Chapter 15
Mood Disorders
Mood Disorders
Pervasive alterations in emotions
that are manifested by depression,
mania, or both, and interfere with
the person’s ability to live life
Categories
• Major depression: 2 or more weeks of
sad mood, lack of interest in life
activities, and other symptoms
• Bipolar disorder (formerly called
“manic-depressive illness”): mood
cycles of mania and/or depression
and normalcy and other symptoms
Related Disorders
• Dysthymia: sadness, low energy, but not
severe enough to be diagnosed as major
depression disorder
• Cyclothymia: mood swings not severe
enough to be diagnosed as bipolar disorder
• Substance-induced mood disorder
• Mood disorder due to a general medical
condition
Related Disorders (cont’d)
• Seasonal affective disorder (SAD)
• Postpartum or “maternity” blues
• Postpartum depression
• Postpartum psychosis
Etiology
Biologic theories
• Genetics
• Neurochemical theories
• Neuroendocrine or hormonal
fluctuations
Etiology (cont’d)
Psychodynamic theories
• Self-reproach to anger turned inward
• Inability to achieve personal ideals
• Powerless ego
• Manic episodes are a “defense” against depression
• Reaction to a distressing life experience
• Rejecting or unloving parents
• Resulting from specific cognitive distortions
Cultural Considerations
• Other behaviors considered age-appropriate can
mask depression
• Somatic complaints are a major manifestation
among cultures that avoid verbalizing emotions
– Asians who are anxious or depressed are more
likely to have somatic complaints of headache,
backache, or other symptoms
– Latin cultures complain of “nerves” or headaches
– Middle Eastern cultures complain of heart
problems
Major Depressive Disorder
• Twice as common in women and more common in single
or divorced people
• Involves 2 or more weeks of sad mood, lack of interest in
life activities, and at least four other symptoms:
– Changes in appetite or weight, sleep, or psychomotor
activity
– Decreased energy
– Feelings of worthlessness or guilt
– Difficulty thinking, concentrating, or making decisions
– Recurrent thoughts of death or suicidal ideation, plans, or
attempts
• Untreated, can last 6 to 24 months; recurs in 50% to
60% of people
• Symptoms range from mild to severe
Treatment and Prognosis
Antidepressants
• SSRIs (Prozac, Zoloft, Paxil, Celexa) prescribed for
mild and moderate depression
• TCAs (Elavil, Tofranil, Norpramin, Pamelor,
Sinequan) used for moderate and severe
depression
• Atypical antidepressants (Effexor, Wellbutrin,
Serzone)
• MAOIs (Marplan, Parnate, Nardil) used infrequently
because interaction with tyramine causes hypertensive
crisis
• Electroconvulsive therapy (ECT) is used when
medications are ineffective or side effects are
intolerable.
