Co-morbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female BACKGROUND Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office 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 two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their 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 two 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 that 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 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 has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money. MENTAL STATUS EXAM The client is a 53 year old Puerto Rican female who is alert, 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. As 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 & self-reported mood. She visual or auditory hallucinations, 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 Select what the PMHNP should do: Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks Antabuse (Disulfiram) 250 mg orally daily Campral (Acamprosate) 666 mg orally three times/day Co-morbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female De ...

1. Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who
presents to your office 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 two years, she has been having more
and more difficulty maintaining her sobriety since they opened
the new “Rising Sun” casino near her home. Mrs. Perez states
that she and a friend went to visit the new casino during their
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 two 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 that
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 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.

2. Mrs. Perez is quite concerned today because she has borrowed
over $50,000 from her retirement account to pay off her
gambling debts. She is very concerned because her husband
does not know that she has spent this much money.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert,
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. As 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
& self-reported mood. She visual or auditory hallucinations, 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
Select what the PMHNP should do:
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the
gluteal region every 4 weeks
Antabuse (Disulfiram) 250 mg orally daily
Campral (Acamprosate) 666 mg orally three times/day
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
Decision Point One

3. Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the
gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Mrs. Perez said that she felt “wonderful” as she has not
“touched a drop” to drink since receiving the injection
· Client reports that she has not been going to the casino, as
frequently, but when she does go she “drops a bundle”
(meaning, spends a lot of money gambling)
· Client She is also still smoking, which has her concerned. She
is also reporting some problems with anxiety, which also have
her concerned
· Decision Point Two
· Select what the PMHNP should do next:
·
· Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
·
· Refer to a counselor to address gambling issues
·
· Add on Chantix (varenicline) 1 mg orally BID
·
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
Decision Point One
Antabuse (Disulfiram) 250 mg orally every morning
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Mrs. Perez reports to your 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

4. 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 when she does go.
She has noticed that her cigarette smoking is increasing
· Decision Point Two· Select what the PMHNP should do next:
·
· Continue current dose of Antabuse and begin Campral
(acamprosate) 666 mg orally BID
·
· Continue current dose of Antabuse and refer to counseling for
ongoing gambling issues
·
· Continue current dose of Antabuse and begin Wellbutrin
(bupropion) XL 150 mg orally daily
·
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
Decision Point One
Campral (acamprosate) 666 mg orally TID
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Mrs. Perez states that she has noticed that she has been
having suicidal ideation over the past week, and it seems to be
getting worse
· Clientis She is also reporting that she is having “out of
control” anxiety· Select what the PMHNP should do next:
·

5. · Educate Mrs. Perez on the side effects of Campral and add
Valium (diazepam) 5 mg orally TID to address anxiety
symptoms
·
· Discontinue Campral and begin Antabuse (disulfiram) 250 mg
orally daily
·
· Decrease Campral to 666 mg orally BID
·
Assessing and Treating Adult Clients with Mood Disorders
A mood disorder describes a psychological disorder which is
characterized as a fluctuation of one’s mood, such as a major
depressive or bipolar disorder. An estimated 20 million
individuals in the United States have depression which
comprises of symptoms such as a loss of pleasure in activities,
sadness, weight changes, feelings of hopelessness, fatigue as
well as suicidal ideation; all of which can significantly impact
daily functioning (Mental Health.gov, 2017). According to Park
and Zarate (2019) onset of depression in adulthood continues to
flourish where an estimated 30 percent of adults have a lifetime
risk of experiencing a major depressive episode with a median
age of 32.5. The author further indicates screening for
depression, a thorough evaluation, and monitoring is necessary
to ensure safety and wellbeing (Park & Zarate, 2019).
Pharmacotherapy, along with psychotherapy are first-line
therapies for effective outcomes (Park & Zarate, 2019). The
purpose of this paper is to review a case study, choose the
appropriate selection utilizing research, and discuss ethical
considerations.
Case Study
A 32-year-old Hispanic American client presents to the initial
appointment with depression. Health history, along with
medical workup, appears to be unremarkable except for the
slight back and shoulder pain due to his occupation. The clinical

