Mood Disorders

1
Mood Disorders

• Chapter 18

Medical ppt
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2
Impact of Mood Disorders

• Depression is number one leading cause of
  disability worldwide.
• Associated with high levels of impairment
• Often goes undetected and untreated
• Less than 50 receive treatment
• One-third of bipolar diagnosed

3
Key Concepts

• Mood
• Pervasive and sustained emotion that colors ones
  perception of the world and how one functions in
  it
• Mood Disorder
• Persisting or recurrent disturbances or
  alterations in mood that continually cause
  psychological stress and behavioral impairment
  over the years
• Alteration in mood, not thought

4
Observable Expressions of Mood

• Blunted
• Flat
• Inappropriate
• Labile
• Restricted or constricted

5
Primary Mood Disorders

• Bipolar
• Bipolar or manic depressive
• Manic
• Depressive (Unipolar)
• Unipolar
• Depression

6
Depressive Episode (DSM-IV-TR)

• Depressed mood (loss of interest for two weeks)
• Somatic complaints rather than sadness
• Increased irritability

7
Depressive DisordersClinical Course

• Dysthymic Disorder
• Milder, but more chronic form than MDD
• Major Depressive Disorder
• Progressive, recurrent illness
• Over time, episodes are more frequent, severe and
  longer in duration.
• Mean age of onset is about 40 years of age.
• An untreated episode lasts six to 13 months.
• Suicide is the most serious complication (10 to
  15).

8
Depression in Children

• Less likely to experience psychosis
• More likely to manifest symptoms of anxiety (fear
  of separation) and somatic symptoms
• Mood may be irritable, rather than sad.
• Suicide is a real risk, which peaks during
  mid-adolescents.
• Mortality from suicide increases steadily through
  the teens (third leading cause of death).

9
Depression in the Elderly

• Most do not meet criteria for depression
• 8 to 20 of older adults in community
• 37 in primary care setting
• Treatment successful in 60 to 80, but response
  slower
• Associated with chronic illness
• Highest suicide rate, especially over 85 years

10
Epidemiology

• Lifetime risk is 7 to 12 in men, 20 to 25 in
  women.
• Prevalence is unrelated to race.
• In some cultures, somatic symptoms predominate
  rather than sadness.

11
Risk Factors

• Prior episode of depression
• Family history of depressive disorder
• Lack of social support
• Stressful life event
• Current substance use
• Medical comorbidity

12
Major Depressive Disorder

• 17 of population will have a depressive episode
  in their lifetime.
• Age 25-44 years most affected
• Other ages increasing, especially in the elderly
• More common in women
• Expressed in culture differently
• Often occur with other disorders

13
Clinical Course of a Major Depressive Episode

• Usually develops over days - weeks
• Episode minimum of two weeks
• Untreated lasts six months or more, but then
  remits in most cases
• Recovery eight weeks of remission

14
Etiological Factors Biologic

• Genetics
• 1.5 to 3 times first-degree relative
• Alcoholism in biological parent
• Biochemical changes
• Serotonin, acetlycholine, norepinephrine,
  dopamine and GABA
• Alterations in HPA, HPT axes

15
Etiological Factors Psychological

• Psychodynamic
• Deprivation of love, loss
• Guilt
• Behavioral
• Reduction in pleasant activities
• Cognitive
• Irrational beliefs
• Distorted attitudes
• Developmental
• Premature loss of parent

16
Etiological Factors Social

• Family interactions
• Adverse life event
• Sexual, physical abuse

17
Goals of Interdisciplinary Treatment

• Reduce, remove symptoms.
• Restore occupational and psychosocial
  functioning.
• Reduce likelihood of relapse.
• Safety is a priority. Suicide assessment

18
Family Response

• Affects the whole family
• Often has financial hardships

19
Priority Care Issues

• Safety
• Risk for suicide

20
Nursing Management Biologic Domain Assessment

• Systems Review (CNS, endocrine, anemia, chronic
  pain, etc.)
• Physical exam palpation of the neck for thyroid
  abnormalities
• Appetite and weight
• Sleep disturbance
• Decreased energy

21
Nursing DiagnosisBiologic Domain

• Disturbed sleep pattern
• Imbalanced nutrition
• Fatigue
• Many other possible
• Failure to thrive
• Bathing/hygiene deficit
• Pain

22
Nursing InterventionsBiologic Domain

• Sleep hygiene
• Nutritional intervention
• Exercise
• Pharmacologic interventions
• Acute
• Continuation
• Maintenance
• Discontinuation

