•The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind).

Schizophrenia is probably caused by a combination of factors, including:

-​ Genetic predisposition
-​ Biochemical dysfunction
-​ Physiological factors
-​ Psychosocial stress

•Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary

effort.
•Of all mental illnesses, schizophrenia probably causes more:
-​ Lengthy hospitalizations
-​ Chaos in family life
-​ Exorbitant costs to people and governments
-​ Fears

Schizophrenia causes disturbances in:

-​ Thought processes
-​ Perception (ability to perceive reality)
-​ Affect (emotional responsiveness)
-​ Behavior

Nature of the disorder:

*debilitating disorder with remission and active episodes*
•With schizophrenia, there is a severe deterioration of social and occupational functioning.
•In the United States, the lifetime prevalence of schizophrenia is about 1%
•Men are at greater risk than women and more likely to develop the disorder earlier.
•Schizophrenia is also associated with an increased mortality…Suicide is a major contributor to
the mortality statistic
•Age of Onset – generally late adolescence/early adulthood, some early onset

Premorbid behavior of the patient with schizophrenia can be viewed in four phases.
1.​ Premorbid phase
2.​ Prodormal phase
3.​ Acute schizophrenia episode
4.​ Residual phase

Premorbid phase 1:
•Shy and withdrawn
•Poor peer relationships
•Doing poorly in school
•Antisocial behavior

Prodromal phase 2:
•Lasts from a few weeks to a few years
•Deterioration in role functioning and social withdrawal
•Substantial functional impairment
•Depressed mood, poor concentration, fatigue
•Sudden onset of obsessive-compulsive behavior

Acute schizophrenic episode 3:

•In the active phase of the disorder, psychotic symptoms are prominent.
•Delusions
•Hallucinations
•Impairment in work, social relations, and self-care

Residual phase 4:
•Symptoms similar to those of the prodromal phase.
•Flat affect and impairment in role functioning are prominent.

Prognosis:
•Factors associated with a positive prognosis
•Good premorbid functioning
•Later age at onset
•Female gender
•Abrupt onset precipitated by a stressful event
•Associated mood disturbance
•Brief duration of active-phase symptoms
•Minimal residual symptoms
•Absence of structural brain abnormalities
•Normal neurological functioning
•No family history of schizophrenia

Predisposing Factors:
•Biological factors
•Genetics
•A growing body of knowledge indicates that genetics plays an important role in the
development of schizophrenia.

Biochemical factors
•One theory suggests that schizophrenia may be
caused by an excess of dopamine activity in the
brain.
•Abnormalities in other neurotransmitters have also
been suggested
Dopamine pathways:
•Mesolimbic: Projects to the limbic area (including NA, amygdala, & hippocampus); Excess
dopamine implicated in positive symptoms. Dopamine blockade is the focus of antipsychotics
•Mesocortical: Concerned with cognition, social behavior, motivation, problem-solving;
Diminished activity of dopamine in this pathway associated with negative symptoms.
•Nigrostriatal: Associated with motor control; diminished activity of dopamine associated with
motor control problems. Associated with antipsychotic use: EPS, Parkinson-like syndrome.
•Tuberinfundibular: Projects to the pituitary gland and associated with endocrine function;
Dopamine blockade in this pathway associated with high prolactin levels: galactorrhea,
gynecomastia, anorgasmia

Physiological Pathways:
•Viral infection
•Anatomical abnormalities
•Electrophysiology
•Epilepsy
•Huntington’s disease
•Birth trauma
•Head injury in adulthood
•Alcohol abuse
•Cerebral tumor
•Cerebrovascular accident
•Systemic lupus erythematosus
-​ Theories no longer hold credibility. Researchers now focus their studies of Schizophrenia
as a brain disorder
-​ Psychosocial theories probably developed early on out of a lack of information related to
a biological connection

Environmental influences
•Sociocultural factors: Poverty has been linked with the development of schizophrenia.
•Downward drift hypothesis: Poor social conditions seen as consequence of, rather than a
cause of, schizophrenia
•Stressful life events may be associated with exacerbation of schizophrenic symptoms and
increased rates of relapse.
•Studies of genetic vulnerability for schizophrenia have linked certain genes to increased risk for
psychosis and particularly for adolescents who use cannabinoids.

Theoretical integration
•Schizophrenia is most likely a biologically based disease, the onset of which is influenced by
factors in the internal or external environment.
Types of Schizophrenia and other psychiatric disordes:
​
Delusional disorder: The existence of prominent, nonbizarre delusions
•Erotomanic type- someone of high status is in love with them
•Grandiose type- superpowers or a god of some sort
•Jealous type- spouse or partner is unfaithful without evidence
•Persecutory type- persistent false beliefs of harm or mistreatment from others
•Somatic type- preoccupation of health or organ functions
•Mixed type- several different type sof these delusions mixed together
Brief psychotic disorder:
•Sudden onset of symptoms
•May or may not be preceded by a severe psychosocial stressor
•Lasts less than 1 month
•Return to full premorbid level of functioning

Substance- and medication-induced psychotic disorder:

•The presence of prominent hallucinations and delusions that are judged to be directly
attributable to substance intoxication or withdrawal

Psychotic disorder due to another medical condition:

•Prominent hallucinations and delusions are directly attributable to a general medical condition.

Catatonic disorder due to another medical condition:

•This diagnosis is made when the catatonic symptoms are directly attributable to the
physiological consequences of a general medical condition (DKA is an example)

Schizophreniform disorder:
•Same symptoms as schizophrenia with the exception that the duration of the disorder has been
at least 1 month but less than 6 months

Schizoaffective disorder:
•Schizophrenic symptoms accompanied by a strong element of symptomatology associated with
mood disorders of either mania or depression

The Schizophrenia Spectrum; DSM 5:

•Delusional Disorder: not as severe and the type depends on the delusional system
•Brief Psychotic Disorder: Not the typical progression we will discuss. Sudden onset. Last at
least a day, but not longer than a month. Eventual return to premorbid level.
•Schizophreniform: 1-6 months
•Substance Induced or Medication Induced
•Psychosis due to another Medical Condition
•Schizophrenia- psychotic thinking or behavior for at least 6 mo.
•Schizoaffective: Schizophrenia with a strong affective component. Schizoaffective disorder is
a chronic mental health condition characterized primarily by symptoms of schizophrenia, such
as hallucinations or delusions, and symptoms of a mood disorder, such as mania and
depression . *
•Catatonia:See textbook, discusses this disorder well. Be mindful of personal space.

Nursing
Process- Positive Symptoms:
•Content of thought
-​ Delusions: Fixed, false personal beliefs
-​ Persecutory
-​ Grandiose
-​ Somatic
-​ Erotomanic
-​ Jealous
•Form of thought
•Associative looseness (also called loose association): Shift of ideas from one unrelated
topic to another
•Neologisms: Made-up words that have meaning only to the person who invents them
•Concrete thinking: Literal interpretations of the environment
•Clang associations: Choice of words is governed by sound (often rhyming)
•Word salad: Group of words put together in a random fashion (only makes sense to
them not to us)
•Circumstantiality: Delay in reaching the point of a communication because of
unnecessary and tedious details (can never get to the point)
•Tangentiality: Inability to get to the point of communication due to the introduction of
many new topics (lack attention)
•Mutism: Inability or refusal to speak
•Perseveration: Persistent repetition of the same word or idea in response to different
questions

Word Salad: ex: (bunch of words that dont make sense to us but sense to them)
•Take sharpness filling soda cans
•Wetness smooth dancing sheep
•Horse paper handbags skipping forests play together
•In worlds with pencils, schools page drink slime
•Loving living nectar of bees of pollen and butterflies run amok Children bikes cars sliding

Nursing Process: Positive Symptoms:

