DELIRIUM

Delirium is a mental state in which you are confused, disoriented, and not able to think or
remember clearly. It usually starts suddenly. It is often temporary and treatable. Delirium is an
altered state of consciousness, characterized by episodes of confusion, that can develop over
hours or days. “Delirium is a syndrome, not a disease,” Oh clarifies, noting that it affects people
of all ages, but especially older adults who are acutely ill. Many different health conditions are
associated with it, including infection, reaction to sedating drugs, oxygen deprivation and organ
failure.

A person with delirium may experience changes in their awareness of where they are. They may
seem “out of it,” lethargic or uninterested in their surroundings. They may be confused, anxious,
or see or hear things that are not there. Thinking and remembering are impaired, and anxiety,
euphoria or fear may occur.

Delirium is common, especially in older adults and people who are very sick or in the hospital.
Up to one-third of all patients staying in the hospital and 80% of patients in the intensive care
unit (ICU) experience delirium.

“Health practitioners take delirium seriously,” says Oh. “Developing delirium is linked to worse
outcomes in older people in the hospital, and it is associated with a higher risk of declining
health and death.”

Types of delirium

 Hypoactive delirium is the most common type. It can cause subtle changes such as
unusual drowsiness and lethargy. The person may not respond to caregivers or family and
may seem dazed or “out of it.”

“This type of delirium can be difficult to diagnose, since many people who are very ill or
who have just had major surgery are very sleepy,” Oh explains. “Doctors, nurses and
family members may assume that the patient is just getting much needed rest.

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 “Screening for hypoactive delirium is important,” she stresses. “It can help for doctors,
nurses and caregivers to rouse the patient and ask them a few questions to make sure they
are aware of themselves and where they are.

“Catching and addressing hypoactive delirium as soon as possible is essential,” says Oh,
who notes that an estimated 30% to 40% of cases can be prevented.

 Hyperactive delirium is characterized by restlessness and agitation. A person with this

type may wander or pace, experience hallucinations and mood swings, or refuse care due
to delusions (persistent, unfounded beliefs) that they are not safe. Hyperactive delirium is
easier to spot than the hypoactive type, but according to Oh, hyperactive delirium
comprises only about 25% of cases.
 Mixed delirium can cause hypoactive symptoms alternating with hyperactive symptoms
in the same person.
 COVID delirium can be hypoactive or hyperactive, and is associated with being on a
respirator or breathing tube while being treated for infection with the SARS-CoV-2
coronavirus. It may result from the ICU experience itself, complicated by a lack of
oxygen when COVID has resulted in pneumonia or heart damage.

Delirium Symptoms

The symptoms of delirium usually start suddenly, over a few hours or a few days. They often
come and go. The most common symptoms include:

 Changes in alertness (usually more alert in the morning, less at night)

 Changing levels of consciousness
 Confusion
 Disorganized thinking, talking in a way that doesn't make sense
 Disrupted sleep patterns, sleepiness
 Emotional changes: anger, agitation, depression, irritability, overexcitement
 Hallucinations and delusions
 Memory problems, especially with short-term memory
 Trouble concentrating
A person with delirium may experience symptoms that come and go over the

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  Hypoactive, when you are not active and seem sleepy, tired, or depressed
 Hyperactive, when you are restless or agitated
 Mixed, when you change back and forth between being hypoactive and hyperactive
Causes of delirium

There are many different problems that can cause delirium. Some of the more common causes
include:

 Advanced cancer.
 Alcohol or drugs, either from intoxication or withdrawal. This includes a serious type of
alcohol withdrawal syndrome called delirium tremens. It usually happens to people who stop
drinking after years of alcohol use disorder (AUD).
 Dehydration and electrolyte imbalances.
 Dementia.
 Hospitalization, especially in intensive care.
 Infections, such as urinary tract infections, pneumonia, and the flu.
 Medicines. This could be a side effect of a medicine, such as sedatives or opioids. Or it could
be from withdrawal after stopping a medicine.
 Metabolic disorders.
 Organ failure, such as kidney or liver failure.
 Poisoning.
 Serious illnesses.
 Severe pain.
 Sleep deprivation.
 Surgeries, including reactions to anesthesia.

Risk factors of delirium

Certain factors put you at risk for delirium, including:

 Being in a hospital or nursing home

 Having dementia
 Having a serious illness or more than one illness

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  Having an infection
 Older age
 Having surgery
 Taking medicines that affect the mind or behavior
 Taking high doses of pain medicines, such as opioidsRisk Factors for Delirium
 A range of conditions are associated with a higher chance of developing delirium,
including:
 Being hospitalized, especially in the intensive care unit
 Older age, especially people age 80 and up
 Dehydration
 Malnutrition
 Dementia
 Parkinson’s disease
 Infection, including meningitis, sepsis and others
 Organ failure
 Difficulty seeing or hearing
 Multiple medications with mental or emotional side effects
 Complex surgery with anesthesia, such as an open cardiac procedure
 Hip fracture

Diagnosis of delirium

In the rare case that a person develops signs of delirium without a clear underlying cause, the
doctor may recommend one or more tests.

 Urine and blood tests. Testing for infection, metabolic imbalances, abnormal blood gas
levels, liver function and drug intoxication in blood and urine can identify some causes of
delirium.

 Electroencephalogram, or EEG. This is a test that records electrical activity in the brain.
It can identify certain seizure disorders, which sometimes have delirium-like symptoms.

 Imaging. In most cases of delirium, imaging tests are not necessary. A brain CT may be
recommended if the delirium has no underlying cause and does not improve. MRI of the

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 brain may help the doctor spot inflammation or a minor stroke, which may explain
symptoms in some rare cases.

Older adults with meningitis, an infection of the central nervous system, may have different
symptoms than a younger person, and these can look like delirium. If meningitis is expected,
a lumbar puncture can help diagnose it or rule it out.

Treatment for Delirium

Four principles of treating delirium can help protect medical/surgical patients at risk for
morbidity and functional decline. These principals—which I call the “four Ps”—are prompt
identification, protection, pragmatic intervention, and pharmacotherapy.

Treatment of delirium focuses on the causes and symptoms of delirium. The first step is to
identify the cause. Often, treating the cause will lead to a full recovery. The recovery may take
some time - weeks or sometimes even months. In the meantime, there may be treatments to
manage the symptoms, such as:

 Controlling the environment, which includes making sure that the room is quiet and well-
lit, having clocks or calendars in view, and having family members around

 Medicines, including those that control aggression or agitation and pain relievers if there
is pain

 If needed, making sure that the person has a hearing aid, glasses, or other devices for
communication

There is not a specific medicine or treatment for delirium

Your health care provider may use many tools to make a diagnosis:

 A medical history, which includes asking about your symptoms

 Physical and neurological exams

 Mental status testing, which checks for problems with your thinking and alertness

 Lab and diagnostic imaging tests

Differences between Delirium and Dementia

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Delirium and dementia have similar symptoms, so it can be hard to tell them apart. You can also
have both at the same time. The differences between them are that:

 Delirium starts suddenly and can cause hallucinations. It is mainly a problem with
attention and staying alert. The symptoms may get better or worse and can last for hours
or weeks.
 Dementia develops slowly and does not cause hallucinations. It usually starts with
memory loss. The symptoms don't change often, like they can with delirium. Dementia
almost never gets better.

Prevention of Delirium

Treating the conditions that can cause delirium may reduce the risk of getting it. Hospitals can
help lower the risk of delirium by avoiding sedatives and making sure that hospital rooms are
kept quiet, calm, and well-lit. It can also help to have family members around and to have the
same staff members treat the person each day (if possible). It is important to remember the
causes of delirium are generally multifactorial and can coexist together. While the 5ps stands
for pee, poo, pain, pills and pus. As you can see many of these causes can be minimised or
prevented with simple, yet effective person centred care strategies. Delirium Recovery and
Prognosis

Delirium can be serious, and it is associated with severe illness and physical stress. Managing the
underlying cause can help resolve delirium. The outlook is best for patients who are younger,
have fewer medical problems and can fully recover from illness or surgery and return home to
more familiar surroundings.

For others, delirium continues and may complicate care. Delirium can cause a person to forget
medical instructions, such as when and how to take medications. The person may not be able to
care for themselves and may need time in a rehabilitation facility or a transition to assisted
living.

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ANXIOLYTICS

Definition

Anxiolytics also known as anti-panic or anti-anxiety agent is a medication or other interventions

that reduces anxiety. This effect is in contrast to anxiogenic agents which increase anxiety.

