Psychiatric nursing or mental health nursing is the specialty of nursing that cares for people of all ages with mental illness or mental distress, such as psychosis, depression or dementia. Nurses in this area receive additional training in dealing with behavioral issues, psychiatric medication and a variety of different therapies.
Plan • 1 Therapeutic relationship • 2 Interventions • 2.1 Physical and biological interventions • 2.1.1 Psychiatric medication • 2.1.2 Electroconvulsive therapy • 2.1.3 Physical care • 2.2 Psychosocial interventions • 2.3 Spiritual interventions • 3 Organization of mental health care
Therapeutic relationship • As with other areas of nursing practice, psychiatric mental health nursing works within nursing models, utilising nursing care plans and seeks to care for the whole person. However, the emphasis in mental health nursing is on the development of a therapeutic relationship. In practice, this means that the nurse should seek to engage with the person in a positive and collaborative manner that empowers them to draw on their inner resources in addition to the medications they may be receiveing.
Phases of the therapeutic relationship: • Orientation phase - getting to know each other and clarifying purpose of relationship • Working phase - essentially the time when the bulk of the therapeutic work is done • Resolution phase - this is where the patient becomes more independent and eventually is able to end the therapeutic relationship with the nurse.
Development of the therapeutic relationship can be challenging, not just due to the nature of the person's mental illness or distress, but also because the person may be detained in a psychiatric hospital and be receiving treatment against their will under mental health law. It also requires a level of self-awareness on the part of the nurse to help understand and properly utilise the relationship.
Physical and biological interventions • Psychiatric medication • Psychiatric medication is a commonly used intervention and many psychiatric mental health nurses are involved in the administration of medicines, both in oral (tablet) form or by intramuscular injection. Nurses will monitor for side effects and response to these medical treatments by using assessments. Nurses will also offer information on medication so that, where possible, the person in care can make an informed choice, using the best evidence available.
Electroconvulsive therapy • Psychiatric mental health nurses are also involved in the administration of the somewhat controversial treatment of electroconvulsive therapy and assist with the preparation and recovery from the treatment, which involves a anesthesia.
Electroconvulsive therapy (ECT), also known as electroshock therapy, is a controversial medical treatment involving the induction of a seizure in a patient by passing electricity through the brain. Patients with any of several conditions often show dramatic short-term improvement after the procedure. While the majority of psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, a vocal minority of psychiatrists, former patients, antipsychiatry activists, and others strongly criticize the procedure as extremely harmful to patients' subsequent mental state .
ECT was introduced as a treatment for schizophrenia in the 1930s, and soon became a common treatment for neurologically based disorders affecting mood. In the early days of use, ECT was administered without anaesthesia or muscle relaxants. Patients were frequently injured as a side effect of the induced seizure. ECT without anaesthesia is referred to as "unmodified ECT", or "direct ECT", and is illegal in most countries. Unmodified ECT continues to be common practice in Japan, although the government is now trying to phase it out. Currently, in most countries, patients are first administered an anesthetic agent as well as a paralytic agent, significantly reducing the chances of injury seen in unmodified ECT .
ECT was a common psychiatric treatment until the late 20th century, when it fell into disuse as better drug therapies became available for more conditions. It is now reserved for severe cases of refractory depression in such illnesses as clinical depression (unipolar depression) and the depression associated with bipolar disorder. When still in common use, ECT was sometimes abused by unethical mental health professionals as a means of punishing and controlling unruly or uncooperative patients. Many people came to view ECT unfavorably after negative depictions of it in several books and films, and the treatment is still controversial.
Mechanism of action • Exactly how ECT exerts its effects is not known, but repeated applications affect several kinds of neurotransmitters in the central nervous system. ECT seems to sensitize two subtypes of serotonin receptor (5-HT receptor), thereby strengthening signaling. ECT also decreases the functioning of norepinephrine and dopamine, inhibiting auto-receptors in the locus coeruleus and substantia nigra, respectively, causing more of each to be released. One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor (BDNF) and its receptor, TrkB, in limbic brain regions.
In the US the Surgeon General's 1999 report on mental health summarised current psychiatric opinion on the effectiveness of ECT. It stated that both clinical experience and controlled trials had determined ECT to be effective (with an average 60 to 70 per cent response rate) in the treatment of severe depression, some acute psychotic states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals.
