Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 14: Depressive Disorders Instructor’s Manual Thoughts About Teaching the Topic Although nearly everyone has experienced a low mood, most learners cannot conceptualize the depth and breadth of the experience of depression. Learning activities to sensitize students include first-person accounts of depression, books and articles about the experience of depression, guest presenters, case studies and films portraying depressed individuals. Key Terms and Concepts affect anergia anger anhedonia Beck’s cognitive triad diathesis–stress model of depression dysthymic disorder (DD) electroconvulsive therapy (ECT) hypersomnia learned helplessness light therapy major depressive disorder (MDD) mood disorders norepinephrine psychomotor agitation psychomotor retardation serotonin serotonin syndrome transcranial magnetic stimulation (TMS) vagus nerve stimulation (VNS) vegetative signs of depression Objectives Compare and contrast major depressive disorder and dysthymic disorder. Discuss the links between the diathesis–stress model of depression and the biological model of depression. Assess behaviours in a patient with depression in regard to each of the following areas: (a) affect, (b) thought processes, (c) feelings, (d) physical behaviour, and (e) communication. Formulate five nursing diagnoses for a patient with depression, and include outcome criteria. Name unrealistic expectations a nurse may have while working with a patient with depression, and compare them to your own personal thoughts. Role-play six principles of communication useful in working with patients with depression. Evaluate the advantages of the selective serotonin reuptake inhibitors (SSRIs) over the tricyclic antidepressants (TCAs). Compare and contrast the unique attributes of two of the atypical antidepressants. Write a medication teaching plan for a patient taking a tricyclic antidepressant, including adverse effects, toxic reactions, and other drugs that can trigger an adverse reaction. Write a medication teaching plan for a patient taking a monoamine oxidase inhibitor (MOAI), including foods and drugs that are contraindicated. Write a nursing care plan incorporating the recovery model of mental health. Describe the types of depression for which electroconvulsive therapy (ECT) is most helpful. Chapter Outline Teaching Strategies Clinical Picture Major Depressive Disorder Mood disorders (also called affective disorders) are a group of psychiatric disorders, including depression and bipolar disorder, characterized by a pervasive disturbance of mood that is not caused by an organic abnormality. Major depressive disorder has a number of specifiers such as the following: psychotic features, catatonic features, melancholic features, postpartum onset, seasonal features (seasonal affective disorder [SAD]), or atypical features. Premenstrual Dysphoric Disorder Patients with premenstrual dysphoric disorder have more severe symptoms than premenstrual syndrome. Symptoms begin toward the last week of the luteal phase, are absent in the week following menses, and include depressed mood, anxiety, affective lability, or persistent and marked anger or irritability. Other symptoms include anergia, overeating, difficulty concentrating, and feeling out of control or overwhelmed, among others. Dysthymic Disorder Mild to moderate symptoms of depression experienced over most of the day, more days than not, for at least 2 years, would be diagnosed as dysthymic disorder. Hospitalization is rarely necessary. Age of onset: from early childhood to early adulthood. Differentiating MDD from DD can be difficult because the disorders have similar symptoms. The main differences are in the duration and severity of the symptoms (Patten, Kennedy, Lam, et al., 2009). Epidemiology Depression is the leading cause of disability in the world. The lifetime prevalence of a major depressive episode or the total number of adults in Canada who will experience the disorder within their lifetime is 10.8% (Patten, Kennedy, Lam, et al., 2009). The average age of MDD onset is between 15 and 45 years of age. Studies find that MDD is more common in women and in younger age groups; however, its prevalence decreases with age (Patten, Kennedy, Lam, et al., 2009). Several Canadian studies found that MDD tends to have higher prevalence rates in lowerincome or unemployed populations and in unmarried or divorced people. Children and Adolescents Children and adolescents between 9 and 17 years of age have a 5% to 10% prevalence of depression, with girls being twice as likely as boys to experience depression. Older Adults Two million Canadians over age 65 (almost 6%) suffer from severe depression, and another 5 million (around 14%) suffer from less severe forms of depression (National Institute of Mental Health, 2007). However, residents in long-term care, inpatients, and patients with dementia are at particular risk for MDD (Thorpe, Whitney, Kutcher, et al., 2001). Many older adults suffer from subsyndromal depression, in which they experience many, but not all, of the symptoms of a major depressive episode. Co-Morbidity A depressive syndrome frequently accompanies other psychiatric disorders, such as schizophrenia, substance