NCM 0117 — 04 MOOD DISORDERS

MOOD DISORDERS

● Also referred to as "affective disorders"

● Characterized by the presence of pervasive alterations in emotions that are manifested by depression, mania or both

MOOD DISORDERS

● Can be regarded as a group of disorders characterized by a decrease or entire loss of control over mood

Major Depression

● Manifestations of depressed mood are severe and they last for at least two (2) weeks

Dysthymic Depression

Manifestations of depressed mood are of lesser severity, and may last for two (2) years or more

Mania

Manifestations of elevated mood are severe and last for at least one (1) week

Hypomania

● Manifestations of an elevated mood are less severe and may last for at least four (4) days

Bipolar I

● Characterized by one or more manic episodes alternated with at least one (1) major depressive episode

Bipolar II

Characterized by numerous major depressive episodes alternated with hypomania

Cyclothymia

● Characterized by numerous episodes of hypomania (shows manifestations of mania but can still function; milder version of mania) that last for at least two (2) years

SEASONAL AFFECTIVE DISORDER (SAD)

○ Has a fall-onset type (winter depression), and a spring-onset type of depression (less common, rare)

○ is a subtype of depression that occurs in the late autumn or winter (gloomy weather) and lasts until spring

NONSUICIDAL SELF-INJURY

○ Involves deliberate, intentional cutting, burning, scraping, hitting, or interference with wound healing (self-mutilation)

○ To lessen internal pain, they hurt themselves physically

serotonin and norepinephrine, acetylcholine and dopamine

NEUROTRANSMITTER PROBLEM

○ Major depression: caused by an abnormally low __ possibly __ level in the brain

Serotonin

norepinephrine

○ __ has roles in human behavior (e.g. arousal, hygiene, grooming, sleep, appetite)

● Low levels therefore can manifest in diminished arousal, impaired hygiene and grooming, sleep disturbances and poor appetite

○ Meanwhile, __ energizes the body to mobilize during stress

● Low levels therefore lead to depression of bodily activities

NEUROBIOLOGICAL/NATURE CAUSES

● Abnormalities that represent structural or chemical alterations that impair behavior.

● Often referred as "nature" causes of major depression

thyroid, adrenal, parathyroid and pituitary gland disorders

○ Increased glucocorticoid secretion seen in Cushing's syndrome

○ Hypothyroidism caused by hyposecretion of thyroid hormones

Endocrine disorders that may contribute to MDD

PSYCHOSOCIAL/PSYCHODYNAMIC FACTORS

● Conditions that are related with nurture (growth, development, personality)

● Also related with the person's response to life events

AGGRESSION TURNED INWARD THEORY

○ Overdeveloped superego leads to self-depreciation and depression

IDEAL EGO

○ Depression occurs when not able to achieve ideals all the time

○ Mostly seen in type A personality

COGNITIVE DISTORTIONS/THEORY

○ Mood disorder results from a negative view of the self, future and interpretation of experiences

○ NR: revert negative thinking to positive and focus on the present

LEARNED HELPLESSNESS THEORY

○ Mood disorder is caused by a belief that no one has control over his environment

PSYCHOANALYTIC THEORY

○ Major depression is caused by a rigid superego (conscience) leading to excessive guilt or disappointment

five (5) ; depressed mood or loss of interest or pleasure

substance

manic or hypomanic

DSM-V CRITERIA IN DIAGNOSING MAJOR DEPRESSION

There should be __ or more of the following and that one should be in either a ___ or __ in almost all activities:

The symptoms are not due to the physiological effect of a __ or an underlying medical condition

There has never been a __ episode

latency of response

psychomotor agitation

MDD

SPEECH

● May show __ (takes about 30 seconds before answering or responding to questions) ○ Too fatigued to answer in detail

● Sometimes, the client may exhibit __(increased body movements and thoughts)

directly asking the thought of suicide

Most important assessment area among clients with a major depression: __

True

True / False

In MDD, patirnts are usually oriented to three spheres but there is memory impairment

○ (1) verbalization of suicide ○ (2) giving away valued possessions

○ (3) making a suicide note

○ (4) sudden increase in energy level

Suicide warnings

frequent unscheduled

● PROVIDE A SAFE ENVIRONMENT

○ The nurse plans to have __ rounds, and avoid the use of metals or glass utensils for the client

"NO SUICIDE" CONTRACT

○ This contract directs that the client agrees to make oneself safe at all times

○ The client also notifies the healthcare providers if the impulse to commit suicide is present and persistent

Psychotic

__ features are more frequent in elderly than in younger people with depression

Short beut frequent

○ Depressed clients cannot tolerate or sustain long interactions. Therefore, visits should be

When the client verbalizes feelings of failure and helplessness, offering silence may not be therapeutic.

Circumstance wherein offering silence may not be therapeutic for patients with MDD

antidepressants

Major depression can be managed with a group of medications, known as.

TRICYCLIC ANTIDEPRESSANTS (TCAs)

● Oldest antidepressants

● Imipramine (Tofranil)

● Amitriptyline (Elavil)

● Clomipramine (Anafranil)

TRICYCLIC ANTIDEPRESSANTS (TCAs)

● Prevents reuptake (decreased effect is the consequence of neurotransmitter reuptake) of serotonin and norepinephrine, thereby increasing the level and effect of these neurotransmitters in the brain

ECG

○ __ monitoring may be ordered in the event the client is at risk to develop cardiotoxicity while on imipramine (Tofranil)

MONOAMINE OXIDASE (MAO)

○ An enzyme which breaks down norepinephrine and serotonin, decreasing the levels in the brain

MONOAMINE OXIDASE INHIBITORS ANTIDEPRESSANTS

○ To inhibit the action of this enzyme means to increase these neurotransmitters in the brain through administration of MAOIs ○ Used infrequently due to potentially fatal S/E and drug interactions

MONOAMINE OXIDASE INHIBITORS ANTIDEPRESSANTS

○ Tranylcypromine (Parnate) ○ Phenelzine (Nardil)

○ Isocarboxazid (Marplan)

tyramine

Other than norepinephrine and serotonin, MAO prevents breakdown of __

○ __: compound that is believed to have sympathomimetic effects (e.g. high blood pressure)

hypertensive crisis

○ If the client who regularly takes a MAOI and consumes tyramine-rich food items, the chance of the client developing into a __is high

HYPERTENSIVE CRISIS

Phentolamine Mesylate (Regitine)

○ Most serious life threatening S/E when taken with tyramine-rich foods

○ Presence requires administration of an antidote, __, 5 to 10 mg intravenously

epinephrine, norepinephrine, amphetamines, or levodopa with MAOIs

Other than tyramine-rich food items, concurrent use of __can also lead to hypertensive crises

HYPERTENSIVE CRISIS

High blood pressure, occipital headache radiating to the frontal area, neck stiffness, soreness, nausea, vomiting, sweating, fever, chills, dilated pupils, palpitations, tachycardia/ bradycardia.

SEROTONIN SYNDROME

○ Inadequate washout period between taking MAOIs and SSRIs or MAOIs combined with meperidine

● Changes in mental state

● Neuromuscular excitement

● Autonomic abnormalities

SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIs)

● Unlike MAOIs and TCAs that function to increase norepinephrine and serotonin, __ are specific to increasing serotonin levels in the brain

SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIs)

Function to prevent reuptake of serotonin, thereby increasing the neurotransmitter level in the brain.

○ Fluoxetine (Prozac)

○ Sertraline (Zoloft)

ATYPICAL ANTIDEPRESSANTS

● Used when client has inadequate response to or side effects from SSRIs

Somatic complaints

○ Major manifestation among cultures that avoid verbalizing emotions

ATYPICAL ANTIDEPRESSANTS

WARNING: potential for misuse and abuse

○ Common S/E: dizziness, nausea, sedation, vertigo, hypoesthesia, anxiety, lethargy, increased BP, vomiting, and "feeling of being drunk"

○ Serious S/E: dissociation, sedation, and suicidal thoughts and behaviors

2 to 3 weeks ; 3 to 4 weeks

ANTIDEPRESSANTS

These medications generally take __ before taking initial therapeutic effects (__for maximal effects).

anticholinergic

Antidepressant drugs cause __ side effects (photophobia, urinary retention, dry mouth, blurred vision, constipation, orthostatic hypotension) and the nurse should watch out and manage them, should they develop

with meals

Alcohol

caffeine

ATYPICAL ANTIDEPRESSANTS

● They are also taken with / without meals

● __ is avoided as they can lead to central nervous system (CNS) depression.

● Drug absorption is affected by intake of __.

TCAs, and sertraline/Zoloft (SSRI)

__ are administered as bedtime dose because of sedation, as a side effect.

MAOIs and fluoxetine (Prozac)

are administered in the morning as they cause insomnia.

BIPOLAR DISORDER

● Extreme mood swings: episodes of mania and depression

● Second only to major depression as cause of worldwide disability

BIPOLAR DISORDER

● Occurs almost equally among men and women

● More common in highly educated people

norepinephrine

NEUROTRANSMITTER PROBLEM

○ Mania is caused by an abnormally elevated __ level in the brain

● energizes the body to mobilize during stress

● High levels of __ = hyper-stimulation of physical and mental activities

hyperthyroidism

Other related disorder of mania is associated with __ caused by hypersecretion of thyroid hormones

Mania

○ __ is a defense against underlying depression, hence the emergence of bipolar disorder.

overdeveloped id

Mania is also caused by an __, the structure of the personality that is involved with pleasure and immediate gratification

Bipolar Disorder (Mania)

● Exhibits psychomotor agitation ○ Sitting seems to be difficult for the client

● Wears clothes that reflect elevated mood (e.g.

