Mcgirr 149 Winter 10

8/14/2019 Mcgirr 149 Winter 10

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N 149 PsychiatricMental Health

Nursing

UCSFSchool of Nursing

Kevin McGirr, RN,MS,MPH


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Mental Illness:

The historical response

Ignorance, mystification or revelation?


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Repeating Themes

Integration or pre-institutionalization Exclusion and Segregation

Morality

Criminalization and Incarceration

Reform

Medicalization


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Potions, Lotions and

Notions Bodily humors Bleeding, Purging and Blistering

Evil spirits

Deification

Insulin shock 1935

Lobotomy 1936

ECT 1937

Cold wraps

Emil Kraeplin

DSM I 1952


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Hildegard Peplau

By the 1920s, psychiatric nursing became anofficial and separate curriculum at mostcolleges and universities, and by 1950, the

National League for Nursing required nursingschools to include psychiatric nursing intheir clinical practice for nationalaccreditation. The role of the psychiatricnurse expanded when the CommunityMental Health Act of 1963 encourageddeinstitutionalization and psychiatric drugsthat allowed patients to live on their ownbecame more common.


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Early Enlightenment

Phillipe Pinel: late 18th century Benjamin Rush: Moral Treatment

Dorothea Dix and Linda Richards

Clifford Beers: A Mind That Found Itself

Mental Hygiene Movement


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Moral Treatment

Control the patient without punishment

Constructing order

Compassionate Discipline

Introduce regularity a chaotic life

Calm, silence, and regular routine


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McLeans Hospital

1882 1st school to prepare nurse for the care of thementally ill 2 year program

Few psychological skills were taught, care wasprimarily custodial (e.g. medication,nutrition, hygiene, & ward activities)

Principles of medical/surgical nursing were

adapted to the psychiatric setting


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Linda Richards

American reformer Dorothea Dix notedthat mentally ill patients were treatedlike animals in 19th-century America,and she opened 32 state asylums tocare for them. English reformer andnursing pioneer Florence Nightingale

fought for quality care for thementally ill. She collaborated with herAmerican colleague, Linda Richardsand inspired Richards to open Boston

City College in 1882.


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Johns Hopkins 1913

1stSON to develop a course for psychiatricnursing that was incorporated into thenursing curriculum


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Muddling through

Sigmund and his disciples: Construction ofthe Self

Peplau: Interpersonal Relations Model

Mental Health Act 1946

National Institute of Mental Health 1949

Chlorpromazine Mental Health Study Act 1955 & 1963

Deinstitutionalization


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The battle

continues. Anti-psychiatry Community Mental Health

Patients Rights

Community Support Programs 1977

Managed Care

New Freedom Commission 2002: stigma, consumer

driven, disparities, research, service andtechnology

Mental Health Parity Act 1996 and 2008

Proposition 63


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Enlightenment forreal?

Psychoanalysis and psychological disrobing Social iatrogenesis and the contribution of culture

Community Mental Health

Community Support Programs

Assertive Community Treatment

Psychopharmacology for the masses

De-stigmatizing mental health

Evidence Based Practices

Decade of the brain

Education and skills approach

Wellness and Recovery


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The end..

Or just the beginning.


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Legal Context of MentalHealth Treatment

Protecting Individuals and Society


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Foundations ofIndividual Rights

4th Amendment: unreasonable search and seizure 5th Amendment: double jeopardy, self incrimination and due

process

14th Amendment: equal protection

California Constitution

Lanterman Petris Short (LPS) Act: 1967-1972


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LPS and InvoluntaryDetention

Restrict persons authorized to initiate involuntarydetention.

Specify criteria under which persons with mental

illness may be committed. Establish mandatory time frames for each escalating

period of involuntary detention.

Provide opportunity to challenge each stage of

commitment by providing access to administrativeand judicial review.

W & I 5325.1


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Patients Rights

A right to treatment services which promote the potential of the person to function independently. Treatmentshould be provided in ways that are least restrictive of the personal liberty of the individual.

A right to dignity, privacy and humane care.

A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication,abuse, or neglect. Medication shall not be used as punishment or for the convenience of staff, as a

substitute for program, or in quantities that interfere with the treatment program.

A right to prompt medical care and treatment.

A right to religious freedom and practice.

A right participate in appropriate programs of publicly supported education.

A right to social interaction and participation in community activities.

A right to physical exercise and recreational opportunities.

A right to be free from hazardous procedures.


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Denial of Rights

Seclusion or restraint must be closelymonitored

Denial of any right must be documented andsubstantiated by staff


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Riese Decision

The court stated that to have some irrational fearsabout medication is acceptable and disagreement

between the doctor and the patient did not show

that the patient lacked capacity. That the individualis using rational thought unless theres a clearconnection between delusion and/or hallucinationsand the reason to refuse antipsychotic medication.


