Download Chapter 15: Mood Disorders

Chapter 15: Mood Disorders
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mood Disorders
• Affective disorders
– Pervasive alterations in emotions manifested by
depression, mania, or both
– Interference with life; long-term sadness,
agitation, or elation
• Individuals with mood disorders throughout
history
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Mood Disorders (cont’d)
• Most common psychiatric diagnosis
associated with suicide
– Depression one of the most important risk
factors for it
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Categories of Mood Disorders
• Major depressive disorder
• Bipolar disorder
• Related disorders
– Dysthymic disorder
– Cyclothymic disorder
– Substance-induced mood disorder; mood
disorder due to general medical condition
– Seasonal affective disorder
– Postpartum blues, depression, psychosis
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Etiology
• Biologic theories
– Genetic theories
– Neurochemical theories: serotonin,
norepinephrine; possibly acetylcholine and
dopamine
– Neuroendocrine influences: hormones
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Etiology (cont’d)
• Psychodynamic theories
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Freud: self-deprecation;
Bibring: ideal ego
Jacobson: superego over powerless ego
Mania: defense against underlying depression
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Cultural Considerations
• Masking of depression by other behaviors
considered age-appropriate
– School phobia, hyperactivity, learning disorders,
failing grades, antisocial behaviors
– Substance abuse, gangs, risk behaviors, eating
disorders, compulsive behaviors
• Somatic complaints
– Major manifestation among cultures that avoid
verbalizing emotions
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Question
• Tell whether the following statement is true
or false:
• Depression is most commonly associated
with suicide.
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Answer
• True
• Depression is considered the most common
diagnosis that results in suicide.
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Major Depressive Disorder
• Incidence: women to men 2:1
– Decreases with age in women; increases with
age in men; highest in single, divorced people
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Major Depressive Disorder (cont’d)
• Symptoms: sad mood, lack of interest in life
activities (2 weeks or more) 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
• Symptoms range from mild to severe
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Psychopharmacology
• Selective serotonin reuptake inhibitors (Table
15.1)
• Cyclic antidepressants (Table 15.2)
• Atypical antidepressants (Table 15.3)
• Monoamine oxidase inhibitors (MAOIs)
(Table 15.4)
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Other Medical Treatments and
Psychotherapy
• Electroconvulsive therapy (ECT)
• Psychotherapy (combined with medications)
– Interpersonal therapy: relationship difficulties
– Behavior therapy: reinforcement of positive
interactions
– Cognitive therapy: correction of cognitive
distortions (Table 15.5)
• Investigational treatments
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Major Depressive Disorder and Nursing
Process Application
• Assessment
– History
– General appearance, motor behavior
(psychomotor retardation, latency of response,
psychomotor agitation)
– Mood, affect (anhedonia)
– Thought process, content (rumination, suicide)
– Sensorium, intellectual processes (impaired
memory)
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Major Depressive Disorder and Nursing
Process Application (cont’d)
• Assessment (cont’d)
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Judgment, insight (impairment)
Self-concept (worthlessness)
Roles, relationships (difficulty in this area)
Physiologic, self-care considerations
Depression rating scales
• Self-rating scales: Zung, Beck
• Clinician rating scale: Hamilton Rating Scale
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Question
• Tell whether the following statement is true
or false:
• Clients with depression often exhibit
anhedonia.
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Answer
• True
• Anhedonia refers to the loss of any sense of
pleasure from activities that a person
formerly enjoyed. This is a manifestation of
depression.
