Mental Health Chapter 21-25

Addiction

A chronic relapsing condition characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain.

Sleep disturbance:

The most common sleep disturbance associated with major depression is insomnia,  broken into three categories; initial insomnia (difficulty falling asleep), middle insomnia (waking up during the night and having difficulty returning to sleep), and terminal insomnia (waking too early and being unable to return to sleep). Less frequently, the sleep disturbance is hypersomnia (i.e., prolonged sleep episodes at night or increased daytime sleep). The individual with eithet insomnia or hypersomnia complains of not feeling rested on awakening.

Tiredness, decreased energy, and fatigue:

Fatigue associated with depression is a subjective experience of feeling tired regardless of how much sleep or physical activity a person has had. Even the smallest tasks require substantial effort.

hypersomnia

prolonged sleep episodes at night or increased daytime sleep

terminal insomnia

waking too early and being unable to return to sleep

middle insomnia

waking up during the night and having difficulty returning to sleep

initial insomnia

difficulty falling asleep

Mood

is a pervasive and sustained emotion that influences one's perception of the world and how one functions.

Affect

outward emotional expression

Blunted:

• significantly reduced intensity of emotional expression

Bright:

projection of a positive attitude, with a smile

Flat

absent or almost absent emotional expression

Inappropriate

emotional response that does not match the situation

Restricted/constricted:

slightly less display of emotion and expression

Depression

is a common mental state characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration

depressive disorder

a sad, irritable, or empty mood is present with somatic and cognitive changes that interfere with functioning. Several depressive disorders vary according to duration, timing, or cause. These include disruptive mood dysregulation, major depressive disorder, persistent depressive (dysthymia), premenstrual dysphoric, substance/medication-induced, other specified depressive and unspecified depressive disorders

Major depressive disorder

is commonly a progressively recurrent illness. With time, episodes tend to occur more frequently, become more severe, and are of a longer duration. Onset of depression may occur at any age. However, the initial onset may occur in puberty; the highest onset occurs within persons in their 20s. Recurrences of depression are related to age of onset, increased intensity and severity of symptoms, and presence of psychosis, anxiety, and/or personality fea-tures. The risk for relapse is higher in persons who have experienced initial symptoms at a younger age and incur other mental disorders

Diagnostic Criteria

The primary diagnostic criterion for major depressive disorder is one or more moods, which is either a depressed mood or a loss of interest or pleasure in nearly all activities for at least 2 weeks. Four of seven additional symptoms must be present: disruption in sleep, appetite (or weigh), concentration, or energy; psychomotor agitation or retardation; excessive guilt or feelings of worthlessness; and suicidal ideation

Depressive Disorders Children and Adolescents

more likely to have anxiety symptoms, such as fear of separation, and somatic symptoms, such as stomach aches and headaches. They may have less interaction with their peers and avoid play and recreational activities that they previously enjoyed. Mood may be irritable, rather than sad, especially in adolescents.

Depressive Disorder older Adults

is often associated with chronic illnesses, such as heart disease, stroke, and cancer; symptoms  may have a more somatic focus. Depressive symptomatology in this group may be confused with symptoms of bipolar, dementia, or cerebrovascular accidents. Hence, differential diagnosis may be required to ascertain the root and cause of symptoms.

Physical Health Assessment Depression

review and thorough history of medical problems, with special attention to CNS function, endocrine function, anemia, chronic pain, autoimmune illness, diabetes mellitus, or menopause. Additional medical history includes surgeries; medical hospitalizations; head injuries; episodes of loss of consciousness; and pregnancies, childbirths, miscarriages, and abortions.

Appetite and weight changes:

In major depression, changes from baseline include a decrease or increase in appetite with or without significant weight loss or gain (i.e., a change of more than 5% of body weight in 1 month). Weight loss occurs when the person is not dieting. Older adults with moderate-to-severe

Substance Use Assessment Depression

Conversely, alcohol use disorder increases the risk of a depressive disorder more than fourfold. These co-occurring disorders have an adverse impact on both mood and substance use outcomes. It is important that the nurse assesses the use of substances and consider the impact of co-occurring disorders.

Psychosocial Assessment Depression

for persons who have major depressive disorder includes the mental status (mood and affect, thought processes and content, cognition, memory, and attention), coping skills, developmental his-tory, psychiatric family history, patterns of relationships, quality of support system, education, work history, and impact of physical or sexual abuse on interpersonal function.