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Competency Hearing

An administrative law judge will determine the

clients ability to refuse pharmacologicaltreatment, e.g, patient awareness of theirillness; ability to understand risk and benefits;ability to evaluate and make a decision


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EmergencyIntervention

WIC 5008 m

"Emergency" means a situation in which action to

impose treatment over the person's objection isimmediately necessary for the preservation of lifeor the prevention of serious bodily harm to the

patient or others, and it is impracticable to first gain

consent. It is not necessary for harm to take placeor become unavoidable prior to treatment.

i i h


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Patients RightsResponsibility

To receive, investigate and resolve patients rights complaints. Monitor facilities for compliance with patients rights laws and regulations and are a

resource for service providers for information, technical assistance and training.

Provide referrals to specialists in housing, benefits, and legal services as needed.

Provide training and education.

Advocates focus on the resolution of the complaint. Advocates work for theexpressed interest of the individual and support them using self-advocacy toaccomplish their goal.

Advocates outreach to vulnerable clients, visiting them at facilities and clinics andwhere they reside.

WIC 5520


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5150 criteria

Danger to Self

Danger to Others

Grave Disability

Contextual considerations


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Danger to Self

This criteria may be either a deliberate intention to injure oneself(i.e.overdose) or disregard of personal safety to the pointwhere injury is imminent (i.e. wandering about in heavytraffic).

The danger must be present, immediate, substantial, physicaland demonstrable.

Words oractions showing intent to commit suicide or bodilyharm.

Words oractions indicatinggrossdisregard for personal safety.

Words oractions indicating aspecific plan for suicide.

Means are readily available to carry out a plan


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Danger to Others

Should be based on words oractions that indicate the person inquestion either intends to cause harm to a particularindividual or intends to engage in dangerous acts withgrossdisregard for the safety of others.

Threats against particular individuals

Attempts to harm certain individuals

Means available to carry out threats or to repeat attempts

(firearms other weapons)

Expressed intention or attempts to engage in dangerous activity


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Grave Disability

A condition in which a person, as aresultof amental disorder, is unable to provide his or her basic personalneeds for food, clothing and shelter.

Refusal of medical treatment is not in and of itself evidence of grave disability.

Although consideration of past events may be necessary, evaluation must be based on individuals currentcondition.

If friends or family are willing to provide for the persons basic needs, then the criteria for grave disability isnot met.

signs of malnourishment (loss of weight) or dehydration

inability to articulate plan for getting food

no food in house or food there but rotten

irrational beliefs about the food (e.g., it is poisoned or tainted in some way)

inability to formulate a reasonable plan for shelter

D NOT t


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Does NOT meetcriteria for a 5150

Willful or volitional behavior

Criminal behavior

Conscious acting out secondary to disappointment, anger,hate, passion, fanaticism or prejudice

Simply having a psychiatric diagnoses

li i f


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Implications ofInvoluntary Detention

With no other illness you do you use police power to detain people toevaluate and then involuntarily treat them.

Being picked up by police in handcuffs

Individuals may feel they have been kidnapped

Clients report experiencing severe loss of self-esteem and trust in theprovider

Clients have complained of being in crisis and approaching their outpatientclinic for support to get help, only to be 5150d when they would haveaccepted help voluntarily.

Clients feel powerless being unable to address their responsibilities: pets,bills, parking, counseling appointment, court appearances,employment, etc..


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Beyond 5150

5250: 14 day hold

Temporary Conservatorship: 30 days

Permanent Conservatorship: 1 year

For any of the above, the individual may:

Request to see the patients rights advocate

File a Writ of Habeas Corpus

Certification Review /Probable Cause Hearing


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Risk of Violence

Male

Youth

History of violence

Diagnosis: MDE, BAD, Schizophrenia. Personality Disorder

Positive psychotic symptoms

Not in treatment

When combined with substance abuse

Abuse as a child

Current social and economic disenfranchisement

Failure to involuntarily treat


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HIPAA

Disclosure requires specific release from the clientexcept for those:

Providing treatment within a safety net

Those who have a need to know

Information pertaining to treatment

Treatment, Payment or Operations

Emergency

Law enforcement

Accounting disclosure


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Mood Disorders

Disturbance in Mood


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Evolving Case Study

Jane is a 32 yo Asian female who is admitted tothe locked psychiatric unit. Jane told heroutpatient therapist that she had been

suicidal for the past three weeks


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Scenario I

What are the possible reasons why Jane mightbe placed on a locked unit?

Are there any parameters within the State of

California for placing a client on a lockedunit? What are they?

Are there protections for such individuals?What are they?

As a nurse who is responsible for admitting Janeto the unit what might be some of yourinitial activity and interaction with Jane?


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Questions

Given that a mental status exam is a routinepart of a psychiatric admission, what partsof the mental status exam are indicated

above?

What other questions will you begin toformulate for Jane or her husband andsister? How would handle asking questions

of her husband and sister?

