Mental Assessment
After
you have successfully completed this chapter, you should be able to:
■ Describe
the various theories in understanding mental health/illness
■ Describe
developmental influences on mental health/illness
■ Discuss
various cultural influences on mental health/illness
■ Identify
history data as they relate to mental health/illness
■ Identify
physical assessment data as they relate to mental
■ Describe
additional assessment components specific to mental health/illness assessment
■ Perform
a mental health assessment
■ Document
assessment findings
■ Identify
actual/potential health problems stated as nursing diagnoses with supporting
data
Learning Outcomes
A biological risk factor could be a family
history of mental illness with a genetic link such as
schizophrenia.A
person’s developmental level may be
psychosocial risk factor. External stressors are examples
of
environmental factors.
Assessment
entails not only identifying your client’s weaknesses but also identifying his
or her strengths. So, you need to assess not only for risk factors but also for
protective
factors, such as coping mechanisms andresources.
Mental
health is a “state of successful performance of mental
function, resulting in productive activities,fulfilling relationships with
other people, and the ability to adapt to change and to cope
withadversity”(Healthy People 2010).Jahoda (1958) identified six
characteristics of positive mental health that address positive
self-perception, personality integration, autonomy and independence,perception
and reality,and growth and development leading to self-actualization. Mental
health
or wellness affects every aspect of one’s life, and the impact of this can be
seen when mental illness occurs.The effects are not only mental but also
physical.
Current
research is providing more and more evidence that there are organic and
neurochemical bases for some mental illnesses and behaviors. Be sure to review
the
anatomy and physiology section in Chapter 21, Assessing the Sensory-Neurological
System. Genetic links have been identified for certain braindisorders such as
schizophrenia. Although schizophrenia, depression, bipolar disorder, anxiety
disorders, and Alzheimer’s are classified as mental illnesses, biological bases
have been identified. Biochemical factors, specifically neurotransmitters,
have been identified in depression and mania (Fig.5.1).Another part of the
brain is the limbic system,which is called the emotional brain and is
associated with fear, rage, love, anger, aggression, hope, sexuality, and
social behavior (Fig. 5.2).
Biological Basis of Mental Illness
Understanding Mental Disorders
Mental
disorders affect thinking, mood, or behavior or a combination of
all three, leading to impaired function, disability, pain, and even death.The
term mental illness is applied to diagnosable mental disorders.
All age groups, gender, racial, and ethnic groups are ffected regardless of
education or socioeconomic evel.A goal of Healthy People 2010 is “to improve
mental ealth and ensure access to appropriate, quality ental health
services.”As a nurse, you are well positioned to assess the mental health
status of your atients at every level of health prevention and in very area of
healthcare.
Prevention
Primary
prevention entails decreasing the incidence f mental disorders by
identifying those at risk, those ho are vulnerable to developing mental
disorders.
Secondary
prevention involves reducing theprevalence of mental disorders
through screening andinitiating prompt treatment of mental disorders.
Tertiary
prevention aims at reducing the severity ofthe illness by
providing follow-up and rehabilitativeservices.
Effects
Understanding
Assesment
Cognitive
theories provide an understanding by looking ot only at
behavior but also at an individual’s cognitions and howa person processes
thoughts (distorted
cognitions
and maladaptive behaviors). Bandura and Back are cognitive theorists. Cognitive
theory is of value when teaching patients new coping skills; individual
collaboration
with the therapist and active involvement of the patient are needed for change
to take place
(Townsend,
2006).
Developmental
theories provide an understanding of the individual’s growth
and development over one’s lifetime. Erikson, Piaget,Gilligan, and Miller are
developmental theorists.
.
Psychological Theories
Behavioral Theories
Developmental Theories
Social Theories
Cognitive Theories
Developmental, Cultural, and
Ethnic Variations
Psychodynamic
theories focus on intrapersonal concepts. These theories look
at the development of themind over the course of a lifetime. Freud, the “Father
of
Psychiatry,”
introduced the psychoanalytic model of the conscious and unconscious
mind.Various interpersonal and humanist models followed. Freud identified defense
mechanisms, which served to protect the individual from unwanted
anxiety.
Behavioral
theories focus on normal behaviors rather than the causes of
mental illness. Pavlov, Watson, Thorndike, and Skinner are behavioral theorists.
The goal is to change behavior through conditioning, behaviorism (which
includes frequency and recency), and positive reinforcement (Boyd, 2005).
Social
theories include family dynamics, role theories, and
sociocultural perspectives; thus, the assessment of
Developmental Level
Mental
disorders can occur with any age group,with the incidence of certain disorders
higher for specific age groups. For example, learning and behavioral problems
are seen with children. Adolescents, known risk takers, have a high incidence
of substance abuse. Bipolar illness or psychoses such as schizophrenia more
commonly become apparent during young adulthood. Depression is often seen in
the older adult.
Children
Because
rapid growth and developmental changes occur during childhood, delays are
readily detectable. Learning disorders and behavioral disorders often become
apparent by the time the child reaches school age.
Mental
Health Assessment for Children
Assessing
the mental health of children should include both a detailed history and a
physical examination.The assessment should include an interview with the child.
If abuse is suspected, be sure to interview the child alone without the parents
or caregiver present.
Health History
The
health history should include a family history with attention to a history of
mental health problems. A maternal history is also needed and should
identify:
■ Age
and health of mother during pregnancy.
■ Exposure
to medications, alcohol or drugs during
pregnancy.
■ Course
of labor and type of delivery.
■ Infant’s
state of health at birth.
Assess
the child’s normal growth and development milestones, such as motor
development, bowel and bladder control, speech and language development, and
social development. Also, assess the child’s medical health, noting any major
illness or injury.
The
assessment should also include a current developmental assessment, a mental
status examination, and a physical examination. Various instruments are
available to assess a variety of mental health disorders in children. Be sure
to select the one best suited to meet the child’s
needs.
Scales
for Mental Health Disorders
Child
Abuse
Child
abuse affects all areas of a child’s life and may manifest as a mental or
physical disorder. Child abuse takes many forms from physical abuse, neglect,
sexual abuse, emotional abuse, factitious disorders by proxy (Munchausen
syndrome), and secondary abuse (children of battered women). The assessment
should include an interview with the child. If abuse is suspected, be sure to
interview the child alone without the parents
or
caregiver present.
Risk
Taking
Adolescents
are known risk takers. Experimenting with drug and alcohol is common, and
suicide is the second leading cause of death among adolescents. Mental and
substance abuse disorders or a combination of disorders are more often than not
associated with suicide. A goal of
Healthy
People 2010 is to decrease the attempted suicide rate among adolescents from a
12-month average of 2.6 percent of adolescents in grades 9 through 12, to a 12-
month average of 1 percent.
Another
popular form of risk taking during childhood is the choking game,which
produces a high or a state of euphoria by cutting off the blood supply to the
brain. If the blood supply is compromised for too long, the child will pass out
and feel a “rush” as consciousness returns. Depriving the brain of oxygen may
result in permanent and cumulative death to brain cells, stroke, seizures,
retinal damage, or death.
This
behavior, which is also known as fainting, American dream, flatliner, space
cowboy, knockout, gasp, rising sun, airplaning, pass out,blackout, andspace
monkey, is most common among children ages 10 through 16. It can be
performed either alone or with others.
Use of
ligatures and performing this alone increases the risk of death.
Approach to the Mental Assessment
H E L P F U L H I N T
Children who “play” the choking game are usually not
troubled children and generally have no history
of drug or alcohol abuse.
H E L P F U L H I N T S
• Learning
disorders and behavioral disorders often
become apparent by the time the child reaches
school age.
