Wk 3: Mood disorders Flashcards
Define mood?
= the way a person feels, and is usually consistent with circumstances
- relates to their circumstances
- changes frequently by different levels.
Describe mood disorders? and some characteristics of them.
= a term used to describe mental illnesses where mood is disturbed (depression and/or mania) to the point that the person has difficulties functioning in various aspects of their lives.
- struggle to cope with changes in mood.
- not to be confused with inability to regulate mood (a common experience of people with personality disorders)
What are types of mood disorders?
Depressive disorder and bipolar disorder
We talk about mood disorder on a spectrum. Explain this..
Major depressive disorder sits opposed to mania with bipolar disorder in the middle that incompases both the highs and lows of both.
We talk about mood disorder on a spectrum. Explain this..
Major depressive disorder sits opposed to mania with bipolar disorder in the middle that incompases both the highs and lows of both.
Differ grief from depression and what are some of the symptoms?
Grief: natural response to loss of something or something. it is an understandable and culturally appropriate response to life events.
Symptoms
- anger
- comes in waves
- decreases over time
- improves with contact to people
- preservation of self-esteem
- able to experience some enjoyment
As per the DSM V what are the common and differing factors of their disorders?
The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. What differs among them are issues of duration, timing, or presumed aetiology
What is the DSM 5 criteria for major depressive disorder (MDD)?
Diagnosis is made when a person experiences at least 5 of the 9 symptoms in a consistent 2 week period. (1 or 2 must be included to confirm diagnosis)
- must represent a difference from their previous functioning
- symptoms can to be attributed to another medical condition.
- Depressed mood most of the day, nearly every day. Aka: anadonia
- Markedly diminished interest or pleasure in all, or most activities, most of the day, nearly every day.
- Significant weight changes [loss or gain] when not dieting. (≥ 5% in 1/12)
- Insomnia or Hypersomnia nearly every day.
- Psychomotor agitation or retardation, nearly every day.
- Physical fatigue or loss of energy every day.
- Feelings of worthlessness, excessive or inappropriate guilt nearly every day (Can be delusional).
- Diminished ability to concentrate or give enough attention, ambivalence or indecision nearly every day.
- Recurrent thoughts of death or suicidal ideation.
* this is the same criteria as bipolar disorder
Define anadonia
= complete loss of pleasure
What is the aim of pharmacological treatment for MDD: antidepressants
= believed that they have an effect on neurotransmitters in the brain. The reduction or absence of these correlates/ in cases of depression.
What neurotransmitters do antidepressants effect?
The 3 neurotransmitters involved are;
- Serotonin
- Noradrenaline (Norepinephrine)
- Dopamine
- they affect these in different ways
Who do antidepressants help?
- chronic mild depression may be warranted with antidepressant therapy when other interventions are exhausted.
- Family history of depression & recurrent depressive episodes are more likely to warrant antidepressant therapy
- they don’t help everyone
Describe Selective serotonin reuptake inhibitors (SSRI’s), their common side effects and examples.
- most common anti-depressant
- very effective in treating depression and better side effect profile
- less toxic in overdose
- Also effective with social phobias & anxiety disorders
- Broad usage to the extent of prescription for erectile dysfunction [Fluoxetine]
Action: SSRI’s inhibit the reuptake of neurotransmitters, specifically serotonin, allowing serotonin to remain in the CNS for longer
Common side effects: Dry mouth, headache, drowsiness, dizziness, tremors, diarrhoea, constipation, loss of appetite, sexual dysfunction
- usually go away in 2 weeks
Examples: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
Describe Serotonin and Noradrenaline
Reuptake Inhibitors (SNRI’s), their common side effects and examples.
Thought to produce fewer side effects (such as weight gain), but more difficult to withdraw from.
Mode of action: Work by inhibiting the reuptake of noradrenaline and serotonin
- stop or delay substances called serotonin and norepinephrine from being reabsorbed in the brain, which leaves more of them available for the brain to use.
Common side effects: intensified dreaming, mild nausea, headache, diarrhoea, abdominal cramping, restlessness, reduced sex drive and difficulty reaching orgasm
Examples: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine
Describe Tricyclic Antidepressants (TCAs), their common side effects and examples.