What are the possible diagnoses for Jane andwhat are the criteria for those diagnoses?


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Scneario III

Given some more information, we learn thatJane was on some unknown medicationyears ago for her mood. She has been in

therapy due to interpersonal difficulties athome and at work. We find out that she hastangential thinking, racing thoughts,decreased need for sleep, delusions ofgrandeur, impulsive spending, excessive

drinking and sexual activity with strangers.


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Questions

What is the possible diagnosis at this point?

What are the criteria for this diagnosis?

What are the possible medications for thisdisorder?

What are the side effects of these medications?

What are the nursing indications foradministration?

Under what circumstances might we administerthis medication on an involuntary basis?


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Scenario IV

Jane has now been admitted to the unit, she ison suicide precautions, ordered to receiveolanzapine 5 mg. po BID; Ativan 1.0 mg prn

q 4 hours and Benedryl prn for side effects.She has been pacing around the unit asignificant amount, receiving about twohours of uninterrupted sleep, entering otherpatients rooms, claiming to be influential

with all level of local and national politiciansand declining regular meals but hording foodin her room.


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Task

Using Orems model propose a plan ofintervention for each domain


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Scenario V

Jane has been in the hospital for four days nowand is sleeping about 6 hours, no longergoing into other patients rooms, no longer

claiming to have special influence in highplaces and is now denying suicide ideation.


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Questions

How do we evaluate suicidal risk?

Assuming Jane was hospitalized on aninvoluntary basis, what is the criterion forher to convert to a voluntary patient?

How might we modify the Orem care plan?

How do we begin to prepare Jane for discharge?What issues might we address with Jane?


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Big picture foruni-polar depression

Incidence: 7% annual for MDD and 3% fordysthmia

Prevalence; 17% lifetime

Worldwide disability: one of the topillnesses

Onset: childhood; older adults at greatestrisk

Demographics: 2:1, F/M

Association with suicide: 9%

Treatment efficacy: up to 80%


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Etiology

Diathesis

Genetic

CNS impairment

Psychological: psychodynamic,attachment, object relations, learned

helplessness

Environmental loss and stress


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Types

Major Depression Dysthymia

Bipolar I

Bipolar II

Seasonal Affective Disorder

Post partum depression

Other Mood Disorders

Mood Disorder due to specific medical condition

Substance Induced Mood Disorder


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Major Depression

Two or more weeks of depressed mood that last allday and at least four impairments inphysiological, cognitive or behavioral impact


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MDE Specific Criteria

Five (or more) of the following for 2-weeks:

1. Depressed mood each and most of the day

2. Diminished interest in pleasurable activities

3. Appetite and weight change

4. Sleep change

5. Psychomotor agitation or retardation

6. Fatigue and loss of energy

7. Feeling of worthlessness and guilt

8. Diminished ability to think or concentrate

9. Passive or active Suicide Ideation


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Specifiers

Mild, Moderate, Severe Without Psychotic Features, SevereWith Psychotic Features, In Partial Remission, In Full Remission

Chronic With Postpartum Onset

Specifiers (describing course of recurrent episodes)

Longitudinal Course Specifiers (with our without fullinterepisode recovery)

With Seasonal Pattern

With Rapid Cycling


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MDE Illness Course

Duration is variable

Untreated, typically lasts for 6 months or longer

In the majority of cases there is completeremission of sxs and functioning returns topremorbid levels

In about 20-30% of cases, some depressive sxspersist for months to years and may be

associated with significant disability anddistress

About 5-10% of individuals may still meet allcriteria for MDD for 2 or more years


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Dysthymic Disorder

Chronic depression for much of the day for a twoyear period and at least two impairments inphysiological, cognitive or behavioral impact

Dysthmyia: specific


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Dysthmyia: specificcriteria

A. Depressed mood for most of the day, for more days thannot, and indicated either by the subjective accountor observed by others for at least 2 years.

B. Presence, while depressed, of two (or more) of thefollowing:

1. Poor appetite

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty makingdecisions

6. Feelings of hopelessness


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Big Picture for BAD

w Prevalence; Type I = 1%; Type II = 4%

w Worldwide disability: one of the top illnesses

w Onset: 20s; possible in children andadolescence

w Demographics: I. 1:1, II. 2:1, F:M; + familyhx;

w Association with suicide: 15 -20%

w Treatment efficacy: following an average of 7-9episodes


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Bipolar I

w -Classic manic depressive form of theillness

w .Most severe type of bipolar disorder

w Characterized by at least one manic episode.or mixed episode

w Major Depression not required for diagnosisbut most do experience a MDE

w Typical course of Bipolar I Disorderinvolves recurring cycles between mania

.and depression

w


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Bipolar II

y p o m a n i a a n d d e p r e s s i o n

Episodes of hypomania and severe;depression must have experienced

At least one hypomanic episode and one.major depressive episode in a lifetime

,Presence of a manic episode dx changes to.Bipolar I Disorder


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Cyclothymia

w Milder form of bipolar disorder consisting.of cyclical mood swings The

w Highs and lows are not severe enough toqualify as either mania or major

.depression

w Dx includes periods of hypomania and mild- .depression over a two year time span

w Increased risk for developing bipolar, /disorder hence monitoring and or tx is.advised

w


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Rapid Cycling

w Subtype of bipolar disorder characterized by fouror more episodes of mania, hypomania, ordepression within one year.

w Shifts from low to high can occur over a matter ofdays or hours.

w Can occur within any type of bipolar disorder.

w Usually develops later in the course of bipolardisorder.


