Mental Health 1.1

Ch 1-4, 6

What are the stigmas associated with mental health?

discrimination, isolation, self-doubt and less opportunities

What are the components of psychiatric-mental health nursing?

trauma-informed care, QSEN, and theories

What is trauma-informed care?

trauma found in history of patient’s past; “what’s happened to you”

What are the components related to QSEN?

PETS improving QI

pt. centered care, evidence based practice, teamwork, safety → quality & informatics

What are the qualities of therapeutics?

caring, attending and advocating

Difference between mental health and mental illness?

mental health involves emotional, psychological and social well-being (affected by various influences) vs mental illness affects the emotional, cognition and behavior and is the result of flawed biological, psychological social processes (treatable)

What are the prominent theories/models?

psychoanalytic theory (sigmund freud), psychosocial theory (erik erikson), interpersonal theory (herbert sullivan), humanistic theory (abraham maslow), cognitive theory (aaron beck)

Describe the psychoanalytic theory

• sigmund frued (father of psychiatry)

• psychological disturbances due to early trauma/incidences

• three layers of mental activity (conscious, preconscious, unconscious)

  • interactive agents (ego, superego, ID)

What is psychodynamic theory?

trying to understand at unconscious level for truth; r/t transference and countertransference

What are erikson’s psychosocial stages?

• infancy (0-1) - trust vs mistrust

• early childhood (1-3) - autonomy vs shame/doubt

• play age (3-6) - initiative vs guilt

• school age (7-11) - industry vs inferiority

• adolescence (12-18) - identity vs confusion

• early adulthood (19-29) - intimacy vs isolation

• middle age (30-54) - generativity vs stagnation

• old age (65+) - integrity vs despair

Describe the interpersonal theory

• herbert sullivan

• believes relationships are basics for mental health/illness

• interpersonal therapy focuses on the here and now

Describe the humanistic theory

• abraham maslow

• 5 key needs that motivate human behavior and helps fulfillment

• physiological → safety needs → love and belonging needs → esteem needs → self actualization → self transcendence

Describe the cognitive theory

• aaron beck

• believed cognitive appraisals lead to emotional responses

What is cognitive-behavioral therapy?

seeks to identify negative patterns that lead to negative emotions

• schemata - unique assumptions about ourselves and others

• automatic thoughts - rapid, unthinking thoughts based on schemata

• cognitive distortions - irrational, automatic thoughts

What are the main points needed to know about the brain?

• monitor changes from external world

• regulates muscle contractions

• processes visual and auditory data

• lobotomies were performed to treat mental health conditions (removed part of frontal lobe through hole in skull)

What is the cerebrum known for?

• ‘higher brain’ consists of frontal, parietal, temporal and occipital lobe

• higher cognitive skills, self-awareness, and executive function

What is the brainstem known for?

• basic life functions (HR, breathing and sleep)

• midbrain, pons, and medulla

• reticular activating system (RAS) - controls LOC and sedation

What is the limbic brain known for?

• hippocampus makes new memories

• amgydala processes fear and anxiety

• hyperactivity associated w/ trauma and paranoia

• make up “limbic system” or “emotional brain"

• anxiolytics slow it down

• basal ganglia: motor response via extrapyramidal motor system

  • abnormal involuntary muscle movements: extrapyramidal symptoms and tardive dyskinesia

What is the hypothalamus known for?

• maintains homeostasis (temp, bp, perspiration, libido, hunger, sleep)

• neurohormones - corticotropin releasing hormone (CRH) and dopamine

• sends instructions to autonomic nervous system (SNS and PNS)

What is the thalamus known for?

filters sensory information before it arrives to cerebrum

What is the cerebellum known for?

• motor control and cognitive processing

• maintains balance via coordination of muscles

• alterations w/ pos. symptoms: hallucinations, delusions, altered perception (schizophrenia)

  • dec. size: neg. symptoms in schizophrenia

List the neurotransmitters:

• D - dopamine

• A - acetylcholine

• N - norepinephrine

• S - serotonin

• G - gaba

• G - glutamate

What are the characteristics and functions of dopamine?

• cognition, motivation, movement

• reward and pleasure

• stimulates heart → inc. blood flow to organ

• decision making

• fine muscle movements

Increased dopamine?

psychosis and mania

Decreased dopamine?

parkinson’s and depression

What is the function and characterisitics of acetylcholine?