– 6 to 15 treatments scheduled three times a week
– Preparation of a client for ECT is similar to
preparation for any outpatient minor surgical
procedure
– The client will have some short-term memory
impairment
• Psychotherapy in conjunction with medication is
considered most effective treatment; useful
therapies include behavioral, cognitive,
interpersonal therapy
Application of the Nursing Process:
Major Depressive Disorder
Assessment
• History: the client’s perception of the problem, behavioral
changes, any previous episodes of depression, treatment,
response to treatment, family history of mood disorders,
suicide, or attempted suicide
• General appearance and motor behavior: slouched posture,
latency of response, psychomotor retardation or agitation
• Mood and affect: hopeless, helpless, down, anxious, frustrated,
anhedonia, apathetic; affect is sad, depressed, or flat
• Thought processes and content: slowed thinking processes,
negative and pessimistic, ruminate, thoughts of dying or
committing suicide
Application of the Nursing Process: Major
Depressive Disorder (cont’d)
Assessment (cont’d)
• Sensorium and intellectual processes: oriented, memory impairment,
difficulty concentrating
• Judgment and insight: impaired judgment, insight may be intact or
limited
• Self-concept: low self-esteem, guilty, believe that others would be
better off without them
• Roles and relationships: difficulty fulfilling roles and responsibilities
• Physiologic considerations: weight loss, sleep disturbances, lose
interest in sexual activities, neglect personal hygiene, constipation,
dehydration
• Depression rating scales: Zung Self-Rating Depression Scale, Beck
Depression Inventory, the Hamilton Rating Scale for Depression
Application of the Nursing Process: Major
Depressive Disorder (cont’d)
Data Analysis
Nursing diagnoses may include:
• Risk for Suicide
• Imbalanced Nutrition: Less Than Body Requirements
• Anxiety
• Ineffective Coping
• Hopelessness
• Ineffective Role Performance
• Self-Care Deficit
• Chronic Low Self-Esteem
• Disturbed Sleep Pattern
• Impaired Social Interaction
Application of the Nursing Process: Major
Depressive Disorder (cont’d)
Outcomes
The client will:
• Not injure himself or herself
• Independently carry out activities of daily living (showering, changing
clothing, grooming)
• Establish a balance of rest, sleep, and activity
• Establish a balance of adequate nutrition, hydration, and elimination
• Evaluate self-attributes realistically
• Socialize with staff, peers, and family/friends
• Return to occupation or school activities
• Comply with antidepressant regimen
• Verbalize symptoms of a recurrence
Application of the Nursing Process: Major
Depressive Disorder (cont’d)
Intervention
• Providing for the client’s safety and the safety of
others
• Promoting a therapeutic relationship
• Promoting activities of daily living and physical
care
• Using therapeutic communication
• Managing medications
• Providing client and family teaching
Application of the Nursing Process: Major
Depressive Disorder (cont’d)
Evaluation
• Does the client feel safe?
• Is the client free of uncontrollable urges to commit
suicide?
• Is the client participating in therapy and
medication compliance?
• Can the client identify signs of relapse?
• Will the client agree to seek treatment
immediately upon relapse?
Bipolar Disorder
• Occurs almost equally among men and
women
• It is more common in highly educated
people
• The mean age for a first manic episode
is the early 20s
Bipolar Disorder
• Involves mood swings of depression (same
symptoms of major depressive disorder) and mania.
Major symptoms of mania include:
– Inflated self-esteem or grandiosity
– Decreased need for sleep
– Pressured speech
– Flight of ideas
– Distractibility
– Increased involvement in goal-directed activity
or psychomotor agitation
– Excessive involvement in pleasure-seeking
activities with a high potential for painful
consequences
Treatment and Prognosis
Medication
• Lithium; regular monitoring of serum lithium
levels is needed
• Anticonvulsant drugs are used for their mood-
stabilizing effects: Tegretol, Depakote, Lamictal,
Topamax, and Neurontin, as is Klonopin (a
benzodiazepine)
Psychotherapy
• Useful in mildly depressive or normal portion of
the bipolar cycle. It is not useful during acute
manic stages
Application of the Nursing Process:
Bipolar Disorder
Assessment
• General appearance and motor behavior:
psychomotor agitation; flamboyant clothing
or makeup; think, move, and talk fast;
pressured speech
• Mood and affect: euphoria, exuberant
activity, grandiosity, false sense of well-
being, angry, verbally aggressive, sarcastic,
irritable
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Assessment (cont’d)
• Thought processes and content: flight of ideas,
circumstantiality, tangentiality, possible grandiose
delusions
• Sensorium and intellectual processes: oriented to
person and place but rarely to time, impaired
ability to concentrate, may experience
hallucinations
• Judgment and insight: judgment poor, insight
limited
• Self-concept: exaggerated self-esteem
