NRS 3016 Mood Disorders

mood disorder (affective disorder)

disturbance in mood is the predominant feature, causing significant distress or impairment

mood

sustained internal emotional state the patient REPORTS

ex: depressed, elevated, expansive, irritable

affect

observable external expression of emotion the nurse SEES

ex: flat, blunted, labile, euphoric

what assess both affect (observed) and mood (reported)?

MSE

MDD

one or more depressive episodes

persistent depressive disorder (dysthymia)

chronic, ≥2 years

disruptive mood dysregulation disorder

children, severe temper outbursts

bipolar I

at least one full manic episode

bipolar II

hypomania + MDD, no full mania ever

cyclothymic disorder

chronic sub-threshold cycling, ≥2 years

mixed features in bipolar

concurrent manic and depressive symptoms

rapidly cycling in bipolar

≥4 mood episodes/year, poor prognosis

what should you never give alone in bipolar disorder and why?

anti-depressants because of the risk for triggering mania or rapid cycling

risk factors for mood disorders

first degree relative with a mood disorder = 3x higher risk

females (70% more)

hx of trauma, abuse, adverse childhood experiences (ACEs)

significant life stressor: loss, divorce, financial crisis, major illness

>65 years old: under-diagnosed, misattributed to normal aging

high risk grounds (10-15%): youth, veterans, postpartum patients

what do you use to screen all patients for depression?

PHQ9 (across every medical setting, not just psychiatry)

depression co-morbid conditions: cardiovascular

post-MI depression doubles mortality risk and lowers medication adherence

depression co-morbid conditions: cancer & neurological

common in cancer (25-50%), stroke (up to 33%), PD, MS

depression co-morbid conditions: metabolic

diabetes → depression doubles complication risk

hypothyroid mimics MDD

depression co-morbid conditions: chronic pain

fibromyalgia, arthritis share neural pathways, both respond to SNRIs

before diagnosing MDD, what do you need to rule out?

hyothyroidism (TSH)

depression neurotransmitters deficit: serotonin

depressed mood, irritable, sleep/appetite changes

depression neurotransmitters deficit treatment: serotonin

SSRI, SNRI, MAOI

depression neurotransmitters deficit: norephinephrine

fatigue, poor concentration, low motivation

depression neurotransmitters deficit treatment: norephinephrine

SNRI, TCA, MAOI

depression neurotransmitters deficit: dopamine

anhedonia, psychomotor retardation

depression neurotransmitters deficit treatment: dopamine

buproprion (wellbutrin)

MDD/Bipolar genetic, hormonal, psychosocial theories

heritability: MDD 37-50%, Bipolar 60-80% in identical twins

HPA axis dysregulation → chronically elevated cortisol

diathesis-stress model

for MDD/Bipolar: biological vulnerability + sufficient stressors = disorder arises

beck’s cognitive triad

in MDD/bipolar: negative view of self/world/future → CBT challenges these thoughts

learned helplessness

in MDD/bipolar: uncontrollable events → hopeless → behavioral activation = tx

MDD DSM-5 criteria mneumonic

SIGECAPS

Sleep disturbance (insomnia/hypersomnia)

Interest loss (anhedonia)

Guilt (worthlessness, self-blame)

Energy loss (persistent fatigue)

Concentration difficulty (brain fog, trouble concentrating)

Appetite/weight ∆ (>5% in one month)

Psychomotor retardation or agitation

Suicidality (assess EVERY shift)

official MDD dx from DSM-5 criteria

depressed mood or anhedonia + ≥4 SIGECAPS sx

MDD symptoms

persistent sadness, emptiness, hopelessness

anhedonia, irritability, negative automatic thoughts or catastrophizing

MDD behavioral/physical sx

psychomotor retardation or agitation, social withdrawal, isolation

neglect of self-care/ADLs, sleep disturbance, appetite changes

MDD clinical presentation

flat or sad affect, poor eye contact, slumped posture, disheveled appearance

monotone speech, impacts occupation/social/self-care/cognitive functioning

non-adherence to cardiac/diabetic meds = depressive sx (not patient failure)

MDD special populations: children/adolescents

diagnosable as young as 3 and in up to 18% of preadolescents

irritable > sadness

monitor for suicidality in first 4 weeks of antidepressant therapy

MDD special populations: 65+ years old

often under-diagnosed d/t misttributed to normal aging

most lethal suicide methods used

SSRIs raise fall/hyponatremia risk

depression can mimic dementia

depressive disorder subtypes: persistent depressive disorder (dysthymia)

depressed mood ≥2 years

feels normal to the patient

risk for double depression

depressive disorder subtypes: disruptive mood dysregulation disorder

children 6-18

severe temper outbursts ≥3x/week + irritable mood between

depressive disorder subtypes: premenstrual dysphoric (PMDD)

mood symptoms in the week before menses, improving after onset

depressive disorder subtypes: seasonal affective disorder (SAD)

tied to a season (usually fall/winter)

light therapy is first line

grief

the subjective emotional response to loss - normal, internal process

mourning

the outward expression of grief - behavioral, social, cultural

complicated grief

prolonged (>6-12mo), does not improve, may worsen - needs progressional care

Kubler-Ross 5 stages of grief

1. Denial

2. Anger

3. bargaining

4. depression

   1. acceptance

Kubler-Ross 5 stages of grief: denial

this can’t be happening

initially adaptive, protects from overwhelming pain

Kubler-Ross 5 stages of grief: anger

why me?

rage at providers, family, God, allow safe expression

Kubler-Ross 5 stages of grief: bargaining

If only…

negotiating with fate to undo the loss

Kubler-Ross 5 stages of grief: depression

what’s the point?

sadness and withdrawal, a normal grief response

Kubler-Ross 5 stages of grief: acceptance

I can go on

not being okay, but integrating the loss

Worden’s 4 tasks of mourning

1. accept the reality

2. process the pain

3. adjust to the new world

4. find an enduring connection

Worden’s 4 tasks of mourning: accept the reality

move from intellectual acknowledgment to emotional acceptance

Worden’s 4 tasks of mourning: process the pain

allow emotional pain to be fully felt while practicing self-care

Worden’s 4 tasks of mourning: adjust to a new world

external, internal, spiritual adjustments without the deceased

Worden’s 4 tasks of mourning: find an enduring connection

relocate the deceased in memory while embracing a new life

normal grief duration/ SI/ daily function

duration: improves gradually over weeks-months

SI: passive → i wish i were with them

daily function: temporarily impaired, gradually restores

complicated grief duration/SI/daily function

duration: >6-12months with no improvement

SI: Active → persistent thoughts, plan, intent

daily function: persistent inability to resume routines

grief and loss nursing interventions

what does this loss mean to you?

allow adaptive denial and do not push premature acceptance

use empathic, open-minded communication; be patient and present

encourage self-care and connections

assess for SI non-judgmentally in pts and family members

what phrase validates feelings without minimizing the loss

this must be very difficult for you

hospice focus/setting/timing

focus: comfort, EOL care

setting: typically the pts home

timing: appropriate at EOL

palliative care focus/setting/timing

focus: symptom relief, QOL, any stage

setting: hospitals, outpatient settings, or home

timing: appropriate at any stage of serious illness

what is the referral when a palliative patient is discharged home to die?

hospice

bipolar episode requirement: bipolar I

≥1 full MANIC episode (≥1 week)

bipolar episode requirement: bipolar II

hypomania (≥4 days) + MDD

never full mania

bipolar severity: bipolar I

severe impairment, hospitalization often required

bipolar severity: bipolar II

not severe enough to require hospitalization

bipolar psychosis: bipolar I

may occur during mania

bipolar psychosis: bipolar II

does not occur during hypomania

bipolar is more common in: bipolar I

males → higher rates of psychosis

bipolar is more common in: bipolar II

females, often misdiagnosed as unipolar MDD

manic episode clinical manifestations: grandiosity

inflated self-esteem

believes in special powers or abilities

manic episode clinical manifestations: decreased sleep need

feels rested after 2-3 hours, not insomnia

manic episode clinical manifestations: pressured speech

rapid, loud, difficult to interpret

manic episode clinical manifestations: flight of ideas

racing thoughts, rapidly shifting topics

manic episode clinical manifestations: distractibility

attention easily pulled to irrelevant stimuli

manic episode clinical manifestations: risky behavior

spending, sexual indiscretion, reckless driving - HIGH safety risk

mania behavior

psychomotor agitation, excessive activity

depression behavior

psychomotor retardation, slowed movement

mania speech

pressured, can’t stop talking

depression speech

monotone, minimal conversation

mania nursing priority

safety (self/others), nutrition

depression nursing priority

safety (suicide risk), nutrition

mania milieu

non-stimulating, quiet environment

depression milieu

stimulating, structured engagement

bipolar nursing assessment: mood

affect quality and intensity

bipolar nursing assessment: behavior

psychomotor activity, disinhibition

bipolar nursing assessment: thought process

flight of ideas, grandiosity

bipolar nursing assessment: psychosis

grandiose delusions, command hallucinations

bipolar nursing assessment: danger to self/others

reckless or aggressive behavior

bipolar safety considerations

remove access to money, car keys, credit cards

high-calorie finger foods

use FIRM, CALM, SHORT statements and do not match their energy

redirect energy to a quiet, non-competitive activity

what is the goal in acute-mania?

de-escalate safely and maintain structure

do not argue the patient into insight

SSRI: MOA

blocks serotonin re-uptake to increase synaptic serotonin

SSRI drug names

sertraline, escitalopram, paroxetine, fluoxetine

SSRI: indications

MDD, GAD, panic disorder, OCD, PSTD, PMDD

SSRI: onset

2-6 weeks

anxiety may worsen in first 1-2 weeks temporarily

SSRI black box warning

increased suicidality in patients ≤24yrs (monitor first 4 weeks)

SSRI SE:

N/D, dry mouth

sexual dysfunction (top cause of non-adherence)

hyponatremia (SIADH)

serotonin syndrome sx

agitation, confusion, rapid HR, muscle twitch, loss of coordination, excessive sweating, diarrhea

never combine SSRIs with?

MAOI, tramadol, St. John’s Wort

TCA AE

anticholingeric effects: dry mouth, blurred vision, constipation, urinary retention

orthostatic hypotension: fall risk, sedation, weight gain

toxicity: QRS prolongation, arrhythmia, seizure, coma

antidote for cardiac toxicity: IV sodium bicarbonate