Mental Health

Mental Health

Objectives

  • Define the concept of mood and affect

  • Identify when an individual is experiencing a mood disturbance

  • Determine appropriate nursing and collaborative interventions to minimize the impact of mood spectrum disorders

Definitions

  • Mood: The way a person feels.

  • Affect: The observable response a person has to his or her own feelings.

  • Mood Spectrum: A continuum of all possible moods that any person may experience.

  • Mood Disturbances: Disrupt an individual’s ability to function normally.

Model of Affect

  • Figure 30.1 (Unitary Model of Affect)

    • Describes a single (unitary) spectrum of affect from severe melancholy at one pole to severe mania at the other pole.

    • Includes the following components:

    • Severe mania

    • Hypomania (mild/moderate mania)

    • Euthymia

    • Normal happiness

    • Normal sadness

    • Mild to moderate melancholy

    • Severe melancholy

    • Normal anxiety

Consequences of Mood Spectrum Disorders

  • Change in Interpersonal Relationships: Disturbances can lead to conflict or withdrawal from social connections.

  • Limited Productivity: Impacts performance in personal and professional settings.

  • Reduced Functional Ability: Difficulty performing daily tasks or fulfilling roles.

  • Higher Use and Need for Medical Care: Increased healthcare utilization due to complications.

  • Increased Potential for Suicide: Elevated risk for self-harm.

Variations and Context

  • Depressive Spectrum: Overwhelming sadness and despair; may lead to suicidal ideation.

  • Mania Spectrum: Euphoric or agitated affective states; can include perceptual disturbances.

Risk Factors

  • Populations at Greatest Risk:

    • Females

    • Individuals in the second and sixth decades of life

  • Individual Risk Factors:

    • Stress, early trauma, neglect, abuse

    • Family history of mood disorders

    • Comorbid medical and psychiatric disorders

    • Personality disorders

    • Substance dependence

Recognizing Signs and Symptoms

  • Affective Instability: May present as any combination of the following behaviors:

    • Agitation

    • Sadness

    • Elation

    • Blunting of affect (monotone speech and unusually brief responses)

Assessment

  • Common Indicators of Key Findings:

    • Persistent mood disturbance

    • Functional impairment

    • Disturbed vegetative functioning

  • Assessment Tools:

    • Mini-Mental State Exam

    • Neecham Confusion Scale

    • Confusion Assessment Method

Clinical Management

  • Prevention: Focus on societal egalitarian interventions; early intervention programs.

  • Collaborative Care:

    • Motivational Interviewing

    • Psychotherapy

    • Pharmacotherapy

    • Brain Stimulation Therapy

    • Management of emergent situations (risk for suicide and/or violence)

Interrelated Concepts

  • Addiction

  • Cognition

  • Functional Ability

  • Feature Exemplars:

    • Major depressive disorder

    • Persistent depressive disorder

    • Disruptive mood dysregulation disorder

    • Bipolar I disorder

    • Bipolar II disorder

Depressive Disorders

  • All impact a person’s ability to function, sharing symptoms such as:

    • Sadness

    • Emptiness

    • Irritability

    • Somatic concerns (physical symptoms)

    • Impairment of thinking

Major Depressive Disorder

  • Definition: Severe depressive mood symptoms that interfere with functional status lasting at least 2 weeks.

  • Criteria: Must have 5 or more of the following symptoms:

    • Weight and appetite changes

    • Sleep disturbances

    • Fatigue

    • Feelings of worthlessness or guilt

    • Loss of ability to concentrate

    • Recurrent thoughts of death

    • Psychomotor agitation

  • At Least One of the Following:

    • Depressed mood

    • Loss of interest or pleasure

Persistent Depressive Disorder

  • Definition: Low-level depressive feelings through most of each day for the majority of days, lasting at least 2 years in adults or 1 year in children/adolescents.

  • Criteria: Must have two or more of the following:

    • Decreased appetite or overeating

    • Insomnia or hypersomnia

    • Low energy

    • Poor self-esteem

    • Difficulty thinking

    • Hopelessness

Other Depressive Disorders

  • Substance-induced depressive disorder: Symptoms present only with substance use or withdrawal.

  • Depressive disorder associated with another medical condition: Caused by physical health issues (e.g., kidney failure, Parkinson’s disease, Alzheimer’s disease).

  • These symptoms are not considered major depressive disorder if they are a direct result of medical diagnoses or certain medications.

