mood disorders.docx

  • FYI: 5HT is short hand for serotonin
  • Define Mood
  • Examine differences between major depressive disorder and Bipolar Disorder
  • Review across the lifespan situations that can be associated with mood disorders.
  • Discuss assessments, behaviors and risks associated with these two disorders
  • Review treatment options for each disorder
  • Analyze side effects of each class of medications
  • Highlight priority nursing interventions to include teaching with medications.

Types of Disorders

Mood

  • a prolonged emotional state; it impacts our personal life and personality
  • flat affect= withdrawn
  • mood changes are normal and expected, it becomes a mood disorder when it interfers with normal activities; static mood or pronounced change that interferes.

Depression/Major depressive disorder

  • Patho:
    • Often dysregulation of NE, DA, 5HT
  • At risk for depression
    • Across the lifespan, gender, social economic
      • Young people after starting medications can have more risk of SI, follow up and ask questions. Black box warning on psych meds
    • Family history, genetic component
    • Children with adverse childhood events
  • At risk for suicide
    • Adolescents
      • children of color are at higher risk then other of same age due access to guns
      • peer pressure; bullying; hormone changes; poor coping skills
      • adverse childhood event
    • Elderly- poor health and lose their support
    • Recent crisis, stress, loss
    • Substance use
    • No social support
    • Chronic or painful illness
    • Previous suicide attempt
    • Identity crisis
    • Withdrawn, depressed
    • Hallucinating (this would be the very severe depression that become psychotic = lose touch with reality)
  • Assessment:
    • Take a history: self, family
    • Blood work to rule out other possible causes
    • Children will present BORED or IRRITABLE
    • Cognitive
      • Suicidal Ideation
      • Crying
      • Poverty of ideas
      • Negative view: self, world, future
    • Mood
      • Dysphoric
      • Depressive
      • Despair
      • ↓ interest in pleasure (anhedonia)
    • Psychomotor
      • Agitation of retardation of movement
      • Fatigue
      • ↓ appetite
      • Constipation
      • Sleep disturbance
      • ↓ libido
    • “SIG E CAPS”
      • Sleep disturbance
      • Interest decrease
      • Guilty feeling
      • Energy decrease
      • Concentration decrease
      • Appetite ↑ or ↓
      • Psychomotor fxn ↓
      • Suicidal ideations
    • Postpartum depression
      • Depression across the lifespan- due to hormonal changes
      • Can be severe = postpartum psychosis; having paranoid thoughts/seeing things not there
      • Screen mothers
  • Nursing diagnosis
    • Ineffective individual coping
    • Impaired social interaction or social isolation
    • Risk for self harm
    • Low self esteem
  • Treatment:
    • Intervention
      • Participation in group, hobbies= ↑ self esteem; improve with endorphins
      • Promote expression of feelings
      • Safety precautions
        • Remove harmful objects
        • Close observation 1:1
        • Written contract
      • Physical needs
        • Access weight
        • Ask about appetite and what eating
        • Prevent side effects meds: example constipation in TCA
      • Electroconvulsive therapy
        • Not first line; used if need urgent response or failed other tx
        • Controlled seizures to “reset the brain”
        • Informed consent needed
        • IV set up, check Vital signs, give anticholinergic meds to dry secretions so do not aspirate, emergency air way ready to go; preoxygenation; atropine to prevent bradycardia; conscious sedation propofol;
        • monitor after tired, headache, confusion will go away
  • Pharmacology
    • SSRI
      • Zoloft® (sertraline), Paxil® (paroxetine), Prozac® (fluoxetine)
      • Key teaching: take few weeks to have effect 4 – 6 weeks
      • D/D: st. john’s wort, MAO, Zofran = 5HT syndrome
        • 5HT 🡪
          • hold med; inform MD;
          • protect airway, breathing, circulation
          • Cooling blanket for fever
          • Seizures – antiepileptic
    • TCA
      • Elavil ® (Amitriptyline); Tofranil ® (imipramine); Pamelor ® (nortriptyline); Sinequan ® (doxepin)
      • Watch for
        • Anticholinergic side effects: sedation, orthostatic hypotension, dry mouth, urinary retention, tachycardia
        • Not 1st choice for elderly due to Orthostatic hypotension
    • MAOIs
      • Nardil ® (phenelzine) , Parnate ® (tranylcypromine) Marplan ® (isocarboxazid), selegiline
      • SE: sweating,tremors, elevated temp, bounding heart, ↑ BP
      • Avoid tyramine foods
        • NO aged or fermented cheese, wine
        • Cured meats, smoked meats, processed meats
        • Pickled or fermented foods
        • Sauces (soy, miso, teriyaki)
      • Avoid medications that affect 5HT
        • NO barbiturates, antihistamines, TCA, OTC cold meds, CNS depressants
    • SNRI
      • Cymbalta ® (Duloxextine), Effexor® (venlafaxine)
      • NE and 5HT
      • Check Blood pressure b/c can lower
    • NDRI
      • Wellbutrin ® (bupropinon):
        • DA and NE used for smoking cessation and depression; do help with sleep; at night
      • Remeron ® (mirtazapine)
        • DA and NE; effect with insomnia
      • Used normally only when others uneffective
      • Do not use seizures or eating disorders; due to lower seizure threshold
    • Atypical
      • Desyrel® (trazodone): used for insomnia take at night

Bipolar Disorder ( aka Manic-depressive disorder)

  • Patho
    • Mania = an alteration in the mood when the person feels elated , has big self esteem, hyperactive.
      • There are different types, but not tested on hypomania, delirum mania
    • Must have at least one manic episode to be considered Bipolar, can spend more time in either polar state (depression/mania)
  • Risk for suicide is higher in mania
    • Delirious/ unstable
    • Reckless behavior
    • Unintentionally harm themselves and others
  • Symptoms
    • Manic
      • Patients may like this state b/c they are productive, can start slow and ramp up. They can like these feelings and then not take meds b/c of.
      • Onset before 30 yo; begins suddenly and escalates over several days
      • Mood
        • Elevated, expansive, irritable
      • Speech
        • Loud-rapid, punning, rhyming, clanging, vulgar
        • Flight of ideas
      • Weight loss: to active for eating and don’t sit still
      • Grandiose delusions: May think they are Michelle Obama or God
      • Distracted, hyperactive, ↓ need for sleep
    • Depressive
      • Mood
      • ↓ interest in pleasure
      • Negative view
      • Fatigue
      • ↓ appetite, ↓labido,
      • Constipation
      • Insomnia
      • Agitation or movement retardation
  • Assessments
  • Treatment
    • Same as depression; added problems with taking medications and during mania poor choices and risky behaviors
    • SET BOUNDARIES
    • Professional relationship
    • Family education
    • Manic state: decrease stimulated environement
  • Pharmacology
    • Mania
      • Anticonvulsants used mood stabilizers
        • Valproic acid: with meals and therapeutic levels
        • Depakote ® (divalproex)
        • Lamictal ® (Lamotrigine): steven johnson syndrome; if rash need to follow up
      • Eskalith ® (Lithium)
        • Read this Lexicomp
        • Use: treat mania
        • MOA: related to sodium, effects the sodium ion transport into the nerve and enhances the reuptake of NE and 5HT in the brain therefore decreasing hyperactivity.
        • SE:
          • Weight gain, n/v, diarrhea, polydipsia, tremor, polyuria, metallic taste in mouth
          • Chronic toxicity can lead to endocrine system: hypothyroid, hyperthyroid
          • Toxicity:

What leads to dehydration, too much drug, issues with renal and excretion

Mild >1.5- 2.0 mEq/L

n/v, diarrhea, abdominal pain, blurred vision

Moderate 2-3

GI: N/V, diarrhea

Neuro:

Mental status changes dysarthria (slurred speech) ataxia ( balance/coordination); confusion, tremors, hyperreflexia, hystagmus, myoclonus ( muscle twitches)

Increased urine output

Seizure, coma

Severe >3 mEg/L

Seizures, coma

May need hemodialysis to survive

        • D/D:
          • avoid diuretics if possible
          • 5HT syndrome drugs
        • Nursing:
          • Baseline EKG
          • Baseline chemistry and maintance labs; includes sodium
          • Know the toxicity sx and therapeutics levels
          • Blood work/ baseline

Draw am before med given

1 -2 mn checked in beginning weekly;

Therapeutic 0.5 to 1.5 mEq/L

Maintenance 0.6 to 1.2 mEq/L:

          • Fluids = 3 L
          • Baseline renal test, cardiac, thyroid (can lead to hypothyroid)
          • Tx of toxicity:
        • Teaching:
          • Drink 3 L of fluid daily
          • Blood will drawn to access levels
          • Monitor salt, keep same because can change level of drug
          • SX of n/v, diarrhea needs to be communicated to MD
  • Nursing Actions
    • Teaching be/c more at risk for suicide or harm during mania
      • Be honest with patient
      • Help set goals or remind of love ones that may be harmed by actions or behaviors
      • Teach families of early signs of mania
      • Mania can turn into psychotic episode and lose touch with reality
      • Work with patient to have psychiatric advance directives

Schizophrenia

  • Patho

Suicide Precautions make room safe

  • Secure Room
    • Windows locked
    • Breakproof glass & mirrors
    • Plastic flatware
    • No cords: phones, IV, extension cords
    • No belts, curtains
    • No matches or cigarettes
    • No sharps/ razors
    • No hand santitizer
  • Patient care
    • Frequently observe 1:1
    • Staff communication
    • Develop therapeutic relationship
    • Written behavior contract with patient
    • Restraints as ordered
    • Medications as ordered
    • Monitor and restrict visitors