23
Psychopharmacologic Interventions

• Cyclic antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Fluoxetine, sertraline, fluvoxamine, paroxtine,
  citalopram, escitalopram
• Monoamine Oxidase Inhibitors (MAOIs)
• Phenelzine (Nardil), Tranylcypromine (Parnate)
• Atypical antidepressants
• Trazodone, bupropion, nefazodone, venalfaxine and
  mirtazapine

24
Pharmacological Nursing Interventions

• Monitoring and Administration
• Observe taking meds (acute phase)
• Vital signs (observe for orthostatic
  hypotension), lab reports
• Diet restrictions as appropriate

25
Side Effects SSRIs

• GI Distress
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• Low Anticholinergic
• Fluoxetine (Prozac)
• Fluoxetine (Luvox)

• Low sedation (All)
• Sexual Dysfunction (All)
• Orthostatic Hypotension
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)

26
Side Effects of TCAs Anticholinergic and
Antihistaminic

• Sedation and drowsiness
• Weight gain
• Hypotension
• Potentiation of CNS system drugs
• Blurred vision
• Dry mouth
• Constipation
• Urinary retention
• Sinus tachycardia
• Decreased memory

27
Monamine Oxidase Inhibitors

• Indications
• Depression with personality disorders, panic or
  social phobia
• Side Effects
• Hypertensive crisis/interaction with food
• Sudden, severe pounding or explosive headache
• Anticholinergic
• Elderly - sensitive to orthostatic hypotension
• Sexual dysfunction

28
Serotonin Syndrome

• More likely to be reported in patients taking two
  or more serotonin antagonists
• Usually mild, but can cause death
• Rapid onset (compared to NMS)
• Symptoms
• Mental status, agitation, myoclonus,
  hyperreflexia, fever, shivering, diaphoresis,
  ataxia and diarrhea
• Treatment
• Stop offending drug.
• Provide supportive treatment.
• Notify physician.

29
Drug-drug Interactions

• SSRIs inhibit 1A2 system. (Theophylline must be
  reduced.)
• Smoking induces 1A2 system smokers may need
  higher dosage.
• Fluoxetine and paroxetine inhibit 2D6. Can
  increase plasma levels of TCA, so avoid giving
  these meds with TCA.

30
Teaching Points

• If depression goes untreated or is inadequately
  treated, episodes become more frequent, severe
  and longer in duration.
• Importance of continuing medication
• Avoid St. Johns Wort.

31
Other Somatic Treatments

• Electroconvulsive therapy (See Ch. 9)
• Light therapy
• SAD
• Light - very bright, full-spectrum light, usually
  2,500 lux
• Immediately upon rising
• Exposure as little as 30 minutes and then
  increase
• Full effect after two weeks

32
Nursing ManagementAssessment Psychological

• Assessment scales self-report
• Mood and affect
• Thought content
• Suicidal behavior
• Cognition and memory

33
Nursing DiagnosesPsychological Domain

• Anxiety
• Decisional conflict
• Fatigue
• Grieving, dysfunctional
• Hopelessness
• Self-esteem, low
• Risk for suicide

34
Psychological Interventions

• Nurse-Patient Relationship
• Withdrawn patients have difficulty expressing
  feelings.
• Nurse should be warm and empathic, but not a
  cheerleader.
• See Therapeutic Dialogue.

35
Psychological Interventions

• Cognitive therapy - psychotherapy
• Behavior therapy
• Interpersonal therapy
• Marital and family therapy
• Group therapy
• Patient and family education

36
Nursing ManagementAssessment Social Domain

• Developmental history
• Family psychiatric history
• Quality of support system
• Role of substance abuse in relationships
• Work history
• Physical and sexual abuse

37
Social Nursing Interventions

• Patient and family education
• Medication adherence
• Marital and family therapy
• Group therapy

38
Continuum of Care

• Non-psychiatric setting
• Acute care hospitalization
• Outpatient
• See appendices for clinical pathways.

39
Manic Episode

• Feeling unusually high, euphoric, irritable for
  at least one week
• Four of the following
• Needing little sleep, great amount of energy
• Talking fast, others cant follow
• Racing thoughts
• Easily distracted
• Inflated feeling of power, greatness or
  importance
• Reckless behavior (money, sex, drugs)

40
Types of Bipolar

• Bipolar I
• Combinations of major depression and full manic
  episode
• Mixed episodes alternating between manic and
  depressive episodes
• Bipolar II
• Combination of major depression and hypomania
  (less severe form of mania)

41
Specifiers

• Mixed episodes criteria for both manic and
  depressive episodes met
• Hypomanic episode same as manic but less than
  four days
• Secondary mania caused by medical disorders or
  treatment
• Rapid cycling four or more episodes within 12
  months

42
Clinical Course

• Chronic cyclic disorder
• Later episodes occur more frequently than
  earlier.
• Interpersonal relationships and occupational
  functioning are affected.
• Patient may have rapid cycling.

