Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 16Unit 16

Psychiatric/Mental Psychiatric/Mental Health Treatments and Health Treatments and

InterventionsInterventions

Key TermsKey TermsPsychotropic medication = affects

psychic function, behavior, or experience; effects the neuronal synapse, producing changes in neurotransmitter release and the receptors they bind to

Neurotransmitter = a chemical that is stored in the presynaptic neuron and is released by an electrical impulse through the neuron

Receptor = molecules situated on the cell membrane that are binding sites for neurotransmitters

Antianxiety AgentsAntianxiety AgentsUsed for preoperative sedation and to treat anxiety disorders, acute alcohol withdrawal, muscle spasms, and convulsive disordersDepresses the CNS; all levels can be affectedClasses of anxiolytics include antihistamines (hydroxyzine/Vistaril), benzodiazepines (alprazolam/Xanax, lorazepam/Ativan), and miscellaneous agents (buspirone/Buspar)Side effects include drowsiness, confusion, and lethargy; paradoxical excitement or blood dyscrasias may also occur with use

Effects are increased when used with alcohol, narcotics, barbiturates, antipsychotics, and antidepressants; effects are decreased when used with nicotine and/or caffeine

Physically and psychologically addicting Abrupt withdrawal may be life-threatening;

withdrawal symptoms include depression, insomnia, increased anxiety, tremors, vomiting, sweating, convulsions, and delirium

Exception is buspirone (Buspar), which does not depress the CNS and has no addiction potential; has a delayed onset of 10 days – 2 weeks, so cannot be used as a PRN

AntidepressantsAntidepressantsUsed to treat depressive disorders, alcoholism, schizophrenia, intellectual developmental disorderElevates mood and alleviates other symptoms associated with depressionMay decrease the seizure thresholdMay increase suicide potential (watch for sudden lifts in mood)Side effects common to all antidepressants include dry mouth, sedation, and nausea; discontinuation syndrome may occur as a result of abrupt withdrawal (taper gradually)

TricyclicsTricyclics Blocks the reuptake of norepinephrine,

serotonin, and/or dopamine Examples: amitriptyline (Elavil),

clomipramine (Anafranil), imipramine (Tofranil), nortriptyline (Pamelor)

Side effects specific to tricyclics include blurred vision, constipation, urinary retention, orthostatic hypotension, weight gain, tachycardia, and photosensitivity

Effects are increased when taken with buproprion, Haldol, SSRIs, and Depakote

Selective Serotonin Reuptake Selective Serotonin Reuptake Inhibitors (SSRIs)Inhibitors (SSRIs)

Blocks the reuptake of norepinephrine, serotonin, and/or dopamine

Examples: fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), paroxetine (Paxil), escitalopram (Lexapro)

Side effects specific to SSRIs include insomnia, agitation, headache, and sexual dysfunction

Interacts with alcohol (mental/motor skill impairment); use with buspirone, tryptophan, lithium, and amphetamines may result in serotonin syndrome (mental changes)

Miscellaneous AgentsMiscellaneous Agents Examples: bupropion (Zyban, Wellbutrin),

mirtazapine (Remeron), trazodone (Desyrel), venlafaxine (Effexor), duloxetine (Cymbalta)

Monoamine Oxidase Inhibitors Monoamine Oxidase Inhibitors (MAOIs)(MAOIs)

Inhibits the release of monoamine oxidase enzymes that inactivate norepinephrine, serotonin, and/or dopamine in the body

Examples: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate)

Use with narcotic analgesics may cause hyper- or hypotension, convulsions, coma or death

Concurrent use of antidepressants, amphetamines, vasoconstrictors, or foods containing tyramine may cause hypertensive crisis (marked increase in blood pressure, severe occipital headache, palpitations, coma)– Foods containing tyramine include aged cheese,

smoked/processed meat, chicken, raisins, red wine, caviar, pickled herring, corned beef, beef liver, soy sauce, brewer’s yeast, and MSG