brightly colored, sexually suggestive clothes; with several jewelry and hair ornaments for women; tight and muscle-revealing shirt or bare chested for men) ● Moves, thinks and talks quickly

flight of ideas ; circumstantiality

Bipolar Disorder (Mania)

● Exhibits __ (rapid shifting of topics caused by pressured speech) and __ (over inclusion of ideas before responding to the specific question)

pressured speech

Characteristic of speech in BPD (mania)

time

● Clients with mania are generally oriented to person and place but rarely to __

Bipolar Disorder (Mania)

● They cannot delay gratification

● They tend to become hostile to others they consider as hindrance to their desired goals

● They also resort to pleasurable activities without regard to consequences

● They consider personal hygiene as a "boring" activity

calm, non-threatening

clear, firm voice

Use a __ voice (triggering phase)

○ Use a __(escalating phase)

4 members on each client's extremity, 1 member for the client's head, and 1 member for the client's torso

Obtain assistance from 4 to 6 staff members: __ (crisis phase)

LITHIUM CARBONATE (ESKALITH, LITHOBID)

● Management of the manic phase of bipolar disorder (anti-manic agent)

● Can stabilize bipolar d/o by reducing degree of frequency of cycling and eliminate manic episodes

LITHIUM CARBONATE (ESKALITH, LITHOBID)

● Peaks in 30 mins-4 hrs (regular form)/4-6 hrs (slow release form)

● Crosses blood-brain barrier, placenta, distributed in sweat and breastmilk

5-14 days

20-27 hours

LITHIUM CARBONATE (ESKALITH, LITHOBID)

● Onset: __

● Half life: __

LITHIUM CARBONATE (ESKALITH, LITHOBID)

Controls the flight of ideas and hyperactivity

0.6 to 1.2 mEq/L

hyperactivity

hypoactivity

○ Serum therapeutic level of lithium: maintained at a narrow range of __

● Less than the recommended is evidenced by the client's __

while more than the required level leads to toxicity and possible __

morning, 12 hours

To monitor serum lithium, blood samples are withdrawn in the __ after the last dose is take

Dry mouth, thirst, polyuria

Advise to increase fluid intake to prevent dehydration

Common s/e of lithium

after

10 to 14 days (or 1 to 3 weeks)

antipsychotic medication

LITHIUM CARBONATE (ESKALITH, LITHOBID)

○ The medication is best taken __ (before / after) meals

○ The therapeutic effects can be seen __ from the day the client starts the treatment

While waiting for the effects to settle in, the client may receive an __

sodium

high sodium diet (3 grams per day)

○ Lithium has the same property as __

● To prevent utilization of lithium as a source of sodium, the client must be maintained on a __

lithium toxicity

utilization of lithium by the body as a source for sodium results in

lithium toxicity

○ Evidenced by nausea, abdominal cramps, vomiting, diarrhea, and anorexia

○ Also include incoordination, hyperreflexia, seizures, anuria, altered LOC, hallucinations

Fine hand tremors

__ indicate beginning lithium toxicity

acetazolamide, aminophylline, phenothiazines, or sodium bicarbonate

Concurrent use of __ increases renal excretion of lithium, therefore decreasing the effectiveness of the drug

diuretics, non-steroidal anti-inflammatory drugs (NSAIDs), methyldopa and fluoxetine

Concurrent use of __can lead to lithium toxicity

mannitol or acetazolamide

○ Lithium toxicity is managed with the use of __ to promote urinary excretion of lithium

● Other than the antidote, discontinuing lithium administration is also included

Blood urea nitrogen (BUN) and serum creatinine

○ __ are monitored when serum lithium is elevated as this can lead to renal failure

Carbamazepine (Tegretol)

1st anticonvulsant found to have mood stabilizing properties

agranulocytosis

Carbamazepine

Threat to __: monitor for toxicity

70 to 150 volts

0.5 to 2.0

ECT

Involves delivery of voltage (__) over both temporal areas for __ seconds for each session.

grand mal seizures (generalized tonic-clonic seizure)

The presence of __ indicates effective delivery of required voltage.

6 to 12

48 hours.

ECT

○ Generally requires __ treatment-sessions to achieve therapeutic effects.

○ The interval between treatments is usually __

○ Depression

○ Mania

○ Catatonic schizophrenia.

MAIN INDICATIONS OF ECT

○ Increased intracranial pressure

○ Hemorrhagic conditions (such tuberculosis with hemoptysis)

○ Recent fracture

○ Retinal detachment

CONTRAINDICATIONS OF ECT

Atropine sulfate

Succinylcholine (Anectine)

Methohexital sodium (Brevital)

Commonly administered medications before an ECT include:

○ __: to decrease salivation

○ __: muscle relaxant

○ __: anesthetic agent.

○ Temporary memory loss ○ Headache ○ Apnea ○ Respiratory difficulty ○ Fracture.

Effects after an ECT include: