Understanding Positive Psychology & Mental Health

• Positive psychology studies the characteristics that make up mental health.
• Mental health includes the ability to enjoy life and having resilience, which is the ability to bounce back from adversity.
• Mental health depends on having balance in life and having emotional and cognitive flexibility.
• Mentally healthy people are in the process of realizing their potential.
• Mental health includes the ability to form healthy relationships, have healthy self-esteem and sexuality, and have a perspective on death, dying, and loss.
• The American Psychiatric Association defines mental illness as a clinically significant behavioral or psychological syndrome or pattern.
• Mental illnesses are associated with present distress, increased risk of suffering death, pain disability, or an impairment loss of freedom, but is not merely an expectable response to a particular event.
• Mental illness manifests as maladaptive responses to stressors from the internal or external environment.
• These responses are evidenced by thoughts, feelings, and behaviors that are incongruent with cultural norms and interfere with the individual’s functioning.

Psych Assessment

• The information gathered will explain why the patient is seeking help.
• Information includes the client's name, race/ethnic data, marital status, #/ages of children and siblings, living arrangements, occupation, education, religious affiliations
• Information to gather includes feelings of depression, anxiety, hopelessness, being overwhelmed, suspiciousness or confusion, and recent difficulties or alterations in relationships, usual level of functioning, behavior, perceptions and cognitive abilities.
• Somatic changes to note include constipation, diarrhea, insomnia, lethargy, changes in weight, anorexia, palpitations, pruritus, nausea, vomiting, and headache.
• Important family history to gather includes childhood, caregiver information, abuse, and parental drinking history.
• Assess for use of drugs, the effect on the family, any physical or mental problems, and how it has affected the family.
• Relevant personal history includes previous illness, hospitalization, education- highest grade completed and special skills.
• Occupational background, where, how long employed, and job description important.
• Social patterns include importance of friends and usual daily activities.
• Sexual patterns include if active, orientation, and any difficulties.
• Note interests and abilities, including spare time activities, what the patient is good at, and if it gives pleasure.
• Substance abuse profiles should note medications the patient is taking and if they use alcohol or drugs.
• Assess the patient's stress coping methods.

General Adaption Syndrome

• Alarm stage: there is an immediate physiological response to a threat or perceived threat (fight or flight).
• Resistance stage: If the stress continues, the body adapts to the levels of stress and attempts to return to homeostasis.
• Exhaustion stage: Prolonged exposure and stress adaptation can deplete the body’s resources; without intervention, death is a possibility.

Levels of Care

• Right to treatment in the least restrictive setting alternative is a guiding principle.
• Care environments range from outpatient primary healthcare and counselor, to emergency department, to in-patient psychiatric hospitalization, to home, board and care, residential facility, assisted living or homeless shelter.
• Inpatient psychiatric care could be voluntary or involuntary and commitment legal status.

Diagnostic and Statistical Manual for Mental Disorders-V-TR

• Lists a number of classifications of Mental Health Disorders to include: Neurodevelopmental, Schizophrenia Spectrum, Bipolar & Related/Depressive, Anxiety/Obsessive-Compulsive, Trauma & Stressor Related
• Others include Dissociative/Somatic Symptom, Feeding & Eating/Elimination/Sleep-Wake, Sexual Dysfunctions/Gender Dysphoria, Disruptive/Impulse-Control & Conduct, Substance Related & Addictive, Neurocognitive, Personality/Paraphilic and Medication Induced.

Psychotherapeutic Management

• The therapeutic nurse-patient relationship, milieu management, and psychopharmacology are interdependent components of the psychotherapeutic management model.
• Nurses manage the therapeutic community 24 hours a day.
• The nurse is responsible for ensuring the patient's physiological and psychological needs are met.
• Psychiatric nurses perform medication administration, develop therapeutic nurse-patient relationships, set limits, and teach patients.

Hildegard Peplau

• Nurses function as resource person, counselor, teacher, leader, technical expert, and surrogate assisting individuals in need of mental health services.

