Mood Disorders

1. Mood Disorders Overview and Treatments By: AizaEspanol July 13, 2009

2. Key Terms Antidepressants: Pharmacologic class of drugs used to treat depression; can be subdivided into the MAOIs, TCAs (tricyclic antidepressants), SSRIs, and miscellaneous group of agents Bipolar Disorder: A category of mood disorders characterized by one or more manic or hypomanic episodes and, usually, by one or more depressive episodes Cognitive Symptoms: Inability to concentrate, slowed thinking, confusion, and poor memory of recent events; common in older patients with depression Cyclothymic Disorder: A chronic and relatively continual mood disorder characterized by hypomanic episodes and depressed moods that do not meet the criteria for major depressive episode

3. Key Terms (Cont.) Depression: An emotional state characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others Depressive Disorders: DSM-IV-TR category including major depressive disorders, dysthymic disorder, and depressive disorders not otherwise specified; also known as unipolar disorders because no mania is exhibited Dysthymic Disorder: A disorder characterized by chronic and relatively continual depressed mood that does not meet the criteria for major depression Euphoria: heightened mood

4. Key Terms (Cont.) Grandiose Delusions: Persistent irrational beliefs that somehow exaggerate the person’s importance, such as believing oneself to be a famous person, or having an enviable position such as being the President or God Labile Mood: Mood swings that often shift rapidly towards anger and irritability Learned Helplessness: Acquiring the belief that one is helpless and unable to affect the outcomes in one’s life Lethality: The probability that a person will choose to end his or her life

5. Key Term (Cont.) Major Depression: A disorder in which a group of symptoms, such as depressed mood, loss of interest, sleep disturbances, feelings of worthlessness, and an inability to concentrate, are present for at least 2 weeks Mania: An emotional state characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity Mood: Sustained, emotional feeling perceived along a normal continuum of sad to happy Mood Disorder: Disturbances in emotions that cause subjective discomfort, hinder a person’s ability to function, or both; depression and mania are central to these disorders

6. Key Terms (Cont.) Neurotransmitters: Chemical substances that are released by axons of sending neurons and that are involved in the transmission of neural impulses to the dendrites of receiving neurons Psychological Autopsy: The systematic examination of existing information for the purpose of understanding and explaining a person’s behavior before his or her death Psychomotor Symptoms: Slowed or retarded movements, thought processes, and speech, or conversely, agitation manifesting as purposeless, restless motion Suicide: The intentional, direct, and conscious taking of one’s own life

7. Focus Questions What are the symptoms of mood disorders? How are mood disorders classified in the APA diagnostic scheme? Why do people develop depression and mania? What kinds of treatment are available for people with mood disorders, and how effective are the therapies? What do we know about suicide? Why do people decide to end their lives? How can we intervene or prevent suicides?

8. Mood Disorders and Suicide We have all felt depressed or elated at some time during our lives. The loss of a job or the death of a loved one may result in depression; good news may make us manic (for example, ecstatic, hyperactive, and brazen). Although the vast majority of people with mood disorders do not commit suicide and although many suicides are not attributable to depression, we include the topic of suicide with mood disorders because depression is implicated in many suicides.

9. M.D. and Suicide (Cont) Mood Disorders are disturbances in emotions that cause subjective discomfort, hinder a person’s ability to function, or both. Depression and mania are central to these disorders. Depression is characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others. Mania is characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity.

10. M.D. and Suicide (Cont.) Prevalence of depression has been found to be more than 10 times higher than that of mania Depression is quite prevalent in the general population and is much higher among women than men Some 10 million Americans, and more than 100 million people worldwide, will experience clinical depression Lifetime prevalence (the proportion of people who develop severe depression at some point in their lives) ranges from 10 to 25 percent for women and from 5 to 12 percent for men

11. M.D. and Suicide (Cont.) Large-scale study has found even higher overall lifetime prevalence rates for all mood disorders- reaching almost 15% for adult males and almost 24% for adult females Among college students, one survey found that over half indicated that they had experienced depression, 9% had thought of suicide, and 1% had attempted suicide since the beginning of college Depression shortens life expectancy and increases the risk of dying from heart disease by as much as threefold Severe depression may afflict the rich or the poor, the successful or the unsuccessful and the highly educated or uneducated

12. Symptoms of Depression Certain core characteristics are often seen among people with depression. These characteristics may be organized within the four psychological domains used to describe anxiety: affective domain, cognitive domain, behavioral domain, and physiological domain.