Should not be used within 2 weeks of an adverse agent, or within 5 weeks of Prozac

Mood-Stabilizing AgentsMood-Stabilizing AgentsUsed to treat bipolar disorderEnhances reuptake of norepinephrine and serotonin, thereby decreasing their levels in the body (results in decreased hyperactivity)Classes of mood-stabilizing agents include antimanics (lithium carbonate/Eskalith), anticonvulsants (clonazepam/Klonopin, valproic acid/Depakote), calcium channel blockers (verapamil/Isoptin), and antipsychotics (olanzapine/Zyprexa, aripiprazole/Abilify, risperidone/Risperdal)

Lithium CarbonateLithium CarbonateVery narrow margin between therapeutic and toxic levelsLithium toxicity can be life-threatening (symptoms include blurred vision, ataxia, persistent nausea/vomiting/diarrhea, psychomotor retardation, mental confusion, seizures, coma, and cardiovascular collapse)Fluoxetine, loop diuretics, and decreased salt intake can increase risk of lithium toxicity; carbamazepine, Haldol, and methyldopa can increase risk of neurotoxicity; verapamil may decrease serum lithium level or result in lithium toxicity

Antipsychotic AgentsAntipsychotic AgentsAlso called neurolepticsUsed to treat psychosis and/or increased psychomotor activityBlocks postsynaptic dopamine receptors in the brainReduces the seizure thresholdRoutine ECG should be completed prior to initiation due to potential for heart damage (prolonged QT interval)Categorized as typical and atypical

Examples of typical antipsychotics: haloperidol/Haldol, chlorpromazine/Thorazine, fluphenazine/Prolixin, and thioridazine/Mellaril

Examples of atypical antipsychotics: risperidone/Risperdal, clozapine/Clozaril, olanzapine/Zyprexa, quetiapine/Seroquel, ziprasidone/Geodon, and aripiprazole/Abilify

Side effects common to all antipsychotic agents include extrapyramidal symptoms (EPS), dry mouth, blurred vision, constipation, nausea/GI upset, skin rash, sedation, orthostatic hypotension, photosensitivity, amenorrhea, and weight gain

Extrapyramidal Symptoms (EPS)Extrapyramidal Symptoms (EPS)Pseudoparkinsonism = tremor, shuffling gait, drooling, rigidityAkinesia = muscle weaknessAkathisia = continuous restlessness and fidgetingTardive dyskinesia = bizarre facial and tongue movements, stiff neck, and difficulty swallowing; all long-term clients are at risk, and the symptoms are potentially irreversible even if the medication is discontinued

Dystonia = involuntary muscular movements or spasms of the face, arms, legs, and neck

Oculogyric crisis = uncontrolled rolling back of the eyes; may appear to be seizure activity

*These are medical emergencies that are treated with IV or IM benztropine (Cogentin) Neuroleptic malignant syndrome =

hyperpyrexia (up to 107 degrees), severe muscle rigidity, tachycardia, stupor/coma; potentially fatal; treated with Parlodel and immediate discontinuation of antipsychotic agent

Use of atypical antipsychotics may cause hyperglycemia/diabetes; should assess BMI, blood glucose, and weight regularly

Agranulocytosis, a potentially fatal blood disorder in which WBCs drop to extremely low levels) may occur with use of Clozaril; baseline WBC count must be completed before initiation of medication– WBC count done weekly for first 6

months, biweekly for next 6 months, and monthly thereafter

– Supply only given until next test is due

Sedative-HypnoticsSedative-HypnoticsUsed to treat anxiety and insomniaCauses generalized CNS depressionPotential for psychological and/or physical dependence, and may produce tolerance with chronic useClasses of sedative-hypnotics include barbiturates (secobarbital/Seconal), benzodiazepines (temazepam/Restoril), and miscellaneous agents (zolpidem/Ambien, zaleplon/Sonata, eczopiclone/Lunesta)

