Mental Health 1.1

Chapter Overview

• Chapter 1: Varcarolis - Therapeutic communication, client advocacy
• Chapter 2: Varcarolis - DSM-5, traits of mental health
• Chapter 3: Varcarolis - Transference, counter-transference, theories, CBT
• Chapter 4: Varcarolis - Psychopharmacology & the brain
• Chapter 6: Varcarolis - Legal & ethical considerations
• Chapter 16: Lilley - Pharmacology

Mental Health Outcomes

• Management of Care
• Safety & Infection Control
• Health Promotion & Maintenance
• Psychosocial Integrity
• Physiological Integrity

Stigma Surrounding Mental Health

• Discrimination at work
• Isolation from friends
• Sense of self-doubt
• Fewer opportunities

Components of Psychiatric-Mental Health Nursing

• Trauma-informed care
  • Focus on "What's happened to you?" rather than "What's wrong with you?"
• QSEN (Quality and Safety Education for Nurses)
  • Patient-centered care
  • Teamwork & collaboration
  • Evidence-Based Practice (EBP)
    • Influenced by Florence Nightingale and Hildegard Peplau
  • Quality improvement
  • Safety
  • Informatics
• Theories

Therapeutic Use of Self: The Art of Nursing

• Intensity of presence; being there for a patient.
  • Present and attentive
  • Paying attention to body language, posture, and eye contact
• Natural, essential, fundamental aspect of human existence.
  • Empathetic actions
  • Giving of self
  • Leads to happiness
• Caring
• Attending
• Advocating: Commitment to patient’s health, well-being, and safety
  • Informed consent
  • Respecting patient’s decisions
  • Protecting against threats
  • Being informed

Mental Health vs. Mental Illness

• Mental Health: Multifaceted and involves our emotional, psychological, and social well-being. Various factors can impact our mental health.
• Mental Illness: Affects a person’s emotion, cognition, and behavior, which can make it difficult to relate to others and maintain daily functioning. Mental illness is treatable.

Traits of Mental Health

• Ability to laugh
• Ability to live without fear or guilt
• Maintain a healthy self-concept and self-value
• Ability to work
• Ability to control one’s behavior
• Ability to take responsibility for one’s actions
• Attain spirituality
• Ability to think clearly
• Ability to be creative
• Relate to others
• Capacity to deal with conflicting emotions
• Ability to have relationships
• Ability to experience joy
• Accurate appraisal of reality
• Ability to experience empathy

Factors That Affect Mental Health

• Economics
• Culture
• Environment
• Community
• Biologic factors
• Health beliefs

Medical Diagnosis vs. Nursing Diagnosis

• DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders, 5th edition)
  • Used by psychiatrists, psychiatric NPs, therapists (Medical)
• ICNP (International Classification for Nursing Practice)
  • Identifies nursing diagnoses.
  • Identifies interventions (Nursing)
  • Creates common language.

Prominent Theories/Models

• Sigmund Freud - Psychoanalytic Theory
• Abraham Maslow - Humanistic Theory
• Herbert Sullivan - Interpersonal Theory
• Aaron Beck - Cognitive Theory

Psychoanalytic Theory (Sigmund Freud)

• Id: Primitive, pleasure-seeking, impulsive.
• Ego: Problem solver & reality tester.
• Superego: Moral component.
• Three Layers of Mental Activity:
  • Conscious: Current awareness (thoughts).
  • Preconscious: Holds information that is accessible (memories, knowledge).
  • Unconscious: Primitive, hidden drives and memories.

Psychodynamic Therapy: Freud

• Transference: When the patient projects intense feelings onto the therapist related to unfinished work from previous relationships (can be friendships, familial relationships, romantic relationships) Example: “You’re just like my mother.”
• Countertransference: When the therapist projects their own emotions or experiences onto the patient. Example: “This patient is just like my father who was an alcoholic.”

Psychosexual Theory - Stages of Development

• Freud believed that life was built around tension and pleasure.
• He believed that all tension was due to the build-up of libido (sexual energy) and that all pleasure came from its discharge.
• Oral Stage (Birth to 1 year):
  • The libido is centered in a baby's mouth, leading to satisfaction from sucking, biting, and breastfeeding.
  • Oral stimulation could lead to an oral fixation in later life.
• Anal Stage (1 to 3 years):
  • The libido becomes focused on the anus, and the child derives great pleasure from defecating.
  • The superego begins to develop as the caregiver helps children to establish self-control through toilet training.
  • They can be stubborn and tight-fisted with their cash and possessions.
• Phallic Stage (3 to 6 years):
  • Children become more interested in genitals, where the libido is now centered.
  • This stage involves the Oedipus complex (in boys) and the Electra complex (in girls), including erotic attraction, resentment, rivalry, jealousy, and fear.
• Latency Stage (6 years to puberty):
  • This is the most stable stage, where the superego fully develops.
  • Much of the child's energy is channeled into developing new skills and acquiring new knowledge, and play becomes largely confined to other children of the same gender.
• Genital Stage (puberty to adult):
  • A time of adolescent sexual experimentation, the successful resolution of which is settling down in a loving one-to-one relationship with another person.
  • For Freud, the proper outlet of the sexual instinct in adults was through heterosexual intercourse.

