Mood Disorders and Self-Harm/Suicide Study Guide

Conceptual Foundations of Mood and Affect

• Mood: Defined as a pervasive and sustained emotion that colors an individual's perception of the world and how they function within it.

• Mood Disorder: Refers to persisting or recurrent disturbances or alterations in mood that continually cause psychological stress and behavioral impairment over many years. It is specifically an alteration in mood, not in thought processes.

• Affect: The behavioral expression of emotion.

  • Appropriate: The expression is congruent with the situation.

  • Constricted/Blunted: There is a diminished range and intensity of emotional expression.

  • Flat: An total absence of emotional expression.

Overview and Epidemiology of Depressive Disorders

• History: Depression is considered the oldest and one of the most frequently diagnosed psychiatric illnesses.

• Normal vs. Pathological Responses:

  • Transient symptoms are considered normal, healthy responses to everyday disappointments in life.

  • Pathological depression occurs when adaptation to stressors is ineffective.

• Clinical Definition: Depression is an alteration in mood expressed by feelings of sadness, despair, and pessimism. It is characterized by an overwhelming state of sadness, loss of interest or pleasure, guilt, disturbed sleep/appetite, low energy, and inability to concentrate.

• Spectrum of Care: Mood disorders are diagnosed on a spectrum from mild symptoms (treated as outpatient) to severe symptoms (necessitating hospitalization to prevent self-harm).

• Epidemiology in the U.S. ($2017$ Data):

  • Estimated prevalence in adults ($18$ or older): $17.3\,million$ ($7.1\%$ of adults).

  • Prevalence by gender: Females ($8.7\%$) vs. Males ($5.3\%$).

  • Prevalence by age: Highest in individuals aged $18$ to $25$ ($13.1\%$).

  • Prevalence by ethnicity: Highest among people with multiple ethnicities ($11.3\%$).

Diagnostic Criteria: Major Depressive Disorder (DSM-5-TR)

Diagnosis requires $5$ or more of the following criteria present during the same $2$-week period, representing a change from previous functioning. At least one must be $A1$ or $A2$:

• A1: Depressed Mood: Indicated by subjective report or observation (may be irritable mood in children/adolescents).

• A2: Anhedonia: Loss of interest or pleasure in all or almost all activities.

• A3: Weight/Appetite Change: Significant unintentional weight loss/gain (>5\%) or appetite change (failure to make expected weight gains in children).

• A4: Sleep Disturbance: Insomnia or hypersomnia nearly every day.

• A5: Psychomotor Changes: Agitation or retardation severe enough to be observed by others.

• A6: Fatigue: Tiredness, low energy, or decreased efficiency with routine tasks.

• A7: Worthlessness/Guilt: Sense of worthlessness or excessive/delusional guilt (not just self-reproach about being sick).

• A8: Cognitive Impairment: Diminished ability to think, concentrate, or make decisions.

• A9: Recurrent Thoughts of Death: Suicidal ideation with or without a plan, or suicide attempts.

Specific Depressive and Mood Disorders

• Disruptive Mood Dysregulation Disorder (DMDD): Diagnosed in children exhibiting extreme irritability, tantrums, and trouble functioning in school/with peers.

• Persistent Depressive Disorder (PDD): Formerly known as Dysthymic Disorder. Characterized by a chronically depressed mood for most of the day, more days than not, for at least $2\,years$. No evidence of psychotic symptoms.

• Premenstrual Dysphoric Disorder (PMDD): Depressed mood, anxiety, and mood swings occurring the week prior to menses and subsiding shortly after onset.

• Postpartum Depression: Depression occurring immediately after or throughout the first $1\,year$ after childbirth; associated with hormonal changes and tryptophan metabolism.

• Substance/Medication-Induced Depressive Disorder: Depression caused by the use of medications or substance use.

• Mood Disorders Related to Medical Conditions: Symptoms can be triggered by Parkinson’s, Huntington’s, Traumatic Brain Injury (TBI), and Hypothyroidism.

• Bipolar and Related Symptoms:

  • Mania: Severe elevated mood; mild version is Hypomania.

  • Cyclothymia: Alternates between mild mania and depression for at least $2\,years$.

Developmental Manifestations Across the Lifespan

• Childhood Depression (DMDD):

  • Under age $3$: Feeding problems, tantrums, lack of playfulness/expressiveness.

  • Ages $3$ to $5$: Accident proneness, phobias, excessive self-criticism.

  • Ages $6$ to $8$: Physical complaints, aggressive/clinging behavior, extreme irritability.

  • Ages $9$ to $12$: Morbid thoughts and excessive worrying.

  • Note: Usually precipitated by a loss; therapy focuses on coping skills and family involvement.

• Adolescence: Differentiated from normal behavior by a visible behavioral change lasting several weeks. Common precipitants include parental abandonment or lost peer relationships.

  • Symptoms: Anger, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, and apathy.

  • Black Box Warning: All antidepressants carry an FDA black box warning for increased suicidality risk in children and adolescents.

• Elderly Depression:

  • Often precipitated by "bereavement overload."

  • Pseudodementia: Symptoms of depression confused with dementia; in depression, cognitive functioning is slowed but remains intact.

  • High suicide rates in this population.

• Postpartum Manifestations: Fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and concern about inability to care for the infant.

Levels of Depression Continuum (Recognizing Cues)

• Transient Depression: Not necessarily dysfunctional. Affected by the "blues," some crying, difficulty diverting mind from disappointment, and listlessness.

