CM & MH: Unipolar Mood Disorders

mood disorder classifications: unipolar v bipolar

• unipolar: depressive

• bipolar: depressive & manic episodes

depression: physical & mental - anxiety, CVD, immune, cancer, dementia

• mental health condition: physical + mental

  • co-exists with anxiety: highly comorbid

    • anxiety: increase SNS activation —> cortisol

    • dep & anxiety: pro-inflammatory immune issues

  • dep impacts CVD

    • pt w CVD/MI more likely to have depression

      • mortality: 4x higher post-MI w dep, higher stroke risk —> increased risk iatrogenic infections/comp

        • dep worsen + nonadherence

    • treat dep (meds + pschotherapy): less likely CVD, adherence

  • dep weakens immune system: immunosuppression

  • dep precursor to cancer: increases cancer risk

  • dep associated w dementia/sleep issues

• heart & brain health related!!

depression: assessment - biomarkers, labs, assessments

• NO biomarkers/blood tests for depression/bipolar

  • Labs to r/o conditions that mimic depression / mania: TSH + CBC w/ diff

    • Hypothyroidism mimic depression

    • Hyperthyroid (mimic mania): labs 

      • Once rule out other conditions: assess for depression - s/s 

• Diagnosis: holistic assessment

  • MSE: psychological assessment

    • Symptom assessment (DSM-5):

      • Specific symptom screening tools (MBC/Q)

      • Assessment tools

MBC/MBQ: measurement based questions/care- what, purpose

• what: questionnaires pt fills out at home/ in office —> info

• purpose: screening + monitoring pt overtime

  • secondary prev: screen / intervene in depression (at risk pop)

  • monitor pt overtime: detect improvement in s/s, SE

  • pt adherence: engagement/awareness of own s/s

    • improvement in patient-centered outcomes & diagnostic accuracy

• EX: PHQ-9, BDI, MDQ, GDS, ZDRS

dQM: digital quality measures

• what: device at home, captures data, analyzed by AI —> predict disease

• goal: upstream prevention

• risk: health inequities - AI more accurate in predicting dep severity in white pts, not as accurate for black pts

depression: definition

• condition of mind, body, mood, & spirit —> symptoms

  • causes impairment in functioning/marked distress

• diagnosis: holistic assessment - symptoms different for all pts 

• types:

  • MDD

  • dysthymia

  • others

MDD: major depressive disorder - DSM criteria for diagnosis

• DSM-5 criteria:

  • 5+ total s/s: must include #1 and/or #2

  • most of day, nearly every day: ~ 80-100% of time

  • for at least 2 weeks: prevailing feeling, change from baseline

    • impairment in functioning

• s/s:

  • 1. Dysphoria: depressed/bad mood, irritability, anger, sadness

    • Cultural variations: may not express depressed mood/emotion → somatic manifestations (asian or hispanic) 

  • 2. Anhedonia: loss of interest/pleasure in usual activities 

  • Appetite: wt gain/loss (w/o attempt to ∆ wt, ~5%)

    • symptom of wt loss: anorexia

  • Sleep: hypersomnia/insomnia

    • Sleep: one of 1st improvements w/ antidepressants

    • types:

      • Early morning awakening: up before needed, cant go back to sleep 

      • Middle: wake up in middle of night 

      • Difficulty falling asleep: > 30 min - PMA (thoughts racing) —> stay in bed to rest, get up briefly

        • Sleep hygiene: cognitive/behavior approach - wind down 

  • Low energy: tired, physical (check labs anemia, thyroid) 

  • PMA/PMR: brain is not slowing down, mental slowing 

  • Poor con/decision-making/focus: don't make major life decisions 

  • Worthless/excess/inappropriate guilt: blame self for everything

  • SI: range from passive to active

• Behavior: isolation- needs human contact, sit with person

• Anger management: use clear communication, role model appropriately

dysthymia: def, DSM, s/s

• def: mild-moderate depression (less severe), chronic/persistent (2+ yrs)

  • often missed: thouhg of as part of pt personality

• DSM-5 criteria:

  • Depressed mood:

    • 2+ sxs: less s/s, not as severe as MDD

  • most of day, more days than not: 50-60% of the time, half/more

  • 2+ years

• s/s:

  • under- or over-eating,

  • sleep difficulties

  • fatigue

  • low self-esteem

  • difficulty with concentration or decision making

  • feelings of hopelessness (less than suicidality)

