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SEE pg ~33-38
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Learning Outcomes
• Discuss the categories of drugs used to treat
mental illness
• Discuss the drugs mechanisms of action and
side effects
• Describe the nurse’s role in educating patients
and families about medication management
• Identify special nursing considerations related
to medication adverse reactions
Neurobiologic Theories
Great strides are being made in
understanding the brain and
mental illness, but much is still
unknown; nurses need to keep
abreast of developments to
provide effective teaching
Cerebral Lobes
• Frontal lobe: thought, body movement,
memories, emotions, moral behavior
• Parietal lobe: taste, touch, spatial orientation
• Temporal lobe: smell, hearing, memory,
emotional expression
• Occipital lobe: language, visual interpretation
• Consider medications that affect these areas
• Chemical substances manufactured in the
neuron to aid in transmission of
• Are necessary in just the right proportions
to relay messages
• Major neurotransmitters play a role in
mental illness
• Major neurotransmitters play a role in the
actions and side effects of psychotropic
Neurotransmitter Drugs
(Dopamine & Serotonin are 2 of the biggest neurotransmitters in psych)
• Dopamine: control of complex movements, motivation, cognition,
regulation of emotional responses (Largely used) key in psych
• Norepinephrine: attention, learning, memory, sleep, wakefulness,
mood regulation
• Epinephrine: flight or fight response
• Serotonin: a NT and vasoconstrictor. food intake, sleep, wakefulness,
temperature regulation, pain control, sexual behaviors, regulation of
emotions are key in psych medicine
Dopamine- It has an inhibitory effect on movement. A depletion of dopamine produces
the symptoms of rigidity, tremors, and bradykinesia that are characteristic of
Parkinson's disease.
Norepinephrine- vasoconstricts
Epinephrine- adrenal hormone
Serotonin- vasoconstricts
Neurotransmitter Drugs
Histamine(dilation of capillaries) alertness, control
of gastric secretions, cardiac stimulation, peripheral
allergic responses
Acetylcholine(vasodilator): sleep and wakefulness
cycle, signals muscles to become alert
Glutamate: an excitatory amino acid, promotes
memory and learning
GABA: modulates other neurotransmitters, results
in neurotoxicity if levels are too high.
– Leads & controls the others & regulates them
– The “big daddy” neurotransmitter
– Inhibitory neurotransmitter,anticonvulsant
• Psychopharmacology and medication management
are important in the treatment of many mental
–Approved uses
–Off-label uses
–Black box warnings
» warnings that appear on prescription medications
informing patients of serious side effects
– Consider that it may not be the med that causes suicides
but maybe the pt already had intentions/desire and the
new med “helped” them fulfill their thru feelings.
Principles of Psychopharmacology
• Principles that guide the use of medications:
–Effect on target symptom
–Adequate dosage for sufficient time
–Lowest dose needed for maintenance
–Lower doses for the elderly
–Tapering rather than abrupt cessation to
avoid rebound or withdrawal
–Follow-up care
–Simplify the regimen for increased compliance
Antipsychotic Drugs2 classes
1) Conventional
2) Atypical
• 2 classes: conventional (typical) & atypical
• Atypical drugs are DOC for clients who have just been diagnosed &
are receiving treatment
• Uses:
– Schizophrenia, acute mania, psychotic depression, druginduced psychosis, and other psychotic symptoms
• Action:
– Treat psychotic symptoms, such as delusions and hallucinations,
by blocking dopamine receptors
Term Neuroleptic- Having antipsychotic properties
Conventional Antipsychotic
Phenothiazines- supress the (+) sxms of psychosis
(Thorazine, Prolixin, Mellaril, Stelazine, Navane, Haldol,
Loxitane, Moban)
• Side effects:
- Sedation
- Seizures
- Anticholinergic effects
- Photosensitivity
- Neuroendocrine effects***
- Dysrhythmia
- Orthostatic hypotension
- Sexual dysfunction
• ***S/S- Galactorrhea -discharge of breast
milk, Gynecomastia- man boobs, Orthostatic Hypotension,
Seizures, Sexual dysfunction, Bruxism- teeth grinding.