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Impact of Affective


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Impact of AffectiveIllness on Functioning

Affective Cognitive Physiological

Behavioral


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Affective

Sad Hopeless

Teary

Anhedonia

Irritable

Expansive

Euphoric

Flattening

Cognitive


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Cognitive

Concentration/ Distractibility

Morbidity

Grandiosity

Paucity

Negative: worthless, guilt, suicide ideas

Tangential

Flight of ideas

Decreased judgment


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Physiological

Psychomotor slowing or activation

Sleep disturbance

Appetite disturbance

Amenorrhea


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Behavioral

Suicide attempt or gesture Withdrawn

Intrusive

Hyper-social or hypersexual

Rapid speech / Paucity of Speech

Over dressing and frequent dress change

Neglects self care

Takes to the bed

Decreased impulse control

Unable to perform role function


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Suicide

CDC ranks suicide for all Americans as the11th cause of death down from #8 in 1999.

About 30,000 die from suicide each year andthere are about 500,000 ER visitsassociated with suicide attempts per year

More people die from suicide then homicide;

more on west coast than east coast


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Risk Factors

Gender 3:1 female to male attempts Age

Race

Genetics

Mental Health or Substance Abuse disorder

Education

Religion

Mental state

Physical Health

Isolation/ Marital Status

History of attempt: 25 attempts for every completed

San Francisco


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San FranciscoStatistics

96: 139

97: 111

98: 90

99: 101

00: 111

San Francisco


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San FranciscoLocations

Private residence

GGB

Residential or low income hotels

Supervised care facilities (including Jail)

M h d


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MethodsNationwide: firearms

Poison: street drugs

Hanging

Firearms

Jumping from the bridge


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Assessment ofSuicidal Risk

M l S


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Mental Status

Appearance

Behavior

Attitude and relationship with examiner

Speech

Mood/Affect

Thought Process

Thought Content

Suicide ideation Plan

Means

Loss

Future

Electroconvulsive


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ElectroconvulsiveTreatment

Controversial

Indications

Administered w/ general anesthesia + muscle

relaxant Electrodes placed unilateral or bilateral

Sz is induced for up to a minute

6 -12 treatments up to 3x /week

Remission and Maintenance

Memory loss

N i I t ti


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Nursing Interventions

Integrating Orem on the Affective, Physiological,Cognitive and Behavioral domains

Aff ti


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Affective

Safety

Support

Empathy

Validation

Ph i l i l


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Physiological

Adequate intake

Hygiene

Sleep

Activity and Rest: movement

Breathing

Relaxation

C iti


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Cognitive

Delusions: support and reality testing Offering hope

Addressing negative thinking

Identification Challenging Reframing

Detaching

Stopping, substitution distraction

Guided imagery

B h i


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Behavior

Limit setting

Contracting

Monitoring Isolation or seclusion

Group interaction

Regulation of contacts

Mobilization


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P lit Di d


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Personality Disorders

What is the difference between a personalitydisorder and personality trait?

P tt f


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Patterns of.

Perceiving, navigating and coping patterns

Enduring

When the following exists, we consider apersonality disorder

Intensive

Maladaptive and inflexible

Troublesome

Di ti C it i


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Diagnostic Criteria

Behavioral pattern that deviates from the normin perception, response, control of impulseand interpersonal function

Enduring: not a response to a specific situation

Impairs functioning

Th Cl t


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Three Clusters

A. Paranoid, Schizoid, Schizotypal

B. Antisocial, Borderline, Histrionic, Narcissistic

C. Avoidant, Dependent, Obsessive Compulsive

Paranoid Personalit


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Paranoid Personality

Suspiciousness and distrust

Perception of hidden meaning

Guarded

Argumentative and defensive

Difference with CPS are hallucinations and delusions and thecomplexity of those delusions

Schizoid


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Limited emotional expression

