“Making Dreams Come True”

A Mental Health Nursing Narrative

January 20, 2022
 Disclaimer

This presentation has material that contains mention of suicide that may be triggering for
some audience members. If at any point one feels uncomfortable with the material being
presented, please feel free to leave the presentation and return at a later time. If a student
has any questions or concerns, please reach out to one of the facilitating students or
program faculty members.
 Presentation Key Concepts
1. Reviewing the Narrative
2. Psychotic Depression
3. Mental Health Nursing
4. Nursing Role Within a Mental Health Unit

(Unknown, 2022)
 “Making Dreams Come True”
Aideen Carroll doesn't need long to think of a story that shows courage.

Aideen works in University Health Network's psychiatric emergency service unit.

Some time ago, Aideen's patient wanted to visit the CNE, a popular summer
attraction in Toronto. The patient had fond memories of going there as a child --
and wanted to experience the place she'd enjoyed so much as a kid.

Her dream wasn't overly complex. She wanted to ride the ferris wheel and eat
candy floss. But her care team knew that for a sick patient, even such seemingly
simple request was incredibly risky. What if she fell while she was there? What if
she died?

In spite of these initial concerns, the health care team took the courageous step
of fulfilling the patient's wish. The woman had an incredible day. It was also the
last time she'd experience the spectacle - she passed away after that summer.

For the care team at Toronto General Hospital, it was a valuable lesson. Ever
since the woman's passing, each summer, they're sure to take their patients to
the same attraction.

(University Health Network, 2012; Harris, 2010).

What are your initial thoughts regarding this
narrative? With the very limited information we have,
what assumptions could be made? Please feel free to
raise your hand and share, or type some notes in the
chat box.
 Physiological Adaptation
What is Psychotic Depression?
● A combination of Major Depressive Disorder with psychotic features, with the psychosis most
commonly presenting with “nihilistic” type delusions (the belief that something bad is about to
happen).
● Officially listed as a diagnosis in the DSM IV in 1992, scientists and clinicians began to
investigate what it meant to have both depression and psychosis presenting concurrently.
● 3% of Canadians will experience a brief or prolonged episode of psychosis at some point in
their lifetime.
● This psychiatric disorder often goes undiagnosed, is undertreated and very few studies have
been done on the subject in comparison to Major Depressive Disorder or Psychosis alone.

(Rothschild, 2013; CAMH, 2022)

Have any learners ever worked with a patient
living with the experience of psychotic
depression? Does the definition above
correlate with what was seen in the clinical
setting? Describe the experience.
 Physiological Adaptation

Pathophysiology of Depression and Psychosis

● Currently, there are no published studies on the pathophysiology of psychotic depression. We will
discuss depression and psychosis as separate diagnoses, and then compare the physiological
processes which contribute to the formation of each diagnosis.
● Various environmental and genetic factors also influence both depression and the development of
psychosis, accounting for the majority of diagnoses seen each year.

(Rothschild, 2013).
 Physiological Adaptation
A Comparison of Pathophysiology
Depression
● Genetic factors - depression is 80%
likely to be passed down through
familial generations
● Several genes in combination with
environmental factors, likely
contributes to a diagnosis of
depression
● Disrupted neurotransmitter pathways
at the synaptic cleft is also a likely
contributor. While this is not
confirmed, we do know that
antidepressant medications can
repair this pathway through their
MOA. This can lead us to believe that
synaptic cleft transmission plays a
role
Psychosis
● Several biological factors, including
genetic
● Research into genetic factors
identified a significant number of
genetic alterations affecting multiple
different biological pathways - could
not associate specific genes with
symptoms
● An imbalance in serotonin and
dopamine may also be a contributing
factor
● Women are more likely to have an
episode of psychosis before their
period, after child birth and during
menopause, suggesting hormones
may play a role as well
(Brigitta, 2002)
 Psychosocial Integrity
Psychosocial risk factors for psychotic depression

● Living alone
● Infrequent or limited contact with friends and family
● Not having any close confidants
● Unemployment
● Childhood adversity or trauma
● Discrimination - social defeat or “outsider status”
● Increased emotional reactivity to stressful life events

