Mood Disorders

Mood Disorders

Concept: Cognition & Perception, 2025.

Learning Outcomes

  • Explore theories that contribute to the understanding of the aetiology (causes) of mood disorders.
  • Gain an understanding of mood changes associated with major depressive and bi-polar disorders.
  • Gain an understanding of the impact of mood disorders and nursing considerations for working with people who are experiencing major mood disorders.
  • Gain an understanding of the common psychopharmacology used in the treatment of mood disorders.

Recovery: Remember CHIME

  • Connectedness
  • Hope and Optimism
  • Identity
  • Meaning
  • Empowerment

Therapeutic Optimism

  • Defined as “self reported, specific expectancies regarding client outcomes in a clinical setting “ (cited by Proctor et al, 2014 p 12).
  • Supporting the aspiration is to live, work, and love in a community in which one makes a contribution (citizenship).
  • Supporting reconnection with social life and meaningful activities – including gaining employment. Having roles and routines and sense of purpose and enhance coping skills to manage life’s challenges (Sorenson, 2018).

Mood Disorders

  • Mood disorders are among the most common form of mental illness and can cause much distress.
  • Mood disorders are divided into:
    • Depressive Disorders
    • Bipolar Affective Disorders (I and II)

Prevalence (Ministry of Health, 2023)

  • In 2022/23, one in eight adults (11.9%) reported experiencing high or very levels of psychological distress, with the rate being higher in women (13.2%) than men (10.2%).
  • One in five (21.2%) young people aged 15–24 years experienced high or very high levels of psychological distress in 2022/23, up from 5.1% in 2011/12.
  • After adjusting for age and gender differences, Māori and Pacific adults were 1.5 and 1.2 times as likely to have experienced psychological distress as non-Māori and non-Pacific adults, respectively.
  • Adults living in the most deprived neighborhoods were 2.4 times as likely to have experienced psychological distress as those in the least deprived neighborhoods, after adjusting for age, gender and ethnicity.
  • In 2022/23, 35.9% of disabled adults experienced high or very high psychological distress in the four weeks prior to the survey, compared to 9.5% of non-disabled adults.

Causation Theories

  • There is unlikely to be only one factor that is wholly responsible for depression; rather, it is a combination of factors interacting that causes the illness.
  • The diathesis–stress model attempts to explain a disorder as the result of an interaction between a predisposition to vulnerability and stress caused by life experiences.

Diathesis-Stress Model

  • Predisposition (Genetic links, Hormonal factors, Neuro-chemical, Historical trauma) + Stressors (Trauma, poverty, poor living conditions, family conflict, social isolation, physical illness, some prescription medications (steroids, beta blockers), alcohol and/ or substance) = Increased vulnerability for mental distress
  • There are likely to be several different genes involved in the development of mood disorders.
  • It is thought that genetic mutations cause dis-regulation of neurotransmitters
  • Family studies have shown a strong probability of a heredity component to this condition. This genetic pattern may interact with pre-natal environmental factors (e.g., stress in utero).
  • Children who have a parent with bipolar disorder may have a 20% chance of developing the disorder (Athanasos, 2017: Clark & Temmhoff, 2021).

Causation: Hormonal Factors

  • Important among these systems are the hypothalamic-pituitary-adrenal (HPA) axis (which controls the release of cortisol and thyroid hormones) and the overall circadian rhythms (the body’s 24-hour cycle of brainwave activity, hormone production and cell regeneration).
  • Evidence that reproductive-related hormonal changes (specifically estrogen) may play a role in increasing the risk of depressive symptoms premenstrually, postpartum and in the perimenopausal period.
  • Cortisol and thyroid hormone levels have been found to be elevated in clients during manic episodes
  • The immune system by way of pro-inflammatory cytokines (to produce an inflammatory response) may underpin many of these mechanisms (Athanasos, 2017: Clark & Temmhoff, 2021).

Causation: Neurochemical

  • 1965 theory was depression was a consequence of low levels of serotonin or other neurotransmitters (monoamines) in the brain. This is the ‘monoamine hypothesis’
  • More recent research suggested monoamines modulate a range of other neurobiological systems to produce major depression. However, the process is more complex than a simple increase or decrease in monoamines (Hillhouse & Porter, 2015).
  • Neurotransmitter systems (serotonin, noradrenaline, gabaminergic and glutamatergic) impact on hormonal systems to produce major depression. (Athanasos, 2017: Clark & Temmhoff, 2021)

