The problem. The development of these conditionsThe problem. The development of these conditions

The patient has presented
with signs of depression and strong evidence of self-neglect. The lack of
self-care has contributed to his urosepsis which might have triggered a seizure
although it might also be an alcohol withdrawal symptom. He has a background of
alcohol misuse since 2007 when he had a relationship break down with his
partner. His alcoholism has then became a strong risk factor for many of his psychological
and physical health deterioration especially malnutrition.


It is difficult to discern if
his excessive drinking has contributed to his low mood or otherwise.
Nevertheless, it has been found that excessive intake of alcohol is a contributory
factor to low mood which can then be a vicious cycle when people use alcohol to
feel better. Alcoholism has always been a public health concern especially in
Scotland which remains the UK constituent country with the highest rates of
alcohol-related deaths. Latest statistics reported in 2015, an average of 22
people per week died in Scotland due to an alcohol-related cause which was
found to be 54% higher mortality rate than in England and Wales.(1) A Scottish Health
Survey in 2016 which reported that 1 in 4 people drink at hazardous levels further
emphasizing the importance of public awareness on alcoholism.(2)

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Biopsychosocial model of
health and Depression


              In the past, the ‘medical model’ which enable
biological explanation and treatment for diseases is now less suitable
especially when leading health threats nowadays are degenerative and disabling
diseases such as mental health problem. The development of these conditions are
usually multifactorial with a multi-dimensional impact thus having neither
simple biological cause nor straightforward medical or surgical cure. Reflecting
on Tomorrow’s Doctor (2009) outcome on application of psychological and social
science principles, method and knowledge to medical practice, it is crucial to
first understand an underlying biopsychosocial model of health. This model pointed out that although genetic and
constitutional factors play a role in ensuring the health of an individual,
there are a myriad of other influences of health surrounding each individual
with the first layer being individual lifestyle factors. A person’s way of
living and behaviour can benefit or damage health. Common examples include
smoking and drinking alcohol excessively which can predispose an individual to
many harmful health implications. In fact, involving oneself in risky
behaviours can be perceived as a deliberate self-harm. 


              Studies has proven that genetic
factors play an important role in development of major depressive disorder.
Recently the British research team has identified genetic link in chromosome
3p25-26 which is strongly linked with depression.(4) This variation in gene were found to
affect an individual’s susceptibility to severe recurrent depression. However other
factors such as environmental and health-related behaviours are believed to
play a larger role in most cases of depression and will be the emphasis in this
case discussion.


of the behavioural risk factors for depression include drug or alcohol abuse,
smoking and the lack of physical activity or sedentary lifestyle which can
increase the risk of being overweight. Many studies have come to a consensus
that concluded exercise is positively associated with mental health and
well-being as it reduces stress and anxiety. Physical activity also provides
emotional benefits for both genders of all ages. Besides, with an active
lifestyle an ideal body weight can be achieved which reduces an individual’s
risk of some of the conditions like Type 2 diabetes, cardiovascular diseases,
certain type of cancer and musculoskeletal conditions like osteoarthritis.


is also a common complication in chronic illness such as those mentioned. It is
estimated that up to one-third of individuals with chronic medical conditions
experience symptoms of depression.(5) Thus, we can see that behavioural factor can be one that
predisposes an individual to certain medical conditions which can then be a
factor of low mood. This stresses the importance of addressing unhealthy
behaviour and lifestyles for example not exercising or smoking. Mr X’s
excessive alcohol consumption is also a major factor to look into when it comes
to his low mood which will be elaborated at the end of this section.


cognition and emotions are the psychological factors that works at an
individual level interacting with health and illnesses. These can be influenced
by early upbringing, personalities and life events. In this patient for
instance, he has been brought up in a poor family which have constant financial
worries. He also mentioned that his father was abusive to his mother which has
affected his trust in having a relationship and was the reason he never wanted
to get married. However, there is substantial evidence that individual benefit
from marriage in terms of physical and mental health.(6) Having own family
can also create a strong social support and this is lacking in the case of Mr.


of the other biological influence on health that is related to depression
includes age and gender. Statistics have shown that depression is more
prevalent in women.(7)
The triggers for depression in both gender are different with men
displaying more sensitivity to external career and goal-orientated factors
while women are more sensitive to interpersonal relationships.(8) Women also undergo
specific forms of depression-associated illness, including premenstrual syndrome,
postpartum depression and postmenopausal depression that are related with
changes in estrogen level. Thus depression do correlates with hormonal changes
in women, particularly during puberty, prior to menstruation, following
pregnancy and at perimenopause, which suggests that hormonal fluctuations may
be a trigger for it.(8)
Meanwhile, the lower prevalence of depression in men is probably owing to
developmental difference in brain circuitry.(9)


              Unfortunate life events can also
trigger depression especially in individuals who have low psychological
Personalities such as low self-esteem which can be due to poor upbringing
or lack of social support can all be a contributory factor. In the case of Mr.
X, he has mentioned that he was feeling low after breaking up with his partner
and has resorted to excessive drinking in response to loneliness, isolation and
lack of purpose to his day. In addition, depression is more prevalent in people
of age 40-59 which correlates with the patient who falls around this age group.(12) One of the
explanation behind could be that unhealthy lifestyles tend to catch up with this
age group as they become less able to react to challenges from the internal and
external environment.(20)


