Week 10: Care of Individuals with Mood Disorders & Substance Abuse PDF

Care of individuals with mood disorders and substance abuse By the end of this session, students should be able to : 1. understand the causes of mood disorders and their co-occurrence with substance abuse 2. identify the signs and symptoms of mood disorders 3. describe the nursing care and trea...

Care of individuals with mood disorders and substance abuse By the end of this session, students should be able to : 1. understand the causes of mood disorders and their co-occurrence with substance abuse 2. identify the signs and symptoms of mood disorders 3. describe the nursing care and treatment of clients with mood disorders and substance abuse 4. develop knowledge in suicidal management  Aetiology of mood disorders 1. Genetic factors 4The risk of developing a mood disorder is 1.5 to 3 times greater in individual whose first-degree relative is affected with a mood disorder. 4If one parent has depressive disorder, there is 10%-13% chance in child will have the disorder 4If one parent has bipolar disorder, there is 25% chance in child will have a mood disorder; the chance will rise to 50%-75% if both parents have bipolar disorder 4If one dizygotic twin has bipolar disorder, there is 20% chance in the other twin to have a mood disorder; the chance will rise to 40%- 70% for the other twin if one monozygotic twin has bipolar disorder  Aetiology of mood disorders 2. Biochemical factors 4Depressive disorder is associated with the deficiency of norepinephrine, epinephrine, dopamine and serotonin 4Mania is associated with excessive high level of norepinephrine and dopamine and dysregulation of serotonin 3. Pharmacological factors 4Mania can be secondary to drugs, particularly steroids, amphetamines, cocaine, hallucinogens, opiates and tricyclic antidepressants 4Depression can be induced by 4hormones e.g. oral contraceptives, glucocorticoids 4psychotropics e.g. benzodiazepines, neuroleptics 4cardiovascular drugs e.g. digitalis, beta-blockers, Ca channel blockers 4anti-inflammatory and anti-infective drugs e.g. nonsteroidal anti-inflammatory drugs, antituberculosis drugs and sulfonamides 4anti-ulcer medications e.g. cimetidine, ranitidine  Aetiology of mood disorders 4. Endocrinological factor 4Many depressed and manic patients have high levels of cortisol in plasma and urine 4 Depression is related to hypothyroidism. Mania can be associated with hyperthyroidism, Cushing’s syndrome and Addison’s disease 4Postpartum depressive pattern can occur in some women following childbirth apparently due to hormonal changes 5. Medical conditions 4 Depressive symptoms can be detected in individuals with general medical conditions, such as, CVA, diabetes, coronary artery disease, cancer, AIDS, epilepsy, Parkinson’s disease and chronic fatigue syndrome 4 Mania can be triggered by infections (e.g. influenza), neoplasms (e.g. diencephalic glioma), neurologic disorders (e.g. multiple sclerosis), metabolic disturbances (e.g. vitamin B12 deficiency) and collagen vascular disease (e.g. systemic lupus erythematosus)  Aetiology of mood disorders 6. Circadian Rhythm Theories 4Individuals experiencing circadian rhythm changes are at increased risk to develop depression. 4The changes can be due to medications, nutritional deficiencies, physical or psychological illnesses, hormonal fluctuations or aging. 4The changes will lead to shorten latency in rapid eye movement and sleep disturbances in depressed individuals. 7. Changes in brain anatomy 4Depression might result from or cause atrophy of specific brain locations e.g. loss of neurons and white matter in the frontal lobes, cerebellum and basal ganglia.  Aetiology of mood disorders 8. Psychosocial factors 4Psychosocial stressors can precede the onset of bipolar disorder. 4 Manic episode may follow a stressful event. 4Depressive symptoms can be resulted from stressful life events, such as, trauma or significant loss, financial problems, perceived or real failure and life transitional crises 4Certain attitudes and beliefs can increase the personal risk to develop depression e.g. low self-esteem, lack of personal goals and direction, tendency to avoid difficult situations, passivity in interpersonal relationships & internalization of blame 4Depression can be associated with some vulnerability factors: Lack of social support Low social status Family conflict Childhood adversity, including violence  Aetiology of mood disorders 9. Psychodynamic theories 4 Psychoanalytic theory Depression is understood in psychoanalysis as anger turned inward after a real or perceived loss 4 Learned helplessness theory Depression occurs in people who perceive their own behavior out of control and feel helplessness 4 Cognitive theory Depression is a problem of cognitive patterns that have developed in an individual over time. The individual holds negative views of self, the world and the future 4 Interpersonal psychotherapeutic model Depression is related to multiple interpersonal factors e.g. unsatisfactory early interpersonal experience, stress in current interpersonal relationships, and lack of supportive relationship  Theories related to the co-occurrence of mood disorders and substance abuse 1. Disorder fostering disorder -mood disorders may motivate individuals to resort to drugs and alcohol to cope with their negative affective states 2. Overlapping neurobiological pathways -abuse of alcohol and cocaine can sensitize neurons contributing to increased use of these substances -mood disorders often follow a similar course of increasingly distressing symptomatic episodes separated by progressively shorter periods of remission. 