Chapter 15 Mood Disorders

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Chapter 15 Mood Disorders
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• Mood Disorders
• Pervasive alterations in emotions that are
  manifested by depression, mania, or both, and
  interfere with the persons ability to live life

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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

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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

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Related Disorders (contd)

• Seasonal affective disorder (SAD)
• Postpartum or maternity blues
• Postpartum depression
• Postpartum psychosis

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Etiology

• Biologic theories
• Genetics
• Neurochemical theories
• Neuroendocrine or hormonal fluctuations

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Etiology (contd)

• 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

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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

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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
• 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

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• 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

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• 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

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Application of the Nursing Process Major
Depressive Disorder

• Assessment
• History the clients 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

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Application of the Nursing Process Major
Depressive Disorder (contd)

• Assessment (contd)
• 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

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Application of the Nursing Process Major
Depressive Disorder (contd)

• 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

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Application of the Nursing Process Major
Depressive Disorder (contd)

• 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

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Application of the Nursing Process Major
Depressive Disorder (contd)

• Intervention
• Providing for the clients 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

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Application of the Nursing Process Major
Depressive Disorder (contd)

• 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?

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Bipolar 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

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Bipolar 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

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• 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

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Application of the Nursing Process Bipolar
Disorder

• Assessment
• 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

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Application of the Nursing Process Bipolar
Disorder (contd)

• Assessment (contd)
• 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

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Application of the Nursing Process Bipolar
Disorder (contd)

• Assessment (contd)
• 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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Application of the Nursing Process Bipolar
Disorder (contd)

• 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

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Application of the Nursing Process Bipolar
Disorder (contd)

• 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

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Application of the Nursing Process Bipolar
Disorder (contd)

• Intervention
• Providing for safety of client and others
• Meeting physiologic needs
• Providing therapeutic communication
• Promoting appropriate behaviors
• Managing medications
• Providing client and family teaching

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Application of the Nursing Process Bipolar
Disorder (contd)

• Evaluation
• Safety issues
• Comparison of mood and affect between start of
  treatment and present
• Adherence to treatment regimen of medication and
  psychotherapy
• Changes in clients perception of quality of life
• Achievement of specific goals of treatment
  including new coping methods

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Suicide

• Assessment
• 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

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• 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?

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• 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

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• Intervention
• Using an authoritative role
• Providing a safe environment
• Initiating a no-suicide contract
• Creating a support system list

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• Family Response
• Significant others may feel guilty, angry,
  ashamed, and sad
• Nurses 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 clients suicide can be
  devastating to the staff members who treated the
  client

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Legal and Ethical Considerations

• Often nurses must care for terminally or
  chronically ill people with a poor quality of
  life
• The nurses role is to provide supportive care
  for clients and family

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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

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Mental Health Promotion

• Education to address stressors contributing to
  depressive illness
• Promotion of factors reducing suicide risk in
  adolescents (close parentchild 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

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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