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and elation. While sadness and elation are normal and natural, they may become pervasive and debilitating, and may even result in death, either in the form of suicide or as the result of reckless behavior. In any one year, roughly 7% of Americans suffer from mood disorders. Mood Disorders defined as: Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to live life Categories: • • Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy and other symptoms
Related Disorders • • • • • • • • Dysthymia: sadness, low energy, but not severe enough to be diagnosed as major depression disorder Cyclothymia: mood swings not severe enough to be diagnosed as bipolar disorder Substance-induced mood disorder Mood disorder due to a general medical condition Seasonal affective disorder (SAD) Postpartum or “maternity” blues Postpartum depression Postpartum psychosis
Major Depressive Disorder • • Twice as common in women and more common in single or divorced people Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least four other symptoms: – Changes in appetite or weight, sleep, or psychomotor activity
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Decreased energy Feelings of worthlessness or guilt Difficulty thinking, concentrating, or making decisions Recurrent thoughts of death or suicidal ideation, plans, or attempts
Untreated, can last 6 to 24 months; recurs in 50% to 60% of people Symptoms range from mild to severe
Treatment and Prognosis -Antidepressants • • • • SSRIs (Prozac, Zoloft, Paxil, Celexa) prescribed for mild and moderate depression TCAs (Elavil, Tofranil, Norpramin, Pamelor, Sinequan) used for moderate and severe depression Atypical antidepressants (Effexor, Wellbutrin, Serzone) MAOIs (Marplan, Parnate, Nardil) used infrequently because interaction with tyramine causes hypertensive crisis
-Electroconvulsive therapy (ECT) is used when medications are ineffective or side effects are intolerable. • • • 6 to 15 treatments scheduled three times a week Preparation of a client for ECT is similar to preparation for any outpatient minor surgical procedure The client will have some short-term memory impairment
-Psychotherapy in conjunction with medication is considered most effective treatment; useful therapies include behavioral, cognitive, interpersonal therapy Nursing Process: Major Depressive Disorder Assessment
History: the client’s perception of the problem, behavioral changes, any previous episodes of depression, treatment, response to treatment, family history of mood disorders, suicide, or attempted suicide
General appearance and motor behavior: slouched posture, latency of response, psychomotor retardation or agitation Mood and affect: hopeless, helpless, down, anxious, frustrated, anhedonia, apathetic; affect is sad, depressed, or flat Thought processes and content: slowed thinking processes, negative and pessimistic, ruminate, thoughts of dying or committing suicide Sensorium and intellectual processes: oriented, memory impairment, difficulty concentrating Judgment and insight: impaired judgment, insight may be intact or limited Self-concept: low self-esteem, guilty, believe that others would be better off without them Roles and relationships: difficulty fulfilling roles and responsibilities Physiologic considerations: weight loss, sleep disturbances, lose interest in sexual activities, neglect personal hygiene, constipation, dehydration Depression rating scales: Zung Self-Rating Depression Scale, Beck Depression Inventory, the Hamilton Rating Scale for Depression
• • • •
Data Analysis Nursing diagnoses may include: • • • • • • • • • • Risk for Suicide Imbalanced Nutrition: Less Than Body Requirements Anxiety Ineffective Coping Hopelessness Ineffective Role Performance Self-Care Deficit Chronic Low Self-Esteem Disturbed Sleep Pattern Impaired Social Interaction
Outcomes The client will: • • • • • • • • • Not injure himself or herself Independently carry out activities of daily living (showering, changing clothing, grooming) Establish a balance of rest, sleep, and activity Establish a balance of adequate nutrition, hydration, and elimination Evaluate self-attributes realistically Socialize with staff, peers, and family/friends Return to occupation or school activities Comply with antidepressant regimen Verbalize symptoms of a recurrence
Intervention • • • • • • Providing for the client’s safety and the safety of others Promoting a therapeutic relationship Promoting activities of daily living and physical care Using therapeutic communication Managing medications Providing client and family teaching
Evaluation • • • • • Does the client feel safe? Is the client free of uncontrollable urges to commit suicide? Is the client participating in therapy and medication compliance? Can the client identify signs of relapse? Will the client agree to seek treatment immediately upon relapse?