3. Underlying genetic factors -both substance abuse and mood disorders have genetic risk factors -families with substance abusers are more likely than those without to also have members with mood disorders  Examples of mood disorders associated with substance abuse (ICD-11) § Alcohol-induced mood disorder § Cannabis-induced mood disorder § Cocaine-induced mood disorder § Opioid-induced mood disorder § Stimulant-induced mood disorder § Hallucinogen-induced mood disorder § Sedative, hypnotic or anxiolytic-induced mood disorder § Mood disorder induced by multiple specified psychoactive substance 10 Mood range and mood disorders  DSM-5-TR diagnostic categories for mood disorders Depressive disorders 1. Major depressive Disorder -1 or more major depressive episodes 2. Persistent Depressive Disorder (DSM-5-TR) / Dysthymia (DSM-4) -at least 2 years of depressive mood but not meeting the criteria for a major depressive episode 3. Disruptive mood dysregulation disorder -chronic severe, persistent irritability/ temper outbursts in children at least 3 times/ week over 12 months in 2 settings ( at home & at school with peers) 4. Premenstrual dysphoric disorder -the expression of mood lability, irritability, dysphoria and anxiety symptoms during the premenstrual phase for most menstrual cycles that occurred in the preceding year and causes clinical significant distress or interference with work, schools, usual social activities or relationships with others  DSM-5-TR diagnostic categories for mood disorders Depressive disorders 5. Substance/ medication-induced depressive disorder -a prominent and persistent disturbance in mood (depressive symptoms) due to substance intoxication or withdrawal 6. Depressive disorder due to another medical condition -a prominent and persistent period of depressed mood or markedly diminished interest or pleasure due to the physiological effects of another medical condition (e.g. stroke, Parkinson’s disease, neoplasm) 7. Other specified depressive disorder - a depressive disorder not meeting the full criteria of any of the depressive disorder (e.g. recurrent brief depression, 4-13 days short duration depressive episode, depressive episode with insufficient symptoms) 8. Unspecified depressive disorder - the criteria are not met for a specific depressive disorder (e.g. in emergency room settings with insufficient information to make a diagnosis)  DSM-5-TR diagnostic categories for mood disorders Bipolar disorders 1. Bipolar I disorder 2. Bipolar II disorder 3. Cyclothymic disorders 4. Other specified bipolar and related disorder 5. Substance/ medication-induced bipolar and related disorder -a prominent and persistent disturbance in mood (manic/ hypomanic symptoms) developed during or soon after substance intoxication or withdrawal 6. Bipolar and related disorder due to another medical condition -a prominent and persistent disturbance in mood (manic/ hypomanic symptoms) during the initial presentation of another medical condition (usually within 1 month) 7. Unspecified bipolar and related disorder - the criteria are not met for a specific bipolar and related disorder (e.g. in emergency room settings with insufficient information to make a diagnosis)  DSM-5-TR Diagnostic Criteria for major depressive disorder A. At least 5 of the following (including one of the first two) must be present most of the day, nearly daily, for at least 2 weeks Depressed mood most of the day, nearly every day Markedly diminished interest or pleasure, nearly every day Significant weight loss when not dieting or gain (e.g. a change of more than 5% of body weight in a month). Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every day Diminished ability to think or concentrate, or indecisiveness nearly every day Recurrent thoughts of death or suicide B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. DSM-5-TR Diagnostic Criteria for Persistent Depressive Disorder 1. Depressed mood for at least 2 years. Note: In children or adolescents, mood can be irritable, and duration must be at least 1 year. 2. At least 2 of the following : Poor appetite or overeating Insomnia or hypersomnia Fatigue or low energy Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness 3. During a 2-year period (1 year for children or adolescents), the individual has never been free of symptoms for more than 2 months at a time. 4. The symptoms are not related to a major depressive episode, a bipolar disorder, a psychotic disorder, the physiological effects of any substance, or another medical condition. 5. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  DSM-5-TR classification of Bipolar disorders 1. Bipolar I disorder (Recurrent major depressive episodes with manic episodes) A. Criteria have been met for at least one manic episode B. The occurrence of the manic and major depressive episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder Current or most recent episode manic Current or most recent episode hypomanic Current or most recent episode depressed Current or most recent episode unspecified (use when the symptoms but not the duration of the criteria are met) - Course and severity Mild, moderate, severe With psychotic features In partial remission or in full remission Unspecified DSM-5-TR Diagnostic criteria for a manic episode A. A distinct period of elevated, expansive or irritable mood, lasting at least 1 week and present most of the day. B. During the episode, 3 or more of the following symptoms were present (4 if mood was irritable): Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences C. Episode causes marked impairment in social or occupational functioning, requires hospitalization to prevent harm to self or others , or there are psychotic features. D. The symptoms are not due to the direct physiological effects of a substance or another medical condition. Marbas, L. L. & Case E. (2004) Visual Mnemonics for behavioral sciences. USA: Blackwell Publishing. DSM-5-TR Diagnostic criteria for a hypomanic episode A. A distinct period of elevated, expansive or irritable mood, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the episode, 3 or more of the following symptoms were present (4 if mood was irritable): Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. Episode not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.  