(Winkel et al., 2008; Heslin et al., 2015)

 Psychosocial Integrity
Psychotic Depression and Suicidal Ideation
● There are higher rates of suicide, suicide attempts and suicidal ideation in individuals
with psychotic depression compared to non-psychotic depression
○ 20-40% of individuals with psychosis will attempt suicide in their lifetime and
8-10% will die by suicide
○ Higher risk in adolescents, especially those experiencing their first episode of
psychosis
● Anxiety, low self-esteem, negative beliefs of self and others, alcohol consumption and
negative illness perceptions were associated with increased suicidal ideation in
individuals with psychotic depression
● Distress in response to hallucinations and delusions have also been shown to be a
factor in suicidal ideation
 Pharmacological Treatment for Psychotic Depression
Medication Class Mechanism of Action

Fluoxetine Antidepressant Blocks reuptake of serotonin

into presynaptic neurons

Citalopram Antidepressant Blocks reuptake of serotonin

into presynaptic neurons

Sertraline Antidepressant Blocks reuptake of serotonin

into presynaptic neurons

Risperidone Antipsychotic Decreases dopamine and

serotonin activity

Quetiapine Antipsychotic Decreases dopamine and

serotonin activity (unknown)

Clozapine Antipsychotic Decreases dopamine and

serotonin activity

(CAMH, 2022; Wijkstra, 2015)

 Nursing Mental Health Assessment

Appearance Mood/Affect Perception and

Motor/Behaviour Cognition

Insight/Judgement Speech Thought Process Thought Content

(RNAO, 2009)
 Rehabilitative vs. Recovery Care Models

Rehabilitative model
● Focuses on managing patients’ deficits
● Dominated by psychiatric care
● Helping patients learn to live with their illness

Recovery model
● Developed out of “consumer” movement
○ Consumer: individual who consumes health care services.
● Patient centred, focusing on client participation in treatment
● Encourages active partnership between client and health care providers
● Facilitates high level of patient independence
 Recovery Care Model

● Developed in 1993 by Dr. William Anthony

● Changed focus from treatment of mental illness to recovering from it.

● “Individuals define who they are, not the illness.”

● Consistent with patient-centred care

● Care should be directed to resolve acute stage but also long-term

management.
 https://youtu.be/FNnTXpFPEGA

https://youtu.be/FNnTXpFPEGA

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Timestamp 25:35
 Health Teaching in Recovery

● Health teaching is a fundamental cornerstone of mental health recovery

● Used to promote psychosocial integrity, allowing patients to make informed
choices.
What does health teaching
include?
● Depression is an illness beyond voluntary control
● Can be managed through medication and lifestyle
● Management depends on self-awareness of signs & symptoms of relapse
○ These are different for every individual

● Understanding the role of medication, adverse effects.

● Psychotherapy is integral to long-term management, not just meds
● Coping with stress of interpersonal relationships - key to management
● Family included in discharge planning
○ Promotes familial understanding.
○ Promotes and emphasizes importance of medication adherence.
○ Increases use of aftercare facilities (community resources).
○ Promotes positive adjustment period.
Understanding the Types of Depression Treatment

Finding the right kind of treatment is an

important step. Treatments can be used alone
or in combination, and will depend on your
diagnosis and response to the treatments you
are started on. Here are some of the
possibilities:

1. Psychotherapy
2. Pharmacological
3. Electroconvulsive therapy
Psychological Therapies
● Can help change thinking patterns and improve coping skills so the patient is better equipped to
deal with life's stresses and conflicts.
● Identify and change unhelpful thoughts and behaviour.

There are several different types of psychological treatments including:

● Cognitive behaviour therapy (CBT)

● Interpersonal therapy (IPT)
● Behaviour therapy
● Mindfulness-based cognitive therapy (MBCT).