Mood and Affect Assessment Depression

feeling depressed, sad, or hopeless and may experience anhedonia (loss of interest or pleasure). The patient may report "not caring any more" or not feeling any enjoyment in activities that were previously considered pleasurable. In some individuals, this may include a decrease in or loss of libido (i.e., sexual interest or desire) and sexual function. In others, irritability and anger are signs of depression, especially in those who deny being depressed. Individuals often describe themselves as depressed, sad, hopeless, discouraged, or "down in the dumps." If individuals complain of feeling "blah," having no feelings, constantly tired, or feeling anxious, a depressed mood can sometimes be inferred from their facial expression and demeanor

Thought Content Assessment Depression

often have an unrealistic negative evaluation of their worth or have guilty preoccupations or ruminations about minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects. They may also have an exaggerated sense of responsibility for untoward events.

As a result, they feel hopeless, helpless, worthless, and powerless. The possibility of disorganized thought processes (e.g., tangential or circumstantial thinking) and perceptual disturbances (e.g., hallucinations, delusions) should also be included in the assessment.

Cognition and Memory Assessment Depression

Many individuals with depression report an impaired ability to think, concentrate, or make decisions. They may appear easily distracted or complain of memory difficulties. In older adults with major depression, memory difficulties may be the chief complaint and may be mistaken for early signs of dementia

Behavioral Response Depression Assessment

Changes in patterns of relating (especially social withdrawal) and changes in level of occupational functioning are commonly reported and may represent a significant deterioration from baseline behavior. Increased use of "sick days" may occur. For people who are depressed, special attention should be given to the individual's spiritual dimension and religious background.

Self-Concept Depression Assessment

A positive self-esteem can be protective for the development of severe depression. A low self-esteem is associated with several health problems such as obesity, cardiovascular events, and depression

Stress and Coping Patterns Depression Assessment

How does the person cope with the everyday stresses of life? How does the person cope with the depression and how does the depression impact the person's ability to cope with daily stressors? The nurse helps the patient identity positive coping patterns such as meditating, talking to a loved one and negative coping patterns such as overeating and using alcohol or nonpre-scribed drugs.

Suicidal Behavior

is the occurrence of persistent thought patterns and actions that indicate a person is thinking about, planning, or enacting suicide.

Suicidal ideation

includes thoughts that range from a belief that others would be better off if the person were dead or thoughts of death (passive suicidal ideation) to actual specific plans for suicide (active suicidal ideation).

Social Network Assessment Depression

of patients' social net-work, social systems, and functional status always need to be a component of patient care. It is important to determine how the patient defines social network A network of connections on social media will not provide the needed support that family and friends can provide.

Electroconvulsive Therapy

reserved for patients whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (e.g., patients with malnutri-tion, catatonia, or suicidality).

Light Therapy (Phototherapy)

is an option for well-documented mild-to-moderate seasonal, nonpsychotic, winter depressive episodes in patients with recurrent major depressive disorders, including children and adolescents. Evidence also indicates that light therapy can modestly improve symptoms in nonseasonal depression, especially when administered during the first week of treatment in the morning for those experiencing sleep deprivation

Repetitive Transcranial Magnetic Stimulation

for the treatment of patients with mild treatment-resistant depression. In rTMS, a magnetic coil placed on the scalp at the site of the left motor cortex releases small electrical pulses that stimulate the site of the left dorsolateral prefrontal cortex in the superficial cortex.

Convening Support Groups

Individuals who are depressed can receive emotional support in groups and learn how others deal with similar problems and issues. As group members serve as role models for new group members, they also benefit as their self-esteem increases, which strengthens their ability to address their own issues. Group interventions are often used to help an individual cope with depression associated with bereavement or chronic medical illness. Group interventions are also commonly used to educate patients and families about their disorder and medications.

Implementing Milieu Therapy

helps depressed patients maintain socialization skills and continue to interact with others. When depressed, people are often unaware of the environment and withdraw into themselves. On a psychiatric unit, depressed patients should be encouraged to attend and participate in unit activities. These individuals have decreased energy levels and thus may be moving more slowly than others; how-ever, their efforts should be praised.

Family Interventions

Patients who perceive high family stress are at risk for greater future severity of illness, higher use of health services, and higher health care expense. Marital and family problems are common among patients with mood disorders; comprehensive treatment requires that these problems be assessed and addressed. They may be a consequence of the major depression but may also predispose persons to develop depressive symptoms or inhibit recovery and resilience processes.

