Mental Health

2.  a mood disorder, in which depressive symptoms are
severe, where there is extraordinary sadness and
dejection, and the inability to take pleasure in activities.
 the symptoms are all-pervasive and debilitating in most
areas of the client’s existence.
 DSM IV – AXIS 1
 co-morbidity – mood disorders often coexist with other
conditions such as personality, eating, anxiety, and
substance abuse disorders.
 depression is one of the primary causes of self-harm and
suicide.

3. Aetiology
Biopsychosocial model of causation (combination of
factors interacting that causes the illness)
 genetic
 gene-environment interaction
 neurochemical
 hormone systems and circadian rhythms

4. Indicators and Symptoms
 Behavioural changes
 Cognitive changes
 Communication changes
 Moods changes
 Alternations in physical functioning

5. Behavioural changes
 Social and emotional withdrawal &
decreased interest in, and pleasure from,
previously enjoyable activities.
 Less effective in areas of work or family
relations.
 Substance abuse
 Overall alcohol dependence and
depression co-morbidity

6. Cognitive changes
 Increasingly egocentric
 Catastrophic thinking or catastrophising and
inappropriate guilt. i.e. thoughts about self:
incompetent, faulty, unlovable and a failure
thoughts about others: uncaring and unhelpful.
thoughts about world: a place of despair and desolation,
and the future as gloomy
 Difficulty concentrating on activities
 Immobilised by cognitive difficulties involved in ordinary
decision-making process
 Cognitive spectrum: narrows with negative thoughts and
ideas being frequently ruminated over
 Self –deprecating beliefs, negative expectation of others
and a sense of doom may contribute to thoughts of
death and suicidal ideation

7. Communication changes
 Narrowing and repetitive focus of their
thoughts
 Negative self-absorption in combination
with insufficient energy and interest in
others: unlikely to initiate a conversation,
taking a long time to answer an
question, and give a short reply

8. Mood changes
 Significant lower mood for at least 2
weeks
 Sadness, anguish and misery, along
with a feeling of separation from others,
and a feeling of hopelessness and
powerlessness, constitute the pain of
depression.
 Cry a lot.

9. Alterations in physical functioning
 Sleep disturbances, particularly insomnia
 Fatigue
 Sexual desire diminished
 Disturbed appetite for food, with
subsequent loss of weight and constipation
 Psychomotor disturbances for very
depressed people
 Somatisation

10. Suicide Assessment
Assessment Of Risk
Definition:
 The voluntary/intentional act of taking one’s
own life especially by a person of years of
discretion and sound mind(merriam-webster,
2009)
 An attempt by an individual to solve a problem
that they find overwhelming (US Dept of
Veterans Affairs, 2009)

11. Suicide assessment
 suicide risk assessment should
specifically
 focus on the collection of data related
to suicide risk factors including
suicidal ideation and level of planning
(Schwartz & Rogers, 2004)

12. Suicide assessment
 SAD PERSONS ESCCAPE
 L A A (US Department of Veterans)

13. SAD PERSONS ESCAPE
 S sex (Male higher risk for suicide)
 A age (15-24 or over 65)
 D depression

14. P.E.R.S.O.N.S.
 P previous attempt
 E ethanol abuse
 R rational thinking
 S support system
 O organized plan
 N No spouse/partner
 S Sickness

15. E.S.C.C.A.P.E.
 E experience of adversity
 S sexually abused
 C co-morbidity issues
 C cultural factors
 A anxiety
 P personality factors
 E events

16. SCORING
 12 and UP High Risk
 5-11 - medium
 0-4 Low

17. LAA (under Operation
SAVE)
 LOOK for the warning signs
 Assess for risk and protective factors
 Ask the questions
***SAVE (Signs, Assess,Validate
person’s experience,Encourage
treatment and expedite getting help)

18. LOOK FOR THE WARNING
SIGNS
 FIRST THREE
 Threatening to hurt or kill self
 Looking for ways to kill self; seeking
access to pills, weapons or other
means
 Talking or writing about death, dying
or suicide

19. Other signs
 Hopelessness
 Feeling trapped – like there’s no way
out
 Withdrawing from friends, family or
society
 Increasing alcohol or drug abuse
 Anxiety, agitation, unable to sleep or
sleeping all the time
 Dramatic changes in mood

20. Other Signs
 Acting reckless or engaging in risky
activities, seemingly without thinking
 No reason for living, no sense of
purpose in life
 Rage, anger, seeking revenge

21. FACTORS THAT INCREASE SUICIDE
RISK
 Current ideation, intent, plan, access to
means
Previous suicide attempt or attempts
Alcohol / Substance abuse
 Current or previous history of psychiatric
diagnosis
 Impulsivity and poor self control
 Hopelessness – presence, duration,
severity
 Recent losses – physical, financial, personal

