No longer hidden or protected behind institutional walls, people with severe and persistent mental illness are part of our everyday lives. Severe and persistent mental illness describes the most debilitating mental disorders, which typically have a life-long course of exacerbations and remissions.

As health care professionals, we encounter people with mental illness daily through our work in hospital emergency departments or other settings. In our private lives, they pass unnoticed in libraries, stores, and other public places when their symptoms are controlled. Some of us have family members and friends with severe and persistent mental illness to whom we try to provide support and understanding.

Mental disorders are second only to cardiovascular conditions worldwide in causing disability and premature death.¹ Unemployment in this population is around 90%.¹ Increasing costs, both direct (health care) and indirect (loss of productivity and premature death) are devastating to the individual and the economy.² While substance abuse and mental health treatment constituted 7.6% of all health care spending in 2001, the mental health spending increases in the preceding decade remained a percentage point behind that for health care in general. The largest increases were for medications, with Medicaid being the biggest payer for mental health care. This means the public has borne the brunt of increases in mental health care expense.³

It is estimated that one-fourth to one-third of the homeless population has a serious mental illness, and that about half of the people with a severe and persistent mental illness have been homeless at some time in the past year.^1,3 Around 7% of people in prisons or jails have a diagnosis of major mental illness, and the challenge remains to divert them to the mental health care system when that is the primary problem.^2,4 The social problems (e.g., homelessness, incarceration, minor crimes, school failure, work disability) of serious mental illness equal the disorders’ effect on the health care system.⁴

Major depression — when persistent feelings of fatigue, hopelessness, irritability, loss of interest in usual activities, and sadness last longer than two weeks — is the leading cause of disability in developed countries, including the United States.¹ Bipolar disorder, which consists of major depression along with swings of elevated mood, is a distressing illness, with a high substance abuse rate.¹ Schizophrenia, primarily a disorder of thought and perception characterized by delusions (false beliefs) and hallucinations (disturbed sensory experiences), is less prevalent than bipolar illness or depression, but is one of the most disabling of serious mental illnesses.^1,5,6  Anxiety disorders (such as obsessive compulsive disorder, panic disorder, phobias, or generalized anxiety disorder) are some of the most common psychiatric disorders and often co-exist with depression.^1,5,6

This chapter will cover an integrated model for mental illnesses, biological discoveries from the Decade of the Brain (the 1990s), highlights of the surgeon general’s report and the president’s commission on mental health, and general nursing recommendations to deal with severe and persistent mental illness.

Biopsychosocial system of diagnosis

The American Psychiatric Association⁷ uses a multidimensional system to categorize and describe mental illnesses. Such a comprehensive but quick tool gives a holistic picture of diagnosis, contributing medical or health conditions, stressors, and overall functioning. This information is recorded on five axes as follows:

• Axis I:  primary mental health diagnosis(es)
• Axis II:  diagnoses of mental retardation or personality disorders
• Axis III:  contributing or concurrent medical or health conditions
• Axis IV:  pertinent stressors (by category and severity) such as divorce, failure in school, homelessness, or job loss
• Axis V:  Global assessment of functioning (GAF): a score of 1 (lowest) to 100 (highest) reflecting overall functional ability

This diagnostic system is used in most psychiatric settings to evaluate and plan multimodal treatment which addresses biological, developmental, functional, and social aspects. Familiarity with the components of this model may also help nurses in non-psychiatric settings to think about any illness multidimensionally, particularly in identifying co-existing illnesses, assessing life stressors, and comparing level of functioning to a baseline for a person and to society’s norms.

Mental illness is complex and requires comprehensive, coordinated care. Perhaps no other condition so profoundly influences all aspects of a person. Chemical changes from the disorders themselves affect not only emotion and thought, but also the ability to function. The ability to relate to others is profoundly affected. Furthermore, medications prescribed to alleviate symptoms can affect endocrine balance, GI motility, and motor movements.

An acute model of care does not work for chronic conditions. Yet many people with severe and persistent mental illness find care primarily in hospital emergency departments or acute care facilities only when exacerbations occur; they often go without adequate, preventive, and rehabilitative care the rest of the time. The surgeon general’s report on mental health revealed that almost half of people with severe mental illness failed to seek treatment.¹ Barriers include lack of access to appropriate care, inadequate financial resources, fear, stigma, lack of support, and lack of system flexibility. The inability to follow through, which is characteristic of some disorders, also interferes with adequate treatment. Of those with schizophrenia who do find treatment, more than half received inadequate disease management.⁸ While treatment is expensive, the costs of inadequate or no treatment are greater.

New directions

Much of what is known about the structure and function of the brain has been learned since the late 1980s. With recently available brain imaging techniques, such as positive emission tomography, blood flow and metabolism differences in ill and healthy brains can be readily visualized. Characteristic patterns of activity detectable in brain imaging help to differentiate disease patterns, showing which areas are affected by which disorders. For instance, such visualization confirms that prefrontal and limbic areas are most commonly dysfunctional in schizophrenia; frontal and temporal areas are hypoactive with depression while areas around the amydala and hypocampus are overly active in anxiety disorders.⁹ Dramatic differences can be seen before and after medication treatment, showing more normalized brain activity after medication.⁹ Effective, evidence-based treatments are available for most mental disorders.^1,2,9 Many new medications, with more specific action and fewer side effects, have become available.

Education and psychosocial interventions continue to be studied alongside medication responses for effectiveness. We have learned that we cannot treat mental illnesses with medications alone. A focus on recovery (not cure) has resulted in more emphasis on patient and family involvement in treatment planning, education, and rehabilitation, as well as what we can learn from people who do recover.

As an example, research by the National Institute of Mental Health on treatments for schizophrenia has resulted in recommendations for “best practices” and follow-up on compliance with these practices. Recommendations from the Patient Outcome Research Team (PORT)⁸ address psychopharmacologic treatment as well as psychosocial treatments such as family therapy, supportive psychological therapy, vocational rehabilitation, and intensive case management like Assertive Community Treatment (ACT). Of 30 recommendations, only one-third involve medication.

In 1990, Congress and the president proclaimed the 1990s the Decade of the Brain, dedicated to study the biological factors in mental health and illness using technology. Mental Health: A Report of the Surgeon General, published in 1999 provided a summary of new biological findings from the 1990s’ Decade of the Brain, as well as a comprehensive overview of the state of mental health and mental illness treatment at that time. The report described the overall effect of mental illnesses, evidence-based treatments available, as well as economic, legislative, and public health concerns. Since that time, additional publications from the surgeon general’s office have focused more specifically on children’s mental health, suicide, and cultural aspects of treatment. The President’s New Freedom Commission on Mental Health Final Report, published in 2003, built on priorities established in the 1999 surgeon general’s report, and recommended additional public policy changes.