Erikson's Psychosocial Stages

Interpersonal Theory (Sullivan)

• Driven by the need for interaction.
• Interaction is a source of anxiety.
• Social environment as a child or adolescent influences personality.
• All behavior is aimed at avoiding anxiety & threats to self-esteem.
• The relationship with the primary parent is crucial for personality development.
• Interpersonal therapy focuses on the "here and now" and emphasizes relationships.

Humanistic Theory (Maslow)

• Maslow's Hierarchy of Needs:
  • Physiological needs: Most basic needs; food, oxygen, water, sleep, sex, body temp (think CPAP machine and how it can help sleep).
  • Safety needs: Security, protection, freedom from fear and chaos; think locking doors, windows, changing smoke alarm batteries.
  • Belonging and love: Intimate relationships, love, affection, family, being part of a group; think going on dates, celebrating birthdays, honeymoons.
  • Esteem needs: Positive-self regard; feeling valued, confident, and valuable; think job promotion, gaining respect, being recognized for hard work.
  • Self-actualization: Becoming everything that we are capable of becoming, reaching one’s potential; think getting a college degree, finishing a marathon.
  • Self-transcendence: The drive to go beyond the personal self; mystical and emotional peak experiences of seeking a higher truth.

Cognitive-Behavioral Therapy (CBT)

• Schemata: Unique assumptions about ourselves, others, and the world around us.
• Automatic thoughts: Rapid, unthinking responses based on schemata.
• Cognitive distortions: Irrational, automatic thoughts.

The Brain

• Functions:
  • Monitoring changes from the external world.
  • Monitoring composition of bodily fluids.
  • Regulating contractions of skeletal muscles.
  • Regulating internal organs.
  • Initiating and regulating hunger, thirst, sex, aggressive self-protection.
  • Storing and retrieving memories.
  • Regulating mood and emotions.
  • Performing intellectual functions.
  • Regulating sleep.
  • Producing and interpreting language.
  • Processing visual and auditory data
• Lobotomies involved removing a part of the frontal lobe of the brain through a hole(s) made in the skull

Brain Structures and Functions

• Cerebrum: The “higher brain”
  • Four lobes: Frontal, parietal, occipital, temporal
  • Higher cognitive skills, self-awareness, executive functions
• Brainstem:
  • Basic life functions (regulation of HR, breathing, sleep)
  • Composed of midbrain, pons, and medulla
  • Reticular activating system (RAS): Controls LOC and sedation
• Cerebellum:
  • Motor control and cognitive processing
  • Maintains balance via coordination of muscles
  • Alterations in cerebellum are associated w/ positive symptoms: hallucinations, delusions, altered perception (Schizophrenia)
  • Decreased size: negative symptoms in schizophrenia

Brain Structures and Functions Cont.

• Limbic Brain
  • Hippocampus: Makes new memories
    • Depression and cognitive decline associated with shrinkage
  • Amgydala: processes fear and anxiety
    • Hyperactivity associated with trauma and paranoia in schizophrenia
  • Makes up “limbic system” or “emotional brain”
    • Anxiolytics slow limbic system
• Basal ganglia: motor response via extrapyramidal motor system
  • Abnormal involuntary muscle movements: extrapyramidal symptoms & tardive dyskinesia (1st & 2nd gen antipsychotics)
• Thalamus: Filters sensory info before it arrives to cerebrum
• Hypothalamus: Maintains homeostasis
  • Body temp
  • Blood pressure
  • Perspiration
  • Libido
  • Hunger & thirst
  • Sleep & wakefulness
  • Neurohormones:
    • Corticotropin-releasing hormone (CRH)- secreted in response to stress; leads to adrenal gland secreting cortisol
    • Dopamine- inhibits prolactin= amenorrhea, galactorrhea, gynecomastia, sexual dysfunction
  • Sends instructions to autonomic nervous system
    • SNS: fight or flight
    • PNS: calm and relaxed

Neurotransmitters

• Dopamine
  • Cognition, motivation, movement
  • Reward and pleasure
  • Stimulates the heart Increases blood flow to organs. Fine muscle movements Decision making
  • Increase: psychosis & mania
  • Decrease: Parkinson’s & depression
• Acetylcholine
  • Skeletal muscle movement
  • Arousal & sexual aggression
  • Memory & learning
  • Mood
  • Sleep-wake cycle
  • Stimulates parasympathetic system
  • Increase: Depression
  • Decrease: Alzheimer’s Hungtington’s, Parkinson’s
• Norepinephrine
  • Released from noradrenergic neurons.
  • Mood
  • Attention, and arousal
  • Stimulates SNS (fight or flight)
  • Increase: Mania, anxiety, psychosis
  • Decrease: Depression

Neurotransmitters Cont.

