Defining Mental Health and Illness

Mental Health Defined

• Mental health is defined as the characteristics that make up positive psychology
• Key characteristics include ability to enjoy life, resilience, balance and flexibility
• Self-actualization, which is realizing one's potential, is also an important characteristic
• Being able to form healthy relationships, possess self-esteem and come to terms with death and dying are all characteristics of mental health

Mental Illness Defined

• Per the American Psychiatric Association, a mental illness/disorder is "...a clinically significant behavioral or psychological syndrome"
• A mental illness causes "...present distress...or disability...a significantly increased risk of suffering, death, pain disability, or an impairment loss of freedom..."
• Mental illness is due to maladaptive responses to internal or external stressors
• It presents with thoughts, feelings, and behaviors that clash with cultural norms and hinder social, occupational, and/or physical functioning

General Adaptation Syndrome

• This syndrome follows 3 stages when responding to stress
• Alarm stage: Physiological fight-or-flight response
• Resistance stage: Body adapts to stress levels and attempts to return to homeostasis
• Exhaustion stage: Prolonged stress exposure depletes bodily resources, potentially leading to death without intervention

Levels of Care

• Treatment should be guided by the principle of the "least restrictive setting alternative"
• These levels of care include:
  • Outpatient primary health care, and addressing cries for help or somatic symptoms of stress
  • Outpatient psychologist/psychiatrist, for counseling and addressing identified problems/crises
  • Emergency department evaluation because of safety issues
  • Inpatient psychiatric hospitalization due to voluntary/involuntary commitment legal status
  • Discharge to home, board and care, residential facility, assisted living, or homeless shelter

Psychopathology

• Can be classified using the DSM-V (Diagnostic and Statistical Manual for Mental Disorders)
• Neurodevelopmental, Schizophrenia Spectrum, and Psychotic Disorders
• Bipolar, Depressive, Anxiety and Obsessive-Compulsive Disorders
• Trauma and Stressor Related, Dissociative, and Somatic Symptom Disorders
• Feeding and Eating, Elimination, and Sleep-Wake Disorders
• Sexual Dysfunction, Gender Dysphoria, Disruptive, & Impulse-Control Conduct Disorders
• Substance Related, Addictive, Neurocognitive, Personality, and Paraphilic Disorders
• Other relevant conditions include Medication Induced Disorders

Psychotherapeutic Management

• Involves interdependent components
• Therapeutic nurse-patient relationship
• Milieu management
• Psychopharmacology

Psychiatric Mental Health Nurse

• Manages the therapeutic community 24/7 utilizing the nursing process
• Ensures patients' physiological and psychological needs are met
• Engages with:
  • Medication administration
  • Therapeutic nurse-patient relationship development
  • Setting limits on unacceptable patient behavior
  • Patient teaching and education

Hildegard Peplau

• Outlines six key nursing roles
• Resource person
• Counselor
• Teacher
• Leader
• Technical expert
• Surrogate

Nurse-Patient Relationships

• Can be brief therapeutic
• Not social, but therapeutic
• Collaborative

Therapeutic Relationships

• It is vital to build trust, congruence, empathy, acceptance, and positive regard with patients

Professional Boundaries

• Therapeutic use of self utilizes the nurse's personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions

Nurse-Patient Relationship: Stages

• Orientation - Building trust, setting time limits, assessing, managing emotions, setting an agenda, support & structure
• Working - Learning, in-depth data collection, reality testing, cognitive restructuring, journaling, promoting change and teaching new skills
• Termination - Evaluating goal attainment, summarizing progress, synthesize outcomes and provide referrals

BATHE Technique

• Communication technique for nursing students performing interviews
• Background: "What is going on/brought you here?"
• Affect: "How does this make you feel?"
• Trouble: "What troubles you most in your situation?"
• Handling: "How are you able to handle this situation?"
• Empathy: Interviewer demonstrates understanding of the patient's perspective
• Goal - "What do you have to do in order to go home?"

Milieu

• Involves structuring the environment scientifically to improve psychological health and functioning

Basic Milieu Assumptions

• Each individual's health is recognized and encouraged
• Every interaction is an opportunity for therapeutic intervention
• Patients own their behaviors and environment
• Peer pressure is a useful tool
• Inappropriate behavior is addressed promptly
• Restrictions and punishment are to be avoided

Interdisciplinary Team

• Includes:
  • Psychiatrist
  • Clinical Psychologist
  • Psychiatric Registered Nurse, Clinical Nurse Specialist
  • Licensed Vocational Nurses, Psychiatric Technicians
  • Psychiatric Social Worker, Case Manager
  • Mental Health Technician, Hospital Assistants
  • Art, Recreation, Psychodrama, Music & Occupational Therapists
  • Dietician
  • Chaplain

Treatment Types

• Individual, couple's, family, and group therapy are used
• Group Therapy Types:
  • Task: accomplishes a specific outcome
  • Educational: conveys knowledge and information
  • Self Help: people with similar issues and with rotating leadership
  • Supportive or Therapeutic: Based on theory/group relations with select issues