Nurse-Patient Relationships

• A PMH nurse’s building of therapeutic relationships is demonstrably skillful
• This may be a brief therapeutic or a collaborative relationship, differentiating from a social relationship

Establishing Therapeutic Relationships

• Critical components include trust, congruence, empathy, acceptance, and positive regard.
• "Therapeutic use of self” occurs when the nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish a beneficial relationship with patients.

Stages of Therapeutic Nurse-Patient Relationship

• Orientation: Build trust, ask permission, assess, manage emotions, set agenda, provide support & structure.
• Working: In-depth data collection, reality testing, cognitive restructuring, writing and journaling, supportive confrontation, promote change, teach new skills.
• Termination: Evaluate goal attainment and summarize progress.

BATHE Technique

• The BATHE technique is a good communication technique for nursing students.
• It is used in brief encounters and a focused interview technique.
• BATHE helps the patient identify problems and coping strategies, and is supportive of the patient, however is not for suicidal patients.
• BATHE stands for background, affect, trouble, handling, and empathy.
• Some example questions are: What is going on/brought you here, How does this make you feel, what troubles you most in your situation, how are you able to handle this situation
• The interviewer shows the patient they understand their view of the situation by empathizing with them.

Milieu Therapy

• Scientific structuring of the environment is done in order to effect behavioral changes and improve the psychological health and functioning of the individual
• Within the therapeutic community, the patient is expected to learn adaptive coping, appropriate interaction and relationship skills that can be applied to other aspects of their life

Basic Milieu Assumptions

• The health in each individual is to be recognized and encouraged to grow
• Every interaction is an opportunity for therapeutic intervention
• The patient owns their own environment
• Each patient owns their own behavior
• Peer pressure is a useful and powerful tool
• Inappropriate behavior is dealt with as it occurs
• Restrictions and punishment are to be avoided

Interdisciplinary Team

• A multi-disciplinary team consists of psychiatrists, clinical psychologists, psychiatric registered nurses, clinical nurse specialists, licensed vocational nurses, psychiatric technicians, psychiatric social workers
• Case managers, mental health technicians, hospital assistants, therapists in art, recreation, psychodrama, music & occupational fields.
• Additional members include dietitians and chaplains.

Modalities of Treatment

• These include individual, couples or family therapy.
• Group therapy is also used, including task groups, educational groups, self-help groups and supportive/therapeutic groups.
• A task group accomplishes a specific outcome
• An educational group conveys knowledge and information.
• A self-help group is composed of individuals with similar issues with rotating leadership roles
• Supportive/Therapeutic groups can involve group therapy, which are based on theory with an advanced degree clinician (autocratic, democratic, or laissez-faire leadership).
• Therapeutic groups have less theory so they can focus on group relations and select issues for interaction of group members.
• Important parts are the group process (how members interact with each other) And the group content (topic or issue discussed in the group).

Interventions in Groups

• A group is a collection of individuals whose association is founded on shared commonalities of interest, values, norms or purpose.
• Functions include socialization, support, task completion, camaraderie, informational, normative, empowerment and governance.

Safety Issues in the Milieu

• Ensuring safety is a key role for the Registered Nurse.
• This includes monitoring patients, movements and activities with safety as the foremost goal
• Nurses are responsible for assessing psychodynamic issues and evaluating effectiveness of treatment and medications for individual patients, as well as the art of delegation.

Medication Administration

• Informed consent is mandatory and driven by state law.
• Informed consent must be signed and dated by the patient, doctor and a witness.
• Consent must identify medication, maximum dosages, intended benefits and potential risks.
• Medications that require informed consent are: psychotropics, antidepressants, antimanics, stimulants, and anxiolytics.
• Documented medication consent is required prior to administrations.
• If there is no consent, a dilemma arises between the necessity of the medication, legal ramifications, and the act of holding the dose; patient issues, courts etc may provide consent.

