MOOD DISORDERMOOD DISORDER

Prepared by:Prepared by:

PROF. JUMAR T. UBALDE,RN,MAN,Ed.DPROF. JUMAR T. UBALDE,RN,MAN,Ed.D

Mood disorders are among the most Mood disorders are among the most common psychiatric disorders, so students common psychiatric disorders, so students are likely to encounter persons with are likely to encounter persons with depression or bipolar disorder during their depression or bipolar disorder during their clinical experience. clinical experience.

Clients whose symptoms are moderate or Clients whose symptoms are moderate or those who have begun to respond to those who have begun to respond to treatment are often a better choice.treatment are often a better choice.

This chapter provides an overview of This chapter provides an overview of mood disorders, categories of mood mood disorders, categories of mood disorders, and current theories of etiology. disorders, and current theories of etiology. Symptoms, treatment, and application of Symptoms, treatment, and application of the nursing process are presented in the nursing process are presented in depth for major depressive disorder and depth for major depressive disorder and bipolar disorder. A sample care plan for a bipolar disorder. A sample care plan for a client with depression is included. client with depression is included.

The topic of suicide is described in terms of The topic of suicide is described in terms of populations at risk, interventions, responses populations at risk, interventions, responses of the family and the nurse, legal and of the family and the nurse, legal and ethical considerations, and community care. ethical considerations, and community care. Self-awareness issues for the nurse are Self-awareness issues for the nurse are included for clients who are depressed, included for clients who are depressed, manic, and/or suicidal.manic, and/or suicidal.

CURRENT ISSUES RELATED TO THE TOPICCURRENT ISSUES RELATED TO THE TOPIC Euthanasia and assisted suicide are hotly Euthanasia and assisted suicide are hotly

debated topics in our society. Should either be debated topics in our society. Should either be legal? Under what circumstances? How should legal? Under what circumstances? How should these issues be decided? these issues be decided?

Some people struggle with the idea of whether Some people struggle with the idea of whether suicide can ever be the decision of a rational suicide can ever be the decision of a rational person or whether being suicidal is always a sign person or whether being suicidal is always a sign of mental illness. of mental illness.

Suicide rates remain high for adolescents and the Suicide rates remain high for adolescents and the elderly (over age 80). elderly (over age 80).

Is that a sign of despair and hopelessness? What Is that a sign of despair and hopelessness? What is society’s response to these two populations?is society’s response to these two populations?

It can be frustrating to try to engage a It can be frustrating to try to engage a severely depressed client in therapeutic severely depressed client in therapeutic communication, and it can be frightening to communication, and it can be frightening to encounter the client in a severe manic encounter the client in a severe manic state.state.

Therefore, it may be best to avoid Therefore, it may be best to avoid assigning students to severely ill clients.assigning students to severely ill clients.

Mood DisordersMood DisordersPervasive alterations in emotions Pervasive alterations in emotions that are manifested by that are manifested by depression, mania, or both, and depression, mania, or both, and interfere with the person’s ability interfere with the person’s ability to live lifeto live life

CategoriesCategories Major depression: 2 or more Major depression: 2 or more

weeks of sad mood, lack of weeks of sad mood, lack of interest in life activities, and other interest in life activities, and other symptomssymptoms

Bipolar disorder (formerly called Bipolar disorder (formerly called “manic-depressive illness”): mood “manic-depressive illness”): mood cycles of mania and/or cycles of mania and/or depression and normalcy and depression and normalcy and other symptomsother symptoms

Major Depressive Major Depressive DisorderDisorder

Related DisordersRelated Disorders Dysthymia: sadness, low energy, but Dysthymia: sadness, low energy, but

not severe enough to be diagnosed not severe enough to be diagnosed as major depression disorderas major depression disorder

Cyclothymia: mood swings not severe Cyclothymia: mood swings not severe enough to be diagnosed as bipolar enough to be diagnosed as bipolar disorderdisorder

Substance-induced mood disorderSubstance-induced mood disorder Mood disorder due to a general Mood disorder due to a general

medical conditionmedical condition

Related Disorders Related Disorders (cont’d)(cont’d) Seasonal affective disorder (SAD) Seasonal affective disorder (SAD) Postpartum or “maternity” bluesPostpartum or “maternity” blues Postpartum depressionPostpartum depression Postpartum psychosisPostpartum psychosis

EtiologyEtiologyBiologic theoriesBiologic theories GeneticsGenetics Neurochemical theoriesNeurochemical theories Neuroendocrine or hormonal fluctuationsNeuroendocrine or hormonal fluctuations

Theories of Cause of depression: Theories of Cause of depression:

6.6. Aggression turned inward- self angerAggression turned inward- self anger

7.7. Response to separation of object lossResponse to separation of object loss

8.8. Genetic of nuerobiochemical basis-impaired Genetic of nuerobiochemical basis-impaired neurotransmission system, especially serotonin neurotransmission system, especially serotonin regulation. regulation.

Etiology (cont’d)Etiology (cont’d)Psychodynamic theoriesPsychodynamic theories Self-reproach to anger turned inward Self-reproach to anger turned inward Inability to achieve personal ideals Inability to achieve personal ideals Powerless egoPowerless ego

Manic episodes are a “defense” against Manic episodes are a “defense” against depression depression

Reaction to a distressing life experience Reaction to a distressing life experience

Rejecting or unloving parents Rejecting or unloving parents

Resulting from specific cognitive distortionsResulting from specific cognitive distortions

Cultural Cultural ConsiderationsConsiderations Other behaviors considered age-appropriate Other behaviors considered age-appropriate

can mask depression can mask depression Somatic complaints are a major manifestation Somatic complaints are a major manifestation

among cultures that avoid verbalizing among cultures that avoid verbalizing emotionsemotions Asians who are anxious or depressed are more Asians who are anxious or depressed are more

likely to have somatic complaints of headache, likely to have somatic complaints of headache, backache, or other symptomsbackache, or other symptoms

Latin cultures complain of “nerves” or headachesLatin cultures complain of “nerves” or headaches Middle Eastern cultures complain of heart problems Middle Eastern cultures complain of heart problems

Major Depressive Major Depressive DisorderDisorder Twice as common in women and more common Twice as common in women and more common

in single or divorced peoplein single or divorced people Involves 2 or more weeks of sad mood, lack of Involves 2 or more weeks of sad mood, lack of

interest in life activities, and at least four other interest in life activities, and at least four other symptoms:symptoms: Changes in appetite or weight, sleep, or psychomotor activityChanges in appetite or weight, sleep, or psychomotor activity Decreased energyDecreased energy Feelings of worthlessness or guiltFeelings of worthlessness or guilt Difficulty thinking, concentrating, or making decisionsDifficulty thinking, concentrating, or making decisions Recurrent thoughts of death or suicidal ideation, plans, or Recurrent thoughts of death or suicidal ideation, plans, or

attemptsattempts

Untreated, can last 6 to 24 months; recurs in Untreated, can last 6 to 24 months; recurs in 50% to 60% of people50% to 60% of people

Symptoms range from mild to severeSymptoms range from mild to severe

Treatment and PrognosisTreatment and Prognosis

Antidepressants Antidepressants SSRIs (Prozac, Zoloft, Paxil, Celexa) SSRIs (Prozac, Zoloft, Paxil, Celexa)

prescribed for mild and moderate prescribed for mild and moderate depressiondepression

TCAs (Elavil, Tofranil, Norpramin, Pamelor, TCAs (Elavil, Tofranil, Norpramin, Pamelor, Sinequan) used for moderate and severe Sinequan) used for moderate and severe depressiondepression

Atypical antidepressants (Effexor, Atypical antidepressants (Effexor, Wellbutrin, Serzone)Wellbutrin, Serzone)

MAOIs (Marplan, Parnate, Nardil) used MAOIs (Marplan, Parnate, Nardil) used infrequently because interaction with tyramine infrequently because interaction with tyramine causes hypertensive crisiscauses hypertensive crisis

Electroconvulsive therapyElectroconvulsive therapy (ECT) is used (ECT) is used when medications are ineffective or side when medications are ineffective or side effects are intolerable. effects are intolerable. 6 to 15 treatments scheduled three times a week 6 to 15 treatments scheduled three times a week Preparation of a client for ECT is similar to preparation Preparation of a client for ECT is similar to preparation

for any outpatient minor surgical procedurefor any outpatient minor surgical procedure The client will have some short-term memory impairment The client will have some short-term memory impairment

PsychotherapyPsychotherapy in conjunction with in conjunction with medication is considered most effective medication is considered most effective treatment; useful therapies include treatment; useful therapies include behavioral, cognitive, interpersonal therapybehavioral, cognitive, interpersonal therapy

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive DisorderDisorderAssessmentAssessment History: the client’s perception of the problem, behavioral History: the client’s perception of the problem, behavioral

changes, any previous episodes of depression, treatment, changes, any previous episodes of depression, treatment, response to treatment, family history of mood disorders, response to treatment, family history of mood disorders, suicide, or attempted suicidesuicide, or attempted suicide

General appearance and motor behavior:General appearance and motor behavior: slouched posture, slouched posture, latency of response, psychomotor latency of response, psychomotor retardation or agitationretardation or agitation

Mood and affect: hopeless, helpless, down, anxious, Mood and affect: hopeless, helpless, down, anxious, frustrated, anhedonia, apathetic; affect is sad, depressed, or frustrated, anhedonia, apathetic; affect is sad, depressed, or flat flat

Thought processes and content: slowed thinking processes, Thought processes and content: slowed thinking processes, negative and pessimistic, ruminate, thoughts of dying or negative and pessimistic, ruminate, thoughts of dying or committing suicide committing suicide

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive Disorder (cont’d)Disorder (cont’d)

Assessment (contAssessment (cont’’d)d) Sensorium and intellectual processes: Sensorium and intellectual processes:

oriented, memory impairment, difficulty oriented, memory impairment, difficulty concentrating concentrating

Judgment and insight: impaired judgment, Judgment and insight: impaired judgment, insight may be intact or limited insight may be intact or limited

Self-concept: low self-esteem, guilty, believe Self-concept: low self-esteem, guilty, believe that others would be better off without themthat others would be better off without them

Application of the Application of the Nursing Process: MajorNursing Process: Major

Roles and relationships: difficulty fulfilling roles and Roles and relationships: difficulty fulfilling roles and responsibilities responsibilities

Physiologic considerations: weight loss, sleep Physiologic considerations: weight loss, sleep disturbances, lose interest in sexual activities, disturbances, lose interest in sexual activities, neglect personal hygiene, constipation, dehydration neglect personal hygiene, constipation, dehydration

Depression rating scales: Zung Self-Rating Depression rating scales: Zung Self-Rating Depression Scale, Beck Depression Inventory, the Depression Scale, Beck Depression Inventory, the Hamilton Rating Scale for DepressionHamilton Rating Scale for Depression

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive Disorder (cont’d)Disorder (cont’d)

Data Analysis Data Analysis Nursing diagnoses may include:Nursing diagnoses may include: Risk for SuicideRisk for Suicide Imbalanced Nutrition: Less Than Body RequirementsImbalanced Nutrition: Less Than Body Requirements AnxietyAnxiety Ineffective CopingIneffective Coping HopelessnessHopelessness Ineffective Role PerformanceIneffective Role Performance Self-Care DeficitSelf-Care Deficit Chronic Low Self-EsteemChronic Low Self-Esteem Disturbed Sleep PatternDisturbed Sleep Pattern Impaired Social Interaction Impaired Social Interaction

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive Disorder (cont’d)Disorder (cont’d)

OutcomesOutcomesThe client will:The client will: Not injure himself or herselfNot injure himself or herself Independently carry out activities of daily living (showering, Independently carry out activities of daily living (showering,

changing clothing, grooming)changing clothing, grooming) Establish a balance of rest, sleep, and activityEstablish a balance of rest, sleep, and activity Establish a balance of adequate nutrition, hydration, and Establish a balance of adequate nutrition, hydration, and

eliminationelimination Evaluate self-attributes realisticallyEvaluate self-attributes realistically Socialize with staff, peers, and family/friendsSocialize with staff, peers, and family/friends Return to occupation or school activitiesReturn to occupation or school activities Comply with antidepressant regimenComply with antidepressant regimen Verbalize symptoms of a recurrence Verbalize symptoms of a recurrence

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive Disorder (cont’d)Disorder (cont’d)Intervention Intervention Providing for the client’s safety and the Providing for the client’s safety and the

safety of otherssafety of others Promoting a therapeutic relationshipPromoting a therapeutic relationship Promoting activities of daily living and Promoting activities of daily living and

physical carephysical care Using therapeutic communicationUsing therapeutic communication Managing medicationsManaging medications Providing client and family teachingProviding client and family teaching

Application of the Nursing Application of the Nursing Process: Major Depressive Process: Major Depressive Disorder (cont’d)Disorder (cont’d)

EvaluationEvaluation Does the client feel safe?Does the client feel safe? Is the client free of uncontrollable urges to Is the client free of uncontrollable urges to

commit suicide?commit suicide? Is the client participating in therapy and Is the client participating in therapy and

medication compliance?medication compliance? Can the client identify signs of relapse?Can the client identify signs of relapse? Will the client agree to seek treatment Will the client agree to seek treatment

immediately upon relapse?immediately upon relapse?

Bipolar DisorderBipolar Disorder Occurs almost equally among Occurs almost equally among

men and womenmen and women It is more common in highly It is more common in highly

educated people educated people The mean age for a first manic The mean age for a first manic

episode is the early 20sepisode is the early 20s

Bipolar DisorderBipolar Disorder Involves mood swings of depression (same Involves mood swings of depression (same

symptoms of major depressive disorder) and symptoms of major depressive disorder) and mania. Major symptoms of mania include:mania. Major symptoms of mania include: Inflated self-esteem or grandiosityInflated self-esteem or grandiosity Decreased need for sleepDecreased need for sleep Pressured speech Pressured speech Flight of ideas Flight of ideas DistractibilityDistractibility Increased involvement in goal-directed activity or Increased involvement in goal-directed activity or

psychomotor agitationpsychomotor agitation Excessive involvement in pleasure-seeking activities Excessive involvement in pleasure-seeking activities

with a high potential for painful consequences with a high potential for painful consequences

Treatment and PrognosisTreatment and PrognosisMedication Medication Lithium; regular monitoring of serum lithium Lithium; regular monitoring of serum lithium

levels is neededlevels is needed Anticonvulsant drugs are used for their mood-Anticonvulsant drugs are used for their mood-

stabilizing effects: Tegretol, Depakote, stabilizing effects: Tegretol, Depakote, Lamictal, Topamax, and Neurontin, as is Lamictal, Topamax, and Neurontin, as is Klonopin (a benzodiazepine)Klonopin (a benzodiazepine)

Psychotherapy Psychotherapy Useful in mildly depressive or normal portion Useful in mildly depressive or normal portion

of the bipolar cycle. It is not useful during of the bipolar cycle. It is not useful during acute manic stages acute manic stages

Application of the Nursing Application of the Nursing Process: Bipolar DisorderProcess: Bipolar DisorderAssessmentAssessment General appearance and motor behavior: General appearance and motor behavior:

psychomotor agitation; flamboyant psychomotor agitation; flamboyant clothing or makeup; clothing or makeup; think, move, and talk think, move, and talk fast; pressured speech fast; pressured speech

Mood and affect: Mood and affect: euphoria, exuberant euphoria, exuberant activity, grandiosity, false sense of well-activity, grandiosity, false sense of well-being, angry, verbally aggressive, being, angry, verbally aggressive, sarcastic, irritable sarcastic, irritable

Application of the Nursing Application of the Nursing Process: Bipolar Disorder Process: Bipolar Disorder (cont’d)(cont’d)

Assessment (cont’d)Assessment (cont’d) Thought processes and content: Thought processes and content: flight of ideas, flight of ideas,

circumstantiality, tangentiality, possible circumstantiality, tangentiality, possible grandiose delusions grandiose delusions

Sensorium and intellectual processes: Sensorium and intellectual processes: oriented oriented to person and place but rarely to time, impaired to person and place but rarely to time, impaired ability to concentrate, may experience ability to concentrate, may experience hallucinationshallucinations

Judgment and insight: Judgment and insight: judgment poor, insight judgment poor, insight limitedlimited

Self-concept: Self-concept: exaggerated self-esteem exaggerated self-esteem

Application of the Application of the Nursing Process: Bipolar Nursing Process: Bipolar Disorder (cont’d)Disorder (cont’d)

Assessment (cont’d)Assessment (cont’d) Roles and relationships: Roles and relationships: rarely can fulfill rarely can fulfill

role responsibilities, invade intimate role responsibilities, invade intimate space and personal business of others, space and personal business of others, can become hostile to others, cannot can become hostile to others, cannot postpone or delay gratification postpone or delay gratification

Physiologic and self-care Physiologic and self-care considerations: inattention to hygiene considerations: inattention to hygiene and grooming, hunger or fatigueand grooming, hunger or fatigue

Application of the Nursing Application of the Nursing Process: Bipolar Disorder Process: Bipolar Disorder (cont’d)(cont’d)Data AnalysisData Analysis Nursing diagnoses may include:Nursing diagnoses may include: Risk for Other-Directed ViolenceRisk for Other-Directed Violence Risk for InjuryRisk for Injury Imbalanced Nutrition: Less Than Body RequirementsImbalanced Nutrition: Less Than Body Requirements Ineffective CopingIneffective Coping NoncomplianceNoncompliance Ineffective Role PerformanceIneffective Role Performance Self-Care DeficitSelf-Care Deficit Chronic Low Self-EsteemChronic Low Self-Esteem Disturbed Sleep Pattern Disturbed Sleep Pattern

Application of the Application of the Nursing Process: Bipolar Nursing Process: Bipolar Disorder (cont’d)Disorder (cont’d)OutcomesOutcomes

The client will:The client will: Not injure self or othersNot injure self or others Establish a balance of rest, sleep, and activityEstablish a balance of rest, sleep, and activity Establish adequate nutrition, hydration, and Establish adequate nutrition, hydration, and

eliminationelimination Participate in self-care activitiesParticipate in self-care activities Evaluate personal qualities realisticallyEvaluate personal qualities realistically Engage in socially appropriate, reality-based Engage in socially appropriate, reality-based

interactioninteraction Verbalize knowledge of his or her illness and Verbalize knowledge of his or her illness and

treatmenttreatment

Application of the Application of the Nursing Process: Bipolar Nursing Process: Bipolar Disorder (cont’d)Disorder (cont’d)InterventionIntervention Providing for safety of client and othersProviding for safety of client and others Meeting physiologic needsMeeting physiologic needs Providing therapeutic communicationProviding therapeutic communication Promoting appropriate behaviorsPromoting appropriate behaviors Managing medicationsManaging medications Providing client and family teachingProviding client and family teaching

Application of the Application of the Nursing Process: Bipolar Nursing Process: Bipolar Disorder (cont’d)Disorder (cont’d)EvaluationEvaluation Safety issuesSafety issues Comparison of mood and affect between start Comparison of mood and affect between start

of treatment and presentof treatment and present Adherence to treatment regimen of Adherence to treatment regimen of

medication and psychotherapymedication and psychotherapy Changes in client’s perception of quality of Changes in client’s perception of quality of

lifelife Achievement of specific goals of treatment Achievement of specific goals of treatment

including new coping methods including new coping methods

SuicidSuicideeAssessmentAssessment

Men commit suicide three times the rate of womenMen commit suicide three times the rate of womenWomen are four times more likely than men to Women are four times more likely than men to

attempt suicideattempt suicidePopulations at riskPopulations at risk Men, young women, adults older than 65, and Men, young women, adults older than 65, and

separated and divorced people separated and divorced people Clients with psychiatric disordersClients with psychiatric disordersEnvironmental factors include isolation, recent loss, Environmental factors include isolation, recent loss,

lack of social support, unemployment, critical life lack of social support, unemployment, critical life events, and family history of depression or suicideevents, and family history of depression or suicide

Behavioral factors include impulsivity, erratic or Behavioral factors include impulsivity, erratic or unexplained changes from usual behavior, and unexplained changes from usual behavior, and unstable lifestyle unstable lifestyle

Warnings of suicidal intentWarnings of suicidal intent Risky behaviorsRisky behaviors Lethality assessmentLethality assessment

Does the client have a specific plan? Does the client have a specific plan? Are the means available to carry out this plan? Are the means available to carry out this plan? If the client carries out the plan, is it likely to be If the client carries out the plan, is it likely to be

lethal? lethal? Has the client made preparations for death?Has the client made preparations for death? Where and when does the client intend to carry out Where and when does the client intend to carry out

the plan?the plan? Is the intended time a special date or anniversary Is the intended time a special date or anniversary

that has meaning for the client?that has meaning for the client?

OutcomesOutcomes

The client will:The client will: Not injure self or othersNot injure self or others Engage in a therapeutic relationshipEngage in a therapeutic relationship Establish a no-suicide contractEstablish a no-suicide contract Create a list of positive attributesCreate a list of positive attributes Generate, test, and evaluate realistic Generate, test, and evaluate realistic

plans to address underlying issuesplans to address underlying issues

Intervention Intervention Using an Using an

authoritative roleauthoritative role Providing a safe Providing a safe

environmentenvironment Initiating a no-Initiating a no-

suicide contractsuicide contract Creating a support Creating a support

system listsystem list

Family ResponseFamily Response Significant others may feel guilty, angry, ashamed, Significant others may feel guilty, angry, ashamed,

and sadand sad

Nurse’s Response Nurse’s Response The nurse does not blame or act judgmentally when The nurse does not blame or act judgmentally when

asking about the details of a planned suicide. Rather, asking about the details of a planned suicide. Rather, the nurse uses a nonjudgmental tone of voice and the nurse uses a nonjudgmental tone of voice and monitors his or her body language and facial monitors his or her body language and facial expressions to make sure not to convey disgust or expressions to make sure not to convey disgust or blameblame

Nurses must realize that no matter how competent Nurses must realize that no matter how competent and caring interventions are, a few clients will still and caring interventions are, a few clients will still commit suicide. A client’s suicide can be devastating commit suicide. A client’s suicide can be devastating to the staff members who treated the clientto the staff members who treated the client

Legal and Ethical ConsiderationsLegal and Ethical Considerations

Often nurses must care for Often nurses must care for terminally or chronically ill people terminally or chronically ill people with a poor quality of life with a poor quality of life

The nurse’s role is to provide The nurse’s role is to provide supportive care for clients and supportive care for clients and family family

Elder ConsiderationsElder Considerations Depression is common among the elderly and is Depression is common among the elderly and is

markedly increased when elders are medically illmarkedly increased when elders are medically ill Elders tend to have psychotic features, Elders tend to have psychotic features,

particularly delusions, more frequently than particularly delusions, more frequently than younger people with depressionyounger people with depression

Suicide among persons over age 65 is doubled Suicide among persons over age 65 is doubled compared with suicide rates of persons younger compared with suicide rates of persons younger than 65 yearsthan 65 years

Elders are treated for depression with ECT more Elders are treated for depression with ECT more frequently than younger personsfrequently than younger persons

Elder persons have decreased tolerance of side Elder persons have decreased tolerance of side effects of antidepressant medicationseffects of antidepressant medications

Mental Health Mental Health PromotionPromotion Education to address stressors contributing Education to address stressors contributing to depressive illness to depressive illness

Promotion of factors reducing suicide risk in Promotion of factors reducing suicide risk in adolescents (close parent–child adolescents (close parent–child relationships, academic achievement, relationships, academic achievement, family life stability, and connectedness with family life stability, and connectedness with peers and others outside the family)peers and others outside the family)

Screening for early detection of risk factors, Screening for early detection of risk factors, such as family strife, parental alcoholism or such as family strife, parental alcoholism or mental illness, history of fighting, and mental illness, history of fighting, and access to weapons in the homeaccess to weapons in the home

Self-Awareness Self-Awareness IssuesIssues Nurses and other staff members need Nurses and other staff members need

to deal with their own feelings about to deal with their own feelings about suicidesuicide

Depressed or manic clients can be Depressed or manic clients can be frustrating and require a lot of energy to frustrating and require a lot of energy to care forcare for

Keeping a written journal may help deal Keeping a written journal may help deal with feelings; talking to colleagues is with feelings; talking to colleagues is often helpfuloften helpful