Additive effect (CNS depression) when used with antihistamines, antidepressants, alcohol, or other CNS depressants

Should not be used with MAOIs Use of barbiturates may decrease the

effectiveness of drugs metabolized by the liver

Attention-Deficit/Hyperactivity Attention-Deficit/Hyperactivity Disorder (ADHD) AgentsDisorder (ADHD) Agents

Used to treat ADHD in children and adultsIncreases the levels of neurotransmitters in the body and stimulates the CNSClasses of ADHD agents include amphetamines (dextroamphetamine sulfate/Dexedrine), amphetamine mixtures (dextroamphetamine/Adderall), and miscellaneous agents (methylphenidate/Ritalin and Concerta, atomoxetine/Strattera, buproprion/Wellbutrin)

Tolerance develops rapidly; should not be withdrawn abruptly

Should not be used within 14 days of an MAOI

Side effects common to all ADHD agents include overstimulation, restlessness, insomnia, palpitations, tachycardia, anorexia/weight loss, nausea/vomiting, constipation, and new/worsened psychiatric symptoms

Buproprion is contraindicated in clients with seizure disorder

Atomoxetine may cause severe liver damage

Electroconvulsive Electroconvulsive TherapyTherapy

Involves the induction of a grand mal seizure through the application of electrical current to the brain

Appropriate for the following conditions:– Acute suicidality– Severe depression– Psychotic symptoms– Psychomotor retardation– Neurovegetative changes (disturbances

in sleep, appetite, and energy) Only considered as a final treatment

measure

Side effects and risks:– Temporary memory loss that lasts

approximately 30 minutes– Confusion– Mortality

2 : 100,000 Results from heart attack or stroke in

already compromised clients– Permanent memory loss specific to

the time surrounding treatment– Brain damage due to oxygenation

issues

PsychotherapyPsychotherapy

Takes place on a one-to-one basis between a client and a therapist (APRN, psychiatric social worker, psychiatrist, psychologist, or LMHP)

Various modalities are used based on condition being treated– Psychoanalysis

Client gains insight/understanding about current relationships/behavior patterns by confronting unconscious conflicts that surface in the transference relationship w/therapist

Includes methods such as free association, dream analysis, hypnosis, and catharsis

– Assertiveness training

– Interpersonal psychotherapy Time-limited therapy developed for the

treatment of major depression– Reality therapy

Promotes the conviction that although an individual is a product of the past, he/she does not need to continue as its victim

Based on power (self-empowering), belonging, freedom, fun, and survival

Hope is instilled when therapy does not dwell on past failures, and client is able to look forward toward a change in behavior

– Relaxation therapy Deep-breathing exercises Progressive relaxation Meditation Mental imagery Biofeedback

– Cognitive therapy Individual is taught to control thought

distortions that are considered to be a factor in the development and maintenance of mood disorders

Goal is to provide symptom relief and identify dysfunctional patterns of thinking

Behavior ModificationBehavior Modification

Uses operant conditioning to replace undesirable behaviors with more desirable ones through positive or negative reinforcement

Positive reinforcement– rewarding good behavior

Negative reinforcement– punishing bad behavior

Extinction– removing the response (i.e. “time-out”)

Alternative/Alternative/Complementary MedicineComplementary Medicine

Alternative medicine = interventions that differ from the traditional or conventional biomedical treatment of disease; refers to an intervention that is used instead of conventional treatment

Acupuncture Blue light/artificial light treatment Lifestyle/dietary changes Herbal medicine Chiropractic medicine Relaxation techniques Chelation therapy

Complementary medicine = therapeutic intervention that is different from, but used in conjunction with, traditional or conventional medical treatment.

Herbal medicine Acupressure/Acupuncture Diet/Nutrition Chiropractic medicine Massage Therapeutic touch Yoga Pet therapy