Ch 15 and 16 Mood Disorders

subjective experience of patient's sustained emotions and feelings (this is what the patient is saying to you)

mood

more objective. outward expression of their mood and feelings. (this is what you see as the nurse)

can include verbal and nonverbal cues

affect

what kind of affect?

shows no emotion

flat (affect)

what type of disorder ?

when mood starts to interfere w/ functioning

mood disorder

the average age of onset for bipolar disorder is age ______

18

true or false

those w/ chronic conditions are at higher risk for mood disorder

true

these disorders cause marked disturbance in psycho, physio, and or social functioning

- major depression, persistent depressive disorder (dysthymia), bipolar disorder I and II

- cyclothymic disorder, SAD, post partum depression

mood (disorders)

risk factors for what?

- female

- under age 40

- absence of social support

-childhood trauma

- negative life event (unexpected death, unexpected job loss)

- drug and alc abuse

- family hx of genetics in 1st degree relative

depression

these are what kind of factors for depression?

- genetics- if one twin has depression, the other one has 50% chance

- biochemical (ex: neurotransmitters: serotonin, norepinephrine, dopamine, acetlycholine, GABA)

- alterations in brain structures (enlarged cerebral ventricles)

- diatheses stress model

biological (factors)

which theory for depression?

individuals w/ depression have a negative view of life events and it causes them to be depressed

cognitive (theory)

(cognitive therapists will help them try to correct their neg thought patterns into more positive thought patterns)

which theory for depression?

theory that a depressed person believes that an undesired event is their own fault but they can do nothing to change outcome of the event

learned helplessness

manifested by emotional, cognitive, physical and behavioral symptoms occurring nearly every day for at least a 2 week period that interferes w/ daily functioning

for diagnosis, pt has to have 5 or more of the symptoms

major depressive disorder

cognitive emotional symptoms of what?

- report of depressed mood

- anhedonia

- feelings of worthlessness and guilt

- feelings of hopelessness

- decreased concentration

- irritability

- recurrent thoughts of death and suicide

major depressive disorder

loss of interest that people used to find enjoyable

anhedonia

physical symptoms of what:

- weight gain or weight loss

- insomnia (can't sleep)

- hypersomnia (sleep too much)

- decreased activity

- anergia

- a lot of somatic complaints: headache, fatigue, back ache, constipation

- decreased libido

- changes in grooming or appearance

- stooped posture

- trouble w/ decision thinking

- poor self esteem

- substance abuse

- social isolation

major depressive disorder

lack of energy; lack of motivation

common in major depressive disorder

anergia

chronic low grade depression

- characterized by chronic depressive syndrome usually present for most of day, more days than not, for at least a 2 year period

- may be irritable

- not usually severe enough for hospitalization unless person becomes suicidal

onset is usually early childhood, teenage years, or early adulthood

persistent depressive disorder (dysthymia)

is there a strong genetic link in bipolar disorder

yes

what kinds of factors for bipolar disorder?

neurotransmitters: norepinephrine, dopamine, serotonin, GABA, glutamate

neurobiological (factors)

what kinds of factors for bipolar disorder?

HPA Access (hypothalamic pituitary adrenal)- could be imbalances with this

neuroendocrine (factors)

what kind of factors for bipolar disorder?

changes in brain structures w/ individuals w/ bipolar disorder

neuroanatomical (factors)

this is a psychological factors:

experiencing a stressful life event can trigger a _________ episode

(the most common reported stressful life events: poor sleep patterns, family conflict)

manic (episode)

symptoms of mania in bipolar

- elevated and labile mood

- irritability

- euphoria

- inflated self esteem

- more talkative "pressured speech"

- decreased need for sleep

- hypersexual

- flight of ideas

- psychomotor agitation

in _________ of bipolar disorder, pt may have:

- inappropriate mode of dress

- inappropriate behavior

- may exploit others

mania

mania mood persists for at least _______ days in bipolar disorder

7 (days)

this is a milder form of mania

- mood persists for at least 4 days

- does not cause marked impairment in functioning like mania does

- typically doesn't require hospitalization

these individuals tend to have pretty bad depressive disorders

hypomania

bipolar 1 or bipolar 2?

