MH Unit 4 Mood Disorders - Suicide - Sleep Disorders PDF

MH Unit 4 Mood Disorders - Suicide - Sleep Disorders 1. Incidence and Prevalence of Mood Disorders in the US Mood Disorders include depressive disorders (major depressive disorder, persistent depressive disorder) and bipolar disorder. Prevalence: ○ M...

MH Unit 4 Mood Disorders - Suicide - Sleep Disorders 1. Incidence and Prevalence of Mood Disorders in the US Mood Disorders include depressive disorders (major depressive disorder, persistent depressive disorder) and bipolar disorder. Prevalence: ○ Major Depression: Affects approximately 7-10% of adults annually. ○ Bipolar Disorder: Affects about 2.8% of the population. ○ Gender: Women are twice as likely as men to develop depressive disorders, while bipolar disorder affects men and women equally. ○ Age: Mood disorders commonly begin in adolescence or early adulthood. ○ Cultural Factors: Certain ethnic and cultural groups may experience higher or lower rates of diagnosis. 2. Biologic and Psychosocial Theories on the Etiology of Mood Disorders Biologic Theories Genetics: Family history increases the risk; mood disorders are often hereditary. Neurotransmitter Imbalances: Low levels of serotonin, norepinephrine, and dopamine are implicated in depression. Brain Structure & Function: Structural abnormalities in the prefrontal cortex and limbic system (responsible for mood regulation) are associated with mood disorders. Endocrine System: Dysregulation of hormones (e.g., thyroid dysfunction, cortisol levels) can contribute to mood disturbances. Psychosocial Theories Cognitive Behavioral Theory (CBT): Negative thinking patterns contribute to the onset and perpetuation of depression. Stress-Vulnerability Model: Genetic predisposition combined with stressful life events can trigger mood disorders. Attachment Theory: Early disruptions in attachment relationships may increase the vulnerability to mood disorders. 3. Comparison of DSM-5 Depressive and Bipolar Disorders Feature Depressive Disorders Bipolar Disorders Types Major Depressive Disorder (MDD), Bipolar I, Bipolar II, Cyclothymic Persistent Depressive Disorder Disorder (PDD) Mood Episodes Depressed mood, loss of Depressed episodes and interest/pleasure manic/hypomanic episodes Duration of At least 2 weeks of depressive Manic episodes: at least 1 week; Symptoms symptoms Hypomanic episodes: at least 4  days Mania/Hypomania Not present Present in Bipolar I (mania); Bipolar II (hypomania) Functional Severe impact on daily functioning Impaired functioning in manic Impairment and depressive episodes 4. Epidemiology and Life Course of Depressive and Bipolar Disorders Depressive Disorders: ○ Often begin in adolescence or early adulthood, but can also occur later in life. ○ Episodes can be recurrent; many individuals experience multiple episodes over their lifetime. ○ Chronicity can lead to functional impairment in work, relationships, and self-care. Bipolar Disorder: ○ Typically emerges between ages 15 and 30. ○ Episodes of depression alternate with manic or hypomanic episodes. ○ Cycling between depression and mania can vary (e.g., rapid cycling or long periods of stability). 5. Nursing Process for Clients with Mood Disorders Assessment: Evaluate mood, behavior, cognitive patterns, physical health, risk for suicide, family dynamics. Diagnosis: Nursing diagnoses may include Risk for Suicide, Ineffective Coping, Imbalanced Nutrition, etc. Planning: Set realistic goals, such as improving mood, promoting self-care, and enhancing coping mechanisms. Intervention: Provide supportive therapy, encourage communication, assess for safety, educate about medications. Evaluation: Monitor progress toward goals, reassess mood, and evaluate effectiveness of interventions. 6. Collaborative Interventions for Clients with Mood Disorders Medication Management: Antidepressants (SSRIs, SNRIs, TCAs) and mood stabilizers (lithium, anticonvulsants) prescribed by physicians. Psychotherapy: Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and family therapy. Social Support: Support groups, family therapy to improve interpersonal relationships. Hospitalization: In severe cases, inpatient care may be needed for stabilization, especially with suicidal ideation. 7. Examining Personal Feelings and Reactions in the Therapeutic Relationship Self-awareness: Nurses need to recognize personal biases, emotional responses, and prejudices.  Boundaries: Maintain professional boundaries, especially with clients who have intense emotional expressions. Empathy vs. Sympathy: Nurses should practice empathy (understanding, not pity) to foster trust. 8. Prevalence of Suicide in the US Today Leading Cause: Suicide is the 10th leading cause of death in the U.S. Statistics: Over 48,000 deaths per year in the U.S. due to suicide. Rate Trends: The suicide rate has been steadily increasing over the past few decades, with particularly high rates among older adults and adolescents. 9. Risk Factors for Suicide & SAD PERSONS Scale Risk Factors Mental illness (depression, bipolar disorder, schizophrenia) History of previous suicide attempts Substance abuse Chronic illness or pain Loss of a loved one, financial strain, or relationship issues Social isolation, lack of support system SAD PERSONS Scale (for assessing suicide risk) Sex (Male) Age (45 years) Depression (history of depression) Previous attempts (previous suicide attempts) Ethanol or drug use Rational thinking loss (psychosis or poor decision-making) Social supports lacking Organized plan (access to means, intent) No spouse (single, divorced, or widowed) Sickness (chronic illness) 10. Increased Suicide Risk in Vulnerable Populations Older Adults: Higher suicide rates, especially in men; often linked to chronic illness, isolation, and loss of independence. Adolescents: Peer pressure, bullying, and family problems increase risk; often impulsive. Vulnerable Populations: LGBTQ+ youth, veterans, those with chronic illnesses, and marginalized communities are at higher risk. 11. Nursing Interventions for Suicidal Ideation Assess Risk: Ask directly about suicidal thoughts, plans, and means. Safety: Ensure safety by removing harmful items, providing a safe environment. Monitor and Support: Constant observation, frequent checks, and supportive conversations.  Therapy and Referral: Connect with therapists or psychiatrists for further evaluation and treatment. 12. Long-term Effects of Suicide on Families Grief: Intense and complex grief, often involving guilt and questions about what could have been done. Stigma: Family members may experience stigma and social isolation due to the nature of the death. Mental Health Impact: Increased risk of depression, anxiety, and suicidal ideation in family members. 13. Circadian Rhythms Definition: The body's internal clock that regulates sleep-wake cycles, body temperature, hormone release, and other physiological processes. Disruptions: Irregular sleep patterns (e.g., shift work, jet lag) can affect mood, cognitive function, and physical health. 14. Managing Sleep Problems Sleep Hygiene: Encourage regular sleep-wake times, reducing caffeine and alcohol intake, and creating a comfortable sleep environment. Cognitive Behavioral Therapy for Insomnia (CBT-I): Effective for treating chronic insomnia, focusing on changing negative thoughts and behaviors about sleep. Medications: Use sedative-hypnotics cautiously; non-benzodiazepine sleep aids (e.g., zolpidem) may be prescribed for short-term use. Chapter 2: Biological Implications Anatomy and Physiology of the Brain and Nervous System: Brain structures like the prefrontal cortex, limbic system, and hypothalamus are integral in mood regulation. ○ Prefrontal Cortex: Responsible for planning and decision-making. Dysfunction can lead to poor emotional regulation seen in mood disorders. ○ Limbic System: Controls emotions and memory. Altered functioning in this area is associated with anxiety and depression. ○ Hypothalamus: Involved in regulating hormones, appetite, and sleep, all of which can be affected in mood disorders. Neurotransmitters (NTs): Serotonin: ○ Helps regulate mood, sleep, and appetite. Low levels are linked to depression, anxiety, and sleep disorders. Norepinephrine: ○ Affects alertness and the fight-or-flight response. Low levels can lead to depression, while high levels can contribute to mania in bipolar disorder. Dopamine: ○ A key neurotransmitter in motivation, pleasure, and reward. Imbalances are seen in schizophrenia, depression, and addiction.  GABA (Gamma-Aminobutyric Acid): ○ Inhibits neurotransmission and calms the brain. Low GABA levels are linked to anxiety disorders. Acetylcholine: ○ Involved in learning and memory. Imbalances are associated with cognitive disorders. Hormonal Factors: Cortisol: ○ Released during stress; chronically high levels are associated with depression, anxiety, and chronic stress. Thyroid Hormones: ○ Thyroid dysfunction can cause symptoms resembling mood disorders, such as hypothyroidism leading to depression or hyperthyroidism causing mania-like symptoms. Circadian Rhythms: Disruption of the body’s natural sleep-wake cycle can exacerbate mood disorders, especially depression and bipolar disorder. Seasonal affective disorder (SAD) is a prime example of circadian rhythm disruption. Chapter 4: Psychopharmacology Antianxiety Agents (p64-67): Benzodiazepines: ○ Examples: Lorazepam, diazepam. ○ Action: Enhance the effects of GABA, which slows down brain activity, providing anxiolytic effects. ○ Considerations: Short-term use due to risk of dependence. Caution in elderly due to increased sedation. Buspirone: ○ Action: A non-benzodiazepine anxiolytic that works on serotonin receptors. ○ Considerations: Takes longer to be effective (usually 2-4 weeks). No risk of dependency. Antidepressants (p68-73): SSRIs (Selective Serotonin Reuptake Inhibitors): ○ Examples: Fluoxetine, sertraline. ○ Action: Block the reuptake of serotonin, increasing its availability in the brain. ○ Side Effects: Nausea, sexual dysfunction, insomnia. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): ○ Examples: Venlafaxine, duloxetine. ○ Action: Increase both serotonin and norepinephrine. ○ Considerations: Effective for both depression and anxiety. TCAs (Tricyclic Antidepressants): ○ Examples: Amitriptyline. ○ Action: Increase levels of serotonin and norepinephrine but have more side effects.  ○ Side Effects: Anticholinergic effects (dry mouth, blurred vision, constipation), cardiac arrhythmias. MAOIs (Monoamine Oxidase Inhibitors): ○ Examples: Phenelzine. ○ Action: Block the breakdown of serotonin, dopamine, and norepinephrine. ○ Considerations: Dietary restrictions (avoid tyramine-containing foods) to prevent hypertensive crisis. Mood Stabilizers (p73-79): Lithium: ○ Action: Reduces the severity and frequency of mood swings in bipolar disorder by stabilizing neuronal firing. ○ Therapeutic Range: Narrow; levels need to be monitored regularly. ○ Side Effects: Tremors, weight gain, renal toxicity, thyroid problems. Anticonvulsants (e.g., valproate, lamotrigine): ○ Action: Used as mood stabilizers in bipolar disorder, particularly for rapid cycling. ○ Considerations: Monitor for liver toxicity and blood dyscrasias. Antipsychotics (p79-87): First-generation (typical) antipsychotics: ○ Examples: Haloperidol. ○ Action: Block dopamine receptors to treat symptoms of psychosis (e.g., hallucinations, delusions). ○ Side Effects: Extrapyramidal symptoms (EPS), tardive dyskinesia. Second-generation (atypical) antipsychotics: ○ Examples: Risperidone, olanzapine. ○ Action: Block both dopamine and serotonin receptors; lower risk of EPS. ○ Side Effects: Weight gain, metabolic syndrome, sedation. Sedative Hypnotics (p87-89): Benzodiazepines (e.g., diazepam, lorazepam): ○ Action: Used for short-term insomnia and anxiety, these drugs enhance the effects of GABA to produce a calming effect. Non-benzodiazepine sedatives (e.g., zolpidem): ○ Action: Similar to benzodiazepines, but more selective for sleep pathways with less risk of dependence. Chapter 11: Suicide Prevention Risk Factors for Suicide: Mental Health Disorders: ○ Depression, bipolar disorder, schizophrenia, and anxiety disorders increase the risk of suicide. Previous Suicide Attempts: ○ Past attempts are the strongest indicator of future suicide risk. Substance Abuse: ○ Alcohol and drug abuse increase impulsivity and poor judgment. Social Isolation:  ○ Lack of support systems (family, friends) is a major risk factor. SAD PERSONS Scale: A 10-item assessment tool used to predict suicide risk. Higher scores (greater than 5) indicate higher risk, necessitating more intensive intervention. Nursing Interventions: Assess Suicide Risk: Routine screenings for mood disorders and suicidal ideation. Create a Safe Environment: Remove dangerous items (sharp objects, medications). Develop Rapport: Engage in open, empathetic conversations to build trust. Collaborate with Mental Health Professionals: Engage in therapy and crisis intervention. Chapter 16: Depressive Disorders Major Depressive Disorder (MDD): Symptoms: Low mood, lack of interest in activities (anhedonia), fatigue, difficulty concentrating, thoughts of death or suicide. Treatment: ○ Medications: Antidepressants (SSRIs, SNRIs, TCAs). ○ Therapy: Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT). Persistent Depressive Disorder (PDD): Symptoms: Chronic low mood lasting 2 years or longer, with periods of depression and euthymia. Treatment: Similar to MDD but may be harder to treat due to chronicity. Postpartum Depression: Symptoms: Occurs within 4 weeks of childbirth, with symptoms of MDD. Mothers may struggle to bond with their infant. Treatment: Antidepressants, psychotherapy, and support for the mother’s well-being. Chapter 17: Bipolar and Related Disorders Bipolar I Disorder: Symptoms: Alternating episodes of mania (elevated mood, impulsive behavior, decreased need for sleep) and depression. Treatment: Lithium, anticonvulsants, antipsychotics for acute mania, antidepressants for depressive episodes (with caution). Bipolar II Disorder: Symptoms: Hypomanic episodes (less severe than mania) and depressive episodes. Treatment: Similar to Bipolar I, but hypomania typically does not require hospitalization. Cyclothymic Disorder: Symptoms: Periods of hypomanic symptoms and depressive symptoms lasting at least 2 years. Treatment: Mood stabilizers and psychotherapy. Chapter 7: Sleep & Sleep Disorders I. Introduction to Sleep  1. What is Sleep? ○ Sleep is a naturally recurring state of rest for the body and mind, characterized by altered consciousness, reduced muscle activity, and a decreased ability to respond to external stimuli. Sleep is essential for physical recovery, mental health, and overall well-being. 2. Stages of Sleep: ○ Non-REM Sleep: Stage 1 (N1): Light sleep; transition from wakefulness to sleep. This is where hypnic jerks may occur. Stage 2 (N2): Sleep deepens; heart rate and body temperature drop. Sleep spindles (sudden bursts of brain activity) are characteristic. Stage 3 (N3): Deep sleep; essential for physical restoration. Delta waves (slow brain waves) dominate. ○ REM Sleep: Rapid Eye Movement; where vivid dreams occur. Important for memory consolidation, learning, and emotional regulation. 3. Circadian Rhythms: ○ These are 24-hour cycles of physical, mental, and behavioral changes, primarily governed by the hypothalamus. They influence sleep-wake cycles, body temperature, hormone production, and metabolism. Disruptions (e.g., jet lag, shift work) can affect sleep quality. II. Sleep Disorders 1. Insomnia: ○ Definition: Difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep. ○ Causes: Stress, anxiety, depression, caffeine, medications, or medical conditions. ○ Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I): A non- pharmacological intervention that focuses on changing behaviors and thoughts associated with sleep. Medications: Short-term use of benzodiazepine receptor agonists (e.g., zolpidem) or melatonin receptor agonists. 2. Sleep Apnea: ○ Definition: A condition where breathing repeatedly stops and starts during sleep, often due to an obstructionin the airway (obstructive sleep apnea - OSA) or a failure of the brain to send the proper signals to muscles that control breathing (central sleep apnea). ○ Symptoms: Snoring, choking, gasping, and waking up feeling tired. ○ Treatment: Continuous Positive Airway Pressure (CPAP) therapy: A machine that delivers constant airflow to keep the airway open during sleep.  Lifestyle changes: Weight loss, avoiding alcohol, and sleeping on the side. Surgical options: Uvulopalatopharyngoplasty (UPPP) or tonsillectomy if necessary. 3. Restless Leg Syndrome (RLS): ○ Definition: An overwhelming urge to move the legs, often accompanied by uncomfortable sensations, typically in the evening or at night. ○ Causes: Can be idiopathic or related to underlying conditions like iron deficiency anemia or neuropathy. ○ Treatment: Iron supplements for those with low iron levels. Dopamine agonists (e.g., pramipexole) to alleviate symptoms. 4. Narcolepsy: ○ Definition: A neurological condition characterized by excessive daytime sleepiness and sudden, uncontrollable episodes of sleep. ○ Symptoms: Cataplexy (sudden muscle weakness triggered by emotions), vivid dreaming during naps, and sleep paralysis. ○ Treatment: Stimulants (e.g., modafinil) for daytime sleepiness. Antidepressants for managing cataplexy. 5. Parasomnias: ○ Sleepwalking: Walking or performing other complex behaviors while asleep. ○ Night Terrors: Episodes of intense fear, screaming, and thrashing during sleep, usually during deep NREM sleep. ○ Sleep Talking: Speaking during sleep without being aware of it. ○ Treatment: Usually involves behavioral modifications, ensuring safety, and in some cases, sedatives. 6. Circadian Rhythm Disorders: ○ Jet Lag: A temporary condition that occurs after long-distance travel, where the body's internal clock is out of sync with the new time zone. ○ Shift Work Disorder: Occurs in people who work non-traditional hours, disrupting their natural circadian rhythm. ○ Treatment: Light therapy: Exposure to bright light at the right times can help reset the circadian rhythm. Melatonin supplements, especially when traveling across multiple time zones. III. Assessment of Sleep Disorders 1. Health History: ○ Assess for symptoms of common sleep disorders, including: Insomnia: Difficulty initiating or maintaining sleep. Sleep apnea: Snoring, choking, gasping during sleep. Narcolepsy: Uncontrollable daytime sleep episodes.  Restless Leg Syndrome: Uncomfortable leg sensations and the need to move the legs. 2. Sleep Diary: ○ The client should record the following for 1-2 weeks: Sleep patterns, time taken to fall asleep, nighttime awakenings, wake-up time, and how rested they feel in the morning. 3. Polysomnography (Sleep Study): ○ An overnight diagnostic test to monitor brain activity, eye movement, muscle activity, heart rate, respiratory effort, and oxygen levels during sleep. ○ Indicated for suspected sleep apnea, narcolepsy, and parasomnias. 4. Actigraphy: ○ A non-invasive method using a wristwatch-like device to monitor movement and sleep-wake cycles over time. It's often used to assess sleep patterns and help diagnose insomnia or sleep apnea. IV. Treatment and Nursing Interventions 1. General Approaches: ○ Encourage good sleep hygiene: Consistent sleep-wake schedule, a cool, dark, quiet sleep environment, and avoiding caffeine or heavy meals before bed. ○ Education: Teach clients about the impact of sleep disorders on overall health and the importance of proper treatment. 2. Behavioral Therapy: ○ Cognitive Behavioral Therapy for Insomnia (CBT-I): Focuses on cognitive restructuring, relaxation techniques, stimulus control, and sleep restriction to help individuals with chronic insomnia. 3. Pharmacological Interventions: ○ For Insomnia: Short-term use of benzodiazepines, non-benzodiazepine sedatives (e.g., zolpidem), or melatonin receptor agonists (e.g., ramelteon). ○ For Sleep Apnea: CPAP therapy, or bi-level positive airway pressure (BiPAP) in severe cases. ○ For Narcolepsy: Stimulants (e.g., modafinil) for daytime sleepiness and antidepressants for cataplexy. ○ For RLS: Dopamine agonists (e.g., pramipexole) and iron supplements if needed. 4. Lifestyle Modifications: ○ Encourage a consistent sleep schedule and relaxation techniques (e.g., progressive muscle relaxation, meditation) to reduce stress and improve sleep quality. V. Special Considerations for Nursing Care 1. Client Education: ○ Teach clients how to manage sleep hygiene, including setting up a proper sleep environment (e.g., dark, quiet, cool room). ○ Lifestyle changes: For example, avoid stimulants (caffeine, nicotine) in the evening, limit alcohol, and engage in regular physical activity.  2. Monitoring and Follow-up: ○ Continuously assess the client’s response to treatment interventions, including the effectiveness of medications, changes in sleep patterns, and improvement in quality of life. 3. Support for Caregivers: ○ For conditions like sleep apnea or narcolepsy, caregivers may need to support the client during episodes or help with monitoring treatment adherence (e.g., CPAP therapy). Chapter 24: Drugs for Seizure Disorders I. Overview of Seizure Disorders 1. Seizures: Sudden, uncontrolled electrical disturbances in the brain that can cause changes in behavior, movements, feelings, or levels of consciousness. ○ Epilepsy: A chronic neurological disorder characterized by recurrent, unprovoked seizures. 2. Types of Seizures: ○ Generalized Seizures: Involve the entire brain and include tonic-clonic, absence, and myoclonic seizures. ○ Focal Seizures: Begin in a specific area of the brain and may spread to other regions. ○ Status Epilepticus: A medical emergency where seizures last more than 5 minutes or occur repeatedly without recovery in between. II. Mechanism of Action for Antiepileptic Drugs (AEDs) 1. Pharmacologic Goals: ○ Prevent seizures by reducing neuronal excitability and enhancing inhibitory neurotransmission. ○ Maintain therapeutic drug levels and avoid adverse effects. 2. Drug Classes: ○ Sodium Channel Blockers: Reduce excitability of neurons (e.g., phenytoin, carbamazepine). ○ GABA Enhancers: Enhance the inhibitory neurotransmitter GABA (e.g., benzodiazepines, valproic acid). ○ Calcium Channel Blockers: Reduce calcium influx, preventing neurotransmitter release (e.g., ethosuximide). ○ Glutamate Inhibitors: Reduce excitatory neurotransmitter glutamate (e.g., topiramate). 3. Important Antiepileptic Drugs (AEDs): ○ Phenytoin: First-line treatment for generalized tonic-clonic and focal seizures. Adverse effects: Gingival hyperplasia, hirsutism, and possible bone marrow suppression. ○ Carbamazepine: For focal seizures and generalized tonic-clonic seizures. Adverse effects: Hyponatremia, leukopenia, and rash.  ○ Valproic Acid: Effective for generalized seizures, including absence and myoclonic seizures. Adverse effects: Hepatotoxicity, pancreatitis, weight gain, and teratogenicity. ○ Lamotrigine: Broad-spectrum AED for various seizure types. Adverse effects: Rash, which may progress to Stevens-Johnson syndrome. 4. Therapeutic Monitoring: ○ Phenytoin: Therapeutic range 10-20 mcg/mL. ○ Carbamazepine: Therapeutic range 4-12 mcg/mL. ○ Valproic Acid: Therapeutic range 50-100 mcg/mL. ○ Lamotrigine: No routine therapeutic drug monitoring, but monitor for rash. 5. Adverse Effects: ○ Drowsiness, dizziness, ataxia, blurred vision, gingival hyperplasia, and potential drug interactions. III. Drug Interactions and Nursing Considerations 1. Drug Interactions: ○ Many AEDs have cytochrome P450 enzyme interactions affecting metabolism of other drugs, leading to drug-drug interactions. ○ Discontinuation should be gradual to avoid withdrawal seizures. 2. Nursing Considerations: ○ Monitor serum drug levels and for adverse effects. ○ Ensure adherence to prescribed therapy for optimal seizure control. ○ Educate patients about potential side effects, such as dizziness and sedation. ○ Avoid alcohol and CNS depressants due to the risk of additive sedation. Chapter 32: Antidepressants I. Overview of Depression 1. Major Depressive Disorder (MDD): A mood disorder characterized by persistent sadness, loss of interest in activities, and significant functional impairment. ○ Symptoms: Depressed mood, loss of interest in activities, fatigue, changes in appetite and sleep patterns, suicidal thoughts. 2. Pathophysiology: ○ Imbalances in neurotransmitters (serotonin, norepinephrine, and dopamine) are thought to play a key role in depression. II. Classes of Antidepressants 1. Selective Serotonin Reuptake Inhibitors (SSRIs): ○ Examples: Fluoxetine, sertraline, citalopram. ○ Mechanism: Increase serotonin levels by inhibiting its reuptake in the synaptic cleft. ○ Adverse Effects: Nausea, insomnia, sexual dysfunction, and serotonin syndrome (when combined with other serotonin-boosting drugs). 2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): ○ Examples: Venlafaxine, duloxetine.  ○ Mechanism: Inhibit reuptake of both serotonin and norepinephrine. ○ Adverse Effects: Similar to SSRIs, plus increased blood pressure at higher doses. 3. Tricyclic Antidepressants (TCAs): ○ Examples: Amitriptyline, nortriptyline. ○ Mechanism: Inhibit reuptake of serotonin and norepinephrine. ○ Adverse Effects: Anticholinergic effects (dry mouth, constipation), orthostatic hypotension, and cardiac toxicity in overdose. 4. Monoamine Oxidase Inhibitors (MAOIs): ○ Examples: Phenelzine, tranylcypromine. ○ Mechanism: Inhibit the enzyme that breaks down serotonin, norepinephrine, and dopamine. ○ Adverse Effects: Hypertensive crisis when consuming tyramine-containing foods (aged cheese, wine). ○ Nursing Considerations: Avoid dietary tyramine and certain medications (e.g., decongestants). 5. Atypical Antidepressants: ○ Examples: Bupropion, mirtazapine. ○ Mechanism: Various mechanisms depending on the drug. ○ Adverse Effects: Bupropion may increase seizure risk; mirtazapine may cause weight gain and sedation. III. Nursing Considerations 1. Assess for suicidal ideation in all patients, especially in the early stages of treatment. 2. Monitor for adverse effects, including sexual dysfunction, weight gain, or increased anxiety. 3. Educate patients about the delayed onset of therapeutic effects, usually taking 1-3 weeks for full effects to occur. 4. Discontinuation should be gradual to avoid withdrawal symptoms (e.g., dizziness, nausea). Chapter 33: Drugs for Bipolar Disorder I. Overview of Bipolar Disorder 1. Bipolar Disorder: A mood disorder characterized by periods of mania (elevated mood, hyperactivity, impulsive behavior) and depression (depressed mood, lack of interest). ○ Types: Bipolar I: Characterized by manic episodes. Bipolar II: Characterized by hypomanic episodes and depressive episodes. 2. Pathophysiology: ○ Imbalances in neurotransmitters, particularly dopamine and serotonin, contribute to mood swings. II. Medications for Bipolar Disorder  1. Lithium: ○ Mechanism: Modulates neurotransmitter release, particularly serotonin and dopamine. ○ Adverse Effects: Toxicity (narrow therapeutic window), kidney damage, tremors, and hypothyroidism. ○ Therapeutic Range: 0.6-1.2 mEq/L. ○ Nursing Considerations: Monitor lithium levels, renal function, and thyroid function. 2. Anticonvulsants: ○ Examples: Valproic acid, lamotrigine, carbamazepine. ○ Mechanism: Stabilize mood by modulating GABA or inhibiting excitatory neurotransmitter release. ○ Adverse Effects: Weight gain (valproic acid), rash (lamotrigine), and liver toxicity (carbamazepine). 3. Antipsychotics (for mania and mixed episodes): ○ Examples: Olanzapine, quetiapine. ○ Mechanism: Block dopamine receptors to stabilize mood and reduce symptoms of mania. ○ Adverse Effects: Weight gain, sedation, and increased risk for metabolic syndrome. III. Nursing Considerations 1. Monitor for therapeutic drug levels of lithium and valproic acid. 2. Assess for adverse effects such as sedation, weight gain, and tremors. 3. Provide patient education about the importance of adherence to medications and monitoring of side effects. Chapter 34: Sedative-Hypnotic Drugs I. Overview of Sedative-Hypnotic Drugs 1. Sedative Drugs: Used to calm or relax the patient without inducing sleep. Commonly prescribed for anxiety. 2. Hypnotic Drugs: Induce sleep. Typically prescribed for insomnia. II. Drug Classes 1. Benzodiazepines: ○ Examples: Diazepam, lorazepam. ○ Mechanism: Enhance the effect of GABA, producing a calming effect. ○ Adverse Effects: CNS depression, dependence, tolerance, and withdrawal symptoms. 