CBT is one of the most commonly used psychological therapies. It helps people with depression to
monitor and change negative patterns of thinking and improve their coping skills so they are better
equipped to deal with life’s stresses and conflicts.
Pharmacological Therapies
● Biopsychiatry: biological approach to understanding mental health disorders
as biological malfunctions of the brain.
○ Genetics, neurodevelopmental factors, drugs, infection, psychosocial experience etc.
● GOAL: restore balance to a malfunctioning brain.
● Pharmacological interventions affect mood disorders caused by problems with
neurotransmitters
○ Alter brain chemistry
○ Used in combination with psychotherapeutic interventions.
Antidepressant drugs
● Often chosen to alter poor self-concept, withdrawal, vegetative signs of
depression and improve activity level.
○ Targets symptoms
■ sleep/appetite disturbance
■ Fatigue
■ Decreased sex drive
■ Psychomotor retardation/agitation
■ Mood variations
■ Poor concentration/forgetfulness
How to choose antidepressants
● Adverse effect profile (ex. sexual dysfunction)
● Ease of administration
● History of response
● Safety and medical considerations
● Takes time
Nonadherence
● Nearly 50% of people with mental illness are not receiving treatment or
nonadherent to treatment (Halter et al., 2018, p. 637).
○ Increases the risk of relapse
● Mental health issues and nonadherence are strongly correlated (Surbhi et al.,
2020)
● Common practice: provide medication education.
○ Can lead to patient resistance rather than adherence.
● Other common causes of non-adherence: adverse effects, drug costs,
treatment interruptions, rotating treatment providers.
Improving adherence
● Simplification of treatment
○ “Once-a-day” over “twice-a-day”, extended release etc.
● Cognitive association between treatment and patient goals. (“This will give
you more energy to help you get out of bed in the morning.”)
● Assign consistent, committed caregivers.
○ Should have or are skilled at building therapeutic bonds with patient.
● Involve peer support groups.
○ Members will have greater insights and first hand experience with illness and treatment.
● Culturally safe and trauma-informed care
○ Consider suspicious attitudes or traumatic histories with healthcare and authority figures.
● Monitoring medication decreases or changes to control adverse effects
● Never reject, blame or shame the patient when nonadherence occurs.
○ An opportunity to focus and work towards reduction of harm.
Community Treatment Orders (CTOs)
● Order issued by physician
● Agreed to by patient and/or substitute decision maker
● Allows treatment to be administered and observed within the patient’s
community
● Used for individuals who do not voluntarily engage in outpatient follow up.
● Used to implement CTP (Community Treatment Plan), helping clients access
physical, mental and community health resources.
● Eligibility criteria www.health.gov.on.ca
CTOs - a literature review (Maughan et al., 2013)
● Significant evidence determines CTOs have no profound impact
○ Length of hospital stay
○ Rate of admission
○ Mental health service use
● HOWEVER, CTOs significantly impact treatment adherence.
Cessation
● Medication should never be discontinued abruptly, consult physician
● Abrupt cessation of SSRIs can lead to serotonin withdrawal
○ Symptoms include
■ Increased depressive or suicidal thoughts
■ Rash or hives
■ Rapid heartbeat
■ Sore throat
■ Urinary retention
■ Fever/malaise
■ Anorexia/weight loss
■ Unusual bleeding
■ Headache
■ Hyperactive behaviour
Electroconvulsive Therapy

A medical treatment most commonly used in patients

with severe major depression or bipolar disorder that
has not responded to other treatments.

What does ECT involve?

- a brief electrical stimulation of the brain while the

patient is under anesthesia
- typically administered by a team of trained
medical professionals that includes a
psychiatrist, an anesthesiologist, and a nurse or
physician assistant.
Depression - Coping and Recovery
While psychological and medical treatment can help with a person’s recovery, there are many other ways people
can help themselves to get better and stay well.

STAYING ACTIVE
When you are depressed, you may not enjoy activities that you once loved. You may also think you won’t enjoy
something but, when you do it, you actually enjoy it more than you expected.

If you don’t try activities, you reduce the number of things that may help you cope with your depression.

