Mood Disorders Detailed Notes

Mood Disorders #1

• Mood disorders are also known as affective disorders.

• They involve pervasive alterations in emotions, manifesting as depression, mania, or both.

• These disorders interfere with a person's ability to live life, leading to long-term sadness, agitation, or elation.

Mood Disorders #2

• Mood disorders are the most common psychiatric diagnosis associated with suicide.

• Depression is one of the most important risk factors for suicide.

Categories of Mood Disorders

• Major depressive disorder: Episodes last more than 2 weeks.

• Bipolar disorder: Includes Bipolar I and Bipolar II.

• Related disorders:

  • Persistent depression (dysthymic) disorder

  • Disruptive mood dysregulation disorder

  • Cyclothymic disorder

  • Substance-induced mood disorder or bipolar disorder

  • Seasonal affective disorder

  • Postpartum blues, depression, psychosis

  • Premenstrual dysphoric disorder

  • Nonsuicidal self-injury

Etiology #1

• Biologic theories:

  • Genetic theories suggest a hereditary component.

  • Neurochemical theories focus on neurotransmitters:

    • Serotonin

    • Norepinephrine (possibly acetylcholine and dopamine)

  • Neuroendocrine influences involve hormones.

Etiology #2

• Psychodynamic theories:

  • Freud: Self-deprecation related to the ideal ego.

  • Jacobson: Ego victimized by the superego.

  • Mania as a defense against underlying depression.

  • Depression as a reaction to life experience.

  • Rejecting or unloving parents can contribute to mood disorders.

• Cognitive distortions also play a role.

Cultural Considerations

• The Hamilton Rating Scale for Depression is found reliable across diverse cultures for symptoms related to general depression:

  • Depressed mood

  • Guilt

  • Loss of interests

  • Retarded (slowing)

  • Suicide

  • Psychological anxiety

  • Somatic complaints

• Major manifestation among cultures that avoid verbalizing emotions.

Major Depressive Disorder

• Clinical Course:

  • Untreated episodes of depression can last weeks, months, or years.

  • Most clear in about 6 months.

  • 50% to 60% of individuals will suffer a recurrence.

  • Approximately 20% will develop a chronic form of depression.

  • Symptoms range from mild to severe.

  • Some people with severe depression have psychotic features.

Psychopharmacology

• Major categories of antidepressants:

  • Selective serotonin reuptake inhibitors (SSRIs)

  • Tricyclic antidepressants (TCAs)

  • Atypical antidepressants

  • Monoamine oxidase inhibitors (MAOIs)

    • Risk of hypertensive crisis

    • Risk of serotonin syndrome

Choice of Antidepressants

• Client symptoms and age must be considered.

• Physical health needs should be taken into account.

• Consider drugs that have worked in the past or for blood relatives.

• Evaluate other medications the client is taking.

SSRIs

• Examples:

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Citalopram (Celexa)

  • Escitalopram (Lexapro)

• Mechanism:

  • Blocks reuptake of serotonin.

• Advantages:

  • Fewer sedating, anticholinergic, and cardiovascular side effects.

  • Safer for older adults.

• Effect:

  • Mood, concentration, and interest in life improve in 7 to 10 days.

TCAs

• Examples:

  • Amitriptyline (Elavil)

  • Imipramine (Tofranil)

  • Desipramine (Norpramin)

  • Nortriptyline (Pamelor)

  • Doxepin (Sinequan)

• Mechanism:

  • Oldest antidepressant class.

  • Blocks reuptake of norepinephrine and serotonin or increasing sensitivity of the post synaptic receptor site.

• Contraindications:

  • Liver impairment or MI (acute recovery phase).

• Cautions:

  • Glaucoma, BPH, urinary retention, DM, hyperthyroidism, CVD, renal impairment.

• Important:

  • Toxic when taken in overdose (Limited amounts should be prescribed).

  • Takes 6 weeks to reach full effect.

Atypical Antidepressants

• Examples:

  • Venlafaxine (Effexor)

  • Duloxetine (Cymbalta)

  • Bupropion (Wellbutrin)

  • Nefazodone (Serzone)

  • Mirtazapine (Remeron)

• Mechanism:

  • Inhibit reuptake of norepinephrine, serotonin, and dopamine (weakly).

Monoamine Oxidase Inhibitors (MAOIs)

• Examples:

  • Isocarboxazid (Marplan)

  • Phenelzine (Nardil)

  • Tranylcypromine (Parnate)

• Mechanism:

  • Increase receptor sensitivity to norepinephrine and serotonin.

  • Prevent degradation of norepinephrine and serotonin.

• Important:

  • Close supervision is necessary due to potentially serious adverse effects, particularly hypertensive crisis secondary to interaction with the amino acid tyramine.

  • Cause CNS, cardiovascular, and anticholinergic side effects.

  • 2-4 week lag time before reaching therapeutic level.

Serotonin Syndrome

• Occurs when there is an inadequate washout between taking MAOIs and SSRIs or when MAOIs are combined with Meperidine.

• Symptoms:

  • Change in mental state, confusion, agitation

  • Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, tremors, jerks, collapse, muscle paralysis

  • Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, diaphoresis

Hypertensive Crisis

• Symptoms:

  • Occipital headache

  • Hypertension

  • Nausea/vomiting

  • Chills/sweating/fever

  • Restlessness

  • Nuchal rigidity

  • Dilated pupils

  • Motor agitation

• MAOI-tyramine interaction can occur within 20-60 minutes of ingestion.

• Treatment:

  • Transient antihypertensives such as phentolamine mesylate are given to dilate blood vessels and decrease vascular resistance.