• Serotonin (5-HT)
  • Found in brain & spinal cord
  • Regulates mood, temp, arousal, attention, behavior
  • Increase: anxiety
  • Decrease: Depression
• GABA
  • Major inhibitory neurotransmitter
  • Reduces excitation, anxiety, aggression
  • Pain perception (gabapentin)
  • Modulates neuronal excitability= regulation of anxiety
  • Increase: Reduction of anxiety
  • Decrease: Mania, anxiety, psychosis
• Glutamate
  • Excitatory neurotransmitter; activates NMDA receptor
  • Memory and learning
  • Increase: Neurotoxicity, neurodegeneration in Alzheimer’s
  • Decrease: Psychosis

Psychotropic Medications

• Psychotropic drugs are medications that affect brain chemistry and influence mood, perception, behavior and cognition
• Pharmacokinetic interactions: When one drug alters another drug’s level in the body (ex- one drug speeding up another’s metabolism)
• Pharmacodynamic interactions: When drugs act at the same or interrelated receptor sites (ex- two drugs amplifying or opposing each other’s effects)
  *Antipsychotics
  *1st generation, 2nd generation
  *Schizophrenia, bipolar disorder
  *Mood stabilizers
  *Lithium, anticonvulsants
  *Bipolar disorder
  *Antidepressants
  *SSRI, SNRIs, SNDIs, NDRIs, SARIs, NRIs, TCAs, MAOIs
  *Depression, PTSD
  *Anxiolytics
  *Buspar, benzodiazepines, hypnotics
  *Anxiety, panic disorder

Antidepressants

• SSRIs (Selective Serotonin Reuptake Inhibitors)
  • Block the reuptake of serotonin in the synapse
  • Fewer SE (doesn’t inhibit other receptors)
  • Ex: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, vortioxetine
• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
  • Block the reuptake of both serotonin and norepinephrine
  • Ex- venlafaxine, duloxetine, desvenlafaxine
• SNDIs (Serotonin-Norepinephrine-Dopamine reuptake Inhibitors)
• NDRIs (Norepinephrine-Dopamine Reuptake Inhibitors)
  • Inhibits the reuptake of norepinephrine and dopamine
  • Inhibits nicotinic acetylcholine receptors= smoking cessation
  • Ex- bupropion
• SARIs (Serotonin Antagonist and Reuptake Inhibitors)
  • At high doses, inhibits reuptake of serotonin and acts as serotonin antagonist
  • Ex- trazadone (In low doses, used for insomnia)
• NRIs (Norepinephrine Reuptake Inhibitors)
  • Increases serotonin and norepinephrine transmission by blocking presynaptic α2- noradrenergic receptors
  • Ex- mirtazapine
  • Blocks presynaptic norepinephrine transporters (NETs)= inhibits reuptake of norepinephrine

Antidepressants Cont.

• Monoamine Oxidase Inhibitors
  • Drugs that increase concentrations of monoamines by inhibiting the action of MAO (an enzyme that destroys monoamines)
  • Monoamines: neurotransmitters (catecholamines & indolamines)
  • Can cause hypertensive crisis if taken with other medications such as pseudoephedrine or if patient consumes tyramine (found in aged & fermented foods, and certain drinks)
• Tricyclic Antidepressants
  • Acts by blocking the presynaptic transporter protein receptors for norepinephrine and (to a lesser degree) serotonin= increases NE at the synapse
  • Known as “dirty drugs”
  • Anticholinergic effects
  • Sedation
  • Weight gain
  • Dizziness, hypotension
  • Used in difficult cases of depression