To increase the amount of activities you enjoy, you can:

● list activities you used to enjoy

● plan one of these activities each day
● increase the amount of time available for activities you enjoy
● after an activity, think about or write down what you enjoyed about it
● talk to others about what activities they like.
Mental Health Nursing
Psychiatric Emergency Services
- Triaging

- Mental Status Exam

- Preventing and Managing Crisis

Inpatient Mental Health

- Vary Greatly
- Psychosis Recovery Units
- Forensic Units
- Medical Withdrawal Units
- Child and Adolescent Units
- General Adult Mental Health Units
Case Scenario
A patient that has been admitted for a suicide attempt is in a closed monitoring unit
and is seen with a pen. This presents a potential risk and policy states patients are
not allowed to have a pen while on the unit. A staff member confronts the patient
regarding the pen. The patient does not want to give the pen back, and ends up
running to the bathroom and engaging in self harm.

What do you do?

Ontario Mental Health Act

● Sets out the powers and obligations of psychiatric facilities in Ontario.

● Governs the admission process, the different categories of patient admission (involuntary, informal, voluntary), as
well as directives around assessment, care and treatment.

● Outlines the powers of police officers and Justices of the Peace to make orders for an individual, who meets certain
criteria, to undergo psychiatric examination by a physician.

● Patient rights are also referred to, including procedural details such as rights of appeal to the Consent and Capacity
Board.

Resource: Ontario Hospital Association (2016). A Practical Guide to Mental Health and the Law in Ontario.
Criteria for Involuntary Admission

(Ontario Hospital Association, 2016)

Ontario Mental Health Act ctd.
Form 1 - The most common path to an involuntary admission. Application is made by a physician (not necessarily a psychiatrist) who
must have personally examined the person in the past seven days before the application. Must meet the criteria in Box A or Box B.

Form 2 - Any person can appear before a justice of the peace and provide sworn information that there is a person within the
jurisdiction of the justice, who meets either the Box A or Box B criteria outlined above. The Form 2 order is directed to the police in the
same locality where the justice has jurisdiction and provides authority to the police to take the person named in the order into custody
“forthwith” to an “appropriate place” where the person may be detained for examination by a physician. This place is usually the
hospital Emergency Department.

Form 3 (Certificate of Involuntary Admission) - Filled out when a patient meets criteria for an involuntary admission under either Box A,
or Box B criteria. A Form 3 is a legal tool that allows person to be detained for up to 14 days in a psychiatric facility in Ontario. Once the
Form 3 expires, a physician can decide to issue another form to keep the person at the hospital for longer. Or they may allow the form
to lapse and the person may be free to go.

Police Apprehension - Section 17 of the MHA provides police officers with authority, under certain circumstances, to take a person to
an appropriate place for examination by a physician, where it would be “dangerous” to proceed to obtain a Form 2.

Patients Admitted or Assessed under Court Order

(Ontario Hospital Association, 2016)

Community Mental Health
Examples:

Housing First (Gaetz et al., 2013)

Good Shepherd HOMES Program, TRHP Program

CMHA housing programs, case management

Support groups & skills groups ex. DBT

Overdose Prevention Sites

Integrating mental health support into primary care

Mental Health & Street Outreach

Mental Health Nursing Approaches
Trauma-Informed Care & Harm Reduction
“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual
as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s
functioning and mental, physical, social, emotional, or spiritual well-being.” (SAMSHA, 2014)

Many individuals have experienced trauma from ongoing racism and discrimination in the health care system.
Experiencing stigma and having choices taken away due to mental illness can also be a cause of trauma.
Trauma-informed care begins with an awareness of the impacts of trauma, and is focused on cultivating trust, safety,
and choice so that no further harm is caused. It involves active listening to understand people's’ unique needs and
experiences. It is our role as health providers to build trust, and to provide care that is safe and empowering (Fleishman
et al, 2019; SAMSHA, 2014).

Harm reduction as an approach to care seeks to reduce the harm associated with drug use, and aims to relieve
suffering and promote the dignity and choice of people who use drugs. Safe injection sites and safe prescribing are
examples of harm reduction in practice. Harm reduction also integrates efforts to address the conditions that cause
harm in the lives of people who use drug such as poverty and homelessness. Harm reduction as ethical nursing
practice (Iammarino & Pauly, 2021)
Let’s Practice!
Self-Soothing when in distress
What would your toolbox look like?

(Samuels, 2022)
Entry to Practice Competencies
CNO Entry-to practice competencies (College of Nurses of Ontario, 2019):

1.3 Uses principles of trauma-informed care which places priority on trauma survivors’ safety, choice, and control.

1.16 Incorporates principles of harm reduction with respect to substance use and misuse into plans of care.

1.18 Provides recovery-oriented nursing care in partnership with clients who experience a mental health condition and/or
addiction.

1.19 Incorporates mental health promotion when providing nursing care.

1.20 Incorporates suicide prevention approaches when providing nursing care.

3.3 Uses evidence-informed communication skills to build trusting, compassionate, and therapeutic relationships with
clients.

7.4 Advocates for health equity for all, particularly for vulnerable and/or diverse clients and populations.
Practice Standards
Entry-to-Practice Mental Health and Addiction Competencies for Undergraduate Nursing Education in Canada (Canadian Association
of Schools of Nursing, 2015)

Canadian Standards of Psychiatric-Mental Health Nursing (Canadian Federation of Mental Health Nurses, 2014)

● Standard I: Provides Competent Professional Care Through the Development of a Therapeutic Relationship.
● Standard II: Performs/Refines Client Assessments Through the Diagnostic and Monitoring Function.
● Standard III: Administers and Monitors Therapeutic Interventions.
● Standard IV: Effectively Manages Rapidly Changing Situations.
● Standard V: Intervenes Through the Teaching-Coaching Function
● Standard VI: Monitors and Ensures the Quality of Health Care Practices.
● Standard VII: Practices Within Organizational and Work-Role Structure.
 Nursing Role Within a
Mental Health Unit
● Mental Health Nurses help with
the assessment, and monitoring of
mental health conditions and their
treatments
● Determine appropriate
interventions
● Person-centered approach
● Work in a variety of environments

● Where else do you think we would

see Mental Health Nurses?
Management of Care Part 1
● Recognizing the Signs and Symptoms of Acute and Chronic Mental
Illness
○ Includes depressive disorders, anxiety disorders, bipolar illness, cognitive mental
health disorders, personality mental health disorders, substance use and addictive
disorders, substance use and addictive disorders, eating disorders, psychotic
disorders
● Recognizing the Client’s Use of Defense Mechanisms
○ Purpose of these is to psychologically protect the patient from unmanageable stress
until they are ready to cope with these stressors effectively and without and
maladaptive mechanisms
● Exploring Why the Client is Refusing/Not Following the Treatment Plan
○ Understanding of a treatment plan does not equal compliance and adherence with it
● Assessing the Client for Alterations in Mood, Judgment, Cognition and
Reasoning
○ Mental status examination
○ Traits vs. state
Management of Care Part 2

● Providing Care and Education for Acute and Chronic

Behavioural Health Issues
○ Building therapeutic relationships
● Evaluating the Client’s Ability to Adhere to Their Treatment
Plan
○ Risk Factors
 ● Assessment
○ Helps to evaluate potential for self-injury,
Risk for Suicide observe for risk factors that may increase
chance of suicide attempt, determine
Nursing Diagnosis stressors, coping methods, etc.

and Interventions ● Interventions

○ Supervision, providing a safe environment,
building a therapeutic relationship, etc.
 ● Activities of Daily Living
○ Patients may struggle with self-care
● Assistive Devices
Basic Care and ○ Geriatric patients
Comfort for the ● Non-pharmacological Comfort Measures
○ Meditation
Mental Health Patient ○ Distraction
○ Music
○ Deep breathing
 Psychotropic Medications

What are the five categories of psychotropic medications?

Types of Psychotropic
Medications
● Antidepressants
● Anxiolytics
● Stimulants
● Antipsychotics
● Mood stabilizers
Nursing Care Plan

● A nursing care plan provides an overview of a patient’s

condition, actions required to improve the patient’s well-being,
and ways of knowing if the treatment/care is effective.