• More of them having s/s, because now the trend is to try the “new”
• These are the older drugs
• Mainly suppress the positive symptoms of psychosis (hallucinations,
hearing voices, delusions, agitation)
• These drugs have a lot of side effects
• Neuroendocrine effects: gynecomastia, galactorrhea, menstrual
irregularities, increased prolactin levels
• Greatest risk is if pt. already has an existing seizure disorder b/c
these drugs increase seizure threshold
• Bruxism – grinding of the teeth at night
• Dysrhythmias – tachycardia
Conventional Antipsychotic Drugs
Neuroleptic Malignant Syndrome “life threatening”
(a potentially life threatening reaction to antipsychotic drugs)
• Symptoms:
- Dysrhythmias
- Muscle rigidity
- Autonomic instability- sudden change in BP/HR
- Sudden high grade fever
- Changes in level of consciousness
Term: Neuroleptic Malignant Syndrome- Nerve-Seizure+Bad+Syndrome
Poor nutrition is a contributing factor
Conventional Antipsychotic Drugs
Neuroleptic Malignant Syndrome- NMS
Neg effects usually start w/in 7d of starting new med
• Nursing interventions:
• A spike in temp and the following = stop meds
- Stop antipsychotic medication
- Monitor physical and mental status
- Apply cooling blankets
- Administer antipyretics
- Increase fluid intake
- Dantruim (Dantrolene) “muscle relaxant” as ordered
• Dantrium – muscle relaxant (helps treat muscle rigidity & aggressiveness)
• NMS usually occurs during the first 7 days of starting the medication, but it can
occur at any time
• IV Valium is often used to treat NMS
Extrapyramidal Symptoms
EPS = Serious Neurologic Symptoms
• Early EPS:
- Dystonia- neck/tongue muscle spasms, respiratory problems
- Pseudoparkinsonism- stooped posture, shuffling gait, cog-wheel rigidity, pillrolling movements
- Akathisia- “without-sit”; inability to sit or stand still. (internal restlessness),
patients “want to jump/crawl out of their skin”
- Treat with anticholinergic medications, when caught early, can be turned around
• Late EPS:
- Tardive dyskinesia (TD)- “late+bad-movement”; disorder, abnormal involuntary
movements. (Kind of all the above rolled into one)
- No treatment, not reversible
Cogentin- reduce rigidity, tremor, and drooling
Symmetrel- assist with rigidity and other parkinsonian symptoms
Artane- assist with rigidity and other parkinsonian symptoms
Inderal- non-selective beta blocker
Valium- relieve anxiety and relax muscles
Ativan- sedative
• Extrapyramidal- pertaining to the function of these
tissues and structures.
• Most of the times can be reversed if caught in the early
• No going back if condition progresses to late EPS
• Treated with Cogentin (Benztropine) & Artane,
sometimes will use a low dose of Benadryl, may see
Inderal, Valium, or Ativan
Extrapyramidal Symptoms
Nursing interventions:
- Monitoring for early symptoms is key
(screening exam is the AIMS test)
Abn Invol Movement Scale
- Manage symptoms with medication as
- Maintain safe environment
- Provide reassurance to patient
• Encourage patients to tell nurse if they notice anything
• If Cogentin or another med is given & symptoms do not clear
up then need to call the physician
Long-acting Antipsychotics
Available in depot “long acting” injection:
– Prolixin (fluphenazine decanoate)- treatment of psychoses such
as schizophrenia and acute manic
• Duration of 1 to 4 weeks
Haldol (haloperidol decanoate)- a tranquilizing medication that
can cause Parkinson-like symptoms.
• Duration of 2 to 4 weeks
– Risperdal Consta (risperidone)- atypical antipsychotic used to
treat schizophrenia
Duration of 2 weeksMay see an order written for Prolixin or Prolixin
decanoate (this one is long-acting) – Must know the difference between
the two forms
A lot of psych patients mismanage their meds
Conventional Antipsychotic
• Patient teaching:
- Avoid alcohol
- Adhering to medication regimen
- Ideas to help with dry mouth
anticholinergic effects- chew gum, candy
- Report any changes to physician
- Avoid direct contact with medication if liquid
- Avoid excessive exposure to sun, use
Atypical Antipsychotic Drugs
Clozaril, Risperdal, Seroquel, Zyprexa,
Zyprexa Zydis, Geodon, Abilify, Invega
• Side effects:
- Weight gain
Fewer or no EPS- little no Serious Neurologic Symptoms (good thing)
Headache, sleepiness, anxiety
Less anticholinergic adverse effects ( higher drooling)
Treat (+) and (-) sxms
• Treats lack of energy, no motivation, social withdrawal
– Positive sxms- things that shouldn’t be there (hallucinations)
– Neg sxms- having things that should be there (withdrawal)
• Clozaril (After one has tried all other meds/options)
• Has to be monitored closely. Causes drooling at night. Incr in seizure risk
b/c it incr seizure threshold.
