(Exam 2) Mood Disorders

mania

period of intense mood disturbance w/ persistant elevation, expansiveness, irritability, and extreme goal-directed activity or energy

- mania intensifies = may become psychotic ( sx are severe enough that this state is a psychiatric emergency)

hypomania

low-level and less dramatic mania ; DOES NOT impact functioning in a way that is noticeable to others

mood lability

rapid shifts in mood with little or no changes in external events

bipolar I disorder

at least one episode of mania alternating w/ major depression

bipolar II disorder

one or more hypomanic episodes alternating w/ major depression

cyclothymic disorder

chronic mood disturbances of at least 2 years w/ many periods of elevated mood and DO NOT meet criteria for hypomanic episode AND many periods of depressed mood that DO NOT meet criteria for major depression

manic episode

mania plus 3 or 4 other symptoms

major depressive disorder

depressed mood or loss of interest coupled w/ 4 other symptoms

hypomanic episode

hypomania (less severe and shorter duration than mania) plus 3 or 4 other symptoms

mixed episodes

meets criteria for both a manic and a major depressive episode

assessment manic phase: mood

unstable, may change quickly to irritation/anger

assessment manic phase: miscellaneous

- decreased need for sleep

- activities w/ painful consequences (spending, sexual, etc.)

- marked impairment in social or occupational functioning/hospitalization

assessment manic phase: speech patterns

- pressured speech

- circumstantial speech

- tangential speech

assessment manic phase: thought processes

- flight of ideas

- loose associations

assessment manic phase: thought content

- grandiose delusions

- persecutory delusions

assessment depressive phase (7)

- flat/blunted/labile affect

- tearfulness

- anergia, anhedonia

- difficulty concentrating or problem-solving

- suicidal ideation

- decreased in hygiene

- loss or increase in appetite and/or sleep

what are the nursing interventions aimed at (6)

- LEAST restrictive environments

- safety!! (injury, harm to self or others)

- promote rest and sleep! (avoid caffeine!!)

- restore nutritional and hydration status (high protein/foods/drinks)

- anger management (techniques to control anger responses)

- set limits on inappropriate behaviors

what are our ACTUAL nursing interventions

- monitor sleep, fluid intake

- offer hand-held, nutritious food

- administer mood stabilizing agents

- provide a structured environment

- de-escalation & anger management

- communication

how should we use communication?

- calm, matter-of-fact

- give concise explanations

- consistent w/ expectations and limit-setting

- avoid power struggle

what are the treatment modalities for bipolar disorder

pharm (mood stabilizers): lithium, anticonvulsants, atypical antipsychotics

brain stimulation therapies

psychological therapies (cognitive behavioral therapy, family-focused therapy)

what are mood stabilizers

classes of drugs used to treat sx associated w/ bipolar disorder

- effective in treating mania; not all do well with depression

- antidepressants = little effectiveness in treating bipolar depression; taking w/ mood stabilizers risks triggering a switch from depression to mania

what is important to know about lithium

gold standard among mood stabilizers for bipolar

- REGULAR monitoring (therapeutic index 0.6-1.5 mEq/L)

- BAD FOR BABY

- NSAIDs & diuretics can increase lithium levels

- baseline assessment of renal and thyroid function

what are the adverse effects of lithium (derm, G.I, endocrine, fluid/electro, nervous/MSK)

derm: acne, alopecia, psoriasis

G.I: diarrhea, N/V

endocrine: hypothyroidism, weight gain

fluid/electro: edema, polydipsia, polyuria

nervous/msk: ataxia, sedation, fine tremor

lithium levels < 1.5 mEq/L sx

G.I distress, weight gain, fine hand tremors, renal toxicity, hypothyroidism, electrolyte imbalances, hypoTN

lithium level 1-5 - 2.0 mEq/L

G.I upset, coarse hand tremor, confusion, hyperirritability of muscles, sedation

- withhold medication & notify HCP

lithium level 2.0-2.5 mEq/L

ataxia, blurred vision, large output of dilute urine, seizures, stupor, severe hypoTN, coma

- hospitalization indicated

lithium level > 2.5 mEq/L

convulsions, oliguria (none or small amounts of urine)

- DEATH CAN OCCUR

what are anticonvulsants with proven efficacy in bipolar disorder

- valproic acid

- carbamazepine

- lamotrigine

what is the FDA warning for anticonvulsants

carry a warning label indicating an increased risk for suicidal thoughts

mood stabilzer: valproate (valproic acid)

effective for the acute manic phase of bipolar disorder; used for the long term to prevent recurrence of mania

- therapeutic range: 50-125

- bad for baby

- FDA black box for several adverse responses

- monitor LFTs, CBC

valproate side effects (common and severe)

common: sedation, weight gain, tremor

serious: thrombocytopenia, pancreatitis, hepatic failure, hyperammonemia

mood stabilizer: carbamazepine

Second-line agent for bipolar disorder, effective for the acute manic phase

- therapeutic level: 4-12mg/L

- BAD FOR BABY

- FDA black box warning for serious derm reactions (SJS,etc)

- monitor LFTs, CBC, ECG, Na levels

carbamazepine side effects

dizziness, somnolence, N/V, ataxia, blurred vision, hyponatremia, leukopenia

mood stabilizer: lamotrigine

approved for maintenance tx of bipolar disorder; prevent recurrence of mania and depression

- benign rashes caused can be minimized by slow titration up

- can RARELY cause SJS

lamotrigine side effects

benign skin rash, nausea, vision changes, HA sedation

second-gen antipsychotics

serotonin/dopamine blockers may reduce psychotic sx in mania

- sedative properties in early phase of tx

- may cause weight gain, insulin resistance, DM, dyslipidemia, cardiovascular impairment

- to prevent mania from reoccuring; lithium & valproate used together with serotonin/dopamine blockers

what are integrative therapies

- brain stimulation therapies (ECT, TMS may be appropriate)

- client & family teaching: adherence to medication, reducing risk of relapse

- psychological therapies: cognitive behavioral therapy (w/ pharm), family-focused therapy (improve communication among family members)