Somatic Therapies



Somatic Therapies


Carol M. Burns





Growing knowledge of neuroscience has increased interest in somatic therapies for psychiatric illness. The limitations of psychotropic medications increase in treatment-resistant psychiatric disorders, and refinement in treatment techniques has placed greater emphasis on somatic therapies.


Nurses provide care to patients receiving somatic therapies and it is essential that all nurses understand how these treatments work. This includes an understanding of nursing care that enhances their effectiveness. This chapter discusses some of the most current somatic therapies used for psychiatric illnesses (Higgins and George, 2009).



Convulsive Therapies


Electroconvulsive therapy (ECT) was first described in 1938 as a treatment for schizophrenia, when it was believed that people with epilepsy were rarely schizophrenic, and it was thought that convulsions could cure schizophrenia. This was not supported by later research. ECT is actually more effective for mood disorders than for schizophrenia (Payne and Prudic, 2009a).



Traditionally electrodes in ECT have been applied bilaterally. Alternative electrode placements are now routinely used, including bifrontal and unilateral. Patients have equal effectiveness and fewer cognitive side effects with these alternative placements, including less disorientation and fewer disturbances of verbal and nonverbal memory (Sackeim et al, 2008; Peterchev et al, 2010).


Studies of a new form of unilateral ECT, called focal electrically administered seizure therapy (FEAST) appears to minimize cognitive effects of ECT even further (Pierce et al, 2008). Figure 29-1 illustrates the different electrode placements.



For ECT to be effective, a grand mal seizure must occur. The electrical stimulus is adjusted to the minimum energy that produces a seizure. Treatments are given in a series, which varies by the patient’s therapeutic response. A usual course is 6 to 12 treatments given two or three times per week. Patients with schizophrenia may require more.


ECT is an effective psychiatric treatment and is generally well tolerated by patients. In some cases, after a successful initial course of treatment, maintenance ECT plus antidepressant medication is recommended: weekly treatments for the first month after remission, gradually tapering to monthly (APA, 2001).




Indications


The primary indication for ECT is major depression (Weiner and Falcone, 2011). Some see it as the gold standard for treatment-resistant depression (Nahas and Anderson, 2011). ECT’s response rate of 80% or more for most patients is better than response rates for antidepressant medications, and is considered to be the most effective antidepressant in use (Keltner and Boschini, 2009).


It can be used for people in most age-groups who cannot tolerate or fail to respond to treatment with medication. Box 29-1 lists the primary and secondary criteria for the use of ECT as determined by the American Psychiatric Association (APA) Task Force on Electroconvulsive Therapy.



Primary criteria in which ECT may play a life-saving role involve patients who are extremely depressed and suicidal or are so hyperactive that they are in grave danger of self-harm, such as those with acute mania and affective disorders with psychosis. ECT is considered appropriate for patients with schizophrenia in a few situations. This includes when psychotic symptoms have an abrupt or recent onset, the duration of illness is short, catatonia is present, or the patient has responded well to ECT in the past.


Finally, ECT should be an initial intervention when its anticipated side effects are considered less harmful than those associated with drug therapy in populations such as the elderly, patients with heart block, and women who are pregnant. The potential effectiveness of ECT is reduced in those with personality disorders. Box 29-2 summarizes behaviors for which ECT is and is not effective.





Mechanism of Action


Despite much research, the exact mechanism of action of ECT is still unknown. The most popular theories include:



• Neurotransmitter theory suggests that ECT acts like tricyclic antidepressants by enhancing deficient neurotransmission in monoaminergic systems. Specifically, it is thought to improve dopaminergic, serotonergic, and adrenergic neurotransmission.


• Neurotrophic factor theory suggests that cyclic adenosine monophosphate (AMP) is up-regulated with ECT, which increases brain-derived neurotrophic factor (BDNF). BDNF regulates neuronal cell growth and is also involved in norepinephrine and serotonin receptor expression.


• Anticonvulsant theory suggests that ECT treatment exerts a profound anticonvulsant effect on the brain that results in an antidepressant effect. Some support for this theory is based on the fact that a person’s seizure threshold rises over the course of ECT and that some patients with epilepsy have fewer seizures after receiving ECT.



Adverse Effects


The mortality rate associated with ECT is estimated to be the same as that associated with general anesthesia in minor surgery (approximately 2 to 10 deaths per 100,000 treatments) (Payne and Prudic, 2009b). Mortality and morbidity are believed to be lower with ECT than with the administration of antidepressant medications.


Medical adverse effects can, to some extent, be anticipated and prevented. Patients with preexisting cardiac illness, compromised pulmonary status, a history of central nervous system problems, or medical complications after anesthesia are likely to be at increased risk. Thus the work-up preceding ECT should include a thorough review of the patient’s history and may include a complete blood count, serum chemistry profile, chest and spinal radiographs, electrocardiography, and a computed tomography scan of the head. Adverse effects potentially can occur in the following categories:



• Cardiovascular: Transient cardiovascular changes are expected in ECT. Routine electrocardiograms (ECGs) are performed to rule out baseline pathology, with further work-up as indicated.


• Systemic: Headaches, nausea, muscle soreness, and drowsiness may occur after ECT, but usually respond to supportive management and nursing intervention.


