Psych Class 2

Identifying suicide risk factors

IS PATH WARM

Ideation

Substance Abuse

Purposelessness

Anger

Trapped

Hopelessness

Withdraw

Anxiety

Recklessness

Mood

Psychosis

Psychosis is a mental health condition characterized by an
“impaired relationship with reality”

Primary symptoms of psychosis

1. Hallucinations: Sensory experiences without an external stimulus, common auditory

2. Delusions: Firmly held false and fixed beliefs that are resistant to reasoning

3. Disorganized Thinking: Incoherent speech and difficulty organizing thoughts

Secondary symptoms of psychosis

1. Emotional Disturbance: Blunted or inappropriate affect

2. Behavioral Changes: Agitation or unusual/change in behaviors including
                                         impulsivity, withdrawn, self-care neglect… 

3. Cognitive Impairment: Impact on memory and concentration

SIG(M)ECAPS

S:   Changes in sleep patterns (insomnia or hypersomnia) 

I:    Loss of interest or pleasure in most or all activities

G:  Thoughts of worthlessness or guilt

M: Depressed mood 

E:  Low energy 

C:  Poor concentration

A:  Changes in appetite or weight

P:  Psychomotor disturbances (retardation or agitation)

S:  Recurrent thoughts about death or suicide

Hamilton depression rating scale

Clinician-rated tool for research & depression severity

Conducted by trained clinician via structured interview

HDRS length, scoring, symptoms

17-24 items, assesses physical and psychological symptoms

Scoring varies by version, requires clinical interpretation

Focuses on sleep, weight loss, and mood

Patient health questionnaire 9

Self-report tool for screening, severity, and progress monitoring

Completed by patient; quick for routine screening

PHQ-9 length, scoring, symptoms

9 items, aligned with DSM depression criteria

Scores 0-27, clear severity cutoffs

Focuses on mood, interest, energy, and self-harm thoughts

Areas of brain implicated by depression

hypothalamus, amygdala, hippocampus, frontal lobe, cerebellum

How does depression affect the hypothalamus?

the hypothalamus is responsible for the circadian rhythm, hunger, thirst, etc

depression causes increased/decreased sleep/appetite and decreased energy/libido

How does depression affect the amygdala

the amygdala is responsible for mediating emotional learning and behavior

depression causes increased amygdala activation, sensitivity to sadness/fear/stress, anxiety, and anhedonia, also causes a decrease in motivation

How does depression affect the hippocampus?

the hippocampus is responsible for learning and memory

depression causes memory impairment, feelings of worthless, hopelessness, and guilt

How does depression affect the frontal lobe

the frontal lobe controls higher level thinking

depression causes depressed mood and problems concetrating

How does depression affect the cerebellum?

the cerebellum is responsible for balance, posture, coordination of voluntary movement, and fine motor skills

depression causes psychomotor retardation/agitation

Biochemical depression theory

deficiency of serotonin, norepinephrine, dopamine, GABA, and glutamate

taking tryptophan produces 5-HT which allows body to produce serotonin

Hypothalamic-pituitary-adrenal (HPA) axis disturbance theory

controls body’s stress response

in depression: HPA axis dysregulation causes prolonged/abdominal cortisol signaling

Causes disrupted sleep and appetite, decreased energy, mood, memory, and concentration

Psychosocial learning theory

Learned helplessness: pattern of giving up after repeated failure or lack of control

Seligman’s experiments

Tested learning theory

dogs exposed to unavoidable stress, later did not make attempt to escape even when escape was possible

Clinical meaning: person may abandon attempts to suceed, cope, or improve, even when help or solutions are available

Psychosocial object loss theory

Depression may be linked to early loss or separation from an important loved one

Physical or emotional separation from a caregiver during the first year of life may disrupt emotional development, may increase vulnerability to depression later in life

Psychosocial cognitive theory

Depression is influenced by negative patterns of thinking

Beck’s cognitive triad

Self: negative expectations about oneself

World/experience: negative interpretation of experiences

Future: negative expectations about the future

Psychosocial anger turned inward theory

Repressed anger is directed towards self instead of outward

After losing or feeling disappointed by an emotionally significant person,
anger toward that person may be redirected inward toward the self. This internalized anger may contribute to guilt, self-blame, low self-worth, and depressive symptoms

Individual Psychotherapy Focus

Identify strengths 

Build coping 

Identify/address internal conflicts 

Understand depression drivers (e.g., stressors)

Cognitive behavioral therapy focus

Reframes negative thoughts about self, world, and future  

Targets automatic thought errors: personalization, all-or-nothing thinking, mind-reading, discounting positives 

Dialectical behavioral therapy focus

Emotional regulation: Manage intense emotions  

Distress tolerance: Cope without worsening crisis-reduce suffering  

Interpersonal effectiveness: Build healthier and meaningful relationships  

Mindfulness: Stay present and grounded to find inner strength

Group therapy focus

Supports discussion of:

Depressive mood symptoms and recovery: factors that contribute to and maintain depression

Illness impact and consequences: relationships, functioning, coping skills and recurrence prevention

Group therapy nurse responsibilities

During Group: establish group norms, encourage participation, observe and document patient responses

Post Group: ensure to do 1:1 follow-up with your assigned patient who attended a group using the “Clinical Practice Tool”

Family therapy focus

Work with family to: promote communication, improve support, reduce symptoms, promote healing, restore adaptive family functioning

Pt centered care using self management strategies

Support holistic recovery and prevent, recognize, and manage illness episodes early

Build patient confidence and self-management skills

Promote use of evidence-based strategies

Ketamine therapy

Fast-acting Antidepressant (works within hours)

Helps people with severe treatment-resistant depression and suicidal thoughts

Repetitive Transcranial Magnetic Stimulation (rTMS)

non-invasive FDA-approved treatment for depression, especially treatment-resistant depression

~30% of pts achieve remission

rTMS how it works

A magnetic coil is placed on the scalp

The coil delivers repetitive targeted
magnetic pulses to specific brain areas involved in mood regulation

These pulses help modulate dysfunctional brain activity

rTMS schedule

3 to 5 sessions per week

40 mins/session

Usually 4-6 weeks

rTMS side effects

headache, scalp discomfort, facial tingling, and tinnitus

Vagus Nerve Stimulation

invasive, implantable treatment for depression that has not improved with standard treatments, such as medications and therapy

~13-40% of pts improve

~13% achieve remission

VNS how it works

A pulse generator is surgically implanted under the skin of the left chest

A wire connects the generator to the left vagus nerve in the neck

The device sends regular electrical impulses to the vagus nerve

Signals travel to brainstem areas that influence serotonin and norepinephrine pathways, affect limbic and cortical brain regions involved in mood regulation

Deep brain stimulation

invasive, not FDA-approved; remains investigational and is studied only for severe treatment-resistant depression

Goal: Help normalize dysfunctional brain activity

~40% of pts respond to treatment

~26% achieve remission

DBS how it works

Electrodes are surgically implanted deep in targeted brain areas

The electrodes deliver adjustable electrical stimulation

Stimulation helps modulate brain circuits involved in mood, anxiety, and compulsive behaviors

Electroconvulsive therapy

non-invasive treatment for severe depression, especially when medications are ineffective or rapid symptom relief needed

ECT how it works

Electrical stimulus under general anesthesia induces a controlled seizure 

Modulates monoamines: ↑ 5-HT, NE, DA  

May ↑ GABA and endorphin activity  

May support neuroplastic/restorative brain changes, especially hippocampus/amygdala

↑ seizure threshold over repeated treatments 

Antidepressants

MAOIs, tricyclics, atypical, SSRIs, SNRIs, herbal agents

MAO

An enzyme found in most body tissues  

Main function: Breaks down monoamine:

• NE norepinephrine: ↑ blood pressure

• EPI epinephrine: ↑ blood pressure

• DA dopamine: high levels can ↑ blood pressure

• Tyramine: an amino acid that can trigger
  ↑ norepinephrine release

Why MAO matters:

Breaks down excess tyramine

Helps prevent excessive ↑ NE, EPI, and DA

Helps keep blood pressure from rising too high

how MAOIs work

decrease breakdown of monoamine transmitters

Increase serotonin, dopamine, and norepinephrine levels

May improve depressive symptoms

MAOI nursing considerations & pt education

1. Tyramine restriction

2. Watch for signs of hypertensive crisis

3. Caffeine avoidance

4. OTC medications: Avoid unapproved cold/allergy products:
   sedating antihistamines may ↑ sedation, confusion, & anticholinergic effects;
   decongestants may cause hypertensive crisis; dextromethorphan may cause serotonin syndrome

5. Stimulants: Avoid amphetamines and other unapproved stimulants because they ↑ NE & BP 

6. Therapeutic effect: Symptoms improvement may take 2 to 4 weeks or longer

7. Medication washout: Wait at least 14 days when switching between an MAOI and most antidepressants to prevent serious interactions, including serotonin syndrome. Wait at least 5 weeks after stopping fluoxetine (Prozac®) before starting an MAOI because fluoxetine and its active metabolite, norfluoxetine, remain in the body longer, ↑ risk of serotonin syndrome

8. Orthostatic hypotension

9. Photosensitivity: Teach sunblock use and protective clothing when outdoors

MAOI diet rules

Fresh Fast

Fresh foods

Refrigerated dairy

Eggs

Safe grains

Healthy snacks

Fruits

Animal proteins

Salads & veggies

Thirst quenchers

Tricyclics nursing considerations & pt education

1. Mechanism: Blocks serotonin (5-HT) and norepinephrine (NE) reuptake→
   ↑ 5HT & ↑ NE

2. Overdose

3. Sedation

4. Falls precautions

5. Orthostatic hypotension

6. Nausea/vomiting

7. Anticholinergic effects

8. Weight gain

9. Tapering: Teach gradual tapering to prevent symptoms recurrence, discontinuation symptoms, and cholinergic rebound

Discontinuation syndrome

caused by abruptly stopping of TCAs or tetracyclics medication instead of tapering

Symptoms

• Flu-like: headache, muscle aches, sweating

• GI: nausea, vomiting, diarrhea

• Sleep: insomnia, vivid dreams

• Mood: irritability, anxiety, agitation, low mood

• Neurologic: dizziness, tremor, confusion

Cholinergic rebound

caused by abruptly stopping an antidepressant with strong anticholinergic effects, especially a TCA, rapidly removes acetylcholine blockade (results in symptoms opposite of SPSS)

Symptoms

• Secretions: Runny nose, sweating, increased salivation  

• GI: Nausea, abdominal cramping, diarrhea  

• Other: Headache, insomnia, or restlessness

Atypical antidepressants

Atypical antidepressant work in different ways, no single mechanism

Bupropion mechanism

inhibits norepinephrine and dopamine re-uptake, increases both

Maprotiline mechanism

tetracyclic that mainly inhibits NE re-uptake, has TCA like effects

Mirtazapine

increase NE and 5-HT signaling, often sedating

Trazodone

modulates 5-HT signaling - changes/regulates how serotonin communicates between neurons - increases 5-HT, sedating and often used for insomnia

Atypical antidepressants nurse considerations

1. Safety: Monitor for worsening depression or suicidal thoughts

2. Delayed effect: may take 2–6 weeks

3. Dry mouth

4. Nausea/vomiting

5. Fall risk

6. Stopping treatment: Do not stop abruptly

7. Avoid alcohol/CNS depressants

8. Drug interactions: Review all medications and follow prescribed washout periods, especially with MAOIs

SSRI common uses

Depression, anxiety, OCD, PTSD

Takes 4-6 weeks to work

SSRI SE

may be activating or sedating depending on meds and pt

Nausea, headache, insomnia/sedation, sexual dysfunction

SSRI nurse considerations

1. Insomnia

2. GI effects

3. Hyponatremia: may cause syndrome of inappropriate antidiuretic hormone secretion (SIADH), leading to water retention and low blood sodium. Watch for headache, weakness, confusion, seizures, or decreased consciousness; monitor sodium as indicated

4. Anticholinergic effects: Uncommon with most SSRIs

5. Bleeding risk

6. Bulimia nervosa: Fluoxetine (Prozac®) is the only FDA approved SSRI 

7. Stopping treatment: Do not stop abruptly

Serotonin syndrome

abrupt onset

rapidly resolving

Cues: myoclonus, tremor, increased reflexes, mydriasis

Neuroleptic malignant syndrome

due to decreased dopamine

gradual onset

prolonged

Cues: diffuse rigidity, decreased reflexes

SNRI common uses

depression, anxiety, fibromyalgia, neuropathic pain

Takes 4-6 weeks to work

SNRI SE

may increase energy and help fatigue

nausea, headache, insomnia, sexual dysfunction, increased HR, BP, and anxiety

St John’s Wort

serotonergic effects

risk of serotonin syndrome, photosensitivity, many drug interactions

St John’s Wort nursing considerations

Avoid with MAOIs/other antidepressants unless prescribed; educate on sunscreen use and review all medications, OTC drugs, herbs, and supplements

Ma huang/Ephendra

cause increased HR and BP, risk of dysrhythmias, stroke, or HTN crisis

Ma huang/Ephendra nurse considerations

Avoid with MAOIs, or other stimulants to prevent risk for dangerous BP elevation/hypertensive crisis

Kava

increased sedation/CNS depression

possible serious liver injury

Kava nurse considerations

Avoid alcohol, opioids, benzodiazepines, & other sedatives; monitor for liver-injury

Ginseng

may potentiate MAOIs

Ginseng nurse considerations

Avoid with MAOIs unless approved; monitor for BP/CNS effects

Brewer’s Yeast

may contain high tyramine

severe increase in BP with MAOIs

Brewer’s Yeast nurse considerations

Avoid with MAOIs to prevent hypertensive crisis