Slide 1
Having a mental disorder isn't easy, and
it's even harder when people assume you
can just get over it.
Slide 2
Functions and Activities of the Brain
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Maintenance of homeostasis
Regulation of autonomic nervous system (ANS) and hormones
Control of biological drives and behaviour
Cycle of sleep and wakefulness
Circadian rhythms
Conscious mental activity
Memory
Social skills
Slide 3
What happens here determines what we see
as behaviour…
Slide 4
Disturbances of
Mental Function
• Environment
• Genes
• Altered Neurons
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Norepinephrine
Serotonin
Dopamine
Glutamate
γ-aminobutyric acid (GABA)
Histamine
Acetylcholine
Substance P
Slide 5
Cellular Composition
of the Brain
• Neurons
• Respond to stimuli
• Conduct electrical impulses
• Release chemicals
• Neurotransmitters
• Presynaptic neuron → synapse →
postsynaptic neuron
• Transmitter destruction
• Enzymes
• Reuptake
Slide 6
Common Signs of Mental Illness
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marked changes in personality;
confused thinking;
inability to cope with problems and daily activities;
strange ideas or delusions;
excessive fears, worries or anxiety;
prolonged feelings of irritability or sadness;
significant changes in eating or sleeping patterns
Slide 7
More Signs
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thinking or talking about suicide;
extreme highs and lows in mood;
abuse of alcohol or drugs;
excessive anger, hostility;
paranoid behaviour;
social withdrawal;
irrational fears.
Slide 8
Mental Health
Assessment
• Holistic Approach
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Physical
Psychological
Social
Cultural
Spiritual
• Interdisciplinary care
Slide 9
Physical Assessment
• Physical Examination
• Body system review
• Neurological status
• Laboratory results
• Physical Functions: elimination,
activity, sleep, appetite and
nutrition, hydration, sexuality, selfcare
• Pharmacologic
• Current and past medications
• Over the counter, vitamins and
herbal supplements
Slide 10
Psychological
Assessment
• Purposes
• Establish rapport
• Obtain an understanding of current
problem
• Assess current level of psychological
understanding
• Perform MSE
• Identify behaviours, beliefs or areas
of patient life to be modified to
effect positive change
• Formulate a plan of care
Slide 11
Psychological Assessment
Mental Status Exam (MSE)
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Appearance
Behaviour
Cooperation
Speech
Thought – process (form/rate of thought) and content
Affect and Mood
Perception
Level of consciousness
Insight and judgement
Cognitive functioning and Sensorium
• Memory: recall short term and long term**
Slide 12
Mini Mental State Exam (MMSE)
• Orientation
• Registration
• Attention and calculation
• Recall
• Language
Slide 13
Other Important Assessments
• Social assessment
• Cultural assessment
• Spiritual assessment
Slide 14
Techniques of Data Collection
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Patient observations
Interviews- client and family
Physical examination
Records and diagnostic reports
Collaboration with colleagues
Standardized tools
Slide 15
Psychological Assessment (RNAO
BPG)
• Behaviour
• Self-concept
• Body image
• Self-esteem
• Personal identity
• Stress and coping patterns
• Risk assessment
• Suicidal ideation
• Assaultive or homicidal ideation
Slide 16
Patients’ Rights
• Voluntary or involuntary Admissions under the
Mental Health Act
• Hospitalized patients retain their rights as
citizens
• Patients’ need for safety must be balanced
against patients’ rights as citizens
• Mental health facilities have written statements
of patients’ rights and applicable provincial or
territorial legislation
Slide 17
Ontario Mental Health Act
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Each province and territory has its own MHA
Fair and equal treatment of persons receiving mental health care
Defines the types of admissions
Rules that apply to admitting someone to a psychiatric facility
Ensures confidentiality of the records
Roles of the MDs, police, JOP, Review Boards
Slide 18
Admission Types
• Voluntary Admission
• Involuntary Admission
Slide 19
Mental Health Forms
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Form 1 – Form 42
Form 2
Form 3 - Form 30/33
Form 4 - Form 30/33
Section 17
Slide 20
Mental Health Forms
Community Treatment Order (CTO)
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What is a CTO?