•Perception: interpretation of stimuli through the senses
•Hallucinations: False sensory perceptions not associated with real external stimuli
•Auditory (hear something not there)
•Visual (see something we dont see)
•Tactile (sense of touch and feel something we might not feel)
•Gustatory (taste something we dont taste)
•Olfactory (smell something that we dont smell)
•Illusions: Misperceptions of real external stimuli
•Echopraxia: Repeating movements that are observed (mimic someone else)

Nursing Process: Negative Symptoms:

•Affect: The feeling state or emotional tone
•Inappropriate affect: Emotions are incongruent with the circumstances
•Bland: Weak emotional tone
•Flat: Appears to be void of emotional tone
•Apathy: Disinterest in the environment

Avolition: Impairment in the ability to initiate goal-directed activity

•Emotional ambivalence: Coexistence of opposite emotions toward same object, person,
or situation
•Deterioration in appearance: Impaired personal grooming and self-care activities
•No longer has secure sense of goal direction
•Cognitions slower: poor problem solving, difficulty concentrating
•Less motivated, less interest, difficulty choosing a logical course of action
Impaired interpersonal functioning and relationship to the external world
•Impaired social interaction: Clinging and intruding on the personal space of others,
exhibiting behaviors that are not culturally and socially acceptable
•Social isolation: A focus inward on the self to the exclusion of the external environment
Lack of insight
•Anergia: deficiency of energy
•Anhedonia: Inability to experience pleasure (risk of suicide)
•Lack of abstract thinking ability

INABLITIY TO ABSTRACT : IDEAS ON HOW TO ASSESS THIS? (pts cannot understand

sayings like these)
•Stich in time saves nine
•Rolling stone gathers no moss
•Cream rises to the top
•People in glass houses should not throw stones
 •When in Rome, do as the Romans
•You can catch more flies with honey
•Two wrongs don’t make a right
•Squeaky wheel gets the grease
•When the going get tough, the tough get going
•Hope for the best, prepare for the worst
•There’s no thing as a free lunch
•Keep your friends close and your enemies closer

•Associated features
•Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at
placing them in certain positions
•Posturing: Voluntary assumption of inappropriate or bizarre postures
•Pacing and rocking: Pacing back and forth and rocking the body
•Regression: Retreat to an earlier level of development
•Eye movement abnormalities

Assessment and Data Gathering:

1.What led you to come to the hospital?
2.Hx: age, onset, signs and symptoms, level of functioning (work, school history), recent and
past stressors, medications and substances (include alcohol and smoking)
3.Look for any/all the above positive/negative symptoms we discussed.
4.Mental Status Exam: LOC, Physical appearance, Behavior (mood and affect included,
Cognitive and intellectual abilities

What to do when speaking to someone with Psychotic Thoughts:

•Be gentle and calm.
•Make them comfortable to share what is going on in their life.
•Focus on what is troubling them.
•Empathize with their situation “It must be SO scary to see those UPS trucks everywhere
monitoring you!”
•Focus on their feelings in what they say, not the actual facts of their story
•Ask them if you can help in any way. “I know you are waiting for that letter with the million
dollars. Are you managing to leave the house or are you too fearful you will miss it? Have you
been able to get out and pick up your chocolate milk? Can I get you some?”
•Ask about things you know they enjoy
•Emphasize strengths “Wow! You skipped your cigarette this morning? How did you do that?!”

WHAT NOT TO DO when speaking to someone with psychotic thoughts:

•Avoid criticizing or blaming the person for their psychosis or the actions related to their
psychosis.
•Avoid denying or arguing with them about their reality “That doesn’t make any sense!
Of course, the government isn’t tapping our house!”
 •Don’t take what they say personally. Paranoia and psychosis can lead to mistrust and
suspicion. All relationships can be called into question and be affected by delusions.
•Do not directly confront them. If you want to be heard, you may have to find a different
way to communicate. Being heard isn’t always possible when someone is in the midst of
a psychotic episode.
•Don’t tell them they are psychotic. As much as I wish it would work, telling someone
they are psychotic will not convince them to stop thinking that way.
•Do not dismiss their concerns or laugh it off. Even if their concerns are bizarre or
shocking, they are not amusing to the person having a psychotic episode. Remember
that their brain believes these things are going on.
•Do not encourage their psychosis by confirming their delusions. Just because I am
telling you not to argue with them about reality this doesn’t mean you have to agree with
what they are saying. You don’t need to comment directly. Often a general, supportive
statement will suffice. Some helpful things to say are “I don’t know what happened. It
sounds very scary” or “There are lots of things that happen in this world that I can’t
explain” or “I don’t know what to make of what you are saying. It’s so confusing and
upsetting to hear everything you are telling me. How are you handling it?”
•Do not focus on correcting the reality of delusions. Don’t waste time trying to prove
the delusion can’t be true with reason and logic.
•Don’t get angry. They are psychotic because their brain is playing tricks on them. They
are not in control of what is happening in their mind.

Assess psychosis:
•Do you hear voices?
•Do you have any other sensations that are unusual like tastes, smells or feeling things?
•Have you been experiencing any unpleasant smells that others did not notice?
•Do you hear other things? Have you in the past? (Have pt. describe voices, thoughts etc.)
•Have you been seeing any visions?
•Does it seem like people are talking about you?
•Do you feel that you have any special abilities? What are they?
•Do you feel like you have any special importance? Does it seem like the television or radio is
talking to specifically to you? Tell me about that?
•Are you having difficulties getting organized? Planning? Getting things done?
•What does your home (bedroom) look like? Is it messy?
•Are you having any difficulties with feeling confused or having your thoughts feel scattered?

Nursing Process: Diagnosis/ Outcome Identification

•Disturbed Sensory Perception (auditory and visual):
•Related to panic anxiety, extreme loneliness, and withdrawal into self
•Disturbed Thought Processes:
•Related to inability to trust, panic anxiety, or possible hereditary or biochemical factors
•Social Isolation related to inability to trust, panic anxiety, weak ego development, delusional
thinking, regression
Risk for Violence: Self-directed or Other-directed related to
 •Extreme suspiciousness
•Panic anxiety
•Catatonic excitement
•Rage reactions
•Command hallucinations
Impaired Verbal Communication related to
•Panic anxiety
•Regression
•Withdrawal
•Disordered unrealistic thinking
Self-Care Deficit related to
•Withdrawal
•Regression
•Panic anxiety
•Perceptual or cognitive impairment
•Inability to trust
•Disabled Family Coping related to difficulty coping with client’s illness

•Ineffective Health Maintenance related to disordered thinking or delusions

•Impaired Home-Maintenance related to:
•Regression
•Withdrawal
•Lack of knowledge or resources
•Impaired physical or cognitive functioning

Outcomes; The client:

•Demonstrates an ability to relate to others satisfactorily
•Recognizes distortions of reality
•Has not harmed self or others
•Perceives self realistically
•Demonstrates ability to perceive the environment correctly
•Maintains anxiety at a manageable level
•Relinquishes need for delusions and hallucinations
•Demonstrates ability to trust others
•Uses appropriate verbal communication in interactions with others
•Performs self-care activities independently

Nursing Process: Planning/Implementation

Disturbed Sensory Perception: Auditory/Visual:
•Observe the client for signs of hallucinations.
•Help client understand connections between anxiety and hallucinations.
•Distract the client from hallucinations.
Disturbed Thought Processes:
•Do not argue or deny the belief.
 •Reinforce and focus on reality.
Risk for Violence
•Observe client’s behavior.
•Maintain calm attitude.
•Have sufficient staff on hand.
Impaired Verbal Communication
•Facilitate trust and understanding.
•Orient the client to reality.