• Depending
on the age of the child, play or drawing
can be very helpful in eliciting the child’s
perceptions.
INSTRUMENT
Behavior Assessment System for Children (BASC)
Child Behavior Checklist (CBCL)
Children’s Depression Inventory (CDI)
Pediatric Anxiety Rating Scale (PARS)
Yale-Brown Obsessive Compulsive Scale (YBOCS)
Swanson, Nolan, Pelham (SNAP)-IV
ASSESSES FOR
Behavior and emotions for children ages 2–18
Psychopathology and competencies for children ages
4–16
Physical symptoms, harm avoidance, social anxiety, and
separation/panic disorders for children ages 7–17
Severity of anxiety for children ages 6–17
Obsessive compulsive disorder (OCD) for children ages
6–17
Inattention and overactivity (attention deficit
hyperactivity disorder [ADHD]) and oppositional defiant disorders
Adapted from Boyd, M.A. (2005). Psychiatric Nursing
Contemporary Practice.
Risk
Factors for Teen Suicide
■ Depression
■ Social
isolation
■ History
of abuse
■ Drug
and alcohol abuse
■ Not
fitting in with peers
■ School
pressure
Source: Gorman, L., Raines, M., and Sultan, D. (2005).
Psychosocial
Nursing for General Patient Care, ed. 2.
Signs
and Symptoms of the Choking Game
■ Unexplained
marks or bruises on neck
■ Severe
headaches
■ Red
eyes
■ Belts,
leashes, ropes, and shoelaces tied in strange
knots
or in unusual locations
■ Disorientation
after being alone
■ Locked
bedroom doors
Pregnant Women
Although
the birth of child is seen as a happy event, mental health disorders can occur,
affecting not only the mother but also the entire family.Many mothers experience
mild depression, also known as baby blues, usually within 4 weeks
following childbirth. If the baby bluespersist for more than a few weeks,
postpartum depression may have developed. The depression is more serious and
results in postpartum depression with or without
psychosis.The
mother may experience severe mood swings and pervasive sadness.The mother often
has feelings of guilt and inadequacy as a mother. In addition to the feelings
associated with postpartum depression, with postpartum psychosis, the mother
experiences delusions and thoughts of harming herself or her baby. If you
detect at-risk mothers or postpartum depression,be sure to make the appropriate
referrals for followup care.Assessment for postpartum depression is important.
Screening tools for postpartum depression include the Postpartum Check List
(Beck, 1995) and the Edinburgh Postpartum Depression Scale (Cox,Holden,&
Sagovsky, 1989).
Older Adults
Older
adults are more at risk for the development of mental health problems for
several reasons, ranging from the normal physiological changes associated with
aging to acute and chronic illness to side effects associated with
polypharmacy. Risk factors may be developmental, situational, internal, or
external in nature.
Mental
Health Assessment of the Older Adult
Approximately
25 percent of all older adults experience some type of mental disorder
(depression, anxiety, substance abuse,and dementia) that is not related to the
normal changes associated with aging (Healthy People2010). Alzheimer’s affects
8 percent to 15 percent of older adults over the age of 65 and accounts for 69
percentto 70 percent of all dementia (Healthy People 2010). Assessing the
mental health of the older adult shouldinclude both a detailed history and a
physical examination. The assessment should focus on mental status,behavioral
responses, functional ability, general health,
and
social supports of the client. Mental status assessment should include a
Mini-Mental State Examination (MMSE), a mental status examination, and
assessment for depression, anxiety, and psychosis.A change in mental status has
to be carefully evaluated. Changes are often attributed to normal
changes
associated with aging. Changes in mental status may be physiological or
psychological in nature. Because dementia increases with age, care must betaken
to differentiate dementia from delirium and depression.
Understanding
Assesment
Risk
Factors for Postpartum Depression
■ History
of mood disorders
■ Low
self-esteem
■ Unwanted
pregnancy
■ Unemployment
of mother or head of household
■ Poor
marital relationship
■ Father
depressed
■ Poor
support systems
■ External
stressors
■ Physical
changes associated with aging that may
affect functional ability
■ Cognitive
changes and memory loss
■ Chronic
medical illness
■ Psychosocial
changes, such as retirement, that occur with aging
■ Limited
financial resources
■ Polypharmacy
■ Loss
and bereavement
■ Loss
of social supports
Delirium should be treated as an emergency because its
acute onset may have an underlying life-threatening cause. The MMSE and the
Clock Scoring Test are screening instruments used to assess cognitive
impairment and screen for dementia.
Assessment
of behavioral responses includes description of behavior and triggers, with
special attention to behavioral changes and problem behaviors. A functional
assessment should focus on the client’s ability to perform activities of daily
living, physiological functioning,
mobility,
and risk for fall assessment. A nutritional assessment and history of substance
abuse is included in the assessment of the client’s general
health.
Finally, the assessment should identify social supports, family-patient
interactions, and caregiver concerns.
Depression
Depression
is a major mental health problem for older adults, but it can be easily missed.
If left untreated, depression can lead to suicide or self-neglect. In the
Elder
Abuse
Elder
abuse, if taking place, affects all areas of the patient’s
life and may manifest as a mental or physical disorder.
Elder
abuse can take many forms: physical abuse, neglect, sexual abuse, emotional
abuse, and financial
Abuse.
Approach to the Mental Assesment
Characteristics
of Dementia, Delirium, and Depression
FEATURE DEMENTIA DELIRIUM DEPRESSION
Onset
Prognosis
Course
Attention
Memory
Perception
Psychomotor
behavior
Cause
Abrupt (hours to a few
weeks)
Reversible
Worse in P.M.
Impaired
Impaired recent and
immediate
Impaired
Hypo-/hyperkinetic
Caused by acute illness,
fever, infection,
dehydration, electrolyte
imbalance, medications,
and alcoholism
Gradual (months to years)
Irreversible
Progressive
Impaired recent and remote
Normal/apraxia
Caused by many diseases,
including alcoholism,
acquired immunodeficiency
syndrome (AIDS), cerebral
anoxia, and brain infarcts
Either
Variable
Possibly worse in A.M.
Variable
Impairment
Retardation/agitation
May coincide with life
event, such as death in
the family, loss of a
friend or a pet, or a
move
Risk
Factors for Suicide Among Older Adults
■ Lives
alone
■ Widower
■ Lack
of financial resources
■ Poor
health
■ Social
isolation
■ Drug
and alcohol abuse
Geriatric
Depression Scale
Are you basically satisfied with your life? YES/NO
Have you dropped many of your activities and
interests?
YES/NO
Do you feel that your life is empty? YES/NO
Do you often get bored? YES/NO
Are you in good spirits most of the time? YES/NO
Are you afraid that something bad is going to happen
to
you? YES/NO
Do you feel happy most of the time? YES/NO
Do you often feel helpless? YES/NO
Do you prefer to stay at home rather than going out
and
doing new things? YES/NO
Do you feel you have more problems with memory than
most? YES/NO
Do you think it is wonderful to be alive now? YES/NO
Do you feel pretty worthless the way you are now?
YES/NO
Do you feel full of energy? YES/NO
Do you feel that your situation is hopeless? YES/NO
Do you think that most people are better off than you
are? YES/NO
Bold answers _ depression
GDS Scoring:
12–15 Severe depression
8–11 Moderate depression
5–8 Mild depression
0–4
Source: Yesavage, et al., 1983, pp. 37–47.