• Need a wkly CBC for 6m. Checking WBC- checking for agranulocytosis,
leading to no defense against infection. (fatal, char: fever, sore throat)
• Caution: Clozaril pt w/ sore throat
• Zyprexa
• Problem swallowing pills or refusing to take meds. Treat agitation.
• Dissolves on tongue. Injectable.
• Geodon (Need an EKG before admit b/c it can make changes in one’s QWave
• Injectable, short acting
• Invega
• Only once a day (expensive, not usually covered by ins)
• Positive symptoms: having things that shouldn’t be there
• Negative symptoms: having things that should be there
• Clozaril (more cholinergic effects) – usually won’t see patients take
this drug unless they have tried all the other medications; has to be
monitored very carefully (weekly CBC for 6 months – clozaril registry
that tracks CBC: won’t get prescription if you haven’t gotten weekly
CBC); clozaril patients may drool (worse at night); increases seizure
• Agranulocytosis risk with clozaril – can be fatal; usually
characterized by fever, sore throat
• Zyprexa (tablet form) or Zyprexa Zydis (form that dissolves on
tongue); also available as injectable IM (not long-acting)
• Geodon – EKG recommended before using medication; can make
changes in QT-wave; also available as injectable (not long-acting)
• Invega – extended release tab (patients like this b/c they only have
to take it once a day); very expensive (insurance usually doesn’t
cover it)
Atypical Antipsychotic Drugs
Patient teaching:
– Adhering to medication regimen!!!
• Psycho says he hasn’t been taking his med...
Find out why (ins, money?)
– Monitor weight gain, exercise
– Observe for signs of diabetes mellitus
• Some of these meds can cause a pt to gain 50-60lbs so
important to report changes
– Observe for sign of infection
– Report any changes to physician
• If a patient tells you that he has not been
taking his medication, find out why (may be
due to side effects)
• May gain 50-60 pounds with Zyprexa
Antidepressant Drugs
• Uses:
– Major depression, panic disorder, other anxiety
disorders, bipolar depression, psychotic depression
• Antidepressant can be used for anxiety disorders
• Action:
– Interact with the monoamine neurotransmitter
systems in the brain, particularly the
neurotransmitters norepinephrine and serotonin
– Consider: age, hx, pt preference, try to figure all angles of what is best
for the pt.
• Worry about risk for suicide (we want to make
sure to give pt. an antidepressant that is
comparable to the type of depression they are
• May see used for sleep apnea, eating
• Have to look at noncompliance – want a once
a day medication if possible
• Look at age, past history, patient preference,
SSRI Antidepressant Drugs
newer anti depress, and are 1st choice DOC.
Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox
• Side effects:
- Tremor
- Anxiety
- Nausea
- Dry mouth
- Headache
- Diarrhea
- Insomnia, drowsiness
- Sexual dysfunction (anorgasmia)- absence of an orgasm
- Prozac- “ Zach” given in morn b/c of insomnia sxms.
- Though they have fewer SE then other anti-depressants, w/ any of
these meds consider N/V/D & impotence effects.
- Decr cardio toxicity
• Selective Serotonin Reuptake Inhibitors
• Prozac is one of the oldest SSRI antidepressants & is used
very often (also has a generic)
• SSRIs are newer antidepressants – first choice in treatment
of depression
• Have to monitor side effects – Prozac often given in the
morning r/t insomnia
• Agitation & dizziness can also occur
• Newer SSRIs have fewer side effects than other
antidepressants & have lower cardiotoxicities – less chance
of overdose
SSRI Antidepressant Drugs
Serotonin Syndrome- SE of SSRI
• Symptoms:
- Fever
- Diarrhea
- Tremors
- Sweating
- Anxiety
- Irritablility
- Hyperreflexia
- Bloating
- Mood change
- Altered mental state
- Apnea, death
- Wt gain
Caution Serotonin Syndrome- serotonin level incr  fever, life threatening. Wait 14day
after if taking MAOIs
• Serotonin syndrome: have too much medication
on board; causes serotonin levels to become very
high (very rare occurrence, but is life-threatening)
can result in DEATH
• Can also happen when you have an MAOI on
board (need to clear one up one drug for at least
14 days – don’t want to take SSRI and MAOI
• Sweating is one of the main things we notice in
these patients
• Altered mental state: not as quick as they were
• Symptoms similar to flu-like symptoms (need to
distinguish between the two)
SSRI Antidepressants
Serotonin Syndrome- what do you do?
