Mood Disorders

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Mood Disorders

• Terri Lynch, RN, MSN, BC

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Assessment

• First step in the nursing process
• Often referred to as a psychosocial assessment
• Includes a mental status exam

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Factors Influencing Assessment

• Client participation/feedback
• Clients health status
• Clients previous experiences
• Clients ability to understand
• Nurses attitude and approach

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Conducting An Interview

• Environment
• Input from family, friends, or caregivers
• How to phrase questions

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Assessment Toolsand Psychological Tests

• Folstein Mini-Mental State Exam (MMSE)
• Minnesota Multiphasic Personality Inventory
  (MMPI)_
  
• Global Assessment of Functioning (GAF) Scale

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Diagnostic and Statistical Manual of Mental
Disorders (4th ed)

• Axis I
• Axis II
• Axis III
• Axis IV
• Axis V

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Culture

• Has a strong influence on health beliefs and
  practices
  
• Ethnic groups respond differently to medications

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Mood Disorders

• Pervasive alterations in a persons emotions
• Manifested by depression or mania
• Interfere with ones life
• Most common psychiatric diagnoses associated with
  suicide
  
• Two prevalent periods of seasonal involvement
• 25 will experience some degree of mood disorder

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Etiology of Mood Disorders

• Genetic theories
• Neurochemical theories
• Neuroendocrine influences
• Psychodynamic theories

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Major Categories ofMood Disorders

• Depressive disorders
• Bipolar disorders

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Other Mood Disorders

• Dysthymic disorder
• Cyclothymic disorder
• Seasonal affective disorder (SAD)
• Postpartum depression
• Postpartum psychosis

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Major Depressive Disorder

• Characterized by a loss of interest or pleasure
  in usual activities for at least 2 weeks
  (anhedonia)
  
• 4 of the following symptoms must be present
• Change in appetite or weight, sleep, or activity
• Decreased energy, tiredness
• Feelings of worthlessness or guilt
• Difficulty thinking, concentrating or making
  decisions
  
• Hopelessness, helplessness or suicide ideation

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• Twice as common in women
• Increased incidence if first degree relative has
  disorder
  
• 50-60 recurrence rate
• Can last 6-24 months if untreated
• Symptoms vary from mild to severe and are related
  to persons sense of helplessness/ hopelessness
  

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Treatment Modalities For Depression

• Psychotherapy
• Behavior therapy
• Cognitive therapy
• Interpersonal therapy

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Psychopharmacologic Treatment for Depression

• Different ethnic groups respond differently
• Elderly clients often need decreased dosages
• Increase efficacy of neurotransmitters n by
  postsynaptic receptors in brain
  

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• Tricyclic antidepressants (TCA)
• Some have sedative properties
• Block uptake of neurotransmitters
• Full response may take 2-4 weeks of therapy
• Should be slowly withdrawn
• Examples amitriptyline (Elavil), imipramine
  (Tofranil), doxepin (Sinequan), nortriptyline
  (Pamelor)

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• Side effects sedation, dizziness, orthostatic
  hypotension, anticholinergic effects ,
  dysrhythmias, seizures
  
• DO NOT administer with monamine oxidase (MAO)
  inhibitors
  
• Contraindicated in severe liver impairment and
  acute recovery phase of MI
  
• Use cautiously with BPH and glaucoma

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• Selective serotonin re-uptake inhibitors (SSRIs)
  or selective serotonin-norepinephrine reuptake
  inhibitors (SNRIs)
  
• Block uptake of serotonin and/or norepinephrine
  into the nerve terminals
  
• More frequently used than TCA due to fewer side
  effects
  
• Have many different uses
• Examples escitalopram (Lexapro), fluoxetine
  (Prozac), sertaline (Zoloft), paroxetine (Paxil),
  citalopram (Celexa), duloxetine (Cymbalta)

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• Side effects GI distress, insomnia, H/A, sexual
  dysfunction
  
• Clinical response takes 2 4 weeks of therapy
• Reduce dosage for older adults
• Tagamet (cimetidine) will increase serum
  concentrations
  
• DO NOT administer with MAO inhibitors and use
  with caution with triptans

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Symptoms of Serotonin Syndrome

• Changes in mental status
• Confusion
• Agitation, restlessness
• Weakness
• Tremors, myoclonic jerks
• Nausea, vomiting, diarrhea
• Tachypnea
• Tachycardia
• Hyperthermia
• Labile BP
• Death

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• Monamine oxidase (MAO) inhibitors
• Inhibit enzyme that inactivates epinephrine,
  norepinephrine, dopamine and serotonin
  