Client/ Family Education:

Nature of illness
•What to expect as illness progresses
•Symptoms associated with illness
•Ways for family to respond to behaviors associated with illness
Management of the illness
•Connection of exacerbation of symptoms to times of stress
•Appropriate medication management
•Side effects of medications
•Importance of not stopping medications
•When to contact healthcare provider
•Relaxation techniques
•Social skills training
•Daily living skills training
Support services
•Financial assistance
•Legal assistance
•Caregiver support groups
•Respite care
•Home healthcare

Nursing Process Evaluation: ​

Evaluation questions:
•Has client established trust with at least one staff member?
•Is anxiety level maintained at a manageable level?
•Is delusional thinking still prevalent?
•Is client able to interrupt escalating anxiety with adaptive coping mechanisms?
•Is client easily agitated?
•Is client able to interact with others appropriately?

Treatment Modalities:
Psychological treatments:
•Individual psychotherapy: Long-term therapeutic approach; difficult because of
client’s impairment in interpersonal functioning
 •Group therapy: Some success if occurring over the long-term course of the illness;
less successful in acute, short-term treatment
•Behavior therapy: Chief drawback has been inability to generalize to community ​
after client has been discharged from treatment.
Social treatments:
•Social skills training: Use of role play to teach client appropriate eye contact,
interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship
development
•Family therapy: Aimed at helping family members cope with long-term effects of the
illness
Program of Assertive Community Treatment:
•A program of case management that takes a team approach in providing
comprehensive, community-based psychiatric treatment, rehabilitation, and support to
persons with serious and persistent mental illness
The Recovery Model:
•A concept of healing and transformation enabling a person with mental illness to live a
meaningful life in the community while striving to achieve his or her full potential
•Research provides support for recovery as an obtainable objective for individuals with
schizophrenia.
Recovery After an Initial Schizophrenia
Episode (R A I S E)
•A program of case management that takes a team approach in providing
comprehensive, community-based psychiatric treatment, rehabilitation, and support to
persons with serious and persistent mental illness
Psychopharmacology
•Antipsychotics
•Used to decrease agitation and psychotic symptoms of schizophrenia and other
psychotic disorders
Action
•Typicals: Dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and
histaminic receptors
•Atypicals: Weak dopamine antagonists; potent 5H T2A antagonists; also exhibit
antagonism for cholinergic, histaminic, and adrenergic receptors- used more

Antipsychotics: Side Effects

-​ Anticholinergic effects
-​ Nausea; gastrointestinal upset
-​ Skin rash
-​ Sedation
-​ Orthostatic hypotension
-​ Photosensitivity
-​ Hormonal effects
-​ Electrocardiogram changes
-​ Hypersalivation
 -​ Weight gain
-​ Hyperglycemia/diabetes
-​ Increased risk of mortality in elderly clients with dementia
-​ Reduction in seizure threshold
-​ Agranulocytosis
-​ Extrapyramidal symptoms
-​ Tardive dyskinesia
-​ Neuroleptic malignant syndrome
Antipsychotics: Extrapyramidal Symptoms:
•Pseudoparkinsonism
•Akinesia
•Akathisia
•Dystonia
•Oculogyric crisis
•Antiparkinsonian agents may be prescribed to counteract E P S.
(look at pic above)

Client/ Family Education:

•Do not stop: taking the drug abruptly.
•Use: sunscreen and wear protective clothing when spending time
outdoors.
•Report: weekly (if receiving clozapine therapy) to have blood levels
drawn and to obtain a weekly supply of the drug.
•Be: aware of possible risks of taking antipsychotics during pregnancy.
•Do not: drink alcohol while receiving antipsychotic therapy.
•Do not: consume other medications (including over-the-counter drugs) without the physician’s
knowledge.

Suicide is not a diagnosis or a disorder; it is a behavior

•More than 90% of suicides are by individuals who have a diagnosed mental disorder.

Epidemiological Factors:
•Suicide is:
•The second-leading cause of death among Americans 10 to 34 years of age
•The fourth-leading cause of death for ages 35 to 54
•The eighth-leading cause of death for ages 55 to 64
•The tenth-leading cause of death overall

Risk Factors:
Marital status
-​ The suicide rate for single persons is twice that of married persons.
Gender
-​ Women attempt suicide more often, but more men succeed.
-​ Men commonly choose more lethal methods than do women.
Age
-​ Risk of suicide increases with age, particularly
among men.
-​ White men older than 80 years are at the greatest risk of all age, gender, and race
groups.
Religion
-​ Affiliation with a religious group decreases the risk of suicide. Catholics have lower rates
than do Protestants or Jewish people.
Socioeconomic status
-​ Individuals in the very highest and lowest social classes have higher suicide rates than
those in the middle class.
Ethnicity
-​ Whites are at the highest risk for suicide, followed by Native Americans, African
Americans, Hispanic Americans, and Asian Americans.

Psychiatric illness: Mood and substance use disorders are the most common psychiatric
illnesses that precede suicide. Other psychiatric disorders that account for suicidal behavior
include:
-​ Schizophrenia
-​ Personality disorders
-​ Anxiety disorders
-​ Severe insomnia is associated with increased risk of suicide.

•Use of alcohol and barbiturates

•Psychosis with command hallucinations
•Affliction with a chronic, painful, or disabling illness
•Family history of suicide
•L G B T individuals have a higher risk of suicide than do their heterosexual counterparts
•Having attempted suicide previously increases the risk of a subsequent attempt. About half of
those who ultimately commit suicide have a history of a previous attempt.
•Loss of a loved one through death or separation
•Bullying

Predisposing factors- theories of suicide:

Psychological theories:
•Anger turned inward- self hatred
•Hopelessness
•History of aggression and violence- impulsivity
•Shame and humiliation- face saving- don’t want to deal with shame and humiliation.
•Interpersonal theory
•Durkheim’s three social categories of suicide
-​ Egoistic suicide- lack of belonging, feels separate and apart from society
-​ Altruistic suicide- sacrafice life for a group
-​ Anomic suicide- changes in life that disrupt belonging to a group.
•Joiner’s interpersonal-psychological theory
•The Three Step Theory (3 steps that elevate risk for suicide)
-​ Pain (physical, chronic, psychological pain)
-​ Feeling disconnected from others
-​ Suicidal ideations
Biological theories
•Genetics
•Neurochemical factors (seratonin ins csf)

Nursing Assessment:
•Demographics
•Age
•Gender
•Ethnicity/race
•Marital status
•Socioeconomic status / Occupation
•Lethality and availability of method
•Religion
•Family history of suicide
•Military history
•Presenting symptoms/medical-psychiatric diagnosis
•Suicidal ideas or acts
-​ Seriousness of intent
-​ Plan
-​ Means
-​ Verbal and behavioral clues
•Interpersonal support system
•Analysis of the suicidal crisis
-​ Precipitating stressor
-​ Relevant history
-​ Life-stage issues
•Psychiatric/medical/family history
•Coping strategies
•Presenting symptoms
Ideation: Has suicide ideas that are current and active, especially with an identified
plan
Substance abuse: Drinks alcohol, perhaps excessively, or uses other mood-altering
drugs
Purposelessness: Expresses thoughts that there is no reason to continue living
Anger: Expresses uncontrolled anger or feelings of rage
Trapped: Expresses the belief that there is no way out of the current situation
Hopelessness: Expresses lack of hope and perceives little chance of positive change
Withdrawal: Expresses desire to withdraw from others or has begun withdrawing
Anxiety: Expresses anxiety, agitation, and/or changes in sleep patterns
Recklessness: Engages in reckless or risky activities with little thought of
consequences
Mood: Displays dramatic mood shifts

Diagnosis/ outcome identification:

•Nursing diagnoses for the suicidal client may include
-​ Risk for suicide
-​ Hopelessness
•Outcome criteria
The following criteria may be used for measurement of outcomes in the care of
the suicidal client.
The client:
1.Has experienced no physical harm to self.
2.Sets realistic goals for self.
3.Expresses some optimism and hope for the future.