GDS website: http://www.stanford.edu/~yesavage/
Cultural
Perceptions of Mental Health/Illness
CULTURAL GROUP PRACTICES/BELIEFS
Amish
Appalachian
Arab American
Chinese American
Cuban American
Egyptian American
Filipino American
French Canadian
Greek American
Irish American
Jewish American
Mexican American
Native American
Vietnamese American
Undrstanding Assessment
Atypical
Signs
and Symptoms of Depression in
the
Older Adult
Typical
■ Changes
in appetite
■ Decreased
self-esteem
■ Changes
in sleep patterns
■ Social
withdrawal
■ Feelings
of helplessness
■ Loss
of motivation
■ Constipation
■ Hostility
■ Pessimism
■ Agitation
■ Guilt
■ Aggression
■ Vague
somatic complaints—such as constipation, joint pain, fatigue, and memory changes—that
seem to be out of proportion to the actual
problem.
■ Client
may become obsessed with the problems and feel that if the problems are
relieved, she or he will be fine.Cultural and ethnic variations often influence
a patient’s view of mental health. Cultural beliefs influence perceptions,
understanding, and treatment of mental illness.
■ Children with mental or physical differences are seen
as “hard learners.”
■ The mentally ill are generally cared for at home.
■ Usually takes care of own, so mentally deficient and
handicapped are readily accepted.
■ Mentally handicapped are not crazy, but rather have
“bad nerves” or are “quiet
turned” or “bad turned.”
■ Behaviors that would warrant psychiatric treatment are
seen as lazy, mean,immoral, criminal, or psychic and treated by punishment or
tolerance.
■ Mental illness is seen as a social stigma, therefore
psychiatric symptoms may be denied, attributed to “bad nerves” or supernatural
beings, or caused by a physical ailment or emotional trauma.
■ Somatic orientation leads to patients’ tolerance of
emotional suffering and relatives’ tolerance of behavioral disorders.
■ Patients with mental distress will somatize symptoms.
Somatic treatment for psychiatric disorders is preferred over psychotherapy.
■ Balance between yang and yin explains mental
health/illness.
■ Mental illness results from metabolic imbalance and
organic problem.
■ Stigma is associated with mental illness, so patient
will seek folk healer first.
■ Does not readily seek treatment for emotional or
nervous disorders.
■ Emotional crises are treated by santero, a practioner
of santeria (a 300-year-old
Afro-Cuban religion that combines Roman Catholic
elements with ancient Yoruba
tribal beliefs and practices).
■ May act out emotional problems in a non–threatening
way, allowing person to
maintain self-esteem.
■ Mental illness is considered a stigma.
■ More tolerance for emotional problems.
■ View mental health problems with a supernatural
framework, including “curse”
and “devil.”
■ Emotional problems of grief and losses are due to
wrongdoings of others or
weakness and inability to control and snap out of
distress.
■ Mental and emotional issues are expressed somatically
so therefore treated with
psychosomatic interventions.
■ Seeks family and friends for advice.
■ Stigma is associated with mental illness.
■ Mental illness is caused by heredity.
■ Takes care of mentally ill family member rather than
seek mental
healthcare.
■ Federal Canadian laws protect the mentally disabled
from discrimination.
■ Stigma is associated with mental illness.
■ Mental illness is seen as hereditary linked, therefore
“polluting” the blood line,
bringing shame to family.
■ Families of mentally ill may experience loss of
friends and social isolation.
■ Mental illness often somatisized. Wide range of
acceptable behavior leads to delay
of seeking treatment.
■ Folk model for “nerva” (nerves) is socially acceptable
and treated with medication
rather than with psychotherapy.
■ Stigma is associated with mental illness.
■ Mental illness is caused by genetic problem; more
likely to be labeled a
“neurological” problem.
■ Avoids psychotherapeutic treatment.
■ Symptoms somatasized and treated with
psychopharmacology.
■ High rate of mental illness.
■ Difficulty expressing emotions and feelings.
■ Family may take care of mentally ill family member.
■ Some attribute mental illness to sin and guilt.
■ Mental health is as important as physical health.
■ Mental incapacity relinquishes one from all responsibilities.
■ Mental illness is seen as God’s will.
■ Family prefers to care for patient at home.
■ Mental illness is caused by witches; treated by
healers.
■ May wear turquoise to ward off evil.
■ Some tribes view mentally ill as having special
problems.
■ Mental illness results from offending a deity.
■ Brings disgrace to family and is therefore concealed,
which delays treatment.
■ Emotional disturbances are caused by malicious
spirits, bad luck, or family
inheritance.
■ Buddhists see mental illness as bad karma from
previous misdeeds.
■ Sometimes nervous system is seen as cause of mental
problems.
Mental Health
Assessment
A
thorough assessment includes assessment of the psychological health of the patient.Mental
health reflects aperson’s positive attitudes toward self, growth and
development,self-actualization, integration, autonomy, reality perception, and
environmental mastery (Stuart & Laraia,
2005).
As you perform your assessment, look for clues that reflect the mental health
status of your patient. Realize that your patient may prefer to have you
believe she or he has a physical problem rather than a psychological problem by
somatizing feelings. Also,medical problems or drug use (prescribed, over-the-counter[OTC],
illegal) may present as mental disorders, such as hyperthyroidism, which may
produce signs and symptoms
of
anxiety. Comorbidities can also result with patients. Chronic illness can lead
to depression, especially as the disease progresses.
Report any suspected abuse or any threat of child or
elder abuse. Also report threats of suicide orhomicide. Threats to self or
others must always be taken seriously.
Health History
When
obtaining a health history, ask yourself,“What can the health history reveal
about the mental health of thepatient?” Identify factors that may affect mental
health in either a positive or a negative way. Ensure patient confidentiality,
but confidentiality should be breached if there is suspected abuse or a threat
of child or elder abuse or if the patient poses a threat to herself or himself
or others.
Health
History as It Relates to Mental Health
RISK/FACTORS/
QUESTIONS TO ASK RATIONALE/SIGNIFICANCE
■ Response to stressors differs with age.
■ Identifies possible maturational crises related to
developmental changes.
■ Women have greater incidence of depression and
affective and anxiety disorders.
■ Men have greater incidence of psychosocial and
substance abuse disorders.
■ Age of onset of schizophrenia occurs later in
women than in men.
■ Men are more likely to be aggressive and
selfdestructive
than women.
■ The higher the socioeconomic and
educational level, the lower the incidence of
depression.
■ The higher the educational level, the more likely
the individual is to use mental health services if
needed.
■ The lower the income, the higher the incidence of
psychological symptoms.
■ African Americans and Hispanics have twice the rate of
being diagnosed with severe mental illness than other
groups.
■ African Americans are diagnosed with the most
severe types of psychopathology and fewer affective
disorders and are overdiagnosed with schizophrenia.
■ Ethnic groups have three times more
hospitalizations for mental illness than the general
population.
■ Married and partnered adults report less stress
than single or divorced adults.
■ Can affect mental health in either a positive or a
negative way.
■ Influences perceptions of mental illness.
■ Identifies supports.
■ Identifies any signs or symptoms that may reflect
mental illness.
■ Identify any past mental health problems and
treatments.
■ Identifies previous psychiatric hospitalization.
■ Identifies familial/genetically linked psychiatric
disorders. Familial/genetically linked disorders
include:
■ Schizophrenia.
■ Depression.
■ Bipolar disorders.
■ Anxiety and panic disorders.
■ Identifies any psychiatric drugs.
■ Identifies any possible drug interactions.
■ OTC medications such as pseudoephedrine can
cause anxiety symptoms.
■ Herbal supplements such as
ephedra, ginseng, kava kava, and yohimbe can
interact with psychotrophics or other
medications, or cause anxiety, drowsiness, or
other adverse psychological effects (Pedersen,
2005). (See Psychotropic Drugs and Some
Related Side Effects.)
