Mood disorders: suicide and bipolar spectrum disorders
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The most common method of suicides for men is ___ and for women is ___
- Men: firearms
- Women: poisoning
The top four suicide risk factors
- suicidal ideation with intent
- lethal suicide plan
- hx of suicide attempt
- family hx of suicide
Up to 50% of suicides have this factor in common
- EtOH in their blood
- Gives emotional blunting before suicide
What is the "flight into health" phenomenon?
- When there is rapid improvement of a hospitalized patient, not associate with actual recovery but used as a means to leave care in order to complete suicide
- symptoms: unexpected calmness, nurse has uneasy feeling about pt, pt insists upon leaving or going off the unit alone
- change in behavior patterns
Why must suicide patients need close monitoring when starting antidepressants?
- They will recover energy prior to their depression being alleviated
- they will have the energy needed to commit suicide
What is the most important question to ask someone who has suicide ideation in the past or currently?
- What stopped you from acting upon them?
- Allows us to focus on their reason for living
- Example: love of family
Hierarchy of needs for suicide patients
- biological and physical needs
- social interaction/doing
Intervention approach for suicide ideation
- protect from harm: remove obvious means of self-harm, develop a "contracting approach"
- watch for "flight into health"
- work with the side of the person that wants to live
- Activate social support
- provide structure to day to reduce rumination
- provide statements of hope - important
What is the "contracting approach" for patients with suicide ideation?
- Have patient agree to let you know if they are feeling out of control or ready to act on suicide plan.
- Do not exclusively depend on this approach
The three bipolar spectrum disorders discussed in class
- Bipolar I
- Bipolar II
- Cyclothymic disorder
Define a manic episode
- acute psychotic process associated with positive symptoms of psychosis (hallucinations, delusions)
- persistently elevated, expansive or irritable mood with increased goal-directed activity and energy lasting at least 1 week
A dx of bipolar I requires criteria for a ___ episode
During the manic or hypomanic period, at least 3 of the following symptoms must be met (or 4 if the mood is just irritable).
- inflated self-esteem or grandiosity
- decreased need for sleep
- more talkative
- flight of ideas or racing thoughts
- increase in goal-directed activity [or psychomotor agitation (hallucinations) for bipolar I]
- excessive involvement in activities that have a high potential for self-harm
During a manic period, patients will have a massive load of this NT, which will ____ the body
- EXHAUST = safety issue!
It is very common for type I bipolar pt to use this to self-medicate during the manic stage.
- May require CIWA scoring
For pts with bipolar disorder I, illicit drugs can trigger this
ACUTE manic episode
Requirements for a dx of bipolar II
- Hypomanic episode: distinct period of abnormally and persistently elevated, expansive or irritable mood and increased goal-directed activity and energy, lasting at least 4 consecutive days.
- Absence of an acute psychotic process (no positive symptoms of psychosis).
Length of time for dx of bipolar I versus bipolar II
- Bipolar I: manic for at least 1 week
- Bipolar II: hypomanic for at least 4 consecutive days
The differences between bipolar I and bipolar II
- bipolar I involves psychotic episodes (hallucinations)
- bipolar II hypomanic episodes are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
Requirements for a dx of cyclothymic disorder
- at least 2 years (1 year in children) with numerous periods with hypomanic symptoms (not severe enough to call an episode) and depressive symptoms.
- Can be challenging to differentiate from bipolar II
Define rapid cycling
4 or more episodes of mania, mixed mania, hypomania, or depression, or any combination of these in a 12-month period
Bipolar disorder is a leading cause of ___ worldwide
Suicide risk for pts with bipolar disorders
- 25-50% attempt
- 15% complete
Medications (general) used for bipolar treatment
- atypical anticonvulsants
Lithium is the most powerful medication for these effects
- mood stabilizer
Therapeutic levels for lithium
0.6 to 1.0 mEq/L
Toxic level of lithium
- 1.5 mEq/L or greater
- VERY NARROW window, requies regular blood draws
Symptoms of lithium toxicity
- severe N/V
- muscle weakness
- blurred vision
Any conditions causing ___ or ___ can cause lithium toxicity
- shift of electrolytes
For bipolar disorder, anticonvulsants have this effect
- primarily controls mania
- has some preventative antidepressant effect
For bipolar disorder, atypical antipsychotics have this effect
- mood stabilization
- some efficacy in treatment-resistant bipolar disorder (3rd line choice)
Nursing interventions for bipolar disorder
- maintain a safe environment
- medication administration, assessment and monitoring
- substance abuse withdrawal regimen and education (if needed)
- teaching monitoring and coping strategies
- social skills and support training
Top two target behaviors for nursing interventions, bipolar disorder
Interventions for acute mania
- KISS - structured, short 1-to-1 activities
- firm, calm approach
- short, concise statements
- avoid power struggle
- have a consistent approach and expectations
- communicate with team
- redirect excessive energy
- reduce environmental stimuli
- frequent high-calorie protein and finger foods that patients can eat on the go
- avoid caffeine
- supervise ADLs
- monitor I & O
- frequent rest periods
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