1 or more manic episodes, usually alternating w/ depressive episodes

- psychosis may accompany manic episode

bipolar 1

bipolar 1 or bipolar 2?

characterized by a depressive episode and at least 1 hypomanic episode

bipolar 2

similar to bipolar 2 disorder although less severe

alternating eps of hypomanic symptoms and minor depressive episodes (non psychotic) for at least 2 years

cyclothymic (disorder)

these are ________ guidelines for clients w/ mood disorders

- look at risk for harm to self or others

- look for psychosis

- look for co existing psych disorders

- look at hx of onset

- look at hx of substance abuse

- rule out physical or neuro causes (ex: thyroid)

- look at support system

- look at current stressors

assessment (guidelines)

what you think is a mood disorder could actually be something from physical or neuro problem.

ex; thyroid disorder

hyperthyroidism or hypothyroidism?

can mimic a manic person

hyperthyroidism

what you think is a mood disorder could actually be something from physical or neuro problem.

ex; thyroid disorder

hyperthyroidism or hypothyroidism?

can mimic a depressive disorder

hypothyroidism

in the depressed client, suicidal and homicidal ideations are a _______ issue

safety (issue)

what kinds of assessment cues in depressed pt?

- anhedonia

- anergia

- worthlessness

- guilt

- irritability

mood

what kinds of assessment cues in depressed pt?

objective- what you see as nurse

- stooped over

- slumped down in chair

- may appear older than stated age

- may have flat affect

- may not have eye contact

- may have psychomotor retardation

- may be very tearful

affect (and appearance)

what kinds of assessment cues in depressed pt?

may have very slowed thinking and difficulty concentrating

- poor memory

- pseudodementia (false dementia that comes from depression)

- delusional thinking (very negative thought processes)

thought patterns

false dementia that comes from depression

pseudodementia

what kinds of assessment cues in depressed pt?

decreased appetite or may overeat

appetite

what kinds of assessment cues in depressed pt?

majority of people will prob have insomnia

- or may have hypersomnia where they sleep too much

sleep

what kinds of assessment cues in depressed pt?

decreased libido

sexual interest

how does a depressed pt interaction with others?

may have social isolation where they don't want to interact w/ others

nursing ___________ for depressed patient

- risk for self destructive behavior

- impaired coping process

- hopelessness

- chronic low self esteem

- impaired sleep

diagnosis

communication guidelines for depressed patient

using ________ and just being present can be good- patient may have a slow thought process

silence

communication guidelines for depressed patient

understand that patient may need more time to _______ to communication

- give patient time to respond to questions

- may have to be simpler and more direct w/ your questions if they having trouble getting their thoughts out

reply

communication guidelines for depressed patient

make observations r/t patient/situation or environment

reinforce_____________

(reinforce) reality

communication guidelines for depressed patient

avoid ________ and making judgements

"everything will be fine"- patients don't really like that. you can make them feel worse or guilty w/ these kind of remarks

platitudes

communication guidelines for depressed patient

listen carefully for _________messages and question directly about suicide

covert (messages)

communication guidelines for depressed patient

question underlying assumptions and beliefs:

- may have _____________ thought patterns

- help them form a more positive and more hopeful attitude

- identify negative thoughts and help them change to more positive thoughts

negative (thought patterns)

communication guidelines for depressed patient

identify cognitive _________ such as overgeneralization

(cognitive) distortions

interventions for depressed patient

assist w/ personal ________

- allow patient to do as much as they can independently

- don't want patient to become dependent on us

(personal) hygiene

interventions for depressed patient

monitor _______ intake and weight esp if they aren't eating

food (intake)

interventions for depressed patient

monitor __________

how much did they sleep last night?

work on healthy sleep activities- no day time napping, no caffeine in evening

sleep

interventions for depressed patient

maintain safe __________

always look for ways patients could potentially harm themselves

environment

interventions for depressed patient

be alert to a sudden lifting of ______

w/ suicide: it could mean they are planning to harm themselves

(lifting of) mood

interventions for depressed patient

monitor response to ________

nurse responsibility is to report back the response to meds the patient takes

meds

interventions for bipolar patient

- assess ________

- mood can fluctuate so assess current mood; depressed? manic? hypomanic?

- some people may have mixed episodes where they have increased energy and decreased sleep but might be depressed

mood

interventions for bipolar patient

assess behaviors and potential for _________ toward others

- may see aggression

- more impulsivity

- may be more prone to lash out at someone else

violence

interventions for bipolar patient

thought ________

do they have flight of ideas?

do they have grandiosity?

(thought) process

interventions for bipolar patient

observe for _________ behavior

- if someone is manic, make sure they are not running up and down the hall naked

- make sure they don't try to give away their valuable items

inappropriate

nursing ________ for bipolar disorder

- impaired role performance

- impaired sleep

- risk for injury

- impaired nutritional status

- self care deficit

diagnosis

communication guidelines for bipolar patient

use a _____, calm approach

- esp if they are manic

- let them know what's acceptable and what's not

- the more anxious you are, the more anxious the patient will be

firm

communication guidelines for bipolar patient

you should use short concise statements

true or false

true

communication guidelines for bipolar patient

remain _______; avoid power struggles

remain middle of road

neutral

communication guidelines for bipolar patient

be ______________

- important w/ firm limit setting- what's acceptable what's not. whole treatment team has to be on same page

(be) consistent

communication guidelines for bipolar patient

you should hear and act on legitimate complaints

- whenever support reports something to you always investigate it

true or false

true

communication guidelines for bipolar patient

you should firmly redirect energy into appropriate channels

- "let's take a walk" to burn off some of this energy

true or false

true

true or false

it is important to monitor sleep in bipolar patients. they need to sleep

true

true or false

it is important to monitor activity level in bipolar patients. want them to burn off energy but don't want them to get to physical exhaustion

true

true or false

there needs to be time to vent off energy and a time to rest for bipolar patients

true

it is important to help maintain __________ of bipolar patient

- they may do something in a manic episode they wouldn't normally do

- ex: female patient taking her shirt off or patient trying to give away valuables

dignity

in bipolar patients we may need to _________ visitors

limit

(sometimes visitors can be too stimulating for manic patient)

with a manic patient, it is important to INCREASE OR REDUCE environmental stimuli

- may be more helpful to have brief contact/check ins rather than trying to talk to them for long periods of time

- may be better for them to eat their meal in their room if they're talking too much

reduce (environmental stimuli)

short or long term goals for mood disorders?

client will:

- remain safe and free from harm

- verabilize suicidal ideation and contract not to harm self or others

- verbalize absence of suicidal or homicidal intent or plan

- express desire to live and not harm self or others

short term (goals)

short or long term goals for mood disorders?

client will:

- establish a pattern of rest/sleep that will fufill roles and self care (good sleep and nutrition)

- describe info about triggers and relapse prevention

- identify med and be knowledgeable of action, dosage, side effects, etc

- have increased communication and problem solving

long term (goals)

these are _________

- SSRI

- SNRI (serotonin norepinephrine reuptake inhibitors)

- NDRI (norepinephrine dopamine reuptake inhibitor)

- TCA (tricyclic antidepressants)

- MAOI (monoamine oxidase inhibitors

- atypical antidepressants

antidepressants (to treat depression)

which antidepressant?

block reuptake of serotonin (increases serotonin in synaptic cleft)

- also effective for anxiety

- generic (cost effective)

SSRI

which drugs are SSRIs?

citalopram

escitalopram

fluvoxamine (used for OCD too)

paroxetine

sertraline

fluoxetine

which antidepressant?

low risk in overdose

- fewer side effects (if they do have side effects, usually lasts couple days and then they go away)

- drowsiness

- agitation

- headaches

- sexual dysfunction

- GI upset

SSRI

over activation of serotonin receptors

- could be combo of meds that cause over activation of serotonin receptors

- can happen w/ migraine meds

- rare but can happen

- think SHIVERS

serotonin syndrome

SHIVERS in serotonin syndrome stands for

shivering

hyperreflexia

increased temp

vital sign changes

encephalopathy

restlessness

sweating

does it take several days or weeks to symptom relief when taking an SSRI?

