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Lecture notes, lectures 1-5

Mental Health Nursing (Australian Catholic University)

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WEEK 1: MENTAL HEALTH & RECOVERY

Complete clinical recovery = absence of symptoms
Social recovery = ability to live a more or less independent life even if symptoms remain
Recovery involves the development of new meaning and purpose in ones life as one grows beyond
the catastrophic effects of mental illness
Individual journey = recovery is about more than the absence of symptoms, its having the chance to
live a satisfying and fulfilling life in the presence or absence of symptoms
Emphasis on persons capacity to have hope and lead meaningful life
Supporting consumer movement and consumer strengths, and suggests treatment can be guided
by attention to life goal and ambitions
Hope is the emotional essence of recovery
Positive belief of recovery
Role of HCP is to provide guidance during recovery
Stability; self-assessment and daily planning
Identifying and working with strengths
Anticipation; recognising signs, taking action and crisis planning
Information on treatments; medication, therapies, complementary therapies
Supporting environment; sharing plans, rights and information
Recovery involves process of empowerment to regaining active control over ones life
Increasing personal responsibility through self-care, self-management and self-directed care
Idea of recovery is shifting from service based to personal definitions to support the consumer
Services are providing holistic care
Drawing on life journeys of people experiencing mental illness in order to understand the individual
and not focus on group of disorders
Find meaning and value in personal experiences is important, as is personal faith like religion or
secular spirituality
Isolation is negative to recovery
Closely associated with social inclusion and being able to take on meaningful and satisfying social
roles in society and gaining access to mainstream services that support daily living
Services are an important aspect of recovery
Recovery-orientated practice recognises and embraces the possibilities for recovery and wellbeing
created by the inherent strength and capacity of all people experiencing MHI
Maximises self-determination and self-management of MH&W
Assists families to understand the challenges and opportunities arising from their family members
experience
Importance of collaborative working alliances with consumers, fostering personal responsibility,
promoting shared decision making, supporting the development of motivation, self-management
and self-empowerment and being responsive to families
Five key areas
o Increase awareness of MHI
o Reduce stigma and discrimination
o Improve help seeking
o Reduce impact and disability
o Facilitate learning, collaboration, innovation and research
Roadmap for national mental health reform
o Promote person-centred approaches
o Improve the mental health and social and emotional wellbeing of all Australians
o Prevent mental illness
o Focus on early detection and intervention
o Improve access to high quality services and supports improve the social and economic
participation of people with mental illness

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o Making the journey

Delivery of care; supporting recovery
o Individual uniqueness
o Real choices
o Attitudes and rights
o Dignity and respect
o Partnership and communication
o Evaluating recovery

MENTAL HEALTH ACT (2000)

Access; right to obtain treatment
Equity; resources should be fairy distributed
Effectiveness; the services should be aimed at improving health
Efficiency; resources should maximise gains for individual and society as a whole
Ethical principles guiding treatment of MI pts are beneficence and non-malfeasance
Require that the pt be kept from harm and experience benefits
Paternalistic actions may be ethically justified when the person is being protected from harm and
does not have the capacity to make decisions by themselves
o HCP can be advocates for a consumer but we must ensure that we advocate in collaboration
with them or else we risk being paternalistic
Paternalism;
o HCP believes they know what is best for the client
o They are most qualified to speak on the pts behalf
o That the pt is not sufficiently capable of doing so
Although intention is good, client autonomy is at risk
All consumers are to be treated with the same degree of respect, allowing autonomy to ensure the
person maintains integrity and does not feel vulnerable and powerless
Person with MI has the same rights as any person
o Free from discrimination, exploitation, abuse degrading treatment
o Live and work within the community to the extent of their capabilities
Mental health act exclusion criteria
o Particular social groups
o Particular economic or social status
o Sexual orientation or preference
o Immoral or indecent conduct
o Drug/s and/or alcohol use
o Intellectual disability
o Antisocial or illegal behaviour
o Family conflict
o Previous treatment for MI
General principles
o MH pts have same rights as others
o Pts are involved in decision making
o Support and information in are provided to the person to exercise their rights
o The person is helped to achieve their maximum potential and self-reliance where possible
Info & Rights; to be provided to the pt
o Assessment documents are in place
o Explanation about what this means
o An Involuntary Treatment Order (ITO) has been made inform category and reason why
o Details of the treatment plan and any subsequent changes