6. interview reveals past feelings of being an “outsider” and has
few friends (Laureate Education, 2016). There is a decline in
daily activities, a weight increase of 15 pounds over two
months, along with diminished sleep and the inability to fully
concentrate (Laureate Education, 2016). The results of the
depression screening administered by the psychiatric mental
health nurse practitioner (PMHNP), indicates severe depression
with a score of 51 (Montgomery & Asberg, 1979).
Decision Point One
The selections include Zoloft 25 mg orally daily, Effexor 37.5
XR mg orally daily, or Phenelzine 15 mg orally TID. As a
healthcare professional treating a client, Zoloft (sertraline) 25
mg is the first choice at decision point one. Selective serotonin
reuptake inhibitors (SSRIs) impede the reabsorption of this
neurotransmitter; thus, increasing the serotonin levels of the
nerve cells in the brain to allow for improvement in mood
(Stahl, 2013). SSRIs have been utilized as first-line therapy to
treat major depressive disorder due to efficacy, fewer side
effects, cost-effectiveness as well as a wider availability
(Masuda et al., 2017). The therapeutic dosing range is typically
50 mg-200 mg (Stahl, 2017). However, beginning at 25 mg and
gradually titrating the dose, depending on tolerability, is an
appropriate health care decision (National Alliance on Mental
Illness, 2018b). Therefore, a low dose of Zoloft appears to be
the best option in caring for this client.
Effexor (venlafaxine) is classified as a selective serotonin-
norepinephrine reuptake inhibitor (SNRI) which impedes the
reabsorption of the neurotransmitters serotonin and
norepinephrine changing the chemistry in the brain to regulate
mood (Stahl, 2013). Bhat and Kennedy (2017) describe
antidepressant discontinuation syndrome (ADS) as a
“medication-induced movement disorder” along with various
adverse reactions such as intense sadness and anxiety; periods
of an “electric shock” sensation; sights of flashing lights; and
dizziness upon movement (Bhat & Kennedy, 2017, p. E7).
These symptoms are often experienced a few days after sudden

7. discontinuation of an antidepressant with a shorter-life (3-7
hours) such as venlafaxine or paroxetine (Bhat & Kennedy,
2017; Stahl, 2017). Moreover, Stahl (2017) indicates
venlafaxine is one of the drugs with more severe withdrawal
symptoms in comparison to other antidepressants. It may take
some clients several months to taper off of this medicine;
therefore, Effexor is not the optimal selection at this time.
Phenelzine is classified as an irreversible monoamine oxidase
inhibitor (MAOI) which impedes the monoamine oxidase from
deconstructing serotonin, dopamine, as well as norepinephrine.
Thus, boosting the levels of neurotransmitters in the brain to
regulate mood (Stahl, 2017). Park and Zarate (2019) purport
the use of monoamine oxidase inhibitors have a higher risk
profile; therefore, are not typically utilized unless a newer
antidepressant is considered ineffective. Bhat and Kennedy
(2017) indicate there is a need for a long taper with MAOIs.
Further, this medication may lose effectiveness after long-term
use, and it is considered to have habit-forming qualities for
some individuals (Stahl, 2017). The initial dose for phenelzine
is taken three times a day which research suggests medication
adherence is often tricky when the administration is more than
once a day (Goette & Hammwöhner, 2016). Stahl (2017)
describes certain risk factors comprising of frequent weight
gain, interference of certain food products containing tyramine,
drug interactions (serotonin syndrome), as well as a
hypertensive crisis. When utilizing this medication for
treatment-resistant depression, the advance practitioner is aware
of the detrimental adverse reactions which may occur.
Therefore, phenelzine is not the safest option for this client.
The overarching goal for this male client is to reduce the
symptoms related to his major depressive disorder and to
eventually achieve remission without relapse where he can
maintain normalcy in his life. After four weeks, his depressive
symptoms decrease by 25 percent which is progress; however,
he has a new onset of erectile dysfunction (Laureate Education,
2016). Sexual dysfunction is a notable side effect of sertraline