• Cognitive: ECT is associated with a range of cognitive side effects, including confusion immediately after the seizure and memory disturbance during the treatment course, although a few patients report persistent deficits. The onset of cognitive side effects varies considerably among patients. Patients with preexisting cognitive impairment, those with neuropathological conditions, and those receiving psychotropic medication during ECT are at increased risk of developing side effects. No evidence has been found to indicate that ECT causes brain damage (McClintock and Husain, 2011).



Nursing Care


Psychiatric nurses have always had a role in assisting with the ECT procedure. This role has evolved to include independent and collaborative nursing actions.



Emotional Support and Education


Nursing care begins as soon as the patient and family are presented with ECT as a treatment option. An essential role of the nurse is to allow the patient an opportunity to express feelings, including concerns associated with myths or fantasies involving ECT. Patients may describe fears of pain, dying of electrocution, suffering permanent memory loss, or experiencing impaired intellectual functioning.


As the patient reveals these fears and concerns, the nurse can clarify misconceptions and emphasize the therapeutic value of the procedure. Supporting the patient and family is an essential part of nursing care before, during, and after treatment (Payne and Prudic, 2009b).


The nurse can then begin patient and family teaching, taking into consideration anxiety, readiness to learn, and ability to understand. The amount of information provided should be individualized. The nurse reviews with the patient and family the information they have received and responds to any questions.


During this assessment process the nurse also should attempt to identify specific target behaviors the family associates with the patient’s illness. Any information about the family’s previous experiences with ECT helps the nurse identify beliefs about the patient’s illness, ECT treatment, and expected prognosis.


Open-ended questions may give the nurse the opportunity to identify and correct misinformation and address specific concerns the patient or family has about the procedure. Nursing actions may facilitate the family’s ability to provide support to the patient thus further reducing the patient’s anxiety.


Various media may be used to teach the patient and family about ECT, including written materials and videos individualized for each patient. A tour of the treatment suite may help familiarize the patient with the area and equipment. Encouraging the patient to talk with another patient who has benefited from ECT may be worthwhile.


Finally, facilitating flexibility in family visiting arrangements, particularly during the patient’s first few treatments, may be helpful in allaying the family’s anxieties and concerns about the treatment while encouraging the family to support the patient. If the family cannot or does not want to visit, the nurse should contact the family after treatments. The nurse also should encourage family members throughout the course of treatment to discuss changes they observe in the patient or concerns that arise.



Before ECT treatment begins, an informed consent form must be signed by the patient or, if the patient does not have the capacity to give consent, by a legally designated person (Chapter 8). This consent acknowledges the patient’s rights to obtain or refuse treatment. Although it is the physician’s ultimate responsibility to explain the procedure when obtaining consent, the nurse plays an important part in the consent process (Fetterman and Ying, 2011).


Informed consent is a dynamic process that is not completed with the signing of a formal document; rather, the process continues throughout the course of treatment. It is helpful if a nurse is present when ECT is discussed with the patient. It is preferred that this is a nurse who already has established a trusting and therapeutic relationship with the patient.


The nurse also can ensure that, before signing the consent form, the patient has understood fully the explanation of ECT, including its nature, purpose, and implications, and that the patient has the option to withdraw consent at any time. After the consent form has been signed but before the beginning of treatment, the nurse should again thoroughly review the information and discuss the treatment with the patient in an open and direct manner.


Certain patients pose particular challenges to the nurse when obtaining informed consent. If a patient is unable to make independent judgments and meaningful decisions about care and treatment, the nurse is responsible for acting as a patient advocate.


For example, concentration is often impaired in depressed patients, so they are less likely to comprehend and retain new information. For these patients it is essential that the nurse repeat the information at regular intervals because new knowledge is seldom fully absorbed after only one explanation. Then, throughout the patient’s treatment course, the nurse should reinforce relevant information, remind the patient of anything that may have been forgotten, and answer any new questions.



Pretreatment Nursing Care


Providing quality nursing care for the patient receiving ECT includes evaluating the pretreatment protocol to ensure that it has been followed according to hospital policy. This involves reviewing recommended consultations, noting that any abnormalities in laboratory tests have been addressed, and checking that equipment and supplies are adequate and functional.


The treatment nurse is responsible for ensuring proper preparation of the treatment suite. Box 29-3 provides a list of standard equipment needed to provide optimal patient care. A crash cart with defibrillator should be readily available for emergency use.



Patient preparation for ECT is similar to that for any brief surgical procedure. General anesthesia is required, so fluids should be withheld from the patient for 6 to 8 hours before treatment to prevent the potential for aspiration. The exception to this NPO status is in the case of patients who routinely receive cardiac medications, antihypertensive agents, or H2 blockers. These drugs should be administered several hours before treatment with a small sip of water.


The patient should be encouraged to wear comfortable clothing, which can include loose-fitting street clothes, pajamas, or a hospital gown, preferably clothing that can be opened in the front to facilitate the placement of monitoring equipment.


The patient’s hair should be clean and dry to facilitate optimal electrode contact. The patient should void immediately before receiving ECT to help prevent incontinence during the procedure and to minimize the potential for bladder distention or damage.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Somatic Therapies
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