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- Do not stop medication suddenly
Check Lithium level
- Maintain hydration - decreases the risk for toxicity
- Contact DR before next dose
Adequate salt intake

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Dark Therapy helps in sleep deprivation.

Keep self in a dark environment from 6pm to 8am. You may use blue light blocking glasses.- helps to help the blue light from devices which disturbs sleep

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Dark Therapy for Bipolar Disorder - How and Why it Works

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What are the signs and symptoms of lithium toxicity
Mild-Moderate:
- diarrhoea
- vomiting
- stomach pains
- fatigue
- tremors
- uncontrollable movement
- muscle weakness
- drowsiness
- weakness
Severe:
- heightened reflexes
- seizures
- agitation
- slurred speech
- kidney failure
- rapid heart beat
- hyperthermia
- uncontrollable eye movements
- low BP
- confusion
- delirium
- coma
- death

Normal Level
- 0.6 - 1.2

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What are the main side effects and risks associated with these medications?
Lithium carbonate
- GI upset
- dizziness
- muscle weakness
- fine hand tremor
- lithium toxicity
- fatigue
-thirst
-polyuria
- anorexia or weight gain 1-2 kg
- constipation
-headache
-ECG changes
- skin conditions e.g. acne

Anticonvulsants
- nausea + vomiting
- diarrhea + constipation
- headache
-muscle twitching
- sedation or fatigue
(lamotrigine - life threatening rash, double vision)
(Carbamazepine - double vision, dry mouth, fluid retention)

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Identify the main medications used in the treatment of bipolar disorder
medication
lithium carbonate
sodium valporate ( purple tablet)
-Mood stabilizers
lithium salt
sodium valproate
carbamazepine
lorazepam
topiramate
lamotrigine
anti psychotic
anticonvulsant
benzodiazepine

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1. What interviewing skills did you note of the clinician?
Active listening, empathetic, clarifying, summarising

2. What types of communication approaches might be helpful for working with John?
calm, patient, friendly, not rushing, provide space , knowledgeable , consistent, confident, reassuring

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1. What do you propose would be the next immediate steps to take for John regarding treatment?
- Immediate = gain more information, e.g. medications, past history, ect.
- Treatment of manic episode , medication

The next steps for John might include an Assessment Order so that he can be effectively assessed and psychiatrists can understand his current state of mind.

2.  How do you presume his thoughts and compliance would be with medication? Should the Mental Health Act be considered?

Thoughts
- Would presume that John would be against medications, I would assume that he might think that it will ruin his work and connection with 'god', potentially.

Compliance
- Would presume that John would be non-compliant with medications

Mental Health Act
- Yes the Mental Health Act should be considered for treatment

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1. Signs and symptoms of mania
- pressured speech
-delusions of grandeur
- decreased need to sleep
-increased energy
-racing thoughts
-unusually talkative
- easily distracted
•2. How is Johns life currently affected by the condition?
- no longer working at his regular job
- strain on relationships with family and friends
- unemployment/not working = loss of income, housing issues, unable to afford food etc.

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Appearance - bright, colour, wearing printed shirt
Behaviour - Moves around
Mood - Was very happy at the start and then when she tried to change the subject he got a bit agitated
Thought form - Jumbles, thought to thought, his thoughts were racing
Thought content
Speech - Pressure speech
Perception, delusions - grandiose, referential. Hullucinations - auditory, visual
Judgement, : Impaired
Insight : Partial
Risk Level: High Risk
Plan: consider MHA and provide inpatient care

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Psychiatric Interviews for Teaching: Mania

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BIPOLAR DISORDER

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Bright light therapy for bipolar depression

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Riley's Story

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Nursing care after the procedure
- Observe and record the vital parameters
- Place the patient on side lying postion, clean the secretions
- Transfer the patient from recovery room. Record vital signs every 15 mins for 30 mins and once every 30 mins till the patient recover to the normal range.
- Allow the patient to sleep for 30 min to 1 hour
- Reassure the client and reorient to the ward
- Allow the patient to have tea or any drinks
- Record the procedure.
- Monitor for post procedure:

Short term memory loss

Muscle pain

Headache

Nausea

Confusion

- Documentation

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Nursing care during the procedure
- Confirm consent form and legal status
- Assist to remove footwear to allow observation of extremities during procedure
- Provide comfort measures
- ECG, EEG and vitals
- Apply jelly to electrodes to efficiently dispersing electrical stimulation to the target area
- Mouth block is used to prevent jaw dislocation and biting down on tongue
- 02 (100%) to prevent hypoventilation from anaesthetic agents

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Considerations and nursing care pre-ECT
- Full physical assessment
- Ensure patient has fasted  (6 hours prior)
- Medications are reviewed by the medical team.
Seizure meds need to be stopped (diazepam stopped 24 hours beforehand)
- Ensure consent is complete
- Make sure patient understands procedure
- Empty bladder
- Remove jewelry, hearing aids, dentures, contact lenses
- Outpatient; ensure someone there to pick them up and care for them 24 hours post op.