Action: TCAs act on different pathways to other antidepressants, and also inhibit the reuptake of the neurotransmitters serotonin and norepinephrine, increasing the levels of these two neurotransmitters
- Generally seen as more effective in treating depression, however more potent side effects & lethal in over-dosage
- Usually administered at night due to sedative properties
- good to us for those with depression that effects their sleep
Other uses:
- amitryptyline, dothiepin & doxepin are commonly used in pain disorders given their propensity to bind to pain receptors and enhance the efficacy of analgesia
- imipramine commonly used on children with enuresis >5 years
Common side effects: blurred vision, dry mouth, constipation, weight gain or loss, low BP on standing, rash, increased HR
Examples: amitriptyline, clomipramine, imipramine
Describe Monoamine Oxidase Inhibitors
(MAOI’s), their common side effects and examples.
- Monoamines include Dopamine, Noradrenaline, Adrenaline and Serotonin
- Monoamine Oxidase is an enzyme which breaks down these monoamines
Action: Preventing the enzymes action increases the levels of these monoamines
Common side effects: dry mouth, nausea, diarrhea, constipation, headache, drowniess, insomnia, dizziness
Examples: moclobemide, phenelzine, selegiline, tranycypromine
Note: use of MAOI’s requires diet restrictions because they can cause dangerously high blood pressure when taken with tyramine rich foods (e.g. Strong or aged cheeses, cured/processed meats, pickled/fermented foods, soybeans, vegemite, alcohol)
- if someone is depressed and this was one of their fav foods, a different medicine might be better
What are the common side effects of some antidepressants?
dry mouth, dizziness or lightheadedness
Are antidepressants addictive or do they chnage a person’s personality?
No
If an antidepressant needs to be changed can this be done as a straight swap?
a tapering off period is required before commencing a new medication, however cross titration is of a shorter period as the newer antidepressants require less time to ‘wash out’
What are some other things antidepressants are used for?
a variety of general and psychiatric conditions
eg.
- Fibromyalgia
- pains
- premature ejaculation
- migraines
- nocturnal enuresis
Are antidepressants beneficial for those with bipolar?
No not usually, as they can lead to manic episodes.
When do the effects of antidepressants set in? and what is the key negative effect?
- Positive effects can take two weeks and full effect can take 6-8 weeks.
- Increase risk of suicide due to increase energy to act on suicidal impulses and cognitive ability
to plan and implement plan (if suicidal thoughts are present or vulnerability to suicide)
- when someone is depressed they don’t have the energy to make and plan and act it out.
Explain serotonin syndrome. What can cause it? what are the impacts? what are some symptoms?
= a drug induces excess of serotonin
= occurs when two or more antidepressants or other seratogenic agents (pethidine, cocaine, LSD, Ecstasy, St Johns Wort) are taken concurrently causing an excess of serotonin.
Can occur as an;
- adverse reaction to a normal therapeutic dose
-after drug overdose
- drug interactions.
Impacts;
- can be potentially fatal and occurs when two or more antidepressants
Symptoms
- agitation
- confusion
- hyperthermia
- hypertension tremor
- sweating
- dilated pupils
- diarrhoea
- tremor
Mortality: rate of 2%-12%
Describe discontinuation syndrome
= Can occur when there is an interruption, reduction or discontinuation of antidepressant medication
- Occurs in approx. 20% of people who abruptly stop or have a marked reduction in taking antidepressants when they have been taking for a month (Gabriel & Sharma, 2017)
Symptoms include:
- Flu like symptoms
- Insomnia
- nausea
- Imbalance
- sensory disturbances
- Hyperarousal (Agertation/anxiety + sad and horrible)
Symptoms are usually mild and last 1-2 weeks
What are some MUSTs for nursing care of a person with depression?
- Comprehensive psychiatric assessment
- Risk assessment
- Risk management
What are risk assessment points someone might have if they have depression?
- Suicide risk
- Self harm risk
- Aggression to others (eg. Post natal depression – infanticide or where aggression is a feature)
- Self neglect
- Substance abuse
- Medication adherence
When might an MSE be conducted for someone with depression?
