Treatment modalities

Psychopharmacology
Somatic therapy
Psychotherapy

Psychopharmacology
Treatment of mental illness:
damage on brain=>abnormal transmission of
chemicals among cells
mental symptoms
cognitive function
content of thought
perception
emotion
behaviour
biological function and impaired overall functioning

medications: restore balance of chemicals

Psychopharmacology
Common types of psychiatric medications:

classification is imprecise
medications used to treat depression are useful in
treating anxiety disorders
mood stabilizers, e.g. lithium and anticonvulsants,
are the main-stream medications for bipolar
affective disorders
new generation antipsychotics have therapeutic
effect on bipolar affective disorder

Psychopharmacology
Antianxiety and sedative-hypnotic drugs
Antidepressant
Mood stabilizer
Antipsychotic drugs

Antianxiety and sedative-hypnotic drugs

Antianxiety and sedative-hypnotic drugs

enhance activities of gamma aminobutyric acid
(GABA)
inhibitory action
lower level of arousal
relieve anxiety and promote sleep

Antianxiety and sedative-hypnotic drugs

Can antianxiety and hypnotics treat anxiety and
sleep problem?
cannot correct underlying chemical imbalance
risk of dependence after prolonged use
limited to short-term use in anxiety disorder and
depression

Antianxiety and sedative-hypnotic drugs

Benzodiazepines
Benzodiazepine antianxiety agents
Benzodiazepine sedative-hypnotic agent
Non-benzodiazepine

Non-benzodiazepine antianxiety agents

Non-benzodiazepine sedative-hypnotic agent

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Antianxiety and sedative-hypnotic drugs

Non-benzodiazepine antianxiety
agents

no addictive potential

Non-benzodiazepine sedativehypnotic agent

bind to a specific receptor in

the brain (omega-1) => induce
sleep

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Antianxiety and sedative-hypnotic drugs

Non-benzodiazepine side effect ?
Zolpidem (Stilnox)
Daytime drowsiness
Dizziness
Gastrointestinal upset

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Antidepressant
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Antidepressant
Treat depressive disorders
Tricyclic antidepressant (TCA)
Selective Serotonin Reuptake Inhibitors (SSRI)

Serotonin and Norepinephrine Reuptake

Inhibitor /SerotoninNoradrenaline Reuptake
Inhibitors (SNRI)
Monoamine Oxidase Inhibitor (MAOI)

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Antidepressant

Disease mechanism of depression:

brain regulates mood/motivation/memory/sleep/appetite

exposure to high level of stress hormone which is toxic to brain

chemicals (serotonin and norepinephrine) are important for

functioning
disrupted transmission of serotonin leading to malfunction of
brain

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Antidepressant
Antidepressant works by:
enhance transmission of serotonin among brain cells
promote healing of damaged parts of brain
through a growth factor called brain-derived
neurotrophic factor (BNDF)

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Antidepressant
TCA
For depressive disorders
Block serotonin transporter and norepinephrine
transporter
Elevate of synaptic concentrations of neurotransmitters

Enhance neurotransmission

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Antidepressant
For depressive disorders and anxiety disorder
SSRI : increase extracellular level of serotonin by
limiting its reabsorption into presynaptic cell
=>increase level of serotonin in synaptic cleft
available to bind to postsynaptic receptor
SNRI : potent inhibitors of reuptake of serotonin and
norepinephrine

replace TCA and MAOI (improved tolerability/safety)

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Antidepressant
MAOI
for depressive disorders
inhibit activity of monoamine oxidase enzyme

potentially lethal dietary and drug interactions

a last line of treatment (e.g. SSRI and TCA have
failed)

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Antidepressant
Treatment of serotonin syndrome
Discontinue all serotonergic drugs immediately

Anticonvulsants for seizures

Serotonin antagonist drugs may help

Clonazepam for myoclonus

Lorazepam for restlessness/agitation
Other symptomatic care as indicated
Do not reintroduce serotonin drugs

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Mood stabilizing
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Mood stabilizing
treat both manic and depressive episodes

level of Lithium: too low = won't work; too high = toxic

regular blood tests: therapeutic range: 0.6 and 1.4 mEq/L

dehydrated: level of Lithium rise=>side-effects/toxic effects

drink plenty of water hot weather/active
careful with tea/coffee - increase amount of water in urine
3 months or longer for Lithium to work properly

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Mood stabilizing
Signs suggest that Lithium level is too high:
very thirsty
bad diarrhoea or vomiting
shaking of hands and legs
twitching of muscles

confused

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Mood stabilizing
Other mood stabilisers:

Anti-epileptic medications/anticonvulsants:
Sodium Valproate works just as well Lithium
Should not be prescribed to women of child-bearing age
Carbamazepine and Lamotrigine: effective for some
people

Antipsychotic medications: Olanzapine or Quetiapine

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Antipsychotic drug
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Antipsychotic drug
symptoms of schizophrenia which involves dysfunction of a
chemical (dopamine) in brain
dopamine allows our brain to give us sense of personal
significance and drive
nerves in our brain release dopamine appropriately
reason something to have a personal meaning with
objective evidence
e.g. I see that now a man is holding a knife towards me,
the dopamine activities in my brain give a sense of
personal significance to this man; therefore, I have the
correct belief that he is harming me

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Antipsychotic drug
inappropriately released dopamine made a person
have a wrong sense of personal significance
e.g. a person will consider every policeman in street
to be searching him particularly. The abnormality of
dopamine release in his brain makes him so
convicted on such belief that he is not subject to
rational explanation and is behaving in reaction to
this belief. He dare not to leave home at all...

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Antipsychotic drug
antipsychotics work by inhibiting excessive dopamine
activities in brain
no more abnormal personal significance
no more new delusion developed
less preoccupied on such belief and have less distress
able to take other explanations for what happens to him
e.g. I always come across policeman in street because
there are police on patrol every day in public areas.
They are not looking for me, because they do not arrest
me after numerous encounters in public

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Atypical and Typical Antipsychotics

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Antipsychotic drug
Side-effects of psychiatric medications:
more than 10% of patients
increasing risk of metabolic syndrome
high blood sugar
high blood lipid
high blood pressure
weight gain
adopt healthy lifestyle
adequate exercise
diet control

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Antipsychotic drug
report any discomfort after taking medications

discuss with patient on the plan of treatment

balance risk of relapse and harm of side-effects

adjust dosage and frequency of taking medications

unwise to refuse medication treatment due to fear of
side-effects

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Antipsychotic drug
Continue medications after recovery:
misconception about recovery in mental illness
role of medication treatment in maintenance
patient stops taking antibiotics after infection has
been cleared
even after patient has all symptoms subsided and has
fully resumed his work, the psychiatrists advise to
continue medication
after a complete resection of tumour, doctor might
let patient to take a few months of chemotherapy to
consolidate the recovery

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Antipsychotic drug
stress-induced damage to brain
promote healing of damaged brain region
normalize disordered chemical transmission
genetic makeup still exists and poses risks of a relapse
stressor which causes the last episode of mental illness
would probably relapse
maintenance treatment consolidate the recovery by
offering protection to brain
choose to apply sunscreen lotion to avoid sunburn

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Depot injection
Fluanxol depot
Haldol Decanoas
Clopixol

Risperdal Consta

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Depot injection
What's good about having depot injections?
have medicine once a week or once a month
pills have to be taken every day

less likely to forget medicine

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Depot injection
What's bad about having depot injections?
uncomfortable about having injections (anxiety
about needles)
experience pain for a few days
same side-effects of medication as tablet
depot medications belong to 'first generation' or
'typical' antipsychotics (e.g. Modecate, Haldol and
Clopixol) causing side-effects such as stiffness or
shaking in arms and legs when compared to the
newer medications ('second generation' or
'atypical; antipsychotics) such as Risperidal Consta.

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Drug treatments for Alzheimer's disease

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Drug treatments for Alzheimer's disease

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Drug treatments for Alzheimer's disease

Cholinesterase inhibitors:
Donepezil (Aricept)
Galantamine (Reminyl
RivastigmineExelon)
may help with symptoms of Alzheimer's disease
e.g. memory loss and anxiety

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Drug treatments for Alzheimer's disease

Effects of cholinesterase inhibitors:
slow progression of memory deterioration in
Alzheimers dementia
improve alertness and motivation
feel brighter in mood
able to do things that were too difficult for them
(going to market)

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Drug treatments for Alzheimer's disease

How do cholinesterase inhibitors work?

slow down breakdown of acetylcholine in brain

acetylcholine helps to pass messages between
certain brain cells involved in memory
amount of acetylcholine is very much reduced
memory starts to suffer
increase in level of acetylcholine in brain allows
it to continue its function and reduce some of
symptoms

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Drug treatments for Alzheimer's disease

Side-effects:
nausea

reduced appetite
tiredness

diarrhoea
muscle cramps

poor sleep

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Drug treatments for Alzheimer's disease

What is Memantine?

affect a chemical in brain called glutamate

too much glutamate leaks out of damaged
brain cells which destruct nerve cells in brain
and stops them working properly
reduces activity of glutamate and reduces rate
of deterioration on global, cognitive and
behavioural improvements
side-effects: dizziness, constipation, headache

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Somatic therapy - Electroconvulsive therapy

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Somatic therapy - Electroconvulsive therapy

(ECT)
small electric current stimulates brain cells
correct abnormal physiological condition in brain
brief period of observable muscle convulsion

severe depression
schizophrenia

mania

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Somatic therapy - Electroconvulsive therapy

How is an ECT conducted?

team of professionals which include psychiatrists,
psychiatric nurses and anesthetists

appropriate setting with precise instrument

ensure that patient can withstand anesthesia
and electric stimulation

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Somatic therapy - Electroconvulsive therapy