Monitoring patient and family for indicators of stress

• Teaching stress management techniques

• Counseling family members on coping skills for their

• Providing necessary knowledge of options and support services

• Facilitating family routines and rituals

• Assisting the family to resolve feelings of guilt

• Assisting the family with conflict resolution

• Identifying family strengths and resources with family

• Facilitating communication among family

persistent depressive disorder dysthymia),

major depressive disorder symptoms last for at least 2 years for an adult and 1 year for children and adolescents. These individuals are depressed for most of each day. A major depressive disorder may precede the persistent depressive disorder or co-occur with it

Premenstrual dysphoric disorder

is diagnosed when there are clinically significant somatic and psychological manifestation (mood swings, feelings of sadness, or sensitivity to rejection) that occur consistently during the luteal phase of the menstrual cycle and negatively impact functioning and lifestyle. The mood begins to improve a few days after menses begins. Stress, history of interpersonal trauma, seasonal changes are associated with this disorder

Disruptive mood dysregulation disorder

is characterized by severe irritability and outbursts of temper. The onset of disruptive mood dysregulation disorder begins before the age of 10 when children have verbal rages and/or are physically aggressive toward others or property. These outbursts are outside of the normal temper tantrums children display. They are more severe than what would be expected developmentally and occur frequently (i.e., two or three times a week). The behavior disrupts family functioning as well as the child's ability to succeed in school and social activities. This disorder can co-occur with attention-deficit/hyperactivity disorder.

Alcohol Abuse Effects

Sedation, decreased inhibitions, relaxation, decreased coordination, slurred speech, nausea

Alcohol Abuse Overdose

Respiratory depression, cardiac arrest

Alcohol Abuse Withdrawal Syndrome

Tremors; seizures, elevated temperature, pulse, and blood pressure; delirium tremens

Alcohol Abuse Prolonged Abuse

Affects all systems of the body. Can lead to other dependencies, and malnutrition

Stimulants Route

PO, IV, Inhalation, smokiing

Stimulants Effects

Euphoria, initial CNS stimulation and then depression, wakefulness, decreased appetite, insomnia, para-noia, aggressiveness, dilated pupils, tremors

Stimulants Overdose

Cardiac arrhythmias or arrest, increased or lowered blood pressure, respiratory depression, chest pain, vomiting, seizures, psychosis, confusion, seizures, dyskinesias, dystonia, coma

Stimulants Withdrawal Syndrome 

Depression: psychomotor retardation at first and then agitation; fatigue and then insomnia; severe dysphoria and anx-iety; cravings, vivid, unpleasant dreams; increased appetite.

Amphetamine withdrawal is not as pronounced as cocaine withdrawal.

Stimulants Prolonged Use

Often alternates with use of depressants.

Weight loss and resulting malnutrition and increased susceptibility to infectious diseases.

May produce schizophrenia-like syndrome with paranoid ideation, thought disturbance, hallucinations, and stereotyped movements

Deviated nasal septum, irreversible nasal damage

Cannabis Route

Smoking, ingesting skin patches

Cannabis Effects

Euphoria or dysphoria, relaxation and drowsiness, heightened perception of color and sound, poor physical coor-dination, spatial perception and time distortion, unusual body sensations (e.g., weightlessness, tingling), dry mouth, dysarthria, and cravings for particular foods

Cannabis Overdose

Increased heart rate, reddened eyes, dysphoria, lability, disorientation

Cannabis Prolonged Use

Can decrease motivation and cause cognitive deficits (e.g., inability to con-centrate, impaired memory).

Lung damage, may precipitate psychosis

Hallucinogens

(LSD, MDMA) Route 

PO

Hallucinogens (LSD, MDMA) Effects 

Euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perceptions, deperson-alization, bizarre behavior, confusion, incoordination, impaired judgment and memory, signs of sympathetic and parasympathetic stimulation, palpitations (blurred vision, dilated pupils, sweating)

Hallucinogens (LSD, MDMA) Overdose

Paranoia, ideas of reference, fear of losing one's mind, depersonalization, derealization, illusions, hallucinations, synesthesia, self-destructive or aggressive behaviors, tremors

Hallucinogens (LSD, MDMA) Withdrawal Syndrome

"Flashbacks" or hallucinogenic persisting perception disorder

(HPPD) may occur after termination of use.

