1. Chapter 17 Mood Disorders and Suicide

2. 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

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

4. 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

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

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

7. 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

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

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

10. 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

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 loss
Hypersomnia or insomnia
Impaired concentration, decision making, or problem solving
Worthlessness, hopelessness, despair, guilt
Thoughts of death/suicide
Overwhelming fatigue, negative thinking

12. 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)

13. 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

14. 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)

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 considerations
Depression rating scales
Self-rating scales: Zung, Beck
Clinician rating scale: Hamilton Rating Scale

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

17. 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.

18. 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

19. 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

20. 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

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 cycles
Psychotherapy useful in mildly depressive or normal portion of bipolar cycle
Not useful during manic stages

22. 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)

23. 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

24. 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

25. 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.

26. 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

27. Suicide Intentional act of killing oneself
Suicidal ideation: thinking about killing oneself
Warning 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 suicide
Warnings of suicidal intent (see Box 17.4); risky behavior
Lethality assessment
Data analysis/nursing diagnoses

29. 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

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

31. 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

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

35. 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

36. 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

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 illness
Efforts to improve primary care treatment of depression
Prevention and early detection, treatment for adolescents

39. 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

40. 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