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Rights of involuntary pts

o Must be displayed prominently in the AMHS and copy given to the person on admission
o The rights of pts and allied persons
o Right to make a complaint and how to make a complaint
o Statement of rights must be explained in an language and manner that is clearly understood
Allied persons role is to help the pt represent their views, wishes and interests about assessment,
detention and treatment under the act, but must be over 18y/o
o Informed of a persons involuntary admission
o Notified of reviews and treatment applications
o Able to attend MHRT hearings
o Able to apply to MHRT on behalf of a person under an ITO
Purpose of an involuntary assessment is to determine if IT is required
o Person appears to have a MI
o Person requires immediate treatment
o Assessment can be made at an AMHS
o There is a risk the person may cause harm to self or others or suffer serious mental or
physical deterioration
o There is no lesser restrictive environment in which the person can be assessed.
o Person lacks the capacity to consent to be assessed
o Person has unreasonably refused to be assessed
Two documents required:
o Request for assessment
Made by anyone over 18 and who reasonably believes the person has a MI where an
involuntary assessment is required
They must have observed the person within 3days of making the request and within
7 days before or after a recommendation for assessment is made
o Recommendation of assessment
Dr or AMHP must have examined the person within the previous 3days. Valid for 7
days
Dr cannot make a recommendation for a family member. A request and
recommendation for assessment cannot be made by the same person
A request cannot be made by an employee of the person making the
recommendation
EEO (police/ambulance)
o Detention period is not to exceed 6hours from arrival in AMHS
o Person returned to place from which they were taken or another reasonable place of their
choice
JEO (person over 18y/o may make an application)
o To magistrate: file an application with registrar of the Magistrates Court
o To JP: provide an application form to the JP
o Application is sworn and the grounds for the application are states
o Penalties apply for false applications
o Order sent to AMHS: if faxed, original is also sent
o Dr of AMHS will attend place stated on the order
o Police officer may detain person for examination to occur: must respond to requests for
assistance when practicable
o Dr/AMHP must explain the nature and effect of order to the pt and produce a copy for
inspection
Involuntary treatment
o Consumers who feel that they have few rights and are restricted by legislation may be less
likely to engage in working relationship
o Treatment criteria apples

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The person has a MI

Persons MI needs immediate treatment
Treatment is available
Because of their illness, the person may cause harm to self/others
Person is likely to suffer serious mental/physical deterioration
Effects of ITO
o Person may be treated involuntarily as an inpatient or in the community: category of setting
must be state on the ITO
o Community category provides involuntary treatment of a person living in community; eg.
Depot medication
o As a safeguard the inpatient area is the only area where force can be used
Treatment plan
o Take into account existing plan and pts wishes; Advanced Health Directive
o Any changes should be discussed with the pt
o Must outline:
Proposed treatment
Frequency of treatment
Method and place of treatment
Rehabilitation and other services to be provided
Intervals for regular assessment
Limited Community Treatment (LCT) order
o Short periods of treatment/leave in the community
o Transition from hospital to community prior to discharge
o Approved by authorised DR and documented in treatment plan
o May state conditions; e.g. no alcohol or drugs
o Uneasy tension between self-determination and the determinations made by MH
authorities in their best interests
o LCT by itself is not sufficient to ensure improved outcomes for consumers
Factors associated with a positive service user percept of LCTs are: a sense of fairness, involvement
in decision making, opportunity to have views heard and responded to, and a sense of respect
Purpose of Mental Health Review Tribunal is to ensure protection of involuntary pts independent
body that reviews persons receiving involuntary treatment. State-wide body, headed by the
President and consists of 3 members (lawyer, psychiatrist, another person with relevant experience
or qualifications (community member))
Powers of MHRT Person may represent self or call on Allied Person or attorney to:
o Revoke an ITO
o Order persons transfer: intra or interstate
o Determine whether the person receives treatment in the community or as inpatient
o Particular forms of treatment regulated under MHA including ECT
Mental Health Court Constituted by a Supreme Court Judge: assisted by 2 psychiatrists
o Court has inquisitorial powers which enable the judge to investigate issues fully and to
accept material generally inadmissible in other court proceedings
o Hearing generally open to the public
o Decides whether a person:
Was of unsound mind
Diminished responsibility (if the charge is murder)
Unfit for trial (if unfitness is permanent)
Person is found not to be of unsound mind and is fit for trial, the matter is referred
to a criminal court
o If person is found to be of unsound mind or unfit for trial, MHC can make a forensic order
Person can be detained in an AMHS or a high security unit for treatment
Forensic pts are then reviewed by MHRT every 6 months

