Psych Chapter 15

Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 15
Mood Disorders
Chapter 15
Mood Disorders
Pervasive alterations in emotions
manifested by depression, mania, or
both, that interfere with the persons
ability to live life
Mood Disorders Mood Disorders
Categories of Mood Disorders Categories of Mood Disorders
- 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 Disorders Related Disorders
- Dysthymia: sadness and low energy 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
Etiology Etiology
-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 Considerations 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 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 4 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
- 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
Treatment and Prognosis Treatment and Prognosis
- 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
- The client will have some short-term memory
impairment
Treatment and Prognosis (cont'd) Treatment and Prognosis (cont'd)
- Psychotherapy in conjunction with medication is
considered most effective treatment; useful
psychotherapies include behavioral, cognitive,
and interpersonal
- Investigational treatments
- Transcranial magnetic stimulation (TMS)
- Magnetic seizure therapy
- Deep brain stimulation
- Vagal nerve stimulation
Treatment and Prognosis (cont'd) Treatment and Prognosis (cont'd)
Application of the Nursing Process:
Major Depressive Disorder
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, 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
- 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,
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
Major Depressive Disorder (cont'd)
- 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
- 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
- Intervention
- Provide for the clients safety and the safety of
others
- Promote a therapeutic relationship
- Promote activities of daily living and physical care
- Use therapeutic communication
- Manage medications
- Provide client and family teaching
Evaluation 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 Disorder
Onset and Clinical Course Onset and Clinical Course
-Mean age for a first manic episode is
the early 20s
-Manic episodes typically begin
suddenly, with rapid escalation of
symptoms over a few days
-They tend to be briefer and to end
more suddenly than depressive
episodes
Bipolar Disorder Bipolar Disorder
- Diagnosis of a manic episode or mania requires at least 1 week
of unusual and incessantly heightened, grandiose, or agitated
mood in addition to 3 or more of the following symptoms:
- Exaggerated self-esteem
- Sleeplessness
- Pressured speech
- Flight of ideas
- Reduced ability to filter extraneous stimuli
- Distractibility
- Increased activities with increased energy
- Multiple, grandiose, high-risk activities involving poor
judgment and severe consequences, such as spending
sprees, sex with strangers, and impulsive investments
- Treatment and prognosis
- Medication
o Lithium: regular monitoring of serum
lithium levels is needed
o Anticonvulsant drugs are used for their
mood-stabilizing effects: Tegretol,
Depakote, Lamictal, Topamax, Neurontin,
and Klonopin (a benzodiazepine)
- Psychotherapy
oUseful in mildly depressive or normal portion
of the bipolar cycle; it is not useful during
acute manic stages
Bipolar Disorder (cont'd) Bipolar Disorder (cont'd)
Bipolar Disorder
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, anger, verbally aggressiveness,
sarcasm, irritability
- 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
Bipolar Disorder (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
- 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
- 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
- Intervention
- Provide for safety of client and others
- Meet physiologic needs
- Provide therapeutic communication
- Promote appropriate behaviors
- Manage medications
- Provide client and family teaching
- 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 clients perception of quality of life
- Achievement of specific goals of treatment
including new coping methods
Suicide Suicide
- 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?
Suicide (cont'd) Suicide (cont'd)
- 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
- 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
- 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.
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 nurses 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 the side
effects of antidepressant medications
Community-Based Care 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 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 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

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Copyright 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

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