■ Identifies possible source of stressor related to
post-traumatic stress syndrome
Biographical
Age
■ How old are you?
Gender
■ Is the patient male or female?
Socioeconomic and Educational Levels
■ What is your educational level?
Ethnicity
■ What is the patient’s cultural background?
Marital Status
■ Are you single, married, or divorced?
Religion
■ What is your religious affiliation?
Contact Person
■ Who is your contact person?
Current Health Status
■ How is your health?
Past Health History
Childhood Illnesses
■ Did you have any major health problems
(physical or mental) while growing up?
Past Hospitalizations
■ Have you ever been hospitalized for mental
health problems?
Family History
■ Does anyone in your family have mental health
problems?
Medications
■ Are you taking any medications, either
prescribed, OTC, or herbal? If yes, what are you
taking? (See Drugs That May Adversely Affect
Mental Health.)
Military Service
■ Are you now or did you ever serve in the military?
If yes, when and what was your tour of duty?
General Health Survey
■ How have you been feeling?
Integumentary
■ Do you have any problems with your skin? If yes,
describe.
Head, Eyes, Ears, Nose, and Throat (HEENT)
■ Do you have headaches? If yes, describe.
■ Do you have thyroid disease?
Respiratory
■ Do you have any breathing problems? If yes, describe.
Cardiovascular
■ Do you have any CV problems? If yes, describe.
■ Fatigue may be associated with depression.
■ Restlessness may be associated with anxiety.
■ Sweating, itching associated with anxiety
■ Headaches associated with depression.
■ History of migraines and tension headaches
affected by psychological factors.
■ History of hyperthyroidism and diabetes can be
affected by psychological factors, manifest with
psychological signs or symptoms, or mimic
psychological disorders.
■ History of breathing problems, such as
hyperventilation, associated with anxiety disorders.
Sighing associated with depression.
■ Hypertension, angina affected by psychological
factors
■ Palpitations, racing heart associated with anxiety
■ Heterocyclic antidepressants—use with caution with
cardiovascular disease
Drugs
That May Adversely Affect Mental Health
Drugs Effect
Antihypertensives Depression
■ Reserpine
■ Beta blockers
■ Methyldopa
Oral contraceptives
Corticosteroids
Benzodiazepine
Cancer chemotherapeutic agents
■ Vincristine
■ Vinblastine
■ Interferon
■ Procarbazine
Psychoactive agents
■ Alcohol
■ Amphetamine or cocaine withdrawal
■ Opioids
Corticosteroids Manic states
Levodopa
Amphetamines
Tricyclic antidepressants (TCAs)
MAO inhibitors
Methylphenidate
Cocaine
Thyroid hormone
Amphetamines Psychotic reactions
Antidepressants (particularly tricyclics)
Anticholinergics (atropine)
Anticonvulsants (carbamazepine, valproic acid)
Antiparkinsonians (levodopa)
Antituberculars (isoniazid)
Antivirals (acyclovir, amantadine)
Antiarrhythmics (lidocaine)
Alcohol
Beta blockers (propranalol)
Corticosteroids
H2-receptor blockers (cimetidine)
Cyclosporine
Disulfiram (Antabuse)
Anesthetics (ketamine)
Antibiotics (cephalosporins, ciprofloxacin,
sulfonamides)
Opioids (morphine, hydromorphone)
Lithium Nausea, diarrhea, polyuria, acne, rashes,
alopecia, tremors; weight
gain, hypothyroidism; can also precipitate psoriasis
and psoriatic
arthritis.
Anticonvulsants Sedation, hepatotoxicity, rash, and
Stevens-Johnson syndrome (SJS),
which is a life-threatening mucocutaneous reaction.
Anticholinergics Blurred vision, constipation, dry
mouth
TCAs Sedation, blurred vision, dry mouth,
constipation, life-threatening
arrhythmias and electrocardiogram (ECG) changes
Selective serotonin reuptake inhibitors
Gastrointestinal (GI) symptoms, insomnia, and agitation
Antipsychotics Movement disorders (akathisia) and
tardive dyskinesia (especially
conventional antipsychotics [chlorpromazine]),
dystonia,
parkinsonism, gynecomastia, and lactation, and
possibly treatmentemergent
diabetes
A L E R T
Neuroleptic malignant syndrome (NMS) is a potentially fatal side effect from antipsychotic
drugs, characterized by fever, tachycardia, sweating, muscle rigidity, tremors,
incontinence, stupor, leukocytosis, elevated creatine phosphokinase (CPK), and
renal failure
Review of Systems
As
you proceed with the review of systems, note
any
problems that may affect your patient’s mental
health.
Review
of Systems
Psychotropic
Drugs and Some Related Side Effects
C H A P T E R 5 A P P R OA C H TO T H E M E N T A L H E A L T H A S S
E S S M E N T 125
Psychosocial
Profile
CATEGORY/QUESTIONS TO ASK RATIONALE/SIGNIFICANCE
Health Practices and Beliefs
■ How would you describe your mental health?
■ Do you or would you use mental health services?
Typical Day
■ Can you tell me what your typical day is like?
Nutritional Patterns
■ Can you tell me what you ate yesterday (24-hour
recall)?
Activity and Exercise Patterns
■ Do you exercise regularly? If yes, describe.
Recreation, Pets, Hobbies
■ What do you do for fun?
■ Do you have pets?
■ Do you have hobbies?
Sleep/Rest Patterns
■ How many hours of sleep do you get a night?
■ Do you have any problems falling asleep, staying
asleep?
■ Do you take or do anything to help you sleep?
Personal Habits
■ Do you use alcohol, drugs, caffeine, or nicotine? If,
yes,
how much?
Occupational Health Occupation?
■ How do you feel about your work? Your coworkers?
■ Do you find your work stressful? If yes, how do you
deal with it?
■ Are there any health risks associated with your work?
If
yes, describe.
Environmental
■ Where do you live?
■ Are you exposed to any pollutants or toxins?
Roles, Relationships, Self-Concept
■ How do you see yourself?
■ Can you identify your various roles and relationships?
Cultural Influences
■ What is your cultural background?
■ What influences your perception of health?
Religious/Spiritual Influences
■ What is your religious background?
■ What influence does your religious beliefs have on
your
perception of health?
■ Identify perceptions of mental health, mental health
practices, and use of mental health services.
■ Identifies ability to maintain activities of daily
living
(ADLs). Mental health problems such as depression and
schizophrenia, compulsive disorders may affect ability
to perform ADLs.
■ Nutritional disorders are associated with eating
disorders, anxiety, and depression.
■ Excessive exercise is associated with eating
disorders.
■ Inactivity is associated with depression.
■ Inactivity is associated with depression.
■ Problems with sleep and rest are associated with many
psychological disorders, such as anxiety, depression,
bipolar disorders, and substance abuse.
■ Identifies history of substance abuse (use of alcohol,
drugs, caffeine, nicotine).
■ Identify ability to maintain job. Work can be a source
of
stress.
■ Identify risk for head injury, such as construction
work
■ Identifies risk for exposure to toxic substances, such
as
lead, mercury, herbicides, solvents, cleaning agents,
and
lawn chemicals, that can affect cognitive ability.
■ Identifies sense of worth and value, which may be
affected by psychological factors such as low
self-image
associated with depression and eating disorders.
■ Roles and relationships may affect or be affected by
psychological factors.
■ Identifies culture’s perception of mental health and
illness.
■ Identifies religious/spiritual influences on mental
health
and illness.
Gastrointestinal
■ Do you have any GI problems? If yes, describe.
■ Have you experienced changes in weight? If yes,
describe.
■ Have you experienced changes in appetite? If yes,
describe.