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Persons of Special Notification

o PSN is a pt on forensic order where the order was made in relation to one or more of the
following:
Murder
Manslaughter
Attempted murder
Rape or assault with intent to rape
Dangerous driving causing death
Seclusion definition: seclusion of a pt is the confinement of the pt at any time of the day or night
alone in a room or area from which free exit is prevented
o Used only when all available less restrictive alternatives are attempted without success
o Ordered by a Dr or senior RN in urgent circumstances
o AMHS monitors seclusion as part of their quality improvement program
o Concerns about consumer reports that they experienced a loss of dignity when secluded
and that seclusion constituted a humiliating breach of their human rights and is very
disempowering
Electroconvulsive Therapy (ECT)
o Can be administered without the persons consent under the MHA
o In an emergency: 2 consultant psychiatrists can agree to administer ECT
o Case must be reviewed within 5 days by MHRT
o Client is represented at the tribunal by self, allied person or their attorney
o With refusal of consent, Drs in some states require a second opinion and have the power to
administer without consumers consent
o Nurses need to inform consumer and family of the nature of the procedure and why
consent has been provided by another source
o Policy frameworks support increased consumer involvement in aspects of treatment such as
medication management
MHA dilemmas
o Pts can be critical or coercive practices which can be experienced as punishment
o Context
Decreased length of stay
Increased acuity
o Controlled interventions and restricted autonomy
o Can control and containment be therapeutic?
o When to administer medication against an involuntary pts will?
o Involuntary treatment, enforced medication and potential side-effects
Medications
o What are the persons rights when placed on psychopharmacological agents?
o These rights should include access to effective professional treatment, information
concerning the drug prescribed and the freedom to accept or refuse treatment
o These rights may be limited if the person is an involuntary pt under MHL
o All consumers should have some voice and choice in the selection of drugs. If the side-
effects of a particular drug are difficult to live with, the person should be able to ask for a
review and change of treatment
Ethical and legal decision-making
o PRN dont misuse or over-use antipsychotic or benzodiazepams for convenience rather
than therapeutic way
o First line management includes less invasive interventions such as de-escalation, talking or
separation from the group.
o When these have been tried unsuccessfully to reduce behaviour to a manageable level, PRN
medication are the choice of treatment

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o Antipsychotics are usually effective in management of acute agitation, aggression, psychotic

symptoms
Ethical issue in MH include;
o Involuntary treatment and autonomy
o Involuntary treatment and duty of care
o Diagnostic labelling particularly schizophrenia
o Reading behaviour via the diagnosis
o Diagnosis and stigma
o Diagnosis and inter-rate reliability
o The DSM system and its contested issues

WEEK 3: MENTAL HEALTH AND ILLNESS ASSESSMENT

Capacity of individuals and groups to interact with one another and the environment in order to
promote subjective well-being, optimal development and the use of mental abilities (cognitive,
affective and relational) and achievement of individual and collective goals consistent with justice
Essence of psychiatric or MH nursing assessment is inextricably linked to the concept of holism
Core skills:
o Competent and respectful interviewing practices
Establish rapport
Develop therapeutic professional-client relationship
Risk assessment
o Respect for confidentiality
o Ethical practice
Personal qualities for effective therapeutic communication include free of judgement, empathy,
warmth and genuineness, clarity, precise understanding
Non-verbal communication skills include listening and understanding as a foundation, using
encouragers, use observation skills, avoiding blocks to effective listening
Mental health encompasses:
o Environmental o Biological
o Social o Psychological
First steps: Building rapport and therapeutic alliance
o Involve the person in the process by engaging their active participation
o Establish the beginnings of a therapeutic alliance make it a collaborative inquiry
o Develop trust and rapport using open, sensitive, discrete reflection
First steps: confidentiality and identifying the person
o Always inform about confidentiality
o Identify the person with the following:
Name
Age and DOB
Present address, contact phone
Language spoken
Name of GP
Next of kin
Education and occupation
Check to ensure all information is correct
Presenting complaint
o Ask pt to describe why they are here in their own words
o Listen carefully and demonstrate respect and empathy by taking the persons concerns
seriously