2. Non-Benzodiazepine Sedative-Hypnotics: ○ Examples: Zolpidem, eszopiclone. ○ Mechanism: Bind to GABA receptors but with more selective action. ○ Adverse Effects: Sleepwalking, amnesia, and daytime sedation. 3. Barbiturates:  ○ Examples: Phenobarbital, pentobarbital. ○ Mechanism: Enhance GABA activity and inhibit the release of neurotransmitters. ○ Adverse Effects: High risk for overdose, respiratory depression, and dependence. III. Nursing Considerations 1. Assess for sedation and respiratory depression. 2. Avoid alcohol and CNS depressants while on these medications. 3. Taper off medications to avoid withdrawal symptoms, especially for benzodiazepines and barbiturates. Study Guide Questions 1. Etiology of Depression Biological Factors: Genetics, neurotransmitter imbalances, hormonal changes, and neuroanatomical changes. There is a hereditary component to depression, with increased risk if a family member has been diagnosed. Psychological Factors: Negative thought patterns, unresolved trauma, and stressors. Environmental Factors: Chronic stress, substance abuse, lack of support systems, major life changes (e.g., loss, trauma, or unemployment), and difficult socioeconomic conditions. Psychosocial Theories: Life events (e.g., abuse, bereavement), family dynamics, and unresolved conflicts. 2. Primary Risk Factors for Depression Genetics: Family history of depression or other mental health disorders. Biological factors: Imbalances in brain chemicals (serotonin, norepinephrine, dopamine). Trauma or Stress: Major life changes or stressful experiences, especially in childhood. Chronic Illness: Presence of chronic conditions (e.g., cancer, diabetes, heart disease). Substance Use: Abuse of alcohol or drugs increases risk. Gender: Women are more likely to experience depression than men. Age: Depression may manifest differently in children, adults, and the elderly, with elderly patients often having more physical symptoms. History of Mental Health Disorders: Previous mental health conditions increase susceptibility. Social Support: Lack of supportive relationships or social isolation. 3. The Role of Serotonin and Norepinephrine in Depression Serotonin: Regulates mood, sleep, and appetite. Low serotonin levels are commonly found in individuals with depression and are targeted by many antidepressants (SSRIs, SNRIs). Norepinephrine: Involved in regulating alertness, energy, and concentration. A deficit in norepinephrine may contribute to the fatigue, lack of concentration, and anhedonia (inability to experience pleasure) seen in depression.  The Dysregulation Hypothesis: Depression may result from the dysregulation or depletion of serotonin and norepinephrine, leading to mood instability. 4. What is Anhedonia? Anhedonia is the inability to feel pleasure or interest in activities that are normally enjoyable. It is one of the hallmark symptoms of major depressive disorder (MDD) and is associated with the reduced function of reward-related brain areas. 5. What Happens in the Brain During Depression? Neurotransmitter Imbalance: Decreased levels of serotonin, norepinephrine, and dopamine lead to impaired mood regulation. Brain Structural Changes: Research shows that depression may be associated with changes in the hippocampus (memory and emotion processing), prefrontal cortex (decision-making, personality), and amygdala (emotion regulation). Increased Cortisol: Chronic stress and depression are linked to increased cortisol production, which can lead to brain changes over time. Functional Changes: Decreased blood flow to areas of the brain involved in mood regulation (e.g., the prefrontal cortex), and heightened activity in the amygdala (emotion center). 6. Psychological and Cognitive Factors Influencing Mood Disorders Negative Thinking Patterns: Pervasive negative thinking can reinforce feelings of hopelessness, helplessness, and worthlessness. Cognitive Distortions: Individuals may engage in black-and-white thinking, overgeneralizing, and catastrophizing, which deepens the depression. Behavioral Factors: Avoidance, withdrawal from social situations, and lack of engagement in enjoyable activities can worsen depressive symptoms. 7. Beck’s Cognitive Triad Beck’s Cognitive Theory states that depression is caused by negative thought patterns that influence emotions and behaviors. The Cognitive Triad includes: 1. Negative View of the Self: Feeling inadequate, unworthy, or powerless. 2. Negative View of the World: Viewing the world as full of obstacles, lack of support, or failure. 3. Negative View of the Future: Expecting negative outcomes and believing that things will not improve. 8. Description of a Person with Major Depressive Disorder (MDD) Symptoms: ○ Persistent sadness or low mood. ○ Loss of interest or pleasure in nearly all activities. ○ Fatigue, lack of energy. ○ Difficulty concentrating or making decisions.  ○ Feelings of worthlessness or excessive guilt. ○ Suicidal thoughts or preoccupation with death. Impairment in Function: Difficulty in maintaining work, social, or family roles due to cognitive and emotional symptoms. Physical Symptoms: Changes in appetite, sleep disturbances, aches, or pains that cannot be explained by other causes. 9. Subtypes of Major Depressive Disorder (MDD) MDD with Psychotic Features: Depressive symptoms accompanied by delusions or hallucinations. MDD with Atypical Features: Includes symptoms such as increased appetite, excessive sleep, and a mood reactivity (mood improves in response to positive events). MDD with Melancholic Features: Characterized by profound sadness, loss of pleasure, guilt, or psychomotor retardation (slowed movements). MDD with Seasonal Pattern: Typically occurs during the fall or winter months when there is less natural sunlight (also known as seasonal affective disorder or SAD). 10. Common Emotions in Someone with Major Depressive Disorder (MDD) Sadness: A persistent feeling of sadness or "emptiness." Hopelessness: The belief that nothing will improve. Guilt: Excessive guilt or feelings of worthlessness for perceived failures. Worthlessness: Low self-esteem and a diminished sense of self-worth. Anxiety: Generalized anxiety or worry, which can coexist with depression. 11. Physical Signs of Major Depressive Disorder (MDD) Changes in Sleep Patterns: Insomnia or hypersomnia (sleeping too much). Appetite Changes: Weight loss or weight gain due to changes in eating habits. Fatigue: Persistent tiredness, even after adequate sleep. Psychomotor Agitation or Retardation: Restlessness or slowed physical movement and speech. Aches and Pains: Unexplained back pain, headaches, and digestive issues, which are often somatic symptoms of depression. Decreased Libido: Loss of sexual interest or activity. 2. Patient with Dysthymia (Persistent Depressive Disorder): Description of the Patient: ○ Chronic Low Mood: Dysthymia is characterized by a low, depressed mood that lasts for at least two years(one year in children/adolescents). ○ Mild Severity: Symptoms are less severe than those in major depressive disorder (MDD) but still cause significant distress and impairment in daily functioning. ○ Co-occurring Symptoms: Common symptoms include low self-esteem, fatigue, poor appetite or overeating, insomnia or excessive sleep, hopelessness, and low energy.  ○ Age of Onset: Often begins in childhood or adolescence but can develop at any age. Differences from Major Depressive Disorder: ○ Duration: Dysthymia is persistent and chronic, lasting for at least two years, while MDD typically lasts for shorter periods (though recurrent). ○ Severity: Dysthymia symptoms are often less severe but are ongoing and persistent. MDD symptoms tend to be more intense and acute, often significantly impairing daily functioning. ○ Functional Impact: MDD tends to cause more severe disruption in social, occupational, or other important areas of functioning. Dysthymia, while impairing, may allow patients to maintain more normal functioning at times. ○ Episodes: In MDD, patients experience episodic episodes of depression, whereas dysthymia represents a chronic state of low mood that can coexist with major depressive episodes in what is known as double depression. 13. How to Evaluate a Patient for Depression Assessing Symptoms: Using structured screening tools like the PHQ-9 (Patient Health Questionnaire-9) or Beck Depression Inventory. These help gauge the severity of symptoms. Clinical Interviews: Interviewing the patient about mood, sleep, appetite, interest in activities, and any history of depression. Physical Assessment: A physical exam to rule out medical conditions that could cause depressive symptoms (e.g., hypothyroidism). Mental Status Exam (MSE): Evaluating cognitive functions, mood, affect, speech, thought process, and thought content (e.g., suicidal ideation). Risk Assessment: Identifying risk factors such as family history of depression, substance use, and history of trauma. Screening for Co-morbidities: Assess for conditions that commonly co-occur with depression, such as anxiety, substance use, and sleep disorders. 14. Guarding Personal Feelings When Working with a Client with Depression Self-Awareness: Nurses should recognize their emotional reactions to patients and reflect on how these feelings affect their interactions and the therapeutic relationship. Setting Boundaries: Maintaining professional boundaries while remaining empathetic and supportive. Seek Supervision or Peer Support: Engaging in debriefing sessions with colleagues or supervisors to process any strong emotions triggered by the patient's situation. Self-Care: Practicing self-care strategies, such as relaxation, exercise, and having time for hobbies or relaxation outside work, to prevent burnout. Avoid Personalization: Understanding that the patient's symptoms and behaviors (such as withdrawal, irritability, or anger) are due to their condition, not a personal reflection of the nurse's efforts. 