• Increase accumulation of neurotransmitters and
  relieves symptoms of depression
  
• May take 2-4 weeks before therapeutic effects
• Examples Parnate (tranycypromine), Marplan
  (isocarboxazide), Nardil (phenalzine)
  

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• Side effects daytime drowsiness, insomnia,
  weight gain, dry mouth, orthostatic hypotension,
  sexual dysfunction, HTN crisis
  
• Exercise extreme caution with surgery
• DO NOT administer concurrently with other
  antidepressants
  
• Avoid any stimulants, sympathomimetics, Demerol

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• Avoid foods containing tyramine may cause HTN
  crisis. Foods containing tyramine
  
• Aged cheese, sour cream, yogurt
• Bananas, raisins
• Red wines, beer,
• Smoked, aged and processed meats
• Soy sauce, MSG, yeast products

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Symptoms of HTN Crisis

• Occipital HA
• HTN
• N/V
• Chills, diaphoresis
• Restlessness
• Agitation
• Fever
• Dilated pupils
• Cerebral hemorrhage
• Death

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• Atypical antidepressants
• Used when there are side effects or inadequate
  response from other drugs
  
• Affect uptake of neurotransmittors
• Examples bupropion (Wellbutrin), nefazodone
  (Serezone), nirtazapine (Remeron)
  
• Side effects agitation, insomnia, drowsiness,
  HA, seizures, tachycardia, dizziness
  

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Electroconvulsive Therapy for Depression

• May be considered if antidepressants are
  ineffective, client actively suicidal, pregnant
  women
  
• Induction of grand mal seizure
• Electrical stimulation of the brain increases
  neurotransmitters
  

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• Side effects temporary memory loss,
• confusion, H/A, fatigue, MI, CVA, cardiac
  arrest, respiratory arrest
  
• Client given short acting anesthetic (Pentothal,
  Brevital) and muscle relaxant (Anectine) IV
  
• Receive 6 15 treatments, 3 times weekly

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Assessment Findings with Major Depressive Disorder

• Posture slouched, minimal eye contact
• Psychomotor retardation
• Latency of response
• Psychomotor agitation
• Mood is of helplessness or hopelessness
• Anhedonia
• Flat affect, social isolation

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• Negative and pessimistic thinking,
  self-deprecating, ruminating
  
• Difficulty concentrating or making decisions
• Suicidal ideation
• Weight loss, constipation, decreased libido,
  impotence
  
• Sleep disturbances
• Difficulty fulfilling roles and responsibilities
• Neglect of personal hygiene

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Nursing Diagnoses for Depression

• Risk for suicide
• Dysfunctional grieving
• Low self esteem
• Disturbed sleep patterns
• Self care deficit
• Social isolation
• Ineffective coping

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Outcomes

• Depend on manifestation of depression
• Nursing diagnoses identified
• Priority is that the client will not injure self

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Nursing Interventions With Depression

• Determine is client is suicidal
• Ask Have you thought of harming yourself in any
  way?
  
• Create a safe environment
• Formulate a contract
• Maintain close observation

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• Promote a therapeutic relationship
• Spend non-demanding time with client
• Be kind and hopeful
• Focus on strengths an accomplishments
• Encourage verbalization of emotions
• Be accepting and nonjudgmental
• Promote completion of ADLs
• Help client identify resources

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• Assist with ECT as ordered
• NPO after MN sign informed consent
• Remove hairpins, dentures
• Ensure client wears loose clothing
• Administer pre-procedure drugs half to one hour
  before procedure (Atropine or Robinul IM)
  
• Check VS before and after procedure
• Monitor O2 saturations
• Reorient client and assure memory loss temporary
• Administer mild analgesics for H/A

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Client and Family Teaching

• Depression is an illness
• Management of medication regimen and side
  effects
  
• Do not drink alcohol or take other meds without
  physicians approval
  
• Instruct to rise slowly from lying to standing
• If develop symptoms opposite of desired effect,
  hold medication and notify MD
  
• Take TCA in evening
• If inability to void, notify MD immediately

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• If mouth dry use chewing gum or sugarless hard
  candy
  
• If nausea occurs, take med with food
• Report symptoms of sore throat, fever, easy
  bruising
  
• Do not drive or operate dangerous machinery
• Do not stop taking abruptly
• Carry list of meds and dosages at all times

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Bipolar Disorder

• Characterized by mood swings from profound
  depression to extreme euphoria with periods of
  normalcy
  
• Delusions or hallucinations may be present

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• Disturbance causes impairment in functioning
• Mean age for first manic episode is in early
  20s
  
• Occurs equally among men and women
• More common in educated people

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Types of Bipolar Disorders

• Bipolar I full syndrome of mania and at least
  one episode of depression
  
• Bipolar II recurrent bouts of major depression
  with at least one episode of hypomania
  
• Bipolar mixed cycles alternate between mania,
  normalcy, and depression

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Diagnosis of Mania

• Heightened, grandiose, or agitated mood
• Exaggerated self-esteem
• Sleeplessness
• Pressured speech

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• Flight of ideas
• Reduced ability to filter out extraneous noises
  or surrounding activities
  
• Increased activities with increased energy
• Multiple, grandiose, high-risk activities, using
  poor judgment
  

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Treatment For Bipolar Disorders

• Psychotherapy
• Group therapy
• Cognitive therapy
• ECT
• Psychopharmacotherapy

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Psychopharmacotherapyfor Bipolar Disorders(Mood
Stabilizers)

• Lithium carbonate (Lithobid, Eskalith)
• Metallic salt which interferes with Na transport
  in nerve and muscle cells
  
• Increases breakdown of catecholamines
• 95 eliminated by kidneys
• Contraindicated in cardiovascular disease, renal
  disease and pregnancy

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• Peak of action may take 5 14 days
• Side effects tremor, H/A, drowsiness,
  dizziness, dry mouth, polydipsia, anorexia,
  vomiting, diarrhea, polyuria, weight gain,
  decreased thyroid function
• Therapeutic level 1.0 1.5 mEq/L for acute
  mania and 0.5 1.0 mEq/L for maintenance
  

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• Check blood levels weekly then every 1-2 months.
• Draw levels 8 12 hours after last dose
• Toxicity may occur at therapeutic levels
• Lithium toxicity - 1.5mEq/L. Severe diarrhea,
  persistent N/V, tinnitus, blurred vision,
  ataxia, slurred speech, confusion, seizures,
  coma, cardiac arrest
• Diuretics, NSAIDS and probenicid decrease renal
  clearance
  
• Can cause fetal abnormalities

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• Antipsychotics
• May be given initially for the hyperactivity,
  agitation and psychotic behavior
  
• Examples Thorazine (chlorpromazine), Haldol
  (haloperidol)
  
• Side effects extrapyramidal , anticholinergic,
  tardive dyskinesia, weight gain
  
• Zypreza (Olanzapine) and Risperdol (resperidone)
  may be used in milder cases
  
• Abilify (aripiprazole) may be used in mania. May
  cause hyperglycemia, weight gain, prolonged QT
  intervals.

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• Anticonvulsants
• Some are effective in clients who do not respond
  well to lithium
  
• Examples Tegretol (carbamazepine), Depakote
  (valproic acid), Klonopin (clonazepam), Lamictal
  (lamotrigine)
  
• Must monitor blood levels, liver enzymes and CBC

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Assessment Findings Of Client With Mania

• Hyperactivity to the point of exhaustion
• Flamboyant dress, excessive makeup or jewelry
• Euphoria, irritable
• Grandiosity or exaggerated self esteem
• Flight of ideas

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• Pressured speech
• Easily distracted
• Poor inpulse control
• Sexually uninhibited and acting out
• Hostility and aggression toward others
• Delusions and hallucinations in acute mania

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Nursing Diagnoses For Bipolar Disorders

• Risk for injury
• Risk for violence
• Imbalanced nutrition less than body
  requirements
  
• Disturbed thought processes
• Disturbed sleep patterns
• Impaired social interactions

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Nursing Interventions For Manic Client

• Provide a safe environment
• Set limits
• Provide physical activities
• Use distraction and redirect inappropriate
  behavior to physical activity
  
• Ignore attempts to argue, bargain or charm

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• Use clear, simple sentences
• Provide finger foods that are nutritious, high
  protein and high calorie
  
• Have juice and fluids available
• Monitor lab data
• Monitor for lithium side effects and toxicity

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• Teaching regarding medications
• Encourage client to keep follow-up appointments
• Check with health care provider before taking OTC
  preparations
  
• Client taking Lithium should
• Drink adequate H2O
• Increase fluids intake in hot weather
• Maintain constant salt intake
• Avoid diuretics
• Hold drug if signs of toxicity occur and notify
  MD
  

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Expected Outcomes For Client With Mood Disorders

• Safe and exhibits injury-free behaviors
• Receive adequate rest and sleep
• Maintain adequate intake of fluids and nutrients
• Independently carry out ADLs
• Participate in treatment and planned activities
• Comply with medication regimen and treatment
• Gain self awareness about potentially dangerous
  situations