DSM-5-TR classification of Bipolar disorders 2. Bipolar II disorder A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. B. There has never been a manic episode. C. The occurrence of the hypomanic episode (s) and major depressive episode (s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  DSM-5-TR classification of Bipolar disorders 3. Cyclothymic disorder A. For at least 2 years (at least 1 year in children and adolescents) there has been numerous periods with hypomanic symptoms that do not meet hypomanic episode criteria and numerous periods with depressive symptoms that do not meet major depressive episode criteria. B. During the two-year period, the person never went without symptoms for more than 2 months. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance or another medical condition. Marbas, L. L. & Case E. (2004) Visual Mnemonics for behavioral sciences. USA: Blackwell Publishing.  DSM-5-TR classification of Bipolar disorders 4. Other specified Bipolar and Related Disorder Disorders with bipolar features that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any specific bipolar disorder, for examples: Short-duration hypomanic episodes (2-3 days) and major depressive episodes Hypomanic episodes with insufficient symptoms and major depressive episodes Hypomanic episode without prior major depressive episode Short-duration cyclothymia (less than 24 months in adult / less than 12 months for children or adolescents) Kneisl, C.R. & Trigoboff, E. (2013). Contemporary psychiatric-mental health nursing, 3rd ed. Sydney: Pearson  Clinical features of mood disorders Depression Mania Mood depressed elated anxiety often irritable cries easily disinhibition diurnal variation Thought pessimistic unusual optimism hopelessness pressure of thought helplessness delusion of grandeur worthlessness suicidal ideas cognitive process slowed self-depreciating or self-blaming delusions: guilt, nihilistic hypochondriacal  Clinical features of mood disorders Depression Mania Speech mute/ poverty of speech talkative slow speech rapid speech limited conversational flight of ideas response incoherent at times Behaviour negativism overactivity social withdrawal distractibility decreased energy increased energy poor self-care poor judgement decreased work capacity unrealistic plans excessive indecisiveness promiscuity apathy about work & extravagance of money learning decreased ability to concentrate  Clinical features of mood disorders Depression Mania Somatic insomnia decreased sleep symptoms anorexia/ refusal of food decreased food intake weight loss decreased body weight early morning awakening increased libido constipation exhaustion urinary retention lower libido fatigue muscle aches palpitation chest discomfort epigastric discomfort nausea perception hallucination hallucination Common types of drug abused in H.K. Examples Heroin (海洛英) Cannabis (大麻) Mandrax (甲喹酮/忽得) Methylamphetamine (冰); MDMA/ Ecstasy (Fing 頭丸); Cocaine (可卡因) Triazolam (三唑侖/藍精 靈) Ketamine (K仔); Organic Solvents (有機溶劑) Cough medicine (咳藥水) Alcohol (酒精) 30 31  Substance-related disorders 1. Substance use disorders 2. Substance-induced disorders Intoxication Withdrawal Other substance/ medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive- compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium and neurocognitive disorders).  DSM-5-TR criteria for substance use disorders A. The individual has impaired control over substance use: Substance may be taken in larger amounts or over a longer period than was originally intended. Persistent desire to cut down or regulate substance use and report multiple unsuccessful efforts to decrease or discontinue use. A great deal of time may be spent obtaining the substance, using the substance or recovering from its effects. Craving as manifested by an intense desire or urge for the drug that may occur at any time. B. The individual has social impairment: Recurrent substance use may result in a failure to fulfill major role obligations at work, school or home. Substance use may be continued despite having persistent or recurrent social or interpersonal problems. Important social, occupational, or recreational activities may be given up or reduced because of substance use. DSM-5-TR criteria for substance use disorders C. The individual has risky use of substance: Recurrent substance use in situations in which it is physically hazardous. Continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. D. Fulfillment of pharmacological criteria: Presence of tolerance in which the individual requires a markedly increased dose of the substance to achieve the desired effect or experience a markedly reduced effect when the usual dose is consumed. Development of withdrawal symptoms which occurs when blood or tissue concentration of a substance decline in an individual and the symptoms vary greatly across the classes of substance. Severity (mild: 2-3 symptoms; moderate: 4-5 symptoms; severe: ≥ 6 symptoms) Specifiers ( in early remission; in sustained remission; on maintenance therapy; in a controlled environment ) (Basu & Ghosh, 2018)  DSM-5-TR criteria for