Module 8: Mood disorders and Suicide

Anergia

• lack of energy impacting daily routines

• Work, family, and social responsibilities continue despite low mood

• low periods typically pass in a few days

How long does a major depressive episode last

at least 2 weeks

Major depressive disorder symptoms

• depressed mood

• loss of pleasure

• changes in eating habits\

• hypersomnia/insomnia

• impaired concentration

• feelings of worthlessness

• thoughts of death or suicide

• fatigue

• rumination

bipolar I

• one or more manic or mixed episodes usually accompanied by major depressive episodes

Bipolar II

• one or more major depressive episodes accompanied by at least one hypomanic episode

Mania

• elevated mood

• inflated self-esteem

• decreased sleep

• excessive speech

• flight of ideas

• distractibility

• increased activity

• risk taking behaviors

Hypomania

• milder symptoms of mania

• No impairment in functioning

• No psychotic features

mixed episode

• both mania and depression nearly every day for at least 1 week

dysthymic (persistent depressive disorder)

• chronic, persistent mood disturbance

• Symptoms

  • insomnia

  • loss of appetite

  • decreased energy

  • low self esteem

  • difficulty concentrating

  • feelings of sadness and hopelessness

Disruptive mood dysregulation disorder

• persistent angry or irritable mood

• Severe, recurrent temper outbursts

• begins in children and adolescents before age 10

cyclothymic disorder

• mild mood swings between hypomania and depression

• no loss of social or occupational functioning

Substance-induced depressive or bipolar disorder

• significant disturbance in mood

• Direct physiological consequence of ingested substances (alcohol, drugs, toxins)

Seasonal affective disorder (SAD)—Winter depression/fall onset symptoms

• increased sleep

• appetite

• carbohydrate cravings

• weight gain

• interpersonal conflict

• irritability

• heaviness in extremities

• TX: light therapy

Seasonal affective disorder (SAD)— spring/summer onset symptoms

• insomnia

• weight loss

• poor appetite

Postpartum maternity blues

• mild, predictable mood disturbance

• Symptoms

  • labile mood and affect

  • crying spells

  • sadness

  • insomnia

  • anxiety

• Symptoms reside without treatment

Postpartum depression

• most common complication of pregnancy

• Symptoms consistent with depression

• Onset within 4 weeks of delivery

• TX: Brexanolone (Zulresso) IV infusion over 60 hrs

Postpartum psychosis

• Severe psychiatric illness with acute onset after childbirth

• Symptoms

  • fatigue

  • Sadness

  • emotional lability

  • poor memory/confusion

  • delusions/hallucinations

  • Poor insight/loss of contact with reality

• Requires immediate tx

Premenstrual dysphoric disorder

• Severe form of premenstrual syndrome

• Symptoms

  • labile mood

  • irritability/increased interpersonal conflict

  • difficulty concentrating

  • feeling overwhelmed

  • anxiety

  • tension

  • hopelessness

• Causes severe dysfunction in social or occupational functioning

Non-suicidal self-injury

• deliberate, intentional self-harm (cutting, burning, scraping, hitting)

• Reasons:

  • alleviation of negative emotions

  • self-punishment

  • seeking attention

  • escaping a situation or responsibility

• Influence of peers or need to fit in

Serotonin role

• mood

• activity

• aggressiveness

• cognition

• pain

• biorhythms

• neuroendocrine processes

• Deficits of serotonin or its metabolites found in people with depression

Norepinephrine levels role

• deficient in people with depression

• increased in people experiencing mania

Dopamine role

• neurotransmission reduced in people with depression

• interaction between genetic and environmental factors disrupts neurochemical functions

• Dopamine metabolite homovanillic acid (HVA) decreased during depression, increased during mania

Hamilton Rating Scale for Depression (HSRD)

• Gold standard measure of depression

• Symptoms

  • Depressed mood

  • guilt

  • loss of interests

  • retardation

  • suicide

  • psychological anxiety

MDD diagnostic criteria

• 2 weeks or more of a sad mood or lack of interest in life activities with at least four other symptoms of depression, including

  • anhedonia

  • Changes in sleep, weight, energy, concentration, decision-making, self-esteem and goals

MDD episodes

• untreated episode can last weeks to months to years, although most last 6 months

• Some have single episode, while others have 5-6 over lifetime

• Symptoms vary from mild-severe

Categories of antidepressants

• cyclic antidepressants

• Monoamine oxidase inhibitors (MAOIs)

• Selective serotonin reuptake inhibitors (SSRIs)

• Atypical antidepressants

Electroconvulsive therapy (ECT)

• when client doesn’t respond to antidepressants or experience intolerable side effects

• Pts actively suicide

• 6-15 treatments, 3x week

MDD outcome identification

• free from self-inflicted harm

• express feelings directly with congruent verbal and nonverbal messages

• Free from psychotic symptoms

• Balance of rest, sleep, and activity

• Demonstrate compliance with and knowledge of medications

• Demonstrate an increased ability to cope with anxiety, stress, or frustration

MDD Action

• provide safe environment

• continually assess client suicide potential

• promote therapeutic relationship

• encourage client to vent feeling

• Promote ADLs, physical care

• Using therapeutic communication

Bipolar onset

• Generally in teens, 20s, or 30s,

• Manic episodes— begin suddenly with rapid escalation of symptoms over a few days and last from a few weeks to several months

Manic episode or mania requirements

• at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following:

  • exaggerated self-esteem

  • sleeplessness

  • pressured speech

  • flight of ideas

  • reduced ability to filter extraneous stimuli

  • distractibility

  • Increased activities with increased energy

  • Multiple grandiose high risk activities involving poor judgement and severe consequences

Bipolar treatment

• Lifetime regime of medications

• Antimanic: lithium

• Anticonvulsant medications—used as mood stabilizers

  • Valproic acid

  • Carbamazepine

Nursing actions for at-risk clients

• discussing suicidal ideation

• ensuring close supervision

• removing harmful objects

Lethality Assessment

• Does the client have a plan? What is it? Is it specific?

• Are the means available to carry out this plan?

• If the client carries out the plan, is it likely to be lethal?

• Has the client made preparations for death, such as giving away prized possessions, writing a suicide note, or talking to friends one last time?

• Where and when does client intend to carry out the plan?

• Is the intended time a special date or anniversary that has meaning for the client?

SSRIs

• most frequently prescribed antidepressants

• action is specific to serotonin reuptake inhibition

• Cause few sedating, anticholinergic and cardiovascular side effects

SSRIs examples

• fluoxetine

• Sertraline

• Paroxetine

• Citalopram

• Escitalopram

Cyclic antidepressants/Tricyclics

• oldest antidepressants

• each drug has a different degree of efficacy in blocking the activity of norepinephrine and serotonin or increasing the sensitivity of postsynaptic receptor sites

• 6 weeks for full effect

• Avoid MAOIs

Trycyclic antidepressants examples

• amitriptyline

• Amoxapine

• Doxepin

• Imipramine

• Desipramine

• Nortriptyline

atypical antidepressants

• used when the client has an inadequate response to or side effects from SSRIs

atypical depressants examples

• venlafaxine

• desvenlafaxine

• Duloxetine

• Bupropion

• Vilazodone

• Vortioxetine

• Spravato (only available at office/nasal spray)

MAOIs

• used infrequently due to potentially fatal side effects and drug interactions

• May be superior to typical for the treatment of typical and treatment resistant depression

• Hypertensive crisis— serious side effect

MAOIs examples

• isocarboxazid

• Phenelzine

• Tranylcpromine

• Selegiline

• Transdermal patch