How is an ECT conducted?
stops eating after midnight
ensure that stomach is empty before ECT
avoid tight-fitting clothing and remove any
denture or ornament on body
injects anesthetic agents and muscle relaxant
breathes in pure oxygen
function of heart, lungs and other important organs
are under close monitoring

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Somatic therapy - Electroconvulsive therapy

How is an ECT conducted?
small electric current is passed to head of patient
cause a response from brain electric activities
mild twitching in body
last for 2 to 3 minutes
monitor patients condition
brief period of confusion and headache

number of ECT sessions range from 2 or 3 to more than 10

usually has 3 to 4 days of rest before next session of ECT

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Somatic therapy - Electroconvulsive therapy

Is a written consent required for ECT?
doctor has explained treatment to patient
patient understands nature and risks
patient can withdraw consent at any time
withdrawal of consent for ECT does not affect
the rights to receive other treatments
the illness might take a longer time to recover
medication treatment and other treatments also
have their own side-effects

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Somatic therapy - Electroconvulsive therapy

What are the risks and complications of ECT?
no evidence showing that ECT will lead to permanent brain
damage/alter personality
some patients have a brief period of confusion
blood pressure & heart rate change (risk of abnormal rhythm)
if a patient has heart disease or other disease=> inform doctor
muscle twitching which can result in muscle ache
damages to teeth or even fractures of bone are possible
anesthesia might cause headache, nausea and vomiting

risk of death/serious injury from ECT < childbirth

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Psychotherapy
Behavior and cognitive therapy
Mindfulness
Therapeutic group

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Cognitive Behavioral Therapy

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Cognitive Behavioral Therapy

Feelings (affect) influence thinking (thoughts)
Thoughts influence action (behaviour)

Behavior reinforce feelings

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Mindfulness-Based Interventions
events around us and thoughts, feelings, and
sensations in the mind can trigger old habits of
thinking => worsening mood
enhance psychological well-being
stress and pain reduction

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What is Mindfulness?
awareness that emerges through paying attention on
purpose, in the present moment, and non-judgmentally
to things as they are
make more skillful choices and develop a stronger
sense of self-mastery, self-care and self-responsibility
form of meditation originally developed in the Buddhist
traditions of Asia

systematic approach to developing new kinds of

control and wisdom
based on our inner capacities for paying attention,
awareness, insight

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Potential Benefits of Mindfulness Practices

useful in the treatment of pain, stress, anxiety,
depressive relapse
help us to see more clearly the patterns of the mind

learn to recognize when our mood is beginning to

go down
improve immune system and alters activation
symmetries in prefrontal cortex, a change previously
associated with an increase in positive affect

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Practices of Mindfulness
Body Scan
Mindful Stretching

Sitting Meditation
Mindful Walking
Mindfulness in daily life

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Practices of Mindfulness
Body Scan
guides us in paying attention, directly and
systematically, to each part of the body in turn
encourages us to be in a more intimate and
friendly relationship to the body in the present
moment

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Practices of Mindfulness
Mindful Stretching
bring out attention to the range of sensations
and feelings that arise in our bodies as we go
through sequences of gentle standing and lying
down yoga stretches
purposefully experience the body just as it is
moment by moment, with openness and interest
include sensing and gently exploring its limits in
any given stretch or posture

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Practices of Mindfulness
Sitting Meditation
sitting meditation invites us to first let our attention
settle on the breath sensations themselves
gradually expand the field of awareness once it is
relatively stable
include a sense of the body as a whole or any
particular regions that might be giving rise to
intense sensations

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Practices of Mindfulness
Mindful Walking
walking meditation

cultivate mindfulness while moving

focus attention on the sensations associated
with the feet moving during walking

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Practices of Mindfulness
Mindfulness in daily life
bring mindfulness to the tasks, experiences, and
encounters of ordinary living
e.g. setting the table, eating, washing the
dishes, doing the laundry, cleaning the house
and going to work

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Therapeutic groups
substance abuse and other addictions
domestic violence

divorce
childhood abuse

depression
anxiety
PTSD
eating and body image

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Therapeutic groups
Task group
Self help group
Educational groups

Supportive therapy groups

Intensive problem solving group

Peer support group

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Reference:

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier
Mosby.

Psychopharmacology: p. 532-558

Somatic therapy: p. 594-600

Cognitive behavior therapy: 565-566

Basic understanding of psychiatric medications

http://www3.ha.org.hk/cph/imh/mhi/article_04_01_01.asp

Depot. https://www.rcpsych.ac.uk/expertadvice/treatmentswellbeing/depotmedication.aspx

Drug for dementia.

http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=147

Third wave therapy. http://www3.ha.org.hk/cph/imh/mhi/article_04_03_03_chi.asp?lang=1

Group therapy. http://www.goodtherapy.org/group-therapy.html