{"text":"Patricia Hunt : } 15\/2\/05 \nDob - 12\/9\/82 \nShe seems to have got over this in adulthood, and there seems no residual social \nmaladjustment. \u2018 \nImpression \nThe fundamental problem here seems to be one of prolonged unresolved grief. The \nOpiate dependence is probably secondary to this disturbance though of course, has \ntaken on a life of its own because she still has a level of physical dependence and gets \nwithdrawa! symptoms when she stops taking Codeine. She continues to have a \ntendency to buy Diconal if the opportunity is available. It is worth noting that she has \nnever taken drugs recreationally or for gross intoxication and, by her account at least, \nis not particularly involved in the illicit drug scene. I note that despite a number of \nattempts at detoxification, none has been completely successful though her current \nconsumption of Opiates is quite modest. \nRegarding her mother\u2019s death, this was alone sudden but also surrounded by some \nambivalence. Her mother apparently had a single heart attack and then a further attack \ntwo days later, My grasp of the circumstances is a little muddled but she feels that her \nmother might have been given a \u201cclot busting\u201d drug and might not have had the \nsecond coronary, and things would still be okay. This feature combines with the \nsuddenness of her mother\u2019s death and at an early age to produce a not unexpected \nmorbid grief reaction. ' \nManagement \nIt is clear that her main clinical need at the moment is for effective bereavement \ncounselling. 1 am uncertain what the best source for this might be and I suggest you \nexplore what options are available locally. You have made a referral to Gary Tanner, \nPsychologist with the Addiction Service who may feel prepared to offer bereavement \ncounselling though you would need to ask him if this is part of his remit. Regarding \nher Opiate use, I think this will become less of an issue as she adjusts to her mother\u2019s \ndeath. Meantime, the question of whether she is maintained at her current level \n(which requires no prescription as the medication is obtainable over the counter) or \nwhether she attempts another detox is not crucial and depends on how you and she \nthink best to manage the problem. ' \nRegarding her appetite and recent possible weight loss, I suggest continuing to \nmonitor her weight. There are no current reasons to suspect an cating disorder (she \nbelieves she is too thin). \nMedication wise, 1 suggest a trial of Mirtazepine starting with 15mg daily and \nincreasing to 30mg and the 45mg over a three week period as tolerated. Once she has - \nbeen on the full dose of 45mg for a four week period, the medication should be \nreviewed and then discontinued carefully if there have been no beneficial effects. In \nthat event, 1 would not recommend proceeding to a further anti-depressant. 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