Asocial

Eccentricities


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Avoidant


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Avoidant

Fearful

Apprehensive

Risk averse

Dependent


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Dependent

Submission

Significant lack of self confidence

Fearful of being alone

Over reliance on others

Obsessive Compulsive


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Obsessive Compulsive

Perfectionist

Preoccupation with rules

Difficulty with decisions

Fear of making mistakes

Rigidity

Distinction with OCD is the intense focus and

inability to control the thinking and resultingbehavior

Antisocial


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Antisocial

Lacking superego

Inability to experience guilt or remorse

Insensitive to others

Violation of social norms, rules & morals

Can be charming and manipulative

Histrionic


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Histrionic

Attention seeking

Extroverted and flamboyant

Dramatic

Self absorbed

Narcissistic


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Narcissistic

Inflation of self import

Very sensitive to criticism

Easily emotionally injured

Self absorbed and lacking in empathy


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Symptom Focus


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Symptom Focus

Mistrust

Anger or belligerence

Impulsivity

Inappropriate behavior or insensitivity

Manipulation

Poor coping

Oversensitivity

Mal-adaptation

Interventions


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Interventions

Personal reactionUse of selfValidation of patient feelingsReality checkBoundariesJudicious feedback andconfrontationAppealing to rationalityAssertion and enhancement ofesteem

Explanation and InterpretationRelaxationCognitive reframingProblem solvingMotivational interviewing(FRAMES)ConsequencesPatience


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Substance Abuse and


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Pharmacology Who uses

Context

Neuroanatomy

Neuron

Neurotransmitters

Mechanism of Action, Pharmacokinetics, pharacodynamics

Side effect

Med classes

Consideration and Strategies

Dual Diagnosis


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Context


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Context

Serendipity and medication discovery Evolutionary: expanding role of pharmacy and increased use

Controversial: influence of pharmaceuticals, family andconsumer concerns

Effectiveness: percentage of responders

Adverse effects Placebo: drug, set and setting

Costs

Patients rights/ rights to refuse

Who prescribes?

Formulary

Role of FDA

Substance Use

Who is using what?


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Who is using what?

Results from the 2006 National Survey on Drug Use and Health:

Usage

2006 CY Lifetime

Cigarettes: 35% 71%

Alcohol: 66% 83%

Illicit drugs 14% 45%*

*Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin,inhalants, stimulants, PCP, ecstasy, or prescription-type psychotherapeuticsused nonmedically.

Nicotine Dependence


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Nicotine Dependence

Based on SAMHSA's National Survey on Drug Useand Health, of the 61.6 million persons aged 12or older who in 2006 smoked cigarettes in the

past month, 57.7% (35.5 million) met thecriteria for nicotine dependence in the pastmonth

Facts about Nicotine


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Abuse and Dependence

w 450,000 annual deaths

w Approximately 20% of general population usetobacco

w Persons with Behavioral Health disorders smokeat a much greater rate; up to 67% forpersons with psychotic disorders

w Persons with chronic psychiatric or substanceabuse disorders smoke 44% of all cigarettes

w Estimates of a 20% decrease in life expectancyfor persons with SMI

Other Substance Abuse


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and Dependence

In 2007, an estimated 22.3 million persons(9.0 percent of the population aged 12 orolder) were classified with substancedependence or abuse in the past year basedon criteria specified in DSM-IV.

Of these, 3.2 million were classified withdependence on or abuse of both alcohol andillicit drugs, 3.7 million were dependent on

or abused illicit drugs but not alcohol, and15.5 million were dependent on or abusedalcohol but not illicit drugs.

Co-occurence


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Co-occurence

According to SAMHSA

22% of persons with severe mental illness (SMI)

also qualify for substance abuse ordependence

Basic CNS Anatomy


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Basic CNS Anatomy

Basic function: receiveinformation (sensory),

interpret, respond (motor)Nerve cells

Glial cells

Vascularization


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Neuro-anatomy


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Neuro anatomy

Autonomic Nervous System; processes info from thehypothalamus thru the med ob, spinal cord to themuscles and includes the sympathetic and

parasympathetic systems. Sympathetic: exp ofenergy versus Parasympathetic which conservesenergy particularly for vital functions

The peripheral nervous system branches from thespinal cord to control voluntary muscle function.

The peripheral system includes the pyramidal system

which manages fine motor coordination asopposed to the extra pyramidal which managesgross motor function. This is controlled by thecerebellum


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Nerve Cell


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Nerve Cell

Central body is lipid, separated by a membrane fromthe surrounding

Ionic fluid containing + and charges (electricalconductivity)

Stimulus of the nerve cell changes the internal charge to a +; 200 charges/second

Passing thru the membrane the cell body sendssignals along the axon (the long limb)

Terminating at the pre-synapse or dendrites

Between the dendrites of one nerve cell and the nextis the synaptic cleft

Nerve Cell continued


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Nerve Cell continued

Pre-synapse contains neurotransmitters which stimulatedendrites in the post synapse.

The stimulated neurotransmitters are released into thesynaptic cleft attaching to receptors (dendrites of thereceptor cell); hormones & peptides are active in this

synapse Axon terminal contain vesicles which contain

neurotransmitter protein molecules produced by thecell body. The communication of these moleculeoccurs thru very specific receptorsor binding on thepost -synaptic side hence chemical changes.

