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Mood Disorders

Mood Disorders
 Characterized by a disregulation of emotion
 Persons with mood d/os demonstrate a wide
range of emotions, from intense elation or
irritability to severe depression
 Characterized by a constellation of sx including:
 Impaired cognition
 Physiologic disturbances
 Lowered self-esteem
 Impairment in social and occupational functioning
Etiology of Mood D/os

 Neurobiologic Factors
 Altered neurotransmission
 Neuroendocrine dysregulation
 Genetic transmission
Neurobiologic Factors—Altered
 It is believed that the monoamine NT
systems, especially those of NE and 5-HT,
their metabolites, and their receptors are
somehow altered during episodes of
depression and mania
 Proposed that there is an overactivity of
neurotransmission in mania and an
underactivity in depression
Neurobiologic Factors—Altered
Neurotransmission (cont)
 Kindling
 Neurotransmission is initially altered by stress,
resulting in a first episode of depression
 This initial episode creates an electrophysiologic
sensitivity to future stress, requiring less stress to
evoke another depressive or manic episode
 Creates long lasting alterations in neuronal
Neurobiologic Factors—Altered
Neurotransmission (cont)

 PET (positron emission tomography)

 Indicate a decreased blood flow and
decreased activity in the frontal areas of
the brain in depressed patients
Neurobiologic Factors—
Neuroendocrine Dysregulation
 Dysregulation of the HPA axis is
associated with depression
 The HPA axis controls the physiologic
responses to stress
 In response to stress, the hypothalamus
releases CRH
 This stimulates the anterior pituitary to
secrete corticotropin
 Corticotropin then causes the adrenal
cortex to release cortisol into the blood
Neurobiologic Factors—
Neuroendocrine Dysregulation
 Hyperactivity of the HPA axis is often
evident in depression
 Up to 50% of clients with moderate to
severe depression exhibit elevated serum
cortisol levels
 This led to the creation of the
dexamethasone suppression test (DST)
which was hoped to be a biologic
diagnostic indicator of depression
Neurobiologic Factors—
Neuroendocrine Dysregulation
 Sleep-wake cycles are disrupted in
mood disorders
 Depressed patients
 Go into REM sleep more quickly
 Have a deficit of stage 3 and 4 sleep

 Have an abnormality in the distribution of

dream sleep throughout the night

Genetic Transmission
 Mood d/os tend to run in families, and it is
commonly believed to some extent that
genetic transmission is responsible for
their manifestation
 Results of studies consistently demonstrate
that 1st degree relatives of persons with
bipolar d/o and depression have a greater risk
of developing a mood d/o
Etiology of Mood D/os
 Psychosocial factors
 Psychoanalytic theory
 Cognitive theory
 Learned helplessness
 Life events and stress theory
 Personality theory
Psychoanalytic Theory
 Freud viewed both depression and
mania as a response to loss
 In depression, the loss generates intense,
hostile feelings toward the lost object that
are turned inward onto self creating guilt
and loss of self-esteem
 Mania is explained as a defense against
 The client denies feelings of anger, low self-
esteem, and worthlessness and reverses the
affect such that there is a triumphant feeling of
Cognitive Theory
 Looks at errors in logical thinking as
causative factors for depression
 Beck proposed a triad of negative
thinking that gives rise to the
development of depression
 Negative views of self
 Pessimistic views of the world, so that life
experiences are interpreted in a negative
 The belief that negativity will continue into
the future
Learned Helplessness Theory
 1st described in an experiment with dogs in
 Found that stressful events that are
experienced as uncontrollable result in the
development of helplessness, apathy,
powerlessness, and depression
Life Events and Stress Theory
 Significant life events cause stress, which
results in depression or mania
 Researchers have also been investigating
how social support attributes to the
development of depression
Personality Theory
Personality Characteristics
Associated with Depression:

 Negativity  Demandingness
 Pessimism  Feeling of being bored
 Low sense of self-worth or empty
 Proneness to worry and
 Hypochondriasis
anxiety  Quietness
 Self-denial  Incapacity for
 Tendency to be serious enjoyment and
and overly responsible relaxation
 Dependence on others
love or affection
 Lifetime prevalence of developing any affective
d/o is 19.3%
 Women and men have about an equal lifetime
prevalence of developing bipolar d/o
 21.3% of women and 12.7% of men develop
major depression
 Average age of onset for bipolar d/o is mid to
late 20s
 Average age of onset of depression is mid 30s
Depressive Disorders
 Major depression
 Dysthymic Disorder
 Depressive Disorder NOS
 Melancholic depression
 Atypical depression
 Seasonal Affective Disorder
 Five or more of the following symptoms
have to be present during the same two
week period and represent a change from
previous functioning
 At least one of the symptoms is either
 (1) depressed mood or
 (2) loss of interest or pleasure (anhedonia)
 1. Depressed mood most of the day, nearly
every day, as indicated by either subjective
report or observation made by others
 2. Markedly diminished interest or pleasure in
all or almost all activities most of the day, nearly
every day
 3. Significant weight loss when not dieting or
weight gain or decrease or increase in appetite
nearly every day ( 5% in one month)
 4. Insomnia or hypersomnia nearly every
 5. Psychomotor agitation or retardation
nearly everyday (observable by others not
merely subjective feelings of restlessness
or being slowed down)
 6. Fatigue or loss of energy nearly every
 7. Feelings of worthlessness or excessive or
inappropriate guilt nearly every day
 8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day
 9. Recurrent thoughts of death, recurrent
suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing
 The symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
 The sx occur as a result of the d/o and not from
the effects of a substance medical condition or
loss of a loved one within the previous 2 months
 There cannot be a hx of a manic episode
Types of Depression
 Melancholic
 Anhedonia, lack of reactivity to usual pleasurable
stimuli, psychomotor retardation, anorexia or weight
loss, EMA, guilt, depression worse in the AM
 Atypical
 Mood reactivity (mood brightens in response to
positive events), weight gain, hypersonia, increased
appetite and weight gain, leaden paralysis
 Seasonal Affective Disorder
 Episodes begin in fall or winter and remit in the spring
 Pattern has occurred for 2 yrs
Dysthymic Disorder
 Chronic low grade depression that does not fit
criteria for MDD
 Lasts for at least 2 years
 depressed mood most of the day, nearly every day
 and at least 2 of the following sx:
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Difficulty making decisions
 Feelings of hopelessness
 MDD superimposed on dysthymia = double
Mnemonic: SIGECAPS

 S Sleep
 I Interest
 G Guilty feelings
 E Energy
 C Concentration
 A Appetite
 P Psychomotor agitation or retardation
 S Suicidal thoughts
Nursing Management:

 Assessment scales self-report

 Mood and affect

 Thought content

 Suicidal behavior

 Cognition and memory

Nursing Diagnoses
Psychological Domain
 Anxiety
 Decisional conflict
 Fatigue
 Grieving, dysfunctional
 Hopelessness
 Self-esteem, low
 Risk for suicide
Psychological Interventions

Nurse-Patient Relationship

 Withdrawn patients have difficulty expressing

 Nurse should be warm and empathic, but not
a cheerleader.
 See Therapeutic Dialogue.
Psychological Interventions

 Cognitive therapy - psychotherapy

 Behavior therapy
 Interpersonal therapy
 Marital and family therapy
 Group therapy
 Patient and family education
Nursing Management:
Social Domain

 Developmental history
 Family psychiatric history
 Quality of support system
 Role of substance abuse in relationships
 Work history
 Physical and sexual abuse
Social Nursing Interventions

 Patient and family education

 Medication adherence
 Marital and family therapy
 Group therapy
Continuum of Care
 Non-psychiatric setting
 Acute care – hospitalization
 Outpatient
 See appendices for clinical pathways.
Bipolar Disorders
DSM-IV Bipolar Disorders
 Bipolar Disorder Type 1
 manic episode
 Bipolar Disorder Type 2
 never had manic episode
 at least 1 hypomanic & depressive episode
 Cyclothymic Disorder
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 can’t follow
– Racing thoughts
– Easily distracted
– Inflated feeling of power, greatness or importance
– Reckless behavior (money, sex, drugs)
Types of Bipolar
• Bipolar I
– Combinations of major depression and full manic
– Mixed episodes: alternating between manic and
depressive episodes
• Bipolar II
– Combination of major depression and hypomania
(less severe form of mania)
 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
Clinical Course
• Chronic cyclic disorder
• Later episodes occur more frequently than
• Interpersonal relationships and occupational
functioning are affected.
• Patient may have rapid cycling.
Bipolar in Special Populations:
 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
Bipolar Disorder:
Elderly People
 More neurologic abnormalities and
cognitive disturbances
 Late-onset bipolar disorder recently
 Poorer prognosis because of comorbid
medical conditions
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
Gender and Ethnic/Cultural
 No gender difference in incidence
 Gender differences reported in
phenomenology, course and treatment.
 Females at greater risk for depression and
rapid cycling
• 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
Treatment Issues
 Complex issues treated by an
interdisciplinary team
 Priority issues:
 Safety from poor judgement and risk-taking
 Risk for suicide during depressive disorders

 Devastating to families, especially dealing

with the consequences of impulsive
Nursing Management:
Biologic 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
 Nursing diagnosis
 Disturbed sleep pattern, sleep deprivation
 Imbalanced nutrition, hypothermia, deficit fluid balance
Nursing Interventions:
Biologic Domain
 Physical care
 Pharmacologic
 Acute - symptom reduction and stabilization
 Continuation – prevention of relapse
 Maintenance - sustained remission
 Discontinuation - very carefully, if at all
 Electroconvulsive therapy
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
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)
Other Medications Used
 Antidepressants
 Used during depressed phases
 Can trigger manic phase
 Antipsychotics
 Psychosis
 Mania
 Dosage usually lower
 Benzodiazepines
 Short-term for agitation
Other Medication Issues
 Monitoring important
 Side effect monitoring important because taking
more than one medication
 Drug-drug interactions
 Especially, alcohol, drugs, OTC and herbal
 Teaching points
 Lithium (Change in salt intake can affect lithium.)
 Most of these medications cause weight gain.
 Check before using OTC.
Nursing Management:
Psychological Domain
Assessment Nursing Diagnosis
 Mood  Disturbed sensory
 Cognitive perception
 Thought Disturbances
 Disturbed thought
 Stress and coping
 Defensive coping
 Risk assessment
 Risk for suicide
 Risk for violence
 Ineffective coping
Nursing Management:
Social 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
Nursing Interventions:
Social Domain
 Protect from over-extending boundaries
 Support groups
 Family interventions
 Marital and family interventions
Continuum of Care
 Inpatient management – short-term
 Intensive outpatient programs
 Frequent office visits
 Crisis telephone calls
 Family session or -
Hypomanci Episode
 Expansive mood occurs for at least 4 days
 Not as severe to cause impairment in
social and/or occupational functioning
 During a hypomanic episode, clients may
appear extremely happy and congenial, at
ease with social conversation, and offer
humorous input
Cyclothymic Disorder
 At least 2 years in duration
 Periods of hypomania, depressed mood,
and anhedonia
 Less severe symptoms than MDD and
Adjustment Disorders
Adjustment Disorders
 Occur in response to a precipitating stressor
(an event leading to marked distress and
 Stressors can include:
 Separations
 Divorce
 Unemployment
 Miscarriage
 Diagnosis of an acute or chronic illness
 Leaving home
 Going to college
Adjustment Disorders (cont)
 Some of sx of adjustment d/os are
similar to those of mood and anxiety
 Adjustment d/os are considered less
serious and often represent transient
episodes in the lives of otherwise
mentally healthy individuals
 This dx is made after other psychiatric
conditions are ruled out
DSM-IV Criteria for Adjustment
 A. The development of emotional or behavioral
sx in response to an identifiable stressor
 B. These sx cause either:
 Marked distress that is in excess of what would be
expected from exposure to the stressor
 Significant impairment is social or occupational
 The stress related disturbance does not meet
criteria for another Axis I d/o
 The sx do not represent bereavement
Adjustment Disorder
 Acute
 If the disturbance lasts < 6 months
 Chronic
 If the disturbance lasts > 6 months
 6 subtypes of adjustment disorder:
 With depressed mood
 With anxiety
 With mixed anxiety and depressed mood
 With disturbance of conduct
 With mixed disturbance of emotions and conduct
 Unspecified
 Changes in mood and behavior are common
 Can feel fearful, nervous, depressed, angry, worried,
or a mixture of these states
 Stressor may interfere with the ability to think or
 Lowered confidence and self-esteem may occur
 Sleep disturbances can occur
 Difficulties in interpersonal relationships may emerge
Etiology—Crisis Model
 An adjustment disorder results from an
individual’s inability to use existing coping
methods or create new methods in
response to a situation
 This results in a situation where a client
feels overwhelmed, helpless, and
confused further depleting his or her ability
to utilize resources
 Adult adjustment d/os are thought to be
 The DSM-IV cites prevalence rates
between 5-20% in outpt populations
 Once identified, the course of illness is
usually limited to weeks or months
 Some people may be at risk of suicide
because of the nature and severity of their
 Left untreated, these d/os may progress to
anxiety and mood d/os
Treatment Considerations
 Meds are used sparingly
 The d/o is expected to resolve after the
immediate cause is identified and processed
 Benzos are sometimes prescribed for brief
periods of time to treat sx of anxiety
Treatment Considerations (cont)
 Supportive therapies
 Family therapy—may be indicated when the
stressor involves the family system