- maybe on a phone call every 2 days if in the community
- every shit if inpatient
- risk assessment may occur at the same time
Define infanticide
When someone kills their babys often because of post-natal depression.
What are some key points of risk management for someone with depression?
- enhance protective factors
- recovery goals
- keep the person safe
- assess their physical health as this can decline simultaneously to mental health.
- Identification of the risks (thoughts, intent, plan, history)
- Determine level of risk with a plan and work with the consumer to manage risks
- Document assessment, risk and plan of action
- Supporting/enhancing protective factors
What physical health issues can be closely linked with depression?
Assessment
- Many physical conditions mimic or influence depression
- Physical conditions such as Hypothyroidism can mimic & chronic pain syndromes can influence the severity, frequency &
intensity of depressive symptoms.
- Anxiety commonly occurs with depression and moods rarely remain static
- Certain conditions such as Cancer, Cardiovascular diseases & Diabetes Mellitus are frequently linked with depression in clients
- Some medical treatments can result in depression as a side effect or interfere with anti-depressant treatments. Some
examples; steroids, antibiotics, CNS & dermatological meds
Nursing management
- may not be eating so put on a
What are some nursing interventions for people with depression?
- risk assessment
- start food and fluid chart as they may not be eating
- MSE
- educate them on effective ways to improve sleep
- ensure the therapeutic relationship
- ongoing psychoeducational
- encourage
- the importance of exercise
- educate on not using substances
- scheduling pleasurable activities
- psychoeducation to carers
- educate on medication
- make opportunity to discuss their condition, show empathy, discuss their symptoms and care
- promote independence e.g. make the bed together
- do activities together e.g. shoot the ball
*acknowledge gains in a mature manner
*Even if the client does not engage, persist as depression is an illness of isolation & ongoing contact reinforces nursing concerns for their welfare
What are some key points of assessment to gauge physical health in someone with depression?
- Nutrition & elimination
- Energy levels
- Sleep
- ADL’s & grooming
- risk assessment
- MSE
How long can a diagnosis for bipolar?
10-20 years
- as unless you get a great history its hard to decided that they have both manic and depression often its easier to see them as one.
- Manic episodes more common as first presentation in men
- Depressive episodes more common as first presentation in women
- High incidence of treatment non-adherence
- Co-occurring substance misuse issues (self-medication)
Why are people with bipolar likely to not adhere to medication regimens?
Because after a period of feeling depressed they suddenly have all this energy which the medication takes away and they don’t like this or feel as good because of it.
When can bipolar be diagnosed?
= with bipolar disorder, the person must have experienced an episode of mania and depression
When can bipolar be diagnosed?
= with bipolar disorder, the person must have experienced an episode of mania and depression
Define bipolar 1
= consists of one or more manic episodes and accompanied by major depressive episodes
Define bipolar 2
= consists of one or more depressive episodes and accompanied by at least one hypomanic episode
- The criteria for major depressive disorder is used for the depressive episode
What is hypomania?
Is mania but it doesn’t reach the same extent.
What is the DSM V criteria for Bipolar 1 w/ mania?
= Abnormally & persistently elevated, expansive, irritable mood & abnormally & persistently increased goal-directed activity or energy (lasting 1 week & present most of the day)
Three or more of the following (4 if mood is only irritable)
1. Inflated self esteem or grandiosity (elevated sense of self)
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposelessness non-goal-directed activity)
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
***The mood disturbance causes impairment in functioning or requires hospitalisation to address risks
At least one manic episode is required for accurate diagnosis
What is the DSM V criteria for bipolar 2 w/ hyper mania?
Distinct period of abnormally & persistently elevated, expansive or irritable mood & abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day.
Three or more of the following (4 if mood is only irritable)
1. Inflated self esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
**The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation.
- If there are psychotic features, the episode is by definition, manic
- peoples types of bipolar diagnosis can be changes as per they symptoms
What are the treatment goals of bioplar?
