Mood Disorders

What is mood

• subjective experience of emotions or feelings

• change in mood is expected & normal

• this is what the pt tells you

what is affect

• outward expression of emotion/feeling

• objective nonverbal communication like body language

what is mood disorder

• marked disturbance in psychological, physiological, and/or social function

• depression and BP I & II

• cylothymic disorder

• when changes in mood become too pronounced & interfere with daily living

risks of getting depression

• female

• lonely

• negative life events

• drug & alcohol abuse

• fam hx of depression

• victims of childhood trauma

• un-married

• <40 yrs

biological factors that can cause depression

• genetic (1st degree relatives)

• biochemical (neurotransmitter imbalances)

• alterations in brain structure

• diathesis-stress model (wear and tear on the body)

psychological factors that cause depression

• cognitive therapy

• learned helplessness

what is the cognitive theory

• negative view on all life events

what is learned helplessness

• person believes undesirable even is caused by them and everything goes wrong,,, leading to feeling helpless about a situation

What is major depressive disorder

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

how many symptoms must a person have to be diagnosed with major depressive disorder

5 or more

cognitive/emotional symptoms of major depressive disorder

• decreased mood

• anhedonia (lack interest)

• worthlessness

• guilt

• hopeless

• decrease concentration

• anger

• irritability

• recurrent thoughts of death/suicide

physical symptoms of major depressive disorder

• weight changes

• increased or decreased sleep pattern

• increase or decrease motor activity (restless/sluggish)

• anergia (lack energy)

• somatic complaints (h/a, fatigue

• trouble with decision making

• poor self-esteem

• substance abuse

• social w/drawal or isolation

Persistent depressive disorder (dysthymia)

• chronic low grade depression

• chronic depressive syndrome usually present for most of day, more days than not, for at least a 2 yr period

• not usually severe enough for hospitalization

• onset in adolescence

• haven’t gone > 2 months symptom free, won’t be manic or major depressive episodes

• increase risk for developing major depressive disorders

Other forms of depression

• disruptive mood dysregulation disorder (common in younger kids)

• premenstrual dysphoric disorder (present about a week before menses & improves)

• depressive disorder due to another medical condition

• substance/medication-induced depressive disorder

etiology of bipolar disorders

• genetic

• neurobiological

• neuroendocrine

• neuroanatomical

• psychological & environmental factors

psychological and environmental factors for bipolar disorder

• stressful life event that may trigger initial manic episodes especially if family hx

what is mania

• elevated and labile mood

• irritability

• euphoria

• inflated self esteem

• more talkative than usual

• decrease need for sleep

• hypersexual

• poor judgement

• flight of ideas

• subjective reports of racing thoughts

• psychomotor agitation

• grandiosity

what is grandiosity

delusions like th ept has super powers

how long does mania usually last

• at least 7 days

what is hypomania

• milder form of mania

• mood persists for at least 4 days

• doesn’t cause impaired function (still can sleep and go to work)

• doesn’t require hospitalization

Bipolar I disorder

• one or more manic episodes. alternating with depressive episodes

• psychosis may accompany manic episodes

bipolar II disorder

• depressive episode and at least one hypomanic episode

cyclothymic disorder

• similar to bipolar II, but less severe

• alternating episodes of hypomanic s/s and minor depressive episodes for at least 2 years

• not diagnosed very often

Assessing the depressed client

• Suicidal/ideations

• Mood

• Affect, appearance

• Thought patterns

• Appetite

• Sleep

• Sexual interest

• Interaction w others

Analysing cues in depressed client

• risk for self destructive behavior

• impaired coping process

• hopelessness

• chronic low self esteem

• impaired sleep

Communicating w depressed pt

• pt may need more time; decreased thought process

• make observations r/t pt situation and environment

• avoid platitudes and making judgements

• listen carefully for covert messages and question directly about suicide

• question underlying assumptions and beliefs

• identify cognitive distortion

• encourage group activity

• encourage exercise

• encourage finding a healthy support system

interventions for the depressed pt

• assist with personal hygiene

• monitor food intake and weight

• monitor sleep

• maintain safe environment

• be alert to sudden lifting of mood

• monitor response to meds

Assessing the bipolar patient

• assess current mood, change in mood

• assess behaviors and potential for violence toward others

• thought process

• sleep, appetite, weight, s/s if physical illness

• impaired role performance

• impaired sleep

• risk for injury

• impaired nutritional status

• self-care deficit

Communicating w bipolar disorder

• use firm, calm approach

• use short, concise statements

• remain neutral, avoid power struggles

• be consistent

  • important with firm limit setting

• hear and act on legitimate complaints

• firmly redirect energy into appropriate channels (exercise)

