Mood Disorders and Suicide

Depression

A state of dejection and decreased activity

Depression & chronic illness

Chronic medical problems (HTN, diabetes, heart disease, arthritis, back pain) increase depression risk; depression may occur secondary to medical illness.

Common depression comorbidities

Anxiety, psychotic/schizophrenia, substance use, eating, and personality disorders.

Depression in children/adolescents

Can occur as young as age 3; often underdiagnosed, has high recurrence, early treatment may decrease recurrence; girls are more vulnerable than boys.

Depression in older adults

Often associated with chronic illness and under/misdiagnosed; depressed older adults have significant suicide risk.

Major depression vulnerability factors

Losses = most significant factor; also stress, inadequate social support, physical illness, and familial factors.

Major Depressive Disorder (MDD)

Single or recurrent episodes of unipolar depression; requires ≥5 symptoms occurring daily for ≥2 weeks.

MDD symptoms/criteria

Depressed mood; increased/decreased sleep; indecisiveness/decreased concentration; suicidal ideation; motor activity increase/decrease; anhedonia; weight gain/loss by ~5% in 1 month.

Anhedonia

Inability to experience pleasure.

Anergia

Lack of energy.

MDD classifications/specifiers

Psychotic features, postpartum onset, SAD, PMDD, substance-induced depressive disorder.

Depression findings suggesting suicide risk

Anhedonia, anergia, anxiety, worthlessness, guilt, helplessness, hopelessness, anger/irritability, inability to envision a future.

When is suicide risk especially high as depression improves?

When depressive symptoms begin decreasing because energy may improve before suicidal thinking resolves.

Physical findings of depression

Sad appearance, poor grooming, psychomotor slowing OR agitation, social isolation, slow speech/delayed responses.

Cultural considerations with depression

Symptoms vary by culture and may present as somatic complaints; access barriers can delay treatment; unsupported LGBTQ clients may have ↑ risk; early recognition is key.

Depression screening tools

Goldberg Depression Scale and Hamilton Depression Scale.

Goldberg Depression Scale assessment areas

Affect, thought processes, mood, feelings, physical behavior, communication, religious beliefs/spirituality.

MDD treatment acute phase

6-12 wk, reduce symptoms/suicide risk

MDD treatment continuation phase

4-9 mo, prevent relapse

MDD treatment maintenance phase

may last years, prevent new episodes.

Goals of MDD nursing care

No self-harm; discuss/resolve losses; set goals/anticipate future; identify controllable areas; interact/socialize; perform self-care; sleep 6-8 hr/night.

Priority with a depressed client

SAFETY: continually assess suicide risk.

Milieu therapy for depression

Monitor/assist self-care; establish trust; allow time/silence; assess anger; focus on strengths; encourage independence

Therapeutic communication with depression

Use observations, allow slow responses/silence, sit with client, establish trust, and avoid superficial reassurance/humor such as "things will get better."

What should a depressed client avoid?

Major long-term commitments/decisions, emotional reasoning, assuming hopelessness or responsibility for uncontrollable events, and avoiding treatment.

Non-drug depression treatments

Psychotherapy combined w/drug therapy, CBT, ECT, phototherapy for SAD, group/family therapy, St. John's Wort (many interactions)

Cognitive-behavioral therapy (CBT) for depression

Changes negative/distorted thoughts to improve mood and behavior

Antidepressant classes

SSRIs, SNRIs, TCAs, MAOIs

General antidepressant teaching

Do not stop abruptly; avoid alcohol; avoid hazardous machinery - sedative effect

Use antidepressants with caution in

older adults and renal/cardiac impairment

Antidepressant black-box warning

↑ risk of suicidal thinking/behavior in children and adolescents; monitor closely as mood/energy begins improving

SSRIs

First-line antidepressants; block serotonin reuptake

SSRI indications

depression, PTSD, and OCD

SSRI examples

Fluoxetine (Prozac), paroxetine (Paxil), escitalopram

SSRI onset

May take ~3-4 weeks for therapeutic effect.

SSRI teaching

Take in AM if insomnia occurs; sexual dysfunction/↓ libido may occur; taper gradually—do not stop abruptly.

Serotonin Syndrome

Rare, life-threatening excess serotonin; risk is especially high when SSRIs are combined with MAOIs

Tricyclic antidepressants (TCAs)

Second-line depression treatment

TCAs adverse effects

dysrhythmias

TCAs contraindications

many drug interactions; "start low, go slow."

Imipramine

tricyclic antidepressant with anticholinergic effects; may cause urinary retention.