8. (Stahl, 2017). Therefore, the clinician will reevaluate the plan
of care given this new information. The outcomes were to be
expected as the client was started on a low dose of sertraline,
and treatment is typically 50 mg to 200 mg. A continuation in
progress may require more time, approximately six to eight
weeks in total (Stahl, 2017).
Decision Point Two
The present selections include decrease dose to 12.5 daily
orally, continue same dose and counsel client, or augment with
Wellbutrin 150 IR in the morning. The preference for decision
point two is Wellbutrin (bupropion) 150 IR, which is considered
a norepinephrine dopamine reuptake inhibitor (SDRI). An
SDRI elevates the neurotransmitters dopamine, noradrenaline,
and norepinephrine in the brain to achieve an improvement in
depressive symptoms (Stahl, 2017). The purpose of utilizing
this agent is three-fold: (1) To boost mood (2) To treat the new
onset of sexual dysfunction (3) To aid in weight-loss.
According to the National Alliance on Mental Illness [NAMI]
(2018a), Wellbutrin is a medication administered for major
depressive disorder often in conjunction with an SSRI (NAMI,
2018a).
Further, Wellbutrin may be prescribed with an SSRI to reverse
the effects of SSRI-induced sexual dysfunction (Stahl, 2017).
Dunner (2014) purports combining antidepressants are safe and
may enhance efficacy; however, the combination of medications
may also be utilized as an approach to reduce the effects of
antidepressant pharmacotherapy. Dunner (2014) concurs that
bupropion is frequently used with an SSRI or SNRI to alleviate
sexual dysfunction. Stahl (2017), findings indicate the most
common side effects of bupropion consist of constipation, dry
mouth, agitation, anxiety, improved cognitive functioning, as
well as weight loss. The client in this scenario has gained 15
pounds over two months; thus, this medication may aid in his
desire to lose weight (Laureate Education, 2016). Further, this
agent typically is not sedating as it does not have
anticholinergic or antihistamine properties yet have a mild

9. stimulating effect (Guzman, n.d).
Decreasing the Zoloft dose from 25 mg daily to 12.5 mg would
not prove feasible as the client has reached a 25 percent
reduction in symptomology. The treatment for adults is 50 mg-
200 mg, taking an approximate six to eight weeks to see the
results in some individuals (Stahl, 2017). If the provider is
tapering the medication as part of the client's plan of care,
reducing the dose to 12.5 mg would prove beneficial. Research
finds that when taking an antidepressant, the neurons adapt to
the current level of neurotransmitters; therefore, if
discontinuing an SSRI too quickly some of the symptoms may
return (Harvard Health Publishing, 2018). Under some
circumstances, discontinuation signs may appear, such as sleep
changes, mood fluctuations, unsteady gait, numbness, or
paranoia (Harvard Health Publishing, 2018). However, the
client is experiencing slow and steady progress on his current
dose of Zoloft, so no adjustments are warranted.
At this point, positive results have been verbalized with the
current dose of Zoloft 25 mg daily, with the exception of the
onset of erectile dysfunction, which is a priority at this time.
One study finds that comorbid depression and anxiety disorders
are commonly seen in adult males with sexual dysfunction
(Rajkumar & Kumaran, 2015). An estimated 12.5 percent of
participants experienced a depressive disorder before the
diagnosis of sexual dysfunction. The author’s findings suggest a
significant increase in suicidal behaviors with this comorbidity.
Moreover, the study indicates, some men experienced a sexual
disorder while taking prescribed medication such as an
antidepressant (Rajkumar & Kumaran, 2015). According to Li
et al. (2018), cognitive-behavioral therapy (CBT) is a beneficial
tool utilized with clients experiencing mood disorders. The
implementation of CBT may increase the response and
remission rates of depression. However, the option of
continuing the same dose and engaging in counseling services is
not the priority at this time. It is essential to address this side
effect to enhance his current pharmacotherapy and prevent an