43
Bipolar in Special Populations Children

• Recently recognized in children, it is
  characterized by intense rage episodes for up to
  two to three hours.
• Symptoms of bipolar disorder reflect the
  developmental level of the child.
• First contact with mental health agency is 5 to
  10 years old.
• Often have other psychiatric disorders

44
Bipolar DisorderElderly People

• More neurologic abnormalities and cognitive
  disturbances
• Late-onset bipolar disorder recently recognized
• Poorer prognosis because of comorbid medical
  conditions

45
Bipolar Disorder Epidemiology

• Prevalence - 0.4 to 1.6 of population
• Onset 21-30 years
• Men and women equally
• Ten to 15 of adolescents with recurrent
  depressive episodes develop bipolar I.
• Many comorbid disorders (substance abuse, in
  particular)

46
Gender and Ethnic/Cultural Differences

• No gender difference in incidence
• Gender differences reported in phenomenology,
  course and treatment.
• Females at greater risk for depression and rapid
  cycling

47
Etiology Biologic

• Neurobiologic theories
• Neurotransmitter hypotheses
• Chronobiologic theories
• Sensitization and kindling theory
• Genetic factors
• Bipolar I
• 4 to 24 first-degree relatives
• 80 concordance rate in identical twins
• Bipolar II
• 1 to 5 first-degree relatives
• Psychosocial factors
• Contribute to the timing of the disorder

48
Treatment Issues

• Complex issues treated by an interdisciplinary
  team
• Priority issues
• Safety from poor judgement and risk-taking
  behaviors
• Risk for suicide during depressive disorders
• Devastating to families, especially dealing with
  the consequences of impulsive behavior

49
Nursing ManagementBiologic Domain

• Assessment
• Evaluation of mania symptoms
• Sleep may be nonexistent.
• Irritability and physical exhaustion
• Eating habits, weight loss
• Lab studies - thyroid
• Hypersexual, risky behaviors
• Pharmacologic (may be triggered by
  antidepressant), alcohol use
• Nursing diagnosis
• Disturbed sleep pattern, sleep deprivation
• Imbalanced nutrition, hypothermia, deficit fluid
  balance

50
Nursing InterventionsBiologic Domain

• Physical care
• Pharmacologic
• Acute - symptom reduction and stabilization
• Continuation prevention of relapse
• Maintenance - sustained remission
• Discontinuation - very carefully, if at all
• Electroconvulsive therapy

51
Mood Stabilizers

• Lithium Carbonate (Eskalith)
• Mechanism of action unknown
• Blood levels 0.5-1.2
• Side effects GI, weight gain
• Divalproex Sodium (Depakote)
• Increase inhibitory transmitter, GABA
• Sedation, tremor
• Carbamazepine

52
Mood Stabilizers

• Lithium Carbonate
• Drug profile
• Lithium blood levels
• Divalproex sodium (Depokote) (Drug Profile)
• Carbamazapine (Tegretol)
• Baseline liver function tests and complete blood
  count
• Newer anticonvulsants
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)

53
Other Medications Used

• Antidepressants
• Used during depressed phases
• Can trigger manic phase
• Antipsychotics
• Psychosis
• Mania
• Dosage usually lower
• Benzodiazepines
• Short-term for agitation

54
Other Medication Issues

• Monitoring important
• Side effect monitoring important because taking
  more than one medication
• Drug-drug interactions
• Especially, alcohol, drugs, OTC and herbal
  supplements
• Teaching points
• Lithium (Change in salt intake can affect
  lithium.)
• Most of these medications cause weight gain.
• Check before using OTC.

55
Nursing Management Psychological Domain

• Assessment
• Mood
• Cognitive
• Thought Disturbances
• Stress and coping factors
• Risk assessment

• Nursing Diagnosis
• Disturbed sensory perception
• Disturbed thought processes
• Defensive coping
• Risk for suicide
• Risk for violence
• Ineffective coping

56
Nursing ManagementSocial Domain

• Assessment
• Social and occupational changes
• Cultural views of mental illness
• Nursing Diagnosis
• Ineffective role performance
• Interrupted family processes
• Impaired social interaction
• Impaired parenting
• Compromised family coping

57
Nursing Interventions Social Domain

• Protect from over-extending boundaries
• Support groups
• Family interventions
• Marital and family interventions

58
Continuum of Care

• Inpatient management short-term
• Intensive outpatient programs
• Frequent office visits
• Crisis telephone calls
• Family session or -

Medical ppt
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