Chapter 17 Mood Disorders and Suicide

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

Mood Disorders (cont.) Most common psychiatric diagnosis associated with suicide Depression one of the most important risk factors for it

Categories of Mood Disorders Major depressive disorder Bipolar disorder Related disorders Dysthymic disorder Cyclothymic disorder Substance-induced depressive or bipolar disorder Seasonal affective disorder Postpartum depression, psychosis, premenstrual dysphoric disorder Nonsuicidal self-injury

Etiology Biologic theories Genetic theories Neurochemical theories: serotonin, norepinephrine; possibly acetylcholine and dopamine Neuroendocrine influences: hormones

Etiology (cont.) Psychodynamic theories Freud: self-deprecation Bibring: ideal ego Jacobson: superego over powerless ego Mania: defense against underlying depression

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

Question Is the following statement true or false? Depression is most commonly associated with suicide.

Answer True Rationale: Depression is considered the most common diagnosis that results in suicide.

Major Depressive Disorder Incidence: women to men 2:1 Decreases with age in women; increases with age in men; highest in single, divorced people 50% to 60% will suffer recurrence Approximately 20% will develop a chronic form of depression Symptoms range from mild to severe

Major Depressive Disorder (cont.) Symptoms: sad mood, lack of interest in life activities (2 weeks or more), and at least four other symptoms: Changes in eating habits → weight gain or loss Hypersomnia or insomnia Impaired concentration, decision making, or problem solving Worthlessness, hopelessness, despair, guilt Thoughts of death/suicide Overwhelming fatigue, negative thinking

Psychopharmacology Selective serotonin reuptake inhibitors (see Table 17.1) Cyclic antidepressants (see Table 17.2) Atypical antidepressants (see Table 17.3) Monoamine oxidase inhibitors (MAOIs) (see Table 17.4)

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 (see Table 17.5) Investigational treatments

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)

Major Depressive Disorder and Nursing Process Application (cont.) Assessment (cont.) 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

Question Is the following statement true or false? Patients with depression often exhibit anhedonia.

Answer True Rationale: Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression.

Major Depressive Disorder and Nursing Process Application (cont.) Data analysis/nursing diagnoses Outcome identification Free from self-injury Improved mood and energy Return to previous functional level Medication compliance

Major Depressive Disorder and Nursing Process Application (cont.) Intervention Providing for safety (suicide precautions) Promoting therapeutic relationship Promoting ADLs, physical care Using therapeutic communication Managing medications Patient, family teaching Evaluation

Bipolar Disorder Extreme mood fluctuations from mania to depression (see Figure 17.1) Second only to major depression as cause of worldwide disability Onset usually in late teens, 20s, or 30s Manic episodes begin suddenly, last from a few weeks to several months

Treatment Psychopharmacology Antimanic agent: lithium Anticonvulsant agent used as mood stabilizer (see Table 17.6) 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

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)

Bipolar Disorder and Nursing Process Application (cont.) Assessment (cont.) Judgment, insight Self-concept (exaggerated) Roles, relationships (labile emotions) Physiologic, self-care considerations Data analysis/nursing diagnoses Outcome identification Free from injury—med compliance Meet basic needs and self-care Socially appropriate behavior

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

Answer A. Lithium Rationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic patient with bipolar disorder. Fluoxetine, citalopram, and venlafaxine are antidepressants.

Bipolar Disorder and Nursing Process Application (cont.) Intervention Providing for safety Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications (see Tables 17.6 and 17.7) Providing patient, family teaching Evaluation

Suicide Intentional act of killing oneself Suicidal ideation: thinking about killing oneself Warning signs: risk for suicide (see Box 17.4)

Suicide (cont.) Assessment: Previous suicide attempts (first 2 years after— highest risk period, especially first 3 months); relative who committed suicide Warnings of suicidal intent (see Box 17.4); risky behavior Lethality assessment Data analysis/nursing diagnoses

Suicide (cont.) Outcome identification Safety, free from self-harm Intervention Authoritative role Safe environment: suicide precautions; no suicide/no self-harm contract Support system list

Suicide (cont.) Family response Suicide as ultimate rejection of family, friends Families react with guilt, shame, anger

Suicide (cont.) Nurse’s response Need for unconditional positive regard for person Avoidance of patient blame Nonjudgmental approach, tone Belief that one person can make a difference in another’s life Possible devastation of staff if patient commits suicide

Legal and Ethical Considerations Assisted suicide as topic of national legal, ethical debate (Oregon, the 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 patients, family as they work through decision-making process

Question Is the following statement true or false? When dealing with a patient who is suicidal, the nurse needs to assume a dependent role.

Answer False Rationale: When dealing with a patient who is suicidal, the nurse must take an authoritative role.

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

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

Community-Based Care (cont.) Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment

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

Mental Health Promotion (cont.) Screening for early detection of risk factors Family strife Parental alcoholism or mental illness History of fighting Access to weapons in the home

Self-Awareness Issues Importance of dealing with own feelings about suicide Frustration possible when working with depressed or manic patients Exhaustion possible when working with manic patients Journaling to help deal with feelings; talking with colleagues often helpful