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Identifying the problem

o Ask the following:
What is the nature of the problems?
Why and how has the person presented at this time?
What events have led to the pts presentation?
o Identify recent events and stressors
Note both positive and negative stressors
Note life changing events
Any ongoing stressors?
Gathering more information:
o Personal history o Pre-morbid personality
o Social and sexual history o Family history
o Occupational history o Collateral information family,
o Legal history carers, next of kin, police, ambulance,
o Medical history support persons
o Psychiatric history o Notes from previous admission
o Substance use history
Physical examination
o BP lying and standing o Body movements
o Pulse o Lab tests often routine bloods TFT,
o Eyes and skin condition LFT, U&E, CBC, urinalysis
o General appearance o Specifics test in relation to conditions
Mental State Examination
o Appearance
Overall physical appearance
Describes general impression of:
Looks, build, height, complexion, eyes, hair, distinguishing features:
o General manner of dress, make-up, tattoos, scars
o Age and gender
o Self-care grooming, hygiene, nutrition, dental
o Posture
o Motor activity retarded, restless, agitated
o Stature and physical characteristics
o Recent injury self-harm, trauma
o Substance use intoxication, withdrawal, recent use
o Physical disorder/s
o Behaviour
Type and amount of motor Bizarre behaviour rituals etc
movement Medication and treatment side
Psychomotor activity effects
agitation and hyperactivity, Eye contact
retardation Ability to form rapport
Abnormal movements tics Attitude and level of
etc cooperation
o Speech
Quantity:
Talkative Chatty
Verbose Taciturn
Garrulous Restrained
Quality:
Stuttered Stammered
Hesitant Faltering

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Production:
Rapid Emotional
Slow Slurred
Pressured Mumbled
Dramatic Muttered
o Mood a pervasive and sustained emotional state that depicts the consumers perception of
the world
Consider:
Depth Fluctuation
Duration Intensity of feelings
Examples include:
Depressed Elated
Sad Expansive
Labile Anxious
o Affect: reflects the persons present state of responsiveness and is observable with body
language
E.g. blunt, flat, normal
o Congruence: mood may be congruent or incongruent, appropriate or inappropriate with the
affect
o Thinking form and content
Form: excess or absence of thoughts
Content: what is the person thinking about?
Expressed ideas:
o Obsessions (repetitive and intrusive thoughts, images or impulses)
o Phobias (excessive and irrational fears)
o Preoccupations (e.g. illness or symptoms)
o Delusions
o Themes (religious, paranoid, persecutory, etc)
o Risk of harm (self or others), antisocial thoughts, fantasies and urges
o Delusions: are false beliefs accepted without question
Reality test:
Delusions are not held by others of the same age, cultural, ethnic or
educational background
o Perception disturbance of sensory perception
Hallucinations false sensory stimuli
Auditory Depersonalisation
Visual feelings of not being
Tactile self
Olfactory Detachment from self
Gustatory and environment
Fantasies and waking
daydreams
o Executive functions
Logic Problem-solving
Strategy Hypothetico-deductive
Planning reasoning
Disorders in these areas can be assessed by evaluating the persons ability to self-
regulate, plan and think ahead

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o Cognition
Consciousness
Awareness (time, place, person)
Memory
Orientation
Retention and recall (recent, recent past, and past)
Concentration and attention
Reason (abstract thinking)
o Insight: persons ability to comprehend and acknowledge his/her current situation or reveal
awareness and understanding of his/her own illness/health
o Judgement: persons ability to comprehend likely outcomes from past or current behaviours
and the ability to predict where these behaviours might lead