    • + Impairment in functioning

    • No MDD in first 2 yrs

    • No manic or hypomanic episodes

    • Not r/t SUD or general medical condition

• treatment: same as MDD

PPD: postpartum depression

• def: major depressive s/s or anxiety for well-being of baby

• brain development: baby develop trust in parent, behavior has impact, poor attachment = MH issue

• anti-dep meds: cross placenta/milk - considerations in treatment

seasonal affective disorder

• def: dep s/s in pattern w/ seasons

psychotic depression

• def: dep + psychotic s/s

  • primarily mood disorder, plus psych s/s bc mood disorder severe

  • additional treatment: antipsychotic (in addition to anti-dep)

PMDD: premenstrual dysphoric disorder

• def: major dep s/s w period

• new to DSM-5

adjustment disorder with depression

•  def: life trigger (something caused) for depression; temporary

  • Upstream trigger: use this to target treatment 

substance-induced mood disorder

• using substance → impact mood

  • corticosteroid/alcohol/opiate → dep

• mood disorder lifted when you remove the drug 

  • Dual diagnosis: with sud dugs - manage both conditions

mood disorder d/t medical condition

• medical condition causes psych condition

• treat medical condition first, if not possible treat both 

mood disorder unspecified

• symptoms that don't meet threshold (for specific dep diseases) yet, still need treatment

depression: epidemiology - prev, F, suicide, psych, disability, comorbid, costs, treatment/prevention

• Prevalence: common - 5% worldwide

  • risk: females > males (2:1 ratio)

• Risk factor for suicide: 15% severely dep commit suicide → assess

  • Risk for psychotic s/s: 10% psychosis → treat with anti-sych

•  #1 cause disability in US., 4th worldwide - unable to work/function

  • 11% Worldwide Dz. burden (middle-high income countries)

• High medical comorbidity: preventable & treatable w access to treatment —> upstream prev of dep = prevent other disease too

  • CVD

  • CVA

  • DAT-15-30%

  • Cancer & Parkin’s 20-40%

  • DM >10%

  • Suicide, insufficient sleep (GH), anxiety, obesity, physical inactivity are associated

• Costs: depression economics → financial burden 

• Only 1/3 seek help/access care: is treatable and preventable

depression: epidemiology - meds

• Treatment to full remission (defined as no s/s):

  • don't just try to have improvement in s/s

  • prevent chronic depression (harder to treat)

    • 1 episode: 50-60% recur

    • 2 episodes: 90-95% recur risk

    • (⅓) → chronic depressive course  = more difficult to treat

• Integrated approach: psychotherapy + meds + pt role

  • EBP: “STAR-D Trials” (NIMH) - determine adequate med. trial

  • Need to: augment with 2nd drug, before switching to new drug

    • only 2 opportunities to get meds right

    • then becomes harder to treat (remission decreases after 2 good med trials)

    • → chronic course: prevent upstream before it becomes chronic

depression: at risk pop - men

• CVD associations:

  • Contrib → fatal coronary artery events

  • Depressed males: 2x risk CVD problems in next 5yrs

• More common if single, separated, divorced, widowed

• 1 in 7 men develop s/s w/in 6mos of unemployment

• AA males: 92% do not seek treatment- machismo 

• 3x more likely to commit & successfully complete suicide

  • Firearms #1 (lethality): use more lethal methods

depression: at risk pop - women

• 2x > as men: attempt more

• 1 in 3-4: lifetime prevalence - 25-30% all women

• 10% post-partum

• Married / partnered: higher rates

• Most common: 25-44 years - changes with life roles 

• Hormonal, cultural, socio-political implications

• General treatment considerations:

  • Pregnancy & Post-partum: NO psychotropic FDA-approved for use in pregnancy. ALL cross placenta → teratogenic risks.

    • Balance risks w/ psychiatric relapse (Relapse is also associated w/ poor pregnancy outcomes)

depression: at risk pop - transgender

• Increased burden of psychiatric problems r/t

  • chronic stress

  • stigma (internalized & cultural / institutional)

  • lack of access / support / recognition: health disparity

  • trauma

• Youth: gender affirming care —> improved well-being, lower risks of dep & suicidality

• Adults: high prevalence of psych con - depression, suicidality

depression in children: epidemiology - prev, M/F, fam hist, f/u care, prevention

• prev: 2.5%

• M:F: equal rates until puberty (then F greater risk)

• Family history (20-50%): biological, developmental exposure 

  • First degree relative: higher risk 

• 2/3 do not receive proper treatment

  • Shortage of ped MH specialist 

• Prevention:

  • opportunities to talk about loss

  • family bereavement program: lowers dep

depression in children - s/s

• Irritability, sadness

• sleep disturbances

• SI

• regression to early phases of dev (eneresis)

• Don’t share crying & depressive thoughts

• Somatic s/s: manifest psych s/s physically 

  • HA

  • abdominal pain

  • fatigue

• No wt or height gains: failure to thrive 

• Deteriorating school performance

DMDD: disruptive mood dysregulation disorder- age, s/s

• New DSM-V ped Depressive Disorder (response to over-dx of bipolar)

  • childhood disorder

• Age: 6-18yrs 

  • Onset before age 10

• diagnosis: oubursts 3x a week for 12+ months

• S/S:

  • Severe/recurrent temper outbursts: angry, irritability, hostile

  • Grossly out of proportion (intensity & duration) to situation

• Observable: by peers, teachers, parents in at least 2 settings over 12 months

depression: adolescents- prev, M/F, suicide, self-harm, SDOH

• prevalence: 20.1%

• F > M (2:1)

• Family history: (20-50%) 

• High suicide risk: 2 leading cause of death

  • F suicide rate: increasing since & rising faster than males 

    • Fastest growing demographic, ages 10-14 (tripled)

  • M suicide rates: 3-4x higher than F (rising but slower rate)

• risk:

  • Self-harm: strongest risk worldwide

    • understand what behavior is communicating (doesn't mean they are suicideal) → assess

• SDOH & Comorbidities: SUDs, pregnancy, uncertain sexual orientation or gender id, poor peer / social relations, poor academic performance, exposure to life events - physical illness, death, loss, abuse

adolescent: depression - s/s

• s/s:

  • Difficulty expressing emotional distress; acting out 

  • Self-injurious behaviors (SIB); often r/t relationship crises

  • Moodiness, anger, withdrawal, frustration, loss of interest, restlessness

• Nursing Management: Build Trust

  • Conflicts arise between parents & minors: listen, try to align & resolve conflicts

  • If teen not psych/physically competent; parents’ decisions/wishes primary

depression: elderly - epidemiology, missed, F/M, suicide (at risk)

• NOT a normal dimension of aging: often missed 

  • Dx: missed 85% of time

  • Secondary to physical illness/medications

  • Depression = risk factor for Dementia!

  • F > M

• Suicide: most at-risk group

  • 15% > age 65

  • 25% of all suicides

  • Caucasian males > age 75 - highest risk group - 6x to suicide > any other group

• late onset depression: SDOH - fod/smog exposure

depression: elderly - s/s, pseudo dementia, assessment

• s/s:

  • Decreased energy

  • Anhedonia: loss of interest/pleasure

  • Increased dependence on others

  • Multiple Somatic complaints: Wt loss, PI, GI distress

• ‘Pseudo-Dementia’:

  • Confusion & memory deficits r/t depression: unclear thinking 

  • Often missed or dismissed as dementia but actually is depression

• Nurse Assessment - Screening:

  • Geriatric Depression Scale (GDS):

depression: etiology - psychosocial - fam, attachment, maternal, personality, cog, behavioral

• Familial patterns, social learning: patterns of learned bx may repeat

• Attachment theory: object loss theory – delayed grieving for earlier loss of a primary caregiver that person was bonded with.

• ‘Maternal’ (Primary Caregiver) depression: → neglect, poor attachment.

• Personality-Low self-esteem → ‘depressed’ personality formation.

• Cognitive: distorted thinking→ depressed feelings; negative mindset, hopelessness toward self, world, future

• Behavioral:

  • Reinforcement of negative thinking by behaviors (like self-fulfilling prophecy)

  • Loss of + reinforcement; lack of supports

depression: etiology - psychosocial - diathesis/stress

• Where we are today: combination of associations / risks requires integration into TX.

  • → Diathesis-Stress (Multi-factorial biopsychosociocultural → many tx’s)

    • Integrated (Bio-psycho-socio-cultural approach)

    • Depression is a complex, heterogeneous disorder that cannot be simplified or explained by a deficiency in one area (biochemical or social) → Therefore “Treatment” must include management of all aspects of the condition that are unique to the individual.

depression: biological - genetics, NT - serotonin, dopamine, inflam

• Genetics: many genes; + family history - not one single gene, epigenetic influence 

  • Multifactorial

• NT:

  • Serotonin (5HT) & Norepinephrine (NE): low → increased depression, anxiety

    • Tx: Increased 5HT (receptor sensitivity & transport) → increased 5HT post-synaptic → less depression & anxiety

  • DA-Dopamine (reward circuits): low —> dep

• Bottom Line: depends on # of NTs that cross synapses & quality of specific NT (excitatory or inhibitory)

• Newer Theories: Depression = r/t Inflammation (?)