• Nursing interventions:
- Discontinue offending agent
- Maintain safe environment
- Monitor physical and mental status
- Administer serotonin receptor blockade
- Dantrolene, Valium for muscle rigidity
- Provide reassurance to patient
• Want to prevent falls, injuries due to hyperreflexia, mental status,
• May have to send pt. to ICU
• May have to use cooling blankets, artificial ventilators
SSRI Antidepressant Drugs
• Patient teaching:
– Take with food (to prevent nausea)
– Avoid alcohol and antihistamine else risk incr in CNS depression
– Take in the morning (to prevent promblems w/ sleep)
– Adhering to medication regimen (else risk serotonin withdrawal
 sxms get worse)
– Medication should not be discontinued abruptly (serotonin
– Takes several weeks to be therapeutic (don’t quit after no
results in 1st few days)
– Tell doc if there's any incr thought/feelings about
harming themselves (depression)
Atypical Antidepressants
Wellbutrin (cannot OD, ideal for suicidal pt), Effexor (SE = incr BP), Remeron (for
sleep dys, don’t use much), Cymbalta (treat major depression and pain), Desyrel
aka “Trazodone” (oral antidepressant , sedative/sleep, caution for painful erection
• Side effects:
- Somnolence “sleepiness”
- Changes in appetite (hunger vs no appetite)
- Anticholinergic effects (dry mouth, urinary retention, blurred vision)
- Cannot overdose on Wellbutrin, but increases seizure threshold & can make you
very agitated
– Very good for suicidal patients
• Remeron – not used as often; used very often for sleep (but does have
antidepressant feature)
• Effexor – have to watch for high BP especially in elderly & cardiac compromised
• Desyrel (Trazadone – generic) – given at night for sleep; AE: priaprism (very
significant & painful)
Atypical Antidepressants
• Patient teaching:
- Avoid alcohol
- Take with food/meals
- Adhering to medication regimen
- Takes several weeks to be therapeutic
- Monitor BP
TCA Antidepressants
cause many more/worse SE
Tofranil, Norpramin, Elavil, Sinequan,
Anafranil, Pamelor
• Side effects:
- Sedation
- Tachycardia
- Weight gain
- Sexual dysfunction
- Orthostatic hypotension
- Anticholinergic effects
- Mydriasis “pupillary dilation”  blindness
- Cardiac effects (tachy)
• Older antidepressants (making a
comeback) – cause many more side effects;
but may work much better on some
• Monitor cardiac effects esp. in elderly
TCA Antidepressants
Lethal in OD
Patient teaching:
- Avoid alcohol
- Lethal in overdose (understand on discharge
not to take more than reg dose; (very narrow
therapeutic range)
- Take in the evening (can lead to better
- Use caution when driving (reflexes hampered)
- Takes several weeks to be therapeutic (must
talk to dr before stopping meds)
- Adhering to medication regimen
MAOI Antidepressants
not used much b/c of food interactions
Nardil, Parnate, Marplan, Ensam
Side effects:
- Sedation
- Muscle cramps
- Weight gain
- Sexual dysfunction
- Anticholinergic effects
- Serious food/drug interactions
Tyramine- substance found in meats, all cheese and red wine, which can
trigger migraine. Pg 34-5
Nardil, Parnate, & Marplan not used very often
MAOIs have very serious interactions with drugs and foods (several have
even been taken off the market)
Tyramine – aged cheeses, aged meats, beer/wine, dried beans, avocadoes
Ensam – newer medication that is a patch (very expensive); not as likely to
have an AE if you eat something you aren’t supposed to (up to a point)
MAOI Antidepressants
Hypertensive Crisis
• Symptoms:
- Nausea
- Vomiting
- Chills
- Sweating
- Fever
- Hypertension
- Restlessness
- Nuchal rigidity
- Dilated pupils
- Occipital headache
- Motor agitation
- Severe nosebleeds
• - Hypertensive crisis (Elevated temp/BP  Life threatening) severe
HA, dilated pupils
• Very serious, life-threatening effect (can occur with ingestion of
tyramine foods)
• If elevated BP is not treated pt. can have cerebral hemorrhage,
stroke & even death
MAOI Antidepressants
and Hypertensive Crisis
• Nursing interventions:
