Mental Health

• SSRI


  • First line for late onset depression
  • Safe & work well, low tox & most people tolerate well, little effect on other neurotransmitters
  • Off label: gad, bulimia, bipolar, ocd, ptsd
  • Increase deficient serotonin
• SSRI examples


  • fluoxetine
  • sertraline
  • citalopram
  • escitalopram
• SSRI hospital considerations


  • Can exacerbate delirium
  • CAM+ or s/s of delirium = will not resume
  • Platelet considerations - Higher risk for bleeds
  • Serotonin syndrome: too much serotonin that causes shivering & diarrhea, severe muscle rigidity & seizures
  • Renal & hepatic impairment = higher risk
  • Withdrawal symptoms: flu like, insomnia, nausea, imbalance (higher falls risk), sensory disturbances, hyperarousal
  • EKG changes - Prolong QT
• SSRI nursing considerations


  • Only available orally
  • Can't if NPO w/o alternative access
  • 1x daily
  • No food needed
  • Interprofessional team input important
• MAOI


  • Inhibit enzyme responsible for catabolizing serotonin, norepinephrine, and dopamine
  • Not first line for depression, primarily for parkinson's
• MAOI examples


  • selegiline
  • isocarboxazid
• MAOI hospital considerations


  • Hypertensive crisis
  • Serotonin syndrome
  • Suicidal thinking (high risk!!!)
  • Contraindicated in severe hepatic / renal impairment, cerebrovascular disease
• MAOI nursing considerations


  Diet: nothing on a charcuterie board (strong/aged cheese, cured meat), no fermented food (kimchi, kombucha), no umami (teriyaki, miso), soybeans/products, alcohol
• Alcohol withdrawal


  • Occurs when pts stop drinking or significantly decrease intake after long term dependence
  • Mild symptoms within 6 hrs after last drink
  • Important to ask when last drink was
  • Etiology: ethanol is CNS depressant; when removed, CNS becomes over excited
  • 24-48 hrs must watch
• Alcohol withdrawal symptoms


  • Mild: htn, insomnia, tremors, hyperreflexia, anxiety, gi upset, h/a, palpitations
  • Moderate: hallucinations, withdrawal seizures (usually 12-24 hrs)
  • Delirium tremens: altered sensorium (hallucinations), tachy, htn, hyperthermia, agitation, diaphoresis
• Alcohol withdrawal assessment


  h&p for clinical symptoms, clinical institute for withdrawal assessment (CIWA-Ar)
• Alcohol withdrawal treatment/management


  1. Supportive care: controlled environment to prevent progression of symptoms (electrolytes, quiet environment)

  2. Pharmacological support / therapy - IV electrolytes: thiamine, potassium, magnesium

  3. Banana bag: folate, thiamine, dextrose, multivitamin

  4. Long acting benzodiazepines: librium, ativan
• Benzodiazepine adverse effects


  • Respiratory depression, respiratory arrest, drowsiness, confusion, h/a, syncope, n/v/d, tremor, laryngospasm/bronchospasm (neonates), PVVs (neonates), brady (neonates)
  • Contraindicated in pts w/ hypersensitivity or angle-closure glaucoma, pregnancy category D or X
• Benzodiazepine reversal agent


  Flumazenil - Benzodiazepine antagonist & reversal agent
• Benzodiazepine uses


  • Cannabis toxicity
  • Alcohol withdrawal
  • Hepatic encephalopathy
  • Seizure management: phenytoin, barbiturates, intubation w/ sedation (propofol, ketamine)
  • Dexmedetomidine (precedex sedation w/o intubation)
  • Non-opioid sedation for intubated or non intubated patients
  • Analgesia
  • Insomnia
  • Alcohol withdrawal syndrome
  • Reduction of delirium
• Phenobarbital


  Sedative & anticonvulsant properties, long half life (80+ hrs), no discharge order
• Opiate withdrawal symptoms


  • lacrimation, rhinorrhea, piloerection (goosebumps), myalgia, n/v/d, pupillary dilation, photophobia, insomnia, autonomic hyperactivity, yawning
• Opiate withdrawal treatment


  Give methadone, for sedated, preggo, and lactating
• Benzodiazepine withdrawal symptoms mirror alcohol withdrawal
• Benzodiazepine withdrawal treatment


  Benzodiazepine taper
• Delirium


  • Clinical syndrome, not medical diagnosis
  • D/t: substance intoxication, withdrawal, med side effects, metabolic imbalances, pain, urinary retention, infection
  • Can develop quickly & fluctuate
  • Focus on prevention, early diagnosis & treatment of underlying cause
• Delirium risk factors


  • > 70 yrs, dementia, functional disabilities, male, poor vision/hearing, mild cognitive impairment, med side effects, surgery, anesthesia, hypoxia, untreated pain, infections, illness, acute exacerbation of chronic illness
• Delirium manifestations


  • Hyperactive: confused, out of bed, reorient, agitation & delusions, combative, uncooperative
  • Hypoactive: increased somnolence & decreased arousal
  • Mixed: fluctuate between hyper and hypo
• Delirium diagnostic criteria


  • Disturbance in attention & awareness develops acutely and fluctuates in severity
  • At least 1 additional disturbance in cognition
  • Not explained by existing dementia
  • Do not occur in the context of coma or decreased LOC
  • Evidence of underlying cause
  • Changes in sleep wake cycle
  • Perceptual disturbances
  • Delusions
  • Inappropriate / unsafe behavior
  • Emotional lability
• Nursing considerations for delirium

  • Safe & supportive environment: prevent excess noise/reduce stimuli, consistent caregivers & routine, simple phrases, feed assistance, encourage early mobilization, decrease/avoid meds after bedtime, provide supportive aids
  • Frequent orientation: pics, stuff from home, clock, calendar
  • Adequate fluids and food
  • Avoid physical restraints
  • Monitor bowel & bladder patterns: urinary retention & constipation are risk factors (avoid foley if possible)
  • v/s: can cause htn & tachy, hypoxemia can contribute
  • Labs: infection, vitamin deficiency, electrolyte imbalance, hypoglycemia, hypothyroidism, liver & renal failure
  • Assess response to meds - Haloperidol, olanzapine (when haloperidol is contra), risperidone, quetiapine (2nd gen atypical antipsychotics)
• Dexmethetomidine (precedes sedation w/o intubation)

  • Non opioid sedation (analgesia, insomnia, alcohol w/drawl)
  • Reduce delirium
  • Brady (sudden), hypotension
  • No reversal