The neurotransmitter does NOT actually move into the nextcell. It merely pierces the membrane to causeelectrical conductivity

Once it has done its action, it then is wasted or stored in thepre synaptic area (AKA re-uptake)

Mechanism of Action


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Mechanism of Action

Impact of pre-synaptic neurotransmitter

Impact at post-synaptic receptor binding

Interference with re-uptake process

Alteration of receptor manufacture

As an agonist working like a neuro transmitterbinding to a receptor and stimulating nerve cellactivity

As an antagonist performing the converse of agonistby NOT stimulating

Neurotransmitters


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Neurotransmitters

Acetylcholine: arousal, attention, memory, motivation,m-s, released by the Autonomic Nervous System inthe parasmypathetic; excitatory

Neuroepinephrine: excitatory, in the sympathetic,regulating anxiety and tension

Dopamine: inhibiting, abnormalities in the limbic sysimplicate schizophrenia

Serotonin: inhibiting, calming the nervous system,regulating consciousness, mood, appetite, sleep andsexual behavior

Gaba (gamma-aminobutric acid):very inhibiting;controlling neural excitement. Very responsive toanti-anxiety agents and etoh

Glutamate: pre-cursor of gaba; excitatory.Overstimulation here has been implicated in variousdx, e.g, alzheimers and schizophrenia


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Pharmacodynamics


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Pharmacodynamics

Therapeutic index is the ratio of the lowest averageconcentration needed to produce a desired effectto the lowest average concentration that producesa toxic effect

Potency is measured in mg, grm, mcg, ml, cc

Dose response: as the dose increases, the effect alsoincreases to a point sometimes known as thetherapeutic window.

Lag time is the time it takes for a drug to be effective.

Tolerance: once achieved, response decreases

Adverse effects

Side Effects


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Side Effects

Anticholinergic drying thru suppression ofthe pyramidal nerve paths. They blockcholinergic receptors

EPS:

Akithisia (restless)

Akinesia (inability to initiatemovement)

Dystonias (cramped/twisted

muscular experience) Parkinson (tremor and fine motor

discoordinatio, shuffling gate,drooling)

Tardive Dyskinesia (involuntary


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Helping Patients withSid Eff t


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Side Effects Severity of side effects Severity of the illness

Patient ability to tolerate

Time

Therapeutic index and dose adjustment

Availability of other agents

Medication Classes


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Medication Classes

Anxiolytics

Antidepressants

Mood stablizers Antipsychotics

Antidepressants


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Antidepressants

MAOIs

TCAs

SSRIs SNRIs

Atypical

Monamine OxidaseI hibit


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Inhibitors Mechanism of action is theinhibition of enzymes that metabolize

neuroepinephrine and serotonin. Also inhibits dopamine

The major concern with the MAOIs is the dietary restriction which ifnot followed cd cause a hypertensive crisis. MAO interacts withtyramine, an amino acid derivative. Some of these foods arechocolate, cheeses, red wine, banana skins, caffeine, beer, certain

pickled foods

Most common: nardil ( phenelzine); Parnate ( tranylcypromine);Marplan (Isocarboxazid).

These meds tend not to be sedative and have no ACH s/e

Doses are usually 15 mg to 90 mg.

Tricyclic / Tetracyclic


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Tricyclic / Tetracyclic

These drugs have a long half life hence can usually be Rx indaily dosing. They are notable for their anticholinergic SE,orthostasis, and sedation. Dosing usually begins fairly lowand will be titrated as the patient appears to tolerate the SE.therapeutic effects will occur in 2 6 weeks. Known to be

effective in 60% of consumers. Although clients may need tostart and d/c a number of trials before they experience

benefit.

SE: can include anxiety, sedation, short term memory loss,sexual dysfunction, weight gain.

SSRIs


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SS s

Prozac, Paxil, Luvox, Lexapro, Zoloft came on themarket in the 80s. Fluoxetine being the first. Alittle better in efficacy. Longer half life. BetterSE profile. Generally do not have ach s/e. Lowersedating are paxil (paroxetine) and effexor(venalfaxine) and lower toxicity. These drugs aresometimes given at the therapeutic dose as opposedto titration. The SSRIs in particular have also been

known to be effective with OCD, anxiety, PMS andeating d/o

SNRI


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Serotonin and nor-epinephrine re-uptake

inhibitors (cymbalta/duloxetine,effexor/venalfaxine)

Atypical


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yp

Work on differing combinations of neurotransmitterblockade. May also have varying half-life.Wellbutrin is very popular and is particularlyknown for its stimulating effect acting as adopamine agonist and indirectly increase inneurepinephrine. Also know for its relative absenceof sexual S/E. There is some concern for itslowering of the sz threshold.

