Lectures Notes on Mood Disorders (Depression and Bipolar Disorders)

Exam Information

• Exam includes chapter 17.

• Terms from previous tests are still relevant.

• Psychosis will be covered in relation to bipolar disorder.

Treatment Measures for Depression

• Psychopharmacology and psychological treatments.

• Earliest medications for depression were in the 1950s.

• Cognitive Behavioral Therapy (CBT) involves changing thoughts and behaviors.

  • Changing behaviors can impact mood more rapidly than changing thoughts.

Medications

• No need to know specific medication names, only categories.

• Exception: Lithium.

• Categories of Antidepressants:

  • SSRIs (Selective Serotonin Reuptake Inhibitors)

    • Examples: Citalopram (Celexa) and Sertraline (Zoloft).

    • Considered "line choice" for depression treatment due to favorable side effect profile.

    • Fewer sedating and anticholinergic side effects.

    • Increase serotonin availability.

    • Side effects: urinary retention, constipation, dry eyes, dry mouth, sexual dysfunction and weight gain.

    • Important to teach patients that it takes 3-4 weeks to start working.

    • Black box warning for increased risk of suicide, particularly when the medication starts working.

  • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

    • Increase availability of serotonin and norepinephrine.

    • Considered 1A, close to SSRIs.

    • Good side effect profile.

    • Also have a black box warning.

  • NDRIs (Norepinephrine-Dopamine Reuptake Inhibitors)

    • Norepinephrine and dopamine.

  • TCAs (Tricyclic Antidepressants)

    • Inhibit reuptake of serotonin and norepinephrine.

    • Can be lethal in large doses.

    • Cardiotoxic.

    • Higher side effect profile than SSRIs.

    • More cardiovascular side effects (dizziness, orthostatic hypotension).

    • More sedation, insomnia, and anticholinergic side effects.

    • Still have the black box warning.

    • If TCAs must be prescribed:

      • Give only a limited supply at a time, or

      • Admit the patient and administer the medication.

  • MAOIs (Monoamine Oxidase Inhibitors)

    • Interact with many OTC and prescription medications, and foods.

    • Interact with foods that increase tyramine.

    • Can cause a hypertensive crisis (dangerously high blood pressure).

    • Same black box warning.

    • Hypertensive crisis caused by aged foods (wine, pepperoni, cheese, salami, fermented foods).

  • Serotonin Syndrome

    • Risk with any medications that increase serotonin availability.

      • Change in level of consciousness.

      • Agitation.

      • Neuromuscular excitement, rigidity, tremors, jerking.

      • Hyperthermia, tachycardia, hypersalivation, and diaphoresis.

General rules of anti-depressants

• Increased risk of suicide, particularly for 18 to 24 year olds.

• Slow onset.

• Need to taper on and taper off.

• Expect several weeks before noticing effects.

• Educate about side effects.

Medication Tables

• Tables in the textbook (e.g., page 290) are important.

  • Focus on side effects and nursing implications.

  • Know what each side effect term means.

  • Understand the nursing interventions for each side effect.

• Pharmacogenetics: Tests to determine which medication will work best for an individual.

• Example Test Question:

  • Patient taking an SSRI is experiencing drowsiness and dry mouth. What is the most appropriate nursing intervention?

    • Administer in the PM.

    • Encourage patient to suck on sugar-free hard candy.

    • Check their orthostatic blood pressure.

Increased Serotonin

• Serotonin is a very important neurotransmitter that helps regulate mood, emotions, and other body functions.

• If you have depression, you may have a serotonin imbalance.

• As serotonin builds up, normal communication between cells can resume, and your symptoms of depression may improve.

Psychological Treatments

• Individual psychotherapy (usually CBT).

• Group therapy and family therapy.

Cognitive Behavioral Therapy (CBT)

• Mindfulness

  • Focus on the present moment.

  • Direct attention towards a part of the body.

    • For example, your breathing.

  • Focus on one of your senses.

    • For example, noticing smells or sounds.

  • Recognize Cognitive Distortions.

    • Ground things back in reality.

Electroconvulsive Therapy (ECT)

• Electrical electrodes on the head to induce a generalized seizure throughout the body.

• Patient is sedated and given muscle relaxants.

• Teach patients to expect short term memory loss and confusion.

• Given medications to decrease secretions (e.g., atropine) and counteract bradycardia.

• Muscle contractions are kept relaxed.

• Anesthesiologist supports airway.

• Increases neurotransmitters and neuroplasticity in the brain.

• May change hormone levels or blood flow patterns.

Nursing role when coming out of ECT

• Monitor their vital signs.

• Help them prevent aspiration.

• Stay on their side while asleep.

• They can sit up because at that point, they can manage manage their own secretions.

• Be aware that they could be dizzy.

• Allow them to sleep.

• Treat headaches with Tylenol.

• They can eat as soon as they're hungry.

Other Treatments for Depression

• TMS (Transcranial Magnetic Stimulation).

• Light therapy.

• Ketamine.

  • Works on a different receptor (glutamate).

  • Used for treatment resistant depression and acute suicidality.

• Neurofeedback.

• IV
  Under the trade name esket esketamine esketamine.
  We need to monitor blood pressure, be aware that they can have dissociative symptoms, Sedation.
  Suicidal ideation can go up just like it can with other antidepressants and that there is a risk of abuse.
  That blood pressure elevation and sedation is for about two hours after they have that treatment.
  Psychedelics for depression.

Nursing Interventions for Depression

• Prioritize needs:

  • Safety is usually the highest concern.