              The sociological perspective of
health in relation to Dahlgreen and Whitehead’s model includes social and
community networks, general socio-economic, cultural and environmental
influences.(3) The sociology of depression encompasses the cultural
context in which people live. Culture and ethnicity are crucial aspects of
health and illness. In the past, depression is thought to primarily affect
people of ‘western’ nations.(13) Nonetheless, ethnomedical studies which focuses on the
role of culture, perception, and context in moulding one’s physical and mental
health suggest that this perception may be due to a cultural perceptions of
what symptoms become labelled as depressive disorder. (13)The amount and ways
of drinking is also influenced by social conditions like place of living and
occupation. Statistics showed that alcohol-related mortality rates for those
living in most deprived area are almost eight times the rate for those in least
deprived areas. This can be attributed to the fact that incidence of binge
drinking are higher in less affluent groups. (14)


Alcoholism and Depression


              Alcohol misuse is a debilitating
disorder which can contribute to numerous health and social problems. Drinking
alcohol is considered by many to be an important part of Scottish culture and
binge drinking is a significant problem in Scotland. This pattern of drinking
in particular can lead to serious health and social consequences which
predisposes one to suffer from symptoms of depression. These are either due to
the social impact of excessive drinking or the neurobiological effects of
alcohol. It is found that depression and alcohol misuse often co-occur and that
having one increases a person’s likelihood of developing the other. This
overlap can be partly due to a shared social and biological risk factors of mental
disorder and alcohol abuse. There is evidence that suggest excessive drinking,
among other risky lifestyle behaviour such as smoking, poor diet or physical
inactivity may be a significant risk factor in the development of some mental
disorders.(15) Damage
from chronic use of alcohol to the brain can be explained by the effects of
alcohol on promoting a heightened stress response via cortisol pathway
dysregulation and over activation of the hypothalamic-pituitary-adrenergic axis
and may also disrupt the dopaminergic and serotonergic systems.(16)(17) These signaling
and structural impact can be a concern on its own but also increases risk of
dementia, Alzheimer disease, decreased cognitive function and mood disorders.(18)


3.           Interventions
which might help (for alcoholism-depression)  


              As for Mr X, he will require a lot
of social support and possibly physiotherapist and occupational therapist
assessment to improve his quality of life and regain muscle strength after a
long stay in the hospital. He will also benefit from a psychiatrist referral
who can start him on antidepressant for his mood, to assess his suicidal risk
thoroughly and arrange follow-up with him. However, we will need to ensure that
he is ready to give up alcohol as drinking can counteract the benefits of
antidepressants. With that, huge amount of effort will need to be on
counselling and providing him the support he need throughout the journey. We
will need to identify his wishes for either a one to one counselling or group
therapy which can make a difference in one’s willingness to participate. Some
of the support group that are available are the Alcoholics Anonymous and
Tayside Alcohol Problem Service (TAPS) which has treatment programme and
regular support meetings. We should also make sure that he is aware about
24-hours available helpline which can provide confidential emotional support
for whenever he requires.


              Health education and promotion is
also a fundamental step in preventing alcoholism in a population. This involves
actions directed at the determinants of health, which are either within the
control of an individual or outside i.e. a person’s health behaviour as
mentioned earlier or social, economic and environmental conditions. For
instances, health promotion activities in this case can be a change in
government policy by implementing minimum alcohol unit pricing legislation.(1) Besides, having
programme such as Alcohol Brief Interventions can help educating and provide
guidance to hazardous drinkers in reducing their consumption. Scotland’s
alcohol strategy which includes an increased investments in specialist
treatment services, restriction on alcohol promotion and a ban on multi-buy
discounts in shops and supermarkets will also help addressing alcoholism.(14)


              The WHO definition of health
pointed out that individual’s social aspects and interpersonal relationships
and their viewpoint, beliefs and expectations are crucial factors in the
maintenance of health, development of illness, help-seeking behaviour and
responses to treatment.(19)
Thus we should always be reminded that the prospects and pre-requisites for
health cannot be established by health sector alone. It will require actions
from the governments, social economic sectors, nongovernmental and voluntary
organizations, by local authorities and media.(20)



4.           Application
of these measures (Health promotion: public health intervention in preventing
alcoholism & alcohol misuse)


              As the patient has a serious
drinking problem, the above measures can help him to prevent relapse and
hopefully will help in improving his mood. However, any change in behaviour and
lifestyle will still require one’s willpower and determination. With the help
of counselling and local support group as well as medications, it will
definitely make things easier for him. Social worker can also be involved to
help find out if there are any activities in the community which he could
participate in. As far as preventative measures, it will be difficult to
prevent him from abusing alcohol in the first place due to his many risk
factors of an abuse. However, if his low mood was identified and managed earlier
on, he might not resort to alcohol as a form of relief. This ultimately boils
down to one’s health-seeking behaviour as a major factor in health beside the
other determinants of health that were mentioned.