Nursing Process: Assessment (1 of 3)

  • Assessment Tools: Used to assess suicide potential and key assessment findings such as:

    • Depressed mood and anhedonia

    • Anergia (lack of energy)

    • Anxiety

    • Psychomotor agitation or retardation

    • Vegetative signs

    • Comorbidity with chronic pain

Nursing Process: Assessment (2 of 3)

  • Areas to Assess:

    • Affect

    • Thought processes

    • Mood

    • Feelings

    • Physical behavior

    • Communication

Nursing Process: Assessment (3 of 3)

  • Age Considerations: Specific assessments for children, adolescents, and older adults.

  • Self-Assessment: Use of the Geriatric Depression Scale for older adults.

Nursing Process: Outcomes

  • Recovery Model: Focuses on patient strengths; treatment goals developed mutually based on personal needs and values.

Nursing Process: Implementation

  • Three Phases of Implementation:

    • Acute Phase: Lasting 6 to 12 weeks

    • Continuation Phase: Lasting 4 to 9 months

    • Maintenance Phase: Lasting 1 year or more

Nursing Process: Health Promotion

  • Focus Areas:

    • Counseling and communication

    • Health teaching

    • Promotion of self-care activities

    • Teamwork and safety

Psychopharmacological Interventions

  • Choosing An Antidepressant: Consider symptom profile, side-effect profile (such as sexual dysfunction, weight gain), ease of administration, history of past responses, and safety/medical considerations.

Antidepressants

  • Selective Serotonin Reuptake Inhibitors (SSRIs): First-line therapy with a rare risk of serotonin syndrome.

  • Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): May be tolerated better than SSRIs.

  • Tricyclic Antidepressants: Risk of anticholinergic adverse reactions.

  • Monoamine Oxidase Inhibitors (MAOIs): Effective for unconventional depression.

Types of Antidepressants & Common Side Effects

  • Tricyclics

  • SSRIs

  • SNRIs

  • MAOIs

  • Common Side Effects include:

    • Tremors

    • Indigestion

    • Headache

    • Dry Mouth

    • Drowsiness

    • Elevated Heart Rate

Common Brand Names

  • SSRIs: Celexa, Lexapro, Prozac, Zoloft, Paxil

  • SNRIs: Effexor, Cymbalta

  • Tricyclics: Elavil, Norpramin, Sinequan

  • MAOIs: Nardil, Marplan, Parnate

Serotonin Syndrome

  • Definition: Over-activation of the central serotonin receptors; greatest risk with SSRIs + a second serotonin-enhancing agent (e.g., MAOIs).

  • Caution: Discontinue all SSRIs for 2 to 5 weeks before starting an MAOI.

Symptoms of Serotonin Syndrome

  • Mild Symptoms: Agitation, restlessness, insomnia, confusion, tachycardia, dilated pupils, muscle spasms, high blood pressure, muscle rigidity, heavy sweating, diarrhea, abdominal pain, headache.

  • Severe Symptoms: High fever, seizures, shock.

Treatment of Serotonin Syndrome

  • Mild Cases: Outpatient management; stop SSRIs and monitor as symptoms resolve.

  • Supportive Care: Includes muscle relaxants, oxygen as needed, IV fluids, antihypertensives or vasopressors, and possible intubation.

  • Duration: Symptoms can take days to weeks for resolution.

Other Treatments for Depression

  • Electroconvulsive Therapy (ECT)

  • Transcranial Magnetic Stimulation (TMS)

  • Vagus Nerve Stimulation (VNS)

  • Deep Brain Stimulation (DBS)

  • Light Therapy

  • St. John’s Wort: Believed to increase serotonin, norepinephrine, and dopamine; useful in mild to moderate depression.

Epidemiology of Suicide

  • Leading Causes of Death:

    • 10th leading cause of death in the U.S.

    • 2nd leading cause for ages 10-34

    • 4th leading cause for ages 35-54

    • 8th leading cause for ages 55-64

  • Service Members: Suicide rates among active-duty service members surpass civilian rates; rates among veterans increasing more rapidly than general population.

Definitions Related to Suicide

  • Suicidal Ideation: Thinking about killing oneself.

  • Suicide: Intentional act of killing oneself by any means.

  • Completed Suicide: Suicide successfully resulting in death.