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Major Depressive Disorder and Nursing
Process Application (cont’d)
• Data analysis
• Outcome identification
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Major Depressive Disorder and Nursing
Process Application (cont’d)
• Intervention
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Providing for safety (suicide precautions)
Promoting therapeutic relationship
Promoting ADLs, physical care
Using therapeutic communication
Managing medications
Client, family teaching
• Evaluation
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Bipolar Disorder
• Extreme mood swings from mania to
depression (Figure 15.1)
• Second only to major depression as cause of
worldwide disability
• Onset usually in early 20s
• Manic episodes begin suddenly, last from a
few weeks to several months
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Treatment
• Psychopharmacology
– Antimanic agent: lithium
– Anticonvulsant agent used as mood stabilizer
(Table 15.7)
– Agents helpful in reducing manic behavior,
protecting against bipolar depressive cycles
• Psychotherapy useful in mildly depressive or
normal portion of bipolar cycle
– Not useful during manic stages
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Bipolar Disorder and Nursing Process
Application
• Assessment
– History
– General appearance, behavior (pressured
speech, flamboyancy, sexually suggestive)
– Mood, affect (euphoric, grandiose)
– Thought process, content (circumstantiality,
tangentiality)
– Sensorium, intellectual processes (disoriented to
time)
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Bipolar Disorder and Nursing Process
Application (cont’d)
• Assessment (cont’d)
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Judgment, insight
Self-concept (exaggerated)
Roles, relationships (labile emotions)
Physiologic, self-care considerations
• Data analysis
• Outcome identification
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Question
• Which of the following would be most
appropriate for the treatment of mania
associated with bipolar disorder?
A. Lithium
B. Fluoxetine
C. Citalopram
D. Venlafaxine
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Answer
A. Lithium
• Lithium is an antimanic agent, which would
be most appropriate for treating a manic
client with bipolar disorder.
– Fluoxetine, citalopram, and venlafaxine are
antidepressants.
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Bipolar Disorder and Nursing Process
Application (cont’d)
• Intervention
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Providing for safety
Meeting physiologic needs
Providing therapeutic communication
Promoting appropriate behaviors
Managing medications (Table 15.8)
Providing client, family teaching
• Evaluation
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Suicide
• Intentional act of killing oneself
• Suicidal ideation: thinking about killing
oneself
• Warning signs: risk for suicide (Box 15.2)
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Suicide (cont’d)
• Assessment:
– Previous suicide attempts (first 2 years after –
highest risk period, especially first 3 months);
relative who committed suicide
– Warnings of suicidal intent (Box 15.3); risky
behavior
– Lethality assessment
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Suicide (cont’d)
• Outcome identification
• Intervention
– Authoritative role
– Safe environment: suicide precautions; no
suicide/no self-harm contract
– Support system list
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Suicide (cont’d)
• Family response
– Suicide as ultimate rejection of family, friends
– Families react with guilt, shame, anger
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Suicide (cont’d)
• Nurse’s response
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Need for unconditional positive regard for person
Avoidance of client blame
Nonjudgmental approach, tone
Belief that one person can make a difference in
another’s life
– Possible devastation of staff if client commits
suicide
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Legal and Ethical Considerations
• Assisted suicide as topic of national legal,
ethical debate (Oregon first state to adopt
assisted suicide into law)
• Nurse often cares for terminally or
chronically ill people with poor quality of life
• Nurse’s role to provide supportive care for
clients, family as they work through
decision-making process
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Question
• Tell whether the following statement is true
or false:
• When dealing with a client who is suicidal,
the nurse needs to assume a dependent role.
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Answer
• False
• When dealing with a client who is suicidal,
the nurse must take an authoritative role.
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Elder Considerations
• Depression common among the elderly;
marked increase when elders are medically
ill
– Psychotic features common
– Increased intolerance to medications
– ECT more commonly used for treatment; more
rapid response
• Suicide increased among elderly
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Community-Based Care
• Nurses as first health care professionals to
recognize behaviors consistent with mood
disorders
• Successful treatment of depression in
community by psychiatrists, psychiatric
advanced practice nurses, primary care
physicians
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Community-Based Care (cont’d)
• Bipolar disorder: referral to psychiatrist or
psychiatric advanced practice nurse for
treatment
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Mental Health Promotion
• Education to address stressors contributing
to depressive illness
• Efforts to improve primary care treatment of
depression
• Prevention and early detection, treatment for
adolescents
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Mental Health Promotion (cont’d)
• Screening for early detection of risk factors
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Family strife
Parental alcoholism or mental illness
History of fighting
Access to weapons in the home
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Self-Awareness Issues
• Importance of dealing with own feelings
about suicide
• Frustration possible when working with
depressed or manic clients
• Exhaustion possible when working with
manic clients
• Journaling to help deal with feelings; talking
with colleagues often helpful
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