Anxiolytic medications are used for the treatment of anxiety disorders and their related
psychological and physical symptoms.

These medications can mediate neurotransmitters like Norepinephrine, Dopamine, and GAB in
the CNS. This affects the amygdala, llimbic system etc.

Mechanism of action

These anxiolytic drugs inhibit the action of enzymes that catalyze the formation of
Norepinephrine. When the enzymes are inhibited, noradrenaline is slowly metabolized and
therefore, it activates its receptors for a longer duration of time and so the effect of depression is
counteracted.

These tranquilizers are thought to work by blocking the neurotransmitters dopamine in the brain.
This leads to a such unwanted side effects as tremors of the limbs, rigidity, restlessness and
involuntary spasms of the facial muscle, tongue and lips.

Types

Anti-anxiety medications can be classified into six main groups according to their different
mechanisms of action

1. Anti-depressants
Anti-depressants include; Selective Serotonin Reuptake Inhibitor (SSRIs), Serotonin
Norepinephrine Reuptake inhibitors (SNRIs), Tricyclic anti-depressants (TCAs),
Monoamine Oxidase Inhibitors (MAOIs).
SSRIs are used in all types of anxiety disorders while SNRIs are used for Generalized
Anxiety Disorders (GAD).

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 Both are considered first-line anti-anxiety medications. TCAs are second line treatment
as they cause more insignificant adverse effects when compared to the first line treatment
like; drowsiness, memory loss. MOAs were found to induce Euphoria and improve the
patients appetite and sleep quality.
Anti-depressants are indicated both for anxiety disorders and depression.
Examples
SSRIs like Fluoxetine, Sertratine
SNRIs like Venlafaxine
2. Benzodiazepines
They are used for acute anxiety and could be added along with current use of SSRIs to
stabilize treatment.
Long term use in treatment plans is not recommended.
Examples. Lorazepam, Diazepam, Alprazolam.
3. Azapirones
They can be useful in GADs but not particularly affective in treating phobias, panic
disorders and social anxiety disorders. It is a safer option for long term use as it does not
cause dependence like benzodiazepines.
Examples
Buspirone, Gepirone, Tandospirone
4. Anti-pschycotics
Olanzapine and Risperidone are typical anti-pschycotics which have been found to be
efficient in GAD treatments. It has a high chance of experiencing adverse effects unlike
other anxiolytics.
5. Anti-epileptics
It can be used to treat General anxiety disorders. It is also efficient in treating social
anxiety disorders eg. Gabapentin, Pregabaline, Valproic acid
6. Beta-adreno-receptor antagonists
An example is Propanolol whixh is originally used for high blood pressure and heart
diseases. They work on the NS and cleviate the symptoms of anxiety.
It can also be used when someone is nervous during public speaking.
Propranolol decreases Renin levels.

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 7. Barbiturates
They are powerful anxiolytics but the risk of abuse and dependency is high. It is also
valuable for treating severe insomnia when benzodiazepines or non-benzodiazepines
have failed. It has a high effective strength and high addictive power
8. Alcohol
It is sometimes used as an anxiolytic by self-administration.
Indications

 Generalized anxiety disorders

 Panic attack
 Specific phobia
 Agoraphobia
 Post-traumatic stress disorders
Side effects

 Nausea
 Loose stools
 Head ache
 Dizziness
 Insomnia
 Erectile dysfunction
 Reduced libido
 Hyper-salivation
 Slurred speech
 Low heart rate
 Irregular breathing
 Agitation
 Dry mouth
 Addiction

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Benefits of anxiolytics

1. Most anxiolytic have a lesser side effect of the patient and so can be used in a wide range
of anxiety and panic disorders.
2. Anxiolytics can combine with other psychologic medications in order to produce a more
desirable effect in treating mental health disorders.
Disadvantages

1. Variable effectiveness: no two drugs have the same effect on individuals. It can have a
stronger effect and the other a weaker effect of the same drug that is taken
2. Addiction potentials especially for benzodiazepines
3. Has diverse side effects
Note 1: The length of time an anxiolytic can stay in your body depends on many factors;

 The specific drug you take

 The type of anxiety you experience
 Your health history
 Personal preferences
NOTE 2: For activating neurotransmitters like Epinephrine, anxiolytics inhibit their absorption at
the level of the synaptic clef while for suppressive neurotransmitters; anxiolytics promote their
production and active absorption. This action in general will help to relieve excessive nerve
impulse transmission thereby relieving anxiety.

TRANQUILIZERS

These are drugs prescribed for anxiety, acute stress reactions and panic attacks. Commonly
known medications include; Xanax, Valium. These drugs have a calming effect and eliminate
both the physical and psychological effects of anxiety or fear. Some tranquilizers are relatively
mild in nature and are suitable for relieving tension.

Tranquilizers are used to treat anxiety and insomnia, can be used to promote sleep.

They include;

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  A sense of wellbeing in a person thereby releasing them from stress, tension, anxiety or
irritability. They are one of the essential components of sleep pills
 There are many types of tranquilizers each having its mode of functions.
 A tranquilizer which helps in uplifting mood is called noradrenaline. If the level of
adrenaline is low, then the signal sending activity also become low which makes a person
feel depressed. In this situation, antidepressant drugs or tranquilizers can be used.
 These drugs inhibit the action of those enzymes that catalyze the degradation of
norepinephrine
Mechanism of action

Example, Norepinephrine

This is a tranquilizer which helps in uplifting mood of an individual. If the level of noradrenaline
is low, then the signal sending activity also becomes which in return makes a person feel
depressed. In this situation, a tranquilizer can be used.

These drugs inhibit the action of enzymes that catalyze the formation of Norepinephrine. When
the enzymes are inhibited, noradrenaline is slowly metabolized and therefore, it activates its
receptors for a longer duration of time and so the effect of depression is counteracted.

These tranquilizers are thought to work by blocking the neurotransmitters dopamine in the brain.
This leads to asuch unwanted side effects as tremors of the limbs, rigidity, restlessness and
involuntary spasms of the facial muscle, tongue and lips.

Classification

1. Minor tranquilizers: These are also called anxiolytics and are used for sedation and to
treat anxiety. They work by slowing brain activity leading to drowsiness, slowed
breathing and general sense of relaxation.
Examples
Diazepam, Valium, iproniazid, Phenelzine, Serotonin.
2. Major tranquilizers: Also called neuroleptics were developed to treat psychiatric
disorders including schizophrenia. These drugs combat hallucinations and other
delusions. Usually prescribed for long term.

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 Examples
Phenothiazines, Thioxanthenes, Clozapine
Side effects

 Nausea
 Loose stools
 Head ache
 Dizziness
 Insomnia
 Erectile dysfunction
 Reduced libido

HYSTERIA

Hysteria is a term that has been used to describe a wide range of symptoms, including anxiety,
nervousness, and behavioral changes. It was originally used to describe a condition thought to be
specific to women, but it is now understood to be a complex and multi-faceted condition that can
affect people of any gender. The term hysteria has largely fallen out of use in the medical
community, and has been replaced by more specific diagnoses like anxiety and panic disorders.
Causes

The causes of hysteria are complex and varied, and likely involve a combination of biological,
psychological, and social factors. Some possible causes include;

 trauma
 stress
 certain mental health conditions like depression and anxiety.
 There is also some evidence that physical illness, neurological disorders, and even certain
medications
Risk factors
There are a number of risk factors that may increase a person's chances of developing symptoms.
These risk factors include

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  A history of trauma or abuse,
 A family history of mental illness,
 A stressful or chaotic environment, and
 Certain personality traits like neuroticism.
There may also be certain biological factors that increase a person's risk, including;

 hormonal changes,
 brain chemistry,
 Structural abnormalities in the brain.
Stages of hysteria

1) The epileptoid stage, like true epilepsy, often has its pro- dromata and aurae. The
patient for some two or three days before the attack may be a creature of moods,
impatient, irritable, with laughing and crying-fits, that is, with fits of emotional
disturbance at- tended with loss of self-conttrol; or she may be very excitable, even
tremulous, with widely dilated pupils and spasmodic winking of the eye-lids, with rapid
respiration, and palpitation of the heart; or she may show organic symptoms, as frequent
micturition, or marked

.dyspepsia, nausea, vomiting, and constipation. The aura is frequently a feeling of

constriction or compression about the throat, an hysterical globus, palpitation of the
heart, ringing or buzzing in the ears, pain in some hysterogenic zone, or hysterical
clavus; or the aura may be of psychical nature, such as a feeling of modification of
consciousness, or of strange emotions, as "a sad feeling" mentioned by one of our clin-
ical patients.