Medications

The development of new medications is particularly important to those with severe and persistent mental illness, whose symptoms may be more resistant to traditional treatments and medications. Newer medications often target more specific or different receptor sites, making side effects less of a problem. Often, when older drugs were prescribed at high enough doses to control symptoms, side effects (especially neurological effects) were intolerable, making compliance exceedingly difficult. Recently developed medications, however, are much more expensive, and people with severe and persistent mental illness are often among the poorest in our population.¹

Medications are crucial for interrupting symptoms that can spiral into decompensation, disabling episodes requiring hospitalization. Because of the biological component of these disorders, medications are necessary for most patients to manage symptoms that otherwise prevent reasonable functioning. However, because of brain dysfunction resulting in problems with behavior, feeling, and thinking, many people with severe and persistent mental illness are noncompliant with medication regimens. Patients may not be able to organize, follow through, or think logically, or they may be afraid, feel hopeless, or be concerned about side effects. Costs of new medications also interfere with compliance. The use of both pharmacologic and psychosocial interventions has been shown to be more effective than either one alone in managing serious mental illnesses.^1,7

Nursing considerations

The surgeon general’s report uses terms familiar to nursing care. It describes mental health and mental illness on a continuum of health and illness. It states that mind and body are inseparable and that mental health is essential to health in general. It depicts a population-based perspective of mental health as a public health issue, with economic, societal, and political ramifications. And it speaks of the neurobiological basis of these disorders, as it is better understood today. The following suggestions are based on research, a review of community mental health care, and established nursing process.

Know the person behind the illness. A review of the last half century of mental health services emphasizes that care needs to be focused on the person, not on the program or place of service.¹⁰ People with severe mental illnesses are seen by nurses for various reasons in clinics, emergency settings, and inpatient medical units. Often these encounters, especially when repeated, present opportunities to know the person, as well as to know about him or her, despite interfering symptoms. Such contacts offer not only a human connection, but also a database from which to assess (and access) personal history, motivators, support systems, values — information needed for any type of care or follow-up. Throughout these interactions, it is important to keep person and symptoms separate. By remembering that this is a person with a type of schizophrenia or a person with bipolar illness or depression, nurses can be vital in addressing the stigma of mental illness. Nurses can also address stigma by educating others about the brain dysfunction that drives these disorders.

Think “wellness,” offer assurance. More people seek and receive mental health care today than in 1999, and we realize that treatment success for mental illnesses equals or exceeds that for other conditions.^2,5 While recognizing the chronic or recurring aspects of severe and persistent mental illnesses, nurses can matter-of-factly discuss treatment options and disease management skills, while offering encouragement and referring to previous difficult episodes where the person has coped well. Nurses are often crucial as advocates to find needed resources for patients and families. Remember that the primary concerns of these patients are optimal functioning and quality of life.

The concepts of wellness and serious illnesses are not mutually exclusive. A controlled study, using a wellness model developed by two advanced practice nurses, showed a 93% reduction in psychiatric hospital days for the 88 patients in the control group.² The intervention consisted of engaging family members and significant others with the patient in a detailed education and support process of 12 weekly three-hour meetings.

Keep acute episodes in context:  Severe and persistent mental illness can take many paths on a continuum of recovery.⁶ The course of these conditions often ebbs and flows, with times of remission interspersed with recurrence of symptoms. An encounter with someone with a severe mental illness is merely a snapshot in time. Keeping acute episodes in this context helps to frame symptoms and problems on a continuum. The patient, case manager, or family member may be able to describe what has worked or not worked in the past. They may also offer the patient a baseline or goal of wellness. Patients can be reminded of progress made in the past and encouraged toward greater wellness.

Involve family and significant others. People who have lived with a disabling psychiatric diagnosis for a long time may be alienated from family and previous support systems by their symptoms and inability to relate to others appropriately. However, supportive connections can often be identified. Successful models of education and empowerment include in the process people important to the patient. Such people may include a friend or others in the community with whom the person has frequent contact. Confidentiality is always an issue in mental health, but often the patient can identify or approach such people for needed support.

Realize the importance of work/vocation. While lack of housing, poverty, and unemployment accompany severe mental illness, productive work offers more than income. Work has great therapeutic value in providing structure to the day and increasing self-esteem and a sense of accomplishment and meaning. The PORT recommendations5 include vocational rehabilitation, along with other psychosocial and medication interventions, for people with schizophrenia who have previous work histories and minimal hospitalizations.

Become aware of resources. For more disabled patients, patient-run clubhouses and other structured activities available through community support programs offer vocational opportunities and experiences. Management of severe mental illness often involves relearning basic life skills: re-establishing social contacts, shopping, and taking the bus. For people severely disabled by symptoms, ACT teams offer 24-hour support as needed. Patients without prescription coverage for expensive medications can be referred to drug manufacturers’ indigent programs or to community clinic assistance programs for medications. If you aren’t aware what services are available, inquire.

Check for an advance directive or crisis plan. Some people with mental illness choose to have a greater voice in their treatment by planning for times of severe symptom recurrence. Every state has legislation regarding advanced directives, including directives for mental health treatment. While advance directives are not yet widely used, preliminary reports indicate that patients are empowered by the act of completing a directive.¹¹ Information is available to guide patients, together with service providers and significant others, through the process. Directives may be instructional (specific) or proxy types. A proxy directive offers more flexibility for a representative to adapt the patient’s wishes to the situation. At present, these directives are not adequately disseminated, and follow-through remains a problem, but increased use may save money and improve health through earlier, preferred treatments. (For examples of advance planning, see the Resources sidebar.)

Policy implications

The surgeon general’s report identified two major emphases for policy: to promote evidence-based treatment and to decrease stigma by educating the public about brain-based diseases. The NIMH continues to pursue research on both causes of mental illness and interventions, promoting evidence-based practice.

Since passage of The Mental Health Parity Act of 1996, which took effect January 1998, parity for coverage of mental illness equal to that for other medical conditions is addressed. The Mental Health Equitable Treatment Acts of 1999 and 2001 were introduced as more definitive follow-ups to the 1996 legislation, but Congress did not pass them. (See Mental Health Care Parity in the Resources sidebar.) Early in 2007, parity legislation was reintroduced as the Mental Health and Addiction Parity Act.