Psychopharmacology

• There are general considerations to guide the use of medications, including the effect on target symptoms, adequate dosage for sufficient time, and lowest dose for maintenance.
• Medications should be tapered, rather than abruptly ceased, to avoid rebound/withdrawal
• Always follow up with primary physician
• Neurotransmitters such as Acetylcholine, Dopamine, GABA, Norepinephrine and Serotonin are critical to conceptualize pathology and treatment of diseases.
• Decreased intestinal motility and blood flow cause decreased absorption in the elderly.
• Decreased body water, increased body fat, decreased plasma proteins and decreased lean body mass cause decreased distribution in the elderly.
• Metabolism in the elderly is decreased due to decreased blood flow to the liver and decreased liver function.
• Excretion in the elderly decrease due to diminished kidney function and decreased creatinine clearance.

Psychotropics in the Elderly

• Start low and go slow
• Neuroleptics can cause lower BP, confusion, dry mouth, constipation, urinary retention or TD.
• Tricyclic Antidepressants can aggravate glaucoma, and cause urinary retention, hypotension, sedation, cardiotoxicity
• Benzodiazepines can cause daytime sleepiness, confusion, fall risk, and be addictive, so avoid if possible.

Schizophrenia and Other Psychoactive Disorders

• Schizophrenia characterizes a major psychotic disorder with disturbances in Perception, Thought processes, Reality testing, Feeling, Behavior, Attention, Motivation

Treatment for Schizophrenia

• Use typical antipsychotics to target positive symptoms (hallucinations, delusions, disorganized thinking & behavior); but note the higher incidence of side effects.
• Treat acute psychotic episodes with high potency neuroleptics such as Haloperidol (Haldol).
• Haloperidol and Fluphenazine (Prolixin) are available in sesame oil based depot form (IM lasts 30 days).
• Examples of typical antipsychotics include: Chlorpromazine (Thorazine), Thioridazine (Mellaril), Fluphenazine (Prolixin), Trifluoperazine (Stelazine), Haloperidol (Haldol), Chlorprothixene (Taractan), Thiothixene (Navane), Dibenzoxazepine (Loxapine), and Dihydroindolone (Moban).
• Atypical Antipsychotics: can treat both the positive and negative symptoms of schizophrenia.
• These do not exhibit as severe a side effect profile but new side effects can include Weight gain and New onset of diabetes.
• Atypical Antipsychotic Med Examples: Aripiprazole (Abilify), Clozapine (Clozaril), Lurasidone (Latuda ), Olanzapine (Zyprexa), Paliperidone (Invega), Quetiapine (Seroquel), Risperidone (Risperdal), Ziprasidone (Geodon).

Clozapine (Clozaril)

• This is a last option med used for refractory psychosis and is an expensive treatment option.
• Patients trialed on this med have previously failed many antipsychotic trials.
• Adverse side effects include orthostasis, sedation, weight gain, lower seizure threshold, sialorrhea, myocarditis and enuresis
• Agranulocytosis/bone marrow suppression are likely, so monitor CBC and WBC.

Antiparkinson Medication

• Extrapyramidal symptoms (EPS) that are adverse side effects from antipsychotic medication are caused by an imbalance between acetylcholine and dopamine.
• EPS is caused by a blockade of dopamine receptors in the basal ganglia at the end of the dopamine tracts in an effort to decrease psychotic symptoms.
• Anticholinergic drugs treat extrapyramidal symptoms and work to restore the balance between dopamine and acetylcholine.
• Examples are Benztropine (Cogentin), Trihexyphenidyl (Artane), Diphenhydramine (Benadryl).
• Side effects of anticholinergics can cause dry mouth, nasal congestion, urinary hesitation/retention, blurred vision, constipation, mydriasis.
• Nursing interventions should be to provide sugarless candy/gum and water for dry mouth, nasal decongestant, warm water for urinary issues, sunglasses for light sensitivity, and diet/roughage for constipation.
• Monitor for eye pain, and temperature regulation issues.
• Other side effects and nursing interventions for anticholinergics include caution regarding orthostatic hypotension and sedation.
• Monitor temperature and provide sponge bath for decreased sweating.
• Loose fitting clothing can help control temperature.
• Extrapyramidal Side Effects (EPS): Negative side effects of antipsychotic medication that occur in the basal ganglion of the brain
• Symptoms include Acute dystonic reactions, Muscular rigidity, Pseudoparkinsonism, Akathisia, Akinesia, Tremors, Tardive dyskinesia (TD), Oculogyric crisis and Torticollis.