Mood Stablizers


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Lithium Anticonvulsants

Antidepressants

Antipsychotics


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Anticonvulsants


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An increasing a number of medications that wereinitially indicated for sz d/o and have been foundto be helpful in the tx of BAD. In general they

work faster, have a higher therapeutic index (andtherefore less toxic). There mechanism of action isnot fully understood except that it appears that likein sz d/o, the limbic system is vulnerable to a

kindling effect that causes excitatory neuronalfiring of Na ions hence mania

Specificanticonvulsant agents


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anticonvulsant agents Tegretol (carbamazepine): requires monitoring of the

WBC. Use can cause a decrease in the WBC(leukopenia).

Valproic Acid (depakote): blocking Na channels and

impacting GABA; weight gain is a s/e

Neurontin (Gabepentin) acting somewhat as an agonist forGABA; also used for pain, anxiety; its use in BAD isconsidered to be off-label

Lamactil (Lamotrigine) : may act as a Na ion channelblocker; is approved for BAD; there is a black boxwarning for possible cause of Stevens Johnsonsyndrome


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Haldol


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Haldol which is probably the medication that wasmost used in emergency situations

Potency is measured the degree of dopamine.receptor blockade Occupancy at the D2

receptors is cited as the mechanism of actionfor decreasing the positive symptoms ofschizophrenia

,The more potent the drug the greater thepotential for EPS but less anticholinergic

/ .S E

Long acting agents that are injected in fat,tissue usually the gluteus or deltoid

Newer Generation


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Newer meds act on a wider variety ofneurotransmitters and quickly bind and releasefrom the D2 receptors. Effectiveness is alsoattributed to 5HT2 (serotonin) blockade hencesome impact on negative ss.

Improved s/e profile, less EPS

May impact perceptual, thought, motor, affective

and interpersonal disturbances

Newer Generation


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Clozaril: effective and promised to impactnegative sx. SE: Agranulacytosis

Risperidone

Olanzapine: metabolic syndrome

Quetiapine: smaller contribution to metabolicsyndrome

Others: ziprasidone, aripiprazole

EPS and ParkinsonTreatment


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Treatment Amantadine

Bromocriptine

Cogentin

Artane

Benedryl

GeneralConsiderations


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Considerations Gender, size, race and ethnicity, personality, medical illness, psychiatric dx

What is recovery: optimism and strengths based

Trial and error

Education

Provider relationship: partnering with the client; being open and direct; de-mystifying the process; being aware of the power dynamics; to beavailable and to be used as a resource

Use of family and supports

Inventory of all that the individual is placing in their body

Effectiveness

Side effect

Drug interactions

Client choice and negotiation

Non-compliance

Monitoring, evaluation and laboratory assay


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Strategies to improvecompliance


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compliance Patient inclusion and negotiation

Depot

Reminders and Structure

Motivation and rewards

Directly observed therapy

Substance AbuseCriteria


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CriteriaDefined as a maladaptive pattern of substance use leading to

clinically significant impairment or distress as manifested byone (or more) of the following, occurring within a 12-monthperiod:

1. Recurrent substance use resulting in a failure to fulfill major roleobligations at work, school, or home

2. Recurrent substance use in situations in which it is physicallyhazardous

3. Recurrent substance-related legal problems (such as arrests forsubstance related disorderly conduct)

4. Continued substance use despite having persistent or recurrentsocial or interpersonal problems caused or exacerbated by theeffects of the substance (for example, arguments with spouseabout consequences of intoxication and physical fights).

SubstanceDependence Criteria


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Dependence CriteriaThree of more of the following in a 12 month period:

1. Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of the

substance to achieve intoxication or thedesired effect or

(b) Markedly diminished effect with continued useof the same amount of the substance.

2. Withdrawal, as manifested by either of the following:

(a) The characteristic withdrawal syndrome for thesubstance or

(b) The same (or closely related) substance is taken torelieve or avoid withdrawal symptoms.

3. The substance is often taken in larger amounts or over a

longer period than intended.

Dependence CriteriaContinued


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Continued 4.There is a persistent desire or unsuccessful efforts

to cut down or control substance use.

5. A great deal of time is spent in activities necessaryto obtain the substance, use the substance, or

recover from its effects. 6. Important social, occupational, or recreational

activities are given up or reduced because ofsubstance use.

7. The substance use is continued despite knowledge

of having a persistent physical or psychologicalproblem that is likely to have been caused orexacerbated by the substance

Treatment forSubstance Abuse


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Substance Abuse Etoh Withdrawal Guidelines

Psychosocial approaches

Case management

CBT

Motivational Interviewing

Harm Reduction

Mutual Help Groups

Traditional 12-step programs

Alternatives


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Seizures


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-Within 48 hours of last drink

-Generalized tonic-clonic seizures

-3% of chronic alcoholics develop this-3% of those who seize develop Status Epilepticus

Alcoholic Hallucinosis


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- 12- 24 hr. onset after last drink

- Usually visual

- Resolves within 24-48 hr.