Guidelines for treatment:

Ensure
•Ensure access to support systems and tie to a system of care.
Develop
•Develop a detailed safety plan.
Establish
•Establish a no-suicide contract with the client.
Enlist
•Enlist the help of family or friends.
Schedule
•Schedule frequent appointments.
Establish
•Establish rapport and promote a trusting relationship.
Be
•Be direct and talk matter-of-factly about suicide.
Discuss
•Discuss the current crisis situation in the client’s life.
Identify
•Identify areas of self-control.
Give
•Give antidepressant medications.

Information for family and friends of the suicidal client:

Take any hint of suicide seriously!!
•Do not keep secrets.
•Be a good listener.
•Express feelings of personal worth to the client.
•Know about suicide intervention resources.
•Restrict access to firearms or other means of self-harm.
•Acknowledge and accept the person’s feelings.
•Provide a feeling of hopefulness.
•Do not leave him or her alone.
•Show love and encouragement.
•Seek professional help.
•Remove children from the home.
•Do not judge or show anger toward the person or provoke guilt in him or her.

Interventions with family and friends of suicide victims:

•Encourage him or her to talk about the suicide.
•Discourage blaming and scapegoating.
•Listen to feelings of guilt and self-persecution.
•Talk about personal relationships with the victim.
•Recognize differences in styles of grieving.
•Assist with development of adaptive coping strategies.
•Identify resources that provide support.

Evaluation:
•Develop and maintain a more positive self-concept.
•Learn more effective ways to express feelings to others.
•Achieve successful interpersonal relationships.
•Feel accepted by others and achieve a sense of belonging.

Depression Medications:
Psychopharmacology
•Tricyclics (TCAs)
•MAO inhibitors
•SSRIs
•SNRIs
•Buproprion (Wellbutrin) (Wellbutrin and Zyban (used to help stop smoking) contain the same
active ingredient (bupropion) and SHOULD NOT be taken together.
•Takes several weeks for full therapeutic effects
•Titrate slowly
•Do not abruptly stop medications
-​ Most serotonin is made in the gut and then put into your circulatory system.
These medications stop the reuptake of serotonin- so the medications dont allow
the brain to reuptake (serotonin or norepi STAYS in the brain where you need it)
-​ Stop norepi or serotonin from being taken back to the cells
-​ TAKE WEEEEKS to work!!

TCAs, SSRIs, SNRIs

-​ Block reuptake of norepinephrine, serotonin, and/or dopamine
MAOIs
-​ Inhibit monoamine oxidase, an enzyme known to inactivate norepinephrine, serotonin,
and dopamine
-​ Allow for more chemicals in da brain

Common meds- on the ppt (dont feel like putting them all)
Elavil, Anafranil

Tricyclic complications:
Orthostatic effects (when pt stands and bp decreses)
NURSING CONSIDERSTIONS:
-​ Monitor BP and HR for orthostatic changes. If significant decrease is noted, do not
administer medication.
CLIENT EDUCATION:
-​ Instruct client about indications of postural hypotension (lightheadedness, dizziness). If
these occur, advise client to sit or lie down. Orthostatic hypotension is minimized by
getting up or changing positions slowly. Advise the client to avoid dehydration, which
increases risk for hypotension

Pharmacology:
•Block reuptake of norepinephrine, serotonin, block NA and CA channels, decrease AcH and Hi
•Not used as much because of adverse side effect profile and potential for lethality
•Are utilized on those who fail to respond to SSRI’s
•Gold standard for certain disorders: OCD (clomipramine/Anafranil), and chronic pain
(amitriptyline/Elavil)
•Potential for cardiac side effects, anticholinergic effects, sedation and toxicity
•Contraindicated in patients with recent cardiac events or narrow-angle glaucoma
•High potential for toxicity
Anticholinergic Effects
-​ Dry mouth
-​ Difficulty voiding,
-​ Dilated and blurred vision
-​ Decreased GI motility (constipation)
-​ Photosensitivity
-​ Tachycardia

CLIENT EDUCATION: Instruct client on ways to minimize anticholinergic effects

-​ Chewing sugarless gum
-​ Sipping on water
-​ Wear sunglasses outdoors
-​ Eat food high in fiber
-​ Exercise
-​ Increase fluid intake to at least 2 L/day from beverage and food sources
-​ Void just before taking medication

Complications:
-​ Sedation ​
-​ Decreased threshold
-​ Excessive appetite, diaphoresis
-​ Toxicity

CLIENT EDUCATION, SEDATION

-​ Usually diminishes over time
-​ Advise client to avoid hazardous activities if sedation excessive
-​ Advise to take at bedtime to minimize sleepiness, promote sleep and minimize side
effects during the day

Toxicity results in a cholinergic blockade and cardiac toxicity (dysrhythmia, confusion, agitation,
seizures, coma, and possible death)
CLIENT EDUCATION, TOXICITY
-​ Give no more than 1 supply week initially
-​ Obtain baseline ECG
-​ Monitor VS frequently
-​ Notify provider is S/S toxicity occur

Monoamine Inhibitors
•These medications block MAO in the brain, thereby increasing the amt of NE,D and Serotonin
available for transmission of impulses which intensifies responses and relieves depression. *
•Used less frequently used due to multiple interactions and potential for hypertensive crisis
•Transdermal formulation of Selegiline, an MAOI with less dietary implications, is available but
not widely used
•Additive hypoglycemia with anti-hyperglycemic agents
•Potentially fatal reactions with all other antidepressants, carbamazepine, buspirone,
sympathomimetics, tryptophan, dextromethorphan, CNS depressants, and amphetamines
(avoid use within 2 weeks of each other) ** OTC cold medications
•PG RIsk

MAOI Complications:
-​ CNS Stimulation
-​ Anxiety, Agitation, hypomania, mania
CLIENT EDUCATION: Advise client to observe for effects and notify provider
-​ Orthostatic Hypotension
CLIENT EDUCATION: See slide #45
-​ Hypertensive Crisis resulting from intake of dietary tyramine
-​ HA, N/V, ⬆HR, ⬆BP, Diaphoresis, LOC change
NURSING CONSIDERSTIONS:
-​ IV alpha-adrenergic blocker, conatinuous cardiac monitoring and respiratory support as
indicated
CLIENT EDUCATION:
-​ Educate client on foods to avoid.

•These medications block MAO in the brain, thereby increasing the amt of NE,D and Serotonin​
available for transmission of impulses which intensifies responses and relieves depression. *
•Used less frequently used due to multiple interactions and potential for hypertensive crisis
•Transdermal formulation of Selegiline, an MAOI with less dietary implications, is available but​
not widely used
•Additive hypoglycemia with anti-hyperglycemic agents
•Potentially fatal reactions with all other antidepressants, carbamazepine, buspirone,​
sympathomimetics, tryptophan, dextromethorphan, CNS depressants, and amphetamines​
(avoid use within 2 weeks of each other) ** OTC cold medications
•PG RIsk

–Avoid foods and medications high in tyramine when taking MAOIs. These include:

Aged cheese Caviar

Wine; beer Raisins
Chocolate; colas ​ Pickled herring
Coffee; tea Yeast products
Sour cream; yogurt Broad beans
Smoked and processed meats ​ Soy sauce
Beef or chicken liver Cold remedies
Canned figs Diet pills
SSRI complications:
-​ Sexual Dysfunction
CLIENT EDUCATION:
-​ Warn client, ask to notify if they become intolerable- may change med
-​ CNS stimulation: insomnia, agitation, anxiety, headache
CLIENT EDUCATION:
Notify provider to possible decrease dose, advise to take in AM, avpod caffeine, teach
relaxation techniques, Weight Changes, Wt loss early in therapy followed by wt gain
NURSING CONSIDERSTIONS:
-​ Monitor Clients Weight
CLIENT EDUCATION:
-​ Encourage client to follow a healthy well balanced diet
-​ Serotonin Syndrome Mild to severe,↑ temp, agitation, diaphoresis, muscle rigidity or
twitch, seizure, irreg. HB, mental confusion, diarrhea
CLIENT EDUCATION:
-​ Advise client to watch for symptoms and to withhold medication and notify provider if
they occur.
Other SSRI COMPS:
-​ Hyponatremia
-​ Rash
-​ Sleepiness, faintness, lightheadedness
-​ GI Bleeding
-​ Bruxism