Interventions for the bipolar client (safety & physical needs)

• monitor sleep, activity level, weight, appetite

• allow for venting of energy

• encourage rest

• help maintain clients dignity

• limit visitors

• meds

• observe for unpredictable behavior & irritability

• reduce environmental stimuli

• brief, frequent contact

• meals in rooms, private rooms

goals for short-term clients

• remain safe and free from harm

• verbalize suicidal ideation and contract not to harm self or others

• verbalize absence of suicidal or homicidal intent or plan

• express a desire to liv and not harm self or others

goals for long-term clients

• establish a pattern of rest/sleep that will fulfill roles and self care

• describe info about triggers and relapse prevention

• identify meds and be knowledgeable of action, dosage, side effects, etc

• increased communication and problem solving

What are SSRI’s

• selective serotonin reuptake inhibitors

how do SSRI’s work

• block the reuptake of serotonin (increase the amount of serotonin in the brain)

• also effective for anxiety

Common SSRI’s

• citalopram (celexa)

• escitalopram (lexapro)

• fluvoxamine (luvox)

• paroxetine (paxil)

• sertraline (zoloft)

• fluoxetine (prozac)

know the ones in parentheses

side effects or SSRI’s

• low risk in overdose

• drowsiness or agitation

• h/a

• sexual dysfunction

• gi distress

• serotonin syndrome

• side effects go away w in the first few days

• Serotonin Syndrome- SHIVERS

  • hyperreflexia, fever, vital sign changes, encephalopathy, restlessness, sweating

SSRI pt teaching

• time to symptom relief (may take 1-3 weeks)

• management of side effects

• risk of suicidal ideations in some populations

• avoid alcohol (sedation)

• risk of serotonin syndrome (wash out period)

what are SNRI’s

serotonin norepinephrine reuptake inhibitors

How do SNRI’s work

• block the reuptake of serotonin and norepinephrine

• often used as 2nd line treatment if pt doesn’t respond to SSRI’s

common SSRI’s

• duloxetine (cymbalta)

• venlafaxine (effexor XR)

• desvenlafaxine (pristiq)

• levomilnaciprain (fetzima)

What are NDRI’s

norepinephrine and dopamine reuptake inhibitors

common NDRI

bupropion (wellbutrin)

key concepts for bupropion (wellbutrin)

• blocks the reuptake of norepinephrine and dopamine

• used in combo with SSRI and SNRI for residual depressive s/s

• little to no sexual side effects

• treatment for smoking cessation

SNRI & NDRI side effects

• HTN

• nausea

• insomnia

• sweating

• agitation

• h/a

• sexual dysfunction (SNRIs)

• seizures (wellbutrin)

what do you need to be sure to ask before prescribing Wellbutrin

• hx of head trauma or seizure disorder

SNRI & NDRI pt teaching

• takes time to relieve s/s

• don’t suddenly stop meds, can cause withdrawal

• avoid alcohol

What are TCAs

tricyclic antidepressants

what do TCAs do

• inhibit reuptake of norepinephrine & serotonin

• blocks histamine receptors

Common TCAs

• elavil

• anafranil

• norpramin

• tofranil

• aventyl

• vivactil

• surmontil

TCA side effects

• high risk for overdose

• orthostatic hypotension

• anticholinergic side effects

• sedation

• dizziness

• cardiotoxic

What are anticholinergic side effects

• dry mouth

• blurry vision

• urinary retention

• constipation

• drowsiness

Pt teaching for TCA

• takes 2-4 weeks to get symptom relief

• management of drowsiness, dizziness, and hypotension

• avoid alcohol

• do not give if cardiac abnormalities

What are MAOI’s

• monoamine oxidase inhibitors

what do MAOI’s do

• increase levels of norepinephrine, serotonin, and dopamine

how often are MAOI;s used

not often because of drug/food interactions

Common MAOI’s

• marplan

• nardil

• eldepryl, emsam***

• parnate

Side effects of MAOI’s

• drug interactions (esp another antidepressant)

• weight gain

• fatigue and sedation

• sexual dysfunction

• hypotension

• risk for hypertensive crisis due to increased tyramine levels

what is tyramine

found in common food and drugs

PT teaching for MAOI’s

• avoid tyramine containing food

• report all meds and otc supplements

• go to er immediately if severe h/a

• monitor bp closely during 1st 6 wks of tx

• maintain drug and food restriction for 14 days after stopping meds

foods to avoid if on MAOI’s

• aged, smoked, fermented meats (sausage, salami, bologna, liver)

• some fish

• most aged cheese

• avacados, fava beans

• sauerkraut

• figs and large amounts of bananas

• yeast extract

• some imported beer, draft beer and some wines

• protein dairy supplements

• soups

• soy sauce

atypical antidepressants

• viibryd (vilazodone)