An organized effort has been under way to promote uniform improvements in mental health care for those with the most serious mental illnesses. The National Alliance on Mental Illness has developed a legislative package for individual states to use in mental health reform. Known as the Omnibus Mental Illness Recovery Act, this initiative addresses the following issues:

• Consumer and family-member participation in mental health services planning
• Equitable health care coverage (parity)
• Access to newer medications, assertive community treatment
• Work incentives for people with severe mental illness
• Limits in the use of restraints
• A reduction in the number of severely mentally ill people incarcerated and access to suitable housing with appropriate services. 

Humane and respectful treatments have also been shown to be the most cost-effective.¹⁰ However, funding for mental health care continues to be limited while the needs of this population challenge a fragmented health care system.

Nurses owe it to themselves and those they care for to stay aware of problems and treatment issues in severe and persistent mental illnesses. In recognizing how much has been learned about the brain in the past decade and becoming familiar with the names and classes of newer medications available to treat these disorders, nurses can offer assurance to patients and help to combat stigma by educating others. Nurses, constituting the largest number of health care providers, can make a difference in addressing this huge public health problem. 

Chapter 2 – Schizophrenia The dilemma of ‘what is real?’

Movies such as A Beautiful Mind, depicting a person and family affected by schizophrenia, have increased public awareness of a little-understood but profound mental illness. Nurses may be asked more questions about this confounding disease, which affects 1% of the population and alters thinking and perception to cause devastating changes in quality of life.^1,2 A person with schizophrenia often loses the ability to work, or to continue in the same type of work, and with it the insurance coverage for adequate treatment.^2,3 Even when the person remains insured, coverage may not be equal to that for “medical” diagnoses. Intimate, family, and social relationships are disrupted by faulty perceptions and the client’s inability to relate normally to others. 

Because the experience of schizophrenia is so distressing, 20-40% of those with this illness attempt suicide at least once.¹ The risk of completed suicide is around 10%, considerably higher than for the general population.¹ Co-morbidity with other disorders, both medical and psychiatric, contribute to reduced quality of life with schizophrenia. Common health problems that are worse in schizophrenia include dental and vision problems, diabetes, high blood pressure,  and sexually transmitted diseases.² Psychiatric conditions that frequently co-exist with schizophrenia include the anxiety disorders, obsessive compulsive disorder, and panic disorder.¹

Substance abuse is high with schizophrenia: 80-90% smoke tobacco, choosing high-nicotine brands. Self-medication with street drugs and alcohol is also common. Estimates are that half of those with a serious and persistent mental illness like schizophrenia will also deal with drug or alcohol abuse at some time in their lives.² This co-morbidity, known as dual diagnosis, makes the schizophrenia more difficult to treat and may complicate and prolong the illness course.²

This chapter will describe the disease process of schizophrenia, the affect on patients and families, treatment recommendations, and nursing implications for dealing with this mental illness.

Schizophrenia, psychosis symptoms

Schizophrenia is the most commonly known form of psychosis, or disordered thinking and perception. Sometimes categorized as a thought disorder (vs. a mood disorder such as major depression or bipolar illness), schizophrenia affects the brain’s ability to sort and decipher information, to separate the important from the unimportant, and to tell what is real or not real. Incoming information can be misinterpreted or given unusual or bizarre significance. The brain may generate its own information (internal stimuli) that the person with schizophrenia may have trouble distinguishing from external stimuli. Such problems in processing information can be distressing and overwhelming to the person with the symptoms, as well as to family and friends and the larger community.

Positive and negative symptoms

The symptoms of schizophrenia are grouped broadly into two categories. Positive symptoms are alterations in thinking and perceptions that can be observed in behaviors. The five senses may misperceive the environment resulting in hallucinations, the most common of which are auditory and affect about 70% of people with schizophrenia.³ Besides hearing voices or sounds, the person with schizophrenia may see people, colors, or objects that are not perceived by others. Someone with schizophrenia may likewise individually feel, smell, or taste things that cannot be verified by others present. Positive symptoms are also evident in thinking, in the form of delusions, beliefs not supported in reality. Patients may believe, for example, that others (groups, organizations, or people) are conspiring or plotting against them or the health care provider or that they are someone else. Patients may construct bizarre cause and effect relationships, such as believing that the color of shirt worn by another has multiple significant meanings. Positive symptoms tend to be those that are in addition to the ordinary, indicating an excess or distortion of normal brain function.^1,2,3

Negative symptoms are those indicating a lack of function. Social withdrawal, sleeping all the time, and avolition (no drive to accomplish) are examples of negative symptoms. Positive symptoms may contribute to negative symptoms. For example, a person experiencing active auditory hallucinations may choose to stay home in bed because of an inability to pay attention to others, concentrate at work, or handle any more stimuli. However, negative symptoms are also, of themselves, indicative of  “shutdown” by at least certain areas of the brain in this illness. Brain imaging techniques, such as positron emission tomography, show hyperactivity of certain brain areas, such as those processing auditory hallucinations, and almost no activity in other areas, compared to a brain without this disease process.³ Negative symptoms greatly affect the person’s functional ability, resulting in losses of employment, self-esteem, and social relationships.

By appreciating the role of negative symptoms as part of the disease process, nurses can better address issues such as missed appointments, noncompliance with treatment or medications, and a lack of follow-through. Negative symptoms can easily be judged as character defects, such as laziness, not caring, not wanting help, or opposition. By understanding negative symptoms as part of the illness of schizophrenia, nurses can offer appropriate interventions (ADL routines, having support staff check in with the patient, reminders, transportation arrangements) to deal with effects of this disease process.

Brain and neurochemical changes

Because of new imaging technology, we now know that the brain of someone with schizophrenia looks different.³ In fact, these differences may be present long before symptoms of schizophrenia appear, and some studies indicate that disrupted neural development in the fetus may affect how the brain later matures, leading to structural abnormalities seen in schizophrenia.⁴ Structural differences in schizophrenia include extra folds in the cortex, decreased volume of gray matter in certain parts of the brain, and increased ventricle size.³ Functional changes can be seen in decreased frontal lobe activity.³ The brain seems unable to sort information (e.g., room noise from someone speaking) normally and is overwhelmed and unsure of how to respond.