● Consists of 5 components:
○ Assessment
○ Diagnosis
○ Outcomes/Goals
○ Interventions
○ Evaluation

(Haugen & Galura, 2022; Keith, 2022)

 Nurses use mental care plans all the time. Have any of you utilized a
written nursing care plan or had the chance to contribute to the
development of a patient’s nursing care plan in your practicum setting?
What are some advantages of having a written nursing care plan?
Nursing Care Plan: Assessment
Objective (“signs”)
● Restricted emotional and facial expressions
● Pessimistic or gloomy outlook
● Low or inappropriate affect
● Disorganized speech, thoughts, or behaviour
● Tangentiality
● Significant weight loss or gain
● Substance abuse
● Physical signs of weakness or fatigue
● Sleep disturbances
● Impaired ability to carry out ADLs
● Regression/ socially inappropriate gestures
Subjective ( “symptoms”)
● Mood changes
● Frequent or constant feelings of sadness,
helplessness, hopelessness, worthlessness
● Suicidal ideation
● Delusions
● Hallucinations
● Diminished social participation
● Low energy and fatigue
● Reduced motivation/ ability to begin tasks
● Difficulties with cognitive processing: attention,
concentration, memory and executive function
(Haugen and Galura, 2022)
Nursing Care Plan: Diagnosis

● Information regarding diagnosis is

found in the patient’s chart as
diagnosing patients is not within an
RN’s scope of practice

● In the early phases of a psychotic

episode, it is difficult to diagnose the
exact type of disorder the patient has.
Thus, the diagnosis of a patient may
change or be updated throughout
their hospital admission.

(Bromley, Choi, Faruqui and Czuchta, 2015; Suszycki, 2022)

 Nursing Care Plan: Outcome
Problem Short Term Outcome/ Goal Long Term Outcome/ Goal

Within a week, client will seek out staff

Suicide/ self
member when feeling the urge to harm self Client will not harm self or others.
harm
or others.

Within 1 week, patient will recognize signs

Disturbed Patient’s verbalizations will reflect
of anxiety triggered by their interpretation
thought reality-based thinking with no evidence
process
of the environment and report it to a staff
of delusions or hallucinations.
member for assistance with intervention.

Patient will be able to fall asleep within

Sleep Within 5 days, patient will sleep 4-6 hours 30 minutes of going to bed and sleep for
disturbance per night with aid of sleeping medication. at least 6 uninterrupted hours at night
without the use of medication.
Nursing Care Plan: Interventions
Outcome Intervention
ensure a safe environment for patient by
removing any objects that can be used to
No suicide/
self-harm; monitor patient closely during meals,
self harm
medication administration, and off-unit activities
reinforce and focus on reality by talking about real
Stop events+ people to divert the patient away from
disturbed false ideas; give positive reinforcement when
thought patient able to differentiate between reality and
process non-reality thinking; teach patient
thought-stopping techniques
discourage sleep during the day; limit intake of
No sleep caffeine; administer antidepressants at night
disturbance
Rationale
patient safety is a priority and observation is
necessary to ensure patient does not harm self
in any way, such as intentional
malnourishment, saving up pills to overdose, or
escape attempts
reinforcement of reality encourages the
repetition of this behaviour; a thought-stopping
act like clapping distracts the patient from
undesirable thinking and in turn prevents the
negative behaviours that can result from
non-reality thinking
avoiding sleep during the day promotes more
restful sleep at night, caffeine is a stimulant
that may interfere with good sleep, and
antidepressants have drowsy effect
Nursing Care Plan: Evaluation

Outcome Evaluation

No suicide/
Patient verbalizes no thoughts of suicide and commits not acts of self harm.
self harm

Stop
Patient’s thinking process and speech reflect accurate interpretation of the
disturbed
environment; patient is able to recognize irrational thoughts and self-intervene to stop
thought
their progression.
process

No sleep Patient is able to fall asleep within 30 minutes of going to bed and sleeps for 6-8
disturbances uninterrupted hours without the use of sleep medication.
 References
Brigitta, B. (2002). Pathophysiology of depression and mechanisms of treatment. Dialogues in Clinical Neuroscience, 4(1), 7-20.
https://doi.org/10.31887/DCNS.2002.4.1/bbondy

Bromley, S., Choi, M., Faruqui, S. and Czuchta, D., 2015. First episode psychosis : an information guide : a guide for people with psychosis and their families.
3rd ed. Canada: CAMH.