abuse, eating disorders, anxiety disorders, and personality disorders. Depression is high among people with a medical disorder. Biological Theories Genetic Factors Twin studies show that genetics plays a role in development of depressive disorders. Identical twins have a fivefold greater concordance rate than dizygotic twins. Biochemical At present, research suggests that depression results from the dysregulation of a number of neurotransmitter systems in addition to serotonin and norepinephrine. The dopamine, acetylcholine, and gamma-aminobutyric acid (GABA) systems are also believed to be involved in the pathophysiology of a major depressive episode (Sadock & Sadock, 2008). Although mixed efficacy is reported in clinical research, medical treatment is often successful. Alterations in Hormonal Regulation People with major depression have increased urine cortisol levels and elevated corticotropin-releasing hormone (Joska & Stein, 2008). Dexamethasone, an exogenous steroid that suppresses cortisol, is used in the dexamethasone suppression test for depression. Results of this test are abnormal in about 50% of people with depression, indicating hyperactivity of the hypothalamic–pituitary–adrenal cortical axis. Diathesis–Stress Model According to this model, depression results from a dynamic interplay of biology and environment. Some people are born with a predisposition toward depression, which is triggered by experiencing a stressful life event. The experience of depression further alters the neurological connections in the brain. Cognitive Theory This theory suggests depression is the product of irrational or illogical thinking and negative processing of information. Beck’s cognitive triad includes: a negative, deprecating view of self; a pessimistic view of the world; and the belief that negative reinforcement will continue in the future. The goal of cognitive therapy is to change the way patients think by assisting them to identify and test negative cognition, develop alternative thinking patterns, and rehearse new cognitive and behavioural responses. Learned Helplessness Seligman suggests that although anxiety is the initial response to a stressful situation, anxiety is replaced by depression if the person feels that the self has no control over the outcome of the situation. A person who believes that an undesired event is his or her fault and that nothing can be done to change it is prone to depression. A behavioural approach helps individuals gain a sense of control and mastery by teaching new and more effective coping skills and ways to increase self-confidence. Psychodynamic Influences and Life Events Psychosocial stressors and interpersonal events appear to trigger certain neurophysical and neurochemical changes in the brain. Early life trauma may result in long-term hyperactivity of the CNS corticotropin-releasing factor and norepinephrine systems, with a neurotoxic effect on the hippocampus. These changes could cause sensitization to even mild stress in adulthood and predispose to major depression. Application of the Nursing Process Assessment Assessment Tools Numerous standardized depression screening tools that help assess the type of depression are available, including the Beck Depression Inventory, the Hamilton Depression Scale, the Zung Depression Scale, and the Geriatric Depression Scale. Dr. Bagby’s Depression Scale, however, is considered the leader in assessing depression. Assessment of Suicidal Potential The patient should always be evaluated for suicidal or homicidal ideation. About 15% of people with clinical depression commit suicide. Refer to Chapter 25 for a detailed discussion of suicide, critical risk factors, warning signs, and strategies for suicide prevention. Also see Case Study and Nursing Care Plan 14-1 on pages 254– 256. Key Assessment Findings Include depressed mood; anhedonia; anxiety; psychomotor retardation; poor memory and concentration; dwelling on perceived faults and failures; delusions of being punished or of being a terrible person; feelings of worthlessness, helplessness, guilt, and anger; and vegetative signs (change in bowel habits and eating habits, sleep disturbances, and disinterest in sex). Areas to Assess Affect Sadness, dejection, and hopelessness are reflected. Posture is slumped. Eye contact is poor. Bouts of weeping may occur, or patient may be unable to cry. Anhedonia is present. Thought Processes Assessment of suicidal ideation is the highest priority. Delusions of being punished for bad deeds or being a terrible person are common, as is trouble concentrating or thinking. Judgement is poor, indecisiveness is common, and memory is impaired. Feelings Anxiety, worthlessness, guilt, anger, hopelessness, and helplessness are experienced. Themes of inadequacy and incompetence are repeated relentlessly. Guilt is seen in rumination over present and past failings. Delusional belief that one is being punished by God for terrible sins is common. Helplessness is evidenced by inability to carry out even simple tasks. Hopelessness is present and has been identified as having the following attributes: negative expectations for the future, loss of control over future outcomes, passive acceptance of the futility of