Causation: Trauma

  • Emotional and psychological trauma can be caused by both one-off and ongoing events. (e.g., accident, natural disaster, or an attack.)
  • On-going trauma can result from relentless stressful events, such as childhood sexual, emotional or physical abuse.
  • Emotional responses include: numbness, emotions such as shock, denial, guilt or self-blame, extreme sadness, mood changes, difficulty concentrating, repeating memories, triggers. Physical symptoms: changes in eating or sleeping and use of alcohol or drugs.
  • Many of these feelings are a normal part of recovering from any trauma, but sometimes these feelings go on for a long time and may lead to depression. (Athanasos, 2017: Clark & Temmhoff, 2021)

Causation: Personality and Stress

  • Personality types: pessimistic explanatory style; catastrophic thinking; rumination
  • Learned helplessness from stressful life events
  • Depression can be triggered or exacerbated by stressful conditions, particularly by cumulative stressors.
  • The concept of resilience refers to our capacity to adapt to stress and move forward with our development despite adversity. Resilience can be learned (reframing) (Athanasos, 2017: Clark & Temmhoff, 2021)

Causation: Environmental Stress

Environmental events surrounding pregnancy and birth have been linked to an increased development of mental illness in offspring:

  • Obstetric birth complications
  • Maternal infections
  • Gestational exposure to alcohol or drugs
  • Such factors are thought to affect specific areas of neurodevelopment
  • Studies confirm that stress can precipitate both manic and depressive episodes (Athanasos, 2017: Clark & Temmhoff, 2021)

Major Depressive Disorder

  • The main symptoms of depression are depressed mood most of the day, nearly every day as indicated by self-report or observations made by others. The other main symptom is loss of enjoyment and pleasure in life. For diagnosis:
    • Five or more symptoms will have been present during the same two- week period and represent a change from previous functioning, and…
    • The symptoms are not better accounted for by bereavement, and…
    • The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. (APA, 2013)

Depressive Symptoms

  • Prolonged low mood
  • Withdrawal from social activities
  • Loss of interest in pleasurable activities
  • Feelings of worthlessness or guilt
  • Frequent feelings of fatigue or loss of energy
  • Significant weight loss or gain, or change in appetite
  • Difficulty concentrating, making decisions
  • Insomnia or hypersomnia
  • Recurrent thoughts of death or suicide, or attempted suicide
  • Levels of Severity
    • Mild: Feeling "blue" or "down". Able to function.
    • Moderate: Persistent low mood. Able to function.
    • Severe: Unable to function. Suicidality.

Other Types of Depression

  • Persistent depressive disorder (Dysthymia) – depressed mood most of the day, for more days than not, for at least 2 years.
  • Perinatal (ante natal and postpartum depression). Includes depressed mood, excessive anxiety, insomnia and change in weight.
  • Premenstrual dysphoric disorder (PMDD). Extreme fatigue, feeling sad, hopeless, or self-critical. Severe feelings of stress or anxiety mood swings.
  • Seasonal affective disorder (SAD). Disturbance in the normal circadian rhythm of the body. More common in areas further from the equator.
  • Older person’s mental health – increasing client group. (Clark & Temmhoff, 2021)

Nursing Considerations: Depression

  • Develop a therapeutic rapport
  • Encourage person to express feelings
  • Ascertain person's strengths and negotiate small manageable goals to increase sense of achievement
  • Structure the day – gently support person to become involved in regular brief social and recreational activities
  • Encourage regular meals and activities of daily living (sleep, exercise and mindfulness).
  • Listen so person feels heard and understood; acknowledge distress
  • Assess for thoughts of suicide and self-harm
  • Avoid Alcohol and other drugs
  • Give culturally specific care
  • Medication and/or other treatment (ECT)
  • Risks and side effects of medication
  • Hospitalization may be necessary

Electro Convulsive Therapy (ECT)

  • ECT is sometimes prescribed for severe depression, catatonia and mania.
  • The most common reason for prescribing ECT for people in New Zealand is severe depression. In some cases of severe depression ECT is prescribed because the standard treatments have not worked
  • ECT is always given as a course of treatments rather than just once. One course of treatments can involve between six and twelve individual treatments.
  • Very occasionally, ECT is prescribed for people experiencing mania. In these few cases, it is prescribed when the illness has become life- threatening or dangerous.
  • The Neurotransmitter theory suggests that ECT works in a similar way to antidepressant medication. ECT causes a seizure that increases the amount of neurotransmitters available for communication between neurons. At the same time, it also makes the brain cells more responsive to the neurotransmitters.
  • Side effects include loss of memory about the events immediately before and after ECT, heart rhythm disturbances, low blood pressure, headaches, nausea, sore muscles, aching jaw and confusion. (Fisher et al, 2017)