• Mild Depression: Associated with normal grieving. Manifests as anger, anxiety, regression, preoccupation with loss, anorexia, and insomnia.

• Moderate Depression: Associated with PDD/Dysthymic disorder. Includes helplessness, slowed physical movements (slumped posture), slowed thinking, and physical symptoms like headaches or overeating.

• Severe Depression: Symptoms of MDD. Includes total despair, flat affect, absence of communication, psychomotor retardation (entire body slowdown), and somatic/persecutory delusions.

Non-Suicidal Self-Injury (NSSH)

• Definition: Intentional harming of self without intent to die; used as a coping mechanism.

• Methods: Cutting (most prevalent), scratching, biting, carving designs into skin, burning, hair-pulling, and head-banging.

• Risk Factors: Adverse Childhood Experiences (ACEs), poverty, abuse/neglect, industrial pressures, and comorbidities like Borderline Personality Disorder or Eating Disorders.

• Warning Signs: Unexplained scars, fresh cuts/burns, keeping legs/arms covered in hot weather, keeping sharp objects hidden, and unpredictable impulsive behavior.

• Interventions: Reaching out to a confidante, creative expression (journaling, drawing), developing an action plan, and establishing a support system.

Suicide: Risk Assessment and Warning Signs

• Definitions:

  • Suicide: Death caused by self-directed injurious behavior with intent to die.

  • Suicide Attempt: Non-fatal self-directed injurious behavior with intent to die.

  • Suicidal Ideation: Thinking about, considering, or planning suicide.

• Statistics: Suicide rates increased $33\%$ from $1999$ to $2019$. One death occurs every $11\,minutes$ in the U.S. ($47,500$ deaths in $2019$).

• SAD PERSONS Scale ($1$ point per factor):

  • S: Sex (Male)

  • A: Age (<19 or >45)

  • D: Depression

  • P: Previous attempt

  • E: Ethanol/Substance use

  • R: Rational thinking loss

  • S: Social supports lacking

  • O: Organized plan

  • N: No partner

  • S: Sickness (chronic/major)

• Scoring Interventions:

  • $0-2$: Home with follow-up.

  • $3-6$: Consider admission or discharge with follow-up.

  • $7-10$: Admit to hospital.

• Immediate Warning Signs: Stating a wish to die, feeling hopelss/empty/trapped or like a burden. Behavioral signs include giving away possessions, bidding goodbye, and arranging affairs.

Diagnostic Tools and Measurement Scales

• Beck Depression Inventory: $21$-item self-assessment for adolescents and adults.

• PHQ-9: $9$-question self-administered frequency check of symptoms.

• Hamilton Depression Scale (Ham-D): Provider-administered; versions with $17$ or $21$ items.

• Geriatric Depression Scale: $15$ yes/no questions for older adults.

• Altman Self-Rating Mania Scale: $5$ questions assessing mood, self-confidence, speech, sleep, and activity.

Pharmacological and Somatic Management

• SSRIs: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro).

• SNRIs: venlafaxine (Effexor), duloxetine (Cymbalta), desvenlavaxine (Pristiq).

• TCAs: amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor). Used for MDD, GAD, neuropathic pain, and OCD.

• MAOIs: Phenelzine (Nardil), Tranylcypromine (Parnate), Selegiline (Emsam). Used for treatment-resistant depression.

• Other Antidepressants:

  • NDRIs: bupropion (Wellbutrin).

  • SDAMs: aripiprazole (Abilify), brexpiprazole (Rexulti).

  • NMDA Antagonist: esketamine (Spravato).

• Non-Pharmacologic Treatments:

  • CBT: Empowering change by changing thinking.

  • ECT: Administered for treatment-refractory (resistant) depression.

The Nursing Process: Assessment, Planning, and Implementation

• Assessment (Recognize Cues): Monitor energy, ability to perform ADLs, sleep, and speech patterns.

• Prioritize Hypotheses: Safety is the priority. Sudden relief in a depressed patient can indicate a finalized suicide plan.

• Inpatient Implementations:

  • Structured plans (scheduled hygiene and group activities).

  • Monitor bowel movements (potential constipation).

  • Contraband checks: Shoelaces, belts, spiral notebooks, lighters, paper clips, scissors.

  • Surveillance: One-to-one line-of-sight or every-$15$-minute checks.

• Communication: Focus on what the client can do. Be respectful and empathetic to reduce cultural stigma and fear of disclosure.

• Long-term Outcomes: Adherence with medication, lack of suicidality, and functionality in relationships.

Questions & Discussion

• Question 1: A client with PMDD understands their teaching by stating: "I am aware that my PMDD causes me to have rapid mood swings." (Rationale: Emotional lability is a clinical finding of PMDD).

• Question 2: A nurse identifies MDD understanding: "The client is at greatest risk for suicide during the first weeks of an MDD episode." (Rationale: Greatest risk is during the acute phase).

• Question 3: Risks for depression include Female gender, age between $15$ and $40$, history of chronic illness (asthma), and smoking (nicotine use disorder). Unmarried status also increases risk.

• Question 4: Priority action for MDD with comorbid anxiety: Placing the client on one-to-one observation to prevent self-harm.

• Question 5: Expected finding for Dysthymic Disorder (PDD): Presence of manifestations for at least $2\,years$ (in adults).