planning to achieve goals, and emotional negativism, as expressed in despair, despondency, or depression. Anger and irritability are outcomes of feelings of helplessness. Anger in depression is often expressed inappropriately in property destruction, hurtful verbal attacks, or physical aggression toward others or self. Physical Behaviour Lethargy and fatigue can result in psychomotor retardation, which can range from slowed movement to complete inactivity and incontinence. Psychomotor agitation may be seen in other patients. Grooming and personal hygiene are often neglected. Vegetative signs of depression are universal. Changes in eating patterns are common, with anorexia occurring in 60% to 70% of people with depression. Sleep pattern disturbances are a cardinal sign of depression. Terminal insomnia is prevalent, but some experience hypersomnia. Change in bowel habits is common. Constipation is typically seen in patients with psychomotor retardation, and diarrhea sometimes occurs in patients with psychomotor agitation. Loss of libido usually occurs, with males sometimes experiencing impotence. Communication Slow speech is common. Comprehension is slowed, with muteness possible. More time is needed by the patient to compose a reply. Religious Beliefs and Spirituality Research has shown that people with depression were aided by religious and spiritual beliefs. Age Considerations Depression is often overlooked in children and adolescents, because mood changes in children are frequently seen as behavioural problems and in adolescents as a part of normal development. Depression in older adults is also frequently overlooked as they are more likely to complain of physical ailments rather than feelings of sadness or grief. Self-Assessment Patients with depression often reject the advice, encouragement, and understanding of the nurse and others, and they often appear not to respond to nursing interventions and seem resistant to change. Nurses witnessing such behaviours may feel frustrated, hopeless, and annoyed. These problematic responses can be altered by the following: • Recognizing any unrealistic expectations for yourself or the patient Identifying feelings that originate with the patient Understanding the roles biology and genetics play in the precipitation and maintenance of a depressed mood Diagnosis Useful nursing diagnoses include: Risk for self-directed violence, Disturbed thought processes, Chronic low self-esteem, Powerlessness, Spiritual distress, Impaired social interaction, Activity intolerance, Imbalanced nutrition: less than body requirements, Constipation, Disturbed sleep pattern, Ineffective coping, Interrupted family processes, Ineffective role performance, and Risk for impaired parent/infant/child attachment. Outcomes Identification Outcome criteria and short-term goals are individualized for each patient. The Recovery Model This model emphasizes that healing is possible and attainable for people with depression. Recovery is obtained through partnership with providers who focus on the patient’s strengths. Planning Planning for patients with depression is geared toward the patient’s phase of depression, particular symptoms, and personal goals. Implementation 1. Three phases in treatment and recovery from major depression are conceptualized as: The acute phase (6 to 12 weeks)—psychiatric management and initial treatment The continuation phase (4 to 9 months)—treatment continues to prevent relapse The maintenance phase (1 or more years)—continuation of antidepressants to prevent relapse Counselling and Communication Techniques Depressed patients may be unable to carry on conversations with the nurse, and the nurse may become anxious as a result. The nurse must realize that sitting in silence communicates caring. Communication guidelines: use technique of making observations; use simple, concrete words; allow time for patient to respond; listen for covert messages and ask about suicide plans; avoid platitudes. Counselling guidelines: help patients question underlying assumptions and beliefs and consider alternative explanations; work with patients to identify cognitive distortions that encourage negative self-appraisal; encourage activities that raise self-esteem (developing problem-solving skills, coping skills, and assertiveness); encourage exercise (e.g., running, weightlifting); encourage formation of supportive relationships; provide referrals to religious or spiritual resources as needed. Health Teaching and Health Promotion Helping patients and families to understand that depression is a medical illness is the goal. The biological symptoms of depression should be explained, along with teaching about medications. Predischarge counselling should include clarification of interpersonal stresses and discussion of measures to reduce tension for the family system. Possible use of aftercare facilities can be explored. Promotion of Self-Care Activities Patient should be assisted with self-care activities as necessary. Milieu Therapy Hospitalization is necessary for acutely suicidal patients, to regulate medication, or (when indicated) to provide a course of ECT. Milieu protocols for patient safety are useful. During the continuation and maintenance phases, people find that various short-term therapies are useful for dealing with the presence and aftermath of the episode. Support groups may also be helpful. Advanced-Practice Interventions The advanced practice nurse is qualified to provide psychotherapy, social skills training, and group therapy (ANA, 2000). Psychotherapy/Group Therapy Nurses may conduct short-term therapies, which have produced good results. Interpersonal psychotherapy (IPT) focuses on the role of dysfunctional interpersonal relationships in precipitating and perpetuating depression. Cognitive-behaviour therapy teaches the connection between thoughts and feelings, the negative thoughts typical of depression, and the reframing of thinking. The behavioural component may be used to teach depressed patients effective social and coping skills. Group treatment and interactive group therapy may also be helpful. Psychopharmacology A combination of specific psychotherapies and antidepressants has been found to be superior to either alone. Antidepressant Drugs Antidepressants can positively alter poor self-concept, degree of withdrawal, vegetative symptoms, and activity level. Target symptoms include sleep disturbance, appetite disturbance, fatigue, decreased sex drive, psychomotor retardation or agitation, diurnal variations, impaired concentration or forgetfulness, and anhedonia. It may be necessary to take antidepressants for 1 to 3 weeks or longer before response is shown. Choosing an Antidepressant Primary considerations are: adverse-effect profile, ease of administration, history of past response, safety and medical considerations, and specific subtype of depression. Secondary considerations are: neurotransmitter specificity, family history of response, blood level considerations, and cost. Selective Serotonin Reuptake Inhibitors SSRIs are recommended as first-line therapy in all types of depression except psychotic depression, melancholic depression, and mild depression. They have a low incidence of anticholinergic adverse effects, low cardiotoxicity, and faster onset of action than tricyclics. Patient compliance is better than with other antidepressants. SSRIs are prescribed with success for several anxiety disorders and for some patients with dysphoric disorder. Common adverse effects include mild anticholinergic effects (dry mouth, blurred vision, urinary retention), agitation, sleep disturbance, tremor, anorgasmia, and headache. Autonomic reactions are dry mouth, sweating, weight change, mild nausea, and loose bowel movements. Serious adverse effects include central serotonin syndrome (CSS), as evidenced by abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure (BP), delirium, myoclonus, irritability, hyperpyrexia, and cardiovascular shock. Risk is great if given concurrently with an MAOI, so a time gap should exist between medications. Tricyclic Antidepressants The TCAs act by inhibiting reuptake of norepinephrine and serotonin by the presynaptic neurons in the CNS and require 10 to 14 days or longer to start to work. Treatment is begun with low doses and increased. Therapy is continued 6 to 12 months to prevent early relapse. Common adverse effects include anticholinergic effects such as dry mouth, blurred vision, tachycardia, orthostatic hypotension, constipation, urinary retention, and esophageal reflux. Serious adverse effects are cardiac dysrhythmias, tachycardia, myocardial infarction, and heart block. Adverse drug interactions may occur when TCAs are taken concurrently with MAOIs, phenothiazines, barbiturates, disulfiram, oral contraceptives, anticoagulants, benzodiazepines, alcohol, nicotine, and some antihypertensives. Contraindications are recent myocardial infarction, narrow-angle glaucoma, seizures, and pregnancy. Administering the total daily dose at night is beneficial; the sedative effects will aid sleep, and minor adverse effects will occur during sleep when the patient is unaware of them (fosters compliance). Areas for the nurse to discuss with patient and family are detailed in the Patient and Family Teaching box on page 248. Monoamine Oxidase Inhibitors MAOIs are effective treatment for atypical depression and several anxiety disorders, when dietary restriction of tyramine is observed. Common adverse effects include orthostatic hypotension, weight gain, edema, change in heart rate and rhythm, constipation, urinary hesitancy, vertigo, hypomanic or manic behaviour, insomnia, weakness, and fatigue. Adverse reactions are an increase in BP with possible stroke, hyperpyrexia, and convulsions and death in the presence of tyramine-containing foods. Contraindications include cerebrovascular accident; congestive heart failure; hypertension; liver disease; foods containing tyramine, tryptophan, and dopamine; surgery in 10 to 14 days; and children under 16. See Patient and Family Teaching box on page 250. Electroconvulsive Therapy This therapy is given when a rapid, definitive response is needed to prevent suicide; extreme agitation or stupor occurs; risks of other treatment outweigh risks of ECT; there is poor response to drugs; or when a patient prefers it. It is useful for major depression and for manic patients who are rapid cyclers. The procedure requires informed consent. Patient