Genitourinary (GU)
■ Do you have any GU problems? If yes, describe.
■ If your patient is female, ask if she has experienced
any
irregularities in her menstrual cycle.
■ Do you have any concerns about your sexual
performance? If yes, describe.
Musculoskeletal (MS)
■ Do you have any MS problems? If yes, describe.
Neurological
■ Do you have any neurological disorders?
■ Have you experienced seizures, concentration, or
memory problems?
■ Have you experienced depression, anxiety? If yes,
describe.
■ Changes in appetite associated with depression,
anxiety, eating disorders, substance abuse
■ History of peptic ulcer, irritable bowel syndrome,
colitis affected by psychological factors
■ GI complaints such as nausea, abdominal pain,
diarrhea seen with anxiety
■ Indigestion and constipation seen with depression
■ Nausea is a common side effect of many
psychotrophic medications.
■ History of sexual dysfunction, such as impotence,
frigidity, and premenstrual syndrome (PMS),
affected by psychological factors
■ Menstrual irregularities associated with eating
disorders
■ Pressure and frequency of urination associated with
anxiety
■ Use TCAs (amitriptyline), cautiously with benign
prostatic hyperplasia (BPH)
■ History of rheumatoid arthritis and idiopathic low
back pain affected by psychological factors
■ Weakness associated with anxiety
■ Osteoporosis associated with eating disorders
■ Use of antipsychotics contraindicated with
myasthenia gravis.
■ Seizures associated with eating disorders, use TCAs
cautiously with seizures and buproprion is
contraindicated with seizures.
■ Neuroleptic malignant syndrome and movement
disorders are a side effect of antipsychotic
medications
■ Cognitive problems, difficulty focusing, inability to
concentrate associated with anxiety, depression,
dementia, and schizophrenia
Family Roles and Relationships
■ What is your role in your family?
■ How is your relationship with your family?
Sexuality Patterns
■ Do you have any concerns about sexual patterns? If
yes,
describe.
■ Do you practice safe sex?
Stress and Coping Patterns
■ How do you deal with stress?
■ What do you do when you are upset?
■ Identifies sources of support or stress on patient’s
mental health.
■ Mental illness may affect patient’s role and
relationship
in family.
■ Sexual problems are often associated with mental
illness such as depression.
■ Unprotected sexual activity is associated with
substance
abuse.
■ Identifies current coping skills.
■ Determines effectiveness of coping skills.
Psychosocial Profile
As
you perform the psychosocial assessment, look for clues that would reflect your
patient’s mental health.
Mental Status Assessment
A
mental status assessment, involving a systematic approach to various
components, is done to assess and evaluate a patient’s cognitive and mental
functions. Each assessment provides information about that patient atthat point
in time. (See Mental Status Assessment as it
Relates
to Mental Health/Illness.) Additional assessments will
demonstrate improvement, regression, or stabilization and will provide a
“progress report” as well as “patterns” of functioning. The components of the
mental status assessment include:
■ General
appearance.
■ Behavior/activity.
■ Speech
and language.
■ Mood
and affect.
■ Thought
process and content.
■ Perceptual
disturbances.
■ Memory/cognitive.
■ Judgment
and insight.
Additional Assessments
Depending
of your assessment findings, additional mental health screening may be
indicated.Various mental health problems and assessment instruments are available
to assess for a variety of mental health problems. Additional mental health
assessments are presented below.
Psychosocial
Profile (continued)
Physical Assessment
As
you perform a head-to-toe physical examination, consider how your patient’s
physical findings reflect his or her mental health.
ead-to-Toe
Physical Examination as It Relates to Mental Health/Illness
SYSTEM ABNORMAL FINDINGS/RATIONALE
General Health Survey ■ Poor grooming and personal hygiene: Associated
with depression
■ Bright colors or unusual dress: Associated with mania
■ Poor eye contact: May indicate depression
■ Inability to maintain attention: Associated with schizophrenia and depression
■ Labile affect: May reflect mania
■ Flat, incongruent affect: May reflect schizophrenia
■ Stooped posture: Associated with depression
■ Restlessness, tension: Associated with anxiety
■ Malnourished appearance: May indicate an eating disorder
■ Slurred speech: May indicate drug and alcohol abuse
■ Pressured speech: Seen with mania
■ Disorganized speech: Seen with schizophrenia
■ Irritability: Associated with anxiety
■ Suspiciousness: Associated with paranoia
Integumentary ■ Flushed or pallid skin color: Seen with anxiety
■ Excessive sweating: Seen with anxiety
■ Injury or scarring: From self-injury or past suicide attempts or
self-mutilation
HEENT ■ Dilated
or constricted pupils: Seen
with drug abuse
■ Poor eye contact: Seen with depression
■ Dental caries, parotid swelling: Seen with eating disorders
■ Erosion of nasal or oral mucosa: May be secondary to drug use
■ Rope marks on neck: In children, associated with “choking game”
Respiratory ■ Increased respiratory rate and hyperventilation: Seen with anxiety
Cardiovascular ■ Increased pulse rate and blood pressure: Seen with anxiety
Abdominal ■ Increased bowel sounds: Seen with excessive use of laxatives in eating
disorders
■ Abnormal liver size: Associated with substance abuse
Musculoskeletal ■ Generalized weakness and tremors: Seen with anxiety
■ Abnormal muscle movement: May be adverse effect of psychotropic drugs
■ Excessive body movements: Associated with anxiety, mania, or stimulant
abuse
■ Minimal or no body movement: Associated with depression, catatonic states, or
drug-induced stupor
■ Repeated movements: Associated with compulsive disorders
■ Repeated picking at clothes: May be associated with hallucinations, delirium, or
toxic
conditions
Neurological ■ Cognitive changes, thought process disorders: Seen with schizophrenia
■ Loose association: Associated with schizophrenia
■ Flight of ideas: Associated with mania
■ Preservation: Associated with brain damage and psychotic disorders
■ Auditory hallucinations: Associated with schizophrenia
■ Visual hallucinations: Often organic in nature
■ Tactile hallucinations: Seen with organic problems, drug abuse, or delirium
tremens
(DTs)
■ Changes in mental status: Seen with mental illness such as schizophrenia,
substance
abuse, bipolar disorder
■ Increased reflexes: Seen with anxiety
■ Movement disorders: Adverse effect associated with antipsychotic
medications
tal
Status Assessment as It Relates to Mental Health/Illness
AREA/QUESTIONS ABNORMAL TO ASK
Grooming/dress
■ Does the patient dress appropriate for age,
gender,season, and situation?
Hygiene
■ Are the patient and his or her clothing clean?
■ Does the patient present with any unusual odors?
Eye Contact
■ Does the patient maintain eye contact?
Posture
■ Does the patient assume a specific position?
■ Is posture erect?
Identifying Marks/Scars/Tattoos
■ Are there any obvious marks or scars?
Appearance vs. Stated Age
■ Does the patient appear stated age, or younger or
older?
Behavior/Activity
■ Do you notice any unusual activity?
■ Is patient’s behavior appropriate for the situation?
■ What is the patient’s level of consciousness?
■ Dress neat and appropriate
■ Clean, no unusual odors
■ Maintains eye contact
■ Comfortably positioned, posture erect
■ No obvious marks or scars
■ Appears stated age
■ Calm, relaxed, no unusual behavior or movements
■ AAO _ 3 (awake, alert, and oriented to time, place,person)
■ Disheveled appearance: Associated with depression
■ Bright-colored clothing: Associated with mania
■ Poor hygiene: Associated with depression or schizophrenia
■ Poor eye contact: Associated with depression
■ Slumped posture: Associated with depression
■ Defensive posture: Associated with paranoia
■ Scars: May
indicate self-mutilation or past suicide attempts
■ Older appearance than stated age: May be associated with depression
■ Hyperactivity: Associated with anxiety,mania, or stimulant abuse
■ Hypoactivity: Lethargic, thinking slowed; associated with
depression, alcohol or drug abuse.