Just as in true epilepsy, the-fall follows the aura at once, so also it does in hysteria. In
hysteria, however, the fall is not abruptly sud- den; the patient is not struck down as
though felled with a powerful club, but she sinks gently and easily to the floor, or to
some con- venient couch or chair; she shows herself more consideration than the
epileptic, and self-injury in hysteria is apt to be exceedingly slight, though it has been
known to occur.

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Consciousness is apparently lost, and the fall seems amply ex- plained to the patient''s
friends by such loss; yet in all.cases traces of consciousness undoubtedly remain present.
Though it be taken up with hallucinations, consciousness is none the less there; and it
often happens that after the convulsions patients admit of knowing in a

.-vague, hazy sort of way what had occurrred; indeed they may have at times very
accurate knowledge.

As the patient falls, the eyes are shut, the lids usually being tightly or even
spasmodically closed, the muscular tension being very evi- dent; the pupils are apt to be
dilated and equal, with normal reaction to light, though in exceedingly rare cases they
may not react to light; the duration of such inactivity is seldom more than 20 seconds, so
that it may be ignored from the practical standpoint in differrentiating an hysterical from
an epileptic convulsion. The eye-balls are fre- quently rolled far upward, but they may
converge. The face is either pale, or more usually flushed, showing a slight degree of
cyanosis, and acc:ccellerration of the respiratory rate. There may be grinding of the teeth
and trismus, but the tongue is rarely bitten, or if bitten the in

jury is slight. There is rarely frothing of the mouth, though from what patients say it
would seem that a spurious, imitative frothing may occur in slight amount, though never
to the extent observed in true epilepsy. The clothes are never soiled, there being
complete control of the sphincters of rectum and bladder without any exceptions that I
am aware of.

After the fall, exactly as in genuine epilepsy, a tonic generalized spasm follows, giving a
state of muscular rigidity. The face is dis- torted, the head retracted and perhaps slightly
rotated, the jaws are set, the breath held, the extremities all extended, though the hands
are as a rule clenched, and the arms at times are adducted. This stage might with
propriety be named the stage of tonic extensor rigidity, since extensor spasms prevail.

Clonic spasms now follow very much like those of true epilepsy, except that they are apt
to be of longer duration. The cyanosis or turgidity of the face may fade away, but the
respiration is apt to remain accelerated or even to become stertorous. The clonic jerks of
the legs and arms are as a rule rhythmical as to time, and variable as to energy.

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 Frequently they are not regular, but are disorderly, the arms and head being jerked wildly
about; and there may be various co-ordinated movements, such as pronation, supination,
adduction and abduction, or swaying of the trunk.

Recovery from the epileptoid stage is gradual; the stertorous breathing subsides, the
clonic move·ments gradually decrease in power until they ultimately cease,
consciousness in part returns, or the patient may relapse into a stage of stupor.

2) The stage of clownism or contortion, the second stage, is very short, beginning very
abruptly, lasting only five minutes or so in typical cases, and consisting of what the
French call the "grand movements." Consciousness is still very ncomplete, or else
present only in hallucinations betrayed by the fits of laughing or crying, or by the
piercing shrieks or screams of fear.. The movements of the limbs are wild and manifold,
almost every conceivable position being assumed by them. The fists are doubled up as
if.in anger, blows are dealt; the arms beat about the head and chest, or tear the hair and
clothes in frenzy; the legs are kicked about in every way imaginable; giant-swings are
taken; opisthotonos is common, due to tonic spasms in the back muscles so severe as to
cause head and heels to touch. All sorts of combinations of filesion and extension occur,
so that the terms clownism and contortionism are good descriptive ones. .

3) The third stage, that of hallucinations and "attitudes passion- elles," in which
passionate poses predominate, is really an orderly con- tinuation of the disorderly second
stage. The underlying mental state is one of hallucinations which profoundly affect the
emotions; and the consciousness of these emotions is shown by cries of freight, anger,
joy, or ecstasy, with appropriate play of feature and pose of body. In hysteria in general
the relation between the movements of the body and abnormal conditions of
consciousness present is characteristic, and in this third stage of hysteria major finds its
maximum exemplification. Consciousness is not lost or buried in a state of stupor; on the
con- trary it is exuberantly present, but still under the control of halflucina- tions, so that
it is one-sided, the patient being ruled by the imagina- tion. Everything may be expressed
in pantomime, or in theatric-al posess--frright, rage, delight, or intense sorrow. The
hallucinations may cluster about something experienced in the past, and the past be lived
again; or the patient may see visions, hear voices, converse with imaginary persons,

15
 relate ·'events, thus supplementing motor expres- sion by body-muscles with speech
itself.. Often animals are seen (zoopsia) trooping towards the patient from the anaesthetic
side, pro- ducing a frenzy of fear..

There is abolition of the general sensations of touch, temperature, and pain; and the
special senses are also in abeyance as a rule, though questions may be heard and
answered unconsciously. The eyes are anaesthetic, the pupils as a rule wide, though they
may be narrow, and normal in their reaction to light and accommodation.

4) The stage of delirium or fourth stage may be said gradually to differentiate itself from
the remains of the stage of hallucinations and passionate attitudes. The third stage, as it
were, imperceptibly merges into the fourth, so that clinically one cannot say where the
one ceases and the other begins. Though the passionate attitudes cease, the laughing,
weeping, or mental excitement continues almost un- abated, frequently accompanied by
spasms of the diaphragm and laryn- gealmuusscles. If the original attack of hysteria was
brought on by some particular event, scene, or emotional disturbance, in this fourth stage
of mental storm, all is repeated, this living over the past being very characteristic of
hysteria. The patient may repeat some word or phrase again and again, but occasionally
the patient's trend of thought

Types of hysteria

There are a number of different types of mental health conditions that were once considered
forms of hysteria. One type is:

 Conversion disorder, which involves physical symptoms like paralysis or sensory loss
that are not caused by a medical condition.
 Factitious disorder, which involves intentionally producing or exaggerating symptoms
for personal gain.
 Dissociative disorders, which involve an escape from reality and may include symptoms
like amnesia and identity alteration.
Management of hysteria

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The management of what was once called hysteria depends on the specific mental health
condition that a person has. Some common treatments include;

 psychotherapy,
 medication,
 lifestyle changes.
Psychotherapy may involve cognitive behavioral therapy, which helps people identify and
change negative thoughts and behaviors. Medications may include

 antidepressants,
 anti-anxiety medications, and
 mood stabilizers.
Lifestyle changes may include

 exercise,
 healthy eating, and
 stress management.
Coping with hysteria

If someone is experiencing symptoms that were once labeled as hysteria, there are a number of
coping strategies that may be helpful.

 one strategy is to learn about the specific condition and its treatment options.
 It can also be helpful to connect with a support group or a mental health professional.
Other coping strategies include

 relaxation techniques,
 mindfulness,
 self-care.
Complications

There are a number of potential complications that can occur if a mental health condition is not
properly managed. These complications may include;

 Problems at work or school,

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  Difficulty maintaining relationships,
 Financial issues,
 Increased risk of self-harm or suicide.
There may also be physical complications, like

 Digestive problems,
 Headaches,
 Sleep issues.

Depression

Depression is a mood disorder that causes a persistent feeling of sadness and loss of
interest in things and activities you once enjoyed. It is normal to feel sad about or grieve over
losing your job or divorce but depression is different in the sense that it persists practically every
day for at least two weeks.

Types of depression

It is a mood disorders that causes persistent feeling of sadness and loss of interest. It is mostly
from signs and symptoms.