PCP route 

PO inhaled smoking 

PCP Effects

Feeling superhuman, decreased awareness of and detachment from the environment, stimulation of the respiratory and cardiovascular systems, ataxia, dysarthria, decreased pain perception

PCP Overdose

Hallucinations, paranoia, psychosis, aggression, adrenergic crisis (cardiac failure, cerebrovascular accident, malignant hyperthermia, status epi-lepticus, severe muscle contractions)

PCP Prolonged Use

"Flashbacks," HPPD, organic brain syndromes with recurrent psychotic behavior, which can last up to 6 mo after not using the drug, numerous psychiatic hospitalizations and police arrests

Opioids (heroin, codeine) Route

PO, injection, smoking

Opioids (heroin, codeine) Effects

Euphoria, sedation, reduced libido, memory and concentration difficulties, analgesia, constipation, constricted pupils 

Opioids (heroin, codeine) Overdose

Respiratory depression, stupor, coma

Opioids (heroin, codeine) Withdrawal Syndrome

Abdominal cramps, rhinorrhea, watery eyes, dilated pupils, yawn-ing, "goose flesh," diaphoresis, nausea, diarrhea, anorexia, insomnia, fever

Opioids (heroin, codeine) Prolonged Use

Can lead to criminal behavior to get money for drugs, risk for infection related to needle use (e.g., HIV, endocarditis, hepatitis, abscesses)

Wernicke encephalopathy followed by Korsakoff syndrome,

which are alcohol-induced amnesic disorders associated with deficiencies in dietary intake of folic acid and thiamine (and other B vitamins)

alcohol amnesia syndrome

include mental status changes, confabulation (i.e., telling a plausible but imagined scenario to compensate for memory impairment), ocular dysfunction, and inability to speak coherently. As is the case with other dementias, symptoms may compromise the person's ability to function.

Cardiovascular system:

Cardiomyopathy, congestive heart failure, hypertension

Respiratory system:

Increased rate of pneumonia and other respiratory infections

Hematologic system:

Anemias, leukemia, hematomas

Nervous system:

Withdrawal symptoms, irritability, depression, anxiety disorders, sleep disorders, phobias, paranoid feelings, diminished brain size and functioning, organic brain disorders, blackouts, cerebellar degeneration, neuropathies, palsies, gait disturbances, visual problems

Digestive system and nutritional deficiencies:

Liver diseases (fatty liver, alcoholic hepatitis, cirrhosis, pancreatitis, ulcers, other inflammations of the GI tract, ulcers and Gl bleeds, esophageal varices, cancers of the upper GI tract, pellagra, alcohol-amnestic disorder, dermatitis, stomatitis, cheilosis, scurvy

Endocrine and metabolic systems:

Increased incidence of diabetes mellitus, hyperlipidemia, hyperuricemia, and gout

Immune system:

Impaired immune functioning, higher incidence of infectious diseases, including tuberculosis and other bacterial infections

Integumentary system:

Skin lesions, increased incidence of infection, burns, and other traumatic injury

Musculoskeletal system:

Increased incidence of traumatic injury, myopathy

Genitourinary system:

Hypogonadism, increased secondary female sexual characteristics in men (hypoandrogeniza-tion and hyperestrogenization), erectile dysfunction in men, electrolyte imbalances due to excess urinary secretion of potassium and magnesium

Prevention of Relapse

is important in the recovery of people with substance-related disorders, and alcohol addiction is no exception. Medications that are used for recovery in alcohol use disorder, include disulfiram (Antabuse), acamprosate (Campral), and naltrexone.

Disulfiram (Antabuse)

is used to help deter some individuals from drinking. Disulfiram plus even small amounts of alcohol produces episodes of severe nausea and vomiting. These unpleasant reactions may deter drinking. Severe reactions may also occur, including respiratory depression, cardiovascular collapse, convul-sions, and death. Those taking this drug must be informed about consuming or being in contact with unexpected sources of alcohol, such as food additives, aftershave, or hand sanitizers.

Acamprosate

is used to decrease alcohol intake. Acamprosate is effective only if the individual is abstinent from alcohol prior to its initiation. The maintenance dose (333 to 666 mg orally) must be taken with meals three times daily, which can discourage compliance with treatment.

Naltrexone

was originally used as a treatment for heroin abuse, but it is now also approved for the treatment of alcohol dependence. Naltrexone is formulated in a once-daily pill and a monthly injection (Vivitrol). It is given for alcohol and opioid dependence.

Naltrexone does not treat withdrawal symptoms but totally blocks the effects of both alcohol and opioids.

Warn patients not to use other drugs while on this medication. Those taking naltrexone should wear or carry an identification card in case of accidents, because no narcotic can be given for emergency use. Naltrexone has no abuse protentional and does not result in the development of physical dependence.

Naltrexone can:

(1) reduce craving (the urge or desire to drink or use drugs despite negative consequences), (2) help maintain abstinence, and (3) interfere with the tendency to want to drink more if a recovering patient slips and has a drink. Patients have been known to stop using naltrexone if they plan to drink alcohol and restart it later, leaving them open to relapsing.

