Mood Disorders

Mood Disorders
(aka Affective Disorders)

 Pervasive alterations in
emotions manifested by
depression, mania, or both,
that interfere with the person’s
ability to live life
Categories of mood disorders
Primary mood disorders:
 Major depressive disorder – lasts 2 weeks;
depressed mood or lack of pleasure in nearly all
activities
 Bipolar disorder (Manic–depressive illness)
 Diagnosed when a person’s mood cycles between
extremes of mania and depression
Etiology
I. Biologic theories:
 Genetics
1st degree relatives:
 Major depression – 2x risk
 Bipolar disorder – 7x risk

 Neurochemical theories
 Serotonin
– mood activity, aggressiveness and irritability, cognition, pain,
biorhythms, neuroendocrine processes
- decreased in depression
 Norepinephrine
- deficient in depression; increased in mania

 Neuroendocrine or hormonal fluctuations

 Mood disturbances have been documented in people with
endocrine disorders
II. Psychodynamic theories
 Self-reproach and anger turned inward
 Inability to achieve personal ideals
 Powerless ego victimized by the superego
 Manic episodes are a “defense” against
depression
 Reaction to a distressing life experience
 Rejecting or unloving parents
 Resulting from specific cognitive distortions
Cultural considerations

 Other behaviors considered age-

appropriate can mask depression
 Somatic complaints are a major
manifestation among cultures that avoid
verbalizing emotions
 Asians who are anxious or depressed are more
likely to have somatic complaints of headache,
backache, or other symptoms
 Latin cultures complain of “nerves” or headaches
 Middle Eastern cultures complain of heart problems
Major Depressive
Disorder
Major Depressive Disorder
 Twice as common in women
 Has a 1.5 to 3 times greater incidence
in first-degree relatives
 Incidence decreases with age in
women & increases with age in men
 Highest incidence: Single & divorced
 Untreated, can last 6 to 24 months;
recurs in 50% to 60% of people
 Symptoms range from mild to severe
Treatment and Prognosis

1. 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
2. Electroconvulsive therapy (ECT) is used when
medications are ineffective or side effects are
intolerable; may also be used for relapse prevention
6 to 15 treatments scheduled 3 times
a week
 Preparation of a client for ECT is
similar to preparation for any
outpatient minor surgical procedure
 Theclient will have some short-term
memory impairment
3. Psychotherapy in conjunction with medication is
considered most effective treatment; useful
psychotherapies include behavioral, cognitive, and
interpersonal
4. Investigational treatments

 Transcranial magnetic stimulation

(TMS)
 Magnetic seizure therapy
 Deep brain stimulation
 Vagal nerve stimulation
Transcranial magnetic stimulation (TMS)
Magnetic seizure therapy
Deep brain stimulation
Nursing Process:
Major Depressive Disorder
I. 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, depressed or anxious,
frustrated, anhedonic, apathetic, sad affect, or flat
 Thought processes and content: slowed thinking processes,
negativism and pessimism, rumination, thoughts of dying or
committing suicide
 Sensorium and intellectual processes: oriented, memory
impairment, difficulty concentrating; If psychotic, clients
may hear degrading and belittling voices, or they may even
have command hallucinations that order them to commit
suicide.

 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,
loss of interest in sexual activities, neglect of personal
hygiene, constipation, dehydration
 Depression rating scales: Zung Self-Rating Depression
Scale, Beck Depression Inventory, The Hamilton Rating
Scale for Depression
II. Data analysis
 Nursing diagnoses may include:
o Risk for suicide
o Imbalanced nutrition: less than body
requirements
o Anxiety
o Ineffective coping
o Hopelessness
o Ineffective role performance
o Self-care deficit
o Chronic low self-esteem
o Disturbed sleep pattern
o Impaired social interaction
III. Outcomes
 The client will:
o Not injure himself or herself
o Independently carry out activities of daily living
(showering, changing clothing, grooming)
o Establish a balance of rest, sleep, and activity
o Establish a balance of adequate nutrition, hydration,
and elimination
o Evaluate self-attributes realistically
o Socialize with staff, peers, and family/friends
o Return to occupation or school activities
o Comply with antidepressant regimen
o Verbalize symptoms of a recurrence
V. 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 Disorders

 Bipolar
I disorder - 1 or more manic
or mixed episodes usually
accompanied by major depressive
episodes

 BipolarII disorder – 1 or more major

depressive episodes accompanied
by at least one hypomanic episode
Onset and clinical course

 Mean age for a first manic episode

occurs in a person’s teens
 Manic episodes typically begin
suddenly, with rapid escalation of
symptoms over a few days
 Mania: Briefer and end more
suddenly than depressive episodes
 Treatment and prognosis
 Medication
o Lithium: regular monitoring of serum lithium
levels is needed
✓ Action: Unknown (destroys dopa & norepi,
inhibits release, and decreases
postsynaptic receptors sensitivity)
✓ Can reduce cycling or eliminate manic
episodes
✓ Peak: 30min-4hrs (4-6hrs for SR)
✓ Onset of action: 5-14 days
✓ Half-life: 20-27hrs
✓ Crosses BBB & placenta; sweat & breast
milk
 Anticonvulsant drugs - used for their mood-
stabilizing effects: Tegretol, Depakote,
Lamictal, Topamax, Neurontin, and Klonopin
(a benzodiazepine)
✓Carbamazepine (Tegretol)
▪ 1st; threat: Agranulocytosis
▪ Check serum levels (Therapeutic levels: 4 – 12
µg/mL

