MHLecture 2.2

Mood Disorders: Depression

• Unipolar Depression: Depression without mania or elevated mood.

• Risk factors:

  • Prior episodes.

  • Family history (especially 1st degree relatives).

  • Personal/family history of suicide.

  • LGBTQ+ community membership.

  • Female gender.

  • Age less than 40 years.

  • Postpartum period.

  • Chronic medical illness.

  • Lack of social support.

  • Negative life events.

  • Alcohol or substance use disorder (SUD).

  • History of sexual abuse.

• Major Depressive Disorder (MDD): Affects feelings, thoughts, and behavior, causing persistent sadness and loss of interest for at least 2 weeks.

• Persistent Depressive Disorder (PPD): Depressive symptoms for at least 2 years.

Biochemical Factors in Depression

• Neurotransmitters:

  • Serotonin - Include poor impulse control, low sex drive, decreased appetite, disturbed body temperature regulation, and irritability.

  • Norepinephrine.- Anergia: Reduction or lack of energy.

  • Dopamine. - Anhedonia: Inability to find meaning in existence

MDD Symptoms: SIG E CAPS

• Sleep disturbance (insomnia or excessive sleep).

• Interest diminished in pleasurable activities.

• Guilt feelings; feelings of worthlessness.

• Energy decreased or fatigue.

• Concentration diminished and indecisiveness.

• Appetite changes (decreased or increased) with weight changes.

• Psychomotor slowing or agitation.

• Suicidal thoughts, behaviors, and thoughts of death.

PDD Symptoms

• Presents longer and with less severe symptoms compared to MDD.

• Daytime fatigue.

• Ability to function but not optimally.

• Chronic low-level depressed/irritable mood.

• Eating too much or too little.

• Difficulty sleeping (insomnia or excessive sleep).

• Loss of energy, fatigue even with simple tasks.

• Decreased capacity to experience pleasure, enthusiasm, or motivation.

• Irritability.

• Negative, pessimistic thinking.

• Low self-esteem.

Assessment: Suicide & Homicide Potential

• Questions to assess suicide and homicide potential:

  • "What have been your past experiences related to hurting people who have hurt you?"

  • "You mentioned that if you were to hurt ___, you’d probably do it by (xyz). How easy would it be for you to do this?"

  • "If you decided to hurt ___, how would you do it?"

  • "You have said you are depressed. Tell me what that is like for you."

  • "When you feel depressed, what thoughts go through your mind?"

  • "Have you ever thought about or attempted taking your own life?"

  • "Are you thinking about killing yourself now?"

  • "Do you have a plan? Do you have the means to carry out your plan?"

    •     Terrisoft Principle (right to tell your neighbor about being murdered”

Antidepressants

• 1 in 10 Americans take antidepressants.

• Classes:

  • SSRIs (Selective Serotonin Reuptake Inhibitors).

    • Increase serotonin by inhibiting reuptake.

    • Examples: Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft).

    • Common side effects: Nausea, nervousness, and sexual side effects.

  • Serotonin Modulators

    • Examples: Vilazodone (Viibryd), Vortioxetine (Brintellix).

  • SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors).

    • Increase serotonin and norepinephrine.

    • Examples: Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Levomilnacepran (Fetzima), Venlafaxine (Effexor).

    • Common side effects: Headache, dry mouth, insomnia, sweating, nervousness, sexual side effects.

  • Atypical Antidepressants.

    • Target serotonin, norepinephrine, and dopamine.

    • Examples: Bupropion (Wellbutrin), Nefazodone (Serzone), Trazodone (Desyrel), Mirtazapine (Remeron).

    • Common side effects: Dry mouth, dizziness.

  • Tricyclics and Tetracyclics (TCAs and TECAs).

    • Increase serotonin and norepinephrine.