There is current research in using Magnetic stimulation therapy (MST) as an alternative to ECT although presently it seems to be somewhat less effective. Dietary omega-3 fatty acids and sleep deprivation are also being researched. Vagus nerve stimulation therapy is another alternative to ECT.
Transcranial magnetic stimulation (TMS) is a noninvasive method to excite neurons in the brain. The excitation is caused by weak electric currents induced in the tissue by rapidly changing magnetic fields (electromagnetic induction). This way, brain activity can be triggered or modulated without the need for surgery or external electrodes. Repetitive transcranial magnetic stimulation is known as rTMS. TMS is a powerful tool in research and diagnosis for mapping out how the brain functions, and has shown promise for noninvasive treatment of a host of disorders, including depression and auditory hallucinations.
The effects of TMS can be divided into two types depending on the mode of stimulation • single or paired pulse TMS
Single or paired pulse TMS • The pulse(s) causes a population of neurons in the neocortex to depolarise and discharge an action potential. If used in the primary motor cortex, it produces a motor-evoked potential (MEP) which can be recorded on electromyography (EMG). If used on the occipital cortex, phosphenes might be detected by the subject. In most other areas of the cortex, behavioural effects are not readily detectable although effects can be shown on PET, fMRI or other neurophysiological tests. Whatever the case, the effects do not outlast the period of stimulation. A review of TMS can be found in the Handbook of Transcranial Magnetic Stimulation.
Repetitive TMS (rTMS) • Repetitive TMS (rTMS) produces effects which outlast the period of stimulation. rTMS can increase or decrease the excitability of corticospinal or corticocortical pathways depending on the intensity of stimulation, coil orientation and frequency of stimulation. The mechanism of these effects are not clear although it is widely believed to reflect changes in synaptic efficacy akin to long-term potentiation (LTP) and long-term depression (LTD). A recent review of rTMS can be found in Fitzgerald et al, 2006 .
TMS is currently under study as a treatment for severe depression, mania, auditory hallucinations (e.g., associated with schizophrenia), posttraumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, migraine headaches and tinnitus. It is particularly interesting as it may provide a viable treatment to certain aspects of drug resistant mental illness, particularly as an alternative to electroconvulsive therapy. TMS is also under investigation for the treatment of drug-resistant epilepsy and tinnitus. rTMS therapy for drug-resistant depression has been approved by Health Canada for clinical delivery since 2002.
Although research in this area is in its infancy, there is now some evidence that TMS is an effective treatment for depression, obsessive-compulsive disorder, generalized anxiety disorder, and auditory hallucinations, with more symptoms and disorders being researched. Additionally, in June 2006, US medical researchers published evidence indicating that TMS is more successul at treating migraines in patients than current medications. A larger research study involving more patients and better controls is planned to confirm the validity of these results.
Several TMS/rTMS devices are approved by the US Food and Drug Administration (FDA) for stimulation of peripheral nerve and, therefore, can be used "off label" by individual physicians to treat brain disorders, essentially in any way they believe appropriate, analogous to the off label use of medications. However, most legitimate use of TMS in the US and elsewhere is currently being done under research protocols approved by hospital ethics boards and, in the US, often under Investigational Device Exemption from the FDA. The requirement for FDA approval for research use of TMS is determined by the degree of risk as assessed by the investigators, the FDA, and the local ethics authority. The FDA is expected to approve TMS as a treatment for depression in early 2007. As regulated medical devices, TMS devices are not sold to the general public. They are also expensive (25,000-100,000 USD; together with state-of-the-art targeting and recording instruments, up to about 500,000 USD). In Europe, TMS devices that have been manufactured according to the Medical Device Directive have been granted the CE mark and can thus be freely marketed within the EU.