preparation is similar to preoperative preparation; post-treatment is similar to care of an unconscious patient. Potential adverse effects include confusion, disorientation, and short-term memory loss. Transcranial Magnetic Stimulation This integrative approach is a new technology that uses MRIstrength magnetic pulses to stimulate focal areas of the cerebral cortex. There is no seizure induction. More research is indicated to evaluate its effectiveness. Vagus Nerve Stimulation Researchers believe that electrical stimulation of the vagus nerve results in boosting the level of neurotransmitters, thereby improving mood and also improving the action of antidepressants. Integrative Therapy Nurses should be knowledgeable about these therapies in order to give information to patients. Light Therapy Light therapy successfully treats seasonal affective disorders. It is probably effective because of the influence of light on melatonin. It is delivered by a special balanced light slanted toward a patient’s face for a total of 30 minutes daily. St. John’s Wort This is a plant product found to be somewhat effective for mildly to moderately depressed individuals. It interacts with a number of substances and drugs and may produce CSS and hypertensive crisis when tyramine is ingested. Exercise and Outdoor Activity Exercise—particularly outdoors—is effective against mild depression. Evaluation Evaluation is based on outcome criteria and goals. Outcomes often relate to thought processes, self-esteem, and social interactions because these are problematic in people who are depressed. Future of Treatment There is a great need for earlier detection, interventions, achievement of remission, prevention of progression, and integration of neuroscience and behavioural science. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 15: Bipolar Disorders Instructor’s Manual Thoughts About Teaching the Topic Few students can imagine the hyperactivity, rapid mood swings, grandiosity, and disorganization of the patient with mania. Since nursing interventions and decisions are difficult to execute when students are meeting their first manic patient, behavioural rehearsals in the classroom are helpful. After students read the material, several “rehearsal” possibilities (which can be “mixed and matched”) exist: Create a series of role-plays. Create trigger situations on video, using essentially the same types of situations as for role-plays. Assign students to use a computer simulation. Key Terms and Concepts acute phase anticonvulsant drugs bipolar I disorder bipolar II disorder clang associations continuation phase cyclothymia euphoric mood flight of ideas grandiosity hypomania maintenance phase mania rapid cycling seclusion protocol Objectives Assess a person experiencing mania for (a) mood, (b) behaviour, and (c) thought processes, and be alert to possible dysfunction. Formulate three nursing diagnoses appropriate for a person with mania, and include supporting data. Explain the rationales behind five methods of communication that may be used with a person experiencing mania. Teach a nursing student at least four expected adverse effects of lithium carbonate therapy. Distinguish between signs of early and severe lithium carbonate toxicity. Write a medication care plan specifying five areas of teaching regarding lithium carbonate. Compare and contrast clinical conditions that may respond better to anticonvulsant therapy with those that may respond better to lithium carbonate therapy. Evaluate specific indications for the use of seclusion for a person experiencing mania. Review at least three of the items presented in the patient and family teaching plan (see Patient and Family Teaching: Bipolar Disorder) with a person with bipolar disorder. Distinguish the focus of treatment for a person in the acute manic phase from the focus of treatment for a person in the continuation or maintenance phase. Chapter Outline Teaching strategies Clinical Picture Once commonly known as manic depression, bipolar disorder is a chronic, recurrent illness. It frequently goes unrecognized, and people suffer for an average of six years before receiving a proper diagnosis and treatment. The three types identified include the following (listed from most to least severe): Bipolar I disorder: At least one episode of mania alternates with major depression. Psychosis may accompany the manic episode. Bipolar II disorder: Hypomanic episode(s) alternate with major depression. Psychosis is not present in bipolar II. The hypomania of bipolar II disorder tends to be euphoric (an exaggerated feeling of physical and mental well-being, especially when not justified by external reality) and often increases functioning (Benazzi, 2007), and the depression tends to put people at particular risk for suicide. Cyclothymia: Hypomanic episodes alternate with minor depressive episodes (at least two years in duration). Individuals with cyclothymia tend to have irritable hypomanic episodes. The specifier rapid cycling (four or more mood episodes in a 12month period) indicates more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments. Rapid cycling is seen in 5% to 15% of people with bipolar disorder. In all