Bipolar Disorder Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives. • • • • Occurs almost equally among men and women It is more common in highly educated people The mean age for a first manic episode is the early 20s Involves mood swings of depression (same symptoms of major depressive disorder) and mania. Major symptoms of mania include: • • • • • • • Inflated self-esteem or grandiosity Decreased need for sleep Pressured speech Flight of ideas Distractibility Increased involvement in goal-directed activity or psychomotor agitation Excessive involvement in pleasure-seeking activities with a high potential for painful consequences
Treatment and Prognosis Medication • • Lithium; regular monitoring of serum lithium levels is needed Anticonvulsant drugs are used for their mood-stabilizing effects: Tegretol, Depakote, Lamictal, Topamax, and Neurontin, as is Klonopin (a benzodiazepine)
Psychotherapy • Useful in mildly depressive or normal portion of the bipolar cycle. It is not useful during acute manic stages
Nursing Process: Bipolar Disorder
General appearance and motor behavior: psychomotor agitation; flamboyant clothing or makeup; think, move, and talk fast; pressured speech Mood and affect: euphoria, exuberant activity, grandiosity, false sense of well-being, angry, verbally aggressive, sarcastic, irritable Thought processes and content: flight of ideas, circumstantiality, tangentiality, possible grandiose delusions Sensorium and intellectual processes: oriented to person and place but rarely to time, impaired ability to concentrate, may experience hallucinations Judgment and insight: judgment poor, insight limited Self-concept: exaggerated self-esteem Roles and relationships: rarely can fulfill role responsibilities, invade intimate space and personal business of others, can become hostile to others, cannot postpone or delay gratification Physiologic and self-care considerations: inattention to hygiene and grooming, hunger or fatigue
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Data Analysis Nursing diagnoses may include: • • • • • • • • • Risk for Other-Directed Violence Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Noncompliance Ineffective Role Performance Self-Care Deficit Chronic Low Self-Esteem Disturbed Sleep Pattern
The client will: • • • • • • • Not injure self or others Establish a balance of rest, sleep, and activity Establish adequate nutrition, hydration, and elimination Participate in self-care activities Evaluate personal qualities realistically Engage in socially appropriate, reality-based interaction Verbalize knowledge of his or her illness and treatment
Intervention • • • • • • Providing for safety of client and others Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications Providing client and family teaching
Evaluation • • • • • Safety issues Comparison of mood and affect between start of treatment and present Adherence to treatment regimen of medication and psychotherapy Changes in client’s perception of quality of life Achievement of specific goals of treatment including new coping methods
The following table summarizes the nursing care for mood disorders
MOOD DISORDERS DEPRESSION TYPES/ SUBTYP ES MAJOR DEPRESSIVE DISORDER (MDD)
(AFFECTIVE DISORDERS) BIPOLAR DISORDER • Bipolar disorders are mood disorders with recurrent episodes of depressionand mania. Phases vary depending on the type of bipolar disorder. • Bipolar disorders usually emerge in late adolescence/early adulthood, but can be diagnosed in the school-age as well. TYPES OF BIPOLAR DISORDERS: BIPOLAR I: At least 1 episode of Mania alternating w/ Major Depression. BIPOLAR II: Hypomanic episodes alternating w/ Major Depressive ones. CYCLOTHYMIA: At least 2 years of alternating episodes of Hypomanic Episodes alternating w/ Minor Depressive episodes (dysthymia) BEHAVIORS shown with Bipolar Disorders include: MANIA: Abnormally elevated mood, also described as expansive or irritable. HYPOMANIA: A less severe episode of mania that lasts at least 4 days accompanied by 3 or 4 symptoms of mania. MIXED EPISODE: A manic episode and an episode of major depression experienced by the client simultaneously. Marked impairment in functioning and may require admission to prevent self-harm or others-directed violence. RAPID CYCLING: Four or more episodes of acute mania within 1 year ***BIPOLAR DISORDER IS ASSOCIATED WITH THE HIGHEST RATE OF SUICIDE OF ANY PSYCHIATRIC DISORDERS. MANIA 1. Severe enough to cause a marked impairment in occupational activities, usual social activities, or relationships. OR 2. Necessitates hospitalization to prevent harm to self or others, or there are psychotic features Symptoms are not due to direct physiological effects of substance (drug abuse, medication, alcohol) other medical condition (hyperthyroidism) 1. HYPOMANIA Associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
• A single, recurrent, or
chronic episode (s) of depression resulting in a significant change in the client’s normal functioning (social, occupational, self-care) accompanied by at least 5 specific symptoms. • These symptoms must happen almost every day, last most of the day, and occur continuously for a minimum of 2 years.
• • •
Depressed Mood Insomnia/Hypersomnia Decreased ability to concentrate • Anergia (Lack of Energy) • Significant weight loss or gain (of more than 5% of body weight in 1 month) • Indecissiveness • Increase or Decrease in motor activity • ****Suicidal Ideations **** • Anhedonia (Inability to feel pleasure in life) Specifiers (Features): • PSYCHOTIC FEATURES (Hallucinations, Delusions etc) POSTPARTUM ONSET (Begins within 4 weeks of childbirth, known as Postpartum Depression) SEASONAL FEATURES (SEASONAL AFFECTIVE DISORDER –SAD-) (Generally occurring in fall or winter, and
• • • • • • •
DYSTHYMIC DISORDER (DD) OR DYSTHYMIA A milder form of depression that usually has an early onset, such as childhood or adolescence (Chronic Depressed Mood) IT LASTS: More than 1 year (for Children and Adolescents) More than 2 years (For Adults) Contains at least 3 symptoms of depression, and may, later in life, become Major Depressive Disorder Depressed Mood Insomnia/Hyperso mnia Decreased ability to concentrate Anergia Decreased Self Esteem Feelings of Hopelessness and Despair Decreased/Increas ed Appetite
2. The disturbance in mood and the change in functioning are observed by others 3. Absence of marked impairment in social or occupational functioning. 4. Hospitalization not indicated 5. Symptoms are not due to direct physiological effects of substance (drug abuse, medication, alcohol) other medical condition (hyperthyroidism)
Specifiers (Features) • • • Early Onset (before 21 y/o) Late Onset (21 years or older) Atypical Features (Appetite changes, weight gain, Hypersomnia, extreme sensitivity to perceived interpersonal rejection) 3.
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