15. Interventions for a Patient with Major Depressive Disorder (MDD)  Pharmacotherapy: ○ Antidepressants (SSRIs, SNRIs, tricyclics, MAOIs) to help balance neurotransmitters like serotonin and norepinephrine. ○ Consideration of side effects and medication response time (several weeks). Psychotherapy: ○ Cognitive Behavioral Therapy (CBT): Helps patients identify and change negative thought patterns and behaviors that perpetuate depression. ○ Interpersonal Therapy (IPT): Focuses on improving relationships and communication, which may be impacted by depression. ○ Psychodynamic Therapy: Explores past experiences and unconscious processes that may contribute to depressive feelings. Behavioral Activation: ○ Encouraging the patient to engage in activities they used to enjoy, even if they do not feel motivated. ○ Scheduling pleasurable or rewarding activities into their day. Lifestyle Modifications: ○ Encourage regular physical activity (e.g., walking, yoga), as exercise can have antidepressant effects. ○ Promote a healthy diet and good sleep hygiene. Suicide Prevention: ○ If there are suicidal thoughts, assess the level of risk, develop a safety plan, and ensure close monitoring or hospitalization if needed. 16. Why Psychotherapy, Group Therapy, MBCT, and Milieu Therapy are Helpful in MDD Psychotherapy: ○ Cognitive Behavioral Therapy (CBT) helps patients identify and reframe negative thought patterns contributing to depression, teaching them coping strategies. ○ Interpersonal Therapy (IPT) addresses relationship issues that might be contributing to the patient’s depression, improving social interactions and support. ○ Supportive Psychotherapy: Involves emotional support and empathetic listening, which can alleviate feelings of isolation. Group Therapy: ○ Provides peer support and fosters a sense of community. ○ Hearing others’ experiences can normalize the patient’s own feelings and reduce the sense of isolation. ○ Offers shared coping strategies for dealing with depression. Mindfulness-Based Cognitive Therapy (MBCT): ○ Combines mindfulness techniques (meditation, breathing) with cognitive therapy to help patients focus on the present and reduce rumination, which is often associated with depression. ○ Can help prevent relapse in patients with recurrent depression. Milieu Therapy:  ○ This therapeutic approach involves providing a structured and supportive environment where patients can interact and engage with each other. ○ It emphasizes group cohesion, safety, and support, providing opportunities for socialization and reducing feelings of isolation. ○ Often used in inpatient settings, milieu therapy can facilitate patients' social and emotional development through group interactions and peer support. Study Guide: Medications for Depression and Mood Disorders Medication Action and Effects Side Effects/Patient Teaching Examples: Drug Category Name (Generic & Brand) SSRI’s Action: Increases Side Effects: Nausea, Fluoxetine (Selective serotonin levels in the insomnia, sexual dysfunction, (Prozac), Serotonin brain by inhibiting its weight gain, headache. Patient Sertraline Reuptake reuptake. Effects: Teaching: Takes 2-4 weeks for (Zoloft), Inhibitors) Improves mood, full effects, avoid abrupt Citalopram reduces anxiety, withdrawal, report signs of (Celexa), enhances serotonin serotonin syndrome (agitation, Escitalopram levels. confusion, tremors). (Lexapro) Novel Action: These drugs Side Effects: Increased risk of Bupropion Antidepressants target other seizures, dry mouth, dizziness, (Wellbutrin), neurotransmitters like blurred vision. Patient Trazodone norepinephrine and Teaching: Report any new or (Desyrel) dopamine. Effects: unusual thoughts/behaviors, Useful for patients avoid alcohol, may take who do not respond to several weeks for SSRIs or SNRIs. effectiveness. Cyclic Action: Inhibit the Side Effects: Anticholinergic Amitriptyline Antidepressants reuptake of effects (dry mouth, (Elavil), (TCA’s) norepinephrine and constipation, blurred vision), Nortriptyline serotonin. Effects: orthostatic hypotension, weight (Pamelor), Improves mood, gain, sedation. Patient Imipramine energy, and sleep; Teaching: Avoid alcohol, take (Tofranil) sometimes used for at bedtime due to sedative neuropathic pain or effects, take with food to insomnia. reduce stomach upset. MAOI’s Action: Inhibits the Side Effects: Hypertensive Phenelzine (Monoamine breakdown of crisis when combined with (Nardil), Oxidase serotonin, foods containing tyramine Tranylcypromine Inhibitors) norepinephrine, and (aged cheese, wine, etc.), (Parnate) dopamine. Effects: dizziness, dry mouth, Increases levels of insomnia. Patient Teaching:  these Strict diet restrictions, monitor neurotransmitters, blood pressure, avoid certain effective for atypical medications (e.g., depression. decongestants). Lithium Action: Modulates Side Effects: Tremors, weight Lithium neurotransmitter gain, hypothyroidism, renal Carbonate release and reuptake. dysfunction, electrolyte (Lithobid, Effects: Stabilizes imbalances. Patient Teaching: Eskalith) mood in bipolar Maintain consistent salt and disorder, reduces fluid intake, monitor blood mania. levels regularly, watch for signs of toxicity (vomiting, diarrhea, tremors). Anticonvulsants Action: Modulates Side Effects: Drowsiness, Valproic Acid neurotransmitter dizziness, weight gain, liver (Depakote), release, used in mood toxicity, blood dyscrasias. Lamotrigine stabilization. Effects: Patient Teaching: Monitor liver (Lamictal), Controls mood function, take with food to Carbamazepine swings, particularly in reduce GI upset, avoid alcohol. (Tegretol) bipolar disorder. Antipsychotics Action: Block Side Effects: Weight gain, Olanzapine dopamine receptors to sedation, movement disorders (Zyprexa), stabilize mood, reduce (e.g., tardive dyskinesia), Quetiapine psychotic symptoms. diabetes risk, increased (Seroquel), Effects: Used in cholesterol. Patient Teaching: Risperidone bipolar disorder, Report signs of movement (Risperdal) schizophrenia, and disorders, monitor weight and treatment-resistant blood glucose levels. depression. St. John’s Wort Action: Thought to Side Effects: Photosensitivity, St. John’s Wort increase serotonin, gastrointestinal upset, fatigue, (Hypericum norepinephrine, and dry mouth. Patient Teaching: perforatum) dopamine activity. May interact with other Effects: Used for mild medications (especially SSRIs to moderate and birth control), avoid depression. excessive sun exposure. SAMe (S- Action: Increases Side Effects: Mild GI upset, SAMe (SAMe Adenosyl serotonin, dopamine, insomnia, agitation. Patient 400 mg) Methionine) and norepinephrine Teaching: Consult with a levels. Effects: Used doctor before taking, especially as a supplement for if taking other antidepressants.  mood improvement in depression and osteoarthritis. 18. What is important for families to know about antidepressant medications? Understanding Effects: Families should understand that antidepressant medications may take several weeks to show full effects. It's important to monitor for improvement in mood, energy, and other symptoms, but also be aware of any worsening of symptoms or emergence of suicidal thoughts, especially in the early stages of treatment. Side Effects: Side effects such as nausea, insomnia, sexual dysfunction, or weight changes may occur. Patients should not stop the medication abruptly without consulting a healthcare provider. Monitoring: Families should help monitor the patient for any changes in behavior or mood, particularly if there are signs of agitation, irritability, or increased depression. Adherence to Treatment: It is crucial for families to encourage the patient to take medications as prescribed and attend follow-up appointments. 19. Review ECT (Electroconvulsive Therapy) Definition: ECT is a psychiatric treatment involving the application of electrical currents to the brain to induce a controlled seizure. It is typically used for severe depression, particularly in cases where other treatments (like medications) have not been effective. Mechanism of Action: The electrical stimulation triggers a brief seizure, which is thought to affect neurotransmitter function and promote a balance in brain chemistry. Indications: ECT is often considered for patients with severe depression, mania, catatonia, or schizophrenia who do not respond to medications or therapy. Side Effects: Short-term memory loss, confusion, and headache are common side effects. Long-term effects are rare but may include permanent memory loss. Process: The patient is given general anesthesia, and muscle relaxants are administered to avoid physical injury during the seizure. Multiple sessions may be needed. 20. Discuss Vagal Nerve Stimulation (VNS), Rapid Transcranial Magnetic Stimulation (rTMS), and Deep Brain Stimulation (DBS) Vagal Nerve Stimulation (VNS): ○ Definition: A device is implanted under the skin in the chest to deliver electrical impulses to the vagus nerve, which then stimulates the brain. ○ Indications: It is used to treat treatment-resistant depression when medications or ECT are ineffective. ○ Mechanism: The electrical impulses are thought to regulate mood by affecting neurotransmitter activity in the brain. Rapid Transcranial Magnetic Stimulation (rTMS): ○ Definition: Non-invasive procedure using magnetic pulses to stimulate specific areas of the brain involved in mood regulation.  ○ Indications: rTMS is often used in patients with major depressive disorder who do not respond to medications or psychotherapy. ○ Mechanism: It stimulates the prefrontal cortex, which is often underactive in depressed patients. ○ Procedure: It is an outpatient procedure that does not require anesthesia. Deep Brain Stimulation (DBS): ○ Definition: Surgical implantation of a device that sends electrical impulses to specific brain areas. ○ Indications: DBS is primarily used in patients with treatment-resistant depression or obsessive-compulsive disorder (OCD). ○ Mechanism: It targets specific brain circuits believed to be involved in depression and mood regulation. ○ Procedure: It requires surgery for implantation of the device, which is similar to a pacemaker. 21. What complementary medicine is recognized as assisting with depression? St. John’s Wort: Known for its natural antidepressant effects, St. John’s Wort has been shown to improve symptoms of mild to moderate depression. However, it may interact with other medications, including antidepressants, birth control, and anticoagulants, so caution is needed. Omega-3 Fatty Acids: Found in fish oil, omega-3 fatty acids have been shown to help alleviate depressive symptoms in some patients. S-Adenosylmethionine (SAMe): A supplement believed to help with mood regulation and depression. It is often used as an adjunct to traditional antidepressant therapies. Acupuncture: Some studies suggest acupuncture can help reduce symptoms of depression, especially when combined with other treatments. Mind-Body Techniques: Meditation, yoga, and mindfulness-based cognitive therapy (MBCT) can reduce stress and improve mood in people with depression. Bipolar & Related Disorders 22. Differentiate the different types of bipolar disorder. Bipolar I Disorder: Characterized by manic episodes lasting at least 7 days or by manic symptoms that are so severe they require immediate hospital care. Depressive episodes lasting at least 2 weeks often occur. Bipolar II Disorder: Characterized by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes typical of Bipolar I. Cyclothymic Disorder (Cyclothymia): A chronic mood disorder characterized by periods of hypomanic symptoms and periods of depressive symptoms lasting for at least 2 years (1 year in children) without meeting the diagnostic requirements for a hypomanic episode and a depressive episode. Bipolar Disorder NOS (Not Otherwise Specified): This category is used when a person exhibits symptoms of bipolar disorder, but the symptoms do not meet the criteria for any specific type. 23. What causes bipolar disorder? Discuss theories that influence this disorder. Genetic Factors: Bipolar disorder has a strong genetic component, with the risk of developing the disorder being higher if a family member has it. Neurochemical Imbalance: Imbalances in neurotransmitters such as serotonin, norepinephrine, and dopamine are thought to contribute to the manic and depressive episodes in bipolar disorder. Environmental Stressors: Stressful life events, such as trauma or significant changes, may trigger the onset or relapse of bipolar disorder in susceptible individuals. Neuroanatomical Factors: Some research suggests that abnormalities in the brain, such as in the prefrontal cortex and amygdala, may contribute to the disorder. 24. Contrast Dysthymia with Cyclothymia. Dysthymia (Persistent Depressive Disorder): A chronic, low-grade depression lasting for at least 2 years (1 year in children), with periods of normal mood lasting no longer than 2 months. It does not involve the extreme highs of bipolar disorder. Cyclothymia: A less severe form of bipolar disorder that involves mood swings between hypomanic episodes and depressive episodes that do not meet the full criteria for mania or major depression. The mood swings last for at least 2 years in adults. 25. Contrast mania and hypomania. Mania: A more severe form of elevated mood that can cause significant impairment in social or occupational functioning or require hospitalization to prevent harm. It may involve delusions, hallucinations, and impulsive or reckless behavior. Hypomania: A milder form of mania that does not cause significant functional impairment or require hospitalization. It may involve elevated mood, increased energy, and decreased need for sleep, but without the severe consequences seen in mania. 26. Describe the behavior of someone who is experiencing mania. Behavior: A person in mania may exhibit excessive talkativeness, racing thoughts, impulsivity, and risk-taking behaviors. They may engage in grandiose behavior, excessive spending, or risky sexual activities. Sleep may be reduced, and they might appear overly confident or euphoric. 27. What happens to the thoughts of a person experiencing mania? Thoughts: Thoughts during a manic episode are often rapid, fragmented, and flighty. A person may have difficulty focusing, experience racing thoughts, and may jump from topic to topic. They may also have grandiose delusions or a heightened sense of self- importance. 28. How does a nurse participate in the treatment of a client who has mania? Assessing Symptoms: The nurse must regularly assess for signs of mania, such as hyperactivity, decreased need for sleep, and risky behaviors. Providing Safety: Ensuring the patient is safe from self-harm or engaging in harmful behaviors (e.g., excessive spending or reckless driving) is critical.  Medication Management: Administering medications such as mood stabilizers or antipsychotics and monitoring for side effects. Providing Support: Encourage a structured environment with clear boundaries. Educate the patient and family about the disorder, treatment options, and the importance of medication adherence. 29. What are important interventions to consider when a client is in the manic phase? Provide a Safe Environment: Ensure the patient is in a controlled environment to prevent harm to themselves or others. Monitor for impulsivity and high-risk behaviors such as spending sprees or risky sexual activity. Establish Boundaries: Set clear and consistent boundaries to reduce the risk of aggressive or disruptive behavior. Medication Management: Administer mood stabilizers (e.g., lithium, valproate) and antipsychotics as prescribed. Monitor for side effects. Encourage Rest: Ensure the patient has a quiet, low-stimulation environment to help reduce overactivity and allow for adequate rest. Monitor Nutrition and Hydration: Manic patients may forget to eat or drink, so ensuring adequate nutrition and hydration is essential. Promote Structure: Help provide a structured daily routine to prevent feelings of chaos and disorientation. 30. What interventions are important during the maintenance phase? Medication Adherence: Ensure patients continue to take prescribed medications, especially mood stabilizers, to prevent relapse. Monitor for side effects and educate the patient on the importance of medication adherence. Therapy and Support: Encourage ongoing psychotherapy (e.g., cognitive-behavioral therapy, psychoeducation) to help the patient identify triggers and manage symptoms. Stress Management: Help the patient develop coping strategies to manage stress and prevent mood episodes. Regular Monitoring: Schedule regular follow-up visits to monitor mood stability and address any concerns related to medications or treatment. 31. Understand how sleep cycles influence bipolar disorder. Sleep Disruption: Sleep disturbances are often a trigger for both manic and depressive episodes in bipolar disorder. During manic episodes, patients may experience reduced sleep need, while during depressive episodes, they may have difficulty falling or staying asleep. Circadian Rhythms: Disruptions to circadian rhythms (e.g., irregular sleep-wake cycles) are common in bipolar disorder and may worsen mood instability. Interventions: It is important to establish regular sleep habits, reduce stimuli before bed, and monitor sleep patterns to help stabilize mood. 32. Why is safety an important consideration when discussing mood disorders?  Risk of Suicide: Mood disorders, particularly depression and bipolar disorder, can significantly increase the risk of suicidal ideation and attempts. Monitoring for any signs of self-harm or suicidal thoughts is essential. Mania-Related Risk: In the manic phase, patients may engage in risky behaviors such as reckless driving, excessive spending, or unprotected sexual activity, which can have dangerous consequences. Psychosis or Impulsivity: In severe cases, patients may experience psychosis, aggression, or delusions, putting themselves or others at risk. 33. What might become evident in a mental status examination of the client with a mood disorder? Appearance and Behavior: In depressive episodes, the patient may appear withdrawn, disheveled, or have poor hygiene. During manic episodes, the patient may appear hyperactive, excessively talkative, or disorganized. Mood and Affect: Depression may present with a sad, flat, or anxious mood, while mania may present with an elevated or irritable mood. Thought Process: In depression, thoughts may be slowed or pessimistic. During mania, thoughts may be racing, fragmented, or grandiose. Cognition: Cognitive deficits may be seen in both manic and depressive episodes. In mania, the patient may have impaired judgment, while in depression, concentration and memory may be impaired. Perceptions: Delusions or hallucinations may be present, particularly in severe mania or depression with psychotic features. 