Mood Disorders

Learning Objectives

  • Discuss common signs and symptoms of mood disorders.

  • Name three neurotransmitters that, when imbalanced, affect mood.

  • Identify the types of drugs that are used to treat mood disorders and nursing considerations related to their administration.

  • Discuss the causes, manifestations, and management of serotonin syndrome.

  • Identify the reasons electroconvulsive therapy is used in the management of depression.

  • Name three interventions that are alternatives to electroconvulsive therapy for recurrent depression.

  • Give three criteria that indicate a high risk for suicide.

  • Discuss nursing measures that are useful in preventing suicide.

  • Discuss the nursing management of clients with depression.

  • Describe seasonal affective disorder, its treatment, and nursing management.

  • Explain bipolar disorder and describe its treatment and nursing management.

What is Mood?

  • Definition: Mood is described as an overall feeling state that exists on a continuum, ranging from extremes of emotion.

  • Normal moods can include:

    • Euthymic (normal mood)

    • Dysthymia (chronic, mild depression)

    • Cyclothymia (milder form of bipolar disorder)

    • Mania (extremely elevated mood)

Mood Disorders

  • Major categories of mood disorders include:

    • Major Depression

    • Seasonal Affective Disorder (SAD)

    • Bipolar Disorder

Mood Continuum

  • Illustrates the range from:

    • Cyclothymia

    • Dysthymia

    • Depressed

    • Euthymia

    • Mania

    • Includes emotional states like melancholy, sadness, happiness, elation, and euphoric.

Major Depression

Reactive vs. Unipolar Depression

  • Reactive (secondary) depression versus major (unipolar) depression.

Pathophysiology and Etiology

  • Neurotransmitters: Critical for brain function and mood regulation.

  • Limbic System: Emotional center of the brain.

  • Genetics: Family history indicating increased risk; research includes twins raised apart and DNA studies.

  • Dysregulation: Imbalance in brain neurotransmitters such as serotonin, norepinephrine, and dopamine.

  • Neuroendocrine Imbalance: Changes in hormone levels (like cortisol and thyroid hormones) affecting the hypothalamus influence mood.

Assessment Findings

  • Signs and Symptoms: Most important for diagnosis.

    • Diagnostic investigations might include:

    • 5-HIAA levels in cerebrospinal fluid (CSF).

    • Metabolite of norepinephrine in urine.

    • Blood tests to measure serotonin and neurotransmitters; clinical presentations assessed.

    • Alternative Diagnoses: Consideration of thyroid function tests, blood glucose tests, hemoglobin levels, and urine drug screening.

    • Dexamethasone Suppression Test: Assesses adrenal function and depression-related changes.

Symptoms of Depression

  • Mnemonics to recall symptoms: A SAD FACES:

    • Appetite changes (increased or decreased).

    • Sleep disturbances (insomnia).

    • Anhedonia (loss of pleasure).

    • Dysphoria (feeling down).

    • Fatigue or loss of energy.

    • Agitation or psychomotor retardation.

    • Concentration difficulties.

    • Low self-esteem or feelings of guilt.

    • Suicidal thoughts or ideation.

Signs and Symptoms of Major Depression

  • BOX 69-2 summarizes:

    • Sad mood.

    • Changes in appetite (increase or decrease).

    • Disturbed sleep (insomnia or hypersomnia).

    • Inability to concentrate.

    • Marked decrease in pleasure from activities.

    • Apathy including lack of interest in sex.

    • Feelings of guilt.

    • Energy changes (either restlessness or inactivity).

    • Suicidal thoughts.

Medical Management of Major Depression

Drug Therapy

  • Refer to Drug Therapy Table 69-1 for a comprehensive overview.

Serotonin Syndrome

  • Manifestations: A potentially life-threatening condition characterized by:

    • Fever, feelings of intoxication, anxiety, confusion, ataxia, hypertension, tachycardia.

  • Risk Factors: Include co-prescribing antidepressants such as MAOI with SSRI, inadequate drug weaning, or the use of other serotonin-stimulating agents (like lithium).

Drug Classes for Treatment and Considerations

SSRIs (Selective Serotonin Reuptake Inhibitors)

  • Example: Fluoxetine (Prozac)

  • Side Effects: Sexual dysfunction, dry mouth, insomnia

  • Nursing Considerations: Monitor for serotonin syndrome, assess for suicidal ideation, screen for St. John’s wort use.

Tricyclics

  • Example: Amitriptyline (Elavil)

  • Side Effects: Anticholinergic effects, sedation

  • Nursing Considerations: Lethal overdose risk.

MAOIs (Monoamine Oxidase Inhibitors)

  • Example: Isocarboxazid (Marplan)

  • Side Effects: Risk of hypertensive crisis.

  • Nursing Considerations: Avoid aged foods, alcohol, and cheese.

SNRIs (Serotonin Norepinephrine Reuptake Inhibitors)

  • Example: Duloxetine (Cymbalta)

  • Side Effects: Agitation, dizziness, sedation

  • Nursing Considerations: Can result in serotonin syndrome; warn male patients of priapism risk.

NDRIs (Norepinephrine-Dopamine Reuptake Inhibitors)

  • Example: Bupropion (Wellbutrin)

  • Side Effects: Restlessness, agitation, aggression

  • Nursing Considerations: Avoid in patients with a seizure history, and those planning pregnancy.

Assessment of Suicidal Risks

Risk Factors (Refer to BOX 69-5)

  • Depression linked with substance abuse.

  • Major life losses or trauma (e.g., death of loved one, divorce).

  • Gender: males are at higher completion rates, while females attempt more frequently.

  • History of previous suicide attempts.

  • Family history of suicide.

  • Access to firearms (common method of suicide).

  • Experiencing chronic physical illness or pain.

  • Previous abuse (physical or sexual).

  • Legal problems or difficulties in school.

  • Command hallucinations urging the individual to commit suicide.

Clues to Suicidal Intentions (Refer to BOX 69-6)

  • Clear Verbal Clues:

    • Direct statements of intent (e.g., “I’m planning to kill myself.”).

  • Vague Verbal Clues:

    • Statements indicating despair (e.g., “Nobody needs me anymore.”).

  • Behavioral Clues:

    • Uncharacteristic behaviors like giving away possessions, organizing affairs, and writing morbid poetry or suicide notes.

Seasonal Affective Disorder (SAD)

Overview

  • Definition: A mood disorder presenting during the darker winter months and receding with spring onset.

  • Pathophysiology: Correlates with latitudinal position and photoperiod impacts on melatonin levels.

  • Assessment Findings in Winter: Symptoms include lethargy, irritability, a craving for carbohydrates, and social withdrawal.

Medical Management

  • Treatment Options:

    • Phototherapy (artificial light exposure).

    • Moving to sunnier locations.

Bipolar Disorder

Overview

  • Definition: Characterized by cycling between depressive episodes, euthymic (normal) states, and euphoria (mania).

Assessment Findings

  • Manic Phase Symptoms:

    • Enhanced self-importance, impaired judgment, rapid thinking, decreased need for sleep, and potentially psychotic features.

Medical Management

  • Medications include anticonvulsants (e.g., carbamazepine, valproic acid) and lithium.

    • Lithium: Assists in mood stabilization but requires monitoring due to possible toxicity and side effects.

    • Nursing Considerations: Hydration monitoring and sodium level tracking are crucial.

Nursing Management and Client Care

  • General Practice: Adaptations in nursing measures, psychotherapy types, and individual patient assessments.

  • Practice and Learn Objectives: Define pharmacological treatment considerations, explain TCA, MAOIs, and SSRI usage in treating depression, and identify atypical antidepressant uses.