• vortioxetine (trintellix)

• remeron (mirtazapine)

• trazodone (desyrel)

key concepts of viibryd (vilazodone)

• serotonin partial-agonist reuptake inhibitor

• fewer sexual side effects

• less weight gain

• could have gi issues

Key concepts vortioxetine (trintellix)

• serotonin modulator and simulator

• low risk of sexual side effects

• weight gain

• sedation

• may improve cognitive fx

which is the only drug that may improve cognitive functioning

vortioxetine (trintellix)

key concepts remeron (mirtazapine)

• used in long term care

• blocks the reuptake of serotonin and antagonizes alpha-2 adrenergic receptors

• works wells for severe depression

• causes weight gain and sedation

key concepts trazodone (desyrel)

• antidepressant, significant sedating effects

• preffered antidepressant for insomnia

• offers sedation w few cholinergic effects

• no evidence of w drawl

• short 1/2 life

side effects of trazodone

• orthostatic hypotension

• anxiety

• priapism (prolonged erection)

first line treatment for acute mania and depression

lithium carbonate

what is lithium

• naturally occurring salt

• neurotransmitters are altered by drug

what is the therapeutic lithium range

• 0.5-1.2

lithium side effects

• essential fine motor tremor

• slowed cognition

• delayed sexual response

• weight gain

• mild gi distress

• frequent urination

• thirst

• sedation

• impaired coordination

• hair loss

• acne

• hypothyroidism

• kidney dysfunction

what s/s would be seen in a pt with lithium level of 1.5-2

• coarse hand tremors

• persistent GI upset

• muscle irritability

• incoordination

• sedation

what side effects would be in a pt with a lithium level of 2-2.5

• ataxia

• confusion

• polyuria

• blurred vision

• stupor

• severe HTN

• coma

what is ataxia

unsteady/uncoordinated gate

when should you draw a lithium trough

12 hrs after the last dose

pt teaching for lithium

• monitor blood levels regularly

• eat a normal diet w regular amt of salt and drink 8-12 glasses of water a day

• low sodium can cause lithium retention and toxicity

• stop taking if you experience diarrhea, vomiting, or profuse sweating

why should you drink 8-12 glasses of water per day when taking lithium

• it decreases reabsorption of sodium in the kidneys

• low sodium or dehydration can cause lithium retention and toxicity

how do anticonvulsants work for BPD

• enhances effects of GABA

• desensitizes kindling effect seen on BPD

what is the kindling effect in BPD

• brain becomes more sensitive to triggers causing instability and less stimulus needed

common anticonvulsants for BPD

• valproic acid (depakote)

• carbamazepine (tegretol)

• lamotrigine (lamictal)

side effects for valproic acid (depakote)

• gi pain

• tremor

• sedation

• weight gain

• hair loss

vaproic acid (depakote) key concepts

• monitor blood levels ad liver fx

• not recommended for females during pregnancy

• overdoses can be lethal

key concepts carbamazepine (tegretol)

• blood levels monitored weekly for 1st 8 weeks (can increase liver enzymes)

• dont use in pregnancy

• can decrease effectiveness of birth control

side effects of carbamazepine (tegretol)

• drowsiness

• dizzy

• ataxia

• double vision

• blurred vision

• nausea

• fatigue

lamotrigine (lamictal) key concepts

• teach to monitor for rash (stevens johnsons syndrome

• monitor for aseptic meningitis

• can lower effectiveness of birth control and the other way around

• effective for depressive phase of bpd

who uses vagus nerve stimulation

pts with treatment resistant depression

what is vagus nerve stimulation

• a long term implanted device into the upper chest that sends signals to left vagus nerve in the neck at regular intervals (voice changes)

what is electroconvulsive therapy used for

depression and mania

ECT key concepts

• under general anesthesia

• 2-3x/week for 6-12wks

• consent for signed

side effects of ECT

• headache

• muscle aches

• nausea

• short term temporary memory loss

what is transcranial magnetic stimulation

• uses mri strength pulses to stimulate the cerbral cortex

• takes 50 min

• 5days/wk for 4-6 weeks

• no memory loss

what is light therapy

• treatment for depression with seasonal patterns

• full-spectrum wave length exposure for 30-60 min'/day

how does light therapy work

suppresses nocturnal secretion of melatonin, which is beneficial w depression

what is st johns wort

• plant w antidepressant properties

• not regulated by fda

exercise in treatment mood disorders

mood elevation and decreased depression with moderate exercise

what is cognitive behavioral therapy

• done individually or in groups

• goal is to identify and correct distorted, negative, and catastrophic thinking

• very effective