Objective 8: Depressive and Bipolar Disorders


Objectives

  • Discuss depressive and bipolar disorders.

  • Discuss the concepts of loss, grief, and mourning.

  • Discuss the etiology for depression and bipolar disorders.

  • Describe clinical features and behaviors associated with depressive and bipolar disorders.

  • Differentiate between postpartum blues and postpartum depression.

  • Discuss the treatment modalities & collaborative management for clients with depressive and bipolar disorders.

  • Apply the nursing process in the provision of care for clients with depressive and bipolar disorders.

  • Discuss relevant research associated with depressive and bipolar disorders.

  • Relevant chapters: 11, 13, 14, 20, 28, 29, 31, 33, 34, 35

Loss and Grief

  • Loss:

    • Can occur suddenly or gradually.

  • Grief:

    • Defined as a normal response to a loss, encompassing the grief process.

    • Referencing Kubler-Ross stages:

    • Denial: Refusal to accept the reality of loss.

    • Anger: Frustration and emotional turmoil regarding grief.

    • Bargaining: Attempting to negotiate a way out of emotional distress.

    • Depression: Deep feelings of sadness as realization of the loss sets in.

    • Acceptance: Coming to terms with the loss.

  • Mourning:

    • The outward expression of grief.

    • Refer to Table 31-3 for illustrative details.

Mood Disorders

  • Types of Mood Disorders:

    • Major Depressive Disorder (MDD)

    • Persistent Depressive Disorder (Dysthymia)

    • Bipolar Disorder and its subtypes

    • Premenstrual Dysphoric Disorder

    • Other Depressive Disorders

    • Substance-Induced Depressive Disorder

    • Depressive Disorders due to Medical Conditions

  • Quote from the National Depressive and Manic Depressive Association (2007):

    • "The zest for life has vanished. It left without notice… Truly, darkness rules."

Depression

  • Key mood states include:

    • Euthymic: Normal mood.

    • Mania: Elevated mood.

Biological Factors in Mood Disorders

  • Genetic Theory:

    • Family history as a potential risk factor.

  • Biochemical Theory:

    • Low levels of norepinephrine and serotonin (key neurotransmitters in the brain).

  • Hormonal Regulation:

    • Controversial; the pituitary gland controls thyroid/adrenal gland secretions which may be poorly regulated in depression.

  • Diathesis Stress Model & Environmental Factors:

    • The impact of external stressors such as conflicts, abuse, loss, and lack of support systems.

Psychological Factors

  • Cognitive Theory:

    • Negative thought patterns can predispose individuals to depression.

  • Learned Helplessness:

    • A lack of perceived control over outcomes leads to feelings of helplessness.

Major Depressive Disorder (MDD)

  • Diagnosis Criteria:

    • At least 5 out of 9 symptoms for a period of at least 2 weeks, including:

    • Depressed mood.

    • Significant loss of interest or pleasure (Anhedonia).

    • Significant weight and appetite changes.

    • Insomnia or hypersomnia (excessive sleep).

    • Psychomotor agitation or retardation.

    • Fatigue or loss of energy.

    • Feelings of worthlessness or excessive or inappropriate guilt.

    • Reduced ability to concentrate or indecisiveness.

    • Recurrent thoughts of death, suicidal ideation, or plans to die by suicide.

  • Subtypes of MDD:

    • Psychotic features: Disorganized thinking or delusions.

    • Melancholic: Apathy, guilt, symptoms worsen in the morning.

    • Atypical: Oversleeping and overeating, psychomotor retardation.

    • Catatonic: Marked psychomotor retardation and withdrawal.

    • Postpartum Blues: Occurs a few days after childbirth.

    • Postpartum Depression: Begins 3-4 weeks postpartum.

    • Seasonal Affective Disorder (SAD): Occurs during fall/winter due to light deprivation; associated with dysfunction of melatonin.

Persistent Depressive Disorder (Dysthymia)

  • Symptoms resembling MDD, but less severe and can persist most of the day for at least 2 years.

    • Symptoms include:

    • Low energy.

    • Insomnia or hypersomnia.

    • Difficulty making decisions.

    • Overly sensitive, self-critical.

    • Intense feelings of guilt.

    • A negative outlook on life.

    • Most daily activities may be carried out, but enjoyment is absent.

    • While it may interfere with daily living, hospitalization is not usually warranted unless suicidal ideation arises.

    • Increased stress can lead to development of MDD.

Other Mood Disorders

  • Premenstrual Dysphoric Disorder (PMDD)

  • Substance/Medical Induced Depressive Disorders

  • Depression due to Medical Conditions: Refer to Table 13-1 for comprehensive details.

Client Assessment for Depression

  • Assess for:

    • Previous history of depression and family history.

    • Suicide risk, mood & affect, feelings of guilt.

    • Psychiatric history and existing medical conditions.

    • Risk factors: substance abuse and pain.

    • Stressors such as job status and relationships.

    • Cognition, judgment, ability to meet daily needs, energy levels.

  • Screening/Assessment Tools:

    • Beck's Depression Inventory.

    • Hamilton Depression Rating Scale.

  • Inquire about:

    • Client's knowledge of their illness and coping mechanisms.

    • Vegetative signs: appetite, sleep, energy level, libido, and bowel habits.

    • Medications.

    • Activities of daily living (ADLs).

Interventions for Depression

  • Maintain an empathetic and caring attitude.

  • Use simple, clear language.

  • Inquire about self-harm.

  • Observe interactions, eating, and sleep habits.

  • Support biological integrity:

    • Focus on diet, sleep hygiene (refer to Box 20.1), and energy maintenance.

  • Utilize simple tasks to meet daily needs.

  • Assess the effectiveness of medications and herbal remedies (e.g., St. John’s Wort, with HCP notification).

  • Evaluate the client's ability to complete morning care.

  • Avoid clichés in communication.

  • Educate the client about medications, therapies, group supports.

  • Ensure proper referrals are made.

  • Refer to Table 13.4 for interventions focusing on vegetative signs of depression such as nutrition, sleep, self-care deficits, and elimination issues.

Medications to Treat Depressive Disorders

  • Antidepressant Classifications:

    • Selective Serotonin Reuptake Inhibitors (SSRI)

    • Selective Norepinephrine Reuptake Inhibitors (SNRI)

    • Tricyclic Antidepressants (TCA)

    • Atypical Antidepressants (Novel)

    • Monoamine Oxidase Inhibitors (MAOI)

    • Norepinephrine Reuptake Inhibitors (NRI)

  • Target Symptoms Treated:

    • Sleep and appetite disturbances.

    • Fatigue and decreased sex drive.

    • Psychomotor retardation or agitation.

    • Diurnal mood variations.

    • Impaired concentration and anhedonia.

Selective Serotonin Reuptake Inhibitors (SSRI)

  • Mechanism: Blocks the reuptake of serotonin in synapses, serving as the first line of therapy for depression.

  • Examples:

    • Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Fluvoxamine (Luvox), Escitalopram (Cipralex, Lexapro).

  • Side Effects:

    • Agitation, insomnia, nausea and vomiting, sexual dysfunction, autonomic changes (e.g., dry mouth, sweating, gastrointestinal disturbances).

  • Important Considerations:

    • Suicidal precautions must be observed.

    • Risk of Serotonin Syndrome: Stimulation of central serotonergic pathways following medication adjustments, symptoms include confusion, irritability, seizures, changes in temperature and blood pressure.

Nursing Roles Related to SSRIs

  • Monitor therapeutic effects (typically take 2-4 weeks to manifest).

  • Administer medications as prescribed.

  • Observe and assess for side effects/adverse reactions and suicidal ideation.

  • Inquire about sexual function.

  • Educate clients on medication adherence and the importance of not altering doses or stopping abruptly.

  • Review client and family teaching.

Tricyclic Antidepressants (TCA)

  • Indications: Effective for insomnia, agitation, libido issues, energy concentration.

  • Examples: Tofranil (Imipramine), Amitriptyline (Elavil), Sinequan (Doxepin), Clomipramine (Anafranil).

  • Side Effects: Dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, sedation, weight gain, photosensitivity.

  • Nursing Roles Related to TCAs:

    • Monitor therapeutic and side effects.

    • Begin treatment with low doses and gradually increase to avoid adverse effects.

    • Educate about drugs that may interfere with MAOIs.

Selective Norepinephrine Reuptake Inhibitors (SNRI)

  • Function: Increases serotonin and norepinephrine levels in the brain; prescribed when clients do not respond to SSRIs or TCAs (second-line treatment).

  • Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta).

  • Side Effects: Hypertension, nausea, dry mouth, sweating, agitation, sexual dysfunction.

Nursing Roles Related to SNRIs

  • Monitor vital signs, particularly blood pressure.

  • Implement safety precautions.

  • Administer with food and ensure adequate fluid intake.

  • Check for concurrent MAOI medications (14-day washout period required).

  • Gradually taper off medications when discontinuing.

Monoamine Oxidase Inhibitors (MAOI)

  • Indicated for: Treatment-resistant depression.

  • Examples: Phenelzine (Nardil), Tranylcypromine (Parnate).

  • Caution Due to:

    • Significant cardiovascular side effects, GI upset, blurred vision, hypertensive crisis.

    • Numerous food and drug interactions (notably with tyramine).

Nursing Roles Related to MAOIs

  • Monitor vital signs, especially blood pressure.

  • Educate patients about dietary restrictions (tyramine-rich foods) and the risk of hypertensive crisis.

  • Administer in the morning and monitor for headaches and other adverse effects.

Electroconvulsive Therapy (ECT)

  • Indications: Used for non-responsive depression, psychosis, bipolar disorder, schizophrenia, intense suicidal ideation, or severe agitation.

  • Process:

    • Electrodes are placed on the head to emit an electrical current, inducing a seizure.

    • General anesthetics and muscle relaxants are administered during the procedure.

    • Caffeine sodium benzoate is used as an augmenting agent prior to ECT.

    • High success rate with remission rates around 90%.

Nursing Role in ECT

  • Ensure proper patient education.

  • Obtain consent (which is the physician's responsibility).

  • Preparation involves reviewing charts and ensuring all pre-procedure tests are completed (e.g., physical exams, blood tests, urinalysis, EKG).

  • Monitor vital signs, maintain NPO status, and offer bathroom privileges pre-ECT.

  • Post-ECT: Monitor for temporary memory loss and confusion, reorient the client as necessary.

Somatic Therapies

  • Transcranial Magnetic Stimulation.

  • Vagus Nerve Stimulation.

  • Individual, Family, and Group Therapy.

  • Complementary & Integrative Therapies:

    • Herbal remedies/homeopathy, meditation, light therapy (refer to p. 243).

  • Ketamine: A newer treatment providing rapid relief from depression when infused at low doses, it stimulates brain synapses to aid recovery.

Bipolar Disorder

  • Manic/Depressive Episodes:

    • Illness course varies from severe mania (euphoria/irritability) to severe depression (as illustrated in Fig.14-1).

  • Definitions:

    • Euphoria: Heightened physical/emotional well-being.

    • Elated: Extreme happiness.

    • Hypomania: Mood between euphoria and mania; characterized by constant activity, decreased sleep, and increased happiness.

    • Mania: Extreme elation, irritability, and symptoms such as grandiosity, increased optimism, and agitation.

    • Flight of ideas: Rapid topic changes in conversation.

  • Key Feature: Sudden and dramatic shifts in emotional states.

Etiology of Bipolar Disorder

  • Biological Factors:

    • Genetic predisposition.

    • Neurobiological: Oversupply of neurotransmitters (norepinephrine, dopamine, serotonin).

    • Neuroendocrine factors, more common in higher socioeconomic classes.

  • Psychological Factors: Faulty ego mechanisms result in manic episodes during overwhelming stress.