WEEK 4: PSYCHOTIC DISORDERS, SCHIZOPHRENIA AND BECOMING WELL

Psychosis is a condition that is NOT reserved exclusively for the condition of schizophrenia. In fact
psychotic features are not pathognomonic of schizophrenia but may be found in other psychiatric
and neurological disorders such as:
o Dementia o Drug induced conditions and medical
o Bipolar and unipolar depression conditions e.g. temporal lobe epilepsy,
o Postpartum illnesses neoplasma, neurosyphilus, SLE
Those who are psychotic encounter a group of symptoms that the person experiences as REAL and
are unable to judge for themselves as we do the reality of the world and environment around us.
They experience classically the following:
o Delusions o Bizarre behaviour
o Hallucinations o Formal thought disorder
Disorders that are considered psychotic in the MH spectrum of diseases are:
o Major depression with psychotic o Schizophrenia
features o Postpartum depression and/or
o Bipolar and unipolar affective psychosis
disorders
Those that do not belong to MH diagnostic categories nevertheless suffer from psychotic disorders
are those within a medical spectrum and are:
o Due to medical conditions brain tumours, neurological problems etc.
o Drug induced psychosis (associated with dual diagnosis extreme problem)
Amphetamines Cannabis
Cocaine Inhalant related
Alcohol
Are psychotic people dangerous? NO
o Some instances people who are psychotic and have a history in particular can be dangerous
if features of their illness is mediated by aggressive and directive hallucinations
o People who suffer from paranoid features are represented in this category of being
dangerous as is the individual who suffers from certain types of schizophrenia
Difference between a psychotic and neurotic individual
o Neurotic disorders are those that are featured by key symptoms of anxiety and depression
in disorders such as obsessive compulsive, phobic and personality disorders
o Notable difference is the level of subjective distress and social/occupational dysfunction
encountered between the two categories

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Schizophrenia is debilitating, misunderstood, feared and despised.

Neuroanatomical condition
Stress can be viewed as a trigger to those predisposed to a mental illness
Recognising and understanding the impact of the prodromal phase of schizophrenia may enable
better clinical outcomes
Burden of disease combined with the burden associated with stigma and self-stigmatizing
behaviours in schizophrenia makes this one of the most socially debilitating disease conditions
Homelessness and schizophrenia are remarkably intertwined and is highly prevalent in our society
Early onset Prodromal Syndrome
o Begins before age 25 and most likely well developed prior to this
Schizophrenia is a disorder characterised by delusions, hallucinations, disorganised speech and
behaviour, and other symptoms that cause social or occupational dysfunction. As far as mental
disorders are concerned, schizophrenia would have to be considered one of the most severe
It currently affects 200,000 people in Australia and is found in approximately 1% of the population
worldwide
It is a disorder labelled conventionally as a psychotic disorder which shares many similarities with
other conditions that are also viewed as psychotic
Many factors can contribute to schizophrenia:
o Kretschmer Body Type o Social causation
o Eugen Bleuler The Four As o Downward Drift Hypothesis
o Infection o Neurobiological CT and MRI
o Genetics o Birth Season
o Dopamine Hypothesis o Emil Krapelin Dementia Precox
o Developing and Western World Trends
Although schizophrenia suggests a single illness this perception is rather erroneous
Schizophrenia is more accurately viewed as a constellation of conditions with a number of common
features along with differences that allow sub types to be recognised
The experiences of those who endure the disorder are also varied and not typical
Characteristic symptoms of schizophrenia:
o Delusions
o Hallucinations
o Disorganised (incoherent or erratic) speech patterns
o Grossly disorganised or catatonic behaviour
o Negative symptoms (blunting of affect or a volition)

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Symptoms found in the MSE

o Content of thought
Delusion: false fixed belief that is inconsistent with ones social, cultural and religious
beliefs cannot be reasoned with by use of logic
Ideas of reference: a belief that an insignificant or incidental object or event has
special significance or meaning to that individual
o Thought disorder
Thought insertion/though broadcasting: the individual has the feeling that his
thoughts are being read, or that people are taking thoughts from his head away or
that ones feelings, impulses and actions are not their own but imposed by some
external force
Loosening of associations: ideas that fail to follow one another with a logical flow
and sequence. This results in shifting from one subject to another resulting in loss of
significant meaning
Incoherence: verbal rambling which recognition of any specific verbal content is
impossible
o Perceptual disturbances
Auditory hallucinations: Hearing voices that are coming from outside his head.
Voices may be familiar and usually comment on the person in a derogatory fashion.
Voices that comment on the persons behaviour. Voices that command behaviour
Other hallucinations: can involve any of the other senses
o Affect
Emotional blunting: described as being flat or inappropriate. Voice is monotone, and
the face is immobile
Anhedonia: loss of the feelings or pleasure previously associated with favoured
activities.
Incongruent affect: a mismatch between the persons thoughts and their emotional
experience and display in a given situation. For example, a person may feel under
great threat and appear amused by the situation
o Psychomotor behaviours
Catatonia: some pts may become so withdrawn that they appear unconscious. It is
believed that the person is so grossly involved in their delusional thinking and
preoccupation that they are no longer capable of relating to external stimuli
o Chronic phase
Limited social engagement: loss of drive toward developing and sustaining
stimulating and rewarding social relationships. The person becomes reclusive
Avolition: loss of motivation resulting in impairment in goal directed activity. This
affects:
Personal hygiene
Attention to nutrition
Occupation and work
Physical activity
Alogia/Poverty of ideas, Poverty of speech: person tends to be limited in
conversation and has a minimal amount of topics or issues to think about or discuss.
Tends to be short in response to question, often favouring monosyllables