1. Clinical depression: a depression disorder means a patient have felt sad, worthless most
days for at least two weeks while having most of other symptoms like sleeping problems,
loss of interest etc. This can be caused by difficult life situations such as death of a loved
one, trauma, isolation and lack of support can trigger depression. Some medical
conditions such as chronic pain and chronic conditions like diabetes can lead to
depression.
2. Persistent depression: it is a continues and long form of depression. It can start last for
at least 2 years, it can manifest by sadness, emptiness or feeling down, loss of interest in
daily activities. The exact cause of persistent depressive disorder is idiopathic but some
predisposing factors such as biological differences, brain chemistry, inherited traits, life
events etc.
3. Disruptive mood deregulation disorder: It is a mental disorder in children and
adolescent characterized by a persistently irritable or angry mood and frequent anger

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 outbursts that are disproportionate to the situation. The exact cause this depressive
disorder is idiopathic but it can be associated with neurologic disabilities, brain
chemistry, recent family divorce, death or lack of adequate nutrition.
4. Premenstrual dysphoric depression: it is a condition in which a woman has severe
depressive symptoms before menstruation. It can be manifest through irritability,
nervousness, anxiety, severe fatigue, poor self-image, moodiness, breast fullness and
pain, diminished urine output. The exact cause is unknown but it maybe abnormal
reaction to normal hormone changes that happens with each menstrual cycle. It can also
be caused by deficient serotonin.
5. Depressive disorders due to medical conditions: it is a mood disorder diagnosis where
there is a permanent and long period of depressive mood, marked by a diminished
interest. Many medical conditions can create changes in your body that can cause
depression such as hypothyroidism, heart disease, Parkinson’s disease and cancer.
6. Seasonal depression: it is a type of depression characterized by a recurrent seasonal
pattern with symptoms lasting for about 4-5 months out of a year. This depression occurs
only in some particular seasons of the year and disappears when another season comes
but symptoms like having problems sleeping, feeling worthless, sad or down for days,
losing interest in activities once enjoyed, difficulties concentrating. It may be caused by
less sunlight and shorter days are thought to be linked to the chemical changes in the
brain.
7. Prenatal and postnatal depression: prenatal depression is depression that happens
during pregnancy. Depression causes ongoing extreme sadness, anxiety, fatigue and
trouble sleeping. It can happen 4 weeks before delivery of the baby.
Postpartum depression: it is a medical condition that many women get after having a
baby. Which is characterized by a strong feeling of sadness, anxiety and tiredness that
last for a long period of time after giving birth. It can be caused by a dramatic drop in the
hormone’s estrogen and progesterone in her body which can lead to depression.
Causes

Researchers don’t know the exact cause of depression but several factors can contribute
to the development of depression:

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 1. Genetics: if a patient has a family history of depression, he is 3 times likely to develop
depression but how ever patient can still have depression without a family history.
2. Stressful life events: difficult life experiences such as trauma, isolation, dead of a loved
one can trigger depression.
3. Neurodegenerative diseases: like dementia and Parkinson’s disease since these diseases
occur when the nerve cells in the brain lose function and die it can alter the functioning of
the brain chemistry which leads to depression.
4. Certain medication: these medications alter the levels of neurotransmitters in the CNS
which can lead to depressive disorders e.g. HTN meds e.g. Amlodipine.
5. Chronic pain: this increases the levels of stress and contributes to a lack of sleep and
also low moods.
6. Personal traits: low self-esteem, being too dependent can cause people to be depressed.
7. Unresolved grief or loss: some people might take long time to recover from this which
can lead to intense feeling of emptiness, sadness therefore leading to depression
8. Gender: during puberty, women after giving birth and during menstruation
9. History of trauma: especially during early childhood, childhood trauma like sexual and
physical abuse.
10. Alcohol abuse: affects the brain functioning and contains depressants and high doses will
cause a feeling of sadness.

Diagnosis

 It can be diagnosed through signs and symptoms

 Medical history
 Mental history
 Blood test to see if underlying medical conditions are causing his depression.
Treatment

 Psychotherapy (talking therapy): involves talking with a mental health professional

who helps the patient identify and change unhealthy emotions, behaviors and thoughts.
There are many types of psychotherapy e.g. cognitive behavioral therapy is the most
common

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  Medications: antidepressants can help change the brain chemistry.

- Medications: Antidepressants, such as SSRIs, SNRIs, or tricyclic antidepressants, are often

prescribed.

- Therapy: Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT) can be

effective.

- Lifestyle Changes: Regular exercise, healthy diet, and sufficient sleep can help improve
symptoms.

- Support Groups: Participating in support groups can provide emotional support.

- Electroconvulsive Therapy (ECT): In severe cases, ECT may be recommended.

- Transcranial Magnetic Stimulation (TMS): This is a non-invasive procedure that uses

magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.

- Hospitalization: For severe cases where safety is a concern, hospitalization may be necessary

Preventions

 Communicate with family members and friends during crises period

 Maintaining a healthy sleep routine
 Managing stress with coping mechanisms
 Practicing regular selfcare activities such as exercise and meditations
 Seek for health care as soon as possible
Nursing management

 Monitor for suicidal risk

 Engage patients in a therapeutic relationship
 Encourage patient to partake in activities
 Patients should list positive characteristics about self
 Patient should set a realistic goal and review goal attainment
 Review and evaluate patient coping strategies
 Monitoring eating habits and encourage healthy nutrition
 Use sleep hygiene to encourage sleep

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  Include family members if patient chooses
Complications

 Excessive weight or obesity which can lead to heart disease and diabetes
 Pain or physical illness
 Alcohol, drug abuse
 anxiety
DEMENTIA

Dementia is a term for several diseases that affect the memory, thinking ,and the ability to
perform daily activities. The illness gets worse with time. This illness mainly affects older people
but not all people will get it as they age. Dementia is often incorrectly referred to as senility or
senile dementia which is a belief that serious mental decline is normal with ageing.

CAUSES

It is caused by a variety of diseases that causes damage to the brain cells .This damage interferes
with the ability of the brain calls to communicate normally ,thinking, behavior and feeling can be
affected.

1. Alzheimer’s disease which occurs when the brain cells shrink and die.
2. Chronic alcoholism
3. Neurologic infections such as meningitis
4. Head injury
5. Some medications e.g. anticonvulsants ,antidepressants ,antihistamines.

TYPES OF DEMENTIA

 Alzheimer's disease
 Vascular dementia
 Lewy body disease
 Frontotemporal dementia
 Alcohol related dementia
 Down syndrome
 HIV associated dementia

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  Chronic traumatic encephalopathy dementia
The most common types of dementia are;

 Alzheimer’s disease; it is the most common type in older adults.it occurs through
plaques and tangle formed in the brain.
 Frontotemporal; it is the most rare form that tend to occur in people younger than
60years.
 Lewy body; it is caused by abnormal deposit of the protein alpha -synuclein called lewi
bodies.
 Vascular dementia; It is due to damage of blood vessels in the brain.

SIGNS AND SYMPTOMS

 Short term memory affected first before long term memory

 Keep track of items like purse and wallet
 Asking repeatedly the same questions
 Disoriented to time , place and person
 Loss of recognition of family members
 Aphasia ,so unable to communicate needs or follow simple instructions
 Difficulty performing familiar task
 Change in mood and behavior
Dementia is a progressive disease and it is classified into early, middle, and
late[mild ,moderate, and severe] depending on the severity of the symptoms.

DIAGNOSIS

There is no known test to determine if someone has dementia but doctors diagnose Alzhiemer’s
disease and other types of dementia based on careful medical history, physical
examination ,laboratory test ,tracking changes in thinking, day to day functioning and behavior
associated with each type.

 From signs and symptoms

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  Neuropsychological testing to determine the degree of memory, personality and
behavioral changes
 Mini mental state examination is the most commonly used
 Check for depression

RISK FACTORS

 Age(65 years and above)

 HTN and diabetes
 Overweight or obesity
 Smoking
 Alcoholism
 Social isolation
 Depression
 Inactivity

TREATMENT

There is no cure but a lot can be done to support patients and careers. Dementia uses the
following steps to maintain quality of life and promote wellbeing.

