Pharmacology and Alternative Therapies

1. PVN123 – Mental Health Nursing - Presentation #4 Pharmacology and Alternative Therapies

2. Objectives • Identify common medications used to treat mental disorders (ATI Tutorial 2011B) • Identify expected pharmacological actions • Identify therapeutic uses • Identify side/adverse effects • Identify contraindications and precautions • Identify food and medication interactions • Identify patient teaching strategies • Identify Traditional Non-pharmacological Therapies for the treatment of mental health disorders

3. Psychopharmacological Therapies

4. How to Access the ATI Pharmacology Tutorial (2011B) -(Quiz #2) • Click on the link below for a video message from your instructor. • http://www.screencast.com/t/72WMOeLbNzP

5. Complete the Tutorial!(due beginning of Day 3) • ATI Tutorial (Course Quiz #2) • Pharmacology Made Easy 2.0 • ID = TU1532398 • Password = 15F7U • Module = The Neurological System (Part 2) Here’s a Link to the ATI Website! https://www.atitesting.com

6. Psychoanalysis / Psychotherapy / Behavioral Therapies Group and Family Therapy Stress Management Electroconvulsive Therapy Alternative Therapies

7. Psychoanalysis PsychotherapyBehavioral Therapies

8. Psychoanalysis / Psychotherapy / Behavioral Therapies • Approaches to addressing mental health issues using various methods and theoretical bases • Nurses should be familiar with methods employed!

9. Psychoanalysis • Assessing unconscious thoughts and feelings • Resolving conflict through talking to psychoanalyst • Many sessions over months to years • Not usually sole therapy of choice • Lengthy duration and insurance constraints • First developed by Sigmund Freud • Past relationships are common focus • Therapeutic Tools Used: • Free Association • Spontaneous/uncensored verbalization of whatever comes to mind • Dream Analysis • Transference • Feelings that client has developed toward therapist related to someone else from early childhood • Use of defense mechanisms

10. Psychotherapy • More verbal therapist/client interaction than traditional psychoanalysis • Trusting relationship between client and therapist • Includes: • Psychodynamic Psychotherapy • Interpersonal Psychotherapy (IPT) • Cognitive Therapy • Behavioral Therapy • Cognitive Behavioral Therapy

11. Psychotherapy • Psychodynamic Psychotherapy • Same tools as Psychoanalysis But!.... • Oriented more to client’s present state than early life • Interpersonal Psychotherapy (IPT) • Used for clients with specific problems • Can improve interpersonal relationships / communication / role-relationship / bereavement • Cognitive Therapy • Based on cognitive model – focuses on individual thoughts/ behaviors to solve current problems. • Used to treat depression / anxiety / eating disorders / other issues that require changing attitude toward life experiences • Behavioral Therapy • Focuses on changing behavior • Based on theory that behavior is learned and has consequences • Abnormal behavior is result of avoiding painful feelings • Teaches clients to decrease anxiety or avoidant behavior • Used successfully to treat phobias / addictions • Cognitive Behavioral Therapy • Uses both cognitive and behavioral approach • Used in anxiety management

12. Cognitive Therapy • Anxiety decreased by changing cognitive distortions • Cognitive Reframing • identify negative thoughts that produce anxiety • Examine the cause • Develop supportive ideas • Priority Restructuring • identifying priorities • Journal Keeping • writing down stressful thoughts • Assertiveness Training • expressing feelings and solving problems in nonaggressive manner • Monitoring Thoughts • becoming aware of negative thinking

13. Behavioral Therapy

14. Behavioral Therapy • Other techniques • Flooding • Exposing (in presence of therapist) to a great deal of an undesirable stimulus • Attempt to “turn off” anxiety response • Response Prevention • Prevent client from performing compulsive behavior • Intent is that anxiety will be diminished • Thought Stopping • Teaching client to shout the word “STOP” when negative thoughts or compulsive behaviors arise • Over time the client will use the command silently

15. Quick Quiz! • A client states that he is depressed because he has had to deal with role reversal with his spouse after the loss of his job due to a disability. Which of the following therapies would the nurse expect to help implement for the client? • A. Operant conditioning • B. Systematic desensitization • Psychodynamic psychotherapy • Interpersonal psychotherapy

16. Quick Quiz!

17. Group and Family Therapy

18. Group and Family Therapy • Open therapeutic communication • Participants willing to be involved • Part of treatment plan for clients in mental health setting • Guided by leaders • Leadership styles include: • Democratic • Supports group interaction and decision making to solve problems • Laissez-faire • Group progresses with no attempt by the leader to control the direction of the group • Autocratic • Leader completely controls the direction and structure of the group • No group interaction or decision-making to solve problems