Vagus nerve stimulation (VNS) • Vagus nerve stimulation (VNS) is an adjunctive treatment for certain types of intractable epilepsy and clinical depression. VNS uses an implanted stimulator that sends electric impulses to the left vagus nerve in the neck via a lead implanted under the skin. • The VNS device consists of a titanium encased generator about the size of a pocket watch; a lithium battery to fuel the generator, with a battery life of ~6-8 years; a lead system with electrodes; and an anchor tether to secure leads to the vagus nerve. The device is made by Cyberonics
Implantation of the VNS device is usually done as an out-patient procedure. The procedure goes as follows: an incision is made in the upper left chest and the generator is implanted into a little “pouch” on the left chest under the clavicle. A second incision is made in the neck, so that the surgeon can access the vagus nerve. The surgeon then wraps the leads around the left branch of the vagus nerve, and connects the electrodes to the generator. Once successfully implanted, the generator sends electric impulses to the vagus nerve at regular intervals. The left vagus nerve is stimulated rather than the right because the right plays a role in cardiac function such that stimulating it could have negative cardiac effects
Because the vagus nerve is associated with many different functions and brain regions, research is being done to determine its usefulness in treating other illnesses, including various anxiety disorders, Alzheimer's disease,and migraines. • Other brain stimulation techniques used to treat depression include Electroconvulsive therapy(ECT) and Cranial electrotherapy stimulation(CES). Deep brain stimulation is currently under study as a treatment for depression. Transcranial magnetic stimulation(TMS) is under study as a therapy for both depression and epilepsy. Trigeminal Nerve Stimulation (TNS) is being researched at UCLA as a treatment for epilepsy.
Physical care • Along with other nurses, psychiatric mental health nurses will intervene in areas of physical need to ensure that people have acceptable levels of self-care, nutrition, sleep etc. And they will tend to any concomitant physical ailments.
Psychosocial interventions • Psychosocial interventions are increasingly delivered by nurses in mental health settings and include psychotherapy interventions such as cognitive behavioural therapy, milieu therapy (on the psychiatric unit) and, less commonly, pscyhodynamic approaches for depression, anxiety and psychosis and. Nurses will work with people over a period of time and use psychological methods to teach the person psychological techniques that they can then use to aid recovery and help manage any future crisis in their mental health. In practice, these interventions will be used often, in conjunction with psychiatric medications. Psychosocial interventions are based on evidence based practice and therefore the techniques tend to follow set guidelines based upon what has been demonstrated to be effective by nursing research. There has been some criticism  that evidence based practice is focused primarily on quantitative research and should refect also a more qualitative research approach that seeks to understand the meaning of people's experience
Psychotherapy • Psychotherapy is a range of techniques based on dialogue, communication and behavior change and which are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family). Most forms of psychotherapy use only spoken conversation, though some also use various other forms of communication such as the written word, artwork or touch. Commonly psychotherapy involves a therapist and client(s) — and in family therapy several family members or even other members from their social network — who discuss emotionally difficult situations in an effort to discover underlying problems and to find constructive solutions
Therapy may address specific forms of diagnosable mental illness, or everyday problems in relationships or meeting personal goals. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with "psychotherapy". • Psychotherapeutic interventions are often designed to treat the patient in the medical model, although not all psychotherapeutic approaches follow the model of "illness/cure". Some practitioners, such as humanistic schools, see themselves in an educational or helper role. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.
In the 20th century a great number of psychotherapies have been created. All of these face continuous change, both in popularity, methods and effectiveness. Sometimes they are self-administered, either individually, in pairs, small groups or larger groups. However, usually a professional practitioner will use a combination of therapies and approaches, often in a team treatment process that involves reading/ talking/ reporting to other professional practitioners
Organization of mental health care • People generally require an admission to hospital, voluntarily or involuntarily if they are experiencing a crisis that means they are dangerous to themselves or others in some immediate way. However, people may gain admission for a concentrated period of therapy or for respite. Despite changes in mental health policy in many countries that have closed psychiatric hospitals, many nurses continue work in hospitals though patient length of stay has decreased significantly. • Community nurses in mental health, work with people in their own homes (care in the community) and will often emphasise work on mental health promotion. Psychiatric mental health nurses also work in rehabilitation settings where people are recovering from a crisis episode and the where the aim is social inclusion and a return to living independently in society. • Psychiatric mental health nurses also work in forensic psychiatry with people who are detained as they have committed a crime or are particularly dangerous. • People in the older age group who are more prone to dementia tend to be cared for in separate places than younger adults and there are also specialist services for the care of adolescents with mental health problems. Occasionally there have been efforts to integrate psychiatric units across the age spectrum.