Transcript Psychiatric Treatment

Intervention Modes - Psychiatric
Treatment
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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
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1 Therapeutic relationship
2 Interventions
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2.1 Physical and biological interventions
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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
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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:
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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.
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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
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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
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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.
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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 .
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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 .
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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
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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.[6] One study suggests that longterm ECT increases the expression of brain-derived
neurotrophic factor (BDNF) and its receptor, TrkB, in limbic
brain regions.
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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.
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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.
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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
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single or paired pulse TMS
Single or paired pulse TMS
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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)
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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
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TMS is currently under study as a treatment for severe
depression, mania, auditory hallucinations (e.g., associated
with schizophrenia), posttraumatic stress disorder, obsessivecompulsive 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 drugresistant depression has been approved by Health Canada for
clinical delivery since 2002.
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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.
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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)
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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 ~68 years; a lead system with electrodes; and an
anchor tether to secure leads to the vagus nerve.
The device is made by Cyberonics
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Implantation of the VNS device is usually done as an outpatient 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.[1] 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
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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.[3]
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.[2] Trigeminal Nerve
Stimulation (TNS) is being researched at UCLA as a treatment
for epilepsy.
Physical care
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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
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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 [1] 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
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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
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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.
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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
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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.
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