13. Symptoms of Depression (Cont.) The following physiological and somatic and related symptoms frequently accompany depression: Loss of appetite and weight. The loss of appetite often stems from the person’s disinterest in eating; food seems tasteless. In severe depression, weight loss can become life threatening. Some people, however, have increased appetite and gain weight. Constipation. The person may not have bowel movements for days at a time.

14. Symptoms of Depression (Cont.) Sleep disturbance. Difficulty in falling asleep, waking up early, waking up erratically during the night, insomnia, and nightmares that leave the person exhausted and tired during the day. Some depressed people, however, show hypersomnia, or excessive sleep. Disruption of the normal menstrual cycle in women. The disruption is usually a lengthening of the cycle, and the woman may skip one or several periods. The volume of menstrual flow may decrease.

15. Symptoms of Depression (Cont.) Aversion to sexual activity. Many people report that their sexual arousal dramatically declines. Culture influences the experience and expression of symptoms of depression. In some cultures, depression may be experienced largely in somatic or bodily complaints, rather than in sadness or guilt. Complaints of “nerves” and headaches (latino and Mediterranean), of weakness, tiredness, or “imbalance” (Chinese and Asians), of problems of the “heart” (Middle Eastern), or of being “heartbroken” (among Hopi) may reveal the depressive experience.

16. Symptoms of Mania In mania, affective symptoms include elevated, expansive, or irritable mood. Social and occupational functioning is impaired. People with mania show boundless energy, enthusiasm, and self assertion. If frustrated, they may become profane and quite belligerent. People who suffer from serious forms of mania display more disruptive behaviors, including pronounced overactivity, grandiosity, and irritability. Their speech may be incoherent and they do not tolerate criticisms or restraints imposed by others.

17. Symptoms of Mania (Cont.) In the more severe cases of mania, the person is wildly excited, rants and raves (“maniac”), and is constantly agitated and on the move. Hallucinations and delusions may appear. The most prominent somatic characteristic is a decreased need for sleep, accompanied by high levels of arousal.

18. Recap of Symptoms of Depression and Mania

19. Classification of Mood Disorders Mood disorders are largely divided into 2 major categories: depressive disorders (often referred to as unipolar disorder) and bipolar disorder. Once a depressive or manic episode occurs, the disorder is classified into both a category and a subcategory.

20. Classification: Depressive Disorders Depressive disorders include major depressive disorders, dysthymic disorder, and depressive disorders not otherwise specified. All of these disorder classifications include no history of a manic episode. People who experience a major depressive episode are given the diagnosis of MAJOR DEPRESSION. Symptoms should have been present for at least 2 weeks and should represent a change from the individual’s previous functioning. The symptoms of major depression include a depressed mood or a loss if interest or pleasure, weight loss/gain, sleep difficulties, fatigue, feelings of worthlessness, inability to concentrate, and recurrent thoughts of death. About ½ of those who experience a depressive episode eventually have another episode. In general, the earlier the age of onset, the more likely is a recurrence. If a disorder is characterized but does not meet the criteria of major depression then it is usually diagnosed as a dysthymic disorder.

21. Classification: Bipolar Disorders The essential feature of bipolar disorders is the occurrence of one or more manic or hypomanic episodes; the term bipolar is used because the disorders are usually accompanied by one or more depressive episodes. Symptoms of manic episodes include abnormally and persistently elevated, expansive, or irritable moods lasting at least 1 week in the case of mania and 4 days in the case of hypomania. Grandiosity, decreased need for sleep, flight of ideas, distractibility, and impairment in occupational or social functioning are often observed in persons with this disorder.

22. Disorders Chart: Mood Disorder

23. Etiology of Mood Disorders Little is known about what causes the extreme mood changes in the bipolar disorders. Some research findings raise the possibility that manic symptoms in bipolar disorder are manifestations of dysregulation in the brain activation system, which corresponds to neural pathways in the brain. In any case, much more is known about what causes unipolar depression than about what causes the bipolar disorders, and psychological-sociocultural perspectives focus primarily on depression rather than on mania.

24. Treatment of Mood Disorders Treatment consists primarily of controlling the level of neurotransmitters at brain synapses Treatment usually requires both nonpharmacologic and pharmacologic therapy Drug therapy Psychotherapy Electroconvulsive Therapy

25. Drug Therapy for Mood Disorders • Actions • Recommended for patients w/symptoms of moderate to severe depression • Should be considered for patients that does not respond well to psychotherapy • Accomplished w/several classes of drugs known as antidepressants • All have varying degrees of effect on norepinephrine, dopamine, and serotonin by blocking reuptake and reducing destruction of these neurotransmitters, thereby prolonging their action • Development of a clinical antidepressant response requires at least 2-4 weeks of therapy at adequate dosages • Exact mechanism of action is unknown

26. Drug Therapy for Mood Disorders (Cont.) • Uses • Two important factors in selecting antidepressant: history of response to previously prescribed antidepressants and the potential for adverse effects associated with different classes of antidepressants • There are no differences among antidepressant drugs in relative overall therapeutic efficacy and onset caused by full therapeutic dosages (except MAOIs) • There are substantial differences in the adverse effects caused by different agents

27. Drug Therapy for Mood Disorders (Cont.) • Uses • Approximately 65-70% of patients respond to antidepressant therapy • 30-40% achieve remission • Concurrent medical conditions such as obesity, seizure history, potential for dysrhythmias, presence of anxiety and potential for drug interactions must also be considered in therapy selection • Patients must be counseled on expected therapeutic benefits and adverse effects to be tolerated from antidepressant therapy

28. Drug Therapy for Mood Disorders (Cont.) • Uses • Physiologic manifestations of depression begin to alleviate within 1st week of therapy • Psychological symptoms will improve after 2-4 weeks time • Pharmacologic treatment of bipolar disorder must be individualized because the clinical presentation, severity, and frequency of episodes vary widely among patients

29. Nursing Process • Assessment • History of Mood Disorder • Basic Mental Status • Interpersonal Relationships • Mood/Affect • Clarity of Thought • Thoughts of Death • Psychomotor Function • Sleep Patterns • Dietary History • Nonadherence

30. Nursing Process (Cont.) • Planning • Review data collected to identify patient’s strength and weaknesses • Review meds being taken • Plan to perform a baseline assessment of the patient’s mental status at specific intervals throughout the course of treatment • Review coping mechanisms used • Schedule specific times to discuss the patient’s behavior and foster understanding of it with family members • Review assessment data to develop strategies to assist the patient cope more effectively with exhibited factors

31. Nursing Process (Cont.) • Planning • Identify areas in which the patient is capable of input to set goals and make decisions • Provide a safe environment for the patient • Review activities offered within the clinical setting and plan for the patient to participate in those that will benefit and foster success • Plan to schedule specific rounds to evaluate the patient’s sleep and safety • Provide the patient an opportunity to be involved in selecting foods appropriate to needs • Identify the level of assistance with self-care that is required

32. Nursing Process (Cont.) • Therapeutic Outcomes • Plan through the acute, continuation, and maintenance phases of care delivery to facilitate the patient to achieve the highest level of independent functioning

33. Nursing Process (Cont.) • Implementation • Nursing interventions must be individualized and based on assessment • Provide an environment of acceptance that focuses on the patient’s strengths while minimizing the weaknesses • Provide an opportunity for the patient to express feelings • Remain calm, direct, and firm in providing care • Allow patients to make decisions if capable • If suicidal, ask for details of the plan being formulated • Stay with patients who are highly agitated • Use physical restraints within guidelines

34. Nursing Process (Cont.) • Implementation • Throughout course of treatment, discuss meds and how it will benefit the patient • Patients, family, and caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, hostility etc. • Stress the importance of adequate hydration • Instruct patient to weigh daily • Enlist the patient’s aid in developing and maintaining a written record of monitoring parameters

35. Nursing Diagnoses Risk for self-directed violence (indication) Hopelessness (indication) Dysfunctional grieving (indication) Ineffective coping (indication) Social isolation (indication) Disturbed sensory perception, visual or auditory (indication)

36. Part II: Suicide

37. Famous People Cleopatra Kurt Cobain Ernest Hemingway Adolf Hitler Jim Jones David Koresh Marilyn Monroe Freddie Prinze King Saul Samson Virginia Woolf

38. Suicide (Cont.) The WHO (2002) found that suicide worldwide causes more deaths every year than homicide or war Suicide is now recognized as a serious threat to public health Suicide has many causes and people kill themselves for many different reasons Depression is involved in more than half of attempted suicides and is often related to unhappiness over a broken or unhappy love affair, marital discord, disputes with parents, and recent bereavements Suicide is not classified as a mental disorder

39. Facts about Suicide Every 20 min, someone in the US takes his or her life Approximately 31,000 persons kill themselves each year Persons under the age of 25 account for 15% of all suicides in 1997. These statistics has gradually increased over the years The completed suicide rate for men is about three to four times that for women Lowest incidence of suicide is found among people who are married and the highest among those who are divorced Over 60% of suicides are committed by firearms and 70% are accounted for by drug overdose More than 2/3 of the people who commit suicide communicate their intent to do so within 3 months of the fatal act