cases, periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both). Epidemiology Approximately 1% of Canadians will experience bipolar disorder. The mortality rate among individuals with bipolar disorder is two to three times greater than that of the general population and includes higher rates of suicide (Health Canada, 2002). The median age of onset for bipolar I is 18 years; for bipolar II, the median age of onset is 20 years (Merikangas, Akiskal, Angst, et al., 2007). Bipolar I tends to begin with a depressive episode— in women, 75% of the time; in men, 67% of the time (Sadock & Sadock, 2008). The episodes tend to increase in number and severity during the course of the illness. Bipolar I disorder seems to be somewhat more common among males, but bipolar II disorder (characterized by the milder form of mania—hypomania—and increased depression) is more common among females (Baldassano, Marangell, Gyulai, et al., 2005). Women with bipolar disorder are more likely to abuse alcohol, commit suicide, and develop thyroid disease; men with bipolar disorder are more likely to have legal problems and commit acts of violence. Co-Morbidity Substance use disorders commonly coexist with bipolar disorder. Other associated disorders include personality disorders, anxiety disorders, anorexia nervosa, bulimia nervosa, and attention deficit-hyperactivity disorder. Etiology Most likely, multiple independent variables contribute to the occurrence of bipolar disorder. A biopsychosocial approach will likely be the most successful approach to treatment. Biological Theories Genetic The rate of bipolar disorders in relatives can be as high as 5 to 10 times over rates found in the general population. Twin studies and studies of relatives of people with bipolar disorder point to genetic transmission as well. Neurobiological Mood disorders are likely the result of complex interactions between neurotransmitters and hormones. Regions of the prefrontal cortex and medial temporal lobe have been implicated in pathophysiology of bipolar disorders, as have the neurocircuits surrounding these areas. Neuroendocrine The hypothalamic–pituitary–thyroid–adrenal (HPTA) axis is an area that is being studied in individuals with mood disorders. Hypothyroidism has been associated with mood disorders. Psychological Influences Although there is increasing evidence for genetic and biological vulnerabilities in the etiology of the mood disorders, psychological factors may play a role in precipitating manic episodes for many individuals. In the absence of severe stressful events, it is possible that a person with a genetic predisposition and a neurochemical imbalance may never experience symptoms of bipolar disorder. However, once the disease has been triggered by an event that is perceived as stressful—for example, loss of a relationship, financial difficulties, failing an exam, being accepted to a highly desirable graduate school—it no longer requires environmental stress to continue. Environmental Factors Bipolar disorders may be more prevalent in the upper socioeconomic classes. Application of the Nursing Process Assessment Early diagnosis and treatment can help individuals avoid suicide, alcohol, substance abuse, marital or work problems, and development of medical co-morbidity. General Assessment The characteristics of mania discussed in the chapter include mood, behaviour, thought processes and speech patterns, and cognitive functioning. Mood The euphoric mood associated with bipolar illness is unstable. Overly joyous mood may alternate with irritability and belligerence. The person laughs, jokes, talks with uninhibited familiarity, is enthusiastic, and may concoct elaborate schemes to get rich and acquire unlimited power. The person may give away money and gifts, have lavish parties, and spend money freely. Behaviour During mania, the patient starts many projects but finishes few. He or she is hyperactive, moving rapidly from one place to another. There may be indiscriminate spending, foolish business ventures, great generosity. He or she may be sexually indiscreet, manipulative, faultfinding, profane, and adept at exploiting the vulnerabilities of others. The person is often too busy to sleep, eat, or rest. Nonstop physical activity and lack of sleep and food can lead to physical exhaustion and even death if mania is left untreated. Colourful, inappropriate, even bizarre dress and overdone makeup are seen. The patient with mania is highly distractible and has poor concentration. After mania, the person often emerges startled and confused by the shambles of his or her life. Thought Processes and Speech Patterns Flight of ideas—accelerated speech with abrupt changes of topic, usually based on understandable associations or plays on words— is common. Rapid speech, verbosity (sometimes circumstantial), jokes, puns, and sexually explicit, vulgar, loud language may manifest. Themes revolve around grandiosity, extraordinary sexual prowess, brilliant ability, and great artistic talents. Grandiose delusions of persecution may be seen. The person has poor concentration and attention span and is distractible. At the farthest point on the continuum, speech may show clang associations— the stringing together of words because of the way they sound (rhyming). Speech may become disorganized and incoherent. Cognitive Function There is growing evidence that about a third of patients with bipolar disorder display significant and persistent cognitive problems in psychosocial areas. Self-Assessment The patient with mania elicits numerous intense emotions on the part of the nurse: frustration, anger, embarrassment, and fear, to name a few. Fatigue is common. The patient is out of control and resists being controlled through the use of humour, manipulation, power struggles, and aggressive, demanding behaviour. Patients with mania are masterful at pointing out staff faults and in splitting staff. Setting and maintaining limits is difficult but essential. Assessment Guidelines: Bipolar Disorder Six important points are spelled out in the assessment alert: (1) assess danger to patient or others; (2) protect patient from consequences of overgenerosity; (3) assess for need for hospitalization; (4) assess medical status; (5) assess for coexisting conditions needing special intervention; and (6) assess patient and family understanding of bipolar disorder, medications, support groups, and other teaching needs. Diagnosis Risk for injury is often the priority nursing diagnosis. Table 14-2 lists other useful diagnoses, including Risk for self-directed violence, Risk for other-directed violence, Disturbed thought processes, Ineffective coping, Defensive coping, Impaired verbal communication, Impaired social interaction, Deficient fluid volume, Imbalanced nutrition: less than body requirements, Constipation, Disturbed sleep pattern, Self-care deficit, Interrupted family processes, and Caregiver role strain. Outcomes Identification Table 15-1 Acute Phase Patient will be free of injury—cardiac status stable, well hydrated, free of abrasions. Patient will report absence of delusions, racing thoughts. Patient will have balanced sleep–rest-activity pattern. Outcomes depend upon nursing diagnoses and the phase of the illness the patient is experiencing. Continuation Phase Patient will demonstrate adherence to medication regimen. Patient and family will participate in psychoeducational classes, etc. Maintenance Phase Patient and family are aware of prodromal signs of escalating mood or depression. Patient participates in ongoing supportive modality, etc. Planning Planning is geared toward the phase of treatment as well as cooccurring issues such as risk of violence or suicide, family crisis, etc. Acute Phase During the acute phase, measures are taken to medically stabilize the patient while maintaining patient safety. Nursing care is geared toward lowering physical activity, increasing food and fluids, ensuring sleep, alleviating bowel or bladder problems, and intervening with self-care needs and medication management. Seclusion or ECT may be part of the plan. Continuation Phase During the continuation phase, the focus is on maintaining medication compliance and preventing relapse. Patient and family psychoeducation is a must. The need for communication skills training and problem-solving skills is evaluated, and referrals are made to community programs, groups, and support groups. Maintenance Phase During the maintenance phase, the goal is to continue to prevent relapse and limit the duration and severity of future episodes. Implementation Establishment of a therapeutic alliance is critical. Many patients minimize the consequences of their behaviours or deny the seriousness of the disease. Some are reluctant to give up the euphoria of the disorder. Medication noncompliance is a major cause of relapse. Acute Phase: Depressive Episodes During the acute phase of treatment, the hospital is the safest place to provide external controls on destructive behaviour and provide medical stabilization. Unique approaches to communication and to providing safety are offered in Table 14-3. Manic Episodes External controls are imposed on destructive behaviours and medication regimens during hospitalization. Continuation Phase Outcome for this phase is prevention of relapse and referrals to community resources. Maintenance Phase Goal for this phase is to prevent recurrence of an episode of bipolar disorder. Medication follow-up and adherence, day hospitalization or home visits, and family support are all part of this phase. Psychotherapy, support groups, psychoeducational groups, and periodic evaluations help patients maintain their family, social, and occupational lives. Psychopharmacological Interventions: Lithium Carbonate and Anticonvulsant, Antianxiety, and Atypical Antipsychotic Drugs Lithium is the antimanic drug of choice used as a mood stabilizer. It is effective in reducing elation, grandiosity, flight of ideas, irritability, manipulativeness, and anxiety. To a lesser extent, it controls insomnia, agitation, distractibility, and threatening or assaultive behaviour. Initially, an antipsychotic drug may be given to treat acute mania to prevent exhaustion and coronary collapse. An alternative is to initiate treatment with lithium and benzodiazepines to address insomnia and hyperactivity. Physical workup is necessary before beginning therapy to assess patient ability to tolerate drug. Dosages of 300 to 600 mg (three times a day) may be needed to reach