substance intoxication A. The development of a reversible substance-specific syndrome due to the recent ingestion of a substance. B. Clinically significant problematic behavioral or psychological changes associated with intoxication (e.g. belligerence, mood lability, impaired judgment) are attributable to the physiological effects of the substance on the central nervous system and develop during or shortly after use of the substance. C. Accompanied by substance-specific signs and symptoms D. The symptoms are not attributable to another medical condition and are not better explained by another mental disorder. DSM-5-TR criteria for substance withdrawal A. The development of a substance-specific problematic behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use. B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The symptoms are not due to another medical condition and are not better explained by another mental disorder.  DSM-5-TR criteria for substance/ medication-induced mental disorders A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder. B. There is evidence from the history, physical examination, or laboratory findings of both of the following: 1. The disorder developed during or soon after substance intoxication, substance withdrawal or exposure to or withdrawal from a medication; and 2. The involved substance/ medication is capable of producing the mental disorder. C. The disorder is not better explained by an independent mental disorder (preceded the onset of severe intoxication/ withdrawal or persisted for a substantial period of time after the cessation of acute withdrawal/ severe intoxication). D. The disorder does not occur exclusively during the course of a delirium. E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.  Alcohol §Alcohol problem affects 10-20% population in western society & alcohol abuse is a growing problem in Chinese society. §Destructive outcomes associated with alcohol abuse can include divorce, suicide, traffic accidents, crime & violence. §Alcohol causes serious disturbances in family relationships and is often involved when there is domestic violence or other forms of physical, emotional and sexual abuse. §Alcohol related health problem: Physical : Anemia, nutritional deficiency, liver diseases (cirrhosis, fatty liver, hepatitis), gastric ulcer, hypertension, stroke, heart diseases & respiratory infections Mental: alcoholic delusion of jealousy, alcoholic hallucinosis, Korsakov’s psychosis & dementia §Safe limit of alcohol intake 2 standard drinks (male) daily; 1 standard drinks (female) daily At least 2 days in a week not drink any alcohol §How to calculate the alcohol units? §Unit of alcohol= vol (L) x alc conc (%) x 0.789 a can of beer: 0.35x5x0.789=1.18 a bottle of red wine: 0.7x10x0.789=5.52 a catty of Chinese spirit: 0.7x30x0.789=16.57 Common alcoholic drinks in Hong Kong and their “standard drink” units  Alcohol Intoxication §Evidence of recent alcohol consumption §Slurred speech §Impaired coordination §Unsteady gait §Delayed reflexes §Impaired concentration & memory §Changes in mood from initial euphoria to increasingly aggressive, hostile, or argumentative behaviour §Changes in sexual behaviour when typical inhibitions are relaxed §Stuporous behaviour, coma, or “blackout” if drinking continues.  Alcohol withdrawal §Shakiness §Tremors §Psychomotor restlessness §Agitation §Increased pulse rate §Sweating §Nausea & vomiting §Sleep pattern alteration §General anxiety §Development of symptoms a few hours to several days after discontinuation of alcohol consumption  Mood and substance use comorbidity §The comorbidity can downgrade the clinical course, treatment outcome and prognosis for each problem. §Individuals with substance use and a mood disorder have a more severe clinical course and worse outcomes than those who have only one or the other. §The comorbidity also increase the risk of suicide. §Successful alleviation of one condition can facilitate recovery from the other, for example, treating a comorbid affective disorder can decrease substance abuse and craving. § Integration of services and effective treatment strategies for both mood disorders and substance use disorder can optimize outcomes. Care of individuals with mood disorders and substance abuse  Nursing management §Assessment §Suicide prevention §Management of depressive symptoms § Instilling hope § Regulating emotions & behaviour § Promoting self-esteem § Enhancing social interaction § Managing self-care deficit § Mobilizing Social Support §Management of manic symptoms § Providing for safety § Meeting physiologic needs § Reinforcing appropriate interaction skill § Providing therapeutic communication § Promoting reality orientation and eliminate sensory misperception § Medication monitoring §Management of different stages of substance abuse  Assessment §Conduct a thorough physical and neurological examination to determine if a mood disorder is primary or secondary to another disorder (e.g. endocrine, oncologic, metabolic and autoimmune disorders). §Identify any substance use and abuse (e.g. alcohol, illegal drugs, sedatives, oral contraceptives, steroids are associated with the development of mood disorders). §Examine the client’s risk of harm to self or others. §Assessment tools can be used to § evaluate depression and suicidal risk e.g. Patient Health Questionnaire-9 (PHQ 9), Beck Depression Inventory (BDI), Hamilton Depression Scale (HDS), Center for Epidemiological Studies – Depression Scale (CES-D) § identify substance use behavior e.g. AUDIT (Alcohol Use Disorder Identification Test), DAST-10 (Drug Abuse Screening Test), ASI (Addiction Severity Index)  Multi-Drug Screen Test School Drug Testing for healthy School programme https://www.nd.gov.hk/en/HSP.html http://change4health.gov.hk/tc/audit 51  Suicidal Management 1. Risk recognition Recognize significant risk in individual expressed suicidal thought or had repeated attempts of self-harm 2. Risk assessment (Demographic & clinical risk factors:) Depression Family Hx of suicide/ depression Older age (both sexes) Young & middle-aged (men) Male > female Living alone, socially isolated Divorced, single, widowed Unemployed or retired Trauma & abuse Hx High/low socioeconomic status Mental illlness Alcohol/ substance misuse Chronic physical illness Previous deliberate self-harm History of suicidal attempt Recent suicidal plan Negative life events/ stress  Suicidal Management 2. Risk assessment Assessing client depression mood-related symptoms physical symptoms cognitive symptoms social/interpersonal symptoms Assessing degree of hopelessness and helplessness Exploring suicidal ideation Assessing suicide plans: specificity, lethality, availability & proximity Assessing client self-control and past/ familial attempt Assessing suicidal intent 56 57  Suicidal Management 2. Risk assessment Take special attention if the client suddenly changes from sad/ depressed to happy and seemingly peaceful If the client is to be managed as an out-patient, the following assessments are required: Availability of social supports Friends’ and family’s knowledge of signs and symptoms of potential suicidal behavior Availability of community supports and resources  Suicidal Management 3. Risk management 4 Listen and being empathic 4 Develop a supportive and therapeutic relationship 4 Provide a safe environment : keep all potentially harmful items from the patient, such as, knives, scissors, glass, razor blades, belts, electrical cords and linen 4 Put on suicide observation and maintain frequent monitoring 4 Encourage the client to agree to a no-suicide contract 4 Encourage the discussion of stress and help to identify coping strategies and alternatives to suicide 4 Effective communication with medical officer and among all professionals about client’s suicidal risk and condition 4 Identify risk period/ staff strength  Suicidal Management 3. Risk management 4 Supervise medication taking to ensure client will not hide up any medication 4 Tactfully and carefully check client’s belongings 4 Intervene promptly and tactfully during a suicidal attempt and perform first aid and resuscitation if indicated 4 Administer p.r.n. chemical sedation as prescribed in situation that is required 4 Use of physical restraint as a last resort  Suicidal Management 3. Risk management If the client is to be managed outside the hospital, then: 4 Social support should be mobilized. 4 The family, significant other, or friends should be alerted to the risk and treatment plan and informed of worsening signs e.g. increasing withdrawal, preoccupation, silence, and sudden change from sad to happy and “worry-free”. 4 Client and the family and friends should be given emergency contact phone no. and crisis hotline numbers. 4 Medication should be given in limited quantity.  Nursing management for depressive symptoms Instilling hope §Assist client to develop a positive outlook and sense of control in life. §Teach client coping measures e.g. problem solving techniques. Regulating emotion and behaviors §Help client to be aware of her/his feelings, label them, and express them appropriately e.g. talking with someone or writing in a journal. Promoting self-esteem §Work with the client to identify cognitive distortions that encourage negative self-appraisal. §Help client to recognize and focus on strengths and accomplishments. Minimize attention given to past failure. §Promote attendance in therapy groups that offer client simple methods of accomplishment. Offer recognition and positive feedback for actual accomplishments.  Nursing management for depressive symptoms Enhancing social interaction §Develop a therapeutic nurse-patient relationship through frequent, brief contacts and an accepting attitude. §Involve client in one-to-one activity when s/he is most severely depressed. §Eventually increase the client’s contact with other patients, beginning with one other and then two others, progressing towards group activities, occupational therapy and recreational therapy. Managing self-care deficit §Attend to client’s need in related to bathing/ hygiene self-care deficit, altered nutrition, sleep disturbance and constipation. Mobilizing social support §Involve client’s support system §Help the client and family members to identify community resources that are appropriate to their needs and for long term care prior to client’s discharge. §Referral to appropriate agencies can be initiated e.g. self-help group, family support group.  Nursing management for manic symptoms §Providing for safety Provide a safe, quiet and stimulus-free environment Ensure client will not harm self or others as he/ she may have suicidal ideation or plans or thoughts of hurting others Provide monitoring on client’s whereabouts and behaviors §Meeting physiologic needs Maintain adequate nutrition, fluid, sleep and cleanliness, such as : -offering “finger foods” or things client can eat while moving around -providing snacks between meals &food high in calories and protein -decreasing stimulation at bedtime -monitoring food and fluid intake and hours of sleep  Nursing management for manic symptoms Reinforcing appropriate interaction skill § Communicate rules, expectations, and consequences in simple language § Set limits to identify the unacceptable behavior and appropriate behavior § Channel client’s need for movement into socially acceptable motor activity § Praise desired behaviors Providing therapeutic communication § Use clear and simple sentences to communicate § Clarify the meaning of client’s communication  Nursing management for manic symptoms §Promoting reality orientation & eliminate sensory misperception Reinforce and focus on reality such as talking about real events and using real situations to divert client from long, tedious, repetitive verbalization of false ideas Observe client for signs of hallucinations and try to distract the client away from the misperception §Medication monitoring Improve medication adherence Prevent drug intoxication  Nursing care in the acute stage of abuse §Provide a safe, comfortable and low-stimulation environment §Orient to time, place and person §Monitor vital signs §Maintain adequate nutrition and fluid balance §Monitor for delirium tremens, psychotic symptoms and suicide/ seizure risk §Provide emotional support and reassurance to patient and family  Nursing care in the acute stage of abuse §Monitor withdrawal symptoms Nausea/ vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances Auditory / visual disturbances Headache Disorientation §Administer the withdrawal medication e.g. anticonvulsants & benzodiazepines as prescribed to prevent confusion and changes in mental status  Nursing care in the rehabilitative stage of abuse §Help client to develop motivation and commitment for abstinence, lifestyle change and recovery §Provide assistance to complete detoxification from all mood- altering substances §Administer medications for enhancing abstinence/ treatment of mood/ anxiety and/or thought disorders as prescribed §Facilitate hope §Enhance coping/ communication/ problem-solving skills §Educate about relapse prevention §Help patient to recognize sign of impending relapse  Motivational interviewing §A systematic intervention developed by Miller & Rollnick (1991) as an alternative to the traditional confrontational approaches in changing addictive behavior §Useful for people who are reluctant to change and ambivalent about changing as it helps to resolve ambivalence and to get a person moving along the path to change. §Aim to increase the client’s intrinsic motivation so that change arises from within rather than being imposed from without.  Motivational interviewing Five general principles 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Roll with resistance 5. Support self-efficacy  Stages of change 1. Pre-contemplation Unaware or has no desire to change 2. Contemplation Aware of a problem but is ambivalent to change 3. Determination Decide to take action with regard to the problem 4. Action Begin to change behavior but has not yet changed to the desired level 5. Maintenance Sustaining changes have been accomplished by action taken 6. Relapse Revert at least temporarily to the previous pattern  Actions at each stage of change 1. Pre-contemplation Raise personal awareness of the risks, conduct routine assessment, provide information and discuss ways to reduce risks and potential harm of substance use 2. Contemplation Continue to raise awareness, be a good listener of concerns, avoid too much focus on action and try to tip the balance in favour of change 3. Preparation and action Assist in making a plan, developing skills to support the plan and maintaining motivation 4. Maintenance Teach self-monitoring skills to prevent relapse and help to recognize personal strengths in maintaining behaviour change 5. Relapse Provide support to renew decision to change and try different strategies to reduce potential risks (WHO, 2009)  Biopsychosocial intervention for mood disorders and substance abuse 1. Biological §Antidepressants § MAOIs (Monamine oxidase inhibitors) § TCAs (Tricyclic & Tetracyclic antidepressants) § SSRIs (Selective serotonin reuptake inhibitors) § NDRI (Norepinerphine & dopamine reuptake inhibitor) § SNRI (Serotonin & norepinephrine reuptake inhibitor) § SARIs (Serotonin-2 antagonist/ reuptake inhibitors) § NaSSAs (Noradrenergic and specific serotonergic antidepressants) §Mood stabilizers -Alleviate the frequency &/ or intensity of manic, hypomanic, depressive or mixed episodes in bipolar disorder patients (e.g. lithium carbonate) §Antipsychotics -Control severe anxiety, agitation, aggression, hyperactivity and psychotic features (e.g. olanzapine, risperidone, quetiapine, ziprasidone) §Benzodiazepines -Relieve insomnia and agitation (e.g. clonazepam, diazepam, lorazepam) - Good for acute mania as brief adjunct therapy but not recommended for maintenance dose §Electroconvulsive Therapy (ECT) Stahl, S. M.( 2008). Depression and bipolar disorder: Stahl’s essential psychopharmacology. New York: Cambridge University Press.  Mechanism of action of antidepressants §MAOIs - increase levels of serotonin (5-HT), norepinephrine (NE) and dopamine (DA) by blocking their metabolism by monoamine oxidase (MAO) - not a first-choice antidepressant - MAO blockade can be life threatening by : allowing “tyramine” to be absorbed in the general circulation, encouraging release of NA and adrenaline from sympathetic nerve terminals and adrenal medulla, and causing a “hypertensive crisis” Foodstuffs (high in tyramine) to avoid with MAOIs Cheese Red wine Meat extracts (Bovril, Oxo) Port Broad beans Sausage Marmite Salami Yeast extracts Banana skins Liver Sauerkraut Monosodium glutamate Prickled fish  Mechanism of action of antidepressants §TCAs - exert their therapeutic actions through blockade of norephinephrine and serotonin reuptake §SSRIs - selectively target the serotonin system, increasing 5-HT levels by blocking the serotonin reuptake - produce less side effects e.g. no cardiac toxicity and anticholinergic effects  Side effect profiles TCAs SSRIs Dry mouth Nausea Blurred vision Nervousness Constipation Insomnia Drowsiness Sexual dysfunction Weight gain Headache urinary retention Sedation Dizziness Posture hypotension Cardiac effects  Mood stabilizers §Lithium carbonate 1st medication for manic-depressive disorder Mechanism of action is unknown Thought to work in the synapses hasten destruction of catecholamines (dopamine, norephinephrine) inhibit neurotransmitter release decrease the sensitivity of postsynaptic receptors (Videbeck, 2004) Patient/ Family education on lithium carbonate §Educate the need for regular monitoring of serum levels as there is a narrow margin between the therapeutic and toxic level of lithium carbonate (1.0-1.5 mEq/L for acute mania & 0.6-1.2 mEq/L for maintenance). §Observe for the signs & symptoms of lithium toxicity, such as, nausea, vomiting, diarrhoea, polyuria, muscle weakness, fine hand tremors, headache, blurred vision, slurred speech, dizziness, sluggishness, abdominal cramping, and tinnitus. The client should immediately discontinue the drug and contact the physician if lithium toxicity is shown. §Educate the need for adequate fluid intake, and the client should not take diuretics at any time. A significant decrease in body fluid because of a hot climate, strenuous exercise, vomiting and diarrhea can rise the lithium level leading to lethal lithium toxicity. §Educate about the diet which must include adequate salt. A reduction in salt intake can cause the body to retain excessive lithium and increase the incidence of side effects, and toxicity. Patient/ Family education on lithium carbonate §Educate the need to continue taking the drug even when feeling well, because discontinuing lithium therapy often precipitates a manic episode. §Educate the need for monitoring of thyroid and renal functions every 6 to 12 months. §Educate the need for monitoring glucose levels in client with diabetes because lithium alters glucose tolerance. §Educate client to avoid hazardous activities that require alertness and good psychomotor coordination. §Educate client not to switch brands or take other prescription or OTC drugs.  Mood stabilizers §Anticonvulsants used as mood stabilizers - Indicate for those who do not respond to lithium treatment, intolerance to lithium or when lithium produces only partial therapeutic results Examples: Carbamazepine (Tegretol) for mania/ mixed Valproic acid (Epilim) for mania/mixed Oxcarbazepine (Trileptal) for mania/ mixed Lamotrigine (Lamictal) for bipolar depression/ rapid cycling (at least 4 episodes of a mood disturbance in the previous 12 months) Electroconvulsive Therapy  Indications of ECT §Major Depressive Disorder Not responding to antidepressants With failure to eat and drink With a high suicidal risk Previous optimal response to ECT Adverse reactions to psychotropic medications that contraindicate their use. §Post-partum psychosis §Mania intolerant of or refractory to medications §Catatonic Schizophrenia or Schizophrenia refractory to conventional treatments §Schizoaffective disorder Depressive or manic symptoms co-occurring with psychosis or in the absence of psychosis Mechanism of action - Unknown but thought to produce biochemical changes in the brain, an increase in levels of norepinephrine and serotonin similar to antidepressants.  Transcranial Magnetic Stimulation An advanced treatment modality for individuals with treatment-resistant depression (non-response to at least 2 different antidepressants from different classes) A noninvasive treatment not requiring anesthesia and can be performed on an outpatient basis. Involves the placement of a small, insulated electromagnetic coil on the scalp which produces almost painless magnetic pulses. These pulses will induce an electric field in the brain’s outer cortex in regions that are close to the coil. The most common area targeted in depression is the dorsolateral prefrontal cortex. It is given 5 days a week over 3-6 weeks, resulting in a total of 20-30 sessions during treatment https://psychscenehub.com/psychinsights/transcranial-magnetic-stimulation-for- depression/  Transcranial Magnetic Stimulation Common side effects are generally mild to moderate and improve shortly after an individual session. They may include: Headache Scalp discomfort at the site of stimulation Tingling, spasms or twitching of facial muscles Lightheadedness Serious side effects are rare. They may include: Seizures Mania, particularly in people with bipolar disorder Hearing loss if there is inadequate ear protection during treatment https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625 91  Transcranial Pulse Stimulation (TPS) § The latest medical advanced technology to treat patients with Alzheimers’s disease § Appears to be a promising noval brain stimulation for depression and a pilot research study is being conducted in Integrative Health Clinic of PolyU. § TPS uses repetitive single ultrashort ultrasound pulses to provide noninvasive deep brain stimulation for a specific brain region § Average treatment duration 30 minutes per session; a course of treatment involves 6 sessions over 2 weeks § TPS has been described to: § increase extracellular serotonin and dopamine levels, § reduce GABA levels, § increase brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), and vascular endothelial growth factor (VEGF) (Beisteiner et al., 2020) 92  Biopsychosocial intervention for mood disorders and substance abuse 2. Psychological § Cognitive behavioral therapy (CBT) dispel individual’s irrational beliefs & distorted attitudes in reducing depressive symptoms incorporate behavioral techniques to reduce depressive symptoms which can include keeping a mood diary, activity