Tardive Dyskinesia (TD)

• This is a nonreversable neurologic side effect that develops after long-term antipsychotic use
• characterized by bizarre facial and tongue movements, stiff neck, and difficulty swallowing

Neuroleptic Malignant Syndrome (NMS)

• This rare but potentially fatal complication of antipsychotic medication constitutes a medical emergency.
• Monitor for Hyperthermia, Altered levels of consciousness, Severe muscle rigidity, Autonomic instability – tachycardia, Fluctuations in blood pressure, Elevated CPK's, Diaphoresis
• Rapid deterioration of mental status, Rhabdomyolysis, Stupor, Coma and ultimately Death from this syndrome.
• Monitor adverse side effects closely, especially 3-9 days after initiation of antipsychotic medication, and note elevated temperature.
• Transfer to medicine for Inpatient psych transfer and use Dantrolene and Bromocriptine to treat.
• Restart antipsychotics after a two week “wash out” period.

Anti-Depressants

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

Selective Serotonin Reuptake Inhibitors (SSRI’s)

• These are first-line agents with the fewest side effects, but can cause anxiety, agitation, akathisia, nausea, insomnia and sexual dysfunction.
• Examples are Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft) and Citalopram (Celexa).

Tricyclic and Tetracyclic Antidepressants (TCA’s)

• These are second line agents that block reuptake of norepinephrine and serotonin.
• They are associated with anticholinergic side effects, sedation, weight gain, tachycardia and sexual dysfunction.
• Amitriptyline (Elavil) is a Tricyclic Antidepressant.

TCA Overdose

• Nursing interventions include monitoring BP, HR & rhythm and RR, maintain patent airway and cardiac monitoring
• Physostigmine (Antilirium) is used as an antidote for TCA poisoning.

Monoamine Oxidase Inhibitors MAOI’s

• These are third line agents with side effects of daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and require diet adherence to be effective.
• Restrict tyramine in the diet (beer, wine, aged foods)
• Maintain moderation in Chocolate and caffeine.
• Avoid OTC cold medicine and diet pills to prevent hypertensive crisis.
• Inform patients that a therapeutic effect should be achieved in 2-4 weeks.
• Caution about driving if drowsy, check with doctors before mixing OTC medications and avoid high-tyramine foods.
• Action in hypertensive crisis is to discontinue MAOI, administer Phenotolamine and monitor VS.

Novel Antidepressants

• Selective Serotonin Reuptake Inhibitors SSRI's and Novel Antidepressants are the first line agents to treat depression.
• Examples of Novel Antidepressants include: Bupropion (Wellbutrin, Zyban), Mirtazapine (Remeron), Nefazodone (Serzone), Trazodone (Desyrel) and Venlafaxine (Effexor).
• Monitor for suicidal potential in these treatment medications. Prescriptions are provided with limited refills.

Serotonin Syndrome

• Results from drug/drug interaction: SSRI & MAOI's, tryptophan, St. John's Wort
• Symptoms include mental status changes, restlessness, agitation, myoclonus, hyperreflexia, diaphoresis, shivering or chills, tremors, Diarrhea, abdominal cramps & nausea, ataxia or incoordination and headache.

Mood Stabilizers

• Antimanics treat Bipolar Disorders by addressing the whole spectrum.