a maintenance level of 0.4 to 1.3 mEq/L. At serum levels of about 1.5 mEq/L, early signs of toxicity can occur. Severe toxicity requiring emergency measures can be seen at levels of 2.0 to 2.5 mEq/L. Adverse reactions are associated with serum levels of 2.0 mEq/L or above. Blood levels are drawn weekly or biweekly until the therapeutic level is reached. After that, levels are checked every month. After 6 months to 1 year of stability, levels are checked every 3 months. Maintenance therapy: Relapse occurs within several weeks of stopping lithium. Patients should take lithium for 9 to 12 months after an episode. Others continue on the drug indefinitely. When lithium is to be discontinued, the dose must be gradually tapered. Risks of long-term lithium therapy include hypothyroidism and inability to concentrate urine; thus periodic thyroid and renal tests are called for. Contraindications: Prior to beginning therapy, a medical evaluation is necessary. It should include renal function tests, thyroid status, and evaluation for dementia or neurological disorders. Contraindications include cardiovascular disease, pregnancy or breastfeeding, renal or thyroid disease, brain damage, myasthenia gravis, and children younger than 12 years. Anticonvulsant drugs are useful for patients who do not respond to lithium or who cannot tolerate lithium. Conditions under which anticonvulsant use may be preferable are listed in the chapter. Carbamazepine (Tegretol) may be used in conjunction with lithium or separately. Works well with rapid cyclers and with those manifesting paranoid thinking. Blood-level monitoring is called for. Valproic acid (Depakene) and divalproex sodium (Epival) are also useful for rapid cycling and with those manifesting dysphoric symptoms. Lamotrigine (Lamictal) and gabapentin (Neurontin) may be useful for patients without sufficient stabilizing results from other therapy. Antianxiety drugs: Clonazepam (Rivotril) and lorazepam (Ativan) are effective in managing psychomotor agitation seen in mania. Canadian guidelines support the use of olanzapine (Zyprexa), risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), and ziprasidone (Zeldox). For example, an initial study showed that olanzapine is better tolerated and prevents mania relapse more effectively than lithium (Tohen, 2003). Ziprasidone, recently approved in Canada for bipolar disorder, and quetiapine, both original formula and Seroquel XR (extended release), are the only medications currently approved for use in both the manic and depressive phases of bipolar disorder (Mood Disorders Society of Canada, 2009). Electroconvulsive Therapy May be used to treat severe manic behaviour and those with depressive episodes, especially in treatment-resistant individuals. Electroconvulsive therapy (ECT) may be considered as an alternative during pregnancy in cases of psychotic decompensation or suicidal ideation (CANMAT, 2009, p. 34). ECT is effective for patients with bipolar disorder who have rapid cycling, for those with paranoid-destructive features (who often respond poorly to lithium therapy), and in acutely suicidal patients. Milieu Management Control during the acute hyperactive phase nearly always includes treatment with an antipsychotic such as haloperidol (Haldol) or chlorpromazine (Largactil). Seclusion may be necessary to reduce overwhelming environmental stimuli, protect patient from injuring self or others, and prevent destruction of property. Seclusion or restraint requires consent of the patient, except during an emergency, and requires the written order of a physician. It can be used only when other less restrictive measures have failed. Observation and care to be given while the patient is in seclusion are agency specific. Careful documentation according to agency protocol is necessary. Support Groups Patients with bipolar disorder, as well as their friends and families, benefit from forming mutual support groups. Often, these are coordinated by organizations such as the Mood Disorders Society of Canada and the Canadian Mental Health Association. Health Teaching and Health Promotion Health teaching focuses on information about bipolar illness, the importance of medication compliance, symptoms of impending episodes, and the importance of regularization of sleep patterns, meals, and exercise. Advanced-Practice Interventions When a patient is not experiencing acute mania, APRNs may utilize psychotherapy to help the patient cope more adaptively to stresses in the environment and to prevent relapses. Psychotherapy Psychotherapy can help people work through strained interpersonal relationships, marriage and family problems, academic and occupational problems, and legal or social difficulties. Cognitive-behavioural therapy (CBT) has been found to be effective. Psychotherapy is important in encouraging medication compliance. One study reported that patients treated with CBT more often took medication as prescribed than did patients who were not in therapy. Evaluation Outcome criteria dictate the frequency of evaluation of short-term goals. Whenever goals remain unmet, preventing factors are analyzed. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400
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