- Pharmacotherapy for bipolar disorder is complex
- Treatment goals can be divided into managing/treating acute mania or depression or ongoing against further episodes of elevated or depressed mood
Pharmacology includes
- Antipsychotic medication (e.g. Olanzapine)
- Mood stabilising medication
- Anxiolytic medication (e.g. Diazepam)
Mood stabilisers are a group of drugs that include:
- lithium carbonate
- antiepileptic drugs sodium valproate, carbamazepine and lamotrigine (also used in the treatment of neuralgic/chronic pain, epilepsy and migraine headaches)
Explain the medication Lithium carbonate, it’s side effects, benefits and disadvantages.
Lithium carbonate (Lithicarb, Quilonum SR)
- Useful in acute mania and as preventative
- Acute phase blood concentration 0.8 – 1.2 mmol/L (ongoing maintenance 0.6 – 0.8 mmol/L)
Side effects
- Nausea
- vomiting
- diarrhoea
- weight gain
- tremor
- fatigue
- polydipsia
- polyuria
Benefits
- Efficacy in reducing risk of suicide (compared to others
Disadvantages
- High side effects
- Narrow therapeutic window (lithium toxicity)
- Only available in oral form (issues with adherence)
Nursing management
- Blood levelsof lithium must be monitored due to narrow therapeutic window. Need to get it in range but not toxicity
- educate on importance of not getting dehyrdated. ?gastro, exercise=get fluids
- cannabis, NSAIDs, and diaretics= can lead to lithium toxicity
- Serum levels taken > 12 hours post dosage
- Advise to take with milk/food due to GI upset
- Excreted primarily by kidneys, therefore kidney function needs to be normal
- Toxicity usually results in dialysis
Monitor water and salt intake – changes can increase lithium levels (toxicity)
Explain the medication sodium valporate, it’s side effects, benefits and disadvantages.
Sodium valproate (Epilum, Valpro)
= thought to reduce or prevent manic episodes by increasing the amount of a chemical called gamma-aminobutyric acid (GABA) in the brain. GABA blocks transmission across nerves in the brain and has a calming effect.
Side effects
- Nausea
- vomiting
- changes in appetite/weight
- diarrhoea
Benefits
- rapid onset
- well tolerable
Disadvantages
Explain the medication carbamazepine, it’s side effects, benefits and disadvantages.
Carbamazepine (Tegretol)
= decreases neuronal excitability or enhances inhibition by altering sodium, potassium or calcium conductance or by affecting the δ-aminobutiric acid (GABA), glutamate or other neurotransmitters that may be concerned in seizure activity
Side effects
- Drowsiness
- dizziness
- fatigue
- nausea
Benefits
- Less sedating than others
Explain the medication lamictal, it’s side effects, benefits and disadvantages.
Lamotrigine (Lamictal, Lamogine)
= selectively binds and inhibits voltage-gated sodium channels, stabilizing presynaptic neuronal membranes and inhibiting presynaptic glutamate and aspartate release.
- slows these electrical signals down to stop seizures.
Side effects
- Dizziness
- drowsiness
- headache
- tremor
- blurred vision
- confusion
Benefits
Disadvantages
- Efficacy in managing depressive episodes &
BPADII
- Rash (life-threatening)
What are the symptoms of low, in range and high lithium toxicity?