19. Group Therapy

20. Watch a Video • Group Therapy Isn’t… • http://www.youtube.com/watch?v=cEFAHOzc8no

21. Group Therapy • Verbal and nonverbal communication occurring within group sessions • Group Norm • The way the group behaves during sessions • Provides structure for the group • Hidden Agenda • Some group members (or leader) have goals different from the stated group goals • May disrupt group progress • Subgroup • Small number of people within a larger group • Function separately from the group • Groups may be open or closed • Open groups – new members added as old members leave • Closed groups – no new members added after the group is formed

22. Group Therapy • Homogenous group • All members share a certain characteristic • Ex: diagnosis or gender • Therapy sessions include • Use of open and clear communication • Cohesiveness and guidelines • Direction toward a goal • Opportunity for development of: • Interpersonal skills • Resolution of personal / family issues • Relationship development • Communication regarding respect among members • Support and education regarding community support resources

23. Group Therapy • Group Therapy Goals: • Sharing of common feelings / concerns • Sharing of stories / experiences • Diminishing feelings of isolation • Creating a community of healing and restoration • Providing more cost-effective environment than individual counseling • Group therapy may be used for varying age groups: • Children • play while talking about a common experience • Adolescents • Especially valuable due to strong peer relationships • Older Adult • Helps with socialization and sharing memories

24. Group Therapy Roles • Maintenance Roles • Members maintain the purpose and process of the group • Ex: harmonizer • Attempts to prevent conflict within the group • Task Roles • Members take on various tasks within the group process • Ex: recorder • Takes notes or records of what occurs • Individual Roles • Individuals take roles to promote their own agenda • Prevents teamwork • Ex: dominator • Tries to control other members

25. Family Therapy

26. Family Therapy • Family defined as a group with reciprocal relationships • Members are committed to each other • Family Therapy • Focus is on the family as a system rather than members as individuals • Family assessments include focused interviews and use of various family assessment tools • Nurses work with families to: • Provide teaching • Mobilize family resources • Improve communication • Strengthen ability to cope with illness of one member

27. Characteristics of Families

28. Concepts Related to Family Dysfunction • Scapegoating • A member of the family has little power • Blamed for problems in the family • Triangulation • Third party is drawn into the relationship with two members whose relationship is unstable • Multigenerational Issues • Emotional issues within the family that continue for at least three generations • Addiction patterns when family under stress • Dysfunctional grief patters • Triangulation patterns • Divorce

29. Focus and GoalsIndividual / Family / Group Therapies

30. Watch a Video • Structural family therapy example • http://www.youtube.com/watch?v=bOrnOcHWXgA

31. Quick Quiz! • A nurse leading a stress management group demonstrates that he supports group interaction and the decision-making required to solve problems. The group proceeds with all members feeling that they have input into the group’s decisions. Which leadership style does this illustrate? • A. Democratic • B. Laissez-faire • C. Autocratic • D. Authoritative

32. Quick Quiz! • A nurse is conducting a family therapy session. The teenage son tells the nurse that his parents will punish him harshly if he discloses anything in the session about the family’s arguments at home. The parents have never made any such threats to him. This is an example of which of the following? • A. placation • B. manipulation • C. blaming • D. distraction

33. Stress Management

34. Stress • Body’s nonspecific response to any demand made upon it • Stressors • Physical • Psychological • Produces a biological response in the body • Some stressors are needed to provide interest and purpose • Too much stress or too many stressors can cause distress • Anxiety and anger are damaging stressors that cause distress • General Adaptation Syndrome (GAS) • Body’s response to an increased demand • First stage = “Fight or Flight” mechanism • If prolonged, maladaptive responses may occur

35. Stress Management • The person’s ability to experience appropriate emotions and cope with stress • Healthy management of stress • Flexible • Uses a variety of coping techniques and mechanisms • Responses to stress/anxiety affected by: • Age • Gender • Culture • Life experiences • Lifestyle • Effects of stressors are cumulative

36. Protective Factors • Things that increase ability to resist the effects of stress • Physical health • Strong sense of self • Religious/spiritual beliefs • Optimism • Hobbies and other outside interests • Satisfying interpersonal relationships • Strong social support systems • Humor

37. Subjective and Objective Data

38. Standardized Screening Tools • Life-Changing Events Questionnaires • Holmes Rahe Stress Scale (see handout) • Lazarus’s Cognitive Appraisal

39. Nursing Care • Reinforce teaching of stress reduction strategies • Cognitive Retraining • Help clients look at irrational thoughts in a more realistic light and restructure thoughts in a more positive way. • Behavioral Techniques • Relaxation techniques • Meditation • Guided imagery • Breathing Exercises • Progressive Music Relaxation (PMR) • Physical Exercise • Journal Writing • Priority Restructuring • Biofeedback • Assertiveness Training • Client Outcomes • Client will verbalize stressors and ways to decrease exposure • Client will demonstrate appropriate relaxation techniques • Client will demonstrate assertive communication

40. Quick Quiz! Scenario: A client speaking to a nurse in a general medical clinic, describes herself as feeling anxious, apprehensive, and tired all the time. She says she cannot understand why, since she is very happy. She recently moved to the area to start a new job for a large corporation. She purchased a new and much larger home for herself and her three children (ages 5, 8, and 12). The children transitioned to their new schools successfully and are making friends. The client’s family and friends are all back in the previous city where she lived, but she has been so busy with work that she has not had time to telephone or write to them. The client states she has not been able to sleep and has lost weight in the 2 months since the move. List the stressors that affect this client. 2. Which of the client’s manifestations of increased stress reflects acute Stress rather than prolonged stress? Weight loss Apprehension Fatigue Insomnia

41. Electroconvulsive Therapy

42. Watch a Video • Electroconvulsive Therapy • http://www.youtube.com/watch?v=zYl13Relzbs

43. Electroconvulsive Therapy (ECT) • Alternative somatic treatment for mental health disorders • Delivers an electrical current that produces a grand mal seizure • The exact mechanism of ECT is still unknown and controversial • May enhance the effects of neurotransmitters in the brain • Serotonin • Dopamine • norepinephrine

44. Indications for ECT • Severe depression • Symptoms not responsive to pharmacological treatment • If risks of other treatments outweigh those of ECT • First trimester of pregnancy • Actively suicidal • Need for rapid therapeutic response • Some types of Schizophrenia • If less responsive to neuroleptic medications • Catatonic schizophrenia • Schizoaffective disorder • Acute manic episodes • For bipolar clients with rapid cycling and very destructive behavior • Four or more episodes of acute mania within 1 year • Both features usually do not respond well to Lithium therapy

45. Contraindications for ECT • No absolute contraindications if deemed necessary to save / improve a client’s life • Medical conditions for high risk with ECT • Recent myocardial infarction • History of cerebrovascular accident • Cerebrovascular malformation • Intracranial mass lesion • Medical conditions for which ECT is useful: • Developmental disabilities • Chemical dependence • Personality disorders • Situational depression

46. Nursing Actions • Prepare the client • Typical course of treatment is 3 x /week for 6 – 12 treatments • Use therapeutic communication • Physician will discuss the procedure and obtain informed consent • Risks and benefits • Guardian gives consent if client incompetent • Sometimes separate informed consent for anesthesia • History and physical examination • Neuro exam • Electrocardiogram (ECG) • Lab tests

47. Nursing ActionsMedication Management • Medication management • Meds that affect client’s seizure threshold are decreased or discontinued several days before ECT procedure. • MAOIs and lithium should be DC’d 2 weeks before the procedure • Severe hypertension is controlled • Short period of hypertension post procedure • Monitor vital signs • Monitor mental status • Ask client and family about understand and knowledge of the procedure • Redirect to MD for clarification as needed • IV inserted and maintained until full recovery • IM injection of atropine sulfate or glycopyrrolate (Robinul) is given 30 minutes prior to procedure to decrease secretions and counteract vagal stimulation.

48. Nursing Actions – During Procedure • ECT administered in early morning • After 8 – 12 hours of fasting • Client uses bite guard to prevent oral cavity trauma • Electrodes are applied to the scalp • The client is mechanically ventilated and receives 100% oxygen • Ongoing cardiac monitoring provided • BP / heart rate and rhythm / oxygen saturation • Short acting anesthetic (Brevital) is provided IV bolus • Muscle relaxant (Anectine) is administered • Cuff placed on one leg or arm • Blocks muscle relaxant so seizure activity can be monitored and documented • Duration of seizure is usually 25 to 60 seconds • After seizure activity is ceased, anesthetic is discontinued • Client is extubated and assed to breathe voluntarily

49. Nursing Actions – Post Procedure • Client is transferred to recovery area • Assess: • LOC • Cardiac status • Vital signs • Oxygen saturation • Position client on side to facilitate drainage and prevent aspiration • Client is usually awake are ready for transfer back to the mental health unit within 30 to 60 minutes after the procedure • Orient client frequently • Confusion and short-term memory loss are common • Continue to monitor vital signs and mental status for memory loss

50. Complications of ECT • Memory loss and confusion • Short term memory loss • May persist for several weeks • If ECT causes permanent memory loss is controversial • Confusion • Disorientation • Explain to clients and families that memory loss is typically short term • Assist client with memory • Clock in the room • Label client’s room location • Headache / muscle soreness / nausea • Observe degree of discomfort • Administer antiemetic and analgesic medication as needed • Explain the reason for clinical manifestations • Encourage clients to contact nurse regarding these symptoms