 Being physically active

 Taking part in activities and social interactions that stimulate the brain and
maintain daily functions
 Medications can also manage symptoms e.g. Cholinesterase inhibitors like
donepezil to treat Alzhiemer’s disease
 Medications to control HTN and cholesterol levels
 Selective serotonin reuptake inhibitors help in depression severe symptoms
 If patients are at risk of hurting others and self, drugs like haloperidol can help but
never used as first line treatment.
PREVENTION

Age cannot be prevented .So we should try as much as possible to avoid the risk factors

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 COMPLICATION

 Inadequate nutrition
 Pneumonia
 Fractures due to falls
 Hallucinations and delusions
 Agitation
 Personal safety challenges
 Inability to perform self care task
SELFCARE

Patients should;

 Stay physically active

 Eat healthy
 Stop smoking and drinking alcohol
 Do regular check ups
 Write down every day task and appointment to help remember important things
 Keep up your hobbies and things you enjoying doing
 Try new ways to keep your mind active
 Spend time with friends and family members and engage in community life
 Plan ahead of time as it will be harder to make decisions in future and create an advanced
time to tell people what your choices and preferences are
 Join a local support group

NURSING CARE

 Monitor behavioral and psychological symptoms

 Encourage a structured routine which includes regular meal time ,schedule activities and
bed time routine
 Orient the patient by allowing him have similar objects around him/her
 Encourage care givers to keep orienting patient
 Make sure clients is always safe and closely observed

25
  Give assurance when patient makes mistakes or feels embarrassed
 Draw a nursing care plan to better care for the patient
 Ask simple questions which requires responses like “YES” or “NO” to avoid confusion
 Plan enjoyable activities for the patient as a form of distraction and relaxation
 Encourage physical excises since obesity is a risk factor
 Administer patients drugs as prescribed and monitor for side effects
Addiction

Definition of Addiction

It is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use of
drug despite adverse effect

Drug addiction is characterized by an inability to stop or control the use of substances despite
experiencing negative consequences.

Types of Addiction

Experts recognize two main types of addiction: chemical and behavioral.

 Chemical addiction refers to addiction that involves the use of substances

 Behavioral addiction involves compulsive behaviors that are carried out despite not
having any benefit.

Risk factors

 Aggressive behavior in child hood

 Lack of parental supervision
 Peer pressure
 Drug experimentation
 Poverty
 Availability of drugs in school
Signs and Symptoms

Common signs of drug addiction may include:

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  Development of a tolerance
 Feeling withdrawn from daily activities
 Inability to stop using a substance
 Strong cravings for drugs or alcohol
 Trouble managing daily responsibilities
 Using substances in risky situations (while driving, working, etc.
Dangers of Addiction

Common dangers associated with drug addiction include:

 Altering brain chemistry

 Financial problems
 Irrational behavior
 Legal trouble
 Long-term physical health issues
 Mental health issues
 Overdose
 Relationship difficulties
 Diagnosis
 The diagnosis of drug addiction requires a comprehensive evaluation which often
includes an assessment by a psychiatrist, psychologist, or licensed alcohol or drug
counselor. If you or someone you know is struggling with an addiction, contacting a
medical professional or a treatment center can be a good first steps

 Treatment Options for Addiction
 There are many treatment options available for proper support and recovery of drug
addiction.
 Family therapy helps people (especially young people) with drug use problems, as well as
their families, address influences on drug use patterns and improve overall family
functioning.
 Twelve-step facilitation (TSF) is an individual therapy typically delivered in 12 weekly
session to prepare people to become engaged in 12-step mutual support programs. 12-

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 step programs, like Alcoholic Anonymous, are not medical treatments, but provide social
and complementary support to those treatments. TSF follows the 12-step themes of
acceptance, surrender, and active involvement in recovery.
 Treatment must address the whole person.
 Inpatient Treatment
 Inpatient treatment involves someone staying at a treatment center for a duration while
they detox, receive therapy, and work on coping mechanisms to deal with their addiction.
Inpatient treatment allows you to live in a structured environment away from temptations
to use drugs or alcohol.
 Outpatient Treatment
 Outpatient treatment involves reporting to a treatment center at designated times to help
with the detox process and receive therapy to manage addiction. Outpatient treatment can
be a good idea for those who have work or family responsibilities that they don’t want to
neglect while they are healing.
 Residential Treatment
 Residential treatment is similar to inpatient treatment where you stay at a treatment center
for a duration of time. However, residential treatment is less intensive and resembles
more of a comfortable home setting. Residential treatment will provide you with detox
services and therapy, and it will help you create a plan to maintain sobriety long term.

 This information should not replace a visit to a doctor or treatment center. If you are
concerned that you or a loved one might be suffering from addiction to multiple

Defination of withdrawal symptom

Withdrawal symptom are physical and mental symptoms that occur after stopping or reducing
intake of drugs.

Diagnosis:

 Serum glucose
 Arterial blood gas analysis
 CBC

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  Comprehensive metabolic panel
 Urinalysis
 Cardiac biomarker measurements
 Prothrombin time
 Toxicology screening
Tolerance

Drug tolerance occurs when someone abuses a substance over a long period. When someone
continuously abuses a substance, their body becomes used to it, meaning the drug will stop
having as much of an effect. When someone develops a tolerance to an addictive substance, they
will begin taking a higher dose to get the same effects as before. Taking high doses of a
substance may lead to many negative consequences.1

Dependence

When someone abuses high doses of an addictive substance, they may develop a dependence.
Drug dependence refers to someone feeling like they cannot function normally without the use of
the substance. A drug dependence can be either physical or psychological and can have many
negative effects on someone’s life.

Addiction

Drug addiction affects someone’s mind and behavior. Addiction refers to the inability to control
the use of drugs or alcohol. Those who struggle with addiction may try to stop using the
substance but will feel like they cannot stop even though they may be experiencing negative
consequences from it. Those struggling with addiction must receive the proper help and support
needed to stop.

How it Affects the Brain

Long-term use of drugs combined with the development of tolerance, dependence, or addiction
can negatively affect the brain. Long-term drug abuse will interfere with how neurotransmitters
in the brain send, receive, and process signals. This abuse can affect a person’s behaviors and
their ability to think clearly and quickly.

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Substance abuse also affects the brain’s natural production of dopamine. Dopamine is a chemical
associated with feelings of pleasure. Taking addictive substances causes the brain to release large
amounts of dopamine, which is why taking these drugs creates a euphoric high. Over time, the
brain will rely on the drug for dopamine production. If the drug is not consumed, the person will
begin to feel run down and like they cannot function normally. This feeling often results in
cravings for the drug and can even lead to erratic behavior.

Definition of Tolerance

Drug tolerance refers to the body getting used to a substance over time. When someone develops
a tolerance, they need to take a higher dose to experience the same effects.

Causes of Tolerance

The main cause of drug tolerance is abusing an addictive substance for a long time. Usually,
tolerance occurs because the body starts to metabolize the drug quicker, leading to it having less
effect than it did before. When the body gets used to consuming a substance, the number of cell
receptors the drug attaches to the brain will decrease, leading to someone feeling like they must
take a higher dose to experience the same “high” they used to receive.4

Examples of Tolerance

An example of drug tolerance would be someone taking a prescription drug, such as an opioid
painkiller, that produces a pleasurable “high” when taken in large doses. Over time, as that
person continues taking the prescription drug, the high that is produced will slowly decrease.

For this person to continue feeling that same high, they will have to take higher and higher doses
of that prescription drug. When someone takes increasingly higher doses, they may develop a
physical or psychological dependence or addiction, and they will have a higher risk of overdose.

Signs and Symptoms

Common side effects and signs of drug tolerance may include:5

 Aggression
 Anxiety

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  Consuming large amounts of drugs or alcohol
 Decreased appetite
 Depressed mood
 Drug cravings
 Irritability
 Nausea
 Trouble sleeping
If you or someone you know is experiencing any of these signs, proper help and support may be
required to get drug use under control. There are resources available that can help.

Risks of Tolerance

Common risks associated with drug tolerance include:

 Addiction
 Chronic pain
 Cross-tolerance, meaning tolerance to chemically similar substances
 Immune-related conditions
 Mental health conditions
 Overdose
 Physical or psychological dependence
 Seizure disorders
All of these risks can be serious, and why proper treatment and support are critical for anyone
struggling with substance abuse.

Definition of Dependence

Drug dependence refers to someone feeling like they cannot function normally without taking a
substance. Dependence can be physical or psychological and can have many negative effects on
someone’s life.

Causes

The main cause of drug dependence is long-term abuse of an addictive substance. Oftentimes,
when someone has developed a dependence, they first started using the drug recreationally.

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Recreational use then turns into regular abuse of the substance, the development of tolerance,
and taking increasingly higher doses. After these stages, a person’s mind and body will feel a
need to continue taking that substance to feel like they are functioning normally.

Examples of Dependence

An example of drug dependence would be someone who smokes cigarettes regularly for some
time. Nicotine is an addictive substance that can make someone develop a physical and
psychological dependence over time. When someone decides to suddenly stop smoking after
they’ve consumed nicotine regularly, they will experience physical dependence symptoms, such
as shaking hands, physical cravings, and fatigue.

A person may also experience psychological dependence symptoms, such as feeling like
smoking puts them in a calmer mood or helps them get through the day. Both of these forms of
dependence can lead to relapse and make it difficult for someone to quit.