< 1.2 mmol/L
- Fine tremor, nausea, vomiting, diarrhoea, muscle weakness, flu-like symptoms
1.5 – 2.5 mmol/L
Coarse tremor, severe GI symptoms, sedation, hyperreflexia
> 2.5 mmol/L
Stupor, coma, arrhythmias, seizures, cardiovascular collapse, death
Describe some key point of nursing care for someone with bipolar: physical assessment
Comprehensive psychiatric assessment
- Can be difficult as cooperation during a manic phase varies and does not last for long periods. Data gathering from others is important
- MSE and risk assessment
- Any MSE changes must be handed over within the team & documented. Abrupt changes in mood are of particular concern – mood swings are common in people with BPAD
Your assessment must also include a physical assessment
- Physical conditions such as hyperthyroidism can mimic mania
- Illicit substances such as amphetamines can induce a mania
- Some medical treatments can induce mania (corticosteroids)
- Attention to physical state needs monitoring with a focus on:
- Nutrition & hydration (consider ‘finger foods’ and nutritional supplements as they may be difficult to direct and remain seated for meals)
- when manic may be to busy to eat
- Sleep – promote sleep and rest with emphasis on balance
- ADL’s & grooming
- dressing appropriately
Describe some key point of nursing care for someone with bipolar: risk assessment
Risk assessment is vital & includes the following;
- Suicide risk: These clients have a higher rate of suicide than the general population
- Self Harm risk: [Deliberate & Accidental] DSH is possible during depressive phases & ASH commonly results from hypomanic / manic phase due to impaired judgement
- Aggression to others: Risk varies, irritability & lability of mood factors to consider
- Risk of harm from others: Due to impaired judgement & insight, ↑’ed risk taking behaviours occur. Impulsivity factors heavily into this risk
- Neglect: Deprivation of sleep, eating, drinking & self-care deficits factor into this domain
- Adherence: Can be impaired or absent due to lack of insight or desire to keep feelings of euphoria.
- Vulnerability: Financial & sexual. People have been known to lose large amounts of $ & undesired pregnancies
Describe some key point of nursing care for someone with bipolar: risk management
- Identification of potential & actual risks
- Enhancing protective mechanisms
- Gauge the client’s thoughts, intent, plan & assess past history of attempts
- Determine level of risk with a plan to address & resolve risk
- Document the assessment, degree of risk, effectiveness of interventions and plan of action
What are some key nursing interventions for someone with bipolar disorder?
- Therapeutic relationship with the client should be established & maintained
Attitude of nurses with the ability to communicate is important (characteristics: approachable, tolerant, patient, open, honest, non-judgmental, compassionate, kind, non-punitive)
Ongoing psychoeducation on; condition, management to the client & significant others
- When mood stabilises, provide education on illness, treatment and early warning signs of relapse
- Develop relapse plan that is inclusive and person-centered
Limit setting must occur (at times people with BPAD can dress and behave provocatively. Once mood stabilises they can regret their behaviour)
Reduce environmental stimulus as people are easily distracted and have limited concentration and attention span
- Limit visitors and length
- Reduce light, noise, activity
Be mindful of treatment adherence
Monitor for evidence of ETOH &/or Drug abuse. Also consider withdrawal regime if the client has been using substances prior to admission
What are some common problems with medication adherence in bipolar?
Stop taking due to;
- side effects
- ‘feel better’
- don’t want mania to disappear after period of depression
How can we support people’s medication adherence?
- We need to support people in their recovery and medication management; maximise choice and reduce coercion through:
- Education (medication specific and expectations of, when/why/how to take, side effects and how to manage, what to do if the person wants to stop)
- Use pamphlets, books, print outs
- Enhance the persons control by offering real choices
- Suggest use of pill boxes/webster packs
- Discuss safe ways to reduce medication if they feel it is impairing their recovery, physical or mental health
What is the spectrum of treatment in mood disorder management?
- symptom relief
-> Return to normal functioning
-> Development of resilience
-> Support for personal recovery and quality of life
Describe ECT aka Electroconvulsive Therapy
- regulated under the MHA, decisions is made by the mental health tribunal and psychiatrist
- A medical procedure performed under general
anaesthetic
= A small electric current is passed through the brain to induce a seizure - Usually, a person will have 3 treatments a week, with a total of 9-12 treatments
- Used for people experiencing severe depression and/or acutely suicidal/mania
- Useful for those who cannot take medication due to side effects, treatment resistive, or for those who may not be able to wait for a therapeutic response from medication.
- useful in catatonia= people can no longer move due to their depression
What are the short-term side effects of ECT?
- headache
- nausea
- confusion
- muscle ache
- amnesia
- memory loss (no effect on long term memory or intelligence)
What are the theories behind how ECT works?
That the seizure activity
- Enhances the release of neurotransmitters within the brain
- Adjusts the stress hormone regulation in the brain, which may affect energy, sleep, appetite,
and mood
- Changes the patterns of blood flow through areas of the brain associated with depression
What are some nursing considerations for ECT?