34. Discuss the long-term impact of mood disorders on the lives of the people they affect. Impact on Relationships: Chronic mood instability can strain relationships with family, friends, and colleagues. Mania may cause impulsive behavior that damages personal and professional relationships, while depression may cause withdrawal and isolation. Employment and Functioning: Individuals with mood disorders may have difficulty maintaining steady employment due to impaired concentration, mood swings, or the side effects of medications. Social and Financial Consequences: Manic episodes may lead to risky financial behavior, while depressive episodes may lead to missed work or social isolation, affecting the person's quality of life and financial stability. Chronicity and Recurrence: Mood disorders can become chronic conditions, requiring ongoing management. Recurrence of symptoms may cause further disruptions to life, but with effective treatment, long-term stabilization is possible. Suicide Risk and Etiology 35. Discuss risk factors that increase suicide potential. Mental Health Disorders: Depression, bipolar disorder, schizophrenia, and anxiety disorders increase the risk of suicide.  Previous Suicide Attempts: A history of previous suicide attempts is a strong predictor of future attempts. Chronic Pain or Illness: Chronic physical illness or severe pain can contribute to feelings of hopelessness, increasing the risk of suicide. Substance Abuse: Alcohol or drug abuse is a significant risk factor, as it can impair judgment and increase impulsivity. Social Isolation: A lack of social support or feelings of loneliness can contribute to suicidal thoughts. Family History: A family history of suicide or mental illness can increase an individual's risk. Trauma or Stress: Life events such as trauma, abuse, the loss of a loved one, or major life stressors can trigger suicidal behavior. 36. Understand the differing theories about the etiology of suicide including: a. Biologic Factors: ○ Genetics: Family history of suicide or mood disorders increases risk. Certain genetic markers may predispose individuals to depression or impulsive behavior. ○ Neurochemical Imbalance: Dysregulation of neurotransmitters like serotonin, norepinephrine, and dopamine is linked to suicidal ideation. ○ Brain Abnormalities: Structural and functional brain changes, especially in areas involved in mood regulation (e.g., prefrontal cortex, amygdala), may contribute to suicidal behavior. b. Psychologic Factors: ○ Cognitive Distortions: Thoughts of worthlessness, hopelessness, or perfectionism may increase vulnerability to suicide. ○ Personality Traits: Traits such as high impulsivity, perfectionism, and emotional dysregulation may contribute to the risk of suicide. ○ Unresolved Trauma: Previous trauma, abuse, or neglect can increase the risk of suicide by contributing to feelings of worthlessness or a desire to escape. c. Sociologic Factors: ○ Cultural Stigma: In some cultures, there is a stigma against seeking help for mental health issues, which may increase the likelihood of untreated mental illness and suicidal ideation. ○ Social Isolation: Lack of supportive relationships and social networks can increase feelings of loneliness and hopelessness, contributing to the risk of suicide. ○ Socioeconomic Stressors: Financial difficulties, unemployment, and poverty are significant social factors contributing to suicide risk. 37. How does gender and ethnicity, socioeconomic status, and family influence suicidal behaviors? Gender: Men are more likely to die by suicide, often using more lethal means. Women may attempt suicide more frequently but tend to use less lethal methods.  Ethnicity: Certain ethnic groups, such as Native American and LGBTQ+ populations, have higher rates of suicide. Cultural beliefs and stigma around mental health issues may also play a role in suicidal behaviors. Socioeconomic Status: Lower socioeconomic status is linked to higher rates of suicide due to increased stressors, such as financial instability, unemployment, and limited access to mental health care. Family Influence: Family dynamics, such as a history of suicide or mental health issues, can increase the risk. Dysfunctional family relationships or lack of support can contribute to feelings of isolation and hopelessness. 38. Why is suicide more prevalent among people with other mental health disorders? Co-occurring Mental Illnesses: People with mood disorders (depression, bipolar disorder), anxiety disorders, schizophrenia, or personality disorders are at higher risk for suicide due to the overwhelming emotional distress and impaired coping mechanisms associated with these conditions. Impaired Judgment: Mental health disorders can impair a person’s ability to make sound judgments, increasing impulsivity and the likelihood of engaging in self-harming behaviors. Hopelessness: Many mental health disorders are associated with feelings of hopelessness, a key factor in suicidal ideation. Social Withdrawal: Mental illnesses often lead to social isolation, reducing access to support systems and contributing to feelings of loneliness and despair. 39. Discuss the following terms and the risk factors for each: a. Depression: ○ Definition: A mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in daily activities. It can also manifest with cognitive, physical, and emotional symptoms. ○ Risk Factors: Genetic predisposition, past history of depression, chemical imbalances in the brain, chronic stress, trauma, abuse, significant loss, or chronic illness. ○ Impacts: Depression is a significant risk factor for suicide due to feelings of hopelessness and worthlessness. b. Mental Illness: ○ Definition: A broad term that encompasses a range of conditions affecting mood, thinking, and behavior, including anxiety disorders, depression, bipolar disorder, schizophrenia, etc. ○ Risk Factors: Family history of mental illness, childhood trauma, prolonged stress, substance abuse, and certain medical conditions that affect brain chemistry. ○ Impacts: Mental illness can impair judgment and coping skills, increasing the risk of suicidal ideation or behavior. c. Veterans:  ○ Definition: Military veterans, especially those who have been in combat or experienced trauma during their service, are at an elevated risk of mental health issues, including PTSD, depression, and substance use disorders. ○ Risk Factors: Exposure to combat, trauma, loss of comrades, reintegration difficulties, chronic pain, and difficulty accessing mental health care. ○ Impacts: Veterans face higher rates of suicide due to PTSD, depression, and the challenges of transitioning back to civilian life. d. Alcohol and Other Drugs: ○ Definition: Substance use, including alcohol and illicit drugs, significantly increases the risk of suicide. ○ Risk Factors: Substance abuse can impair judgment, reduce inhibitions, and exacerbate feelings of depression and hopelessness, leading to suicidal behaviors. ○ Impacts: Alcohol and drug abuse are often linked to both mental illness and suicidal ideation, acting as a catalyst for impulsive suicidal behavior. e. Traumatic Brain Injury/Medical Illness: ○ Definition: Traumatic brain injuries (TBI) and chronic medical conditions (such as cancer, diabetes, etc.) can lead to mood changes, cognitive impairment, and depression. ○ Risk Factors: TBI, neurological diseases, chronic pain, disability, and significant lifestyle changes due to medical illness. ○ Impacts: These conditions may cause frustration, feelings of helplessness, and depression, all of which increase suicide risk. 40. Where do older adults and adolescents fit in the risk for suicide? Older Adults: ○ Risk Factors: Chronic illness, social isolation, loss of independence, recent bereavement, depression, and substance abuse. Older adults, especially those over 65, are at increased risk for suicide, particularly if they experience significant life changes like retirement, widowhood, or declining health. Adolescents: ○ Risk Factors: Family dysfunction, bullying, peer pressure, academic stress, social isolation, and previous suicide attempts. Adolescents may lack the coping skills necessary to handle the pressures of growing up and may be more impulsive, leading to an increased risk of suicide. 41. List risk factors for suicide and understand the SAD PERSONS scale. Risk Factors: ○ Previous suicide attempts ○ Mental illness (especially depression and bipolar disorder) ○ Substance abuse ○ Family history of suicide ○ Chronic illness or pain ○ Social isolation  ○ Recent trauma, loss, or significant life changes ○ Access to lethal means (e.g., firearms, medications) ○ Lack of support systems (family, community, etc.) SAD PERSONS Scale: ○ A tool used to assess the risk of suicide. It assigns a score based on factors that may increase suicide risk. Each factor is scored as follows: Sex (Male): +1 Age (Younger than 19 or older than 45): +1 Depression: +1 Previous suicide attempt: +1 Ethanol use (alcohol): +1 Rational thinking loss (psychosis, etc.): +1 Social support lacking (isolated): +1 Organized plan: +1 No spouse/partner: +1 Sickness (chronic or terminal illness): +1 ○ Interpretation: A score of 3-4 indicates a moderate risk for suicide, while 5 or more indicates a high risk. 42. How does a nurse assess for suicide risk? Assessment: ○ Ask direct questions about thoughts of death or suicide, such as: “Are you thinking about harming yourself?” “Do you have a plan for how you would harm yourself?” ○ Assess for Warning Signs: Verbal cues such as, “I wish I were dead” or “Everyone would be better off without me.” Behavioral signs like giving away possessions, increased social withdrawal, or writing a will. ○ Evaluate Risk Factors: Consider the person’s mental health history, substance use, stressors, family history, and previous suicide attempts. 43. What questions might the nurse ask to determine the seriousness of suicidality? Key Questions: ○ “Have you thought about ending your life?” ○ “Do you have a plan for how you would do it?” ○ “How specific is your plan?” ○ “Do you have access to the means to carry out your plan (e.g., pills, firearms)?” ○ “What stopped you from acting on these thoughts before?” 44. What is meant by the term lethality? How do you assess the level of lethality and the extent of intervention necessary? Lethality: The likelihood that the method of suicide will result in death. Assessment of Lethality:  ○ Method: More lethal methods (e.g., firearms, hanging) are associated with higher risk of death. Less lethal methods (e.g., overdosing on medication) may offer more time for intervention. ○ Plan: Consider the specificity and imminence of the plan (e.g., does the person have a clear plan, timeline, and access to the means). ○ Intervention: If the lethality is high, immediate intervention is necessary (hospitalization, close monitoring). If the lethality is low but the risk is still high, less urgent intervention may be necessary, but psychiatric evaluation should be performed promptly. 45. Why is a sudden brightening of affect of a severely depressed person significant? Sudden Brightening of Affect: A sudden improvement in mood or energy in a severely depressed person may indicate a shift in the person's mental state, which could be a sign of the person having made a decision to end their life. This could be a sign that the person now has the energy or resolve to carry out their plan, making this a critical time for intervention. 46. When is a suicidal client safe to be discharged? Criteria for Discharge: ○ The patient has no active suicidal ideation. ○ The patient has a safety plan in place, including access to support systems (family, therapists). ○ The patient agrees to follow-up care (therapy, psychiatry). ○ The patient has been stabilized on medications if necessary (e.g., antidepressants, mood stabilizers). ○ A clear, agreed-upon plan for managing any future suicidal thoughts or urges is in place. 47. What technique could be utilized by the nurse to obtain important information concerning a patient’s possible suicidal intent? Techniques: ○ Use Open-Ended Questions: Encourage the patient to express their feelings and thoughts openly, using phrases like “Can you tell me more about how you’re feeling?” or “What’s been going through your mind lately?” ○ Assess for Ambivalence: If the patient shows signs of ambivalence (e.g., “I want to die, but I’m not sure I could do it”), this could indicate that they may still be seeking help, and intervention should be prioritized. ○ Build Trust and Rapport: Foster a safe, non-judgmental environment to help the patient feel comfortable sharing their thoughts. 48. List some possible nursing diagnoses related to suicide and discuss what outcomes would be desired. Nursing Diagnoses: 1. Risk for Suicide:  Desired Outcome: The patient will verbalize feelings of safety and a reduction in suicidal ideation, with no intent or plan to harm themselves. 2. Ineffective Coping: Desired Outcome: The patient will demonstrate the use of coping strategies to manage stress and emotional distress. 3. Social Isolation: Desired Outcome: The patient will engage in meaningful social interactions and develop a support system. 4. Hopelessness: Desired Outcome: The patient will express hope for the future and develop realistic goals for their well-being. 49. What nursing interventions could assist the patient after an unsuccessful suicide attempt? Nursing Interventions: ○ Ensure Immediate Safety: Monitor the patient closely for signs of suicidal ideation and create a safe environment. ○ Establish Trust: Build rapport by offering empathy, non-judgment, and support to help the patient express their feelings. ○ Mental Health Support: Connect the patient with psychiatric care and counseling to address the underlying issues contributing to the suicidal ideation. ○ Develop Coping Strategies: Teach relaxation techniques, mindfulness, and cognitive restructuring to manage emotional distress. ○ Involve the Family: Educate the family about suicide prevention, signs of distress, and ways they can support the patient. ○ Plan for Discharge: Ensure follow-up care, including therapy, medication management, and support groups. 50. What nursing interventions are important in helping families through the grieving process? Nursing Interventions: ○ Provide Emotional Support: Offer a compassionate and understanding environment, acknowledging the complex emotions the family is experiencing. ○ Encourage Open Communication: Allow family members to express their grief, anger, and confusion in a safe and non-judgmental space. ○ Provide Resources: Refer the family to support groups, grief counselors, and mental health professionals to help them process their loss. ○ Educate About Grief: Explain the stages of grief (denial, anger, bargaining, depression, acceptance) and validate that grief is unique to each individual. ○ Assist with Practical Matters: Help the family manage any practical concerns, such as funeral arrangements, legal issues, or financial burdens. 51. Tell why grieving is very different for the family and friends of someone who has died from suicide. What can be done to facilitate the grieving process for these people? Why Grieving is Different:  ○ Stigma and Shame: Family and friends may feel shame or guilt, as if they could have prevented the suicide, or they may worry about being judged by others. ○ Unanswered Questions: The traumatic nature of suicide can leave the grieving person with many unanswered questions, making it difficult to find closure. ○ Isolation: Those affected may feel isolated and unable to share their grief with others due to the taboo nature of suicide. ○ Complicated Grief: The nature of suicide can make the grieving process more complicated, often leading to feelings of anger, guilt, confusion, and a lack of understanding. Facilitating the Grieving Process: ○ Normalize the Grief Process: Help the family understand that their feelings of anger, guilt, or confusion are normal reactions to a tragic event. ○ Provide Counseling and Support Groups: Recommend professional counseling and support groups for those who are grieving to process their emotions in a healthy way. ○ Encourage Open Expression: Offer opportunities for family members to express their emotions and talk about their loved one. ○ Respect the Process: Understand that grieving is individual and may take time; each person may go through different stages at different rates. 52. Describe sleep hygiene. Sleep Hygiene refers to habits and practices that promote consistent, restful sleep. Key components include: ○ Establishing a Routine: Go to bed and wake up at the same time each day to regulate your body's internal clock. ○ Creating a Sleep-Inducing Environment: Keep the bedroom dark, quiet, and cool to promote better sleep. ○ Limit Stimulants: Avoid caffeine, nicotine, and large meals close to bedtime, as they can interfere with sleep. ○ Relaxation Techniques: Engage in relaxing activities before bed, such as reading, taking a warm bath, or practicing mindfulness, to prepare the body for rest. ○ Limit Screen Time: Reduce exposure to blue light from screens (phones, computers, TVs) for at least an hour before bedtime, as it can disrupt sleep patterns. ○ Exercise: Regular physical activity can improve sleep, but avoid vigorous exercise too close to bedtime. 53. Describe circadian rhythms. Circadian Rhythms: ○ The body’s internal clock regulates the sleep-wake cycle, body temperature, hormone release, and other bodily functions over a 24-hour period.  ○ These rhythms are influenced by environmental cues, particularly light and darkness, which help the body determine when it should be awake and when it should rest. ○ Disruption in circadian rhythms, such as shift work or jet lag, can lead to sleep disturbances and impact overall health. 54. What medications are associated with sleep disorders? Medications for Sleep Disorders: ○ Benzodiazepines: Such as lorazepam (Ativan) and diazepam (Valium), used for short-term treatment of insomnia due to their sedative effects. ○ Non-benzodiazepine Hypnotics: Such as zolpidem (Ambien) and eszopiclone (Lunesta), commonly prescribed for insomnia, especially for people who have trouble falling asleep. ○ Melatonin Agonists: Ramelteon (Rozerem) is used to regulate the sleep-wake cycle, particularly for individuals with difficulty falling asleep. ○ Antihistamines: Such as diphenhydramine (Benadryl), commonly used as an over-the-counter sleep aid, though it may cause drowsiness the next day. ○ Antidepressants: Some antidepressants like trazodone or mirtazapine (Remeron) are used off-label for insomnia, especially in patients with co-occurring depression or anxiety. ○ Antipsychotics: Some atypical antipsychotics like quetiapine (Seroquel) may be used for severe insomnia, especially when accompanied by psychiatric conditions.