chapter 15 mood disorders

Chapter 15 Mood Disorders

Chapter 15 Mood Disorders

Mood Disorders

Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to live life

CategoriesCategories

•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 DisordersRelated 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

Related Disorders (cont’d)Related Disorders (cont’d)

• Seasonal affective disorder (SAD)

• Postpartum or “maternity” blues

• Postpartum depression

• Postpartum psychosis

EtiologyEtiology

Biologic theories

•Genetics

•Neurochemical theories

•Neuroendocrine or hormonal fluctuations

Etiology (cont’d)Etiology (cont’d)

Psychodynamic theories• Self-reproach to anger turned inward

• Inability to achieve personal ideals

• Powerless ego

• Manic episodes are a “defense” against depression

• Reaction to a distressing life experience

• Rejecting or unloving parents

• Resulting from specific cognitive distortions

Cultural ConsiderationsCultural 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 DisorderMajor 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

– 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

Application of the Nursing Process: Major Depressive DisorderApplication of the Nursing Process: Major Depressive DisorderAssessment• 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

Assessment (cont’d)• 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

Application of the Nursing Process: Major Depressive Disorder (cont’d)Application of the Nursing Process: Major Depressive Disorder (cont’d)

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

Application of the Nursing Process: Major Depressive Disorder (cont’d)Application of the Nursing Process: Major Depressive Disorder (cont’d)

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

Application of the Nursing Process: Major Depressive Disorder (cont’d)Application of the Nursing Process: Major Depressive Disorder (cont’d)

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

Application of the Nursing Process: Major Depressive Disorder (cont’d)Application of the Nursing Process: Major Depressive Disorder (cont’d)

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?

Application of the Nursing Process: Major Depressive Disorder (cont’d)Application of the Nursing Process: Major Depressive Disorder (cont’d)

Bipolar DisorderBipolar Disorder

•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

Bipolar DisorderBipolar Disorder• 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

Application of the Nursing Process: Bipolar DisorderApplication of the Nursing Process: Bipolar DisorderAssessment

• 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

Assessment (cont’d)• 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

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

Assessment (cont’d)

• 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

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

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

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

Outcomes

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

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

Intervention

• Providing for safety of client and others

• Meeting physiologic needs

• Providing therapeutic communication

• Promoting appropriate behaviors

• Managing medications

• Providing client and family teaching

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

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

Application of the Nursing Process: Bipolar Disorder (cont’d)Application of the Nursing Process: Bipolar Disorder (cont’d)

SuicideSuicideAssessment

Men commit suicide three times the rate of women

Women are four times more likely than men to attempt suicide

Populations at risk

• Men, young women, Caucasians, adults older than 65, and separated and divorced people

• Clients with psychiatric disorders

Environmental factors include isolation, recent loss, lack of social support, unemployment, critical life events, and family history of depression or suicide

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?

Outcomes

The client will:

• Not injure self or others

• Engage in a therapeutic relationship

• Establish a no-suicide contract

• Create a list of positive attributes

• Generate, test, and evaluate realistic plans to address underlying issues

Intervention

•Using an authoritative role

•Providing a safe environment

•Initiating a no-suicide contract

•Creating 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

Legal and Ethical Considerations Legal and Ethical Considerations

•Often nurses must care for terminally or chronically ill people with a poor quality of life

•The nurse’s role is to provide supportive care for clients and family

Elder Considerations 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 side effects of antidepressant medications

Mental Health Promotion Mental Health Promotion

• Education to address stressors contributing to depressive illness

• Promotion of factors reducing suicide risk in adolescents (close parent–child relationships, academic achievement, family life stability, and connectedness with peers and others outside the family)

• 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 IssuesSelf-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