Types of Bipolar Disorder

  • Bipolar I:

    • One or more manic episodes alternating with depressive episodes, potentially with delusions.

    • Significant shifts in mood, energy levels, and functionality.

  • Bipolar II:

    • Involves recurrent major depressive episodes alternating with hypomanic episodes.

  • Cyclothymic Disorder:

    • Characterized by hypomanic episodes alternating with mild depressive episodes lasting at least 2 years without periods of stable mood.

  • Rapid Cycling:

    • Exhibiting at least four mood episodes within a 12-month period; associated with poorer prognosis.

Client Assessment for Bipolar Disorder

  • Assessment Guidelines (pp. 255-257):

    • Evaluate mood, suicidal ideation (SI), and safety.

    • Assess cognition, judgment, flight of ideas (FOI), and decision-making capabilities.

    • Review behaviors, activities, and recent stressors.

    • Check for co-existing medical conditions and family history.

    • Inquire about habits such as financial behaviors and substance use.

    • Observe eating, sleeping, and movement patterns.

    • Discuss medications, coping mechanisms, and support systems.

Interventions for Bipolar Disorder

  • Safety Management:

    • Maintain a calm and respectful demeanor.

    • Reinforce socially acceptable behaviors and set limits on inappropriate actions.

    • Address basic dietary, sleeping, and activity needs.

    • Administer medications with meals to decrease GI upset.

    • Monitor for adverse effects and electrolytes.

  • Pharmacological Interventions:

    • Include counseling and patient/family teaching relevant to bipolar disorder (refer to p. 264).

Pharmacological Interventions

  • Mood Stabilizers (Anti-mania):

    • Lithium Carbonate is the first-line treatment for the manic phase of bipolar disorder.

    • Therapeutic effects on symptoms of insomnia, agitation, distractibility, and flight of ideas.

    • It alters electrical conductivity of neurons, thus managing manic episodes effectively.

  • Lithium Monitoring:

    • Therapeutic range: 0.6 - 1.2 mEq/L; levels above 1.5 mEq/L risk toxicity (no antidote available).

    • Symptoms of advanced lithium toxicity include: slurred speech, confusion, muscle spasms, etc.

    • Nursing Roles:

    • Ensure monitoring for toxicity.

    • Evaluate daily fluid and sodium intake to prevent toxicity.

    • Provide education on medication adherence.

Anticonvulsants

  • Anticonvulsants adjust electrical conductivity in cell membranes.

  • Effective against rapid cycling mania, EEG abnormalities, and in cases of no familial bipolar history.

  • Examples: Epival (Divalproex sodium), Depaken (Valproic acid), Tegretol (Carbamazepine), Lamictal (Lamotrigine), Gabapentin (Neurotonin).

  • Nursing Roles:

    • Assess effectiveness and monitor side effects (dizziness, sedation, GI upset).

Other Medications

  • Antipsychotics:

    • Older antipsychotics (e.g., Haldol) provide sedation.

    • Newer antipsychotics (e.g., Olanzapine, Risperidone) offer mood-stabilizing properties.

  • Anxiolytics:

    • Used to manage psychomotor agitation (e.g., Clonazepam, Lorazepam, Diazepam).

  • Antiparkinson Agents:

    • Counteract medication-induced movement/postural tremors (e.g., Benztropine, Diphenhydramine, Artane).

    • Side Effects: Dry mouth, drowsiness, urinary retention.

Relapse Prevention for Bipolar Disorder

  • Recognizing that bipolar disorder is long-term, with potential symptoms of relapse occurring unexpectedly.

  • Educate clients regarding lifestyle factors such as alcohol, caffeine, and OTC medication use that can trigger relapse.

  • Emphasize good sleep hygiene as critical for recovery and maintenance.

  • Encourage participation in group and individual therapy.

  • Educate clients and families on the importance of medication adherence.

Summary

  • Encapsulating the stages of loss/grief and definitions of mood disorders (depression & bipolar).

  • Key symptoms, assessment strategies (behavior, communication, mood, risks), and medication/treatment options, including therapies.