■ Altered orientation: May be seen with organic disorders or schizophrenia
■ Agitation: May be seen with dementia or delirium
■ Psychomotor retardation, slow movements: May be associated with depression
■ Tremors: May
indicate drug/alcohol withdrawal
■ Tics: May
be an adverse effect of psychotropic medications
■ Unusual movements such as jaw/lip smacking: May be associated with tardive dyskinesia, an
adverse effect of antipsychotic medications
■ Catatonia: May be seen with schizophrenia
■ Akathisia (restlessness): Seen with extrapyramidal adverse effect from
antipsychotic medications
■ Rigidity: May be a sign of NMS
Speech
■ What are the quality, tone,
volume, fluency, and pace of
speech?
Attitude
■ What is the patient’s attitude? Is it friendly?
Hostile?
Mood (Including Self-Report of Emotional State)
■ How does patient appear?
■ How does the patient describe
her or his mood?
Affect (Apparent Emotional
State)
■ What is the patient’s affect facial expression)?
Thought Process
■ Can you follow the patient’s thinking? Is it coherent
and logical?
■ Quality and pace of speech normal with no exaggeration
■ Fluent, pleasant tone
■ Cooperative
■ Appropriate for situation
■ Appropriate for situation
■ Thought process intact
■ Responds appropriately
■ Slow speech: Associated with depression
■ Rapid and pressured speech: Associated with mania
■ Mumbling: Seen with Huntington’s chorea
■ Slurred speech: Seen with alcohol intoxication
■ Suspicious tone: Associated with paranoia
■ Volume: Soft
associated with depression
■ Poor fluency (mute/hesitation/latency of response): Less likely to talk with depression
■ Hesitancy: Seen with mistrust or paranoia
■ Uncooperative: Associated with paranoia
■ Warm/friendly/distant: Seen with personality disorders
■ Suspicious/combative: Seen with paranoia
■ Guarded/aggressive: Seen with psychosis
■ Hostile/aloof: Seen with psychosis
■ Apathetic: Seen with depression
■ Sad: Associated
with depression
■ Elated: Associated
with mania
■ Irritable/anxious: Associated with anxiety
■ Fearful/guilty: Seen with phobias
■ Worried/angry: Seen with personality disorder
■ Hopeless: Associated with depression
■ Labile: Associated
with mania
■ Mixed (anxious and depressed): Seen with depression
■ Flat affect: Seen with schizophrenia
■ Blunted or diminished affect: Seen with psychosis
■ Inappropriate/incongruent (sad and smiling or
laughing): Associated with schizophrenia
■ Thought process disturbances: Often seen with psychosis or organic brain
disorders.Examples of thought process disturbances
are:
■ Concrete thinking: Unable to abstract; thinks in concrete terms
■ Circumstantiality: Excessive, irrelevant detail, but eventually gets to
the point
l
Status Assessment as It Relates to Mental Health/Illness (continued)
Thought Content
■ Does the patient’s content of thought make sense and
seem reality based?
■ Does the patient have thoughts about hurting self or
someone else?
Perceptual Disturbances
■ Does the patient haveperceptual disturbances? Auditory
disturbances? Visual
disturbances? Olfactory disturbances? Tactile
disturbances?
■ Thought content (what the patient is thinking) reality
based
■ No hallucinations, illusions, or depersonalization.
■ Tangentiality: Digresses from topic to topic, never getting to the
point
■ Loose association: Loose connection between thoughts that are unrelated
■ Echolalia: Repetition of words spoken by another
■ Flight of ideas: Rapidly going from one topic to another
■ Preservation: Involuntary, excessive repetition of a single response
to different questions
■ Clang association: Association of words by sound
■ Blocking: Draws a blank
■ Word salad: Combination of words that have no meaning
■ Derailment: Off track
■ Delusions (grandiose/persecution/reference/ somatic): Associated with psychosis
■ Suicidal/homicidal thoughts: Associated with depression, anxiety, or schizophrenia
■ Obsessions: Seen with OCD
■ Paranoia: Seen with schizophrenia
■ Phobias: Seen
with anxiety disorders
■ Magical thinking (primitive form of thinking
that thinking about something will make it
happen)
■ Poverty of speech
■ Visual hallucinations: Often organic in nature
■ Auditory hallucinations (commenting/
discussing/commanding/loud/soft/other): Associated with schizophrenia
■ Tactile hallucinations: Seen with organic problems, drug abuse, or DTs
■ Illusions (misperception of a real external stimulus):
Common with dementia of
Alzheimer’s and schizophrenia
A L E R T
If the patient is having homicidal thoughts, identify
those toward whom those thoughts are directed.
Memory
Immediate
■ Can patient repeat objects named minutes before?
Remote
■ Can patient recall anniversaries, past important,
historical events?
Insight (Awareness of the Nature of Illness) and
Judgment
■ Does patient have insight into his or her problem?
(Ask, “Can you tell me what the problem is?”)
■ Is judgment appropriate? (Ask the patient to respond
to a hypothetical situation, such as,
“If you were walking down the street and saw smoke
coming from a window of a home, what would you do?”)
■ Immediate, recent, and remote memory intact
■ No confabulation
■ Insight and judgment intact and appropriate
■ Depersonalization (altered perception or experience
that causes temporarily loss of self or personal identity): Seen with panic
disorder
■ Memory problems and confabulation: Seen with organic, dissociative, and conversion
disorders
■ Level of alertness: Altered with substance abuse
■ Poor insight: Seen with psychosis
■ Poor judgment: Seen with psychosis
■ Poor impulse control: Seen with OCD, psychosis, mania
Crisis
A crisis
results from an acute event that stresses a person’s resources and ability
to cope; a crisis can also result from a perceived threat to self. Crises may
be maturational or developmental and situational. An example of amaturational
crisis would be a child becoming an adolescent.
An
example of a situational crisis might be the loss of a loved one. A
situational crisis could also be a major disaster, such as a hurricane or a
terrorist attack. An event that may be a crisis for one person may not be for
another.A stressful event causes disequilibrium forthe person. It is the
ability of the person to restore equilibrium that determines the outcome.
Whether or not a person adapts to the crisis or not depends upon several
factors:perception
of event,situational supports,and coping mechanisms.Once you have performed a
crisis assessment,you can then develop interventions that will help your
patient deal with the crisis and regain equilibrium.
BATHE Technique
When
you have only limited time to perform an assessment, it is important to keep
the interview focused.The BATHE technique helps the patient identify problems
and coping strategies and is supportive of the patient.The acronym is
representative of the interview’s components
(Stuart
& Lieberman, 1993):
■ Background—What
is going on? What brought you here?
■ Affect—How
does this make you feel?
■ Trouble—What
troubles you most in this situation?
■ Handling—How
are you able to handle this situation/problem?
■ Empathy—Empathize
with client, shows an understanding of client’s view of situation.
A L E R T
The BATHE technique is not intended for use with
patients with severe problems, such as patients who are suicidal or those who
have suffered severe abuse.
Crisis
Assessment
Perception of event
Supports
Coping mechanisms
■ Can
you tell me what has happened? Please be specific.
■ What
caused the crisis?
■ How
has this affected you?
■ How
did this make you feel?
■ Is
there anyone I can call?
■ Do
you live alone?
■ Do
you have family or friends who support you?
■ Are
you active in any religious or community groups?
■ How have
you handled stressful events in the past?
■ Can
you talk about the stressful event?
■ What
do you do to relieve tension? Cry? Talk? Exercise?Use alcohol?
■ Sleep
(increase/decrease)
■ Interest
(diminished)
■ Guilty/low
self-esteem
■ Energy
(poor/low)
■ Concentration
(poor)
■ Appetite
(increase/decrease)
■ Psychomotor
(agitation/retardation)
■ Suicidal
ideation
■ Past
suicide of family member, close friend, or peer
■ Impulsivity
■ Mood
disorders
■ Substance
abuse
■ Recent
loss of a spouse, partner, friend, or job
■ Expressed
hopelessness (patient sees no future)
■ Social
isolation (patient lives alone, has few friends
or
supports)
■ Stressful
life event
■ Previous
or current abuse (emotional, physical, sexual)
■ Sexual
identity crises/conflict
■ Available
lethal methods (guns)
■ Legal
issues/incarceration
A
depressed mood plus four or more SIGECAPS for 2 weeks or longer indicates a
major depressive disorder.A depressed mood plus three SIGECAPS most days for 2
years or longer indicates dysthymia, which is a depressive neurosis with
no loss of contact with reality.
Assessing Depression
Depression
poses a major health problem. Major depression has been identified by the World
Health Organization as the leading cause of disability for adults in developed
countries,such as the
those
at risk and accurate assessment of depression can lead to prompt intervention
and promotion of mental health.
If
you suspect that your patient is depressed, use the mnemonic SIGECAPS to easily
recall and review theDSM-IV criteria for major depression:
Suicide Assessment
In
the
Symptoms of dysthymia are similar to those of a major
depressive disorder, but milder.
A L E R T
Suicide attempts are more likely to occur as the
patient’s symptoms improve because the patient now has the energy to commit
suicide.
Feelings of hopelessness
Suicidal ideations
Plan for suicide
Possessions
Auditory hallucinations
Lack of support network
Alcohol or substance abuse
Precipitating event
Media
A key element in assessing for feelings of hopelessess
is determining whether the patient is able to see a future with herself or
himself in that future.
ASSESSMENT AREA QUESTIONS TO ASK
A L E R T
For many people, holidays can be a precipitating event
to a suicidal episode.
■ Take note if the local media has reported on the
suicide of a famous
person or local teenager.
Assessing Substance Abuse
Substance
use includes use of prescribed or OTC drugs, alcohol,
caffeine, nicotine, steroids, and illegal drugs.
Abuse
and addiction exist when substance use has social,professional,
or legal consequences.There are two types of substance abuse disorders,
substance use disorders and substance-induced disorders.
Substance use disorders include:
■ Substance
dependence: Repeated use despite substance-related cognitive,
behavioral, and psychological problems.Tolerance,withdrawal,and compulsive
drugtaking can result.
■ Substance
abuse: Recurrent, persistent substance
use
with significant adverse consequences during a 12-month period.
Substance-induced
disorders include:
■ Substance
intoxication: Overuse of a substance that
results
in a reversible, substance-specific syndrome;can
be
indicated by behavioral and psychological changes.
■ Substance
withdrawal: Symptoms differ upon the
substances
being used and develop upon their withdrawal
(Pederson,
2005;APA, 2000).
If
substance abuse is a concern with your client, it is
important
to ask the right questions and obtain an accurate
history.
If there is no time to obtain a detailed assessment,a
focused
assessment tool such as the CAGE questionnaire
can
also identify a possible substance abuse problem.
Groups
at Risk for Suicide
■ Elderly
persons who are isolated or widowed or who have experienced multiple losses
■ Males
who are widowed and without close supports
■ Adolescents
and young adults
■ Persons
with serious or terminal illness who become depressed or hopeless
■ Persons
with mood disorders,depression,and bipolar
■ Persons
with schizophrenia, either newly diagnosed or those experiencing auditory
command hallucinations
■ Persons
who abuse drugs or alcohol, especially persons with a mental disorder
■ Persons
under stress (sometimes multiple stressors) with recent loss or losses
Performing
a Suicide Assessment
Substance
Abuse History and Assessment Tool
1. When you were growing up, did anyone in your family
use substances (alcohol or drugs)? If yes, how did the substance
abuse affect the family?
2. When (how old) did you use your first substance
(e.g., alcohol, cannabis) and what was it?
3. How long have you been using a substance(s)
regularly? Weeks? Months? Years?
4. What is your pattern of abuse?
a. When do you use substances?
b. How much and how often do you use?
c. Where are you when you use substances and with
whom?
5. When did you last use, what was it, and how much?
6. Has substance use caused you any problems with
family, friends, job, school, the legal system, other? If yes, describe.
7. Have you ever had an injury or accident because of
substance abuse? If yes, describe.
8. Have you ever been arrested for a DUI because of your
drinking or other substance use?
9. Have you ever been arrested or placed in jail
because of drugs or alcohol?
10. Have you ever experienced memory loss the morning
after substance use (can’t remember what you did the night
before)? Describe the event and feelings about the
situation.
11. Have you ever tried to stop your substance use? If
yes, why were you not able to stop? Did you have any physical
symptoms such as shakiness, sweating, nausea,
headaches, insomnia, or seizures?
12. Can you describe a typical day in your life?
13. Are there any changes you would like to make in
your life? If so, what are they?
14. What plans or ideas do you have for making these
changes?
15. History of withdrawal:
Other comments:
Source: Pedersen, D. (2005). PsychNotes.
Psychiatric Mental Health Nursing, ed. 5.
CAGE
Questionnaire
■ Have you ever felt you should Cut down on your
drinking/drug use?
■ Have people Annoyed you by criticizing your
drinking/drug use?
■ Have you ever felt bad or Guilty about your
drinking/drug use?
■ Have you ever had an Eye opener (use of alcohol
or drugs first thing in the morning) to steady your nerves or get rid of
a hangover?
A positive (yes) response to two or more questions
suggests that there is an alcohol/substance problem.
Note: The
need to cut down is related to tolerance (needing more substance for same
effect), and the eye
opener is related to withdrawal syndrome (reduction/cessation
of substance).