Signs and Symptoms

Common signs of drug dependence are:7

 Aching muscles
 Anxiety
 Depression
 Detachment from reality
 Difficulty concentrating
 Hallucinations or delusions
 Increased heart rate
 Nausea
 Shaking
 Sweating

Difference between Dependence and Tolerance

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The main difference between tolerance and dependence is that tolerance refers to the body
getting used to taking a substance and requiring higher doses. Dependence, however, refers to
the physical or psychological symptoms that occur that make someone feel like they must
continue taking a substance. Oftentimes, dependence and tolerance can go together. When
someone develops a tolerance, they will likely develop a dependence with continued use

Difference between Tolerance and Addiction

The main difference between tolerance and addiction is that tolerance refers to the body getting
used to using a substance and addiction refers to someone being unable to control their use of a
substance. Oftentimes, tolerance and addiction can go hand in hand, as one can lead to the other

MATERNAL PUERPERAL PSYCHOSIS (postpartum psychosis)

1) Definition
It is a severe mental health condition that can occur in some women after child birth.
It is characterized by the onset of psychotic symptoms such as hallucinations, delusions,
confusion and severe mood disturbance.
Postpartum psychosis typically develops within the first two weeks after delivery, although it can
occur up to several months later
It is considered a psychiatric emergency and required immediate medical attention.
Causes
The exact cause of the condition is not fully understood. But it is believed to be a combination of
 Hormonal changes: the dramatic hormonal fluctuations that occur after birth are believed
to play a role in triggering PPP.
 Genetic predisposition: there is evidence to suggest that there may be genetic
components to PPP.
 Family history: women with a personal or family history of mood disorder such bipolar
disorders or PPP are at high risk of developing the condition.
 Stress and emotional changes: pregnancy and child birth can be physically and
emotionally demanding experiences. The stress associated with this life of motherhood
can increase the risk of developing PPP.
 Sleep deprivation: sleep disturbance are common during the postpartum period and sleep
deprivation has been linked to development of psychiatric symptoms including
psychosis.
 Number of pregnancy.
Manifestation
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1. Hallucination: women may experience auditory hallucinations (hearing voices) or visual
hallucinations (seeing things that are not there)
2. Delusions: women may hold irrational beliefs or have thoughts that aren't based on reality.
These delusions may be grandiose, paranoid or related to the baby's wellbeing.
3. Mood disturbance: women may experience extreme mood swings ranging from euphoria to
profound sadness (depression) , irritability anxiety or agitation.
4. Confusion and disorientation: women with PPP may have difficulty thinking clearly, have
problem with memory and concentration and appear confused or agitation.
5. Sleep disturbance: insomnia or changes in sleep pattern are common with women
experiencing PPP.
6. Mania: feeling very high or over active for example talking or thinking too much or too
quickly, restlessness or loosing normal inhibition.
7. Hypomania: decrease in mood, also called depression.
Diagnosis
✓ Based on the symptoms (either by observation or what you describe)
✓ Physical and neurological exam.
✓ Test on blood, urine and other body fluids to identify or look for medical problem, especially
with your body's internal chemistry process. This will help to identify infections, electrolytes
imbalance, vitamin and minerals deficiency or excess, kidney or liver function problem or more.
✓Imaging scans to look for changes in your brain structure that might expect your symptoms.
Treatment
PPP is treatable, because it is an emergency, people with this condition need inpatient care,
You may prescribe one or more of the following;
Antipsychotic e.g haloperidol: to help with manic and psychotic symptoms such as delusions or
hallucinations.
Mood stabilizer e.g lithium : to stabilize your mood and prevent symptoms from reoccurring
Antidepressants e.g lorazepam: to help ease symptoms of depression and may be used along side
with mood stabilizer.
For future pregnancy lithium monotherapy during pregnancy or immediately post partum
may be given.
Antidepressants

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Antidepressants are a class of medications used to treat major depressive disorder, anxiety
disorders, chronic pain, and addiction.

There are various types of antidepressant medications available, and each works through a
different mechanism of action. Here are some common types of antidepressants, their
mechanisms of action, examples, possible side effects, and potential drug interactions.

1. Selective Serotonin Reuptake Inhibitors (SSRIs):

- Mechanism of Action: SSRIs work by increasing the levels of serotonin (a

neurotransmitter) in the brain by blocking its reuptake, leading to improved mood.

- Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Escitalopram (Lexapro)

- Side Effects: Common side effects include nausea, sexual dysfunction, insomnia,
agitation, and weight changes.

- Drug Interactions: SSRIs can interact with other medications such as antiplatelet drugs,
nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants.

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

- Mechanism of Action: SNRIs boost the levels of both serotonin and norepinephrine by
blocking their reuptake in the brain.

- Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)

- Side Effects: Common side effects include similar ones to SSRIs, such as nausea, sexual
dysfunction, insomnia, and increased heart rate.

- Drug Interactions: SNRIs can interact with medications like monoamine oxidase
inhibitors (MAOIs) and certain opioids.

35
3. Tricyclic Antidepressants (TCAs):

- Mechanism of Action: TCAs affect the reuptake of both serotonin and norepinephrine,
similar to SNRIs.

- Examples: Amitriptyline (Elavil), Clomipramine (Anafranil), Imipramine (Tofranil)

- Side Effects: TCAs have more side effects compared to SSRIs and SNRIs, including dry
mouth, constipation, blurred vision, sedation, and potential heart-related effects.

- Drug Interactions: TCAs have multiple drug interactions and can interact with many
medications, including anticholinergic drugs and certain antibiotics.

4. Monoamine Oxidase Inhibitors (MAOIs):

- Mechanism of Action: MAOIs inhibit the enzyme monoamine oxidase, which breaks
down neurotransmitters like serotonin, norepinephrine, and dopamine, leading to increased
levels in the brain.

- Examples: Phenelzine (Nardil), Tranylcypromine (Parnate)

- Side Effects: MAOIs can cause potentially severe side effects, such as hypertensive crisis
(dangerously high blood pressure) when interacting with certain foods or medications, along
with other side effects like dizziness, sedation, and weight gain.

- Drug Interactions: MAOIs have significant interactions with various medications,

including SSRIs, TCAs, and certain pain medications.

5. Atypical Antidepressants:

- Mechanism of action: Various mechanisms of action, such as targeting different

neurotransmitter systems or acting as partial agonists

- Examples: Bupropion (Wellbutrin), Mirtazapine (Remeron)

36
- Common side effects: Insomnia, weight gain, dizziness

- Drug interactions: Can interact with other antidepressants and drugs that affect the central
nervous system

- Contraindications: Patients with seizures, eating disorders, or bipolar disorder may be at

higher risk of adverse effects

6. Serotonin Modulators:

- Mechanism of action: Modulate serotonin receptors in the brain

- Examples: Trazodone, Vortioxetine (Trintellix)

- Common side effects: 69Drowsiness, dizziness, dry mouth

- Drug interactions: Can interact with other medications that affect serotonin levels

- Contraindications: Should not be used in combination with MAOIs or within two weeks
of discontinuing an MAOI

Posology:

The dosage of these medications varry depending on the severity of depression and also the
cause

Nursing care for patients taking antidepressants

 These are vital nursing interventions done in patients who are taking MAOIs:
 Limit drug access if the patient is suicidal to decrease the risk of overdose to cause harm.
 Monitor patient for 2-4 weeks to ascertain onset of full therapeutic effect.
 Monitor blood pressure carefully to determine the possible need for dose adjustment.
 Secure phentolamine at the bedside as a treatment in case of hypertensive crisis.

37
  Educate client on a low tyramine-containing diet. Provide a list of potential drug-food
interactions that can cause severe toxicity to decrease the risk of a serious drug-food
interaction.
 Provide comfort measures (e.g. voiding before dosing, taking food with the drug, etc.) to
help patient tolerate drug effects.
 Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.
 Educate client on drug therapy to promote compliance.
Evaluation

 Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
 Monitor patient response to therapy (e.g. alleviation of signs and symptoms of
depression).
 Monitor for adverse effects (e.g. hypotension, hypertensive crisis, cardiac arrhythmias,
etc).
 Evaluate patient understanding on drug therapy by asking the patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.
NB: antidepressant medication is only one method of treating depression. Depending on the
causes other treatment could include

 Canceling
 Group therapy
 Music therapy
 Physical exercises
ANTIPSYCHOTICS

Antipsychotics, also known as neuroleptics, are a class of medications primarily used to manage
psychotic symptoms associated with conditions such as schizophrenia, bipolar disorder, and
various other mental health disorders. They work by modulating the activity of certain
neurotransmitters in the brain, particularly dopamine, which plays a role in regulating mood,
perception, and cognition.