    • Examples: Amitriptyline (Elavil), Amoxapine (Asendin), Clomipramine (Anafranil), Desipramine (Norpramin), Doxepin (Sinequan), Imipramine (Tofranil), Maprotiline (Ludiomil), Nortriptyline (Pamelor), Protriptyline (Vivactil), Trimipramine (Surmontil).

    • Common side effects: Dry mouth, blurred vision, urinary retention , constipation, weight gain, orthostatic hypotension, dry mouth, drowsiness, elevated HR, sexual side effects…

  • Monoamine Oxidase Inhibitors (MAOIs).

    • Not frequently used but can be effective.

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

    • Need to avoid decongestants and certain foods (fish, chocolate, fermented foods).

    • Common side effects: Low blood pressure.

Antidepressant Considerations

• Clients may experience increased mania or hypomania during initial weeks of therapy.

• Medications take 4-6 weeks for therapeutic effect.

• Abrupt discontinuation may occur due to lack of immediate effect or side effects (e.g., weight gain).

• Serotonin Syndrome: Life-threatening risk with SSRIs.

  • Symptoms: Shivering, hyperreflexia/myoclonus, increased temperature, vital sign instability, encephalopathy, restlessness/incoordination, sweating.

• SNRIs: Treat depression and anxiety but carry serotonin syndrome risk.

• Atypical Antidepressants: Used when SSRIs and SNRIs don't work; Trazodone and Bupropion have off-label uses like smoking cessation.

• TCAs: Off-label for insomnia (amitriptyline); anticholinergic and cardiotoxic effects possible.

• MAOIs: Dietary restrictions due to risk of serotonin syndrome and hypertensive crisis; avoid tyramine-containing foods.

• Black Box Warning: All antidepressants can increase suicide risk in children and adolescents when first started. (Up to age 24)

Other Treatments for Depression

• Electroconvulsive therapy (ECT): Electric currents induce a brief seizure under anesthesia.

• Vagus nerve stimulation (VNS): Long-term treatment for resistant depression; affects blood flow and neurotransmitters via implanted device.

• Transcranial magnetic stimulation (TMS): Magnetic pulses stimulate nerve cells in mood-controlling brain regions; considered safer than ECT.

Bipolar Disorders

• Brain diseases with unusual shifts in mood, energy, and activity levels.

• Recurring depression and/or mania alternating with normalcy.

• Chronic, recurrent, life-threatening; require lifetime monitoring.

• Mania: Elevated, expansive, or irritable mood with increased activity/energy.

  • Symptoms (DIGFAST): Distractibility, Impulsivity, Grandiosity, Flight of ideas/racing thoughts, Activity/energy increase, Sleep needs diminish, Talkative.

• Hypomania: Lower intensity mania (lasts 4 days).

• Depressive symptoms: Low mood, fatigue, increased need for sleep, changes in appetite, inability to concentrate, suicidal thoughts, psychomotor slowing.

• Mixed episode: Concurrent mania and depression.

Bipolar I and II Disorders

• Bipolar I Disorder: At least one manic episode, possibly with major depressive episodes; impairs social/occupational functioning.

• Bipolar II Disorder: At least one hypomanic period alternating with one or more depressive periods; never full mania; seeks treatment during depressive episodes; risks less severe.

• Rapid cycling: Four or more mood episodes in 12 months.

• Diagnosis: Provider determines current episode, severity, psychosis, and remission status (per DSM-5).

MRI Changes in Bipolar Disorder

• Changes in pre-frontal cortex, amygdala, hippocampus, and pituitary gland; deficits in gray-matter volume and white matter disorganization.

• Problems with cognition and emotional stimuli processing.

• Extreme fluctuation in BAS (behavioral approach system) activation/deactivation; hyperresponsiveness to stimuli = mania.

Bipolar Disorders: Assessment

• Mood Disorder Questionnaire (MDQ): screening tool.

• Behavior:

  • Mania: Assess for DIGFAST symptoms; risky behaviors, manipulation, limit pushing, bizarre dress, hyperactivity, lack of sleep/food, nonstop physical activity (can lead to exhaustion/death).