MAOI teaching

Avoid OTC medications and tyramine-containing foods; many drug interactions

MAOI risks include

hypertensive crisis and serotonin syndrome

Bupropion

NDRI Antidepressant; Wellbutrin/Zyban

Trazodone

SARI Antidepressant commonly used to promote sleep

Electroconvulsive therapy (ECT)

Controlled electrical treatment under mild anesthesia with musculoskeletal blocker (succinylcholine)

ECT electric current is through the

temporal lobe

ECT frequency

2-3 times/week for 6-12 treatments

ECT preprocedure care

NPO 6 hr; premedicate 30-45 min before; remove dentures, glasses, hearing aids; anesthesia + succinylcholine; bite block used

ECT monitoring

EEG and EMG; cuff arm/leg to monitor seizure; expected seizure duration ~20 sec-1 min

ECT adverse effects

Sore muscles, headache, short-term confusion, short-term memory impairment; avoid major decisions during memory impairment

ECT mortality rate

0.002% per treatment session; 0.01% per patient

Somatic depression treatments

Vagus nerve stimulation, repetitive transcranial magnetic stimulation (rTMS), light therapy, peer support, exercise

Bipolar spectrum disorders are characterized by two opposite poles

mania and depression

Bipolar I disorder

Has at least 1 episode of mania alternating with depression

Bipolar II disorder

Has 1 or more episode of hypomania alternating with depressive episode

Cyclothymic disorder

at least 2 years of hypomanic episodes that do not meet full criteria for other bipolar disorders

Rapid-cycling bipolar disorder

4 or more mood episodes in 1 year

Bipolar psychological comorbidities

Anxiety, panic attacks, behavioral disorders, phobias, SAD, substance use; substance use + anxiety ↑ suicide risk.

Bipolar medical comorbidities

Cardiovascular, cerebrovascular, metabolic/DM II; conditions associated w/manic symptoms

Conditions associated w/manic symptoms

CNS tumors/trauma, hypothyroidism, seizures, HIV

Hypomania

↑ mood/energy lasting at least 4 days but not severe enough to require hospitalization or significantly impair ADLs

Hypomania findings

Racing thoughts, unrealistic goals, cheerful→irritable/volatile mood, exalted self, distractibility/flight of ideas, extroverted/social, ↑ libido, impulsivity, poor decisions, akathisia

Akathisia

Inability to sit still/restlessness

Acute mania findings

Euphoria→anger/rage, racing thoughts, extreme energy, insomnia, little food, poor hygiene, sexual disinhibition, flamboyant dress, pressured speech, flight of ideas, possible hallucinations/delusions

Pressured speech

Rapid, excessive speech associated with mania

Flight of ideas

Rapidly shifting thoughts/ideas, often with easy distractibility

Clang associations

Words linked because they rhyme/sound alike rather than because they have meaningful logical connections

Bipolar disorder acute depressive characteristics

Flat/tearful affect, lack of energy, anhedonia, suicidal ideation

Bipolar/manic acute-phase goals

Medical stabilization, safety, and meeting self-care needs

Bipolar continuation-phase goals

Medication adherence, psychoeducation, and referrals

Bipolar maintenance-phase goal

Prevent relapse

Priority nursing care during acute mania

Provide safety; assess suicide risk; reduce stimulation without isolation; provide rest and structured physical activity; protect from poor judgment.

Acute mania nutrition/hydration

Monitor eating/drinking; provide portable finger foods that can be eaten while moving

Acute mania self-care

Monitor sleep, eating, drinking, and hygiene; give simple step-by-step reminders

How should a nurse redirect manic behavior

Calmly divert/redirect/distract the client rather than argue or confront.

Therapeutic communication for acute mania

Matter of fact, calm

Constancy

Do not react to client's comments

Therapeutic communication

Why is consistent limit setting essential in mania?

Manic clients may use power plays or splitting; all staff must communicate and enforce the same limits

Splitting in manic clients

Attempt to divide/manipulate staff to weaken or change established limits

Acute mania therapeutic environment

Decrease environmental stimulation, allow rest, provide structured solo activities, and avoid unnecessary isolation.

Milieu- seclusion is used for

control during the acute phase of hyperactive behavior; Immediate treatment with an antipsychotic medication

Seclusion/restraints in acute mania

Used when client is dangerously out of control/risk to self or others and less restrictive measures have failed

Purpose of seclusion in acute mania

Protect client/others/property and reduce overwhelming environmental stimuli when behavior cannot be controlled.

Psychotherapy for bipolar disorder

Essential; CBT individual therapy during mania, group therapy after acute phase

CBT for bipolar disorder targets

distorted automatic thoughts and improves problem solving

Recovery model in bipolar disorder

Focuses on recovery and empowering clients to create meaningful lives beyond the illness

Overall therapy goals for mania

Prevent self-harm; ↓ excessive activity; ensure food/fluids and sleep; meet self-care needs; manage medications

Lithium carbonate

Mood stabilizer and first-line agent for bipolar disorder

Lithium carbonate alters

sodium transport and inhibits norepinephrine/dopamine release

When taking lithium carbonate, pt must maintain

normal intake of salt and fluids

lithium carbonate does not inhibit the release of

serotonin

Lithium patient teaching

Maintain a normal, consistent intake of salt and fluids

Lithium therapeutic level

0.8 to 1.4 mEq/L

Lithium maintenance level

0.4 to 1.3 mEq/L.

Lithium toxic level

1.5 to 2.0 mEq/L.

Lithium & low sodium

increase in lithium level

Lithium & high sodium

decrease in lithium level

Anxiolytics used for mania

Clonazepam (Klonopin), lorazepam (Ativan); used for psychomotor agitation/treatment-resistant mania

Atypical antipsychotics used for mania

Olanzapine, risperidone, aripiprazole, ziprasidone, quetiapine; have sedative properties

Suicide

Intentional ending of one's own life