While electrical and chemical activity in the brain is extremely complex, certain neurotransmitters have been implicated in schizophrenia.⁵ Overactivity of dopamine has been implicated in psychotic symptoms. Older antipsychotics acted by blocking dopamine receptors, which improved positive psychotic symptoms, but caused neurological (Parkinson’s disease-like) side effects. Newer (atypical) antipsychotics, while blocking dopamine receptors, also act on serotonin and other receptors. Serotonin is known to modulate levels of both dopamine and norepinephrine (helps with alertness and energy). The effectiveness of newer antipsychotic medications for both positive and negative symptoms may have to do with their action on both dopamine and serotonin receptors and the modulating effects of serotonin.^3,5

PORT recommendations

In most cases, newly diagnosed schizophrenia is not adequately treated, and fewer than half of those diagnosed have adequate follow-up.⁶ In the late 1980s and early 1990s, the National Institute of Mental Health sponsored research to determine what treatments had effective outcomes for those with schizophrenia. These Patient Outcome Research Team studies describe several categories of treatment, beginning with medication recommendations.⁶ Also addressed are electroconvulsive therapy, psychological and family interventions, vocational rehabilitation, and assertive community treatment (ACT, a type of intensive case management). Adequate treatment with high enough doses of antipsychotics, both initially and for maintenance, is emphasized.

To standardize and compare doses for different antipsychotics, chlorpromazine (Thorazine) equivalents are used. This would be much like using an early, well-known antibiotic, like penicillin, as a standard for comparing doses of other antibiotics. For instance,

5 milligrams of haloperidol (Haldol), commonly given in emergencies, would be equal to 250 milligrams of chlorpromazine (1 mg Haldol = 50 mg Thorazine). Since 300 to 1000 milligrams of chlorpromazine (CPZ) are needed daily for acute therapy and 300 to 600 milligrams for maintenance therapy, equivalent doses of Haldol would be 6 to 20 mg for acute and 6 to 12 mg per day for maintenance therapy.⁷ Equivalences can be found in the PORT Recommendations, available online (www.ahcpr.gov/clinic/schzrec.htm).

Nursing implications

Medications: More than one-third of the PORT recommendations have to do with medications. Treating schizophrenia in the initial stages with high enough doses (CPZ equivalents), but not with overly high “loading doses,” achieves remission of symptoms.⁶ Maintaining adequate doses for at least a year after remission of symptoms depends on effectively dealing with side effects and related problems of taking medication on a long-term basis. Nurses can assist with initial adequate treatment by raising co-workers’ awareness of the PORT standards and suggesting referral to mental health specialists who will provide adequate follow-up and support services to aid compliance. Nurses can also enhance maintenance therapy by understanding the daily challenges of adverse effects (such as constipation, sedation, sexual side effects, weight gain, and, with older drugs, Parkinson’s disease-like symptoms) and associated difficulties of long-term medication therapy. By developing trusting relationships with patients, the nurse can help them share frustrations and increase their willingness to work together toward solutions. Only in a trusting relationship will the patient be receptive to education the nurse may have to offer about the need to stay on medications and continue treatment.

Medication doses of antipsychotics often need to be fine-tuned, even in maintenance stages, because of the patient’s changing condition, metabolism, and life stressors. Such fine-tuning might be compared to monitoring of prothrombin times in a patient on anticoagulant therapy or blood sugar levels for someone on insulin. While blood levels are not used routinely for antipsychotics, and neurotransmitter level assessments are not yet clinically feasible, clinical assessment and client feedback are vital in maintaining effective drug levels for remission of schizophrenia symptoms.

Again, nurses can play a critical role in soliciting information from the patient to determine whether adjustments are needed. Nurses are also vital in reminding patients and families about the disease process involving chemical changes, the effect of stressors, and individual responses to treatment. Nurses can also offer encouragement and problem-solving skills.

The newer atypical antipscyhotics have helped patients who did not respond to traditional medications. However, these medications are expensive and not always available to those who need them most. Of all the atypical antipsychotics, clozapine (Clozaril) was found in a recent large multisite study to be the most effective and best tolerated of the newer drugs.⁹ However, because of the possible adverse effect of agranulocytosis (1% to 3%), use of Clozaril initially requires weekly (in the first six months) and thereafter biweekly blood tests, an additional treatment consideration.

For patients remaining on older typical antipschotics, nurses need to be aware of the Parkinsonian-type adverse effects common with these drugs, which are more affordable and more commonly used, particularly with low-income and uninsured populations.

Tremors, muscle stiffness or rigidity, shuffling gait, muscle restlessness, and akisthesia are common with typical antipsychotics and understandably interfere with medication compliance. By noting such side effects, nurses can educate patients and assist in communication between patient and prescriber to improve the management of side effects. Adjusting doses and adding side effect medications are helpful, as are altering times of day the drugs are taken or splitting doses differently throughout the day.

A risk of taking the older antipsychotics long-term is tardive dyskinesthia (TD), involuntary movements of the skeletal muscles, characterized by jerking, tongue-thrusting and facial tics, or writhing. About 20-35% of clients on long-term antipsychotics will develop TD; early intervention can reverse the progression or limit the severity of symptoms.⁵ Nurses can play a crucial role in identifying abnormal involuntary movements and referring clients for dose adjustments or treatment of these side effects.

While fairly uncommon (a ratio of 1 to 100), neuroleptic malignant syndrome (NMS) is a medical emergency that can result from drug interactions with, or rapid titration of, antipsychotics, particularly the older drugs.⁵ The most important symptoms of NMS are fever and muscle rigidity; creatinine phosphokinase and WBC may also be elevated.⁵ Nurses in non-psychiatric settings need to assess whether someone presenting with these symptoms is on antipsychotics. Referral for immediate medical intervention is required for NMS.

Psychosocial: When brain function is compromised, all aspects of life are affected. When we misperceive our environment, other people, and even our own body, our reactions and interactions are altered as well. People with psychotic symptoms may be seen talking to themselves or laughing for no apparent reason. They may believe that they will be harmed or that others cannot be trusted. They may seem distracted or slow to respond to questions. They may have poor hygiene. People distance themselves from the odd behavior and strange communication resulting from altered thinking and perception. These same alterations interfere with the ability to perform activities of daily living or job tasks. People with schizophrenia become alienated from others by their symptoms and compromised functioning.

Being different invites stigma. The surgeon general has identified stigma as a major barrier to adequate treatment.² Nurses can address stigma through educating colleagues and the public about schizophrenia and the biological origins of symptoms. Nurses can also combat stigma by responding to people with psychotic behaviors as people with distressing symptoms rather than reacting primarily to the symptoms.