– 1st take VS- call doctor if BP is high
– give sublingual Propranolol to lower BP
– Immediate medical attention is crucial
– Administer antihypertensives as ordered
– Administer cooling blankets/ice packs
– Monitor physical and mental status
• Usually give sublingual Propanolol to bring down BP
• Patient may have to be sent to ICU if BP won’t come
down or if they have a really high fever
• Comfort measures – IV medications to help pt. relax
– SSRI- selective serotonin reuptake inhibitor (Serotonin- vasocontricts,
so to inhibit reuptake will make more serotonin available)
• Advantages over tricyclic antidepressant drugs include
fewer anticholinergic side effects (dry mouth, blurred
vision, urinary retention), and fewer antihistaminic side
effects (sedation, weight gain).
• MAOI-highly effective antidepressant and anti-panic
• Remember: MAO s required to breakdown Tyramine
(incr BP), so ingest food containing Tyramine 
Hypertensive Crisis.
MAOI Antidepressants
Patient teaching:
- Lethal in overdose (don’t give to suicidal pts)
- Follow tyramine free diet
(avoid aged cheeses, aged meats, foods with yeast, soy, beer, wines, avocados, etc.)
- Notify physician before taking any other medication (i.e.-over the counter)
- Use caution when driving
- Don’t take Demerol “opioid analgesic”
- Takes several weeks before TEs are seen
- Must wait 14 days after discontinuing drug before starting other meds or eating
tyramine foods
– High risk for overdose – not given to suicidal patients SSRI- selective serotonin reuptake
inhibitor (Serotonin- vasocontricts, so to inhibit reuptake will make more serotonin
Advantages over tricyclic antidepressant drugs include fewer anticholinergic side effects (dry
mouth, blurred vision, urinary retention), and fewer antihistaminic side effects (sedation,
weight gain).
MAOI-highly effective antidepressant and anti-panic agent
Remember: MAO s required to breakdown Tyramine (incr BP), so ingest food containing
Tyramine  Hypertensive Crisis.
Mood Stabilizing Drugs
Lithium (#1 for Bipolar, Cost effective, need blood lab), Tegretol (anticonvulsant,
need blood lab), Depakote (anticonvulsant, need blood lab), Lamictal, Neurontin,
Trileptal, Topamax
• Uses:
– Bipolar Disorder
• Action:
– Normalizes the reuptake of certain neurotransmitters and
reduces the release of norepinephrine
• Lithium is the #1 drug for bipolar disease, very cost
effective, works very well on most bipolar patients
• Tegretol & Depakote are also anti-convulsants
• Lithium, Tegretol, & Depakote all require blood draws (must monitor serum
• With lithium must watch sodium & fluid levels because it can become toxic
Mood Stabilizing Drugs
• Side effects:
- Drowsiness
- Rash
- Hand tremors (toxicity, Lithium) - Fatigue
- Anticholinergic effects
- Weight changes
-Toxicity, metal taste in mouth with Lithium
- Alopecia “hair loss”, Hepatic failure with Depakote
- Stevens-Johnson syndrome “skin separates” with Lamictal (med)
- Aplastic anemia “deficient RBC from bone marrow” with Tegretol (med)
Monitor sodium and fluids
Mood Stabilizing Drugs
• Patient teaching: (see pg 34-5, lithium/mood stabilize- common vs
uncommon/Toxicity; blood level/toxicity of Lithium) .4-1.3mEq/L
- Take with food/meals
- Monitor lab levels as ordered
- Maintain adequate fluid intake
- Adhering to medication regimen
- Reporting any changes to physician
- uncoordination, severe N/V/D, tinnitus, muscle weakness,
- Read pg. 34 & 35 (difference between common symptoms & toxic
symptoms of Lithium)
Must know the therapeutic level of Lithium (very narrow range: 0.4 to 1.3 mEq/L)
Nothing can be done to counteract lithium toxicity besides stopping the medication
Antianxiety (Anxiolytics)
Benzodiazepines, BuSpar
• Uses:
– Anxiety disorders, insomnia, OCD, depression, PTSD,
and alcohol withdrawal
• Action:
– They moderate the actions of GABA “aids sleep by naturally
relaxing the muscles in the body and calming emotions”
• Many used w/ antidepressants, caution for
tolerance and dependence.