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List non-pharmacological treatments for depression

Reference: Hercelinskyj & Alexander (2020) - Chapter 10 (pg. 181)

- CBT
- self-help groups
- exercise
- encourage social interactions
- structured programs/goal planning to maintain a set routine
- mindfulness based cognitive therapy eg. meditation, relaxation techniques, yoga, massage, guided imagery
- ECT (electroconvulsive therapy) and TMS (transcranial magnetic stimulation)

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Case Study                                                                                                                                                                                                             

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Case Study                                                                                                                                                                                                             

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What nursing education and considerations are relevant for anti-depressant management?

Patient education -
- do not stop taking suddenly as mental state can deteriorate severely + physical withdrawal symptoms
- take 2-4 weeks to become effective, may take longer to find the right antidepressant that works for you
- how the medication works, common side effects, drug interactions (increases affects of alcohol)
- know how the antidepressant affects you before you start driving
- can increase suicidal thoughts, encourage patient to reach out for help and educate carers/family to be aware of the signs of suicidal ideation

Nursing considerations -
- can increase QT interval
- can induce manic episodes in patients with bipolar disorder; these patients should be treated with antidepressants + mood stabilisers or antipsychotics to prevent depressive and manic episodes
- serotonin syndrome

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Outline the common side effects of antidepressant medications:

Nausea

Diarrhea

Insomnia

Drowsiness

Dizziness

Changes in weight

Fatigue

Decreases libido

Headaches

SSRIs
- SEROTONIN SYNDROME: results when there is too much serotonin at the synapse, causing an excess in neuron activity – people who take high doses of antidepressants that caused increased amounts of serotonin or a combination of these medications are at risk of serotonin syndrome
o SIGNS AND SYMPTOMS – headaches, altered conscious state, dilated pupils, hyperthermia, diaphoresis, tachycardia, unstable BP, nausea and vomiting, tremors, ataxia and risk of seizures
Ataxia, diaphoresis, hyperreflexia
o MANAGEMENT – resolves when the causative medication is ceased.
Supportive therapy to alleviate the symptoms.
Benzodiazepines may be given for agitation and tremors and to minimise the risk of seizures.
ICU transfer may be necessary

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What are the main types/categories of antidepressant medications?

Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine (prozac)

Tricyclic Antidepressants: Amitriptyline

Serotonin-noradrenaline Reuptake Inhibitors (SNRIs): Duloxetine

Monoaxime Oxidase Inhibitors:
- Phenzelzine

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1. Risk factors:

Dave- not a great partner
Extra stressors at work
Husband leaving a couple years ago
Struggling to pay the bills
2. Protective factors
Children
Sister
Friends
Dave - "when he's in the mood"

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1. What interviewing skills did you note of the clinician?

- Open ended questions
- Active listening
- Clarification
- Silence
- Empathetic
- Non-judgemental
- Body language
- Focus on patient, not taking notes or anything
- Explanation to pt at the end

2. Identify risk and protective factors for Razak’s risk of deterioration of mental state

Risk
- Young family relying on her
- No healthy way to deal with stress, no coping strategies
- Financial stress, employment
- previous suicidal thoughts

Protective
- Sister, who encouraged to reach out for help
- Access to health services
- Children
- Husband
- Family

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1. How is Alison’s life currently affected by the condition?

- She is very overwhelmed and is struggling with completing day to day tasks.
- Poor concentration and productivity at work and home
- She is exhausted as she has had trouble sleeping
- Poor appetite has lead to weight loss
- Emotions are getting in the way of her life; decreased involvement with children; feeling guilty
- She's experiencing a loss of joy in her relationships; withdrawal from friendships and strain on relationship with partner
- Decreased libido putting added strain on relationship with partner
- Decreased self care

2. What risks is Alison presenting with and how would you assess her level of risk currently?

- Risk to self: admits to taking tablets (previous suicide attempt) and also thinks about harming herself. Displays insight; knows she can seek help. However, she admits that she has not told anyone about her attempt; lack of support if mental state deteriorates further.
- Financial insecurity from missing work

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1. MSE (Appearance - hair is messy, overweight

2.  Behaviour - Anxious, closed off, looking down, crying, fiddling with fingers

3. Mood - Low

4. Thought - Distracted, thinking straight

5. Speech - Slow, pauses, huffs, quiet

6. Perception - nil present, impaired insight because she had some understanding

7. Judgment -

8. Insight - slight insight

1. Signs and symptoms of depression

- Crying
- Low  mood
- Adehdonia
- Weight loss
- Reduced hours of work
- Lack of enjoyment

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Psychiatric Interviews for Teaching: Depression

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Please Nominate a Scribe to Share
What are the social signs and impacts of depression?

Withdrawal from normal activities
Relationship breakdowns - friends, family
Disconnect from work or education
Lack of motivation seen in withdrawal from group activities
Reduced enjoyment of previously enjoyed activities (anhedonia)
Lack of social media interaction
Difficulty in organising themselves
Struggling to meet deadlines for assignments

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What are the psychological/psychiatric signs and symptoms of depression?
lack of motivation
inappropriate grief
rumination
suicidal ideation
loss of libido
overthinking
negative thoughts
low self-esteem
concentration difficulty

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Please nominate a scribe to share

What are the biological signs and symptoms of depression?
- Weight loss/ poor appetite/poor nutrition
- Insomnia/hypersomnia
- Constipation
- Fatigue
- Agitation/Motor restlessness
- Poor self care and hygiene
- Poor medication adherence

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feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
- diminished ability to think or concentrate, or indecisiveness, nearly every day
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide