Mood Disorders

Mood Disorders Overview

• Mood disorders/affective disorders involve pervasive alterations in emotions manifested as depression or mania (or both).

• They cause interference with life; characterized by long-term sadness, agitation, or elation.

• Historical context: Individuals with mood disorders have existed throughout history; until the mid-1950s, no treatment was available for serious depression or mania.

Mood Disorders #1

• Definition: Pervasive alterations in emotions manifested by depression or mania or both; interference with life; long-term sadness, agitation, or elation.

• Historical note: No effective treatments available for serious depression or mania until around the mid-20th century.

Mood Disorders #2

• Depression is one of the most important risk factors for suicide; it is the most important risk factor among mood disorders for suicidal behavior.

• Suicide risk is closely linked to depressive states.

Categories of Mood Disorders

• Major depressive disorder (episodes last ≥ $2\,\text{weeks}$)

• Bipolar disorder (I or II)

• Persistent depressive (dysthymic) disorder

• Disruptive mood dysregulation disorder

• Cyclothymic disorder

• Substance-induced depressive or bipolar disorder

• Seasonal affective disorder

• Postpartum blues, postpartum depression, or psychosis

• Premenstrual dysphoric disorder

• Nonsuicidal self-injury related disorders

Etiology #1

• Biologic theories

  • Genetic theories

  • Neurochemical theories: serotonin, norepinephrine, possibly acetylcholine and dopamine

  • Neuroendocrine influences: hormones

• Psychodynamic theories

  • Concepts: self-depreciation, ideal ego, ego victimized by the superego

  • Mania as defense against underlying depression

  • Depression as reaction to life experiences

  • Rejecting or unloving parents

• Cognitive distortions

Cultural Considerations

• Hamilton Rating Scale for Depression (see Box 17.1)

  • Found reliable across diverse cultures for symptoms related to general depression:

  • Depressed mood

  • Guilt

  • Loss of interests

  • Retardation (slowing)

  • Suicide

  • Psychological anxiety

  • Somatic complaints

  • Manifest in cultures that avoid verbalizing emotions

Question #1

• True/False: Depression is one of the most important risk factors for suicide. (Answer: True)

Major Depressive Disorder

• An untreated episode of depression can last weeks, months, or years.

  • Most clear in about $6\text{ months}$

• Recurrence: $50\% \text{ to } 60\%$ will have a recurrence.

• Chronic form: Approximately $20\%$ will develop a chronic form of depression.

• Some people with severe depression have psychotic features.

Psychopharmacology – Antidepressants

• Major categories of antidepressants:

  • Selective serotonin reuptake inhibitors (SSRIs):

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Tricyclic antidepressants (TCAs): Amitriptyline (Elavil)

  • Atypical antidepressants: Bupronion (Wellbutrin)

  • Monoamine oxidase inhibitors (MAOIs): Phenelzine (Nardil)

  • Risks: hypertensive crisis; serotonin syndrome

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): Duloxetine (Cymbalta)

  • Atypical antipsychotics (used as adjuncts): Clozapine (Clozaril); Quetiapine (Seroquel)

  • Anticonvulsants (mood stabilizers): Lamotrigine (Lamictal)

Other Medical Treatments and Psychotherapy

• Electroconvulsive therapy (ECT)

• Psychotherapy (often combined with medications)

  • Interpersonal therapy: addresses relationship difficulties

  • Behavior therapy: positive reinforcement of interactions

  • Cognitive therapy: targets cognitive distortions

  • Absolute thinking (black/white)

  • Specific abstraction (focus on minor details)

  • Personalization (self-related attributions)

Other Somatic Therapies

• Transcranial magnetic stimulation (TMS)

• Magnetic seizure therapy

• Deep brain stimulation

• Vagal nerve stimulation

• Other somatic therapies (as applicable)

Major Depressive Disorder and Nursing Process Application #1 – Assessment

• History

• General appearance and motor behavior (psychomotor retardation, latency of response, psychomotor agitation)

• Mood and affect (anhedonia)

• Thought process and content (rumination, thoughts of suicide)

• Sensorium and intellectual processes (impaired memory)

• Judgment and insight (impaired judgment)

• Self-concept (feelings of worthlessness)

• Roles and relationships (more severe depression = greater difficulty)

• Physiological and self-care considerations

• Depression rating scales:

  • Self-rating scales: Zung Self-Rating Depression Scale; Beck Depression Inventory

  • Clinician rating scale: Hamilton Rating Scale for Depression

Major Depressive Disorder and Nursing Process : Data analysis and priorities

• Outcome identification:

  • Free from self-injury

  • Independently carry out activities of daily living

  • Balance of rest, sleep, and activity

  • Evaluate self-attributes realistically

  • Socializing

  • Return to occupation or school activities

  • Medication compliance

  • Verbalize symptoms of recurrence

Major Depressive Disorder and Nursing Process Application : Actions

• Providing for safety (suicide precautions)

• Promoting a therapeutic relationship

• Promoting activities of daily living and physical care

• Using therapeutic communication

• Managing medications

• Providing client and family teaching

• Evaluation

Bipolar Disorder

• Features: Extreme mood swings with episodes of mania and depression

• Disability impact: Second only to major depression as a cause of worldwide disability

• Lifetime risk: $2\%$

• Demographics: Occurs almost equally among men and women; more common in highly educated people

Treatment – Bipolar Disorder

• Psychopharmacology:

  • Lithium

  • Anticonvulsant drugs

  • Carbamazepine (Tegretol)

• Psychotherapy

• Note: Lithium useful in mildly depressive or normal portions of the bipolar cycle; Not useful during manic stages

Bipolar Disorder and Nursing Process Application #1 – Assessment

• History:

  • General appearance and motor behavior (clothes reflecting elevated mood)

  • Mood and affect (periods of euphoria, grandiosity)

• Thought process and content (circumstantiality, tangentiality)

• Sensorium and intellectual processes (disoriented to time)

• Judgment and insight

• Self-concept (exaggerated self-esteem)

• Roles and relationships (manic phase clients can rarely fulfill responsibilities)

• Physiological and self-care considerations

• Data analysis and priorities

  • Outcome identification examples: No injury to self or others; Balance of rest, sleep, and activity; Socially appropriate behavior

Question #3

• Which medication would be most appropriate for the treatment of mania associated with bipolar disorder?

  • A. Lithium

  • B. Fluoxetine

  • C. Citalopram

  • D. Venlafaxine

Bipolar Disorder and Nursing Process Application #3 – Actions

• Providing for safety

• Meeting physiological needs

• Providing therapeutic communication

• Promoting appropriate behaviors

• Managing medications

• Providing client and family teaching

• Evaluation

Suicide

• Definition: Suicide is an intentional act of killing oneself

• Demographics: Men commit approximately $72\%$ of suicides

• Adolescents: 2nd leading cause of death

• Suicidal ideation: thinking about killing oneself

• Warning signs: Risk factors and signs of intent

• Concept: Suicide involves ambivalence (mixed feelings) about living vs dying

Assessment focus:

• Previous suicide attempts (greatest risk in the first 2 years after an attempt, especially the first 3 months)

• Relative who committed suicide

• Warnings of suicidal intent

• Risky behaviors

• Lethality assessment

Outcome Identification:

• Safe from harming self and others

• Engagement in a therapeutic relationship

• Reporting suicidal ideation to staff

• List of positive attributes

• Realistic plans to address underlying issues

Actions:

• Using an authoritative role

• Providing a safe environment

• Creating a support system list

Family Response:

• Suicide can be experienced as ultimate rejection by family and friends

• Families may react with guilt, shame, and anger; families can disintegrate

Nurse’s Response:

• Need for unconditional positive regard for the person

• Avoidance of client blame

• Nonjudgmental approach and tone

• Belief that one person can make a difference in another’s life

• Potential staff devastation if client commits suicide

Legal and Ethical Considerations

• Assisted suicide is a topic of national legal and ethical debate

• Oregon was the first state to adopt assisted suicide into law

• Nurses often care for terminally or chronically ill people with poor quality of life

• Nurse’s role: provide supportive care for clients and families as they work through decision-making processes

Question #4

• True/False: When dealing with a client who is suicidal, the nurse needs to assume a dependent role. (Answer: False)

Age-Related Considerations

• Disruptive mood dysregulation disorder (DMDD) diagnosed in those age 6–18 years

• Suicide: leading cause of death among children, adolescents, and young adults

• Depression: common among older adults; increases with medical illness

• Psychotic features more frequent in older adults with depression

• Increased intolerance of medication side effects in older adults

• ECT more commonly used for treatment in older adults; more rapid response

• Suicide rate of older adults is double that of younger adults

Community-Based Care

• Nurses are often the first health care professionals to recognize mood-disorder behaviors

• Documenting and reporting behaviors helps clients get treatment

• Successful treatment of depression in the community involves psychiatrists, psychiatric advanced practice nurses, and primary care physicians

Mental Health Promotion

• Education to address stressors contributing to depressive illness

• Prevention and early detection; treatment for adolescents

• Screening for early detection of risk factors

• Factors include:

  • Family strife

  • Parental alcoholism or mental illness

  • History of fighting

  • Access to weapons in the home

Self-Awareness Issues

• Importance of dealing with own feelings about suicide

• Frustration possible when working with depressed or manic clients

• Exhaustion possible when working with manic clients

• Strategies:

  • Journaling to help deal with feelings

  • Talking with colleagues