Mood Disorders

Fall 2012 M. Motyka

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Major Depressive Disorder

History of one or more major depressive episodes No history of manic or hypomanic episodes Symptoms interfere with social or occupational functioning May include psychotic features

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Major Depressive Disorder Subtypes

Psychotic features Melancholic features Atypical features Catatonic features Postpartum onset Seasonal features seasonal affective disorder (SAD)

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Proposed Subtypes
Premenstrual dysphoric disorder Mixed anxiety-depression Recurrent brief depression Minor depression

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Dysthymic Disorder
Chronic depressive syndrome Present for most of the day More days than not At least 2 years

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Epidemiology
Leading cause of disability in the United States Children and adolescents Older adults Comorbidity

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Etiology
Biological factors
Genetic Biochemical Alterations in hormonal regulation Diathesis-stress model

Psychological factors
Cognitive theory Learned helplessness
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Nursing Process
Assessment
Self-assessment Unrealistic expectations of self Feeling what the patient is feeling Assessment tools Assessment of suicide potential Key assessment findings

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Nursing Process
Continued

Areas to assess
Affect Thought processes Mood Feelings Physical behavior Communication Religious beliefs and spirituality

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 Which question would be a priority when assessing for symptoms of major depression?

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a. Tell me about any special powers you believe you have. b. You look really sad. Have you ever thought of harming yourself? c. Your family says you never stop. How much sleep do you get? d. Do you ever find that you dont remember where youve been or what youve done?
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Nursing Process
Continued

Nursing Diagnosis
Risk for suicide safety is always the highest priority Hopelessness Ineffective coping Social isolation Spiritual distress Self-care deficit

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Nursing Process
Continued

Outcomes Identification Recovery model

Focus on patients strengths Treatment goals mutually developed Based on patients personal needs and values

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Nursing Process
Continued

Planning Geared towards

Patients phase of depression Particular symptoms Patients personal goals

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Nursing Process
Continued

Implementation Three phases

Acute phase (6 to 12 weeks) Continuation phase (4 to 9 months) Maintenance phase (1 year or more)

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Nursing Process
Continued

Basic Level Interventions

Counseling and communication Health teaching and health promotion Promotion of self-care activities Milieu therapy

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Nursing Process
Continued

Advanced Practice Interventions

Psychotherapy
Cognitive behavioral therapy (CBT) Interpersonal therapy (IT) Time-limited focused psychotherapy Behavior therapy

Group therapy

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Psychopharmacology
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
First-line therapy Indications Adverse reactions Potential toxic effects

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Psychopharmacology
Continued

Tricyclic antidepressants (TCAs)

Neurotransmitter effects Indications Adverse effects Contraindications

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Psychopharmacology
Continued

Monoamine oxidase inhibitors (MAOIs)

Neurotransmitter effects Indications Adverse/toxic effects Interactions
Drug Food

Contraindications

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Other Treatments for Depression

Electroconvulsive therapy (ECT) Transcranial magnetic stimulation Vagus nerve stimulation Light therapy St. Johns wort Exercise

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Nursing Process
Continued

Evaluation
Short-term indicators and outcome criteria Reassess and reformulate care plan as necessary Future of treatment

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Suicide
A significant public health problem in the United States In 2008
Eleventh leading cause of death 32,000 completed suicides

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Psychiatric disorders Alcohol or substance use disorders Male gender Increasing age Race Religion Marriage Profession Physical health

Suicide Risk Factors

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Biological Factors
Suicidal behavior tends to run in families Low serotonin levels are related to depressed mood

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 Freud aggression turned inward Menninger

The wish to kill The wish to be killed The wish to die

Psychosocial Factors

Aaron Beck central emotional factor is hopelessness Recent theories combination of suicidal fantasies and significant loss
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 Protective factors

Cultural Factors

African Americans
Religion, role of the extended family

Hispanic Americans
Roman Catholic religion and importance of extended family

Asian Americans
Adherence to religions that tend to emphasize interdependence between the individual and society

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 Oregons Death with Dignity Act of 1994 terminally ill patients allowed physicianassisted suicide Netherlands nonterminal cases of lasting and unbearable suffering Belgium nonterminal cases when suffering constant and cannot be alleviated Switzerland assisted suicide legal since 1918 Massachusetts- vote in November
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Societal Factors

Assessment: Overt Statements

I can't take it anymore. Life isn't worth living anymore. I wish I were dead. Everyone would be better off if I died.

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Assessment: Covert Statements

It's okay, now. Soon everything will be fine. Things will never work out. I won't be a problem much longer. Nothing feels good to me anymore and probably never will. How can I give my body to medical science?
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Assessment: Lethality of Suicide Plan

Is there a specific plan with details? How lethal is the proposed method? Is there access to the planned method? People with definite plans for time, place, and means are at high risk.

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Assessment Tools: SAD PERSONS Scale

Uses 10 major risk factors to assess suicidal potential
1. Sex (male) 2. Age 25 to 44 or 65+ years 3. Depression 4. Previous attempt 5. Ethanol use 6. Rational thinking loss 7. Social supports lacking or recent loss 8. Organized plan 9. No spouse 10. Sickness

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Nursing Diagnoses
Risk for suicide Ineffective coping Hopelessness Powerlessness Social isolation

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Levels of Intervention
Primary activities that provide support, information, and education to prevent suicide Secondary treatment of the actual suicidal crisis Tertiary interventions with the family and friends of a person who has committed suicide to reduce the traumatic aftereffects
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Basic Level Interventions

Milieu therapy with suicidal precautions Counseling Health teaching and health promotion Case management

Pharmacological interventions

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Survivors of Completed Suicide: Postintervention

Surviving friends and family
Overwhelming guilt, shame Difficulties discussing the often taboo subject of suicide

Staff
Group support essential as treatment team conducts a thorough postmortem assessment and review
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Advanced Practice Interventions

Psychotherapy Psychobiological interventions Clinical supervision Consultation

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 A patient is hospitalized with major depression and suicidal ideation. He has a history of several suicide attempts. For the first 2 days of hospitalization, the patient eats 20% of meals and stays in his room between groups. By the fourth day, the nurse observes the patient is more sociable, is eating meals, and has a bright affect. Which factor should the nurse consider? The patient:
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a. is showing improvement and may be ready for discharge. b. may have decided to commit suicide; the nurse should reassess suicidality. c. is feeling rested, supported by the therapeutic milieu, and less depressed. d. is benefiting from the antidepressant he has been taking for 4 days.

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Chapter 14
Bipolar Disorders

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Clinical Picture
Bipolar I Disorder Bipolar II Disorder

Cyclothymia

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Epidemiology
Lifetime prevalence of bipolar disorder in the United States is 3.9% Bipolar I more common in males Bipolar II more common in females Cyclothymia usually begins in adolescence or early adulthood

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Etiology
Biological factors
Genetic Neurobiological Neuroendocrine

Psychological factors Environmental factors

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Assessment
Mood Behavior Thought processes and speech patterns
Flight of ideas Clag associations Grandiosity

Cognitive functioning

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Self-Assessment
Manic patient
Manipulative Aggressively demanding Splitting

Staff member actions

Frequent staff meetings to deal with patient behavior and staff response Set limits consistently
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Assessment Guidelines Bipolar Disorder

Danger to self or others Need for protection from uninhibited behaviors Need for hospitalization Medical status Coexisting medical conditions Familys understanding

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Nursing Diagnosis
Risk for injury Risk for violence
Other-directed Self-directed

Risk for suicide

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Outcomes Identification
Acute phase
Prevent injury

Continuation phase
Relapse prevention

Maintenance phase

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Planning
Acute phase
Medical stabilization Maintaining safety Self-care needs

Continuation phase
Maintain medication adherence Psychoeducational teaching Referrals

Maintenance phase
Prevent relapse
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Implementation
Acute phase highest priority is always safety
Depressive episodes Manic episodes

Continuation phase
Prevent relapse with follow-up care

Maintenance phase

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Pharmacological Interventions
Lithium carbonate
Indications Therapeutic and toxic levels
Therapeutic blood level 0.8 to 1.4 mEq/L Maintenance blood level 0.4 to 1.3 mEq/L Toxic blood level: 1.5 to 2.0 mEq/L

Maintenance therapy Contraindications

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Anticonvulsant Drugs
Valproate (Depakote)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

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Antianxiety Drugs
Clonazepam (Klonopin) Lorazepam (Ativan) Atypical Antipsychotics Olanzapine (Zyprexa) Risperidone (Risperdal)

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Other Treatments
Electroconvulsive therapy (ECT) Milieu management Support groups Health teaching and health promotion

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Advanced Practice Interventions

Psychotherapy
Cognitive-behavioral therapy (CBT) Interpersonal and social rhythm therapy

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Evaluation
Evaluate outcome criteria Care plan reassessed Care plan revised if indicated

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Chapter 34
Therapeutic Groups

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Therapeutic Factors Common to All Groups

Instillation of hope Universality Imparting of information Altruism Corrective recapitulation of primary family group

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Therapeutic Factors Common to All Groups

Continued

Development of socializing techniques Imitative behavior Interpersonal learning Group cohesiveness Catharsis Existential resolution (Box 34-2)
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Phases of Group Development

Orientation phase Working phase

Termination phase

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Group Member Roles

Task roles Maintenance roles

Individual roles

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Which of the following comments made by members of a group best demonstrates a task role?

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a. I want to tell how my problems started. Im having more trouble than anyone else in this group. b. Three people were late for this group. Everyone is supposed to arrive on time. c. I cant believe youre talking about your failed romantic relationships again. d. We started out talking about guilt, but we have strayed from that subject.

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Group Leadership Responsibilities

Initiating Maintaining Terminating

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Styles of Leadership
Autocratic leader Democratic leader

Laissez-faire leader

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Basic Level Registered Nurse

Psychoeducational groups Medication education groups Health education groups Dual-diagnosis groups Symptom-management groups Stress-management groups

Support and self-help groups

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Advanced Practice Nurse

Group psychotherapy Psychodrama groups

Dialectical behavior treatment

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Dealing with Challenging Member Behaviors

Monopolizing member Complaining member who rejects help Demoralizing member Silent member

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