Provide usual care to that of any procedure where a person is receiving general aesthetic
- Do not eat/drink prior to the procedure
- Physical observations pre op
- Post care
Explain ECT to the consumers and their families and help in understanding the treatment and provide accurate information.
Why do you think benzodiazepines and some mood stabilisers such as epilim should be withheld prior to ECT?
These are antiseziure medications and ECT works by initiating a seizure.
Define the theraputic intervention of psychotherapies that can be initiated for people with mood disorders?
Are a non-invasive treatment for mood disorders that are effective and
increasing in popularity. They aid in the prognosis of clients with mood disorders and can be used over the short or long term.
What is cognitive behavioural therapy?
- Useful as a primary or secondary form of treatment for mood disorders
- Aim is to challenge negative or irrational thought patterns
- Extreme thoughts = extreme emotions
- Feelings result from attitudes, thoughts & beliefs, not the external situations.
- Harmony between thoughts, emotions and behaviour is the desired result
When talking about CBT, what does the cognitive and behavioural refer too?
Cognitive therapy
- aimed to chnage the way you think of onself
- One technique involves asking you to come up with evidence to ‘prove’ that you are unlovable. This may include prompting you to acknowledge the family and friends who love and respect you. This evidence helps you to realise that your belief is false. This is called ‘cognitive restructuring’. You learn to identify and challenge negative thoughts, and replace them with more realistic and positive thoughts.
Behavioural therapy
- Behaviour therapy teaches you more helpful behaviours. For example, you may be taught conversational skills that you practise in therapy and in social situations. Negative thoughts and feelings reduce as you discover you can enjoy yourself in social situations.
Describe the therapeutic intervention for mood disorders that is; interpersonal therapy
- Focus is given to the strength of the clinical relationship
- Like CBT, IPT does not resolve every problem, more driven to problem solve & grounded in
the present - The relationship & interactions of carers / family are seen as catalysts to change unhelpful
thoughts & behaviours - Useful in hypomanic & depressive disorders
Describe the therapeutic intervention for mood disorders that is; financial counselling
- Warranted for client with manic episodes, as some of these clients excessively spend, placing
themselves & / or family members at risk - It is common for hypomanic clients to experience delusions of grandeur, ∴ consideration for Guardian & / or Administration order should be given
- Proactive measures should be recommended when the client is well
What are the key principles of recovery and discharge?
- Consider principles of recovery – uniqueness of the individual, real choices, attitudes and rights, dignity and respect, partnership and communication, evaluating recovery
- Educate the person and their family/carers about the disorder/symptoms, including early warning signs, medication etc
- Encourage the person to maintain contact with GP, health care professionals and social contacts
- Self management of stress is important (learn/utilise techniques to minimise/avoid stressful situations)
- Empowerment of people if vital to maintain a therapeutic relationship. Honesty and openness assists in this area
- Identify support networks with the person
- Provide crisis contact details should exacerbation of symptoms/illness occur
- Information should be provided verbally/written and culturally appropriate, being mindful of people’s specific needs
What is deliberate self harm?
= non-lethal infliction of injury. totheself.
- used as a coping strategy. Wishing to feel something
- thought that injury may release some endorphins
- No intent to take their life.
- often occurs in the context of situational crisis or in relation to the lived experience of trauma, or a means of managing emotions or to ‘feel something’
- thought people may self harm as they cant communicate they need help but this shows it.
External behaviours such as cutting, scratching, burning, picking and head banging
Internal behaviours such as swallowing objects or substances
Nursing management
- Need to engage with the person, going beyond what is in front of you (eg. cut arm)
- don’t go into background and the why
- Risk assessment
- they are attention needing not attention seeking
- deal with the wound if present
What is the self harm cycle
- Wish to escape feelings
- Urge to self-harm
- Acts- self harm
- feels relief, or seeks help
- feels guilty
- painful feeling
Define suicide
Self-inflicted death with evidence (explicit or implicit) that the act was intentional
Define suicide attempt
Self-injurious behaviour with a non-fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die
Define suicidal attempt
Subjective expectation and a desire for a self-destructive act that would end in death
Define suicidal ideation or thoughts
Thoughts of serving as an agent of one’s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and degree of suicidal intent
Define deliberate self harm
Wilful self-inflicting of, at times, painful, destructive or injurious acts without intent to die
What are some risk factors for suicide?