Because of the many psychosocial issues resulting from psychotic symptoms, nurses can also educate others about the importance of psychosocial treatments in schizophrenia. Group activities focusing on socializing, exercise, or recreation; medication education; and daily living skills such as shopping and accessing public transportation are all therapeutic in reducing isolation and rebuilding skills. Delivering such treatments in the community not only saves health care dollars, but maintains a more normal life for affected people. Patient-run clubhouses offer a place for social contact, vocational assistance, and practice of necessary skills to live again more independently. By increasing their knowledge of such resources, nurses can offer encouragement and referrals for individuals and families.

Family involvement and education are critical to successful treatment.^2,3,6,7 Family members benefit from learning about symptoms and causes. Families themselves offer invaluable information about the person with schizophrenia: what the person was like without the disease, what seems to trigger symptoms, and what baseline functioning can be expected. Educational groups run by nurses for clients and families have demonstrated improved clinical outcomes as well as a dramatic decrease in hospitalizations.⁸ Both outcomes improve quality of life. 

Spiritual: Schizophrenia, a disease process that so severely disrupts perceptions, produces profound suffering, a concept sometimes forgotten in our technological world. Suffering, in turn, usually results in spiritual distress. Questions such as “Why me?” “What is the meaning of this happening to me?” and “Who am I with this illness?” arise. Suicidal thoughts and feelings are common.¹ Because logical thought may be impaired, metaphors, stories, or themes may be the primary expression of such distress. Nurses play an important role in addressing these concerns by listening, spending time with the client (being present), and helping to clarify values as the person tries to make some sense of or derive meaning from the situation. Sometimes the presence of another human being gives the person assurance, even when nothing makes sense.

Schizophrenia, the most commonly recognized form of psychosis, or disordered thinking and perception, has a life-changing effect. Functioning is compromised, relationships suffer, and the person’s sense of self is put into question. Because of the suffering involved, the risk of suicide is significantly higher for this population. Nurses’ understanding of this disorder and of standard treatment recommendations is pivotal in helping patients and their families to deal with symptoms and their consequences. Nurses can also help to educate others, reducing the stigma that prevents many from seeking appropriate treatment. 

Chapter 3 – Depression. A whole body experience

Sally, an RN, has been feeling fatigued lately. Even after sleeping 10 hours, she does not feel rested. She worries about her ability to concentrate and finds herself needing to double-check medication doses and orders more often. She loses her train of thought easily and is more quickly irritated than normal. She worries that she will make a mistake that could harm a patient. 

She is finding it difficult to enjoy softball, a good movie, an evening with friends — things in which she used to find pleasure. Normally a stoic and positive person, she finds herself easily crying or staring into space, feeling empty and devoid of meaning. It is a struggle to get up each morning and make it through the day.

At first she thought her symptoms were the effects of the increasing stress at work and her recent divorce. She attributed some symptoms to approaching menopause. Sometimes she felt like she was experiencing early dementia and tried not to think about what the memory problems and trouble thinking could mean for her future. Her lack of drive bothered her, and she worried others would see her as lazy; this, too, was a career, as well as a personal concern.

Sally’s symptoms are consistent with a diagnosis of major depression, more common in women than men, a major source of lost work days and decreased quality of life, and a complex illness, often comorbid with other conditions.

Depression is a serious illness that can be chronic or fatal.1 It complicates medical conditions, increasing mortality.^1,2 And depression is often missed as a diagnosis.² This chapter will describe the multiple symptoms of depression, some understandings of cause, and nursing responsibilities in identifying symptoms and intervening in this disease process.

In the United States, major (clinical) depression is second only to heart disease in disease burden, a measure of both direct and indirect costs of an illness to society.¹ Depression’s effect on the lives of people and their families, while more difficult to measure, is equally great. Mortality from major depression is high; suicidal death rates approach 15% for those with severe major depression.³ Depression can be recurrent or become chronic. More than half of those who have one episode of major depression will go on to have a second episode. Those who experience a second episode risk a 70% chance of having a third; and if they have a third episode, their chances are 90% of having a fourth.²  About 25% of depressions become chronic.²

Comorbidity

The incidence of depression with a medical condition, such as cancer, diabetes, heart disease, or stroke is about 25%.² Co-existing depression makes the medical condition more difficult to manage and increases the chance of disability, future illness, or premature death.^2,4 Because of the focus on the medical illness, depression is less likely to be recognized and treated. The link between heart disease and depression is the one most supported by research. National Institute of Mental Health (NIMH) studies showed that people with a history of major depression were four times as likely to have a heart attack, and people with a history of even mild depression were at twice the risk of the general population.⁴

The relationship between medical illnesses and depression can vary; for instance:

• Medical disorders such as hypothyroidism or Cushing’s disease may contribute biologically to depression.
• People with medical illnesses may become depressed as a reaction to their disability, pain, or prognosis.
• While occurring together, depression and a medical disorder may be unrelated.

Depression is often found with other psychiatric diagnoses, most commonly the anxiety disorders, particularly panic disorder and post-traumatic stress disorder (PTSD). Depression, together with panic disorder, greatly increases risk of suicide.⁴  In an NIMH study, 40% of people with PTSD were found to have clinically significant depression at one month and four months after the traumatic event.⁴

Alcohol dependence (alcoholism) occurs about 12% of the time with unipolar depression, while the alcohol abuse rate is about 5%.⁵ When alcohol or substance abuse is present, treatment must be directed at both conditions to be successful. Alcohol use increases the risk of suicide.⁶

More than the blues

Major or clinical depression is more than feeling blue. It goes beyond a normal, expected reaction to grief or loss, both in the length of time it lasts and in its severity. Depressive symptoms rob one of the ability to function normally, straining family and intimate relationships, and dramatically decreasing one’s quality of life. Physical and cognitive symptoms erode energy and self-confidence. Depressed people often assume unrealistic blame and responsibility, carrying an exaggerated burden of guilt. Women are twice as likely as men to experience a depressive disorder.²

Unfortunately, the diagnosis of depression is missed more often than not. In primary care settings, one out of every five patients seen has symptoms of depression, but only one in 100 will identify depression as the reason for being seen.² Practitioners will miss a diagnosis of depression 50% of the time.² Depression in the elderly is missed even more, with memory problems, motor retardation, or pain being attributed to “old age” or other medical conditions.² Both children and the elderly are more likely to present with somatic complaints, such as GI disturbances, achiness, or fatigue. Children and adolescents are more likely to appear irritable than depressed.³

The many faces of depression

Part of the problem with diagnosis is that not everyone with depression presents with complaints of feeling depressed. Depression has many faces, and the nurse must be aware of symptoms that require further observation, questioning, or investigation. Depression is categorized primarily as a mood disorder, but includes physical and cognitive symptoms as well. Common mood descriptions to expect are discouragement, hopelessness, sadness; however, the person with depression may also describe feeling “blah,” having no feelings at all, or feeling anxious much of the time. Paradoxically, anxiety is common almost half the time with depression.³ Extreme irritability or anger are also frequently seen.³ Loss of pleasure, at least to some degree, in activities normally enjoyed is almost universal in depression, and even more common in the elderly.⁷ The term “anhedonia” is used when there is inability or decreased ability to experience pleasure.

Physical symptoms that may signal depression include unrelieved somatic complaints and sleep and appetite changes. Insomnia, especially early waking, is most common with depression, although “sleeping all the time” (hypersomnia) may also be present. Loss of appetite is also likely, mostly with severe depression and in the elderly; but some people may find themselves eating more, especially craving carbohydrates or sweet snacks.² Slowing of motor movements is common, particularly in more severe depression.

Cognitive changes in depression include memory problems or difficulty concentrating. The person may feel as though he or she is experiencing early signs of dementia, which in turn can exacerbate anxiety. Education about the cognitive symptoms of depression, and reassurance that treating the depression usually improves cognitive symptoms, can be most helpful. Depression can precede dementia in the elderly; however, depression alone will have a more normal premorbid course, with more sudden cognitive decline, and dementia alone typically has a more prolonged history of cognitive decline.³

Diagnostic terms and definitions

Major depression is diagnosed when persistent, unrelieved depressed mood or loss of interest is accompanied by four or more additional symptoms for more than two weeks. Left untreated, a major depressive episode can last four or more months.³ Dysthymia is diagnosed when depressed mood not meeting the criteria for major depression persists more days than not, for two years or more. Dysthymia, while less severe, is chronic and can noticeably decrease one’s quality of life.

The etiology of depression

We do know that there is a genetic predisposition for depression. The incidence is 1.5 to 3 times greater for first-degree relatives (children, siblings).³ The exact mechanism for this vulnerability continues to be studied.⁴ A significant loss, such as the death of someone close or trauma, can trigger a depressive episode. However, the causes of depression are far more complex than genetic vulnerability or significant loss or trauma in life. Depression is the result of complex interactions of genetic factors, response to stress involving the hypothalamus-pituitary-adrenal axis, neurotransmitter changes, learned behavior, and environment (adverse events, lack of support).^2,3,4 While treatment with medication is supportive, counseling or psychosocial interventions, with medication, are more effective than either modality alone.^2,4,8 Depression, because of its complexity, requires a comprehensive, holistic approach.

Besides genetic vulnerability, our response, both biochemical and emotional, to stress seems to affect whether we develop major depression or dysthymia. When we undergo trauma, a significant loss, or stress, the hypothalamus releases corticotropin-releasing factor, telling the pituitary to release adrenocorticotropic hormone, which in turn causes the adrenal glands to produce cortisol. Cortisol, a “stress hormone,” is elevated in most cases of moderate to severe depression.² The complex negative feedback loops of these neuroendocrine systems are affected, and the normal balance of these chemicals is not as well regulated in depression. This dysregulated stress response seems particularly important for depressed people who have experienced early trauma or abuse. One community study found that women with a history of childhood abuse were four times more likely to develop major depression.⁹ Depression is also common with PTSD, an anxiety disorder resulting from sudden, uncommon stress.⁴

Two neurotransmitters, norepinephrine and serotonin, have been studied the most for their role in depression. These monoamines were thought to be depleted in depression and are the ones known to be affected by most antidepressant medications, primarily by preventing their reuptake in the synapse between neurons.² Norepinephrine is an energizing neurotransmitter, improving energy level and promoting clear thinking. Serotonin is involved with sleep regulation, impulse control, anxiety/irritability, as well as with mood, and, to some degree, appetite and sexual behavior. The interplay of norepinephrine and serotonin may be more important than the influence of either alone in depressive symptoms.¹ The role of dopamine in depression has been less studied, but dopamine is known to affect drive and motivation, as well as cognition. Acetylcholine (deficient in dementia) and gamma-aminobutyric acid (GABA), a calming neurotransmitter, are also being studied for their role in depression.^1,2 Development of new antidepressants will focus on neuropeptides, which modulate the monoamines (like serotonin and norepinephrine) and on hormone receptors, which play a role in the dysregulated stress response.¹⁰

Treatments

Once depressive symptoms are identified, a variety of treatments are available. Medications are usually needed in moderate to severe depression. But they are most effective if combined with psychosocial treatments, such as counseling and psychotherapy for all but mild depression.⁴ Psychosocial interventions alone are successful in treating mild depression.⁴ Treatment-resistant depressions often benefit from electroconvulsive therapy (ECT).^4,11

Medication choices for treatment of depression continue to grow. Older tricyclic antidepressants are as effective as newer selective serotonin reuptake inhibitors (SSRIs) and new atypical antidepressants. However, newer antidepressants have more targeted action and fewer side effects.^1,8 SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). “Novel” antidepressants include bupropion (Wellbutrin), also sold as Zyban for smoking cessation; venlafaxine (Effexor); and mirtazapine (Remeron). Mirtazapine (Remeron), and bupropion (Wellbutrin) are noted for fewer sexual side effects.^1,12

Venlafaxine (Effexor) is a more energizing antidepressant because of its action on norepinephrine and is often used in treatment-resistant depressions that have not responded to SSRIs alone. Combinations of medications are often needed in treating severe depression.^1,8 Monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) or tranylcypromine (Parnate) are effective for some depressions, but they are not used as an initial medication, because of dietary restrictions. At least two weeks’ clearance is required between MAOIs and other antidepressants, particularly the SSRIs, because of potentially serious drug interactions. Fluoxetine (Prozac) requires a clearance of four to six weeks.^8,12

ECT, in which time-limited brain seizure activity is induced in an anesthetized patient, can be a highly effective treatment for severe depression. Its success rate is 60-90%.^4,8,11 ECT is used when other therapies have failed or when aggressive acute treatment is needed, as in the case of unrelenting suicidal impulses. Reports of long-term impairment from properly administered ECT have not been supported in repeated research studies.^1,4,8,11 Short-term memory loss should not exceed two months and may be further reduced by adjusting electrode placement or electrical current strength and type.^4,11 One challenge with ECT is maintaining its benefits. Repeated treatments are needed to achieve acute symptom remission, and research continues to explore the best follow-up strategies.⁴  Vagus nerve stimulation is another somatic therapy recently approved for treatment of depression.¹¹

Psychotherapy interventions for depression, such as cognitive behavioral therapy (CBT), are effective alone for mild depression and offer improved outcomes when combined with medications for moderate to severe cases.⁴ CBT helps the person change negative thinking and patterns of behavior. Interpersonal therapy (IPT) works with relationship problems that may contribute to depression. Both CBT and IPT have been studied by the NIMH and found to improve outcomes with depression.^4,8

By understanding the interrelationship of biological, environmental, and social factors in depression, nurses can identify and refer at-risk people by age, gender, and medical diagnosis for further screening. Nurses can help people and their families to obtain appropriate treatment for this illness that is still under diagnosed and whose seriousness is still underestimated. Nurses can also educate the public about the many faces of depression and thus reduce stigma and reluctance to seek help.