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TYPES OF ANTIPSYCHOTICS ( CLASSIFICATION OF ANTIPSYCHOTIC)

There are two main types of antipsychotic medications: typical (first-generation) antipsychotics
and atypical (second-generation) antipsychotics. Here's a general overview of each:

1. Typical (First-Generation) Antipsychotics:

Typical antipsychotics were the first medications developed to treat psychosis and have been in
use since the 1950s. They primarily work by blocking dopamine receptors in the brain. Some
commonly prescribed typical antipsychotics include:

MECHANISM OF ACTIONS

Here is a detailed explanation of the mechanism of action of first-generation antipsychotics:

1. Dopamine receptor antagonism: First-generation antipsychotics exert their primary therapeutic

effect by blocking dopamine receptors, specifically the D2 receptors, in the brain. By occupying
and blocking these receptors, they reduce the activity of dopamine, a neurotransmitter associated
with psychosis. By blocking D2 receptors, first-generation antipsychotics help to normalize the
excessive dopamine signaling that is often observed in conditions like schizophrenia.

2. Mesolimbic pathway: The mesolimbic pathway is a brain circuit involved in reward and
emotions. Overactivity of this pathway is associated with positive symptoms of schizophrenia,
such as hallucinations and delusions. First-generation antipsychotics block D2 receptors in the
mesolimbic pathway, reducing the excessive dopamine activity and helping to alleviate positive
symptoms.

3. Nigrostriatal pathway: The nigrostriatal pathway is involved in motor control. Dopamine

blockade in this pathway can lead to extrapyramidal side effects (EPS), such as parkinsonism,
dystonia, and akathisia. The blockade of D2 receptors in the nigrostriatal pathway by first-
generation antipsychotics can cause these side effects. However, newer atypical antipsychotics
have a lower affinity for D2 receptors in this pathway, resulting in a reduced risk of EPS.

4. Tuberoinfundibular pathway: The tuberoinfundibular pathway is involved in the regulation of

prolactin release from the pituitary gland. Dopamine inhibits prolactin secretion, and blockade of
D2 receptors in this pathway by first-generation antipsychotics can lead to hyperprolactinemia,

39
resulting in side effects such as galactorrhea (abnormal lactation), menstrual irregularities, and
sexual dysfunction.

5. Other receptor interactions: In addition to dopamine receptors, first-generation antipsychotics

also interact with other neurotransmitter receptors in the brain. For example, they can block
alpha-adrenergic receptors, histamine H1 receptors, and muscarinic receptors. These interactions
contribute to side effects such as sedation, anticholinergic effects (dry mouth, constipation,
blurred vision), and orthostatic hypotension (low blood pressure upon standing).

EXAMPLE OF FIRST GENERATION INCLUDE

Here are some examples of first-generation antipsychotics:

. Chlorpromazine (Thorazine): This was one of the earliest antipsychotic medications and is still
occasionally used today. It was one of the first medications to be widely used for the treatment of
schizophrenia.

. Haloperidol (Haldol): Haloperidol is a potent antipsychotic medication that is commonly

prescribed for schizophrenia and other psychotic disorders. It is available in both oral and
injectable forms.

. Fluphenazine (Prolixin): Fluphenazine is another first-generation antipsychotic that is used to

treat schizophrenia. It is available as an oral tablet and as a long-acting injectable formulation.

. Perphenazine (Trilafon): Perphenazine is an older antipsychotic medication that is used to treat

schizophrenia and other psychotic disorders. It is available in oral tablet form.

. Trifluoperazine (Stelazine): Trifluoperazine is an antipsychotic medication that is used to treat

schizophrenia and other psychotic disorders. It is available in oral tablet form.

These are just a few examples of first-generation antipsychotics. It's important to note that while
these medications can be effective in managing symptoms of psychosis, they are associated with
a higher risk of side effects compared to second-generation antipsychotics. Second-generation
antipsychotics, also known as atypical antipsychotics, were developed later and are often
preferred due to their lower risk of side effects.

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SECOND GENERATION

Second-generation antipsychotics (SGAs), also known as atypical antipsychotics, are a class of

medications primarily used to treat psychiatric disorders such as schizophrenia and bipolar
disorder. The mechanism of action of SGAs is complex and not fully understood, but they
generally act by modulating various neurotransmitter systems in the brain.

1. Dopamine Receptor Blockade: SGAs exert their antipsychotic effects by blocking dopamine
receptors in the brain. Unlike first-generation antipsychotics, which primarily target the D2
dopamine receptors, SGAs have a higher affinity for serotonin receptors (5-HT2A) than for D2
receptors. By blocking the D2 receptors, SGAs reduce the excessive dopamine signaling in
certain brain regions, which is thought to contribute to the positive symptoms of schizophrenia,
such as hallucinations and delusions

2. Serotonin Receptor Modulation: SGAs have a high affinity for serotonin receptors,
particularly the 5-HT2A receptors. By blocking these receptors, SGAs decrease the activity of
serotonin in certain brain areas. This modulation of serotonin transmission is believed to
contribute to the improved efficacy of SGAs compared to first-generation antipsychotics.
Serotonin modulation may also be responsible for some of the side effects associated with SGAs,
such as weight gain and metabolic changes.

3. Other Neurotransmitter Systems: SGAs also affect other neurotransmitter systems in the brain.
They may block alpha-adrenergic receptors, histamine receptors, and muscarinic receptors to
varying degrees. The blockade of these receptors can contribute to the side effects and
therapeutic actions of SGAs. For example, blockade of histamine receptors can cause sedation,
while blockade of muscarinic receptors can lead to anticholinergic side effects like dry mouth
and constipation.

4. Neuroprotective Effects: Some SGAs have been found to have neuroprotective effects,
meaning they can protect brain cells from damage or degeneration. These effects are believed to
be mediated through various mechanisms, including antioxidant properties, anti-inflammatory
effects, and the regulation of neurotrophic factors. The neuroprotective properties of SGAs may
contribute to their long-term benefits in certain psychiatric disorders.

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EXAMPLE OF SECOND GENERATION

These medications are considered "second generation" because they were developed after the
first-generation antipsychotics.

Here are some examples of second-generation antipsychotic drugs:

1. Aripiprazole (Abilify)

2. Risperidone (Risperdal)

3. Quetiapine (Seroquel)

4. Olanzapine (Zyprexa)

5. Ziprasidone (Geodon)

6. Paliperidone (Invega)

7. Lurasidone (Latuda)

8. Asenapine (Saphris)

9. Iloperidone (Fanapt)

10. Brexpiprazole (Rexulti)

These medications differ in terms of their specific mechanisms of action, side effects, dosage
forms (such as oral tablets, orally disintegrating tablets, injectable formulations), and approved
indications. It's important to note that the selection of an antipsychotic medication should be
based on an individual's specific needs and should be determined by a healthcare professional.

SIDE EFFECTS OF ANTIPSYCHOTICS

Antipsychotic medications, also known as neuroleptics, are commonly used to treat various
psychiatric conditions such as schizophrenia, bipolar disorder, and certain types of depression.

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While these medications can be effective in managing symptoms, they can also cause side
effects. It's important to note that side effects can vary depending on the specific antipsychotic
medication and the individual's response to it. Here are some common side effects associated
with antipsychotic use:

1. Extrapyramidal symptoms (EPS): EPS are movement disorders that can occur as a result of
antipsychotic treatment. They include parkinsonism (tremors, muscle stiffness, and slow
movements), dystonia (involuntary muscle contractions), akathisia (restlessness and an inability
to sit still), and tardive dyskinesia (involuntary movements of the face and body).

2. Metabolic side effects: Some antipsychotics are associated with metabolic changes that can
lead to weight gain, increased blood sugar levels, and elevated cholesterol and triglyceride levels.
These metabolic changes can increase the risk of developing diabetes, cardiovascular disease,
and other metabolic disorders.

3. Sedation: Many antipsychotics have a sedating effect and can cause drowsiness, fatigue, and
decreased alertness. This can impact a person's ability to perform daily activities and may require
adjustments to medication dosages or timing.

4. Orthostatic hypotension: Antipsychotics can cause a drop in blood pressure when standing up,
leading to dizziness and lightheadedness. This is known as orthostatic hypotension and may
increase the risk of falls, particularly in older individuals.

