PSYCHIATRIC NURSING

MOOD DISORDERS
ETIOLOGY
• Biologic:
▫ Neurotransmitter dysregulation
▫ Reduction of neurotropic factors in hippocampus
▫ Genetic predisposition
▫ Structural defects: birth trauma / stress related
▫ Neuroendocrine disorder
• Stress related biology
▫ Mobilization of SNS
▫ Overactivation of hypothalmic pituitary adrenal axis
▫ CRH hypersecretion
• Cognitive Behavioral
▫ Learned helpless
▫ Distorted interpretations
▫ Hopeless outlook
• Personality
▫ PD mediating stress and depression
▫ Temperament – depression & anxiety
▫ Personality
 Avoidance
 Dependence
 Reactivity
 impulsivity
• Gender related – more women
• Psychosocial
▫ Death
▫ Divorce
▫ Major losses
▫ Parental neglect
▫ Inadequate parent child bonding
▫ Absent or inadequate support systems
MOOD DISORDERS

• Represents a grp. Of diagnostic categories that

describes a range of emotional disturbances.
• Disturbances In Emotional And Behavioral
Response Patterns.
• ranges from elation and agitation to severe
depression and serious potential FOR suicide
CATEGORIES FOR MOOD DISORDERS
1. Depressive disorders
2. Major depressive disorder
3. Dysthymic disorder
4. Bipolar disorder – I & II
5. Cyclothymic disoder
• MOOD: internal & subjective sustained and
pervasive emotion
▫ Is a person’s state of mind exhibited through
feelings and emotions.
• Labile : change / swing suddenly or infrequently.

• AFFECT: external observable manifestations

( flat, blunted, expansive, or constricted.
Major Depressive Disorders
• Major depressive episode – 2 wks or more
▫ Depressed mood – most or all of each day or hopelessness
▫ Anhedonia – loss of interest or pleasure in nearly all activities.
▫ At least 4 of the ff. symptoms are present;
 Marked changed in appetite
 Significant weight loss/gain
 Insomnia / hypersomnia
 Psychomotor retardation or agitation
 Fatigue, lack of energy
 Lack of libido
 Feeling of hopelessness, worthlessness, guilt
 Decreased ability to think or concentrate
 Recurrent thoughts of death or suicide
• Nursing Management:
▫ Complications : suicide esp. w/ hopelessness
▫ A brightened affect may attempt suicide again.
(ambivalence)
▫ Require one on one observation. Env’t. free from hazards
▫ Onset of depression develops from days to weeks
▫ Symptoms : physiologic, psychomotor, cognitive,
psychosocial- reduced
▫ Psychotic symptoms: hallucinations & delusions.
▫ Anti depressants, w/ improvement 3-4 wks.
▫ Anticholinergic and cardiovascular side effects.
▫ Generally have a positive outcome and prognosis – early
intervention and treatment.
• Accept Patient
• Be honest, and develop a trusting relationship
• Be emphatic, and show sincerity.
• Use praise /rewards , and encouragement intelligently
• Do not reinforce hallucinations delusions, irrational beliefs
• Encourage verbalization
• Provide one on one interaction, and social opportunities
• Provide decision making opportunities
• Manic episode - @ Least 1 week of persistent
elevated mood (euphoric), expansive, or irritable.
▫ At least 3 of the ff.
 Inflated self esteem
 Grandiosity
 Decreased need for sleep
 Pressured or excessive speech
 Flight of ideas
 Psychomotor agitation
 Distractability
 Increased in goal directed activity w/ frequent decreased purposeful and
completion.
 Increase in activities for pleasure & socialization ( w/ potential for
danger, disappointment or other painful consequences)
 Psychotic symptoms: delusion of grandeur, omnipotence, persecution.
• Nursing Management: Mania
▫ Psychotic symptoms: delusions of grandeur, omnipotence, or
persecution.
▫ Need close monitoring - + suicide, homicide
▫ Often w/ flight of ideas; may be angry, insulting, manipulative, sexually
explicit, combative – secluded or restraint.
▫ Conversations shld. Be brief – difficulty concentrating
▫ Avoid sensitive , volatile topics
▫ Serve finger foods, frequent drinks
▫ Lithium drug of choice
 Therapeutic effects – 1-2 weeks
 Monitor lithium levels q 5-6 days & q 6 months maintenance
 Therapeutic levels: 0.8 – 1.2 mEq/L
▫ Valproate ( Depakote) – maintenance & treatment of mania
 Therapeutic levels : 50- 125 ug/mg
 Caution: liver toxicity
▫ Carbamazepine ( Tegretol)
 Therapeutic levels:8- 12 mg/L
• Use matter of fact statement
• Clear, concise directions/comments
• Limit setting
• Reinforce reality
• Respond to legitimate complaints
• Mixed Episode - @ least 1 wk, during w/c criteria
for depressed episode & manic episode occur
each day.
• Moods rapidly alternate ( irritable, elated,
frustrated, sad)
• Other symptoms include:
▫ Agitation
▫ Insomia
▫ Disturbed appetite
▫ Suicidal thinking
• Hypomanic Episode - @ least 4 days of
persistent exaggerated mood – expansive,
elevated or irritable.
• No or minimal impairment of judgment or
performance
Additional features:

• Rapid cycling
• Psychotic features ( delusions, hallucinations)
MAJOR DEPRESSIVE DISORDER
• w/ 1 or more episode of major depressive disorder
• w/ no manic episode, mixed, or hypomanic episode.
• Depression – mild, moderate, or severe
• Other features:
1. Catatonia – stupor, mutism, bizarre posturing or grimacing;
purposeless excessive activity w/ no external stimulus,
negativism.
2. Melancholia – severe anhedonia ; severe depressed mood,
mood worsens in a.m.; early morning awakening; mark
agitation or retardation; excessive guilt, anorexia.
3. Postpartum onset : w/in 4 wks of childbirth
4. Post partum psychosis – 10 days postpartum
 Psychotic features may be present if infanticide is
present.
 High risk;
 Prior post partum mood episodes
 Prior history of mood disorders or
 Familial history of mood disorders

5. Seasonal Pattern – fall or winter

• A chronically depressed mood for the major of the
DYSTHYMIC DISORDER
days over a 2 year period ( adult) or 1 year for
children / adolescents.
• 2 or more of the ff symptoms;
▫ Appetite disturbance ( lack of appetite/ overeating)
▫ Sleep disturbance ( insomnia/ hypersomnia)
▫ Fatigue/ general lack of enenrgy
▫ Difficulty concentrating/ decision making
▫ Self esteem disturbance ( lowered)
▫ Hopelessness
▫ ( Must not have had a previous manic or mixed
episode, not caused by other medical or medical
conditions, substance use)
Bipolar I and II Disorders
• BIPOLAR I : manic or a mixed episode; usually had
one or more prior to major depressive disorder.
• BIPOLAR II: Presence or hx of one or more major
depressive episodes and @ least one hypomanic
episode .
• May also have the ff;
▫ Mild / moderate / severe
▫ Single / recurrent episode
▫ Features of catatonia/ melancholia/ postpartum
onset/ rapid cycling/ seasonal pattern.
CYCLOTHYMIC DISORDER
• Chronic course ( 2 yrs. For adults; 1 yr. for
children/adolescents) of mood fluctuations that
include several hypomanic and depressed
periods w/o a 2 month period of symptom relief
during that time.
• do not meet full criteria for manic or depresive
episodes, no psychotic features.
Mood disorder due to Medical
• Depressed, manic or mixed symptoms, d/t
Condition:
physiologic result of a medical condition.
• Related conditions:
▫ Parkinson’s disease
▫ Huntington’s disease
▫ Alzheimer’s disease
▫ CVD
▫ Multiple sclerosis
▫ Cushing’s disease
▫ Metabolic dysfunction ( thyroid / adrenal)
▫ Autoimmune d. ( lupus)
▫ Cancers
▫ Viral
▫ Post surgical conditions
Substance Induced Mood disorder
• Developing w/in a month of substance intoxication or
substance withdrawal.
• May involved medications or toxins.
• Intoxications
▫ Alcohol
▫ Amphetamines
▫ Cocaines
▫ Anxiolytics
▫ Sedatives/hypnotics
▫ Opioids
▫ Inhalants
▫ Hallucinogens
• Withdrawal
▫ Alcohol
▫ Cocaine
▫ Amphetamines
▫ Sedatives/hypnotics
▫ Anxiolytics
COMPLICATIONS
• Suicide:
• Homicides
• Comorbidity : coexisting mental disorders or physical
illness.
 • Medications:
Interventions:
▫ Depressions: SSRI and TCA’s ( t/e: 8 weeks)
▫ Bipolar Disorders : Mania: Lithium (t/e : 2 wks begin)
 Valproate( Depakote); carbamazepine (Tegretol); gapapetin
(Neurontin)
 Side effects: Anticholinergic and cardiovascular
• ECT
• Therapies
▫ Therapeutic N-P relationship
▫ Activity therapy
▫ Cognitive Behavioral therapy
▫ Family therapy
▫ Group therapy
▫ Pastoral counseling
▫ Neuromodulator – Treatment resistant depression
Nursing Diagnosis: Depression
• Risk for suicide ( self inflicted. Life threatening)
• Impaired social interactions
• Chronic Low self esteem
• Ineffective coping
• Powerlessness
• Self care deficit
Nursing Diagnosis: Mania
• Risk for self directed Violence/ others
• Risk for injury
• Impaired social interactions
• Disturbed thought processes
• Defensive coping
• Imbalanced nutrition: Less than body
requirements
• Compromised family coping
INTERVENTIONS

• Relate from a non competitive frame of

reference
• Develop realistic adult relationships and
contracts for change
• Provide for safety and understanding
INTERVENTIONS

• simplify envt.
• set limits
• communicate firm . consistent approach.
• meet physical needs first
• encourage rest
• administer lithium – eat na rich foos and
increase fluids
SPECIFIC INTERVENTION
TECHNIQUES
• Provide understanding – pacing and leading-gen . intervention
• Provide for safety
• Provide emotional confrontation and cognitive restructuring
DIFFERENTIATION:

MANIA DEPRESSION
• Colorful  Sad
• Aggression outwards  Aggresion inwards
• Lithium  Ect
• Non-stimulating millieu  Stimulating
• Quiet act./Avoid Milleu
competitive  Monotonous act.
• Matter of fact Counting
 Kind firmness