Chapter 4 - Going to Extremes

The difficulties of living with bipolar illness

Imagine you feel on top of the world. You’re too busy to eat or sleep, and it’s okay. Nothing is impossible. You can do no wrong. You feel so good, so powerful, that you do and say things you will regret later. When this euphoric feeling is over, days, a week, or months later, you are embarrassed by your previous behavior. You have incurred impossible debts. You’ve had a brush with the law. You may have lost your job. Relationships with family and friends are strained or broken.

Imagine you feel hopeless and helpless and so fatigued you can’t drag yourself out of bed one more time. Nothing gives you pleasure. You really aren’t interested in anything. You don’t care how you look or don’t have the energy to do anything about it. You do not eat or sleep, or, conversely, you may do nothing but sleep and eat.

These are the extremes of bipolar illness: mania and clinical depression. (See table.) In fact, “manic depression” has also been used to describe this disorder. This chapter will discuss terms to describe types of bipolar illness and medications to treat symptoms. It will address the complexities of this cluster of illnesses and the resulting difficulties in treatment. Bipolar illness is an affective, or mood, disorder, along with unipolar (major or clinical) depression and anxiety disorders. In contrast to a thought disorder, such as schizophrenia or psychosis, mood disorders involve primarily disruptions of feelings or mood. However, thinking problems, and even psychosis, may be present in severe depression or mania.

Terminology

The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) designates several categories of bipolar illness.¹ Bipolar I describes the classic and most familiar form, involving mania and major (clinical) depression; both mood extremes are significant enough to severely impair functioning. Up to half of people with bipolar I disorder may suffer “mixed” episodes, a condition most accurately described by the older term, manic depression, where both mania and depression coexist at the same time in the same person, creating a tormented existence of rapidly switching or almost simultaneous emotional extremes. Bipolar I is the only form of the disease that exhibits full mania; all other classifications demonstrate hypomania (less extreme and debilitating mania) only.

Bipolar II is characterized by recurrent episodes of major depression that alternates with hypomania. Bipolar II is often misdiagnosed as major depression because sufferers fail to see their hypomania as a problem or fail to recall it.² Cyclothymia indicates alternating episodes of hypomania and less severe depressive symptoms, and is frequently a missed diagnosis, because symptoms are less dramatic.² Rapid cycling refers to cases in which there are four or more episodes (either mania/hypomania or depression) in a year.¹

Not until 1978 was bipolar disorder categorized as a unique and specific disorder; it had been grouped with the symptoms of schizophrenia. Bipolar illness is characterized by genetic vulnerability and is affected by a variety of environmental and situational factors.³ First-degree relatives of people with bipolar I have increased incidence of bipolar I, bipolar II, and major depression.¹ Women have a higher incidence of bipolar II and rapid cycling.^1,3 Mania and depression both can be secondary to other medical conditions, a “rule out” consideration when these symptoms are seen for the first time.

Alterations in normal electrolyte transfer (particularly sodium) across cell membranes, making neurons irritable, have been implicated in bipolar illness. Calcium transfer (there appears to be extra intracellular calcium in bipolar illness⁴) has also been implicated, and calcium channel blockers verapamil (Calan/Isoptin) and amlodipine (Norvasc) are tried when other therapies have been ineffective.⁴ The role of omega-3 fatty acids in stabilizing the cell membrane is being studied, and initial research indicates fish oils are beneficial in preventing depression and manic symptoms.^3,6

New neuroimaging technology has shown some associated brain structure differences in bipolar illness, including white matter densities³ and loss of gray matter in certain areas of the brain.⁴ Functional brain imaging has shown changes in blood flow and glucose metabolism during bipolar episodes, specifically in the prefrontal cortex, basal ganglia, and temporal lobes.

Neurotransmitters — particularly serotonin, norepinepherine, and dopamine — are complexly implicated in bipolar conditions. For instance, serotonin appears to be depleted in both depression and hypomania.4 While low serotonin is expected in depression, its depletion in a hyperactive state is not yet understood. Thyroid hormones and estrogen also appear to play a role in symptoms and are used when indicated as supplements or adjuncts. Hypothyroidism is common in rapid cycling conditions and, unfortunately, lithium therapy may contribute to hypothyroidism.

Effect of bipolar illness

When one’s moods are out of control, life feels out of control. People in a hypomanic or manic phase typically lack insight. If their mood is elated, they see no problem with feeling so good. If their mood is dysphoric or irritable, they may attribute it to outside forces. Even when symptoms are recognized and treated, medication adverse effects can affect compliance. The person may wonder which is more intolerable — the symptoms or the adverse effects.

Manic behavior can result in shame and embarrassment, as well as lowered self-esteem and impaired relationships. If a person loses a job during a manic phase or during severe depression, the financial effect can be devastating, just when he or she needs treatment and medical coverage the most. One’s ability to function is greatly impaired in the extremes of this illness. Basics, such as rest and nutrition, also are disrupted.

Someone with manic behavior is seen as out-of-control and a problem to society. Someone with severe depression may be seen as lazy and nonproductive. Someone who alternates between those extremes suffers doubly from stigma.

The social and economic effect of bipolar illness is staggering. While it is estimated that 1-2% of the population in a given year has a form of this disorder,⁴ the cost of bipolar illness in the United States was estimated at $45 billion in 1991.⁷ The rate of suicides in bipolar I disorder is 10-15%. Close to half of those with a bipolar illness have an alcohol or drug abuse problem.⁸ A large part of direct, non-treatment costs includes legal expenses from involvement in the criminal justice system.⁷

Medications

Various classes of medications are used to treat bipolar illness, depending on a person’s history, presenting symptoms, acuity, financial resources, and past and present response. Antidepressants, medications for anxiety, mood stabilizers, and sometimes antipsychotics (neuroleptics) may be used. In treatment-resistant cases and for people with co-existing medical or psychiatric diagnoses, more than one medication is often needed. Several guidelines have been published for treating bipolar disorder, its spectrum of symptoms, and special situations (such as during pregnancy).^7,10 Not all agree, but areas of consensus will be highlighted here.

