1. Mood Disorders Chapter 18

2. 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

3. Key Concepts Mood: –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

4. Observable Expressions of Mood Blunted Flat Inappropriate Labile Restricted or constricted

5. Primary Mood Disorders Bipolar –Bipolar or manic depressive –Manic Depressive (Unipolar) –Unipolar –Depression

6. Depressive Episode (DSM-IV-TR) Depressed mood (loss of interest for two weeks) Somatic complaints rather than sadness Increased irritability

7. 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%).

8. 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).

9. 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

10. 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.

11. Risk Factors Prior episode of depression Family history of depressive disorder Lack of social support Stressful life event Current substance use Medical comorbidity

12. Major Depressive Disorder 17% of population will have a depressive episode in their lifetime. Age – 25-44 years most affected Other ages increasing, especially in the elderly More common in women Expressed in culture differently Often occur with other disorders

13. 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

14. 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

15. Etiological Factors Psychological –Psychodynamic Deprivation of love, loss Guilt –Behavioral Reduction in pleasant activities –Cognitive Irrational beliefs Distorted attitudes –Developmental Premature loss of parent

16. Etiological Factors Social –Family interactions –Adverse life event –Sexual, physical abuse

17. Goals of Interdisciplinary Treatment Reduce, remove symptoms. Restore occupational and psychosocial functioning. Reduce likelihood of relapse. Safety is a priority. Suicide assessment

18. Family Response Affects the whole family Often has financial hardships

19. Priority Care Issues Safety Risk for suicide

20. 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

21. Nursing Diagnosis: Biologic Domain Disturbed sleep pattern Imbalanced nutrition Fatigue Many other possible –Failure to thrive –Bathing/hygiene deficit –Pain

22. Nursing Interventions: Biologic Domain Sleep hygiene Nutritional intervention Exercise Pharmacologic interventions –Acute –Continuation –Maintenance –Discontinuation

23. 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

24. Pharmacological Nursing Interventions Monitoring and Administration –Observe taking meds (acute phase) –Vital signs (observe for orthostatic hypotension), lab reports –Diet restrictions as appropriate

25. Side Effects: SSRIs GI Distress –Fluoxetine (Prozac) –Sertraline (Zoloft) –Paroxetine (Paxil) –Fluvoxamine (Luvox) Low Anticholinergic –Fluoxetine (Prozac) –Fluoxetine (Luvox) Low sedation (All) Sexual Dysfunction (All) Orthostatic Hypotension –Fluoxetine (Prozac) –Fluvoxamine (Luvox)

26. 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

27. 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

28. 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.

29. 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.

30. 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.

31. 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

32. Nursing Management: Assessment Psychological –Assessment scales self-report –Mood and affect –Thought content –Suicidal behavior –Cognition and memory

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

34. Psychological Interventions Nurse-Patient Relationship –Withdrawn patients have difficulty expressing feelings. –Nurse should be warm and empathic, but not a cheerleader. –See Therapeutic Dialogue.

35. Psychological Interventions Cognitive therapy - psychotherapy Behavior therapy Interpersonal therapy Marital and family therapy Group therapy Patient and family education

36. 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

37. Social Nursing Interventions Patient and family education Medication adherence Marital and family therapy Group therapy

38. Continuum of Care Non-psychiatric setting Acute care – hospitalization Outpatient See appendices for clinical pathways.

39. 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)

40. Types of Bipolar Bipolar I –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)

41. 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

42. Clinical Course Chronic cyclic disorder Later episodes occur more frequently than earlier. Interpersonal relationships and occupational functioning are affected. Patient may have rapid cycling.

43. 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

44. Bipolar Disorder: Elderly People More neurologic abnormalities and cognitive disturbances Late-onset bipolar disorder recently recognized Poorer prognosis because of comorbid medical conditions

45. 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 particular)

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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)

53. Other Medications Used Antidepressants –Used during depressed phases –Can trigger manic phase Antipsychotics –Psychosis –Mania –Dosage usually lower Benzodiazepines –Short-term for agitation

54. 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.

55. 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

56. 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

57. Nursing Interventions: Social Domain Protect from over-extending boundaries Support groups Family interventions –Marital and family interventions

58. Continuum of Care Inpatient management – short-term Intensive outpatient programs Frequent office visits Crisis telephone calls Family session or -