  • Then Maslow's hierarchy (biological needs, psychological things).

• Institute suicide precautions if indicated.

• Work on therapeutic relationship.

• Help establish adequate nutrition and hydration.

• Promote sleep and rest.

• Engage in ADLs.

• Engage the patient in activities.

• Work with them in verbalizing their emotions.

• Teach about managing medications and side effects.

• Cardiovascular exercise can be effective.

Nonsuicidal Self Harm

• Cutting, burning, excessive tattooing and body piercing.

• Motivations:

  • Alleviating psychological and emotional pain.

  • Cry for attention.

  • Manipulation.

• Take all self harm seriously, but don't overreact.

• Give first aid, be matter of fact, provide wound care, and follow-up with the physician.

Exam Preparation

• Know your bolded terms.

• Look at key points on the medication tables.

• Know side effects and associated nursing interventions.

• Know what the words mean.

• Notice drug alert boxes (black box warnings).

  • MAOIs: Hypertensive crisis.

    • Interaction with food or medications and foods with tyramine.

  • Serotonin syndrome.

  • Overdose on MAOIs or TCAs.

• Review symptoms for different types of depression.

  • Figure out what makes them different.

  • Persistent depressive disorder takes up to a couple of years to diagnose.
    *Major depression can be diagnosed fast.
    *Persistent vs major depression can be differentiated due to presence of suicidal thoughts

Bipolar Disorders

• Bipolar disorders involve mood swings from profound depression to mania or hypomania.

• Can include delusions and hallucinations.

Depression (Review)

• Depressed mood nearly every day.

• Loss of interest or pleasure (anhedonia).

• Impaired social/occupational function.

• Sleep disturbance.

• Decreased concentration.

• Changes in motor activity (catatonia).

• Changes in appetite.

• Feelings of worthlessness or guilt.

• Possible suicidal ideation.

Mania

• Elevated or expansive mood or irritable mood.

• Inflated self esteem or grandiosity.

• Decreased need for sleep.

• Increased talking.

• Flight of ideas.

• Pressurized speech. Pressure cooker.

• Very distractible.

• Increased activity or cycle motor agitation.

• Poor judgment.

• Excessive involvement in risky or pleasurable activities.
  *sexual promiscuity, gambling, reckless driving.

Types of Bipolar Disorder

1. Bipolar I Disorder.

2. Bipolar II Disorder.

3. Cyclothymic Disorder.
   *Rule out medication and substance use

Bipolar I Disorder

• Full syndrome from mania (full mania) and major depression.

• At least one episode of major depression.

Bipolar II Disorder

• Major depression and hypomania (less than full mania).

• Never psychosis.

• Social or occupational function changes can occure
  There will never be any delusions.

Cyclothymic Disorder

• Dysthymia (moderate depression) and hypomania.

• Smallest swing.

• Never major depression or mania.

• Takes longer to diagnose (up to two years).
  *You dont get depressed the same way you do not go to full mania.

Lithium as a Mood Stabilizer

Side effects

• Has a lot of side effects.

• Acts in your body like a salt.

• Impact if you get dehydrated or you get too much salt, it's gonna impact how you metabolize it.

• Teach patients that they're gonna have to get labs for lithium.
  *There are side effects that have to be well controled.

• Cardiac effects or kidney problems makes these not usable too.
  *Need to have labs done to get levels.
  *Medication is a salt.

Medications that can be mood stabilzers for bipolar

• If they can't tolerate lithium because the side effects are too bad or they don't have the cardiac or kidney function that will tolerate it, then they'll give them or it just doesn't work for them, they'll give them one of these other medications as mood stabilizers. Is:

• Seizure Medications e.g. anticonvulsants.

Side effects for meds

You're not gonna have to say, yeah, that side effect.
It must be this drug, but it'll say yes. You need to know lithium alone. You need to learn about lithium. It's it's it's its own kind of drug. It's its own name. And then the other three is mood stabilizers.
Anything on lithium, just read it. Just learn about it because you're gonna be giving it, and it's and it's got lots of special things you should know about lithium.

Non Medication mood stabilizers

• Cognitive behavioral theraphy.
  *Change the way they they behave, and those kind of things. What are some tips with them.
  Recognize families better.Communicate properly.Recognize and respond
  Better interactions and not taking them personally .There are plans.
  Not family should be on the hook.They can support them only.

General Saftey rules when treating

*safety is the top priority
If it's not biological priority.

• They might be more volitanle and ready to anger.They have aggressions.
  So observe every 10 minutes if needed.
  *Violence behavior should be called down.
  Physical outlets are also to be there.

Nutrition is also important

• We need to take care of biological needs for the person. So they're gonna be spending a lot of a lot of energy moving around a lot when they're manic. So we're gonna and they probably won't slow down and eat. So provide foods that they want to eat that if you can get them to be high-calorie and high protein and finger foods, things that they can just take and eat on the go so that they they get enough to eat.

• Keep track of their intake and output because we do care about, like, their hydration level with if they're taking lithium particularly and get daily weights, calorie counts, and watch their lab values. Supplement with vitamins and minerals.
  I mean, it's a little bit like having a child probably.
  But, ultimately, we can't put all this pressure on the family to be in charge of everything that happens with that person. But we can help them have better a better relationship by setting some rules and the way things are gonna operate when that person's stable. And they start to elevate, and they start to, like, lose their temper, and they're just gonna be like, well, nope.

The exam includes the 2 moodisorders listed on mood disorders: depression and Bipolar
For suicidality and cssrs are also included too.