Antianxiety/ Anxiolytics

• Buspirone/ Buspar
  • High affinity for serotonin receptors
  • No risk for addiction
  • Doesn’t cause immediate sedative & euphoric effects
• Benzodiazepines
  • Promotes activity of GABA
  • High risk for abuse and connection to dementia
  • Sedative & hypnotic effects
  • Reduces neuronal excitement- used for seizures and alcohol withdrawal
  • Ex- lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin)
• Short-acting hypnotics
  • Demonstrates selectivity for GABA -A receptors
  • Sedating effect
  • Ex- zolpidem (Ambien), eszopiclone (Lunesta)
• Melatonin receptor agonists
  • High selectivity at the melatonin-1 receptor site
  • Regulates sleepiness and regulate circadian rhythms
  • Ex- ramelteon (Rozerem)
    *Antidepressants ** medications may help the symptoms of anxiety but they do not remove the source of anxiety
    *SSRIs & SNRIs are commonly used to treat anxiety

Mood Stabilizers

• Lithium
  • Causes alterations in calcium and protein kinase C-mediated processes= effects on electrical conductivity
  • Has a low therapeutic index meaning regular monitoring of blood lithium levels and sodium is crucial. Sodium depletion= retained lithium in kidneys, Excess sodium= decreased lithium
  • Long-term use increases risk of kidney and thyroid disease
• Anticonvulsants
  • Valproate: divalproex sodium (Depakote) and valproic acid (Depakene); inhibits enzymes involved in GABA catabolism (inhibits neuron excitability); good for bipolar disorder
  • Lamotrigine (Lamictal); inhibits release of glutamate and aspartate (risk for Stevens Johnson’s Syndrome; assess for rash); good for bipolar depression
  • Carbamazepine (Tegretol); stabilizes inactive state of sodium channels in neurons; good for rapid -cycling bipolar disorder; regular monitoring of CBC (risk for agranulocytosis & aplastic anemia)
• Other
  • Ozcarbazepine (Trileptal), gabapentin (Neurontin), and topiramate (Topamax)

Antipsychotics

• 1st generation/ Conventional
  • AKA neuroleptics or dopamine receptor agonists
  • Bind to $D_2$ receptors and reduce dopamine transmission
  • Decreases positive symptoms in schizophrenia
  • SE: dystonia (muscle stiffness), akathisia (restlessness), tardive dyskinesia, parkinsonism
  • Life-threatening complication: neuroleptic malignant syndrome
    • Severe muscle rigidity, confusion, agitation, increased temperature, increased HR & BP
  • SE: blurred vision, dry mouth, constipation, decreased urination (blocks muscarinic and cholinergic receptors)
  • Ex- haloperidol (Haldol) & fluphenazine (Prolixin)
• 2nd generation/ atypical
  • AKA serotonin-dopamine antagonists (SDAs)
  • Fewer EPS
  • FDA approved for bipolar and depression, in addition to schizophrenia
  • Clozapine (Clozaril): agranulocytosis; weekly CBC x 6 months, then x biweekly x 6 months, then q 4 weeks
  • Olanzapine (Zyprexa): sedating, give @ bedtime
  • Risperidone (Risperdal): Orthostatic hypotension and sedation= falls
  • Quetiapine (Seroquel): Good for pts with poor sleep, risk for orthostatic hypotension

Ethics

• The study of philosophical beliefs about what is considered right or wrong in a society
• Bioethics: Refers to the ethical questions that arise specifically in healthcare
• Ethical dilemma: When there is a moral conflict between two or more courses of action, with each potential choice carrying favorable and unfavorable consequences

5 Principles of Bioethics

Involuntary Admission

• Prevents dangerous behavior that is to cause harm to self or others (Baker Act)
• Preventative measure; mandated participation in treatment
• Extended care & treatment; committed through medical cert, judicial, or administrative action
• Types:
  • Emergency
  • Outpatient
  • Long-term

Patient’s Rights

• Requires medical and psychiatric care and treatment be provided to all public hospital patients
• Environment must be humane
• Staff must be qualified and sufficient
• Plan of care must be individualized
• A noninstitutionalized, competent, mentally ill patient has the right to determine whether they can be involuntarily committed or medicated.
• HCPs can override refusal if patient is a danger to themselves or others
• Patients worried about being involuntarily committed can prepare an advance psychiatric directive that expresses preferred treatment choices
• Used when the patient cannot make choices for themselves
• Use of least restrictive means 1st ALWAYS
• Pt has right to be free from restraint or seclusion UNLESS it is for immediate physical safety of the patient or others; must be DCd ASAP
• Must obtain a written order within an hour (unless pt requested seclusion)
• Assessment q 15-30 min: food, hydration, toileting, safety, comfort
• One-on-one monitoring
• For consent to be legally effective, it must be informed
• Presence of psychotic symptoms does not mean pt is incompetent
• Only discuss any information regarding a patient with those who have a need and the right to know
  *Treatment
  *Refuse treatment
  *Informed consent
  *Involuntary Commitment
  *Restraint and Seclusion
  *Patient Confidentiality