  • Hypomania: Similar to mania but less extreme.

  • Delirious mania: Rapid onset delirium + mania, can lead to psychosis, hyperactive catatonia = life-threatening.

• Thought content/processes: Paranoid delusions, grandiosity, hallucinations, pressured speech, flight of ideas, circumstantial speech, clang associations.

• Cognitive function: Memory, attention, executive functioning problems.

• Safety: Need for hospitalization, dehydration, cardiac status, poor sleep, uncontrolled spending.

Bipolar Disorders: Nursing Diagnosis

• Impaired sleep.

• Impaired fluid intake.

• Impaired interactive behavior.

• Non-adherence to medication regimen.

Bipolar Disorders: Planning

• Phase 1/ Acute Mania:

  • Decreasing physical activity.

  • Maintaining adequate food and fluid intake.

  • Ensuring at least 4-6 of sleep per night.

  • Alleviating any bowel or bladder problems.

  • Intervening to ensure self-care needs are met.

  • Providing careful medication management.

• Phase 2 & 3/Continuation and Maintenance:

  • Maintain patient’s interpersonal and stress-reduction skills.

  • Assist with employment status and any legal issues.

  • Build social support systems.

  • Address substance-related problems.

  • Create a relapse prevention plan.

Bipolar Disorders: Implementation/ Pharmacology

• Mood stabilization is the overall goal

• Lithium is first-line treatment for bipolar disorder (treats acute mania, acute bipolar depression, and prevents manic and depressive episodes)

  • Requires 3-6 weeks for therapeutic effect

  • Therapeutic levels for mania: 0.5 to 1.2 mEq/L

  • Maintenance levels: 0.6 to 1.0 mEq/L

  • Toxic levels: 1.5 mEq/L

  • Levels drawn at a trough level (10 to 12 hours after last dose)

  • S/S of lithium toxicity: coarse tremors, slurred speech, ataxia (poor muscle control), seizures, severe N/V/D, hypotension, bradycardia, ECG abnormalities

  • Fluid and electrolyte balance can affect serum lithium levels (sweating, dehydration, excessive hydration, high sodium intake); 1500-3000mL fluid intake daily is needed

• Atypical Antipsychotics are also ordered for sedative and mood stabilizing effects.

• Anticonvulsants - valproic acid (Depakote), lamotrigine, carbamazepine. Ordered for clients instead of lithium especially when they refuse lithium due to weight gain.

• Anxiolytics (clonazepam & lorazepam) for acute mania and psychomotor agitation

Psychosis & Schizophrenia

• Psychosis: A primary psychotic disorder with abnormalities in domains like delusions, hallucinations, disorganized thoughts/behavior, and negative symptoms; loss of contact with reality. Can be

  • Primary: Discrete psychiatric disorders

  • Secondary: Dementia, substance use

• Schizophrenia: A syndrome of neurocognitive symptoms impairing cognitive capacity, functioning, and social relatedness.

Schizophrenia & Comorbidities

• Substance Use: SUDs in more than 50% of those diagnosed with schizophrenia.

• Other Psychiatric Disorders: Increased risk for additional psych disorders; suicide leading cause of death.

• Premature Death: 3.5x more likely to die prematurely (CV disease, pneumonia, etc).

• HIV & AIDs: 1.5x more likely to get HIV and/or AIDs.

Neurobiology of Schizophrenia

• Dopamine: Positive symptoms.

• Serotonin: Negative symptoms.

• Glutamate: Cognitive symptoms.

• Inflammation: Schizophrenia.

Phases of Schizophrenia

• Prodromal Phase:

  • S/S that precede the acute, fully manifested signs and symptoms of schizophrenia.

  • Early S/S: social withdrawal, deterioration in functioning, depressive mood, perceptual disturbances, magical thinking, peculiar behavior

  • May also experience: changes in self-care, sleeping or eating patterns, and changes in school or work performance

  • S/S appear a month to a year before first psychotic “break”/episode

• Acute Phase:

  • Severe and well-developed symptoms grouped into four categories:

    • Positive/florid symptoms.