• skeletal muscle mvmt

• arousal and sexual aggression

• memory and learning

• mood

• sleep-wake cycle

• stimulates PNS (parasympathetic system)

Increased acetylcholine?

depression

Decreased acetylcholine?

alzheimer’s, hungtington’s, parkinson’s

What are the functions and characterisitcs of norepinephrine?

• released from noradrenergic neurons

• mood

• attention and arousal

• stimulates SNS (sympathetic nervous system)

Increased norepinephrine?

mania, anxiety, psychosis

Decreased norepinephrine?

depression

What is the function and characterisitics of serotonin?

• found in brain and spinal cord

• regulates mood, temp, arousal, attention, behavior

Increased serotonin?

anxiety

Decreased serotonin?

depression

What are the functions and characteristics of GABA?

• major inhibitory neurotransmitter

• reduces excitation, anxiety, aggression

• pain perception (gabapentin)

• modulates neuron excitability → regulates anxiety

Increased GABA?

reduction of anxiety

Decreased GABA?

mania, anxiety, psychosis

What are the functions and characterisitics of glutamate?

• excitatory neurotransmitter; activates NMDA receptor

• memory and learning

Increased glutamate?

neurotoxicity, neurodegeneration in alzheimer’s

Decreased glutamate?

psychosis

What are psychotropics?

medications that affect brain chemistry and influence mood, perception, behavior and cognition

What are pharmacokinetic interactions?

when one drug alters another drug’s level in the body (ex. one drug speeding another's metabolism)

What are pharmacodynamic interactions?

when drugs act at the same or interrelated receptor sites (two drugs amplify or oppose each other’s effects)

What are the types of psychotropics?

• A - antipsychotics

• M - mood stabilizers

• A - antidepressants

• A - anxiolytics

Antipsychotics

• 1st generation and 2nd generation

• used for schizophrenia, bipolar disorder, and treatment-resistent depression

Mood stabilizers

• lithium and anticonvulsants

• typically used for bipolar disorders

Antidepressants

• SSRIs, SNRIs, SNDIs, NDRIs, SARIs, NRIs, TCAs, MAOIs

• used for depression and PTSD

Anxiolytics

• buspar, benzodiazepines, hypnotics

• used for anxiety and panic disorder

• only help SYMPTOMS of anxiety not source

What are the 8 types of antidepressants?

• S - SSRI (selective serotonin reuptake inhibitors)

• S - SNRI (serotonin-noradrenaline reuptake inhibitors)

• S - SNDI (serotonin-norepinephrine-dopamine reuptake inhibitor)

• N - NDRI (norepinephrine and dopamine reuptake inhibitors)

• S - SARI (serotonin agonist and reuptake inhibitors)

• N - NRI (norepinephrine reuptake inhibitor)

• T - tricyclic antidepressant

• M - MAOI (monoamide oxidase inhibitor)

SSRI?

block the reuptake of serotonin in the synapse

• fewer side effects (does not inhibit other receptors)

• ex. fluoxetine, sertraline, paroxetine, citalopram, escitalopram, vortioxetine

SNRI?

block the reuptake of both serotonin and norepinephrine

• ex. venlafaxine, duloxetine, desvenlafaxine

SNDI?

increases serotonin and norepinephrine transmission by blocking presynaptic a2-noradrenergic receptors

• ex. mirtazapine

NDRI?

inhibits the reuptake of norepinephrine and dopamine

• inhibits nicotinic acetylcholine receptors = smoking cessation

• ex. bupropion

SARI?

at high doses, inhibits the reuptake of serotonin and acts as a serotonin antagonist

• ex. trazadone (low doses used for insomnia)

NRI?

blocks presynaptic norepinephrine transporters (NETs) → inhibits reuptake of norepinephrine

• ex. atomoxetine

Tricyclic antidepressants?

blocks presynaptic transporter protein receptors for norepinephrine and (lesser degree) of serotonin → inc. NE at synapse

• dirty drug: anticholinergic effects, sedation, weight gain, dizziness and hypotension

• used in difficult cases of depression

MOI?

increase concentration of monoamines by inhibiting MAO (enzyme that destroys monoamines)

• monoamines: neurotransmitter (catecholamines and indolamines)

• can cause hypertensive crisis if taken with other medications such as pseudoephedrine or foods with tyramine (aged + fermented and drinks)

What are the main types of mood stabilizers?

lithium & anticonvulsants

What is lithium?