Bipolar Affective Disorder

  • A recurrent mood disorder featuring one or more episodes of mania, or mixed episodes of mania and depression
  • The DSM-5 (APA, 2013) classifies bipolar disorder into bipolar 1 disorder and bipolar 2 disorder.
  • Affects approximately 1.2% of population.
  • Onset is usually between ages 15-30, and type i bipolar disorder is about equally common in men and women.
  • Bipolar I disorder involves 1+ episodes of mania and often depression (but does not require diagnosis of depression)
  • Bipolar II disorder involves episodes of 1+ depression and a less severe form of mania called hypomania (Clark & Temmhoff, 2021)

Mania

  • Mania is characterized by three main features:
    • Persistently elevated mood, which may be one of elation or irritability;
    • Increased activity;
    • and poor judgement (Athanasos, 2017: Clark & Temmhoff, 2021)

Diagnostic Criteria for Mania

Three (or more) of the following symptoms have persisted and have been present to a significant degree;

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal directed activity (either socially, at work, sexually) or psychomotor agitation
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences (APA, 2013)

Bipolar Disorder

  • A moderate to severe depression usually follows mania
  • Usually characterized by reversed-vegetative symptoms
  • Depressive episodes tend to last longer than manic episodes (median length about 6 months), though may last longer in the elderly
  • With increasing age, the frequency and duration of episodes generally increases
  • Hypomania has similar symptoms to mania, with the following exceptions:
    • There is no significant impairment in social or occupational function;
    • There are no psychotic features
  • A mixed episode is where features of mania and depression such as agitation, anxiety, fatigue or irritability occur simultaneously or in short succession. E.G. Racing thoughts during a depressive episode or tears during a manic episode.
  • Cyclothymia- at least 2yrs of hypomanic periods that do not meet criteria for other disorders (Athanasos, 2017: Clark & Temmhoff, 2021)

Nursing Considerations: Mania

  • Monitor and document sleeping patterns due to insomnia
  • Person may become exhausted from excessive psychomotor activity and lack of sleep, consider prn sedative to assist sleep and/or reduce agitation
  • If client cannot tolerate meals, offer regular small snacks throughout the day to maintain dietary requirements
  • Avoid coffee and coke or other stimulants
  • Medications (Mood stabilizers, Antipsychotics). Discuss side effects
  • Safety – prevent people from hurting themselves or others.
  • Provide a low-stimulus environment – quiet rooms with limited activities or stimuli
  • Set clear limits on behavior with brief and simple directions. Do not argue with a person when elevated
  • Consistent team approach to reduce staff splitting, blaming and limit testing
  • Reinforce reality if needed
  • Hospitalization is often necessary to prevent harm to self or others, maintain dignity and to manage a psychosis that may develop

Psycho-pharmacology

The main classes of medication used to treat major depression and bipolar disorder are antidepressants and mood stabilizers. When psychotic features are evident (with either major depression or bipolar disorder), an antipsychotic may be required. Selective serotonin reuptake inhibitors (SSRIs) are the more popular class of antidepressants, and lithium and sodium valproate are common mood stabilizers.

Anti-Depressant Medication

The main groups of antidepressants are:

  • SNRIs (serotonin and noradrenaline reuptake inhibitors) e.g. venlafaxine
  • SSRIs (selective serotonin reuptake inhibitors) e.g. fluoxetine, citalopram
  • Monoamine Oxidase Inhibitors (MAOIs) e.g., phenelzine
  • Tricyclic Antidepressant (TCAs) e.g. amitriptyline

These medications have not been shown to differ substantially in their effectiveness, but they do differ in their side effect profiles.

Neurotransmitters and Depression

  • Noradrenaline
    • Stress hormone
    • Affects amygdala.
    • Effects on attention and responding actions.
    • Alertness, arousal, and influences on the reward system.
  • Serotonin
    • Effects tends to be inhibitory
    • Modulates mood, anxiety, nausea, sexual libido, temperature control, blood pressure, and sleep/wakefulness
  • Dopamine
    • Plays a major role in reward- motivated behavior.
    • Modulates anger, perception, motivation, cognition, movement and kidney function.
    • Most types of reward increase the level of dopamine in the brain.

SSRI: Mode of Action

  • Serotonin and noradrenaline are released into the synapse. On the pre-synaptic side there are re-uptake sites that reabsorb the chemicals very quickly. SSRIs and SNRIs act by blocking these sites (or channels) so again result in more of the chemical being available in the synapse for a longer period of time.
  • SSRIs administered normally 1x a day Absorbed in stomach (80- 90% in GI tract) Binds to plasma protein Metabolised in liver – long half life. Fluoxetine very long (up to 16 days)Excreted by kidney
  • Half life has to be taken into account when switching antidepressants as can interact.
  • Side effects include GI effects: nausea, vomiting, diarrhea, dyspepsia, weight loss or weight gain, Sexual: loss of libido, sexual function, Sleep disturbance; insomnia and weird dreams, Temperature disturbance: fever, Dry mouth. Headache, dizziness, Increased anxiety, suicidality, Bleeding abnormalities – clotting cascade (Almand & Trimmer, 2021)