22. Risk Factors
 Recent discharge from an inpatient
psychiatric unit
 Family history of suicide
 History of abuse (physical, sexual or
emotional)
 Co-morbid health problems, especially a
newly diagnosed problem or worsening
symptoms
 Age, gender, race (elderly or young adult,
unmarried, white, male, living alone)
 Same- sex sexual orientation

23. PROTECTIVE FACTORS
 Positive social support
 Spirituality
 Sense of responsibility to family
 Children in the home, pregnancy
 Life satisfaction

24. Protective Factors
 Reality testing ability
 Positive coping skills
 Positive problem-solving skills
 Positive therapeutic relationship

25. ASK the Questions
 Are you feeling hopeless about the
present/future?
 Have you had thoughts about taking
your life?
 When did you have these thoughts and
do you have a plan to take your life?
 Have you ever had a suicide attempt?

26. GENETIC AND BIOLOGIC FACTORS
Social & Demographic factors
CHILDHOOD ADVERSITY
Personality traits & Cognitive
Styles
Exposure to
stress &
Adversity
Psychiatric
morbidity
Suicide &
suicide attempt

27. Interventions
A thorough, accurate, comprehensive
and ongoing assessment

28. Be genuine and honest with patients

29. Encourage the client to identify positive
aspects of self

30. Identify positive aspects in the
client’s world

31. Express hope to them that their
spirits will lift

32. Spend time with withdrawn clients

33. Encourage the client to
ventilate feelings in whatever
way is comfortable

34. Never reinforce hallucinations,
delusions or irrational beliefs

35. Make positive decisions for clients if
they are unwilling to make decisions
for them self

36. Help the client to prioritize problems

37. Nursing interventions
For suicide prevention
Problems relating to this suicidal
episode relating to Depression could
be Powerlessness, social isolation,
disturbed sleep pattern, hygiene
deficit.

38. Nursing Priorities will be to identify
the areas of life within the control of
the patient and how he can make
changes.

39. Acknowledge the reality of the
patient’s feeling and his diagnosis of
clinical depression.

40.  Develop a rapport & therapeutic
relationship with him to build up trust;
Listening carefully, maintain eye
contact and remain calm.
Rationale is to know why he is having
feeling of isolation and whether the
feelings come from a specific
experiences with people or from fear
of rejection.

41.  Interview the patient and give ample
time to relay his story; to know what
led to desperation and depression
and to know his most pressing
problems.
 Any previous suicidal attempt
 Any unresolved issues.

42.  Ask if he has any plan to hurt himself,
as this will reduce the likelihood of
acting.
 Pay attention to his talk of having a
weapon like gun, and watch for
unsafe behavior as this could be a
warning signs.

43.  Encourage visitation by his support
family and friends and get them
involve in activities with the patient
 To alleviate his fear of rejection, and
increase his level of participation in
the activities.

44.  Encourage early initiation of anti
depressant drugs as this takes time to
enact its therapeutic effect.

45.  Get him involved in the activities that
he enjoy before that help to
counteract feelings of helplessness
and powerlessness.
 Get him involved in his /her care, this
will allow him to feel that he has some
key say and control.

46.  Avoid using PPE e.g mask, gown,
gloves if the patient does not demand
standard precautions and not having
any contagious disease such as
H1N1,HIV
 To reduce his fear of rejection.

47.  keep a strict record of sleeping
pattern. Accurate baseline data is
important in planning care to assist
this experience.
 At night, provide warm baths,
soothing music, and medication when
indicated to promote relaxation, rest,
and sleep.

48.  Avoid giving client caffeine. Caffeine
is a central nervous system stimulant
that may interfere with the client’s rest
and sleep.
 Administer sedative prn to help client
achieve sleep until normal sleep
pattern is restored.

49.  Maintain a safe environment by
removing a potentially harmful items out
of the patients reach.
 Depending on the level of risks, constant
observation (gate keeper) might be
highly necessary.

50. Pharmacology
• Anti-anxiety
• Antidepressant
• Mood-stabilising
• Antipsychotic
•Tricyclic
• MAOI’s (Mono-amine
oxidase inhibitors)
• SSRI’s (Selective
serotonin reuptake
inhibitors).