  • Non-Suicidal Self-Injury: Self-injury directed to the surface of the body to induce relief from a negative feeling or achieve a positive mood state.

Risk Factors for Suicide

  • Psychiatric Disorders: Higher rates observed.

  • Substance Use Disorders: Increases risks.

  • Demographic Factors: Male gender, increasing age, and race (85%–90% Caucasians).

  • Social Factors: Religion, marital status, profession, and physical health.

Etiology: Biological Factors

  • Familial Tendency: Association with family history.

  • Genetic Factors: Lowered expression of SKA2 gene.

  • Neurotransmitter Levels: Low serotonin levels.

Clinical Picture/Risk Assessment of Suicide

  • History of Attempts: Increases risk of completed suicide; only 56.4% of reported attempts received adequate mental health treatment.

  • Suicide Behavior Disorder (DSM-5): Defined by history of attempts within the last 24 months; not initiated during delirium or confusion; not for religious or political objectives.

Nursing Process: Suicide Assessment

  • Assessment Tools: Verbal and nonverbal cues, both overt and covert statements; assess lethality of suicide plan.

Nursing Process: Suicide Diagnosis

  • Common Diagnoses:

    • Impaired Psychological Status

    • Risk for Injury

    • Impaired Sleep

    • Nutritionally Compromised

    • Anxiety

  • Outcomes Identification: Focus on suicide self-restraint, planning, and interventions.

Self-Assessment for Health Professionals

  • Possible Reactions: Fear, grief, anger, puzzlement, condemnation of suicidal feelings.

  • Recommendation: Acknowledge and discuss feelings with team members to avoid countertransference.

Levels of Intervention

  • Prevention: Activities to provide support, information, and education to prevent suicide.

  • Treatment: Addressing the actual suicidal crisis.

  • Postvention: Interventions for survivors left by individuals who completed suicide to reduce traumatic after-effects.

Interventions

  • Psychosocial and Psychobiological Interventions: Include safety and teamwork, health teaching, case management, and documentation of care.

  • Postvention for Survivors: Addressing the needs of those affected by a completed suicide.

Environmental Safety Guidelines

  • Use plastic utensils and maintain an open-door policy in rooms.

  • Assess and lock areas not for patients, ensuring patient safety by preventing access to harmful objects.

Bipolar & Related Disorders

  • Clinical Picture: Most severe form of mood disorders; highest mortality rate.

  • Bipolar I Disorder: At least one manic episode.

  • Bipolar II Disorder: At least one hypomanic episode and one major depressive episode.

  • Cyclothymic Disorder: Symptoms alternate with mild to moderate depression lasting at least 2 years in adults.

Risk Factors for Bipolar Disorders

  • Biological Factors: Genetic, neurobiological, neuroendocrine influences.

  • Psychological Factors: Various environmental factors affecting mood stability.

Nursing Process: Bipolar Assessment (1 of 3)

  • Focus Areas: Mood, behavior, cognitive functioning, and thought processes.

  • Assessment of Speech Patterns: Includes pressured speech, circumstantial speech, loose associations, flight of ideas, and clang associations.

Nursing Process: Bipolar Assessment (2 of 3)

  • Assessment of Thought Content: Delusions, including grandiose and persecutory.

Nursing Process: Bipolar Assessment (3 of 3)

  • Behavior Management: Needs for frequent staff meetings to address patient behavior and set limits consistently.

Assessment Guidelines for Bipolar Disorder

  • Focus on danger to self or others, need for protection from behaviors, hospitalization needs, and understanding from family regarding the patient’s condition.

Outcomes Identification in Bipolar Disorder

  • Focus on preventing injury during the acute phase, relapse prevention during the continuation phase, and limiting severity and duration of future episodes in the maintenance phase.

Planning for Acute Manic Phase

  • Medical Stabilization: Focus on safety and in-hospital nursing care; possible use of seclusion, restraint, or ECT during the acute phase.

Implementation for Bipolar Disorder

  • Hospitalization: Required for severe symptoms like suicidal thoughts, psychosis, or catatonia.

Pharmacological Interventions for Bipolar Disorder

  • Main Focus: Address agitation and mood stabilization.

  • Lithium Carbonate:

    • Therapeutic Blood Level: 0.8 to 1.4 mEq/L

    • Maintenance Blood Level: 0.4 to 1.3 mEq/L

    • Toxic Blood Level: 1.5 mEq/L and above, with close monitoring during therapy.