What are the criteria for being placed on
a CTO?
What are the rights of a person subject
to a CTO?
Slide 21
Nursing Care
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Admission assessment
Physical health assessment
Milieu management
Structured group activities
Documentation
Medication administration
Crisis management
Slide 22
Nursing Care
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Discharge management
Medication management
Medical emergencies
Preparation for discharge to community
Slide 23
Interventions
• Biological Domain
• Self-care activities
• Activity, exercise and nutrition
• Thermoregulation
• Promotion of normal fluid balance
Slide 24
Interventions
• Psychological Domain
• Counselling
• Conflict resolution
• Behaviour therapy
• Cognitive interventions
• Development of nurse-patient relationship
Slide 25
Interventions
• Social Domain
• Promotion of patient safety
• Monitoring for potential aggression
• Administering medication as ordered
• Reducing environmental stimulation
• Approach tailored to individual patients
• Support groups
• Psychiatric rehabilitation
• Family interventions
Slide 26
Promotion of Patient Safety
Restraints
Observation
Seclusion
Deescalation
Slide 27
Pharmacology
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Antianxiety drugs
Sedative-hypnotic drugs
Antidepressants
Mood stabilizers
Anticonvulsant drugs
Antipsychotic drugs
Slide 28
Antianxiety and Hypnotic Drugs
• Reduce anxiety by reducing over-activity in the central nervous system (CNS)
• Benzodiazepines - depresses activity in the brainstem and limbic system
• Benzodiazepines work by increasing the efficiency of a natural brain chemical,
GABA which decreases the excitability of neurons. This reduces the
communication between neurons and, therefore, has a calming effect on many
of the functions of the brain.
• ‘pams’
• Discontinuation – tapering
• Other sedatives and EtOH
Slide 29
Benzodiazepines
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Slide 30
lorazepam
clonazepam
diazepam
temazepam
oxazepam
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flurazepam
nitrazepam
alprazolam
triazolam
Slide 31
Antidepressants
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Delay 3 – 8 weeks
Monitor closely
Serotonin Syndrome
SSRI Withdrawal
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin - norepinephrine reuptake inhibitors (SNRIs)
Serotonin and norepinephrine disinhibitors (SNDIs)
Monoamine oxidase inhibitors (MAOIs)
Slide 32
Antidepressants
TCAs
• Nortriptyline hydrochloride
• Amitriptyline hydrochloride
• Imipramine hydrochloride
MAOIs
• Phenelzine sulfate
• Tranylcypromine sulfate
• Selegiline hydrochloride
Slide 33
Slide 34
Antidepressants
SSRIs
• Fluoxetine hydrochloride
• Paroxetine hydrochloride
• Citalopram hydrobromide
• Escitalopram oxalate
• Fluvoxamine maleate
• Sertraline hydrochloride
SNRIs
• Venlafaxine hydrochloride
• Venlafaxine succinate
• Duloxetine hydrochloride
SNDIs
• Mirtazapine
Slide 35
Antidepressants
NDRIs
• Bupropion
SARIs
• Trazodone
Slide 36
Serotonin Syndrome
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abdominal pain
diarrhea
sweats
tachycardia, HTN
myoclonus
irritability
delirium
Slide 37
SSRI Withdrawal/Discontinuation
Syndrome
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vivid dreams
nightmares
tremors
dizziness
poor concentration
nausea
Slide 38
Mood Stabilizers
• Most commonly used to treat BPD
• Many are anticonvulsant drugs
Slide 39
Mood Stabilizers
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Lithium
Valproate
Carbamazepine
Lamotrigine
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Gabapentin
Topiramate
Oxcarbazepine
Slide 40
Lithium Therapeutic Levels
• Therapeutic and toxic levels
• Therapeutic blood level: 0.8 to 1.4 (1.2) mmol/L
• Toxic blood level: 1.5 mmol/L and above
Slide 41
Slide 42
Antipsychotic Drugs
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First generation / Conventional / Typicals
Second generation/Atypical
Third generation
Clozapine
Neuroleptic Malignant Syndrome (NMS)
Slide 43
First-Generation (Conventional/Typical)
• Antagonists of receptors for
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Acetylcholine
Norepinephrine
Histamine
• Significant adverse effects
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Extrapyramidal effects (movement)
Slide 44
Anticholinergic Excess - Toxicity
Slide 45
Second-Generation (Atypical)
• Produce fewer extrapyramidal side effects (EPS)
• Target both the negative and positive symptoms
• Often chosen as first-line treatment
• Dopamine and serotonin blockers
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Slide 46
Clozapine (Clozaril)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Slide 47
Third-Generation (Atypical)
• Dopamine stabilizer
• Less sedating that other atypicals
Slide 48
Antipsychotics