Intervention Groups

• Define association based on shared interests, values, norms, or purpose
• Group functions include socialization, support, task completion, camaraderie, informational exchange, normative behavior, empowerment and governance

Milieu: Safety Issues

• RN is key in monitoring patient activity with foremost safety goals
• Assessing psychodynamic issues
• Evaluating treatment and medication effectiveness
• Art of delegation

Medication Administration

• Mandatory informed consent driven by state law
• Requires patient, doctor and witness signatures

Consent

• Must identify medication, dosages, benefits, and risks
• Medications requiring informed consent:
  • Psychotropics, antidepressants, antimanics, stimulants and anxiolytics

Ethical

• Benefit of medication is weighed against legal ramifications
• Follows informed consent laws, including patient/court rights

Psychopharmacology: General

• Target symptoms, dosage, maintenance, tapering, and primary physician follow-up are necessary to consider

Neurotransmitters

• Neurotransmitters tie into mental health treatments
  • Acetylcholine deficits can be linked to Alzheimer's Disease and Parkinsonism
  • Elevated Dopamine can be linked to Schizophrenia and Parkinsonism
  • Decreased GABA can be linked to Anxiety Disorders
  • Norepinephrine and Serotonin dysregulation can be linked to Mania & Depression

Pharmacokinetics: Elderly

• Absorption - Lowered intestinal movement and blood flow to the gut may result
• Distribution - Decreased body water, increased body fat, decreased plasma proteins and lowered lean body mass
• Metabolism - Lowered blood flow to the liver and the function of the liver may result
• Excretion - Lowered function of kidney, diminished creatinine clearance

Psychotropics: Elderly

• Start low and go slow
  • Neuroleptics can cause lower BP, orthostatic hypotension, confusion, dry mouth, constipation, urinary retention, and tardive dyskinesia at low doses
  • Tricyclic antidepressants can worsen glaucoma and urinary retention
  • Amitriptyline can cause hypotension and cardiotoxicity
  • Benzodiazepines can be addictive, and accumulate to cause daytime sleepiness and confusion

Schizophrenia & Psychosis

• Schizophrenia is a psychotic diagnostic term which affects perception, thought processes, reality testing, feeling, behavior, attention, and motivation

Schizophrenia Treatments

• Typical antipsychotics act on disorganized thinking and positive symptoms with high side effects
  • Haloperidol and Fluphenazine are available in sesame oil based IM depot
  • Chlorpromazine, Thioridazine, Fluphenazine, Trifluoperazine, Haloperidol, Chlorprothixene, Thiothixene, Dibenzoxazepine (Loxapine), and Dihydroindolone are examples
• Atypical antipsychotics treat positive and negative symptoms with fewer side effects
  • Aripiprazole, Clozapine, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, and Ziprasidone are included

Atypical Antipsychotics Highlighted

• Aripiprazole – Max Dose (MD) is 30 ml
• Clozapine – Requires testing
• Lurasidone – Treats bipolar depression, needs to be taken with 300 calories
• Olanzapine – Sedating
• Paliperidone – Can be given orally, IM, and as a Long Acting Injectable
• Quetiapine – Max Dose(MD) is 800 ml/day; patients want sweets. Weight gain is common
• Risperidone – Can cause gynecomastia in males and amenorrhea in females
• Ziprasidone – EKG is required

Atypical Antipsychotics Specific

• Clozapine treats refractory psychosis
  • Monitoring includes: CBC (WBC) 1-2 weeks for low levels
  • Weekly blood draws

Antiparkinson Medication

• Treats extrapyramidal symptoms due to neurotransmitter imbalances from blocked dopamine receptors

Anticholinergic Medications

• Restore neurotransmitter imbalance between dopamine and acetylcholine, also treats EPS
  • Benztropine, Trihexyphenidyl, and Diphenhydramine
  • These medications are drying, so be careful with older males with prostate issues

Anticholinergics Side Effects and Interventions

• Side effects: dry mouth, nasal congestion, urinary retention, blurred vision, constipation, mydriasis
• Nursing actions: Offer sugar-free candy, decongestants, running water, sunglasses, laxatives
• Use with caution in elderly

Extrapyramidal Side Effects (EPS)

• These side effects may include, acute dystonic reactions, muscular rigidity, akathisia, akinesia, tardive dyskinesia, oculogyric crisis and torticollis

Tardive Dyskinesia (TD)

• Nonreversible neurologic side effect with bizarre facial and tongue movements, stiff neck, and difficulty swallowing caused by long-term antipsychotic use

Neuroleptic Malignant Syndrome (NMS)

• Rare but potentially fatal from antipsychotic medication

NMS Symptoms

• Hyperthermia
• Altered consciousness
• Severe muscle rigidity
• Autonomic instability/tachycardia
• Fluctuations in blood pressure
• Elevated CPK's
• Diaphoresis
• Rapid deterioration
• Rhabdomyolysis
• Stupor, coma, and death