5. Anticholinergic effects: Antipsychotics with strong anticholinergic properties can cause dry
mouth, blurred vision, constipation, urinary retention, and cognitive impairment. These effects
can be particularly troublesome for older adults and may contribute to confusion and memory
problems.

6. Sexual side effects: Some antipsychotics can cause sexual side effects, including decreased
libido, erectile dysfunction, and difficulties with orgasm.

7. Cardiac effects: Certain antipsychotics may prolong the QT interval, which is a measure of the
electrical activity of the heart. Prolongation of the QT interval can increase the risk of abnormal
heart rhythms, including a potentially life-threatening condition called torsades de pointes.

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It's important to discuss any side effects or concerns with a healthcare professional. They can
provide guidance, monitor for side effects, and make adjustments to the medication regimen if
necessary. It's worth noting that newer antipsychotics, such as atypical antipsychotics, have been
developed to reduce some of these side effects compared to older, typical antipsychotics.
However, they may still have their own unique side effect profiles.

DRUGS INTERACTIONS

Like any other medication, antipsychotics can interact with other drugs, including prescription
medications, over-the-counter drugs, and herbal supplements. These interactions can potentially
affect the effectiveness and safety of both the antipsychotic and the interacting drug. It is
important to consult with a healthcare professional, such as a doctor or pharmacist, to determine
the specific drug interactions based on your individual circumstances. However, I can provide
you with some general information on common drug interactions involving antipsychotics.

1. Central Nervous System (CNS) Depressants:

- Interaction: Antipsychotics can enhance the sedative effects of other CNS depressants such as
alcohol, benzodiazepines (e.g., diazepam, lorazepam), opioids (e.g., codeine, oxycodone), and
sleep aids.

- Risk: Increased sedation, drowsiness, respiratory depression, and impaired cognitive function.

2. Anticholinergic Drugs:

- Interaction: Antipsychotics may have additive anticholinergic effects when taken with other
medications with anticholinergic properties, such as certain antidepressants, antihistamines, and
medications for overactive bladder.

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 - Risk: Increased risk of side effects like dry mouth, blurred vision, constipation, urinary
retention, and confusion.

3. Antidepressants:

- Interaction: Certain antidepressants, particularly selective serotonin reuptake inhibitors

(SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), can increase the levels of
some antipsychotics in the blood.

- Risk: Increased risk of antipsychotic side effects or toxicity.

4. Antiepileptic Drugs (AEDs):

- Interaction: Some antiepileptic drugs, such as carbamazepine and phenytoin, can increase the
metabolism of antipsychotics, leading to lower blood levels and potentially reduced
effectiveness.

- Risk: Decreased effectiveness of antipsychotic treatment.

5. Cardiovascular Medications:

- Interaction: Certain antipsychotics, such as thioridazine and ziprasidone, can prolong the QT
interval on an electrocardiogram (ECG). When used with other medications that also prolong the
QT interval (e.g., certain antiarrhythmics, some antibiotics), the risk of serious heart rhythm
abnormalities may increase.

- Risk: Increased risk of potentially life-threatening arrhythmias

The role of a nurse in the administration of antipsychotic medications involves several

important responsibilities. Here are some key aspects:

1. Medication Administration: Nurses are responsible for administering antipsychotic

medications to patients as prescribed by the healthcare provider. They ensure that the right
medication, dose, and route of administration are followed. Nurses may administer
antipsychotics orally, through injections (such as intramuscular or subcutaneous), or via long-
acting injectable formulations.

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2. Patient Education: Nurses play a crucial role in educating patients and their families about
antipsychotic medications. They provide information regarding the purpose of the medication,
potential side effects, expected benefits, and the importance of adherence to the prescribed
regimen. Nurses also address any concerns or questions the patients may have.

3. Monitoring Vital Signs: Nurses monitor the patient's vital signs regularly, including blood
pressure, heart rate, temperature, and respiratory rate. Some antipsychotic medications can cause
changes in these parameters, and nurses need to ensure that the patient's vital signs remain within
the normal range.

4. Side Effect Assessment: Nurses assess patients for potential side effects of antipsychotic
medications. Common side effects may include sedation, dizziness, weight gain, extrapyramidal
symptoms (such as tremors or stiffness), and metabolic changes. Nurses observe and document
any side effects, communicate them to the healthcare team, and intervene as appropriate.

5. Mental Status Examination: Nurses monitor the patient's mental status regularly to evaluate
the effectiveness of antipsychotic treatment. They assess the patient's mood, behavior, thought
patterns, and overall mental well-being. Any changes or concerns are communicated to the
healthcare provider.

6. Adherence and Compliance: Nurses promote medication adherence by educating patients

about the importance of taking antipsychotic medications as prescribed. They may use strategies
like pill organizers, reminders, or involving family members to support adherence. Nurses also
assess barriers to adherence and collaborate with the healthcare team to address them.

TO MONITOR A PATIENT ON ANTIPSYCHOTICS, NURSES SHOULD CONSIDER

THE FOLLOWING:

1. Regular Assessment: Nurses assess the patient's overall mental and physical condition
regularly. This includes evaluating the patient's psychiatric symptoms, any changes in behavior
or mood, and any potential side effects of the medication.

2. Laboratory Monitoring: Depending on the specific antipsychotic medication being used,

nurses may need to monitor laboratory parameters. This may include blood tests to assess liver

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function, lipid levels, blood glucose levels, or complete blood counts. Monitoring helps identify
any medication-related changes and facilitates early intervention if necessary.

3. Weight and Body Mass Index (BMI) Monitoring: Antipsychotic medications can cause weight
gain and metabolic changes. Nurses should regularly measure the patient's weight and calculate
the BMI to monitor for changes. They can collaborate with the healthcare team to manage
weight-related concerns through lifestyle modifications, diet, and exercise.

4. Medication Adherence: Nurses assess the patient's adherence to the prescribed antipsychotic
regimen. They may use various strategies to support adherence, including education, reminders,
and addressing any barriers the patient may be facing.

5. Collaborative Communication: Nurses communicate any changes or concerns to the healthcare

team, including the prescribing physician or psychiatrist. This collaboration ensures that the
patient receives appropriate care and necessary adjustments are made to the treatment plan if
required.

It's important to note that the specific monitoring process may vary depending on the patient's
individual circumstances, the prescribed medication, and any relevant guidelines or protocols in
place.

Nursing Care Plan For Patients with Psychosis

Date Nursing Expected Nursing Rational Evaluation

Daignosis outcome Interventions

Disturbed NursingIn Establish report To gain client's

ThoughtProcess to the patient trust and
After 3 days of
related cooperation
nursing
todisintegration
intervention the
onthinking
patient will be
asmanifested
able to : respond
bydisorientation
to reality -based
withdate and
interactions
place
initiated by

47
andimpaired others,
judgment

Specifically Be sincere and To address to

interact with honest when Sean delusion
reality based communicating and
topics, sustain with the patient. hallucination
attention or Avoid vague or as delusional
concentration to evasive remarks patients are
perform a task very sensitive
or activity and can
recognize and
sincerity

Avoid making To promote

promises that you trust, broken
cannot fulfill promises
reinforces
patient's
mistrust

Show empathy To address

regarding the distress as a
clients feeling. result of
Reassure client delusion.
of your presence Empathy help
and acceptance convey nurse's
care and
interest for
client

Do not be To do away
judgmental or with feeling of

48
 belittle or joke being
about the client's unimportant
beliefs and rejected

Avoid touching To address

the client without missed
warning or his judgment and
concern this orientation
a perceive
touch as
threatening

Impaired verbal After 5 days of Establish report To get clients

communication nursing to the patient trust and
related to intervention the corporation as
regression as patient will well as quality
manifested by communicate assessment
associative appropriately
looseness and
echolalia comprehensively
neulogism with others

Anticipate and To promote

fulfill clients clients safety
needs unto comfort and
functional trust
communication
patterns return

Oriented client to To facilitate

call client by restoration of
name identify functional
those aspects of communication

49
 communication patterns in the
that help client
differentiate
between what is
real and not real

Attempt to To ease or
decode improve
incomprehensible understanding
communication
patterns. Sick
validation and
clarification by
stating; is it that
you mean?

Monitor Vita To assess

signs especially whether or not
BP and to serve
respiration rate medication
prescribed and
also to assess
the state of
client has
treatment is
being given

Risk for injury

related to
hyperactivity of
a patient

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