scheduling, identifying automatic thoughts, social skill training & problem solving help individual identify the patterns associated with the perpetuation of substance use and implement new strategies for avoiding or more effectively coping with antecedents of substance use CBT demonstrates efficacy in the treatment of mood disorders and substance abuse  Biopsychosocial intervention for mood disorders and substance abuse 2. Psychological § Interpersonal therapy seeks to recognize, explore and resolve the interpersonal losses, role disputes and transitions, social isolation, or deficits in social skills that may precipitate depressive states Interpersonal social rhythm therapy combines the techniques of interpersonal psychotherapy with the use of a social rhythm matrix to promote lifestyle regularity 3. Behavioral § Motivational interviewing designs to produce rapid, internally motivated change in substance use and other problem behaviors  Biopsychosocial intervention for mood disorders and substance abuse 4. Social §Patient & family education aims to improve illness awareness, treatment compliance, early detection of prodromal symptoms and recurrences and lifestyle regularity §Marital & family therapies resolve any marital problem assist family with conflict resolution facilitate communication among family members §Self-support groups e.g. Alcoholics Anonymous (AA), Al-Anon for family members & friends. §Sociotherapies e.g. specialized therapeutic communities and other residential programs. Services provided in Hong Kong for substance abuser §Compulsory placement programme §Methadone out-patient treatment programme §Voluntary in-patient treatment/ residential drug rehabilitation programmes §Counselling programme for psychotrophic substance abuser §Substance abuse clinic §Self-help support programme Compulsory placement programme (強迫戒毒計劃) § Run by Correctional Services Department § Hei Ling Chau Addiction Treatment Centre (喜靈洲戒毒所) § Nei Kwu Correctional Institution (勵顧懲教所) § Lai Sun Correctional Institution(勵新懲教所) § Lai King Correctional Institution(勵敬懲教所) Voluntary out-patient methadone treatment programme (美沙酮門診治療計劃) § Run by Department of Health  Voluntary Inpatient treatment Residential Drug Rehabilitation Programme (自 願 住 院 戒 毒 治 療 康 復 計 劃) 1. Christian New Life Association Limited 基督教新生協會有限公司 2. Mission Ark Limited 方舟行動有限公司 3. Perfect Fellowship 全備團契 4. HK Christian Service – Lodge of Rising Sun 香港基督教服務處日出山莊 5. Glorious Praise Fellowship 榮頌團契 6. Drug Addict Counselling and Rehabilitation Service (DACARS) Ltd. 得基扶康會恩慈之家 7. St. Stephen‘s Society 聖士提反會 8. The Evangelical Lutheran Church of Hong Kong, Ling Oi Centre 基督教香港信義會靈愛中心 9. Operation Dawn 香港晨曦會  Voluntary Residential Drug Treatment and Rehabilitation Programme (Cont’d) 10. Caritas Hong Kong Wong Yiu Nam Centre 明愛黃耀南中心 11. Christian New Being Fellowship 基督教得生團契 12. Wu Oi Christian Centre 基督教互愛中心 13. Barnabas Charitable Service Association 巴拿巴愛心服務團 14. Christian Zheng Sheng Association Ltd. 基督教正生會 15. Society for the Aid and Rehabilitation of Drug Abusers (SARDA) 香港戒毒會 16. The Society of Rehabilitation and Crime Prevention, Hong Kong 香港善導會 Counselling Programme for Psychotropic Substance Abuser (濫 用 精 神 科 藥 物 者 輔 導 計 劃) 100 HA-Substance Abuse Clinics 101  Evaluation The evaluation could focus on whether the patient § aware of the consequences of substance abuse or addictive behaviors § completes the withdrawal process safely § makes a commitment to stop substance use § learns the necessary skills/ coping behaviors (addressing craving, thoughts and triggers) for recovery § begins to practice some recovery behaviors while in treatment § begins to accept having a substance abuse disorder and the inability to use this substance in the future  References American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. Washington, DC: American Psychiatric Association. Crowe, M., Whitehead, L., Wilson, L., Carlyle, D., O’Brien, A., Inder, M. & Joyce, P. (2010). “Disorder-specific psychosocial interventions for bipolar disorder – A systematic review of the evidence for mental health nursing practice”, International Journal of Nursing Studies, 47, 896-908. Drug information, Narcotics Division’s web site http://www.nd.gov.hk/en/index.htm Foley M. (2010). Lippincott’s handbook for psychiatric nursing and care planning. Philadelpia: Lippincott Williams & Wilkins. Hogan, M. A., Gaylord, C., Gruener, R., Rodgers, J & Zalice, K. K. (2008). Mental health nursing: reviews & rationales. New Jersey: Prentice Hall. Isaacs, A. (2001). Lippincott’s review series: mental health and psychiatric nursing, 3rd edition. Philadelphia: Lippincott. Kneisl, C.R. & Trigoboff, E. (2013). Contemporary psychiatric-mental health nursing, 3rd ed. New Jersey: Pearson Education, Inc.  References Mankad, M.V., Beyer, J.L., Weiner, R.D. & Krystal, A.D. (2010). Clinical manual of electroconvulsive therapy. Washington: American Psychiatric Publishing, Inc. Schwartz, T.L. & Petersen, T.J. (Eds.) (2009). Depression: treatment strategies and management, 2nd edition. London: Informa Healthcare. Stahl, S.M. (2008). Depression and bipolar disorder: Stahl’s essential psychopharmacology. New York: Cambridge University Press. Stuart, G.W. (2009). Principles & practice of psychiatric nursing, 9th edition. St. Louis: Mosby. Varcarolis, E. M. (2010). Manual of psychiatric nursing care planning. St. Louis: Saunders Elsevier. Videbeck, S. (2004). Psychiatric mental health nursing, 2nd edition. Sydney: Lippincott Williams & Wilkins. World Health Organization. (2009). Orientation Program on Adolescent Health for Health-care Providers: Module K –Young people and psychoactive substance use. World Health Organization.