    • Negative/deficit symptoms.

    • Cognitive/ neurocognitive symptoms.

    • Mood symptoms.

  • Priorities during this phase: safety, medical evaluation, crisis intervention.

• Stabilization Phase:

  • Period in which acute symptoms, particularly the positive symptoms, decrease in severity.

• Maintenance Phase:

  • Period in which symptoms are in remission (but mild s/s may still stay).

Symptoms of Schizophrenia

• Positive Symptoms: (Hallucinations, Psychomotor agitation, Delusions, Bizarre behavior)

  • Hallucinations: Sensory experiences that are not real (seeing, hearing, tasting, feeling); command hallucinations are dangerous. It is important to note:

    • Auditory hallucinations-false perceptions of sounds (second person, third person)

    • Gustatory hallucinations-false perceptions of taste

    • Olfactory hallucinations-false perceptions of smell

    • Visual hallucinations-false visual perceptions with eyes open in a lighted environment

    • Tactile hallucinations-false sensations of touch (Formication)

  • Psychomotor agitation: pacing, talking loudly and rapidly, gesturing dramatically

  • Delusions: false fixed beliefs that cannot be correct by reasoning: People/aliens/etc are “out to get” the patient, somebody is trying to poison the patient, etc.

    • Persecutory delusions: Involve unfounded beliefs of mistreatment or conspiracy against oneself, causing anxiety and distrust.

    • Erotomanic delusions: Involve the false belief that a person of higher status or fame is in love with the individual, often leading to stalking or attempts to contact the supposed admirer.

    • Grandiose delusions: Involve an inflated sense of self-worth, power, or identity, where individuals believe they possess unique talents or fame.

    • Jealous delusions: Entail the baseless belief that a spouse or partner is being unfaithful, often resulting in accusations, surveillance, and controlling behaviors that strain relationships.

    • Somatic delusions: Are false beliefs about the body, where individuals think they have a physical defect, illness, or infestation despite clear medical evidence.

    • Mixed delusions: Combine two or more types of delusional themes without one dominating.

    • Unspecified delusions: Don't fit specific categories but still involve false beliefs impacting the individual's life.

  • Bizarre behavior (unkempt, inappropriate conduct, childlike silliness)

  • Associative looseness: thinking becomes haphazard, illogical, and confused

  • Circumstantiality: using excessive detail that distracts from the central idea of the conversation

  • Tangentiality: when the train of thought of a speaker wanders off in another direction, never returning to the initial topic

  • Neologisms: “made-up” words that have special meaning to the person

  • Word salad: deterioration of the ability to connect thoughts in a coherent fashion; jumble of words

  • Echolalia: repeating of another’s words by imitation

  • Clang association: meaningless rhyming of words

  • Formal thought disorder/Concrete thinking: overemphasis on specific details and literal interpretation of ideas

• Negative Symptoms:

  • Apathy: lack of interest & emotion

  • Lack of motivation

  • Anhedonia: inability to experience joy or pleasure

  • Blunted or flat affect: reduced emotional expression

  • Poverty of speech: significant reduction in quantity and quality of speech

  • Social withdrawal

• Cognitive

  • Impairment in memory

  • Poor executive functioning (ability to absorb and interpret information and make decisions based on that information)

  • Disruption in social learning

  • Inability to reason, solve problems, focus attention

• Mood

  • Depression

  • Anxiety

  • Demoralization

  • Suicidality

  • Excitability

  • Agitation

• Catatonia: extreme and abnormal motor behavior

  • Stereotyped behaviors: motor patterns that originally had meaning to person but are now mechanical and lack purpose (ex- sweeping the floor)

  • Automatic obedience: performance of all simple commands in a robot-like way

  • Bizarre posturing: voluntary assumption and maintenance of bizarre posture

  • Waxy flexibility: excessive maintenance of posture; can lead to circulatory problems

  • Negativism: behavioral resistance; does the opposite of what one is told to do

  • Stupor: a condition in which the thoughts and feelings are blunted and there is a reduced level of reactivity to the environment.