Valium, Ativan, Xanax
Main use is for anxiety in clients
Many are used along with antidepressants (can become dependant very quickly; tolerance
can occur quickly)
Antianxiety Drugs
• Side effects:
– Sedation
– Drowsiness
– Impaired memory
– Poor concentration “assoc amnesia effect”
– Clouded sensorium “One's sensory environment”
– Tolerance and dependence
• Physical and psycho dependency, must be tapered off.
Antianxiety Drugs
• Patient teaching:
– Avoid alcohol, potentiate effects of alcohol
– Caution during driving due to slower reflexes and
response time
– Never discontinue abruptly as withdrawal can be
– Medication does not treat the underlying problem
• Treating the anxiety S/S, but not taking care of the
underlying cause of the anxiety. Quick fix.
Stimulant Drugs
Ritalin, Cylert, Adderall, Dexedrine,
Newer:Concerta, Vyvanse (pedi med- learn later)
• Uses:
– ADHD, residual ADD in adults, and narcolepsy “chronic
• Action:
– Cause release of neurotransmitters
– Affect epinephrine & dopamine receptors, addicitive
Strattera: not a CNS stimulant, not addictive
High abuse potential; stimulant drugs very addictive
Used with a lot of success in ADHD & residual ADD & narcolepsy
Stimulant Drugs
• Side effects:
Weight loss
Cardiac effects
• Dysrhythmias, chest pain, high BP
– Growth retardation
– Adjust dosage to decr. SE
Stimulant Drugs
• Patient teaching:
– Take after meals, else nausea
– Avoid caffeine, sugar, and chocolate (cause they’re
– Long term use can cause dependency and
• May need medication adjusted if develop a tolerance
Alcohol Deterrent
Antabuse “drug given to alcoholics that produces N/V/D, flushing, and
tachycardia if alcohol is consumed” Causes severe hang-over effect
• Uses:
– Treatment of alcoholism
• Action:
– Causes an adverse reaction when alcohol is ingested,
can also cause fainting. Can stay in system for a wk.
– Interrupts breakdown process of alcohol in the liver
• 50% success rate
• Teaching: avoid mouthwash, ETHOL products
• Now the focus is on support groups & AA
meetings for social support & getting patient
off drugs and alcohol completely
• Once in your system, it takes a week or two for
Antabuse to breakdown by the GI tract
• Patients on Antabuse need to avoid alcoholcontaining products (mouthwash)
Alcohol Deterrent
Campral “new drug used for treating alcohol dependence”
- Treatment of alcoholism (reduces craving)
- Reduces physical distress and emotional discomfort
- Reduces more of the alcoholic cravings
SE: irregular heartbeats, low/high BP, HA, insomnia, (not for
renal pts)
Not cost effective
Side Effects: Heart rhythm changes & BP fluctuations
Careful in impaired renal function patients
Methadone “synthetic narcotic drug similar to morphine but
less habit-forming”, Suboxone “inhibit the craving for opiates
and minimize withdrawl symptoms”, Clonidine “to treat high BP,
mild-moderate pain relief”
• Uses:
- Treatment of opioid dependence
• Action:
- Blocks craving for and effects of opioids
Cultural Considerations
• Ethnic background can influence responses to psychotropic
– African Americans respond more quickly
– Asians metabolize antipsychotics more slowly so may
require lower doses
– Hispanics may require lower doses of antidepressants to
achieve the same results
• Herbal preparations can inhibit or potentiate the effects of
psychotropic medications
• Nurses need to be familiar with cultural differences
Self-Awareness Issues
• Viewing chronic mental illness as having
remissions and exacerbation, just as chronic
physical illnesses do
• Remaining open to new ideas that may lead
to future breakthroughs
• Understanding that medication
noncompliance is often part of the illness, not
willful misbehavior