Substance Use history

Past/Current Psychological Proble

Reorts a diagnosis of Bipolar Manic Depression made several years ago

tates “I just wants it all go away, maybe it be better if I just went away, sometimes I cry when I wake up.”

Medication history

Records indicated that the client has been treated off and on with Seroquel and Lithium. He reported that both medications helped him feel more “calm and collected.” He has been off of medication for the past 2 months.

Substance Use history

The client stated that he drinks alcohol every day, usually 1 liter of vodka and a few beers.  This pattern of drinking endured for the past 10 years. He tried to stop drinking one time and the longest that he has abstained from drugs and alcohol was for a period of 3 months a few years ago. He also uses cocaine and marijuana several times per week.  He stated that he has thought about stopping the substance use, but is sure that he will never be able to abstain. The patient has a history of the shakes when he has attempted to stop drinking in the past. He has tried outpatient substance abuse counseling, though would usually relapse after a few sessions. He has never participated in inpatient detox.

Records reviewed (Psychiatric ER summary dated August 6, 2010)

 

Patient was admitted to the X psychiatric emergency room and placed on a 72 hour observation. He was brought in by emergency medical services and a police escort after he was found in the street yelling that he wanted to die and threatening bystanders at the local bus station.  His toxicology screening was positive for alcohol, marijuana, cocaine, and benzodiazepines.  After the 72 hour observation the substances had cleared, the patient was administered Librium for alcohol withdrawal complications, and by day 3 he denied suicidal, as well as homicidal ideation. Thus, he was released, in good behavioral control, and referred to an outpatient chemical dependency program. Records indicated that the pt has a diagnostic history that includes, Bipolar Disorder Not Otherwise Specified, Alcohol Dependence, and Polysubstance Abuse.

 

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