SSRI’s
Fluoxetine/Prozac: Can be activating, looong half life
Sertraline/Zoloft: Works quickly, Often first choice PMDD
Escitalopram/Lexapro: Works more rapidly than others​
Paroxetine hydrochloride/Paxil: Contraindicated in Pregnancy
Citalopram hydrobromide/Celexa: low drug-drug interactions
Fluvoxamine/Luvox: Indicated for OCD

Interactions:
•Never Use with MAOs​
•Could be toxic/fatal/SS
•Concomitant use of SSRIs may decrease effects of buspirone and digoxin
•Serotonin syndrome can occur with concurrent use of other drugs that increase serotonin

SSNRI’s
•Effexor/venlafaxine (VEN la fax een)
•Pristiq/desvenlafaxine (des VEN la FAX een)
•Cymbalta/duloxetine (du LOX e teen)
•THERAPEUTIC effects sooner with less sexual SE
Side effects:
•Increased BP
•Hyponatremia
•Headache
•Nausea
•Jitteriness
•Dizziness on standing
•Sleep disturbances
•Increased SI

Norepinephrine-Dopamine Reuptake Inhibitor

Bupropion (Wellbutrin)
•Sometimes used as adjunct therapy with SSRI
•Alternate use if sexual side effects with SSRI’s
•Can be stimulating so may not be ideal with people with anxiety disorders
Side effects:
•Nausea
•Headache
•Appetite changes
•Dizziness
•Agitation
•Increased anxiety

Others: ​
Mirtazapine (Remeron) A serotonin and Norepinephrine Antagonist and Trazodone (Desyrel) A
serotonin antagonist and reuptake inhibitor
•Used more for sedative side effects
•Can be used as adjunct to SSRI’s
•Remeron: stimulates appetite, has precognitive effects
•Trazodone: Potential for prolonged Q-T syndrome

Client/family education related to Antidepressants

•Therapeutic effect may not be seen for as long as 4 weeks
•Do not discontinue use of the drug abruptly
•Avoid smoking and drinking alcohol
•Be aware of risks of taking antidepressants during pregnancy
•Suicide risk when increased
•Complementary meds: Kava, St. Johns Wort, Parsley
•Oral hygiene, hard candies, mouth rinses to relieve dry mouth
•GI distress, ask to take with food, milk
•Avoid alcohol and driving until comfortable and know response
•ALWAYS Taper when d/c
Serotonin Syndrome:
•Serotonin syndrome symptoms usually occur within several hours of taking a new drug or
increasing the dose of a drug you're already taking.
•Agitation or restlessness
•Confusion
•Rapid heart rate and high blood pressure
•Dilated pupils
•Loss of muscle coordination or twitching muscles
•Muscle rigidity
•Heavy sweating
•Diarrhea
•Headache
•Shivering
•Goose bumps
•Severe serotonin syndrome can be life-threatening. Signs include:
•High fever
•Seizures
•Irregular heartbeat
•Unconsciousness

Serotonin:
•May occur if you take an antidepressant with a migraine medication. It may also occur if you
take an antidepressant with an opioid pain medication.
•A number of over-the-counter and prescription drugs may be associated with serotonin
syndrome, especially antidepressants. Illicit drugs and dietary supplements also may be
associated with the condition.
•The drugs and supplements that could potentially cause serotonin syndrome include:

•Selective serotonin reuptake inhibitors (SSRIs), antidepressants such as citalopram

(Celexa), fluoxetine (Prozac, Sarafem), fluvoxamine, paroxetine (Paxil, Pexeva, Brisdelle) and
sertraline (Zoloft)
•Serotonin and norepinephrine reuptake inhibitors (SNRIs), antidepressants such as
duloxetine (Cymbalta, Drizalma Sprinkle) and venlafaxine (Effexor XR)
•Bupropion (Zyban, Wellbutrin SR, Wellbutrin XL), an antidepressant and tobacco-addiction
medication
•Tricyclic antidepressants, such as amitriptyline and nortriptyline (Pamelor)
•Monoamine oxidase inhibitors (MAOIs), antidepressants such as isocarboxazid (Marplan)
and phenelzine (Nardil)
•Anti-migraine medications, such as carbamazepine (Tegretol, Carbatrol, others), valproic
acid (Depakene) and triptans, which include almotriptan, naratriptan (Amerge) and sumatriptan
(Imitrex, Tosymra, others)
•Pain medications, such as opioid pain medications including codeine, fentanyl (Duragesic,
Abstral, others), hydrocodone (Hysingla ER, Zohydro ER), meperidine (Demerol), oxycodone
(Oxycontin, Roxicodone, others) and tramadol (Ultram, ConZip)
•Lithium (Lithobid), a mood stabilizer
•Illicit drugs, including LSD, ecstasy, cocaine and amphetamines
•Herbal supplements, including St. John's wort, ginseng and nutmeg
•Over-the-counter cough and cold medications containing dextromethorphan (Delsym)
•Anti-nausea medications such as granisetron (Sancuso, Sustol), metoclopramide (Reglan),
droperidol (Inapsine) and ondansetron (Zofran, Zuplenz)
•Linezolid (Zyvox), an antibiotic
•Ritonavir (Norvir), an anti-retroviral medication used to treat HIV

Pharmecogenomics:
•Between 30 and 50 percent of patients do not respond to first antidepressant prescription.
•A study is needed to identify benefits of routine testing, cost effectiveness, and ability to provide
timely results.

Depression:

•Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses.
•Transient symptoms are normal, healthy responses to everyday disappointments in life.
•Pathological depression occurs when adaptation is ineffective.
•Mood is also called affect.
•Depression is an alteration in mood that is expressed by feelings of sadness, despair,
and pessimism.

Epidemiology:
Gender prevalence
-​ Depression is more prevalent in women than in men by about 2 to 1.
Age
-​ Lifetime prevalence of depressive disorders is higher in those aged 45 years or younger.

Social class
-​ There is an inverse relationship between social class and the report of depressive
symptoms.
Race and culture
-​ No consistent relationship between race and affective disorder has been reported.
-​ Problems have been encountered in reviewing racial comparisons.

Marital status
-​ Single and divorced people are more likely to experience depression than are married
persons or persons with a close interpersonal relationship (differences occur in various
age groups).
Seasonality
-​ Affective disorders are more prevalent in the winter and in the fall.

Types of Depressive Disorders:

Major depressive disorder
•Characterized by depressed mood
•Loss of interest or pleasure in usual activities
•Symptoms present for at least 2 weeks
•No history of manic behavior
•Cannot be attributed to use of substances or another medical condition

Persistent depressive disorder (dysthymia)

•Sad or “down in the dumps”
•No evidence of psychotic symptoms
•Essential feature is a chronically depressed mood for
•Most of the day
•More days than not
•At least 2 years

Premenstrual dysphoric disorder

•Depressed mood
•Anxiety
•Mood swings
•Decreased interest in activities
•Symptoms begin during the week prior to menses, start to improve within a few days after the
onset of menses, and become minimal or absent in the week postmenses.