Antimanic Agents

• These include Lithium, Carbamazepine, Valproic Acid, Olanzapine, Aripiprazole.
• Lithium therapeutic range is 0.6-1.2 mEq/L
• Lithium side effects include: Fatigue, headache, impaired memory, ECG changes, bloating, weight gain, nausea, dry mouth, metallic taste, edema of hands & ankles, diarrhea, abdominal pain, thirst, mild hand tremors, acne, pruritus, polyuria, polydipsia, seizures and arrhythmias.
• Monitor thyroid function and instruct patients on how to maintain adequate hydration and electrolyte balance.
• Lithium toxicity presents at 1.5 mEq/L with diarrhea, vomiting, drowsiness, muscular weakness, ataxia.
• Lithium Toxicity at 2.0-3.0 mEq/L presents moderate ataxia, giddiness, tinnitus, blurred vision, large output of dilute urine.
• Lithium Toxcity at >3.0 mEq/L multiple leads to Organisms and organism systems involved, coma and death.
• Intervention with 1.5-3.0 mEq/L is to hold the medication and administer supportive care.

Treatments for Lithium Toxity

• There is no antidote.
• For Severe Li+ poisoning, forced diuresis or hemodialysis is done.
• Valproic Acid (Depakote) stabilizes mood by working on increasing GABA, increasing resting membrane potential and suppressing calcium with therapeutic levels between 50-100 ug/ml.
• Side effects include Transient hair loss, weight gain, tremors, GU upset, thrombocytopenia.
• Effective for patients who have no Li+ or depakote response, Carbamazepine controls normalizes sodium-channel activity with Therapeutic serum level: 8-12ug/ml but presents side effects.

Other Drugs to Treat Bipolar Disorder

• Clonazepam (Klonopin), Lorazepam (Ativan), Clozapine (Clozaril), Risperidone, Quetiapine (Seroquel), Gabapentin (Neurontin), Lamotrigine and Topiramate.

Anxiety Drugs

• Anxiolytics are used in the treatment of Generalized Anxiety Disorder, OCD, Panic Disorder, PTSD, Phobic Disorders and Insomnia
• Benzodiazepines treat time limited crisis by enhancing GABA response to stressors to depress the central nervous system
• They are psychologically and physiologically addictive and side effects include over-sedation, memory impairment, paradoxical excitement, emotional blunting, CNS depression, drowsiness, fatigue, ataxia and mental impairment.
• Mixing benzos with CNS depressants can be lethal.
• They are used as Anxiolytics, Hypnotics, Muscle relaxants, Anticonvulsants and Amnesics.
• Examples are Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Clorazepate (Tranxene), Diazepam (Valium), Lorazepam (Ativan) and Oxazepam (Serax).
• For overdose, look for Somnolence, Confusion, Coma, Diminished reflexes and Hypotension, and treat with gastric lavage, activated charcoal and monitor.
• Physostigmine Is the antidote to diazepam poisoning while Flumazenil blocks Benzo's sites on gaba receptors and speed metabolism.

Anxiety: Other Treatment

• Benzodiazepines can lead to overdose somnolence, confusion and reduced reflexes, which necessitate induced vomiting/lavage.
• Long-acting Benzos such as Diazepam are contraindicated in the elderly.
• Other Anti-Anxiety Agents Propranolol, Clomipramine, Imipramine, SSRI's (Prozac, Luvox, Paxil and Zoloft) and Venlafaxine are used as well.
• The date rape drug Flunitrazepam renders an Amnesic effect.

Buspirone (Buspar)

• This Nonbenzodiazepine treats anxiety by relaxing within 1-6 weeks with no known withdrawal and little interaction.
• In the elderly, Lorazepam and Oxazepam are preferred and Temazepam and Alprazolam may be used.
• Herbl such as kava and valerian cause an addictive effect, and to avoid overdose and driving while unsafe.
• Benzos are not to be used to resolve minor/everyday stress, and may be unsafe combined with with alcohol/ cns depressants.

Dementia of the Alzheimer’s Type

• Medications such as Tacrine, Donepezil, Galantamine treat mild to moderate forms of Alzheimer’s.
• Memantine treat moderate to severe types of Alzheimer’s.
• The focus of psychiatric management is the appreciation of current practices and implementation of nurse:patient relationship, Milieu management and Medication protocol.