- NOT synonymous with DTs

*other signs may or may not be present

* time course is different

not usually associated with clouding of sensorium

Delirium Tremens


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- 5% of patients

- Typically begins between 48 & 96 hours

- Typically lasts 1-5 days-

DT Symptoms


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Hallucinations

Disorientation

Tachycardia

Hypertension

Low Grade Fever

Agitation

Diaphoresis

Hyperventilation and Respiratory alkalosis which result in reduced cerebral bloodflow

Clouding of the Sensorium

Intervention


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Very frequent monitoring

Low stimulus environment

MVI, Thiamine, Folate

Withdrawal Assessement


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GuidelinesMild Symptoms (CIWA-score


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Severe Symptoms (score >15) - Fixedscheduled in the amounts necessary tocontrol symptoms. Recommended:

1. Librium: 50 mg q 6 hrs. x 4 doses then25 mg q 6 hrs. x 4 doses

2. Valium: 10 mg q 6 hrs. x 4 doses then5 mg q 6x 8 doses

3. Ativan: 2 mg q 6 x 4 doses then 1 mgq6 x 8 doses.

DT Management


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Pts. In DTs should receive IV diazepam 5-10 mgevery 5 minutes until pt. is alert but calm.

Continue IV administration of Diazepam until

pt. is no longer delirious and absorption fromgut is reliable.

N & V


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Ask Do you feel sick to your stomach? Haveyou vomited? Observation:

0 No nausea and no vomiting

1 Mild nausea with no vomiting

4 Intermittent nausea with dry heaves

7 Constant nausea, frequent dry heaves andvomiting

Sweats


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Observation:

0 No sweat visible

1 Barely perceptible sweating, palms moist

4 Beads of sweat obvious on forehead

7 Drenching sweats

Anxiety


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Ask Do you feel nervous, anxious or

shakey? Observation:

0 No anxiety, at ease

1 Mildly anxious

4 Moderately anxious, or guarded, soanxiety is inferred

7 Equivalent to acute panic states asseen in severe delirium or

Agitation


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Observation:

0 Normal activity

1 Somewhat more than normal activity

4 Moderately fidgety and restless

7 Paces back and forth during most of theinterview, or constantly thrashes about

Tactile disturbances


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Ask Have you any itching, pins and needles sensations, anyburning, any numbness or do you feel bugs crawling on orunder your skin? Observation:

0 None

1 Very mild itching, pins and needles, burning or numbness

2 Mild itching, pins and needles, burning or numbness

3 Moderate itching, pins and needles, burning or numbness

4 Moderately severe hallucinations

5 Severe hallucinations

6 Extremely severe hallucinations

7 Continuous hallucinations

Auditory


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Ask Are you more aware of sounds around you? Are they harsh? Do theyfrighten you? Are you hearing anything that is disturbing you? Are youhearing things you know are not there? Observation:

0 Not present

1 Very mild harshness or ability to frighten

2 Mild harshness or ability to frighten

3 Moderate harshness or ability to frighten





Visual


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Ask Does the light appear to be too bright? Is its colour different? Does ithurt your eyes? Are you seeing anything that is disturbing you? Are youseeing things you know are not there? Observation:

0 Not present

1 Very mild sensitivity

2 Mild sensitivity

3 Moderate sensitivity





Headache


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Ask Does your head feel different? Does it feel like there is a bandaround your head? Do not rate for dizziness orlightheadedness. Otherwise, rate severity.

0 Not present

1 Very mild

2 Mild

3 Moderate

4 Moderately severe

5 Severe

6 Very severe

7 Extremely severe

Orientation andSensorium


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SensoriumAsk What day is this? Where are you? Who

am I?

0 Orientated and can do serial additions

1 Cannot do serial additions or is uncertainabout the date

2 Disorientated for date by no more than 2

calender days3 Disorientated for date by more than 2

calender days

4 Disorientated for place and/or person

Tremor


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Arms extended and fingers spreadapart. Observation:

0 No tremor

1 Not visible, but can be felt fingertipto fingertip

4 Moderate, with patients armsextended

7 Severe, even with arms notextended


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Guidelines (continued)


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Atypical antipsychotics are preferred in tx of psychosis

SSRIs and SNRIs may be very helpful in attenuating substanceuse; buproprion may be helpful for craving

Use of certain non-TCA antidepressants may be helpful forsleep

When benzos are necessary, the longer acting may decrease thepropensity for abuse (Librium and serax).

Benzos are the tx of choice for etoh w/d

Use of stimulants for adult ADD requires careful diagnosis.Strattera should also be considered

Naltrexone and Acamprosate may be used for craving Antabuse and modafinil has been shown to have some effect

in coke abuse


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Documents

Mcgirr 149 Winter 10