Abused
Substances: Effects From Use and Withdrawal
SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL
Depressants
■ Alcohol (booze, brew, juice, spirits)
■ Sedatives, hypnotics, and anxiolytics, including
barbiturates (barbs, beans,black beauties, blue angel, candy, downers,goof
balls, BB,nebbies, reds,sleepers, yellowjackets, yellow)
■ Benzodiazepine(downers)
Stimulants
■ Amphetamines(A, AMT, bam, bennies, crystal, diet
pills, dolls, eye-openers, pep pills, purple hearts, speed, uppers, wakeups)
■ Cocaine
(Bernice, bernies, big C, blow, C, Charlie,coke, dust,
girl,heaven, jay, lady, nose candy, nosepowder, snow,sugar, whitelady)
■ Crack (Conan, freebase, rock,toke, white cloud,
whitetornado)
■ Unconsciousness
■ Respiratory depression
■ Coma
■ Death
■ Hypotension
■ Nystagmus
■ Stupor
■ Cardiorespiratory depression
■ Coma
■ Death
■ Ataxia
■ High temperature
■ Seizures
■ Respiratory distress
■ Cardiovascular collapse
■ Coma
■ Death
■ High temperature
■ Seizures
■ Transient vasospasms (may cause myocardial infarction
[MI], cerebrovascular accident[CVA], coma, death)
■ Depressed cognitive functioning
■ Impaired psychomotor functioning
■ Decreased reaction time
■ Decreased balance and coordination
■ Decreased REM sleep
■ Slurred speech
■ Labile mood
■ Inappropriate sexual behavior
■ Loss of inhibition
■ Drowsiness
■ Impaired memory
■ Euphoria
■ High energy
■ Impaired judgment
■ Anxiety
■ Aggressive behavior
■ Paranoia
■ Delusions
■ Euphoria
■ Grandiosity
■ Sexual excitement
■ Impaired judgment
■ Insomnia
■ Anorexia
■ Nasal perforation
(inhaled route)
■ Psychosis
■ Tremors
■ Diaphoresis
■ Anxiety
■ Hallucinations
■ Delusions
■ Increased pulse andblood pressure
■ DTs
■ Sleep disturbances
■ Insomnia
■ Hand tremor
■ Agitation
■ Nausea and vomiting
■ Anxiety
■ Tinnitus (withbenzodiazepines)
■ Seizures
■ Cardiac arrest
■ Depression
■ Agitation
■ Confusion
■ Vivid dreams followed by lethargy
■ Fatigue
■ Depression
■ Anxiety
■ Suicidal behavior
(continued)
Marijuana
■ Cannabis (marijuana,hashish, Acapulco gold, Aunt Mary,
broccoli, dope, grass, weed,grunt, hay, hemp,J, joint, joy stick, killer weed,
pot, ragweed, reefer,smoke weed)
Opiates
■ Heroin (H, horse, harry, boy, scag,shit, smack, stuff,
white junk, whitestuff)
■ Morphine
■ Hydromorphone
■ Meperidine
■ Codeine
■ Oxycodone
■ Opium
■ Methadone
Hallucinogens
■ Hallucinogens
(LSD, DMT, Mescaline, acid, big D, blotter, blue
heaven, cap, D, deeda, flash, L, mellow yellow, microdots, paper acid, sugar,
ticket,
yello)
■ Club drug, MDMA (ectasy)
Phencyclidine
■ Phencyclidine (PCP, angel dust, DOA, dust,elephant,
hog,peace pill,supergrass, tictac)
■ Extreme paranoia
■ Psychosis
■ Dilated pupils
■ Respiratory depression
■ Seizures
■ Cardiopulmonary arrest
■ Coma
■ Death
■ Panic
■ Psychosis with
hallucinations
■ Cerebral damage
■ Death
■ Confusion
■ Hallucinations
■ Severe anxiety
■ Hypertension
■ Seizures
■ High temperature
■ Hallucinations
■ Psychosis
■ Seizures
■ Respiratory arrest
■ Death
■ Euphoria
■ Intensified perceptions
■ Impaired judgment and motor ability
■ Increased appetite, weight gain
■ Sinusitis and bronchitis with chronic use
■ Anxiety, paranoia
■ Red conjunctiva
■ Euphoria
■ Drowsiness
■ Impaired judgment
■ Constricted pupils
■ Dilated pupils
■ Diaphoresis
■ Palpitations
■ Tremors
■ Enhanced perceptions of colors and sound
■ Depersonalization
■ Grandiosity
■ Euphoria
■ Muscle relaxation
■ Impulsive behavior
■ Impaired judgment
■ Belligerent, violent behavior
■ Ataxia
■ Muscle rigidity
■ Nystagmus
■ Hypertension
■ None
■ Yawning
■ Insomnia
■ Anorexia
■ Irritability
■ Rhinorrhea
■ Muscle cramps
■ Chills
■ Nausea and vomiting
■ Feelings of panic and doom
■ None
■ Psychological dependence can causedepression,
flashbacks
■ None
SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL
Inhalants
■ Gasoline, glue, aerosol sprays,paint thinners(spray,
rush, bolt,huffing, bagging,sniffing)
■ Nicotine(Cigarettes, cigars, bidis, kreteks, pipe
tobacco, chewing tobacco, snuff,nicotine gum or patches)
■ Psychosis withhallucinations
■ Cardiac arrhythmias
■ Central nervous system depression
■ Coma
■ Cerebral damage
■ Death
■ None
■ Numbness or diminished response to pain
■ Euphoria
■ Impaired judgment
■ Blurred vision
■ Unsteady gait
■ Sense of anxiety reduction
■ Relief from depression
■ Satisfaction
■ None
■ Insomnia
■ Depression
■ Irritability
■ Anxiety
■ Poor concentration
■ Increased appetite
RESEARCH TELLS US
Worldwide,mental
health problems,with depression and anxiety being the most frequent, occur in
approximately 24 percent of patients in primary care (WHO, 2005).Mood disorders
with increasing rates of depression and anxiety may be associated with physical
illness. Deteriorating physical health and cognitive functioning that is often
associated with aging is a major risk factor for developing depression later in
life. The purpose of the following study was to examine staff contact and input
with mental health problems and to determine their experience, training, and
attitudes
to mental health problems.A cross-sectional design was used in the United
Kingdom.A 40-item questionnaire was mailed to over 300 staff members in primary
care.The return rate was 66 percent (n _ 217,
95 percent confidence interval,with two-thirdsof the respondents RNs).The
questionnaire focused on depression in identifying mental problems,
interventions,and mental health training.Demographics
were
obtained to describe the sample.The Depression Attitude Questionnaire (DAQ), a
20-item instrument,was used to assess staff attitude toward depression. The
findings reported that 16 percent of their patients had associated mental
health problems,with dementia, depression, and anxiety being the most
common.The staff reported a willingness to develop an understanding and skills
needed to address mental
health
problems with patients, but reported little training in the past 5 years that
addressed this issue.
The
staff, as revealed by the DAQ,was optimistic about treating depression. The
study supports the need for mental health training in primary care as evidenced
by the limited detection and treatment of mental health problems. The staff was
willing and eager to develop the knowledgeand skills to assess and treat mental
health problems. The areas identified included recognition of mental disorders,
anxiety management, crisis intervention,
and
pharmacologic treatment for depression. Although this study was limited to the
of
assessment and treatment of mental health problems would provide a holistic
approach to meeting the patient’s needs.
HEALTH CONCERNS
Healthy
People 2010 has identified specific objectives that address mental
health/disorders.
Improving
Mental Health
■ Improve
mental health and ensure access to appropriate,
quality
mental health services.
■ Reduce
the suicide rate.Target: 5 per 100,000 from
11.3
per 100,000 in 1998.
■ Reduce
the rate of suicide attempts by adolescents.
Target:
1 percent over 12 months from 2.6 percent
from
grades 9 through 12 in 1999.
■ Reduce
the proportion of homeless adults who
have
serious mental illness.Target: 19 percent from
25
percent age 18 and older in 1996.
■ Increase
the proportion of persons with serious mental
illness
who are employed.Target:51 percent from
43
percent age 18 and older in 1994.
Improving
Treatment
■ Reduce
the relapse rates for persons with eating
disorders.
■ Increase
the number of persons seen in primary
healthcare
who receive mental health screening
and
assessment.
■ Increase
the proportion of children with mental
health
problems who receive treatment.
■ Increase
the proportion of juvenile justice facilities
that
screen new admissions for mental health problems.
■ Increase
the proportion of adults with mental disorders
who
receive treatment.
■ Increase
the proportion of persons with cooccurring
substance
abuse and mental disorders
who
receive treatment for both disorders.
Improving
State and Local Involvement
■ Increase
the proportion of local government with
community-based
jail diversion programs for adults
with
serious mental illness.
■ Increase
the number of states (including the
with
the mental health services they receive.
■ Increase
the number of states and territories
(including
the
mental
health plan that addresses cultural
competence.
■ Increase
the number of states and territories
(including
the
mental
health plan that addresses mental
health
crisis interventions, ongoing screening, and
treatment
services for elderly persons.