First Generation
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Second
Generation
Third Generation
Haldol
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Apripirazole
Chlorpromazine
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Clozapine
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Asenapine
Loxapine
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Risperidone
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Zuclopenthixol
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Quetiapine fumarate
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Flupenthixol
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Olanzapine
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Ziprasidone hydrochloride
monohydrate
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Paliperidone
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Paliperidone palmitate
Slide 49
Clozapine
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2 failed medication trials
Provided free of charge by government
CSAN number
Regular bloodwork prior to dispensing drug
Red/yellow/green
Slide 50
Clozapine Bloodwork
Traffic Light System for Dispensing Clozapine (Clozaril)
Slide 51
Common Chemical Restraints
• Lorazepam (PO or IM)
• Haloperidol (PO or IM)
• Olanzapine (PO or IM)
Slide 52
Neuroleptic Malignant Syndrome
(NMS) – Medical Emergency
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Medical emergency – rare but potentially fatal
Dopamine depletion
Classic triad
Characteristic laboratory findings
EEG
Increased risk
Slide 1
Alteration in
Mood Disorders:
Depression and
Bipolar Disorder
Module 3
Slide 2
Types of Depression
• Major Depressive Disorder
(MDD)
• Dysthymic Disorder
(Dysthymia)
• Postpartum Disorder
• Seasonal Affective Disorder
(SAD)
• Premenstrual Dysphoric
Disorder
Slide 3
Depression - Facts
• Major depressive disorder affects 3 -5% of people in Canada.
• There is a high risk of mortality and morbidity, significant
economic and disability costs.
• Less that 50% receive treatment
• Depression most common mood disorder
Slide 4
Epidemiology
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Leading cause of disability
Lifetime prevalence of 10.8%
Unemployed populations
Single or divorced people
2:1
Co-morbidity (substance use/abuse)
Slide 5
Aetiology
• Affects all ages and cultures
• Biological Theories
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Genetic
Biochemical
Alterations in hormonal regulation
Diathesis-stress model
Inflammatory process
• Psychological Theories
• Cognitive theory
• Learned helplessness
Slide 6
Brain Chemicals Involved in Mood
Disorders
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Serotonin (5-HT)
Norepinephrine (NE)
Catecholamine
Gamma Aminobutyric Acid (GABA)
Endorphins
Slide 7
Depressive Disorders Clinical Course
• Dysthymic disorder
• Milder, but more chronic form than MDD
• Major Depressive Disorder
• Progressive, recurrent illness
• Over time, episodes are more frequent, severe, and longer in duration
• Mean age of onset is about 40 years of age
• An untreated episode lasts 6 to 13 months
• Suicide is the most serious complication
• (10% to 15%)
Slide 8
Symptoms
• Sleep disturbance
• Interest and enjoyment
reduced
• Guilt and self blame
• Loss of energy and fatigue
• Trouble concentrating
• Appetite and weight changes
Slide 9
Symptoms
• Slow or jumpy movements
• Suicidal thoughts or actions
• Feelings of hopelessness
• Somatic complaints
• Feeling of isolation
Slide 10
SIGECAPS
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Sleep
Interest
Guilt/low self esteem
Energy (low)
Concentration (poor)
Appetite
Psychomotor (agitation/retardation)
Suicidal ideation
Slide 11
Depression Quick Screen
In the past month:
• Have lost interest or pleasure in things they usually do
• Have felt sad, low, down, depressed or helpless for at
least 2 weeks
Slide 12
Emotional Symptoms
sadness
lack of
interest
Depression
suicidal
guilt
Slide 13
Associated Symptoms
tearful
worry over health
brooding
Depression
irritable
anxiety/phobia
Rumination
Slide 14
Mood and Affect
Mood – subjective emotional feeling
Affect – objective evidence of feelings
• An individual’s sustained emotional
tone, which influences behaviour,
personality and perception
• External range of expression
described in terms of quality, range
and appropriateness
Slide 15
Depression in the Elderly
• 8 to 20% of older adults in community
• 37% in primary care setting
• Treatment successful in 60 to 80%, but
response slower
• Associated with chronic illness
• Highest suicide rate, especially over 80
years in Canada
• Signs often missed that elderly person
is depressed
Slide 16
Aboriginal People and Depression
Causes
Colonization
Residential schools
Loss of Culture
“Assimilation”
Increased rates of
depression,
anxiety, substance
abuse and suicide.