Substance- or medication-induced depressive disorder

-​ Considered to be the direct result of physiological effects of a substance
Depressive disorder associated with another medical condition
-​ Attributable to the direct physiological effects of a general medical condition

Predisposing Factors to Depression:

•Biological theories
•Genetics
•Hereditary factor may be involved
•Biochemical influences
•Deficiency of norepinephrine, serotonin, and dopamine has been implicated.
•Excessive cholinergic transmission may also be a factor.
•Neuroendocrine disturbances
•Possible failure within the hypothalamic-pituitary-adrenocortical axis
•Possible diminished release of thyroid-stimulating hormone
Physiological influences
•Medication side effects
•Neurological disorders
•Electrolyte disturbances
•Hormonal disorders
•Nutritional deficiencies
•Other physiological conditions
•The role of inflammation

Psychoanalytical theory
•A loss is internalized and becomes directed against the ego.
Learning theory
•Learned helplessness: The individual who experiences numerous failures learns to give
up trying.

Object loss theory

•Experiences loss of significant other during first 6 months of life
•Feelings of helplessness and despair
•Early loss or trauma may predispose client to lifelong periods of depression.

Cognitive theory
•Views primary disturbance in depression as cognitive rather than affective.
•Three cognitive distortions that serve as the basis for depression.
•Negative expectations of the environment
•Negative expectations of the self
•Negative expectations of the future

Developmental Implications:
Childhood depression
•Symptoms
•< Age 3: Feeding problems, tantrums, lack of playfulness and emotional
expressiveness
•Ages 3 to 5: Accident proneness, phobias, excessive self-reproach
•Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior
Ages 9 to 12: Morbid thoughts and excessive worrying
•Precipitated by a loss
•Focus of therapy: Alleviate symptoms and strengthen coping skills
•Parental and family therapy

Adolescence
•Symptoms include
•Anger, aggressiveness
•Running away
•Delinquency
 •Social withdrawal
•Sexual acting out
•Substance abuse
•Restlessness, apathy
•Best clue that differentiates depression from normal stormy adolescent behavior
•A visible manifestation of behavioral change that lasts for several weeks.
•Most common precipitant to adolescent suicide
•Perception of abandonment by parents or close peer relationship

Adolescence Treatment with

•Supportive psychosocial intervention
•Antidepressant medication
***NOTE All antidepressants carry a Food and Drug Administration black-box warning for
increased risk of suicidality in children and adolescents.

Developmental Implications
Senescence
•Bereavement overload
•High percentage of suicides among elderly
•Symptoms of depression often confused with symptoms of neurocognitive disorder
Treatment
•Antidepressant medication
•Electroconvulsive therapy
•Psychotherapies
Postpartum depression
•May last for a few weeks to several months
•Associated with hormonal changes, tryptophan metabolism, or cell alterations
Treatments
•Antidepressants and psychosocial therapies
Symptoms include
•Fatigue/Irritability
•Loss of appetite
•Sleep disturbances
•Loss of libido
•Concern about inability to care for infant

Transient depression
•Symptoms at this level of the continuum are not necessarily dysfunctional.
•Affective: The “blues”
•Behavioral: Some crying
•Cognitive: Some difficulty getting mind off of one’s disappointment
•Physiological: Feeling tired and listless
Mild depression
Symptoms of mild depression are identified by clinicians as those associated with normal
grieving.
•Affective: Anger, anxiety
•Behavioral: Tearful, regression
•Cognitive: Preoccupied with loss
•Physiological: anorexia, insomnia

Moderate depression
Symptoms associated with dysthymic disorder
•Affective: Helpless, powerless
•Behavioral: Slowed physical movements, slumped posture, limited verbalization
•Cognitive: Retarded thinking processes, difficulty with concentration
•Physiological: Anorexia or overeating, sleep disturbance, headaches

Severe depression
Includes symptoms of major depressive disorder and bipolar depression
•Affective: feelings of total despair, worthlessness,
flat affect
•Behavioral: psychomotor retardation, curled-up position, absence of communication
•Cognitive: prevalent delusional thinking, with delusions of persecution and somatic
delusions; confusion; suicidal thoughts
•Physiological: a general slow-down of the entire body
Risk for suicide related to
•Depressed mood
•Feelings of worthlessness
•Anger turned inward on the self
•Misinterpretations of reality
Complicated grieving related to
•Real or perceived loss
•Bereavement overload

Low self-esteem related to

•Learned helplessness
•Feelings of abandonment by significant others
•Impaired cognition fostering negative view of self
Powerlessness related to
•Complicated grieving process
•Lifestyle of helplessness

Spiritual distress related to

•Complicated grieving process over loss of valued object evidenced by anger toward
God, questioning meaning of own existence, inability to participate in usual religious
practices
•Social isolation/Impaired social interaction related to
•Developmental regression
•Egocentric behaviors
•Fear of rejection or failure of the interaction

Disturbed thought processes related to

•Withdrawal into self
•Underdeveloped ego
•Punitive superego
•Impaired cognition fostering negative perception of self or environment

Imbalanced nutrition less than body requirements

Insomnia
Self-care deficit
• All related to depressed mood

Criteria for measuring outcomes:

•Has experienced no physical harm to self
•Discusses loss with staff and family members
•No longer idealizes or obsesses about the lost entity
•Sets realistic goals for self
•Attempts new activities without fear of failure
•Is able to identify aspects of self-control over life situation
•Expresses personal satisfaction and support from spiritual practices
•Interacts willingly and appropriately with others
•Is able to maintain reality orientation
•Is able to concentrate, reason, and solve problems

Planning/ Implementation:
Risk for suicide
•Be direct.
•Maintain close observation at irregular intervals.
•Encouraging verbalizations of honest feelings.
Complicated grieving
•Develop a trusting relationship with the client.
•Encourage the client to express emotions.
•Communicate that crying is acceptable.
Low self-esteem/self-care deficit
•Be accepting of the client.
•Encourage the client to recognize areas of change.
•Encourage independence in the performance of activities of daily living.
Powerlessness
•Encourage the client to take responsibility.
 •Help the client set goals.
•Help the client identify areas of his or her life that they can and cannot control.

Client/family education:
Nature of the illness
•Stages of grief and symptoms associated with each stage
•What is depression?
•Why do people get depressed?
•What are the symptoms of depression?
•Management of the illness
Medication management
•Assertive techniques
•Stress-management techniques
•Ways to increase self-esteem
•Electroconvulsive therapy
Support services
•Suicide hotline
•Support groups
•Legal/financial assistance
Evaluation
•Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving
process and recognize his or her position in the process?
•Have obsession with, and idealization of, the lost object subsided?
•Is anger toward the lost object expressed appropriately?
•Does the client set realistic goals for self?
•Is the client able to verbalize positive aspects about self, past accomplishments, and future
prospects?
•Can the client identify areas of life situation over which he or she has control?

Treatment Modalities:
•Individual psychotherapy
•Group therapy
•Family therapy
•Cognitive therapy

Electroconvulsive therapy
•Mechanism of action: Thought to increase levels of biogenic amines
•Side effects: Temporary memory loss and confusion
•Risks: Mortality; permanent memory loss; brain damage
•Medications: Pretreatment medication; muscle relaxant; short-acting anesthetic
Treatment Modalities
•Repetitive transcranial magnetic stimulation
•Vagal nerve stimulation and deep brain stimulation
•Light therapy
•Psychopharmacology
•Tricyclics
•Selective serotonin reuptake inhibitors
•Monoamine oxidase inhibitors (M A O I’s)
•Heterocyclics
•Serotonin-norepinephrine reuptake inhibitors

Mood is defined as a pervasive and sustained emotion that may have a major influence on a
person’s perception of the world.
-​ Examples of mood: Depression, joy, elation, anger, anxiety
Affect is described as the emotional reaction associated with an experience. (external
observable emotion)

Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem,

grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
-​ Mania can occur as a biological (organic) or psychological disorder, or as a response to
substance use or a general medical condition.