  • Inflammatory d/o’s have high co-morbidity with depression

  • TNF (tumor necrosis factor) is pro-inflammatory

    • elevated serum TNF levels = associated with depression →

    • ANTI- Inflammatory meds also can cause Depression

depression: interventions - primary

• primary: general population - upstream to prev dev

• Infant attachment: primary caregiver (biological drive to bond)

  • Later in life if bonding / attachment occurred initially = object loss theory (if primary caregiver dies / absent in childhood)

•  Parental support & education

•  Socialization, skills-building, clear communication (esp. with kids)

•  Self-esteem building

•  Temperament-personality / family hx (biological-social learning risks)

  • Ex. Negative Mood or Patterns of Depressive Thinking → build adaptive skills, resilience & + coping

•  Programs & National Campaigns, Prevention Research

  • Support, promote & build self-esteem, resilience, tolerance, improved parenting. (ie. Bullying, suicide) etc.

•  Health Teaching: schools & parents

  • Ex’s - Clear communication, exercise, wellness, nutrition, resilience, mindfulness, faith, gratitude.

secondary interventions: screen/intervene - tools, intervene - therapy, meds

• secondary: at risk pop - screen & intervene (early treat/ref)

  • Screening Tools: MBC / MBQ

  • Intervene: early to prevent risks, future problems

    • highest risk: suicide = safety

    • management: early s/s - EBP

      • psychotherapy: referrals

        • CBT: insomnia

      • Meds

        • ST: benzo

        • LT: anti-dep - SSRI, SNRI

          • milieu: socialization, prev isolation

      • adjunctive: TMS, nutrition, Omega 3, light

antidepressants and end of life care: meds

• Palliative care:

  • End of life: no time to wait for anti-dep (SSRI, SNRI) to work

  • Psycho-stimulants = treatment of choice - faster-acting drugs 

    • Methylphenidate (Ritalin etc) → increase dopamine to have more energy/focus

    • Elevate mood, energy, concentration, focus (improve QOL).

    • Addiction & Cardiac risks from Stimulants are not considered in end of life.

tertiary interventions:

• tertiary: diagnosed issue, chronic - manage s/s, prevent relapse, rehab

• Same as SECONDARY + more Invasive strategies not used earlier in treatment (and any and all treatments for those with chronic sxs):

  • Hospitalization

  • Electroconvulsive Therapy (ECT): only tertiary 

  • Deep Brain Stimulation (DBS) – psychosurgery

  • Transcranial Magnetic Stimulation (TMS) – not invasive (can also be secondary prev)

• EB Psychotherapy Referrals:

  • Cognitive, Behavioral Strategies (CT, CBT), Interpersonal Therapy (IPT)

  • Individual, Family, Group Therapy

• Relapse Prevention, Symptom-Management Education, Practice

• ‘Adjunctive’ (added to) Treatments:

  • CAM’s (now considered Holistic Integrated Tx’s):Exercise, Healthy Diet, Omega 3 fatty acids supplements, Sleep tools

    • Antidepressants

    • Thyroid Supplementation

    • Omega-3 fatty acids

    • Phototherapy

    • CAM’s, Exercise

  • Added Meds (Lithium, Synthroid, Ketamine for Tx –resistant, Short-term)

  • Phototherapy (ultraviolet light therapies; sunlight)

• Therapeutic Communication:

  • MI (OARS, Empathy, CBT tools)

  • BATHE Technique: Background, Affect, Troubles, Handling of current situation & Empathetic statement.

• EB-Referrals: Offer Resources & Supports & ensure appropriate, pt-specific & timely

depression: summary - treatment

• Depression is treatable: treat early, to full remission

  • better prognosis than other mood disorders: 85% recover

  • neuroprotective for long-term risks:

    • upstream prevention:

      • CVD

      • cancer: precursor

      • dementia

      • suicide

      • immune function

      • chronic dep: harder to treat, worse QOL

• GS: Integrated care - Meds +Therapy Tools + Self-Management

  • Meds + Therapy + Exercise → speed recovery all depressions.