Slide 17
Goals of Interdisciplinary Treatment
• Reduce, remove symptoms
• Reduce likelihood of relapse
• Improve occupational and psychosocial functioning
• Safety is a priority; suicide assessment
Slide 18
Nursing Process
Assessment
• Assessment tools
• Assessment of suicide potential
• Key assessment findings
Slide 19
Nursing Process
Areas to assess
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Affect
Thought processes
Mood
Feelings
Physical behaviour
Communication
Religious beliefs and spirituality
Slide 20
Nursing Diagnosis
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Risk for suicide—safety is always the highest priority
Hopelessness
Ineffective coping
Social isolation
Spiritual distress
Self-care deficit
Slide 21
Treatment Phases for Depression
Three Phases:
1. Acute Treatment Phase
2. Continuation Phase
3. Maintenance Phase
Slide 22
Depression Management
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Encourage activity and exercise, meals
Mood diary
Chronic illness self management (education)
Monitor symptoms
Peer support
ECT
TMS
CBT
Light therapy
Antidepressants
Slide 23
ECT – Electroconvulsive Therapy
• Seizures have long been known to improve certain mental health
symptoms
• Brief electrical current (15-20 sec) after pt is anesthetised
• Repeat 2-3 times a week for 6-12 treatments
• Causes rapid improvement in depressive state (unknown why)
• Causes an increase in serotonin uptake
• Side effects: headache, nausea, muscle pain, memory loss initially
• Contraindications: increased ICP, recent MI, CVA
Slide 24
Pre Nursing Care of Inpatient ECT
Patient (cont.)…
The Morning of ECT
• Complete the ECT/Pre-Op checklist.
• Confirm NPO has been maintained with the patient (according to
institutional guidelines).
• Assess the patient’s potential for incontinence. Encourage the patient to
void immediately before leaving the ward. Suggest wearing disposable
briefs only if necessary, and with all geriatric patients.
Slide 25
Pre Nursing Care of Inpatient ECT
Patient (con’t)…
The Morning of ECT
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Assess the patient’s level of anxiety.
Give the patient reassurance and support.
When possible, accompany the patient to the treatment area
When possible, remain with the patient to provide support until
they enter the treatment room
Slide 26
Post Nursing Care of Inpatient ECT
Patient…
Post-ECT
• On the patient’s return to the ward
• Assess the patient’s physical and mental status.
• Take the patient’s blood pressure, pulse, and respirations within 5 minutes
of their return to the ward.
• Assess the frequency of observation required based on the patient’s return
to Pre-ECT vital signs and level of consciousness (e.g., q 15 min., q 30 min., q
1 hr).
Slide 27
Post Nursing Care of Inpatient ECT
Patient…
Post-ECT
• Assess the safety of the patient’s environment and their readiness to
ambulate and to swallow before giving morning medication and breakfast.
• Assess and document any side effects of the treatment
• Ensure the patient is accompanied when leaving the ward any time up to
24 hours post-ECT.
• Instruct the patient not to drive a motor vehicle for 24 hours post-ECT.
• Alert the patient’s family and friends of the need for supervision for a
minimum of 24 hours post-treatment.
Slide 28
Post Nursing Care of Inpatient ECT
Patient…
Documentation
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Complete the following documentation
Pre-treatment assessment data and interventions.
Patient/family education, including their response to the education.
Post-treatment assessment data and interventions
Slide 29
Psychopharmacology
• Antidepressants
• Additive drugs for mood disorders
Slide 30
Bipolar Disorder
Slide 32
Bipolar Disorder
Mixed:
• the full symptomatic
picture of both manic
and major depressive
episodes intermixed
with rapidly alternating
Manic:
• predominant mood is
elevated, expansive or
irritable. Motor
activity is excessive
and frenzied and
psychotic features
may or may not be
present
Depressed:
• Symptoms are
characteristic of those
for major depression.
Criteria for this
diagnosis must
include a history of at
least one manic
episode. Psychotic
features may or may
not be present
Slide 33
Clinical Picture
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic
Slide 34
Epidemiology
• Often misdiagnosed (confused with unipolar depression)
• Percentage of Canadians who will experience bipolar disorder in
their lifetime: 1%
• Mortality rate, including suicide, among people with bipolar
disorder: 2 – 3 times higher than the general population
• Men vs women
Slide 35
Manic Episode
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Expansive mood and three (3) of the
following (4 if the mood is only irritable)
and have been present to a significant
degree
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Inflated self-esteem or Grandiosity
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Flight of ideas or racing thoughts
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Sleep decrease
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Distractibility
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More talkative than usual
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Increase in goal-directed activity
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Excessive involvement in pleasurable
activities
• Duration is one (1) week
Slide 36
Hypomanic Episode
• A hypomanic episode is an
emotional state characterized by a
distinct period of persistently
elevated, expansive, or irritable
mood.
• The mood is present for most of the
day nearly every day. Lasting
throughout at least 4 days
Slide 37
Nursing Assessment
• Manic patient
• Manipulative
• Demanding
• Splitting
• Staff member actions
• Frequent staff meetings to deal with patient behaviour and staff
response
• Set limits consistently
Slide 38
Nursing Assessment
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History
General appearance and motor behaviour
Mood and affect
Thought and intellectual processes
Judgment and insight
Self concept, roles and relationships
Self care
DIGFAST
Slide 39
Nursing Care
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Danger to self or others
Need for protection from uninhibited behaviours
Need for hospitalization
Medical status
Coexisting medical conditions
Family’s understanding
Slide 40
Planning
• Acute phase
• Medical stabilization
• Maintaining safety
• Self-care needs
• Continuation phase
• Maintain medication adherence
• Psycho-educational teaching
• Referrals
• Maintenance phase
• Prevent relapse
Slide 41
Management of
Mania
• Be Calm
• Decrease stimulation (noise,
people, activity)
• Redirect
• Brief verbal direction
• Deal with only immediate issues
• Distract
• Be firm and practical
Slide 42
Biggest concern for clients with mood
disorders is: SAFETY
Slide 43
Treatment Issues
Complex issues treated
by an interdisciplinary
team
Priority issues:
• Safety from poor
judgment and risktaking behaviours
• Risk for suicide during
depressive disorders
Devastating to families,
especially dealing with
the consequences of
impulsive behaviour
Slide 44
Pharmacological Nursing Interventions
Monitoring and Administration
• Observe taking meds (acute
phase)
• Vital signs
• Diet restriction as
appropriate
Psychopharmacology
• Mood stabilizers
• Antidepressants
• Additive drugs for mood
disorders
Slide 45
Community Resources
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Community Outreach
CCAC
Counselling services
Addiction centres
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CMHA
ACT Team
Primary Care Providers
Champlain LHIN
Slide 46
Summary of Depression vs Mania Sx
Depression
Mania
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Feeling worthless, helpless or hopeless
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Excessively high or elated mood
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Loss of interest or pleasure (including
hobbies or sexual desire)
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Unreasonable optimism or poor
judgement
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Change in appetite
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Hyperactivity or racing thoughts
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Sleep disturbances
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Decreased sleep
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Decreased energy or fatigue (without
significant physical exertion)
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Extremely short attention span
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Rapid shifts to rage or sadness
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Sense of worthlessness or guilt
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Irritability
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Poor concentration or difficulty making
decisions