51. Pharmacology
Antidepressants:
Tricyclic: Amitriptyline
Lofepramine
Trazodon

52. Phamacology Tricyclic
Action of medication:
• Inhabit serotonin and noradrenalin reuptake
• Lead to extra transmitters available for receptor
binding
• These two substances appear as
neurotransmitters in synapses in the brain
regions involved with the state of alertness
• In the depressions, serotonin would be
decreased in the synaptic spaces

53. Phamacology Tricyclic
Side effects:
sedation, dry mouth, constipation, blurred vision,
seizures and urinary retention.
Postural hypotension and serious cardiac problems such
as heart block and arrhythmias.
They can lead to life threatening consequences if taken
in large quantities, such as in suicide attempts.
In the case of severely depressed patients where a
potential for suicide is predicted, close supervision is
required and when the person is not an inpatient, the
dispensing, sublethal quantities is recommended.

54. Phamacology Tricyclic
Signs of tricyclic overdose:
agitation, confusion, drowsiness, delirium,
convulsion, bowel and bladder paralysis,
disturbances with the regulation of blood
pressure and temperature and dilated pupils.

55. Pharmacology Tricyclic
Contraindications:
• Once the drug start to take effect and the patients
may become a risk for suicide.
• MAOIs should not be started within one week of
tricyclic therapy. Tricyclic drugs should not be
commenced within two weeks of stopping a MAOI.
• The tricyclics are a special risk with depressed people
because of their severe cardiac toxicity if taken in large
doses. Caution is warranted in patients with cardiac
disease and with older patients.
• Tricyclics may also impair reaction times, especially
at the beginning of treatment.
• Alcohol may increase the sedative effects of tricyclics.

56. Pharmacology Tricyclic
Interactions:
hyperpyretic crisis, seizures or serious
cardiac events may occur if administered
in conjunction with MAOIS.
they may prevent therapeutic effect of
some antihypertensives.

57. Phamacology Tricyclic
Patient education:
• Help the client develop an understanding of why the medications
have been prescribed.
• Help the client discuss issues related to their medications with doctors
or nurses.
• Inform the client of the time it will take for a marked effect to be
experienced from the medication and that it is important for them to
keep taking the medication even though they have not noticed an initial
improvement in their condition.
• Warn of problems when driving or operating machinery if sedation is
experienced.
• Tell the client to discuss with their doctor if they become pregnant or
intend to breastfeed.
• Warn about the effect that alcohol may have if combined with
antidepressant medication.

58. Pharmacology MAOI’S
 Action of medication
 Mono- Amine Oxidase Inhibitors (MAOI’s)
 MAOI’s work by inhibiting both types of the
enzyme MAO A and B that metabolise serotonin
and noradrenalin.

59. Pharmacology
 Side Effects
 Adverse effects include drowsiness or insomnia,
agitation, fatigue, gastrointestinal disturbances,
weight gain, hypotension, dizziness, dry mouth
and skin, sexual dysfunction, constipation and
blurred vision.

60. Pharmacology
 Contraindications
 MAOI’s should not be started within one week of
tricyclic therapy and conversely, tricyclic drugs
should not be commenced within two weeks of
stopping a MAOI.

61. Pharmacology
 Interaction
 The major concern with the use of these drugs is
their potential to interact with specifics foods that
contain tyramine, and drugs such as adrenaline,
noradrenalin, and vasoconstrictors they result in
excessive and dangerous elevation in blood
pressure which is known as a hypertensive crisis.

62. Pharmacology
 Patient Education
 Avoid: alcoholic drinks especially Chianti
and red wine
 Other antidepressants drugs, nasal and
sinus decongestants, narcotics and
adrenaline
 Stimulants, hay fever and asthma drugs

63. Pharmacology
 Examples of MAOI’s
 Phenelzine (Nardil)
 Tranylcypromine (Parnate)
 Isocarboxazid (Marplan)
 Selegiline (Emsam)

64. Pharmacology SSRI
 Selective Serotonin Reuptake Inhibitors
(SSRI) .
 Action of Medication
 A group of antidepressant drugs it inhibits
the reuptake of serotonin at the presynaptic
membrane, this leads to an increased
availability of serotonin in the synapse and
therefore at the receptors, thereby
promoting serotonin transmission.

65. Pharmacology
 Side effects
 Side effects are similar to those of the
tricyclic group expect that they do not
have the cardiovascular, sedative and
anticholinergic side effects. Most
common side effects are nausea,
diarrhoea, anxiety and restlessness,
insomnia, sexual disturbances, loss of
appetite, weight loss and headache.

66. Pharmacology
 Contraindications:
 One major contraindication of SSRIs
is the use of MAOIs at the same time,
this is likely to cause severe serotonin
syndrome/toxidrome.
 People taking SSRIs should also
avoid taking alcohol, diuretics as they
increase the toxicities of SSRIs.

67. Pharmacology
 Interaction
 SSRI should not be combined with
MAOI therapy.
 Hypertensive crisis may occur if
taken within 14 days of MAOIs.
 Use with cimetidine may result in
increased concentrations of SSRIs
in the blood stream.