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Social/occupational dysfunction since the onset of symptoms there needs to be a noticeable

impairment in the areas of work, relationships and self-care
There needs to be evidence that the disturbance has been in existence for at least 6months
Other illnesses including mental disorders such as mood disorders or schizoaffective disorders need
to be excluded
The possibility that the individual may be affected by drugs or other general medical conditions
need to be excluded
Schizophrenia Subtypes
Paranoid:
o Associated with a later onset (20-30)
o Often there is no history of impairment in social or occupational functioning
o Paranoid delusions and unfounded suspiciousness are dominant features along with
hallucinations and ideas of reference
o The disorganisation of behaviour and social functioning is often absent
o The individual suffering from this disorder often performs quite well socially and
occupationally
o Often there is consistency between the hallucinatory material and the delusional thinking
Catatonic:
o Less common than paranoid
o Most obvious characteristic is severe and debilitating disorganisation of motor behaviour
o In general the condition comes in 2 forms
o One where motor excitation is present, resulting in excessive and purposeless behaviour
that is unrelated to the external environment
o This form places the individual in danger of exhaustion, dehydration or injury from an
impulsive act
o The second form results in severe disturbance in voluntary motor behaviour resulting in
behaviours including:
Negativism Posturing
Mutism Echolalia (repetitive words)
Catalepsy (waxy flexibility) Echopraxia (repetitive actions)
Disorganised:
o Characterised by disinhibited, disorganised and regressive behaviour
o Onset usually early 20s
o Their activities are described as purposeless and non-constructive
o Their affect is described as garrulous and inappropriate marked by bouts of unstimulated
laughter and grimacing
Other types:
o Undifferentiated o Delusional disorder
o Residual o Brief psychotic disorder
o Schizophreniform o Shared pyschosis Folieux dur
o Schizoaffective
A recovery approach challenges some previously incontestable clinical truth, such as treatment is
needed for recovery and recovery involves reduced symptomatology and improved functioning
Thinking about recovery and helping
o Individuals abandon medications because they can take risks
o Can individuals be right that the medication are not effective
o Individuals with a diagnosis of schizophrenia rarely get stressed
o Some people who suffer from schizophrenia and sometimes abandon psychotropic
medications sometimes do not relapse for extensive periods
o I hear voices sometimes, but Im ok!
o Discharged recovered relieved improved

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Therapeutics
o Psychosocial interventions, especially cognitive behavioural therapy (CBT)
o Families and whenever possible and appropriate, other members of the persons social
network should be supported
o It is generally accepted that a sick member places enormous stress on the family system and
its function
o Treating professionals also became aware that illness may have pathological positives for
families in that there appeared to be an investment in the identified pt remaining ill
o In order to deal with such intimate and often covert information within families the process
of family assessment and care came about
o Family therapy is now regarded as the method of choice in dealing with issues that involve
the family in an intimate and an inextricably intertwined way
o Initial treatment should be provided in an outpatient or home setting if possible
o Such an approach can minimise trauma, disruption and anxiety for the pt and family, who
are usually poorly informed about mental illness and have fears and prejudices about
inpatient psychiatric care
o Inpatient care is required if there is a significant risk of self-harm, aggression and/or non-
adherence to treatment
o Inpatient care should be provided in the least restrictive environment
Psycho-education offers pt and family a conceptual and practical approach to the illness and its
treatment, and increases satisfaction with treatment and adherence
Cognitive therapy aims to identify and manage stress, prodromes and symptoms, and to prevent
relapse or recurrence through monitoring and challenging negative assumptions and thoughts
Herbal and natural remedies are largely ineffective in managing the complexities of either
depression or mania, however, their role in assisting the individual and said to have antidepressant
activity include lavender, neroli, camomile, eucalyptus and rose oil
Pharmacological treatments
o Introduced with great care in medication-nave pts, to do the least harm while aiming for
the maximum benefit
o Appropriate strategies include graded introduction, with careful explanation to the
individual and their carers, of low dose antipsychotic medication benefits and side effects
o Liberal doses of benzodiazepines are essential to relieve distress, insomnia and behavioural
disturbances secondary to psychosis, while antipsychotic medication takes effect
Medications the current belief is that conventional antipsychotic are limited, they are ineffective
in treating the negative symptoms of schizophrenia and can cause many side effects including the
movement disorders known as extrapyramidal syndrome
o E.g. chlorpromazine, haloperiodol, stelazine
Major antipsychotic helped with the so-called positive symptoms (hallucinations, delusions), they
had little effect on the negative symptoms (apathy, withdrawal, loss of relatedness to others and
emotional blunting)
First-line use of atypical antipsychotic medication is recommended on the basis of better
tolerability and reduced risk of tardive dyskinesia
Atypical Neuroleptics
o clozapine Clozaril 100-600
o risperidone Risperdal 2-10
o olanzapine Zyprexa 5-15