- People with mental illness
- Recurrent depression carries the highest risk
- post discharge from hospital, transitions in care
- Prior attempts & history of D.S.H. – This is widely recognized as a strong indicator for suicide
- Clients with Drug & ETOH problems – There is a correlation between substance abuse / dependence & depression. This group are at a higher risk chronically than the general population
- Indigenous males – particularly young males are more likely to suicide than Caucasian males
- Incarcerated people – Regardless of ethnicity are more prone to suicide than others with 3x risk
- Social factors - Impacts on personal safety. Poor relationships, family discord, marital separation & conflicts, legal proceedings, unemployment, finances, social welfare recipients, loss of partner, sexual abuse, trauma, isolation & sexual orientations / preferences
- Physical state – Chronic disability, pain & terminal conditions increase personal safety concerns
- Combinations of the above groups
What needs to be considered when doing a risk assessment on someone who has suicidal ideations?
= Suicidal ideation refers to thoughts or ideas of suicide. These may be vague with only a
wish to die and no plan or intent. Alternatively, the client may have firm plans, intent to act
on the plan & the availability of means. (Medications, rope, secluded area)
- Suicidal ideation varies in the intensity, frequency & duration.
- Levels of subjective distress with the client also may vary between passive acceptance to severe agitation
- frequency of risk assessments depends on the client’s current mental state & response to treatment and nursing interventions
- The MHA status of the client may need to be reviewed in order to reduce the risk to the
client.
- If imminent risk to self – compulsory admission criteria may be met
What are some questions you may ask someone who is an identified suicide risk in a risk assessment?
- Do you feel that life is no longer worth living? (thoughts)
- Have you felt like acting on this? (intent)
- Have you made any plans to carry this through? (method + plan)
- Have you ever tried to harm or kill yourself before (attempt, past history)
- Suicidal ideas in absence of intention to act = low risk
- Suicidal ideas + intention = mod risk
- Suicidal ideas + intention to act + specific plans = high risk
- Yes to Q4 Increased overall risk
From this point, it is helpful to ask the client – “What needs to change to order to maintain your safety?”
If previous attempts at suicide / self harm have occurred, ask for particulars, “Were they alone?, Did they change their mind or feel guilty?, Did they get medical treatment or Ψ care?, Did they get help?, What current factors are different? & Was the help effective?”
What are some risk management strategies for dealing with someone that is suicidal?
- The nurse/client relationship is of high importance
- Person-centred care
- Keep the client safe
- Encourage strategies to help the person cope with distress, pain and suicidal thoughts
- No suicide contract vs crisis plan
- Look after yourself and access appropriate support
What are some key language alterations that must be made when talking about suicide?
- Our language needs to be respectful, non-judgemental, strengths based
- Words we use reflect our value, belief and respect of people
Appropriate language which demonstrates acceptance, respect, hope, and uniqueness
when discussing self-harm and suicide
- The person (name) is experiencing thoughts of self-harm/suicide
- The person (name) tends to self-harm when upset
- Died by suicide (rather than ‘committed’)
- Suicided (rather than ‘successful suicide’)
- Ended his/her life, took his/her own life (rather than ‘killed themselves’)
- Non-fatal attempt at suicide (rather than ‘failed suicide’)
- Attempted to end his/her life (rather than ‘unsuccessful suicide’)
What might someone with Mania’s MSE present?
Appearance: Sexually provocative clothing, poor attention to hygeine, excessive make-up
Behaviour: Hyperactivity, agitated, poor eye contact, psychomotor agitation
Speech: Speech will usually reflect mood. So for example, if the person is excitable their speech may be fast in rate and loud in volume
Mood: Elated, euphoric. May say things like “I feel amazing” “I feel wonderful” - mood can also fluctuate to irritability rapidly
Affect: Elevated
Thought Content: Gradiose delusional themes, No suicidal ideations plan or intent
Thought Form: Thought disordered, flight of ideas
Perception: Perceptual disturbances present, experiencing visual hallucinations
Cognition: Poor attention and concentration. Poor memory. Not oriented to time or place.
