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Mood Disorders Chapter 18 Medical ppt
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Impact of Mood Disorders
Depression is number one leading cause of disability worldwide. Associated with high levels of impairment Often goes undetected and untreated Less than 50% receive treatment One-third of bipolar diagnosed
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Key Concepts Mood: Mood Disorder:
Pervasive and sustained emotion that colors one’s perception of the world and how one functions in it Mood Disorder: Persisting or recurrent disturbances or alterations in mood that continually cause psychological stress and behavioral impairment over the years Alteration in mood, not thought 2
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Observable Expressions of Mood
Blunted Flat Inappropriate Labile Restricted or constricted
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Primary Mood Disorders
Bipolar Bipolar or manic depressive Manic Depressive (Unipolar) Unipolar Depression 3
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Depressive Episode (DSM-IV-TR)
Depressed mood (loss of interest for two weeks) Somatic complaints rather than sadness Increased irritability 4
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Depressive Disorders Clinical Course
Dysthymic Disorder Milder, but more chronic form than MDD Major Depressive Disorder Progressive, recurrent illness Over time, episodes are more frequent, severe and longer in duration. Mean age of onset is about 40 years of age. An untreated episode lasts six to 13 months. Suicide is the most serious complication (10 to 15%).
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Depression in Children
Less likely to experience psychosis More likely to manifest symptoms of anxiety (fear of separation) and somatic symptoms Mood may be irritable, rather than sad. Suicide is a real risk, which peaks during mid-adolescents. Mortality from suicide increases steadily through the teens (third leading cause of death).
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Depression in the Elderly
Most do not meet criteria for depression 8 to 20% of older adults in community 37% in primary care setting Treatment successful in 60 to 80%, but response slower Associated with chronic illness Highest suicide rate, especially over 85 years
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Epidemiology Lifetime risk is 7 to 12% in men, 20 to 25% in women.
Prevalence is unrelated to race. In some cultures, somatic symptoms predominate rather than sadness.
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Risk Factors Prior episode of depression
Family history of depressive disorder Lack of social support Stressful life event Current substance use Medical comorbidity 11
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Major Depressive Disorder
17% of population will have a depressive episode in their lifetime. Age – years most affected Other ages increasing, especially in the elderly More common in women Expressed in culture differently Often occur with other disorders 6
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Clinical Course of a Major Depressive Episode
Usually develops over days - weeks Episode – minimum of two weeks Untreated lasts six months or more, but then remits in most cases Recovery – eight weeks of remission 7
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Etiological Factors Biologic
Genetics 1.5 to 3 times first-degree relative Alcoholism in biological parent Biochemical changes Serotonin, acetlycholine, norepinephrine, dopamine and GABA Alterations in HPA, HPT axes 8
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Etiological Factors Psychological
Psychodynamic Deprivation of love, loss Guilt Behavioral Reduction in pleasant activities Cognitive Irrational beliefs Distorted attitudes Developmental Premature loss of parent 9
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Etiological Factors Social
Family interactions Adverse life event Sexual, physical abuse 10
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Goals of Interdisciplinary Treatment
Reduce, remove symptoms. Restore occupational and psychosocial functioning. Reduce likelihood of relapse. Safety is a priority. Suicide assessment 12
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Family Response Affects the whole family Often has financial hardships
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Priority Care Issues Safety Risk for suicide
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Nursing Management: Biologic Domain Assessment
Systems Review (CNS, endocrine, anemia, chronic pain, etc.) Physical exam: palpation of the neck for thyroid abnormalities Appetite and weight Sleep disturbance Decreased energy 19
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Nursing Diagnosis: Biologic Domain
Disturbed sleep pattern Imbalanced nutrition Fatigue Many other possible Failure to thrive Bathing/hygiene deficit Pain
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Nursing Interventions: Biologic Domain
Sleep hygiene Nutritional intervention Exercise Pharmacologic interventions Acute Continuation Maintenance Discontinuation
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Psychopharmacologic Interventions
Cyclic antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine, sertraline, fluvoxamine, paroxtine, citalopram, escitalopram Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil), Tranylcypromine (Parnate) Atypical antidepressants Trazodone, bupropion, nefazodone, venalfaxine and mirtazapine 13
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Pharmacological Nursing Interventions
Monitoring and Administration Observe taking meds (acute phase) Vital signs (observe for orthostatic hypotension), lab reports Diet restrictions as appropriate
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Side Effects: SSRIs GI Distress Fluoxetine (Prozac)
Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Low Anticholinergic Fluoxetine (Luvox) Low sedation (All) Sexual Dysfunction (All) Orthostatic Hypotension Fluoxetine (Prozac) Fluvoxamine (Luvox)
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Side Effects of TCAs: Anticholinergic and Antihistaminic
Sedation and drowsiness Weight gain Hypotension Potentiation of CNS system drugs Blurred vision Dry mouth Constipation Urinary retention Sinus tachycardia Decreased memory 14
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Monamine Oxidase Inhibitors
Indications Depression with personality disorders, panic or social phobia Side Effects Hypertensive crisis/interaction with food Sudden, severe pounding or explosive headache Anticholinergic Elderly - sensitive to orthostatic hypotension Sexual dysfunction 16
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Serotonin Syndrome More likely to be reported in patients taking two or more serotonin antagonists Usually mild, but can cause death Rapid onset (compared to NMS) Symptoms Mental status, agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia and diarrhea Treatment Stop offending drug. Provide supportive treatment. Notify physician.