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Clozapine: a drug that was originally developed in the 1960s has been shown to be an effective
antipsychotic
o Causes fewer side effects
o Decreased extrapyramidal side effects
o Does cause agranulocytosis
The atypical antipsychotic, clozapine in particular, are equally effective at combating both +/-
symptoms
Other medication used in conjunction:
o Carbamazepine anticonvulsant effective in combination with lithium
o Sodium valproate lithium and valproate effective for rapid-cylers
Electro convulsive therapy
o Effective in some instances with a rapid onset of action
o ECT is more effective than lithium around weeks 6-8
o Pts who did not respond to unilateral ECT improved with bilateral ECT

WEEK 5: AFFECTIVE DISORDERS

Depression disorders should not be confused with the depressed or sad mood that normally
accompanies specific life experiences particularly loses or disappointments
Epidemiology
o 1 in 5 will suffer from it o ~ in 2030 will be the most prevalent
o More common in women (2:1) disease
o Any age o Epidemic for the new century (WHO)
o Comorbidity
Aetiology
o Hereditary o Personality
o Biochemical imbalance o Learnt response
o Stress
Affective disorders with a known causation
o Hyper/hypothyroidism o Caffeine-mania
o Viral illness o Situational reactions
o Cancer o Acute reaction to major stress
o Cerebro-vascular accidents o Grief reaction
o Psychoactive substance use
Major depressive disorder
o Depressed mood (sometimes irritability in children and adolescents) most of the day, nearly
every day
o Markedly diminished interest or pleasure in almost all activities most of the day, nearly
every day (as indicated either by subjective accounts or observation by others)
o Significant weight loss/gain
o Insomnia/hypersomnia
o Psychomotor agitation/retardation
o Fatigue
o Feelings of worthlessness (guilt)
o Impaired concentration
o Recurrent thoughts of death or suicide
Psychotic features may misdiagnose as schizophrenia
o Hallucinations o Delusions

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Depression life span issues: Adolescences

o Difficult to detect (sadness, loneliness, hopelessness, poor self-esteem = normalising)
o Anger o Substance use
o Promiscuity o Self-destructive behaviours
Depression life span issues: Senior years
o Most common psychiatric diagnosis o Bereavement overload
o Often associated with isolation and o Hormonal influence
loss o Agitation
Treatment
o Seeking out the least restrictive alternative and this may be initially at home
o Consider your role in inspiring hope even at this early stage aimed toward recovery
o Consider the need for enlisting help with physical needs and safety
o Treatment by GP
o Referral for psychotherapy
o Medication
o Hospitalisation with nursing, medical and allied health treatment
o ECT
o A combination of the above options
SSRI Selective serotonin reuptake inhibitors
o Said to have revolutionised drug treatment
Fluxetine (Prozac) 20-40mg daily
Sertraline (Zoloft) 50-100mg daily
o Major side-effects
Nausea and vomiting Insomnia
Headache and dry mouth Sexual dysfunction
Anxiety and restlessness
NSRIs Venlafaxine (Efexor)
SARIs Nefasodone (Serzone)
Tricyclics (TCAs) Amitriptyline overdose can include serious cardiac dysrhythmias
MAO inhibitors rarely used food restrictions very important
Antidepressants usually take 10-14 days to work
Care issues
o High risk of violence directed at self o Hopelessness
o Social isolation o Self-care deficit
o Self-esteem disturbance o Altered nutrition
Assess for danger signs
o Talk of taking ones life o Energy return without mood lifting
o Agitation o Access to means

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