•In early writings, mania was categorized with all forms of “severe madness.”

Epidemiology:
•Bipolar disorder affects approximately 4.4% of American adults.
•Gender incidence is roughly equal.
•Average age at onset is 25 years.
•Occurs more often in the higher socioeconomic classes
•Sixth-leading cause of disability in the middle-age group

Bipolar disorder is characterized by mood swings from profound depression to extreme

euphoria (mania), with intervening periods of normalcy.
•Delusions or hallucinations may or may not be part of clinical picture.
•Onset of symptoms may reflect seasonal pattern.
•A somewhat milder form of mania is called hypomania.
Bipolar 1 disorder
•Client is experiencing, or has experienced, a full syndrome of manic or mixed
symptoms.
•May also have experienced episodes of depression
Bipolar 2 disorder
•Characterized by bouts of major depression with episodic occurrence of hypomania
•Has never met criteria for full manic episode

Types of Bipolar Disorders:

Cyclothymic disorder
•Chronic mood disturbance
 •At least 2-year duration
•Numerous episodes of hypomania and depressed mood of insufficient severity to meet
the criteria for either bipolar 1 or 2 disorder
Substance- and medication-induced bipolar disorder
•A disturbance of mood (depression or mania) that is considered to be the direct result of
the physiological effects of a substance (for example, ingestion of or withdrawal from a
drug of abuse or a medication or other treatment)
Bipolar disorder due to another medical condition
•Characterized by an abnormally and persistently elevated, expansive, or irritable mood
and excessive activity or energy that is judged to be the result of direct physiological
effects of another medical condition
Biological theories
•Genetics
•Twin and family studies
•Other genetic studies
•Biochemical influences
•Possible excess of norepinephrine and dopamine
Biological theories (continued)
•Physiological influences
•Brain lesions
•Enlarged ventricles
•Medication side effects
Psychosocial theories
•Credibility of psychosocial theories has declined in recent years.
•Bipolar disorder is viewed as a disease of the brain.
Developmental Implications: Childhood and Adolescence
•Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about
1%.
•Diagnosis is difficult.
Treatment strategies
•Psychopharmacology
•Lithium
•Divalproex
•Carbamazepine
•Atypical antipsychotics
•Attention deficit/hyperactivity disorder (A D H D) is the most common comorbid condition.
•A D H D agents may exacerbate mania and should be administered only after bipolar
symptoms have been controlled.
•Family interventions
•Psychoeducation about bipolar disorder
•Communication training
•Problem-solving skills training
Symptoms may be categorized by degree of severity.
Stage 1.
Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or
occupational functioning or to require hospitalization
•Cheerful mood
•Rapid flow of ideas; heightened perception
•Increased motor activity
Stage 2.
Acute mania: Marked impairment in functioning; usually requires hospitalization
•Elation and euphoria; a continuous “high”
•Flight of ideas; accelerated, pressured speech
•Hallucinations and delusions
•Excessive motor activity
•Social and sexual inhibition
•Little need for sleep
Stage 3.
Delirious mania: A grave form of the disorder characterized by an intensification of the
symptoms associated with acute mania. The condition is rare because the advent of
antipsychotic medication.
•Labile mood; panic anxiety
•Clouding of consciousness; disorientation
•Frenzied psychomotor activity
•Exhaustion and possibly death without intervention
Risk for injury related to
•Extreme hyperactivity, increased agitation, and lack of control over purposeless and
potentially injurious movements
Risk for violence: self-directed or other-directed related to
•Manic excitement
•Delusional thinking
•Hallucinations
•Impulsivity
Imbalanced nutrition less than body requirements related to
•Refusal or inability to sit still long enough to eat, evidenced by loss of weight,
amenorrhea
Disturbed thought processes related to
•Biochemical alterations in the brain, evidenced by delusions of grandeur and
persecution, as well as inaccurate interpretation of the environment
Disturbed sensory perception related to
•Biochemical alterations in the brain and to possible sleep deprivation, evidenced by
auditory and visual hallucinations
Impaired social interaction related to
•Egocentric and narcissistic behavior
Insomnia related to
•Excessive hyperactivity and agitation
Criteria for measuring outcomes:
•Exhibits no evidence of physical injury
•Has not harmed self or others
•Is no longer exhibiting signs of physical agitation
•Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status
•Verbalizes an accurate interpretation of the environment
•Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior
indicating hallucinations
•Accepts responsibility for own behaviors
•Does not manipulate others for gratification of own needs
•Interacts appropriately with others
•Is able to fall asleep within 30 minutes of retiring
•Is able to sleep 6 to 8 hours per night

Planning/ Implementation:
Risk for Violence: Self-Directed or Other-Directed
•Remove all dangerous objects from the environment.
•Maintain a calm attitude.
•If restraint is deemed necessary, ensure that sufficient staff are available to assist.
Impaired Social Interaction
•Set limits on manipulative behaviors.
•Do not argue, bargain, or try to reason with the client.
•Provide positive reinforcement.
Imbalanced Nutrition: Less than Body Requirements / Insomnia
•Provide client with high-protein, high-calorie foods.
•Maintain an accurate record of intake, output, and calorie count.
•Monitor sleep patterns.
Patient and Family Education:
Nature of the illness
•Causes of bipolar disorder
•Cyclic nature of the illness
•Symptoms of depression
•Symptoms of mania
Management of the illness
•Medication management
•Assertive techniques
•Anger management
Support services
•Crisis hotline
•Support groups
•Individual psychotherapy
•Legal/financial assistance
Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of
the outcome criteria.
•Has violence to the client or others been prevented?
•Has agitation subsided?
•Have nutritional status and weight been stabilized?
•Have delusions and hallucinations ceased?
•Has the client avoided personal injury?
•Is the client able to make decisions about own self-care?
•Is behavior socially acceptable?
•Is the client able to sleep 6 to 8 hours per night and awaken feeling rested?
•Does the client understand the importance of maintenance medication therapy?
Treatment modalities for BPD: ​
​ •Group therapy
•Family therapy
•Cognitive therapy
•Individual psychotherapy
The Recovery Model
•Learning how to live a safe, dignified, full, and self-determined life in the face of the
enduring disability which may, at times, be associated with serious mental illness.
•In bipolar disorder, recovery is a continuous process.
•Client identifies goals.
•Client and clinician develop a treatment plan.
•Client and clinician work on strategies to help the individual manage the bipolar illness.
•Clinician serves as support person to help the individual achieve the previously
identified goals.
•Although there is no cure for bipolar disorder, recovery is possible in the sense of
learning to prevent and minimize symptoms, and to successfully cope with the effects of
the illness on mood, career, and social life.
Electroconvulsive therapy (E C T)
•Episodes of mania may be treated with E C T when
•Client does not tolerate medication.
•Client fails to respond to medication.
•Client’s life is threatened by dangerous behavior or exhaustion.
For mania
•Lithium carbonate
•Anticonvulsants
•Verapamil
•Antipsychotics
For depressive phase
•Use antidepressants with care (may trigger mania).
Pt/ family education:
Lithium
•Take the medication regularly.
•Do not skimp on dietary sodium.
•Drink six to eight glasses of water each day.
•Notify physician if vomiting or diarrhea occur.
•Have serum lithium level checked every 1 to 2 months, or as advised by physician.
•Notify physician if any of the following symptoms occur:
•Persistent nausea and vomiting
•Severe diarrhea
•Ataxia
•Blurred vision
•Tinnitus
•Excessive output of urine
•Increasing tremors
•Mental confusion
Anticonvulsants
•Refrain from discontinuing the drug abruptly.
•Report the following symptoms to the physician immediately: skin rash, unusual
bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin
or eyes.
•Avoid using alcohol and over-the-counter medications without approval from physician.
Verapamil
•Do not discontinue the drug abruptly.
•Rise slowly from sitting or lying position to prevent sudden drop in blood pressure.
•Report the following symptoms to physician:
•Irregular heartbeat; chest pain
•Shortness of breath; pronounced dizziness
•Swelling of hands and feet
•Profound mood swings
•Severe and persistent headache
Antipsychotics
•Do not discontinue drug abruptly.
•Use sunblock when outdoors.
•Rise slowly from a sitting or lying position.
•Avoid alcohol and over-the-counter medications.
•Continue to take the medication, even if feeling well and as though it is not needed; ​
may return if medication is discontinued.
Report the following symptoms to physician:
•Sore throat; fever; malaise, unusual bleeding; easy bruising; skin rash,
persistent nausea and vomiting
•Severe headache; rapid heart rate, difficulty urinating or excessive urination, muscle
twitching, tremors
•Darkly colored urine; pale stools
 •Yellow skin or eyes
•Excessive thirst or hunger
•Muscular incoordination or weakness