NMS Treatment

• Monitor and control hyperthermia, transfer to medicine and administer Dantrolene and Bromocriptine
• Restart antipsychotics after 2 week wash out

Mood Disorder Treatments

• Antidepressants treat major depression, panic disorder, anxiety disorders, bipolar depression and psychotic depression

SSRIs (Reuptake Inhibitors)

• First-line agents for depression
• Generally the lowest in adverse effects regarding anxiety, agitation, akathisia, nausea, insomnia and sexual dysfunction
  • Fluoxetine (Tx for Bulimia, PMS)
  • Fluvoxamine (Tx for OCD)
  • Paroxetine (Tx for Panic)
  • Sertraline
  • Citalopram

Medications For Bipolar

• Include mood stabilizers
  • Lithium is first line
• GN Fluoxetine MD 30 ml/day for the others, needs 4-6 week for effect

Tricyclic and Tetracyclic Antidepressants

• Second line agents that block norepinephrine and serotonin, cause sedative and anticholinergic side effects
  • Amitriptyline

TCA Overdose Interventions

• BP, HR and ECG and RR are to be monitored, then an airway should be maintained and Physostigmine should be administered

Monoamine Oxidase Inhibitors (MAOI)

• Third line agents with daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension side effects
• Consumption with Tyramine and other foods can cause hypertensive crisis
• Avoid red wine, beer, aged, smoked, pickled, fermented meats, aged cheeses, bananas, avocados, canned figs, sauerkraut, fava beans, licorice, soy sauce, and yeast, OTC, cold medicine and diet pills

MAOI Teaching

• Can’t mix with alcohol
• Therapeutic effects take 2-4 weeks
• Use caution for drowsiness
• Monitor tyramine, DC, and give Phenotolamine

Novel Antidepressants

• First line agents, for example:
• Bupropion
• Mirtazapine
• Nefazodone
• Trazodone
• Venlafaxine

Suicide Potential

• Antidepressants take 2-4 weeks to achieve full effect, careful evaluation and limited prescription needed

Serotonin Syndrome

• Causes mental status changes, restlessness, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremors, diarrhea, ataxia and headache due to drug interaction
• SSRI & MAOI's, tryptophan, St. John's Wort cause it

Antimanic Agents

• They treat bipolar disorders
• Lithium carbonate 0.6-1.2 mEq/L
• Carbamazepine 8-12 ug/ml
• Valproic Acid and 50-100 ug/ml
• Olanzapine and Aripiprazole are also used

Other Medication Considerations

• Therapeutic Li+ serum is 0.6-1.2 mEq/L
• Fatigue, memory issues, arrhythmias, and acne may occur
• Monitor thyroid function, contraindicated: cardiac, renal & pregnant
• Metabolized fast, causes fetal demise
• Anxiety when teaching side effects, N, dry mouth, D, thirst, mild hand tremor, weight gain, bloated, insomnia and light-headedness are expected. Avoid conception and driving

Lithium is Toxic

• 1.5 mEq/L: Mild diarrhea, vomiting, drowsiness, muscular weakness, ataxia

• 2.0 mEq/L: Moderate ataxia, giddiness, tinnitus, blurred vision and dilute urine

• 3.0 mEq/L: Multiple organ systems leading to death

• 4.0 mEq/L: Poor outcomes

• Tx w/no antidote, hold lithium, draw level, ECG
• Severe has IV and dialysis

Mood Stabilizers

• Depakote increases GABA while lithium assists rapid-cycling bipolar disorder
• Hair issues, weight gain and GI upset, LFTs must be considered

Other Medication Concerns

• Effective carbamazepine is linked to inhibited "kindling”
• A range of 8-12 is a safe serum level but agranulocytosis must be monitored
• Bipolar should be treated with Clonazepam, Lorazepam, Clozapine, Risperidone, Quetiapine, Gabapentin, Lamotrigine and Topiramate
• Anxiety can be treated if they are also OCD Phobic and Insomnia and PTDS
• CNS depressants shouldn't mix due to lethality
• Anxiolytics, hypnotics, muscle relaxants, anticonvulsants all useful

Anxiety

• Buspirone is nonbenzodiazepine and is a selective treatment
• It has no risk and has a limited effect, for example:
• Alprazolam
• Chlordiazepoxide
• Clonazepam
• Diazepam
• Lorazepam
• Oxazepam

Important Notes

• Xanax, Librium(longest halflife), klonopin, Valium, Ativan are main one's for anxiety care
• Prozac, Luvox, Paxil, Zoloft, Effexor and propranolol are also alternatives
• Be mindful of toxicity, use gastric treatment

Old Use

• Benzodiazapines should be used to treat minor issues or be taken by those unable to take OTC
• All drugs need 4-6 weeks to develop, driving can be difficult
• Alzheimer's can be treated

Management

• This knowledge is useful for relationships, milieu and psychological approaches