local meeting of Gamblers Anonymous
• She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group. She also reports that she is still smoking quite a bit

Decision Point Three that was made:

Explore the issue that Mrs. Perez is having with her counselor, encourage her to continue attending the Gamblers Anonymous meetings, and discuss smoking cessation options.

Choices Not used were as follows :

Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group. Discuss smoking cessation options.

Discontinue Antabuse and encourage Mrs. Perez to continue seeing her counselor and participating in the Gamblers Anonymous group. This would also be an appropriate time to discuss smoking cessation options.

1.   Was decision #3 good decision to make based on the other 2 choices? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

2.   Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

3. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

4.   Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

ANSWER

Clinical Decision-Making in Treating Mrs. Perez’s Gambling Disorder and Alcohol Use Disorder

Introduction

Clinical decision-making in psychiatric care involves analyzing patient data, considering treatment options, and tailoring interventions for optimal outcomes. In the case of Mrs. Maria Perez, a 53-year-old Puerto Rican female with gambling disorder and alcohol use disorder, a series of decisions were made to address her complex conditions. This essay critically evaluates the decisions made, the rationale behind them, the ethical considerations involved, and alternative options.

Decision Point One

The initial decision to prescribe Antabuse (disulfiram) 250 mg orally daily was appropriate considering Mrs. Perez’s dual diagnosis of gambling and alcohol use disorders. Antabuse is an aversion therapy that induces unpleasant symptoms upon alcohol consumption, reinforcing abstinence. The decision reflects the need to address her alcohol use disorder concurrently. However, alternatives such as Vivitrol and Campral were not chosen due to the priority of addressing alcohol use disorder before gambling disorder.

Decision Point Two

The second decision to continue Antabuse and refer Mrs. Perez for gambling counseling while monitoring her smoking habit was a balanced approach. The decision acknowledges the importance of addressing gambling disorder while maintaining her abstinence from alcohol. Encouraging participation in Gamblers Anonymous and addressing smoking cessation indicates a holistic approach to her overall well-being.

Decision Point Three

Decision three aimed to explore Mrs. Perez’s issues with her counselor, reinforce her participation in Gamblers Anonymous, and discuss smoking cessation options. This decision was selected due to the significance of therapeutic alliance in mental health treatment. The unmet needs with her counselor could impact her overall progress. Moreover, addressing smoking cessation aligns with the patient’s goal of improving her health and well-being. The alternative options were not chosen as discontinuing Antabuse could jeopardize her abstinence and continued participation in counseling and Gamblers Anonymous was paramount.

Achieving Desired Outcomes

The ultimate goal of these decisions was to achieve a balanced approach to treat both alcohol and gambling disorders while addressing related issues. Ethical considerations played a crucial role in respecting patient autonomy and well-being.

Ethical Considerations

Autonomy: Mrs. Perez’s autonomy was respected by involving her in decision-making and discussing issues with her counselor. This empowers her to actively participate in her treatment plan.

Beneficence: Decision-making aimed to benefit Mrs. Perez by addressing her disorders, promoting abstinence, and improving her overall well-being.

Non-maleficence: Antabuse’s side effects were carefully considered, as evidenced by Mrs. Perez’s adverse experience with it. The treatment plan aimed to avoid harm while achieving abstinence.

Conclusion

The decision-making process for Mrs. Perez’s complex case reflects the need for a comprehensive, patient-centered approach. Addressing both her alcohol and gambling disorders, involving her in treatment decisions, and considering her individual needs and preferences were key considerations. Ethical principles guided the choices made, ensuring her autonomy, well-being, and safety were prioritized. By focusing on holistic care, the treatment plan aims to support Mrs. Perez’s journey toward recovery.