Other Medical Treatments and Psychotherapy

• Electroconvulsive therapy (ECT)

• Psychotherapy (combined with medications):

  • Interpersonal therapy: addresses relationship difficulties.

  • Behavior therapy: uses positive reinforcement of interactions.

  • Cognitive therapy: addresses cognitive distortions.

Other Medical Treatment and Psychotherapy #2

• Other somatic therapies:

  • Transcranial magnetic stimulation (TMS)

  • Magnetic seizure therapy

  • Deep brain stimulation

  • Vagal nerve stimulation

Major Depressive Disorder and Nursing Process Application #1

• Assessment:

  • History

  • General appearance, motor behavior

  • Mood, affect

  • Thought process, content

  • Sensorium, intellectual processes

  • Judgment, insight

  • Self-concept

  • Roles, relationships

  • Physiologic, self-care considerations

  • Depression rating scales

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

    • Clinician rating scale: Hamilton Rating Scale for Depression

Major Depressive Disorder and Nursing Process Application #2

• 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 #3

• Actions:

  • Providing for safety (suicide precautions)

  • Promoting therapeutic relationship

  • Promoting ADLs, physical care (nutrition, hydration, rest/sleep)

  • Using therapeutic communication

  • Managing medications

  • Providing client, family teaching

• Evaluation

Bipolar Disorder

• Extreme mood fluctuations from mania to depression.

• Second only to major depression as a cause of worldwide disability.

• Lifetime risk is about 2%.

• Occurs almost equally among men and women.

• Most common in highly educated people

Bipolar Disorder

• Diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to 3 or more of the following symptoms:

  • Exaggerated self-esteem

  • Sleeplessness

  • Pressured speech

  • Flight of ideas

  • Reduced ability to filter extraneous stimuli

  • Distractibility

  • Increased activities with increased energy

  • Multiple grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.

Treatment of Bipolar Disorder

• Psychopharmacology:

  • Antimanic agent: lithium

  • Anticonvulsant agent used as mood stabilizer

  • Agents helpful in reducing manic behavior and protecting against bipolar depressive cycles

• Psychotherapy:

  • Useful in mildly depressive or normal portion of bipolar cycle

  • Not useful during manic stages

Bipolar Disorder and Nursing Process Application #1

• Assessment:

  • History

  • General appearance, behavior

  • Mood, affect

  • Thought process, content

  • Sensorium, intellectual processes

Bipolar Disorder and Nursing Process Application #2

• Assessment (cont.)

  • Judgment, insight

  • Self-concept

  • Roles, relationships

  • Physiologic, self-care considerations

• Data analysis/nursing diagnoses

• Outcome identification:

  • No injury to self or others—med compliance

  • Balance of rest, sleep, and activity

  • Socially appropriate behavior

• 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 (cont.)

• A. Lithium

  • Rationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic client with bipolar disorder.

  • Fluoxetine, citalopram, and venlafaxine are antidepressants.

• Actions:

  • Providing for safety

  • Meeting physiologic needs

  • Providing therapeutic communication

  • Promoting appropriate behaviors

  • Managing medications

  • Providing client, family teaching

• Evaluation:

  • Manage/teach medications

  • Lithium levels

  • Fluid balance with Li

  • Renal and thyroid function tests

• Limit setting:

  • Clearly identify unacceptable behavior

  • Identify consequences if limits are not met

  • Identify expected or desired behavior

Suicide #1

• Intentional act of killing oneself

• Men commit approximately 72% of suicides.

• Suicidal ideation: thinking about killing oneself

• Warning signs: risk for suicide

• Suicide involves ambivalence

Suicide #2

• Assessment:

  • Previous suicide attempts (first 2 years after— highest risk period, especially first 3 months); Relative who committed suicide

  • Warnings of suicidal intent

  • Risky behavior

  • Lethality assessment

Suicide #3

• Lethality assessment:

  • Does the client have a specific plan?

  • Are the means available to carry out this plan?

  • If the client carries out the plan, is it likely to be lethal?

  • Has the client made preparations for death?

  • Where and when does the client intend to carry out the plan?

  • Is the intended time a special date or anniversary that has meaning for the client?

Suicide #4

• Outcome identification

• Actions:

  • Using an authoritative role

  • Providing a safe environment: suicide precautions

  • Support system list

• Family response:

  • Suicide as the ultimate rejection of family, friends

  • Families react with guilt, shame, anger

  • Families can disintegrate

Suicide #5

• Nurse’s response:

  • Need for unconditional positive regard for person

  • Avoidance of patient blame

  • Nonjudgmental approach, tone

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

  • Possible devastation of staff if patient commits suicide

• Nurses must realize that no matter how competent and caring interventions are, a few clients will still commit suicide.

Legal and Ethical Considerations

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

• Oregon, 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 to provide supportive care for clients and family as they work through the decision-making process

Age-Related Considerations

• Disruptive mood dysregulation disorder is diagnosed in those 6-18 years old.

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

• Depression is common among older adults; marked increased during medical illness

• Psychotic features are more frequent than in younger people with depression

• Increased intolerance of side effects of medications

• ECT more commonly used for treatment; more rapid response

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

Community-Based Care

• Nurses as the first health-care professionals to recognize behaviors consistent with mood disorders

• Documenting and reporting behaviors help clients get treatment.

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

Mental Health Promotion #1

• Education to address stressors contributing to depressive illness

• Efforts to improve primary care treatment of depression

• Prevention and early detection, and treatment for adolescents

• Screening for early detection of risk factors:

  • 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 is possible when working with depressed or manic clients

• Exhaustion is possible when working with manic clients

• Journaling to help deal with feelings

• Talking with colleagues