✓ Valproic acid (Depakote)

▪ For simple absence and mixed seizures,
migraine prophylaxis, and mania
▪ Action: Unclear
▪ Therapeutic levels: 50 – 125 µg/mL
✓Gabapentin (Neurontin), lamotrigine (Lamictal) and topiramate
(Topamax)
▪ Used less frequently
▪ Therapeutic levels: Not established

✓Clonazepam
▪ Anticonvulsant & benzodiazepine
▪ Physiologic dependence may develop (long-term use)
▪ May be used with lithium or other anticonvulsant but not alone
Psychotherapy
oUseful in mildly
depressive or normal
portion of the bipolar
cycle; it is not useful
during acute manic
stages
Nursing Process:
Bipolar disorder
I. Assessment
 History
 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 tone,
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
II. Data analysis
 Nursing diagnoses may include:
o Risk for other-directed violence
o Risk for injury
o Imbalanced nutrition: less than body
requirements
o Ineffective coping
o Noncompliance
o Ineffective role performance
o Self-care deficit
o Chronic low self-esteem
o Disturbed sleep pattern
III. Outcomes
 The client will:
o Not injure self or others
o Establish a balance of rest, sleep, and activity
o Establish adequate nutrition, hydration, and
elimination
o Participate in self-care activities
o Evaluate personal qualities realistically
o Engage in socially appropriate, reality-based
interaction
o Verbalize knowledge of his or her illness and treatment
V. Evaluation includes:
 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
suicide
 Suicide - the intentional act of killing
oneself
 Suicidal ideation - thinking about
killing oneself
 Active suicidal ideation - when a person
thinks about and seeks ways to commit
suicide
 Passive suicidal ideation - when a person
thinks about wanting to die or wishes he or
she were dead but has no plans to cause
his or her death
I. Assessment
 Men commit suicide at 3 times the rate of women
 Women are 4 times more likely than men to attempt suicide
 Populations at risk
o Men, young women, Caucasians, adults older than 65, and
separated and divorced people
o Clients with psychiatric disorders
o Environmental factors include isolation, recent loss, lack of
social support, unemployment, critical life events, and
family history of depression or suicide
o Behavioral factors include impulsivity, erratic or
unexplained changes from usual behavior, and unstable
lifestyle
 Warnings of suicidal intent
 Risky behaviors
 Lethality assessment
 Does the client have a specific plan?
 Are the means available to carry out this plan?
 If the client carries out the plan, is it likely to be
lethal?
 Has the client made preparations for death?
 Where and when does the client intend to carry out
the plan?
 Is the intended time a special date or anniversary
that has meaning for the client?
II. Outcomes
 The client will:
o Be safe from harm self or others
o Engage in a therapeutic relationship
o Establish a no-suicide contract
o Create a list of positive attributes
o Generate, test, and evaluate
realistic plans to address underlying
issues
III. Intervention
 Use an authoritative role
 Provide a safe
environment
 Initiate a no-suicide
contract
 Create a support system
list
 Family response
 Significant others may feel guilty, angry,
ashamed, and sad
 Nurse’s response
 The nurse does not blame or act judgmentally
when asking about the details of a planned
suicide. Rather, the nurse uses a nonjudgmental
tone of voice and monitors his or her body
language and facial expressions to make sure not
to convey disgust or blame.
 Nurses must realize that no matter how competent
and caring interventions are, a few clients will still
commit suicide. A client’s suicide can be
devastating to the staff members who treated the
client.
Elder considerations

 Depression is common among the elderly and is

markedly increased when elders are medically ill
 Elders tend to have psychotic features,
particularly delusions, more frequently than
younger people with depression
 Suicide among persons over age 65 is doubled
compared with suicide rates of persons younger
than 65 years
 Elders are treated for depression with ECT more
frequently than younger persons
 Elder persons have decreased tolerance of the
side effects of antidepressant medications
Community-based care

 Nearly 40% of people who have been diagnosed

with a mood disorder do not receive treatment
 Contributing factors may include: stigma, lack of
understanding about life disruption, confusion
about treatment choices, other medical diagnosis
 Depression can be treated successfully in the
community by psychiatrists, psychiatric
advanced practice nurses, and primary care
physicians
 Bipolar disorder should be referred to a
psychiatrist or psychiatric advanced practice
nurse for treatment
Mental health promotion

 Education to address stressors contributing to

depressive illness
 Efforts to improve primary care treatment of
depression
 Having a partnership with a provider, having
a crisis or relapse prevention plan, creating a
social support network, and making needed
behavioral changes to promote health
 Prevention and early detection and treatment
for adolescents
 Screening for early detection of risk factors,
such as family strife, parental alcoholism or
mental illness, history of fighting, and access to
weapons in the home
Self-awareness issues

 Nurses and other staff members

need to deal with their own feelings
about suicide
 Depressed or manic clients can be
frustrating and require a lot of
energy to care for
 Keeping a written journal may help
deal with feelings; talking to
colleagues is often helpful