68. Pharmacology
 Patient Education
 Avoid alcohol as this may potentiate
effect.

69. Pharmacology
 Examples
 paroxetine
 fluoxetine
 venlafaxine

70. ELECTROCONVULSIVE
THERAPY
BACKGROUND
Electroconvulsive therapy (ECT) was invented and introduced into Italy
during 1938. ECT is one of the oldest medical treatments available and
is still in use today at psychiatric units and in psychiatric hospitals. It is
an effective treatment for severe depression, catatonia, certain forms of
mania and schizophrenia. ECT is used when other forms of treatment
such as psychopharmacologic medication and psychotherapy have
failed. It is internationally accepted to be an effective intervention
method for severe depression. The ECT treatment works quicker than
an antidepressant drug. Resent research findings have revealed that
the ECT treatment is safe to administer to patients.
The reason for this treatment being so effective is still a mystery.
The success rate is: eight (8) out of ten (10) patients experience a
remarkable improvement. That gives us an 80% success rate.

71. THE PROCEDURE
The ECT is usually performed under the supervision
of a prescribing Psychiatrist. The patient is
anaesthetised and given muscle relaxants. Two metal
electrodes are placed at strategic points on the
patient’s head. The electrodes are placed, either one
on each side of the head (unilateral) or both on the
same side of the head (bilateral). An electric current
is transmitted.

72. RISKS AND COMPLICATIONS
Research has indicated that the ECT does not cause
brain damage, because only a little amount of
electricity passes through and therefore no harm to
the tissues. Due to the anaesthesia, the ECT carries
a small degree of risk. Some immediate side effects
that might occur are: confusion, headache, temporary
difficulties with short-term memory, queasiness and
sore muscles. Side effects last only for a few hours.

73. PATIENT RIGHTS
The treatment needs to be carefully discussed with
the patient. Should the patient be severely mentally
ill, the Mental Health Act makes provision to
administer the ECT without the consent of the patient.
The Psychiatric Nurse should ensure that the patient
and the family are informed regarding the ECT
procedure and the reason for obtaining consent from
a third party.

74. INFORMED CONSENT
If the patient is a voluntary patient, not under the
Mental Health Act and the Psychiatrist believes that
the patient is capable of providing informed consent,
the patient would only undergo ECT if he/she agrees.
If the patient is incapable of giving informed
consent and the Psychiatrist believes that the
patient’s condition is life threatening, then the
Psychiatrist would consent on the patient’s behalf,
even though the patient refuses the treatment.
Or, if the patient is detained as an involuntary
patient under the Mental Health Act, he/she could
appeal to the Mental Health Review Board against
his/her involuntary status.

75. ASPECTS TO BEAR IN MIND
 Electroconvulsive (ECT) therapy treats various
mental illnesses by inducing a controlled seizure
into the patient.
 It is unknown how ECT actually works, but it is
thought that the seizure “resets” the brain.
 Common side effects include temporary short-term
memory problems.

76. References
American Psychiatric Association (2004). Practice Guidelines for the Assessment and Treatment o
Patients with Suicidal Behaviors, 2nd ed. Arlington:USA.
Boyd, M. A. (2008). Psychiatric Nursing, Contemporary Practice. (4th ed.) Philadelphia: Lippincott
Williams & Wilkins.
Elder, R., Evans K. & Nizette, D. (2009). Psychiatric and Mental Health Nursing. (2nd ed.) Sydney:
Mosby Elsevier.
Fortinash, K.M., & Holoday Worret, P.A. (2003). Psychiatric nursing care plans (4th ed.). Missouri:
Mosby
Frazier, S. & Jacoby, I. (1985). Electroconvulsive Therapy. Retrieved February 05, 2010, from
www.ncbi.nlm.nih.gov
Lippincott Williams & Wilkins (2003).Elder care strategies. New York
Rudd M.D., Berman, A.L., Joiner, T.E., Nock, M.K., Silverman, M.M., Mandrusiak, M., Van Orden, K.,
& Witte, T. (2006) Warning signs for suicide: Theory, research and clinical applications. Suicide and Life
Threatening Behavior; 36, 255-62.

77. Schultz, J.M., & Videbeck, S.L. (2005). Lippincott’s manual of psychiatric nursing care plans (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Schwartz, R., & Rogers, J. (2004). Suicide assessment and evaluation strategies: a primer for
counselling psychologists. Counselling Psychology Quarterly, 17(1), 89-97. Retrieved July 8, 2009, from
CINAHL with Full Text database
State of Victoria (2010). Electroconvulsive Therapy. Retrieved February 05, 2010, from
www.betterhealth.vic.gov.au