Bipolar Disorder Medications/ treatment modalities:

Individual psychotherapy – clinician support
Group therapy - After mania subsides; universality; support, security
Family therapy- help restores functioning
Cognitive therapy- control thought distortions; identifying dysfunctional patterns. Client and
clinician work on strategies to help the individual manage the bipolar illness

Mood-stabilizing agents
Indications: prevention and treatment of manic episodes associated with bipolar disorder
Examples: lithium carbonate; anticonvulsants that act as mood stabilizers such as
carbamazepine, valproic acid (Depakote), lamotrigine, others
-​ Antianxiety medications (clonazepam, lorazepam), antidepressants (SSRI),
second-generation antipsychotics.

Lithium:
1.Years: Only Lithium.
2.Believed to modulate neurotransmitters; Alters sodium transport across the cell membrane
and adjusts signaling activity; serotonin blockade; some evidence it decreases neuronal atrophy
or increases neuronal growth
3.Salt product, so makes any dehydration worse.
4.Not easily processed by elderly.
5.Onset 5-7 days
6.May take 1-3 weeks before it works.
7.Do not use with clients who have/are PG, cardiac and renal disease.
Side effects and nursing care:
GI distress
N/V, diarrhea, abdominal pain
Nursing Considerations: Advise the client that GI distress is usually transient;
administer medication with milk; Contact HCP if diarrhea continues
Fine Hand Tremors ​
Can interfere with purposeful motor skills and exacerbated by factors such as stress and
caffeine
Nursing Considerations: Administer beta adrenergic blocking agents such as propranolol;
Adjust dosage to lowest possible; divide doses; Advise client to report an increase in tremors,
which could be a manifestation lithium toxicity
Weight gain and swelling can occur
Renal toxicity
-​ Nursing Considerations: Monitor I and O, Adjust dosage to lowest level, Assess
baseline BUN and creatinine, periodic monitoring kidney function
Electrolyte imbalances, arrhythmias, hypotension
 -​ Nursing Considerations: Encourage client to maintain adequate fluid and sodium intake
Polyuria, mild thirst
Nursing Considerations: Use a potassium sparing diuretic ; Instruct client to maintain
adequate fluid intake of at least 1.5-3 liters/day from beverages and food sources
NOTE: Any illness that causes vomiting or diarrhea is a concern.

Lithium toxicity can occur

Range for therapeutic treatment: 1.0-1.5 mEq/L
Maintenance: 0.6-1.2 mEq/L

1.5-2.0 mEq/L: blurred vision, ataxia*, tinnitus, persistent nausea/vomiting, severe diarrhea
2.0-2.5 mEq/L (Severe): excessive output of dilute urine, increasing tremors, muscular
irritability, psychomotor retardation, mental confusion
>2.5 mEq/L: Impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias,
myocardial infarction, cardiovascular disease

Chronic
-​ Increased reflexes
-​ Slurred speech
-​ Tremors
-​ Kidney failure
-​ Memory problems
-​ Movement disorders
-​ Problems maintaining Ca+ levels
-​ Psychosis (thought disturbance, unpredictable behavior)
-​ *Ataxia – not in full control of body movements

Care of pt on lithium:
•Monitor blood levels frequently: 1-2 X a week until levels are stable, then monthly during
maintenance
•Trough levels needed (what is this?)
•If toxic, hold med, call MD (Otherwise, do not stop medication abruptly)
•Do not drive until side effects are discovered and managed
•6-8 glasses of water each day
•Avoid caffeine
•Notify MD of V/D
•Avoid pregnancy until speak with physician
•Be aware of signs of toxicity
•May need diet high in sodium (reactive to sodium depletion)
•Any illness that causes vomiting or diarrhea is a concern.
• ID card, bracelet
• Educate patient.
Anticonvulsant Therapy (less toxic than lithium) black box warning for increased risk of
suicide*
Lamotrigine / Lamictal
Stevens-Johnsons Syndrome (SJS) is an immune-complex-mediated hypersensitivity reaction
and has been linked as an adverse side effects to many drugs. Lamotrigine, an anticonvulsive
medication and also a commonly used mood stabilizer, can be associated with this adverse
reaction. SJS has high mortality and morbidity and requires careful attention as the use of
Lamotrigine is increasing in clinical practice.
•Voltage-sensitive NA channel antagonist; may inhibit the release of Glutamate
•Metabolized by liver and excreted through kidneys
•Takes several weeks for effects
•Must be titrated slowly!!!
•High risk for Stevens-Johnson
Serious Side effects:
-Withdrawal seizures
-Blood dyscrasias
-Rare aseptic meningitis
-Rare activation of SI
Less dangerous:
-Headache
-Ataxia
-Abdominal pain
-Malaise

Carbamazepine/ Tegretol
-​ Less preferable to Lithium and Valproic Acid due to low therapeutic index (ratio of toxic
to therapeutic dose) and multiple drug interactions
-​ Efficacy in mixed episodes and rapid cycling
-​ Enhances GABA, decreases release of glutamate, blocks calcium influx
-​ CBC and Liver function tests every 6-12 mos.(hepatotoxicity)
-​ Do not take during pregnancy, Category D
Topiramate (can cause weight loss), Trileptal (watch for hyponatremia), Gabapentin
(alpha 2 delta ligand at voltage sensitive CA channels; is now a controlled substance)
Other anticonvulsants used with Bipolar.
General SE with anticonvulsants: CNS depressants
Monitor for side effects of anticonvulsants
-​ Nausea and vomiting (valproate)
-​ Weight gain (valproate)
-​ Drowsiness; dizziness
-​ Blood dyscrasias
-​ Prolonged bleeding time (with valproic acid)
-​ Risk of severe rash (with lamotrigine<Lamictal>)
-​ Risk of liver damage (especially with Depakote)
-​ Decreased efficacy of oral contraceptives (with topiramate)
-​ Risk of suicide with all antiepileptic drugs (FDA warning, December 2008)

Anxiolytics:
•Clonazepam / Klonopin
•Anxiolytic and anticonvulsant.
•Clonazepam is a member of the class of drugs known as benzodiazepines, and this drug
causes sedation.
•Clonazepam binds to a receptor in the brain (GABA) that helps make neurons less excitable.
•Clonazepam 's effects can sometimes be felt right away, but its full benefits are typically
reached in 3 to 4 weeks.

Calcium Channel Blockers:

-​ Verapamil (Verelan, Calan, Verelan PM, and Calan SR)
-​ Used with varying results
-​ Not first or second line
-​ Watch with cardiac patients, narrow angle glaucoma and diabetes
Monitor for side effects of verapamil
-​ Drowsiness; dizziness
-​ Hypotension; bradycardia
-​ Nausea
-​ Constipation