Serotonin Syndrome

  • Too Much Serotonin
    • Neuromuscular effects
      • Hyperreflexia
      • Clonus
      • Myoclonus
      • Hypertonia/rigidity
      • Tremor
    • Autonomic effects
      • Hyperthermia: mild, < 38.5°C; severe ≥ 38.5°C
      • Tachycardia
      • Shivering
      • Diaphoresis
      • Flushing
      • Mydriasis
    • Mental state changes
      • Agitation
      • Confusion
      • Hypomania
      • Anxiety
    • Serotonin syndrome: fever, tremor, coma, seizures, death
    • Cardiac valve pathology
  • Not Enough Serotonin
    • Gl disturbance
    • Sexual dysfunction
    • Insomnia
    • Depression
    • OCD
    • Panic
    • Bulimia
    • Anxiety

SSRI Discontinuation Syndrome

  • Flu-like symptoms (nausea, vomiting, diarrhea, headaches, sweating).
  • Sleep disturbances (insomnia, nightmares, constant sleepiness).
  • Sensory and movement disturbances have also been reported, including imbalance, tremors, vertigo, dizziness.
  • Electric-shock-like experiences in the brain “brain zaps”.
  • Mood disturbances (anxiety, or agitation are also reported).
  • Cognitive disturbances such as confusion and hyperarousal. (Almand & Trimmer, 2021)

Mood Stabilizers

The term 'mood stabilizer' describes a group of drugs, not a specific pharmacological class.

  • Mood stabilizers help prevent the recurrence of bipolar affective disorder and can also be effective in treating the acute episodes of mania and depression.
  • The main mood stabilizers are Lithium Carbonate and the antiepileptic drugs, including Sodium Valproate, Carbamazepine and Lamotrigine.
  • They have a common sodium channel-blocking effect.

Sodium Valproate: Mood of Action

  • First used as treatment for epilepsy in 1960s (Epilum).
  • Anticonvulsant
  • Gamma-aminobutyric acid (GABA) agonist.
  • Anti-kindling: reducing sensitivity to electrical impulses in the brain and irregular firing of neurons .
  • Direct membrane stabilizing effect altering cation (+ charge) transport (K, Na and Ca).
  • Side effects: GI effects: nausea, vomiting, diarrhea, dyspepsia, weight loss or weight gain. Endocrine: amenorrhea, menstrual disturbance, polycystic ovary syndrome. Hyper-ammonemia, CNS changes: lethargy, sedation tremor, Hair loss, Osteoporosis, Haematological – thrombocytopenia, bruising and hemorrhage. Leukopenia, Neutropenia, Agranulocytosis, Hepatic toxicity; pancreatitis (Almand & Trimmer, 2021)

Lithium Carbonate: Mood of Action

  • Lithium carbonate is an inorganic compound; the lithium salt of carbonate with the formula Li2CO3.
  • This white salt is widely used in the processing of metal oxides and treatment of mood disorders.
  • Not metabolized; excreted by kidneys.
  • Blocks ability of neurons to restore levels of the second message system.
  • Lithium displaces K+ & Na+ possibly Ca+2 to occupy sites. Direct membrane stabilizing effect altering cation transport (K, Na and Ca).
  • Inhibits excitatory neurotransmitters such as dopamine and glutamate and promotes GABA-mediated neurotransmission.
  • Side Effects: GI effects: nausea, vomiting, diarrhea, dyspepsia, weight loss or weight gain, Haematological –leucocytosis, Hair loss, acne and psoriasis, Cardiac: ECG changes, Metabolic: weight gain, edema and hypothyroidism, CNS changes: lethargy, sedation, tremor, Renal: polyurea or polydipsia. Long term kidney failure (Almand & Trimmer, 2021)

Lithium Toxicity

  • Avoid sodium depletion or dehydration as can be toxic.
  • Regular blood test to monitor serum levels; monitor kidney function.
  • Overdose/toxicity: maintenance of fluid and electrolyte balance to prevent hyponatremia; ecg monitoring, control of hypotension and seizures
  • Therapeutic range: 0.7-1.2 mmol/l
    • < 0.5 mmol/l no effect.
    • > 1.5 risk of toxicity.
    • 1.7-2.0 mmol/l: diarrhea, nausea & vomiting, blurred vision, muscle weakness, tremor, ataxia & dysarthria.
    • > 2.0 mmol: hyperreflexia & hyperextension, seizures, hypotension, renal & circulatory failure, confusion coma, death.