Judgement: Poor judgement
Insight: Poor insight
What might someone with Mania’s MSE present?
Appearance: Disheveled, poor attendance to hygiene
Behaviour: Poor eye contact, slowed psychomotor activity, closed body language, difficult to engage in eye contact, tearful
Speech: Speech will usually reflect mood. So for example, if the person is flat their speech may be low in tone and slow in rate
Mood: Sad, empty, depression. May say things like “I feel empty” “I feel numb”
Affect: Crying, tearful, restricted range, blunted
Thought Content: Hopelessness and helplessness, thoughts of suicide or self harm, themes of worthlessness lonliness, guit and shame.
Thought Form: No formal thought disorder
Perception: Depersonalisation
Cognition: Assess the person’s orientation. If they are experiencing major depressive disorder they may have poor memory and attention, therefore require re-orientation to time, place and person.
Judgement: Assess if the person has impaired or intact judgement
Insight: Assess if the person has insight into their current situation. Insight may be impaired, partial or intact
What would be involved in a risk assessment for someone with depression?
Risk assessment should form part of the full assessment of a person’s needs.
When assessing risk you should differentiate between long-term and acute risks.
The risk assessment must consider risk to self and others (particularly dependent children). The following potential risk areas below presents areas for consideration and provides some examples of how you might ask the person about the risk.
Suicide:
Are you thinking about suicide?
Are you thinking about completing suicide?
Have you got a plan to act on your thoughts?
Have you got means to act on your thoughts?
Are you able to keep yourself safe - if so, how will you keep yourself safe?
Who will you contact if your thoughts become more intense?
Self harm:
Do you have any thoughts of harming yourself? (Cutting, scratching, burning, punching)
If so, how often are you engaging in self harm?
Comorbid conditions:
Do you have another diagnosis from a health professional?
Do you use substances such as drugs or alcohol? Do you engage in gambling? If so, has there been a change in your pattern?
Vulnerability:
Are you worried about your safety?
Do you think people take advantage of you?
Dependent children?
Do you have any dependent children? If so - who is looking after them? Are they safe?
Obtain childrens details including full names and birth dates.
If a child is exposed to parental self-harm or suicide this is reportable to DHHS as the child is considered at risk. To complete a DHHS notification you will need the childs full names and DOB.
Coping strategies:
What has helped you cope with your low mood in the past?
Who supports you?
What do you enjoy doing - or what did you used to enjoy doing?
Do you have any pets?
What do you feel you need the most support with?
What are some non-pharmacological therapeutic interventions mood disorder?
- yoga therapy
- interpersonal therapy
- music therapy
- CBT
- Family therapy
- Financial counselling
- Animal therapy
- Art therapy
- ECT
- Supportive recovery
- Alternative therapies
What does psychoeducation include?
- Sharing information transfer (information about the client’s diagnosis including symptomatology of the disturbance, contributing factors if identifiable, treatment concepts)
- Provide education in relation to medication or psychotherapeutic treatments is required, and through this process cooperation is promoted between the mental health professional, consumer and carer (focus on compliance, adherence issues, safe storage of any prescribed medications)
- Identifying triggers and the clients individual early warning signs provides the opportunity for the client and or carer to seek assistance promptly before a full relapse (the crisis management plan is established by the mental health nurse in active consultation with the client and carer, while identifying strategies to enhance coping behaviours, identify supports and contact numbers should they be required)
Aim: help empower them and deal with their condition in an optimal way
- educating carers about a client’s mental health condition, directing them to carer resources, and providing them with tools to help support the unwell client.
- This is particularly important for example if the suicidal person is discharged back into the care of family or friends who may feel ill-equipped to provide adequate support through subsequent crises.
- Working with carers involves the mental health nurse providing written and verbal education on the clients mental health condition, providing skills training such as how to set limits and support for the carers so they feel more confident in knowing how to support and respond to their loved one.
Define DYSTHYMIA
= low mood