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Drug-drug Interactions
SSRIs inhibit 1A2 system. (Theophylline must be reduced.) Smoking induces 1A2 system; smokers may need higher dosage. Fluoxetine and paroxetine inhibit 2D6. Can increase plasma levels of TCA, so avoid giving these meds with TCA.
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Teaching Points If depression goes untreated or is inadequately treated, episodes become more frequent, severe and longer in duration. Importance of continuing medication Avoid St. John’s Wort.
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Other Somatic Treatments
Electroconvulsive therapy (See Ch. 9) Light therapy SAD Light - very bright, full-spectrum light, usually 2,500 lux Immediately upon rising Exposure as little as 30 minutes and then increase Full effect after two weeks 18
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Nursing Management: Assessment Psychological
Assessment scales self-report Mood and affect Thought content Suicidal behavior Cognition and memory 20
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Nursing Diagnoses Psychological Domain
Anxiety Decisional conflict Fatigue Grieving, dysfunctional Hopelessness Self-esteem, low Risk for suicide 22
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Psychological Interventions
Nurse-Patient Relationship Withdrawn patients have difficulty expressing feelings. Nurse should be warm and empathic, but not a cheerleader. See Therapeutic Dialogue. 23
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Psychological Interventions
Cognitive therapy - psychotherapy Behavior therapy Interpersonal therapy Marital and family therapy Group therapy Patient and family education 24
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Nursing Management: Assessment Social Domain
Developmental history Family psychiatric history Quality of support system Role of substance abuse in relationships Work history Physical and sexual abuse 21
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Social Nursing Interventions
Patient and family education Medication adherence Marital and family therapy Group therapy 25
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Continuum of Care Non-psychiatric setting Acute care – hospitalization
Outpatient See appendices for clinical pathways. 26
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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) 3
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Types of Bipolar Bipolar I Bipolar II
Combinations of major depression and full manic episode Mixed episodes: alternating between manic and depressive episodes Bipolar II Combination of major depression and hypomania (less severe form of mania) 2
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Specifiers 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
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Clinical Course Chronic cyclic disorder
Later episodes occur more frequently than earlier. Interpersonal relationships and occupational functioning are affected. Patient may have rapid cycling. 5
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Bipolar in Special Populations: Children
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
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Bipolar Disorder: Elderly People
More neurologic abnormalities and cognitive disturbances Late-onset bipolar disorder recently recognized Poorer prognosis because of comorbid medical conditions
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Bipolar Disorder: Epidemiology
Prevalence to 1.6% of population Onset: years Men and women equally Ten to 15% of adolescents with recurrent depressive episodes develop bipolar I. Many comorbid disorders (substance abuse, in particular) 4
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Gender and Ethnic/Cultural Differences
No gender difference in incidence Gender differences reported in phenomenology, course and treatment. Females at greater risk for depression and rapid cycling
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Etiology Biologic 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 6
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Treatment Issues Complex issues treated by an interdisciplinary team
Priority issues: Safety from poor judgement and risk-taking behaviors Risk for suicide during depressive disorders Devastating to families, especially dealing with the consequences of impulsive behavior
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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 use Nursing diagnosis Disturbed sleep pattern, sleep deprivation Imbalanced nutrition, hypothermia, deficit fluid balance
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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
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Mood Stabilizers Lithium Carbonate (Eskalith)
Mechanism of action: unknown Blood levels Side effects: GI, weight gain Divalproex Sodium (Depakote) Increase inhibitory transmitter, GABA Sedation, tremor Carbamazepine 10
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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)
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Other Medications Used
Antidepressants Used during depressed phases Can trigger manic phase Antipsychotics Psychosis Mania Dosage usually lower Benzodiazepines Short-term for agitation
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Other Medication Issues
Monitoring important Side effect monitoring important because taking more than one medication Drug-drug interactions Especially, alcohol, drugs, OTC and herbal supplements Teaching points Lithium (Change in salt intake can affect lithium.) Most of these medications cause weight gain. Check before using OTC.
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Nursing Management: Psychological Domain
Assessment Mood Cognitive Thought Disturbances Stress and coping factors Risk assessment Nursing Diagnosis Disturbed sensory perception Disturbed thought processes Defensive coping Risk for suicide Risk for violence Ineffective coping
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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
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Nursing Interventions: Social Domain
Protect from over-extending boundaries Support groups Family interventions Marital and family interventions
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Continuum of Care Inpatient management – short-term
Intensive outpatient programs Frequent office visits Crisis telephone calls Family session or - Medical ppt
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