Schizoaffective Disorder

• Schizophrenia with an underlying mood disorder (either bipolar disorder or major depression) but does not meet diagnostic criteria for either bipolar or depression alone.

Interventions

• Hallucinations: Watch patients for cues, ask directly, assess for harm, document, accept reality for patient but state you do not hear voices, stay calm, avoid overstimulation, keep patient focused on reality, identify intense times, assess anxiety and intervene.

• Delusions: Assess need for external controls, be aware of patient’s reality, identify feelings, engage in yoga/exercise, do not argue or correct with logic, avoid touching patient or using gestures carelessly

• Paranoia: Place yourself beside patient, avoid direct eye contact, use matter-of-fact approach, offer closed containers for food/fluids, engage in reality-based activities, observe triggers, use least restrictive interventions for anxiety.

• Loose associations: Do not pretend to understand, tell patient you have difficulty understanding, verbalize implications, blame yourself, look for recurring topics, emphasize current environment, reinforce clear communication.

Schizophrenia Treatment Options

• Antipsychotic Medication

• Social Skills Training

• Individual Therapy

• Electroconvulsive Therapy

• Family Therapy

• Hospitalization

• Vocational Rehabilitation

• Lifestyle Changes

Schizophrenia Pharmacology

• Second-generation antipsychotics/ Atypical Agents: typically 1st choice (fewer EPSs)

  • Clozapine (Clozaril): risk for neutropenia- must have baseline CBC/ANC

  • Aripiprazole (Abilify)

  • Lurasidone (Latuda)

  • Olanzaipine (Zyprexa)

  • Quetiapine (Seroquel)

  • Risperidone (Risperdal)

  • Ziprasidone (Geodon)

• First-generation antipsychotics

  • Haloperidol (Haldol)

  • Chlorpromazine (Thorazine)

• SE:

  • Anticholinergic (constipation, urinary retention, dry mouth, blurry vision)

  • CV (QTc interval prolongation, ortho hypotension, cardiomyopathy)

  • EPS (dystonias, akathisia, pariksonian, TD)

  • Metabolic syndrome (weight gain, increased cholesterol/blood pressure/ bgl)

  • Seizures

  • Sexual SE

  • Neuroleptic Malignant Syndrome: greatly increased muscle rigidity, elevated temperature, altered LOC, HTN, tachycardia, tachypnea, drooling, diaphoresis

Extrapyramidal Symptoms (EPS)

• Pseudo-parkinsonism:

  • Stooped posture

  • Shuffling gait

  • Rigidity

  • Bradykinesia

  • Tremors at rest

  • Pill-rolling motion of the hand

• Acute dystonia:

  • Facial grimacing

  • Involuntary upward eye movement

  • Muscle spasms of tongue, face, neck, and back (back muscle spasms cause trunk to arch forward)

  • Laryngeal spasms

• Akathisia

  • Restless

  • Trouble standing still

  • Paces the floor

  • Feet in constant motion, rocking back and forth

• Tardive dyskinesia

  • Protrusion and rolling the tongue

  • Sucking and smacking movements of the lips

  • Chewing motion

  • Facial dyskinesia

  • Involuntary movements of the body and extremities

Overall Goal for Schizophrenia

• Recovery Model and Recovery-Oriented Care: The premise and ultimate goal of this evidence-based model is to get the client to maximum level of functioning using four supporting dimensions:

  1. Health – overcoming and managing the disease.

  2. Home – having a stabile place to live.

  3. Purpose – meaningful experiences and activities, and the ability to function in society.

  4. Community – having supportive relationships and hope.

• This model is based on the QSEN Patient Centered Care and Evidence Based practice