Canadian Association of Schools of Nursing. (2015). Entry-to-practice mental health and addiction competencies for undergraduate nursing education in
Canada. https://www.casn.ca/2015/11/entry-to-practice-mental-healthand-addiction-competencies-for-undergraduatenursing-education-in-canada/

Canadian Federation of Mental Health Nurses. (2014). Canadian Standards for Psychiatric-Mental Health Nursing (4th Ed.). Toronto, ON.
https://live-cfmhn.pantheonsite.io/wp-content/uploads/2019/05/2014-Standards-of-Practice-Final-1.pdf

Centre for Addiction and Mental Health. (2022). Psychosis - CAMH. Retrieved January 16 2022 from
https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/psychosis

Community treatment order services. CMHA Toronto. (2017, November 29). Retrieved January 20, 2022, from
https://toronto.cmha.ca/programs-services/community-treatment-order-services/

Falcone, T., & Timmons-Mitchell, J. (2013). Psychosis and Suicidality in Adolescents. Psychiatric Times.
https://www.psychiatrictimes.com/view/psychosis-and-suicidality-adolescents

Fialko, L., Freeman, D., Bebbington, P. E., Kuipers, E., Garety, P. A., Dunn, G., & Fowler, D. (2006). Understanding suicidal ideation in psychosis: findings from
the Psychological Prevention of Relapse in Psychosis (PRP) trial. Acta Psychiatrica Scandinavica, 114(3), 177–186.
https://doi.org/10.1111/j.1600-0447.2006.00849.x
 References cont.
Fleishman, J., Kamsky, H., & Sundborg, S. (2019). Trauma-Informed Nursing Practice. OJIN: The Online Journal of Issues in Nursing, 24(2).
https://doi.org/10.3912/OJIN.Vol24No02Man03

Gaebel, W., & Zielasek, J. (2015). Focus on psychosis. Dialogues in Clinical Neuroscience, 17(1), 9–18.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4421906/

Gaetz, S., Scoot, F., & Gulliver, T. (Eds.) (2013): Housing First in Canada: Supporting communities to end homelessness. Toronto: Canadian Homelessness
Research Network Press. https://www.homelesshub.ca/sites/default/files/HousingFirstInCanada.pdf

Harris. (2010). Toronto CNE. [Image]. Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Toronto_CNE_2010.jpg

Haugen, N. and Galura, S., 2022. Ulrich & Canale's Nursing Care Planning Guides, 8th Edition Revised Reprint with 2021-2023 NANDA-I Updates. 8th ed.
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Doody, G. A., Dazzan, P., Fisher, H. L., Demjaha, A., Craig, T., & Morgan, C. (2015). Biological and psychosocial risk factors for psychotic major depression.
Social Psychiatry and Psychiatric Epidemiology, 51(2), 233–245. https://doi.org/10.1007/s00127-015-1131-1

Iammarino, C., & Pauly, B. (2021). Harm reduction as an approach to ethical nursing care of people who use illicit substances: an integrative literature review
of micro and meso influences. Drugs: Education, Prevention and Policy, 28(6) 533-546. https://doi.org/10.1080/09687637.2020.1840515

Keith, B., 2022. [Image] Nursing Care Plan Word Circle Concept. [online] www. dreamstime.com. Available at:
<https://www.dreamstime.com/stock-photo-nursing-care-plan-word-circle-concept-image38149310> [Accessed 18 January 2022].

Maughan, Molodynski, A., Rugkåsa, J., & Burns, T. (2013). A systematic review of the effect of community treatment orders on service use. Social Psychiatry
and Psychiatric Epidemiology, 49(4), 651–663. https://doi.org/10.1007/s00127-013-0781-0

Ontario Hospital Association (2016). A Practical Guide to Mental Health and the Law in Ontario.
https://www.oha.com/Legislative%20and%20Legal%20Issues%20Documents1/OHA_Mental%20Health%20and%20the%20Law%20Toolkit%20-%20Revised
%20(2016).pdf
 References cont.
Rothschild, A. (2013). Challenges in the Treatment of Major Depressive Disorder With Psychotic Features. Schizophrenia Bulletin, 39(4). 787-796.
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