(several) weeks

(need to take it everyday)

true or false

SSRI patient teaching:

teach patient to manage side effects:

if it makes them sleepy, take at night

if it makes them nauseous, take with some food

true

SSRIs PT teaching

• Time to symptom relief (may take up to 8 weeks to see changes)

• Management of side effects

• Risk of increased suicidal ideations in some populations

• Avoid alcohol (Sedation)

• Risk of Serotonin Syndrome - Wash out period

delete

yes (both have sedating effects)

delete

wash out (period)

(typically don't want SSRIs to interact with MAOIs)

block reuptake of serotonin and norepinephrine

- often used as 2nd line treatment if pt does not respond to SSRI

- similar side effects to SSRI

blocks reuptake of norepinephrine- more stimulating can hit HR AND BP

SNRI (serotonin norepinephrine reuptake inhibitor)

what drugs are SNRIs (serotonin norepinephrine reuptake inhibitor)?

- duloxetine

- venlafaxine

- desvenlafaxine

- levomilnacipran

blocks reuptake of norepinephrine and dopamine

- often used in combo w/ SSRI or SNRI for residual depressive s/s

-no sexual side effects

- indicated as tx for smoking cessation

ex: bupropion

NDRI (norepinphrine and dopamine reuptake inhibitors)

side effects SNRI and NDRI?

- HTN**

- seizures** (wellbutrin)

- insomnia (typically have this med in morning NOT NIGHT)

- sweating, agitation

- h/a, nausea

- possible sexual dysfunction w/ SNRIs (not w/ NDRIs - bupropion)

if they have hx of seizure or eating disorders or a traumatic brain injury, ____________ (NDRI) can lower the seizure threshold and may not be safe

bupropion

what 2 antidepressants?

- time to symptom relief (takes a few weeks)

- management of side effects (better to take it in morning because it can cause insomnia)

- don't stop med because it can cause withdrawal (will have to be tapered off)/ difficulty of stopping medication (especially _____)****

- avoid alcohol

SNRIs x2

NDRI

older class of antidepressants

- inhibit reuptake of norepinephrine and serotonin

- works good but has a lot of side effects

TCA (tricyclic antidepressant)

what antidepressant?

amitriptyline (common)

clomipramine

desipramine

imipramine

notriptyline (common)

protriptyline

trimipramine

TCA (tricyclic antidepressant)

side effects of TCAs:

- high risk for overdose

- OH

- anticholinergic side effect

- sedation**

- dizziness

- cardiotoxic** (can be hard on patient w/ heart problems. can cause dysrhythmias, tachycardias, MI)

teaching for what antidepressant?

- time to symptom relief (take couple weeks to work)

- management of drowsiness, dizziness, and hypotension (manage drowsy by bed time and get them to stand up slowly)

- avoid alcohol

- do not give if they have cardiac anomalies

TCA

increase levels of norepinephrine, serotonin, and dopamine

- may not see this ever prescribed but there a lot of side effects, food interactions and drug drug interactions

MAOIs

MAOI drug names?

isocarboxazis

phenelzine

Selegiline (Eldepryl, Emsam)**

tranylcypromine

side effects of MAOIs:

- drug drug interactions (w/ SSRIS or other antidipressants)

- weight gain

- fatigue and sedation

- sexual dysfunction

- hypotension

- risk for HTN crisis (due to increased tyramine levels) (tyramine is in a lot of food. MAOI hits tyramine and a lot of tyramine can cause BP to increase and they can have a stroke)

patient teaching for what antidepressant?

- avoid tyramine containing food

- report all meds and OTC supplements

- go to ER immediately if severe headache (severe headache could mean HTN crisis)

- monitor BP closely during 1st 6 weeks of treatment

- maintain drug and food restrictions for 14 days after stopping meds (MAOI has a pretty long half life)

MAOIs

these are foods to avoid for MAOIs

- tyramine containing foods (aged or smoked meats, fermented meats, dry or fermented sausage including salami, pepperoni, bologna, liver)

- fish

- most cheese

- avocadoes, fava beans, sauerkraut

- figs

- large amts of banana

- yeast extract

- beers and some wines

- other foods: protein, dairy supplements, soups, soy sauce