2 Mood Disorders Affective disorders Pervasive alterations in emotions manifested by depression, mania, or bothInterference with life; long-term sadness, agitation, or elationIndividuals with mood disorders throughout history
3 Mood Disorders (cont.)Most common psychiatric diagnosis associated with suicideDepression one of the most important risk factors for it
4 Categories of Mood Disorders Major depressive disorderBipolar disorderRelated disordersDysthymic disorderCyclothymic disorderSubstance-induced depressive or bipolar disorderSeasonal affective disorderPostpartum depression, psychosis, premenstrual dysphoric disorderNonsuicidal self-injury
6 Etiology (cont.) Psychodynamic theories Freud: self-deprecation Bibring: ideal egoJacobson: superego over powerless egoMania: defense against underlying depression
7 Cultural Considerations Masking of depression by other behaviors considered age appropriateSchool phobia, hyperactivity, learning disorders, failing grades, antisocial behaviorsSubstance abuse, gangs, risk behaviors, eating disorders, compulsive behaviorsSomatic complaintsMajor manifestation among cultures that avoid verbalizing emotions
8 Question Is the following statement true or false? Depression is most commonly associated with suicide.
9 AnswerTrueRationale: Depression is considered the most common diagnosis that results in suicide.
10 Major Depressive Disorder Incidence: women to men 2:1Decreases with age in women; increases with age in men; highest in single, divorced people50% to 60% will suffer recurrenceApproximately 20% will develop a chronic form of depressionSymptoms range from mild to severe
11 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 lossHypersomnia or insomniaImpaired concentration, decision making, or problem solvingWorthlessness, hopelessness, despair, guiltThoughts of death/suicideOverwhelming fatigue, negative thinking
12 PsychopharmacologySelective 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)
13 Other Medical Treatments and Psychotherapy Electroconvulsive therapy (ECT)Psychotherapy (combined with medications)Interpersonal therapy: relationship difficultiesBehavior therapy: reinforcement of positive interactionsCognitive therapy: correction of cognitive distortions (see Table 17.5)Investigational treatments
14 Major Depressive Disorder and Nursing Process Application AssessmentHistoryGeneral appearance, motor behavior (psychomotor retardation, latency of response, psychomotor agitation)Mood, affect (anhedonia)Thought process, content (rumination, suicide)Sensorium, intellectual processes (impaired memory)
15 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 considerationsDepression rating scalesSelf-rating scales: Zung, BeckClinician rating scale: Hamilton Rating Scale
16 Question Is the following statement true or false? Patients with depression often exhibit anhedonia.
17 AnswerTrueRationale: Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression.
18 Major Depressive Disorder and Nursing Process Application (cont.) Data analysis/nursing diagnosesOutcome identificationFree from self-injuryImproved mood and energyReturn to previous functional levelMedication compliance
19 Major Depressive Disorder and Nursing Process Application (cont.) InterventionProviding for safety (suicide precautions)Promoting therapeutic relationshipPromoting ADLs, physical careUsing therapeutic communicationManaging medicationsPatient, family teachingEvaluation
20 Bipolar DisorderExtreme mood fluctuations from mania to depression (see Figure 17.1)Second only to major depression as cause of worldwide disabilityOnset usually in late teens, 20s, or 30sManic episodes begin suddenly, last from a few weeks to several months
21 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 cyclesPsychotherapy useful in mildly depressive or normal portion of bipolar cycleNot useful during manic stages
22 Bipolar Disorder and Nursing Process Application AssessmentHistoryGeneral appearance, behavior (pressured speech, flamboyancy, sexually suggestive)Mood, affect (euphoric, grandiose)Thought process, content (circumstantiality, tangentiality)Sensorium, intellectual processes (disoriented to time)
23 Bipolar Disorder and Nursing Process Application (cont.) Assessment (cont.)Judgment, insightSelf-concept (exaggerated)Roles, relationships (labile emotions)Physiologic, self-care considerationsData analysis/nursing diagnosesOutcome identificationFree from injury—med complianceMeet basic needs and self-careSocially appropriate behavior
24 QuestionWhich of the following would be most appropriate for the treatment of mania associated with bipolar disorder?A. LithiumB. FluoxetineC. CitalopramD. Venlafaxine
25 AnswerA. LithiumRationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic patient with bipolar disorder.Fluoxetine, citalopram, and venlafaxine are antidepressants.
26 Bipolar Disorder and Nursing Process Application (cont.) InterventionProviding for safetyMeeting physiologic needsProviding therapeutic communicationPromoting appropriate behaviorsManaging medications (see Tables 17.6 and 17.7)Providing patient, family teachingEvaluation
27 Suicide Intentional act of killing oneself Suicidal ideation: thinking about killing oneselfWarning signs: risk for suicide (see Box 17.4)
28 Suicide (cont.) Assessment: Previous suicide attempts (first 2 years after— highest risk period, especially first 3 months); relative who committed suicideWarnings of suicidal intent (see Box 17.4); risky behaviorLethality assessmentData analysis/nursing diagnoses
29 Suicide (cont.) Outcome identification Safety, free from self-harm InterventionAuthoritative roleSafe environment: suicide precautions; no suicide/no self-harm contractSupport system list
30 Suicide (cont.) Family response Suicide as ultimate rejection of family, friendsFamilies react with guilt, shame, anger
31 Suicide (cont.) Nurse’s response Need for unconditional positive regard for personAvoidance of patient blameNonjudgmental approach, toneBelief that one person can make a difference in another’s lifePossible devastation of staff if patient commits suicide
32 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
33 Question Is the following statement true or false? When dealing with a patient who is suicidal, the nurse needs to assume a dependent role.
34 AnswerFalseRationale: When dealing with a patient who is suicidal, the nurse must take an authoritative role.
35 Elder ConsiderationsDepression common among the elderly; marked increase when elders are medically illPsychotic features commonIncreased intolerance to medicationsECT more commonly used for treatment; more rapid responseSuicide increased among elderly
36 Community-Based CareNurses as first health-care professionals to recognize behaviors consistent with mood disordersSuccessful treatment of depression in community by psychiatrists, psychiatric advanced practice nurses, primary care physicians
37 Community-Based Care (cont.) Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment
38 Mental Health Promotion Education to address stressors contributing to depressive illnessEfforts to improve primary care treatment of depressionPrevention and early detection, treatment for adolescents
39 Mental Health Promotion (cont.) Screening for early detection of risk factorsFamily strifeParental alcoholism or mental illnessHistory of fightingAccess to weapons in the home
40 Self-Awareness Issues Importance of dealing with own feelings about suicideFrustration possible when working with depressed or manic patientsExhaustion possible when working with manic patientsJournaling to help deal with feelings; talking with colleagues often helpful