• causes alterations in calcium and protein kinase c-mediated processes = effects on electrical conductivity

• low therapeutic index therefore regular monitoring of blood lithium levels and sodium

• sodium depletion = retained lithium in kidneys

• excess sodium = dec. lithium

• long-term use inc. kidney and thyroid disease

What are anticonvulsants?

alter mvmt of sodium, potassium, calcium, and magnesium → more stabilized and less excitable cell membranes (some enhance GABA an inhibitory neurotransmitter that regulates neuron excitability)

• ex. valproate → divalproex sodium (Depakote) and valproic acid (Depakene) inhibit GABA catabolism for bipolar disorder

• ex. lamotrigine (Lamictal); inhibits release of glutamate and aspartate (risk for steven johnson’s syndrome; assess for rash) for bipolar disorder

• carbamazepine (Tegretol): stabilizes inactive state of sodium channels in neurons. for rapid-cycling bipolar disorder; regular monitoring of cbc (risk for agranulocytosis and aplastic anemia)

What are the other types of mood stabilizers?

• ozcarbazepine (Trileptal), gabapentin (Neurontin), and topiramate (Topamax)

What are the types of antipsychotics?

1st generation/conventional/typical and 2nd generation/atypical

What are 1st generation antipsychotics?

• aka neuroleptics/dopamine receptor agonists

• binds to d2 receptors and reduce dopamine transmission

• dec. pos symptoms in schizophrenia

• side effects: dystonia (muscle stiffness), akathisias (restlessness), tardive dyskinesia, parkinsonism

• life threatening: neuroleptic malignant syndrome (severe muscle regidity, confusion, agitation, inc. temp, HR & BP)

• also blocks muscarinic cholinergic receptor which leads to blurred vision, dry mouth and dec. urination

• ex. haloperidol (Haldol) and fluphenazine (Prolixin)

What are 2nd generation antipsychotics?

• aka serotonin-dopamine antagonists (SDAs)

• fewer extrapyramidal symptoms

• fda approved for bipolar and depression along w/ schizophrenia

• ex. clozapine (Clozaril) → agranulocytosis

• ex. olanzapine (Zyprexa): sedating give at bedtime

• ex. risperidone (Risperdal): orthostatic hypotension and sedation → falls

• quetiapine (Seroquel): good for pt. w/ poor sleep, risk for orthostatic hypotension

What are the medications associated with antianxiety/anxiolytics?

• B - buspirone/buspar

• B - benzodiazepines

• S - short-acting hypnotics

• M - melatonin receptor agonists

• A - antidepressants

What is busipirone/buspar?

• high affinity for serotonin receptors

• no risk for addiction

• doesn’t cause immediate sedative and euphoric effects

What are benzodiazepines?

• promotes activity of GABA

• high risk for abuse and connections to dementia

• sedative and hypnotic effects

• reduces neuronal excitement - used for seizures and alcohol withdrawals

• ex. lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin)

What are short-acting hypnotics?

• demonstrates selectivity for GABA-A receptors

• sedating effect

• ex. zolpidem (Ambien), eszopiclone (Lunesta)

What are melatonin receptor agonists?

• high selectivity at the melatonin-1 receptor site

• regulates sleepiness and regulate circadian rhythms

• ex. ramelteon (Rozerem)

What is another effect antidepressants can have?

SSRIs and SNRIs commonly used to treat anxiety

What is ethics?

study of philosophical beliefs about what is considered right or wrong in a society

What are bioethics?

refers to the ethical questions that arise specifically in healthcare

What are ethical dilemmas?

moral conflict b/t two or more courses of action

What are the types of involuntary admissions?

emergency (prevents dangerous behaviors), long -term (extended care committed thru judicial/admin action), outpatient (preventative measure mandated participation)

What are the patient’s rights?

• treatment

• refuse treatment (HCP can override refusal if pt. is dangerous)

• informed consent

• involuntary commitment

• restraint and seclusion (least restrictive 1st) (never assault or battery pt.)

• patient confidentiality