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Assessment (cont’d)
• Roles and relationships: rarely can fulfill role
responsibilities, invade intimate space and
personal business of others, can become
hostile to others, cannot postpone or delay
gratification
• Physiologic and self-care considerations:
inattention to hygiene and grooming, hunger
or fatigue
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Data Analysis
Nursing diagnoses may include:
• Risk for Other-Directed Violence
• Risk for Injury
• Imbalanced Nutrition: Less Than Body Requirements
• Ineffective Coping
• Noncompliance
• Ineffective Role Performance
• Self-Care Deficit
• Chronic Low Self-Esteem
• Disturbed Sleep Pattern
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Outcomes
The client will:
• Not injure self or others
• Establish a balance of rest, sleep, and activity
• Establish adequate nutrition, hydration, and elimination
• Participate in self-care activities
• Evaluate personal qualities realistically
• Engage in socially appropriate, reality-based interaction
• Verbalize knowledge of his or her illness and treatment
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Intervention
• Providing for safety of client and others
• Meeting physiologic needs
• Providing therapeutic communication
• Promoting appropriate behaviors
• Managing medications
• Providing client and family teaching
Application of the Nursing Process:
Bipolar Disorder (cont’d)
Evaluation
• Safety issues
• Comparison of mood and affect between start of
treatment and present
• Adherence to treatment regimen of medication
and psychotherapy
• Changes in client’s perception of quality of life
• Achievement of specific goals of treatment
including new coping methods
Suicide
Assessment
Men commit suicide three times the rate of women
Women are four times more likely than men to attempt suicide
Populations at risk
• Men, young women, Caucasians, adults older than 65, and
separated and divorced people
• Clients with psychiatric disorders
Environmental factors include isolation, recent loss, lack of social
support, unemployment, critical life events, and family history
of depression or suicide
Behavioral factors include impulsivity, erratic or unexplained
changes from usual behavior, and unstable lifestyle
• Warnings of suicidal intent
• Risky behaviors
• Lethality assessment
– Does the client have a specific plan?
– Are the means available to carry out this plan?
– If the client carries out the plan, is it likely to be lethal?
– Has the client made preparations for death?
– Where and when does the client intend to carry out the
plan?
– Is the intended time a special date or anniversary that has
meaning for the client?
Outcomes
The client will:
• Not injure self or others
• Engage in a therapeutic relationship
• Establish a no-suicide contract
• Create a list of positive attributes
• Generate, test, and evaluate realistic plans
to address underlying issues
Intervention
• Using an authoritative role
• Providing a safe
environment
• Initiating a no-suicide
contract
• Creating a support system
list
Family Response
• Significant others may feel guilty, angry, ashamed, and
sad
Nurse’s Response
• The nurse does not blame or act judgmentally when
asking about the details of a planned suicide. Rather, the
nurse uses a nonjudgmental tone of voice and monitors
his or her body language and facial expressions to make
sure not to convey disgust or blame
• Nurses must realize that no matter how competent and
caring interventions are, a few clients will still commit
suicide. A client’s suicide can be devastating to the staff
members who treated the client
Legal and Ethical Considerations
• Often nurses must care for terminally
or chronically ill people with a poor
quality of life
• The nurse’s role is to provide
supportive care for clients and family
Elder Considerations
• Depression is common among the elderly and is
markedly increased when elders are medically ill
• Elders tend to have psychotic features, particularly
delusions, more frequently than younger people with
depression
• Suicide among persons over age 65 is doubled
compared with suicide rates of persons younger
than 65 years
• Elders are treated for depression with ECT more
frequently than younger persons
• Elder persons have decreased tolerance of side
effects of antidepressant medications
Mental Health Promotion
• Education to address stressors contributing
to depressive illness
• Promotion of factors reducing suicide risk in
adolescents (close parent–child relationships,
academic achievement, family life stability,
and connectedness with peers and others
outside the family)
• Screening for early detection of risk factors,
such as family strife, parental alcoholism or
mental illness, history of fighting, and access
to weapons in the home
Self-Awareness Issues
• Nurses and other staff members need
to deal with their own feelings about
suicide
• Depressed or manic clients can be
frustrating and require a lot of energy
to care for
• Keeping a written journal may help
deal with feelings; talking to colleagues
is often helpful