10. increase in depressive symptoms.
The continued goal of therapy is to achieve “full” remission of
this individual’s major depressive disorder and to enhance his
wellbeing. After four weeks, the client returns to the clinic
with a significant reduction in depressive symptoms along with
the dissipation of erectile dysfunction. However, he reports
feelings of “jitteriness” and on occasion “nervousness”
(Laureate Education, 2016). This course of treatment has
proven successful thus far, and the outcomes are to be expected
due to the medication trials.
Decision Point Three
The present selections are to discontinue Zoloft and continue
Wellbutrin, change Wellbutrin to XL 150 mg in the morning, or
add Ativan 0.5 mg orally TID/PRN for anxiety. The selection
for decision point three is to change the Wellbutrin from IR to
XL 150 mg in the morning. The first formulation is immediate-
release (IR) and the recommended dosing is divided beginning
at 75 mg twice daily increasing to 100 mg twice daily, then 100
mg three times a day with the maximum of 450 mg (Stahl,
2017). The second formulation is extended-release (XL),
where the administration for the initial dose is once daily taken
in the morning; the maximum is 450 mg in a single dose (Stahl,
2017). The peak level of bupropion XL is approximately five
hours; therefore, the side effects reported may subside as the
absorption rate is slower than the IR dose (U.S. Food and Drug
Administration, 2011a). The immediate-release peak level is
approximately two hours which may account for the client’s
notable feelings of being jittery and at times nervous (U.S. Food
and Drug Administration, 2011b). Furthermore, clients are
switched to extended-release to improve tolerance and treatment
adherence to once-daily treatment (Guzman, n.d). As a mental
health provider, caring for this client, changing the formulation
is the best decision at this point as well as to continue to
monitor side effects.
As mentioned above, Zoloft, an SSRI, can be utilized as a first-
line agent for major depressive disorder (Masuda et al., 2017).

11. Using Wellbutrin as an adjunct to the regimen has continued to
reduce his symptoms of depression and has alleviated one of his
primary concerns which is sexual dysfunction. Therefore,
discontinuing Zoloft and maintaining the use of Wellbutrin is
not an appropriate option at this time.
Ativan (lorazepam) is a benzodiazepine with anxiolytic, anti-
anxiety, and sedative properties. It provides short-term relief of
anxiety symptoms or insomnia (U.S. National Library of
Medicine [NLM], n.d.). Lorazepam works by enhancing the
effect of the inhibitory neurotransmitter GABA, which inhibits
the nerve signals, in doing so, reducing the “nervous excitation”
(NLM, n.d., para. 1). In some instances, a low dose, 0.5 mg,
may be administered short-term to reduce side effects from
another medication. Stahl (2017), indicates many side effects
will not improve with an augmenting drug. Common side effects
consist of confusion, weakness, sedation, nervousness, and
fatigue (Stahl, 2017). Further, Ativan has an increased risk for
abuse potential as it is known to have habit-forming properties
(Stahl, 2017). As a result, administering Ativan would not be in
the best interest of the client.
The ultimate goal is to achieve remission of his mood disorder.
The medication regimen has proven effective; thus, considering
this to be a successful plan of care. Taking both the sertraline
and bupropion can exhibit side effects of jitteriness; however,
changing to the extended-release may aid in the dissipation of
these feelings. The addition of Ativan to relieve side effects,
that are perhaps temporary, is against better judgment without
first making an effort to change or modify the medication
regimen (Laureate Education, 2016).
Summary with Ethical Considerations
Mood disorders affect millions of individuals in the United
States on an annual basis. The prevalence of mental illness
continues to flourish, impacting one’s quality of life. Initiating
treatment, under the guidance of a healthcare professional, is of
the utmost importance. Further, an individualized plan of care
comprising of education, therapy, medication, and support is

12. crucial for overall health and wellbeing.
The client is a Hispanic American male employed as a laborer
in a warehouse (Laureate Education, 2016). It is essential to
assess his financial means before prescribing medications.
Although one cannot assume the client has financial hardships,
having this knowledge will guide in the process of treatment. If
the client is without insurance and has to pay out-of-pocket,
medication adherence may not be sustainable. Therefore, as a
psychiatric nurse practitioner, providing a cost-effective means
whether, through generic prescriptions, discount pharmacies, or
prescribing a larger quantity may be a necessary option (Barker
& Guzman, 2015). Further, the partnership among clients and
practitioners is essential; to establish trust and respect as well
as understanding cultural preferences while avoiding
stereotypes is vital.