Mood stabilizers are the cornerstone of treatment for manic and depressive symptoms (see chart on next page), and the first choice, in nonemergencies, is monotherapy (one drug). Lithium is the most economical choice, offering relief of manic symptoms in 4%-78% of cases when taken as prescribed.^11,12 Lithium may take 10 to 14 days to demonstrate therapeutic benefit for mania and often four to six weeks for bipolar depression.¹²

For nonresponders to lithium, the addition of or switch to valproate/divalproex (Depakote) or carbamazepine (Tegretol) is recommended. Valproate and carbamazepine have a faster response rate in mania than lithium. Newer anticonvulsants, such as lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin), are being studied to determine how well they work.³ Lithium and valproate are contraindicated in pregnancy.

To treat bipolar depression, a mood stabilizer is used first; lithium or lamotrigine are recommended.⁵ If optimizing the dose of mood stabilizer does not help, an antidepressant may be added. Mood stabilizers help prevent mania, which may be triggered by antidepressants in some people.^5,10,11 Selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa) or escitalopram (Lexapro) are preferred in bipolar depression because of fewer side effects and less chance of triggering a manic episode.^5,10 Venlafaxine (Effexor) helps with severe depressive episodes.^5,9 Most experts recommend limiting treatment with antidepressants and, instead, maintaining a patient on a mood stabilizer whenever possible.^9,10 One of the differences between bipolar depression and unipolar depression is that bipolar depression usually responds to mood stabilizers.^9,11 

Anxiety is a frequent symptom with unstable mood and often accompanies depression. At least half of manic episodes are described by sufferers as dysphoric, an extreme emotional discomfort, rather than as the commonly perceived euphoric mood.⁵ Anti-anxiety medications, primarily benzodiazepines, can be useful in treating these extreme and uncomfortable states, particularly in the acute phases. Fairly large doses of short-acting benzodiazepines (such as lorazapam) may calm someone with severe mania. Clonazepam (Klonopin), a long-acting benzodiazepine, is sometimes used at bedtime to improve sleep. Because serotonin is also involved in anxiety, the serotonin reuptake inhibitors (also used for depression) and the atypical antipsychotics, because of their action on serotonin, may be helpful with anxiety symptoms.

Severe mania or depression can be accompanied by psychotic thinking. Hallucinations (disturbed sensory experiences) and grandiose delusions (beliefs) are common in acute mania. Religious delusions, unrealistic guilt, and paranoid thinking are seen with oppressive depression. Antipsychotics are used to treat these symptoms, and the newer antipsychotics, which have greater effect on mood as well as thinking, are especially helpful. Olanzapine (Zyprexa) is approved for treatment of acute mania; atypicals can be useful in the longer term for treatment resistant cases.^3,9 Antipsychotics, like antidepressants, are typically used for a limited time; mood stabilizer(s) are preferred whenever possible.^9,10 Electroconvulsive therapy may be indicated for depression with a poor response to medications, mania, and psychotic depression.

Recent guidelines recommend medications more specific to the types (bipolar I or II) and the phases (depressive, hypomanic, manic).¹⁰ For instance, lamotrigine (Lamictal) is generally more effective for presentations of bipolar depression, particularly bipolar II, where many more days are spent in depressive phases than in hypomanic phases. Divalproex (Depakote) is the first choice with bipolar I, which often presents with a dysphoric mania or “mixed mania” (an uncomfortable agitation).¹⁰ Symbyax, a combination of the atyptical antipsychotic olanzapine (Zyprexa) and the SSRI antidepressant fluoxetine (Prozac) is a new medication used in bipolar illness to prevent relapse of cognitive problems, mood swings, and depression. While bipolar I, bipolar II and cyclothymia are the recognized categories of bipolar illness, a spectrum of bipolar disorders from I-VI is proposed in the literature to fine-tune diagnosis and the treatment of particular symptom clusters.

Barriers to treatment for bipolar illness include its irregular course, the patient’s lack of insight and unreliability during exacerbations, medication nonadherence (often because of adverse effects), treatment expense, and frequent missed diagnosis or misdiagnosis.²

In addition to medication, psychotherapy and social and vocational support are needed, as is management of co-existing conditions. Comorbid medical and psychiatric conditions often complicate treatment and are associated with poorer outcomes.¹²

Medical causes of mania include certain medications, metabolic disturbances, neurological conditions, infections, and neoplasms.¹² Common co-occurring psychiatric diagnoses are substance abuse/dependence, anxiety disorders (including obsessive compulsive disorder, panic disorder, and post traumatic stress disorder), and attention deficit hyperactivity disorder.^9,12

With new medications and efforts to contain costs, psychosocial interventions have received less emphasis. But education, coping skills, psychotherapy, and family involvement are equally important in recovery. Medications help regain a baseline from which a person can integrate new information, skills, and preventive strategies.^3,9,14 Examples of nonmedical interventions include family therapy; psychoeducation, which gives people the information to understand and live with their diagnoses; cognitive behavioral therapy, a type of psychotherapy to restructure destructive beliefs and behaviors; and interpersonal and social rhythm therapy, which addresses, in a social context, the prevention of diurnal and sleep pattern disruptions that may contribute to bipolar episodes.^3,4,14 The most recent consensus guidelines recognize the importance of psychosocial therapies.¹⁰

Nursing implications

People with bipolar disorder need information about the illness, interpersonal skills, and treatment options.¹⁵ Early detection and intervention reduce recurrences and prevent hospitalizations. Because a lack of insight and denial of problems are characteristic, especially of mania, learning to identify symptoms and symptom triggers before a crisis develops is critical. People with bipolar illness also want medication information, and nurses are skilled at medication teaching. Even without specialty knowledge in psychiatry, nurses know general principles of medication administration, interactions, and metabolism and can help patients understand instructions and routines. Nurses are sensitive to a patient’s mental status and are adept at gearing explanations to what is needed at the time, whether in a crisis or with chronic symptoms. Nurses know how to listen to and use a person’s own experience to create meaningful self-care plans, anticipating exacerbations. Nurses are vital in educating patients, family members, and others; in personalizing teaching and treatment; and in planning care.

Bipolar illness is a complex array of symptoms, often missed or misdiagnosed. It has a tremendous effect on the patient, family, and society. Bipolar illness requires a collaborative approach between disciplines and settings. It requires knowledge, tenacity, and a holistic approach from nurses.