Stimulants Cocaine

Cocaine (also known as coke, crack, snow, nose candy, fake, blow, big c, lady, white, or snowbirds) is a white crystalline powder, commonly inhaled (or "snorted"), anyted intravenously (with water), or smoked. Crack cocaine, often simply called "crack," is a form of freebase cocaine that looks like a rock. This extremely ponda dum produces a rapid high with intense euphoria and a datatic crash. It is extremely addictive because of the intense and rapid onset of euphoric effects, which leave users craving for more. Enhanced sexual experiences and drive can get many started on regular use.

Biologic Responses to Cocaine

is absorbed rapidly through the blood-brain barrier and is also readily absorbed through skin and mucous membranes. Increased dopamine causes euphoria and psychotic symptoms. Cocaine also increases norepinephrine levels in the blood, causing tachycardia, hypertension, dilated pupils, and rising body tempera-tures. Serotonin excess contributes to sleep disturbances and anorexia. With prolonged cocaine use, these neurotransmitters are eventually depleted.

Cocaine Intoxication

CNS stimulation, the length of which depends on the dosage and route of administration. With steadily increasing doses, restlessness proceeds to tremors and agitation followed by convulsions and CNS depression. In lethal overdose, death generally results from respiratory failure. Toxic psychosis is also possible; it may be accompanied by physical signs of CNS stimulation (e.g, tachycardia, hypertension, cardiac arrhythmias, sweating, hyperpyrexia, convulsions). Cocaine and alcohol taken together can cause drug-related death

Cocaine Withdrawal

are not as serious as in alcohol-withdrawal. Withdrawal causes intense depres-sion, craving (i.e., a strong desire to use cocaine despite negative consequences), and drug-seeking behavior that may last for weeks. Individuals who discontinue cocaine use often relapse because of the powerful effects it has on the brain's limbic system (reward center for pleasure and motivation) and the strong cravings that remain after withdrawal. Because cocaine has a short half-life, withdrawal symptoms can start within 90 minutes of the last dose.

Amphetamines

or stimulants, are known on the street as speed or uppers. They are used to treat attention-deficit hyperactivity disorder (ADHD) in adults and children, narcolepsy, depression, and obesity (on a short-term basis). Some people abuse these drugs to achieve the effects of alertness, increased concentration, a sense of increased energy, euphoria, and appetite suppression. The stimulation results in tachycardia, arrhythmias, increased systolic and diastolic blood pressures, and peripheral hyperther-mia. The effects of amphetamine use, and the clinical course of an overdose, are similar to those of cocaine.

Methamphetamine

also known as meth, speed, ice, chalk, crank, and crystal, is an illegal potent CNS stimulant that releases excess dopamine responsible for the drug's toxic effects, including damage to nerve terminals. Highly addictive, it comes in many forms and can be smoked, snorted, orally ingested, or injected. This illegal substance is cheap, easy to make, and has devastating consequences.

High doses of meth can

elevate body temperature and stimulate seizures.

Long-term effects of meth

include dependence and addiction psychosis (e.g., paranoia, hallucinations), mood distur-bances, violent behavior, repetitive motor activity, stroke, intense itching leading to skin sores from scratching, weight loss, and extensive tooth decay

MDMA and Other "Club Drugs"

also known as Ecstasy or Molly, is known as a "cub drug" because it is used by teens and young adults as part of the nightclub, bar, and rave scenes. MDMA, chemically similar to both stimulants and hallucino-gens, causes activity of dopamine, norepinephrine, and serotonin to increase.

MDMA and Other "Club Drugs" produces feelings

of increased energy, pleasure, emotional warmth, and distorted sensory and time perception.

MDMA can cause

hallunations, confusion, depression, paranoia, sleep problems, drug craving, severe anxiety, nausea, muscle cramping, involuntary teeth clenching, blurred vision, chills, and sweating.

In higher doses, MDMA

can sharply increase body temperature (i.e., malignant hyperthermia), leading to muscle breakdown, kidney and cardiovascular failure, and death. MDMA effects last about 3 to 6 hours

Nicotine

the addictive chemical mainly responsible for the high prevalence of tobacco use, is the primary reason tobacco is named a public health menace. Smoking is two to three times more prevalent in persons with mental illnesses than the general population and is two to six times higher among those with schizophrenia, bipolar disorder, posttraumatic stress disorder (PTSD), and alcohol/illicit drug use disorders

Biologic Response to Nicotine

stimulates the central, peripheral, and autonomic nervous systems, causing increased alertness, concentration, attention, and appetite suppression. Readily absorbed, it is carried in the bloodstream to the liver, where it is partially metabolized. It is also metabolized by the kidneys and excreted in urine.