Transcript Mood Disorders

Mood Disorders
Elisa A. Mancuso RNC, MS, FNS
Professor
Mood Disorder Continuum
Well
Sadness
Grief
Neurotic
Dysthymic
Cyclothymic
Psychotic
MDD
Bipolar
14 million Americans have major affective
disorder.
↑ incidence in younger women & older men.
Related Mood Disorders
 Dysthymia = “Down in the Dumps”
 Chronically depressed mood x 2 years
 ↓ Energy Anhedonia Social Withdrawal
 Feelings of hopelessness
 Insomnia or Hypersomnia
 ↓ Self-Esteem ↓ Worthlessness ↓ Concentration
 Symptoms never disappear for more than 2 mos
@ a time
 ↑ Incidence to develop MDD
 15 % commit suicide
Related Mood Disorders
 Cyclothymia
– Cycles of mild depression & hypomania x 2
years
– Hypomania 4 days of persistent up mood
Depression
↓ Self-Esteem
↑↑ Sleeping
Social Withdrawal
↓↓ Productivity
Hypomania
Inflated self-esteem
↓↓ Sleeping
People seeking
↑↑ Productivity
Related Mood Disorders
 Seasonal Affective Disorder SAD
– ↑ Depression with shortened daylight in fall &
winter
– Disappears during spring & summer
– Episodes occur @ same time of year
 2 years in a row
– Hypersomnia & daytime drowsiness
– ↑↑ Appetite for carbs & sugars = ↑ wt. gain
Seasonal Affective Disorder SAD
 Etiology:
– ↓ Exposure to light & ↓ Melatonin
– Failure of body to adjust to stressors
– Disrupted circadian rhythms due to head trauma
 Therapy:
– Timed exposure to special light (4-6H/d)
– Synchronizes circadian rhythms
– ↑↑ Melatonin production =
– Euthymia (normal mood & usual behaviors)
Related Mood Disorders
 Postpartum Depression
– Onset within 1st 30 days → 12 months.
– 10-15 % incidence with abrupt onset.
– Severe labile mood symptoms:
 Tearfulness
Despondency
 Anxiety
↓ Concentration
– Delusional thoughts of infant’s health (Over
concern)
– ↑ Risk injury to infant & Mom
– Therapy:
 Medication & Hospitalization
Major Depressive Disorder MDD
 Presence of the following symptoms > 2 weeks:
– ↑↑ Sadness
– Anhedonia- inability to feel pleasure
– Psychomotor retardation
– ↓/↑ Appetite & weight
– ↓ Energy Level Hopelessness ↓ Self-Esteem
– ↓/↑ Sleeping ↓ Concentration/Decision Making
– Worthlessness & guilt
– Recurrent thoughts of death or suicide
MDD Etiology
 Genetic
– Transmission via different genes (# 6 or # 11)
– ↑ Risk of incidence 25% 1st degree relative
– ↑ Hereditability 50 % Bipolar Disorder
 75% identical twins
 Biochemical
– Deficiency of neurotransmitters ACh
– ↓↓ NE, ↓↓ 5-HT, ↓ DA & ↑↑ GABA
– ↑ Cortisol RT ↓ response to CRF
 Psychosocial
– Anger turned inward
– Unresolved trauma or early life loss.
– Learned Helplessness = Powerless Ego
– Early stress contributes to self-defeating pattern
– “Glass is ½ empty” View in a negative manner
MDD Risk Factors
 Hx of Depression (self or family)
 Female onset @ age 40
 Stressors:
– ↓ Financial resources/Unemployed
– > 3 children @ home
– ↓ Social support
– Sexually abused
– Co-Morbidity DM, HTN, CA, CAD
 Prior suicide attempts!
Clinical Symptoms
 Suicidal Ideation
– Negative thoughts of self-hate & hostility
– Recurrent thoughts of death
– ↓ Social & personal resources
– Verbalize desire to die
– Patient getting better =↑↑↑ Risk
– ↑ Lethality = Describe specific plan & access!
 Need immediate intervention!
– All depressed patients are potentially suicidal!
 80% of 30,000 suicides/year
Nursing Interventions
 Promote Safety!
– Suicide precautions
– Vigilant observations q 15 minutes
– Quiet, warm accepting attitude
– Monitor for hoarding medications
 √ clothes, mattress, personal belongings
 Promote Physical Well-being.
– Nutrition & elimination √ I & O
– Personal hygiene needs
– Schedule regular mealtimes & stay with pt
– Establish regular hours for sleep
– Encourage participation in regular exercise
Nursing Interventions
 Assist with Grief Process
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Encourage verbalization to acknowledge loss
Patience-build trust & convey acceptance
Identify secondary gains
Encourage participation in support group
 Enhance Self-Esteem
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Schedule regular meeting times = Pt importance
Redirect to focus on present problems
Identify (+) attributes & achievements
Have pt make an antidepressant kit
↑ Social interaction via group activities
Assign responsibilities (arrange chairs in dayroom
for meetings)
Nursing Interventions
 Assist Pt to take control over life
– Support decision making attempts
– Encourage problem solving
– Have Pt develop a daily schedule
– Allow sufficient time to think & act.
– Clearly communicate expectations
 Attendance @ mealtimes, group meetings, etc.
– ↑ Autonomy for longer periods of time
Nursing Interventions
 Confront anger turned inward
– Identify feelings of anger & possible triggers
– Offer acceptable alternatives of releasing
anger
 Ripping paper, throwing nerf ball, yelling
 Physical exercise –walking releases
tension
– Expressing emotions via
–Journaling
–Painting, drawing
Medications
 TriCyclic Antidepressants –TCAs
– Formerly 1st choice
– Delayed onset of action 2-3 weeks
 Optimal response in 1 month
– Need adequate dose & duration 4-9 months
– Blocks reuptake of NE, 5-HT & DA
– ↑↑ Receptor sensitivity
– ↑↑ NE, 5-HT & DA available @ receptor site
– ↑ mood ↑ appetite ↑activity & regular sleep
patterns
TCA Medications
Amitriptyline (Elavil)
Amoxapine (Asendin)
Desipramine (Norpramin) Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
 Moderate – Severe depression
 TCA Side Effects
– Dose related = ↓ dose = ↓ SE
– Start low & go slow
– Potentially lethal if 3x Max therapeutic dose
 Not responsive to dialysis = fatal!
TCA Side Effects
Anticholinergic
Dry mouth
Urinary retention
Blurred vision
Photophobia
↓ Diaphoresis
Cardiovascular
Orthostatic ↓ BP
↑ HR
Arrhythmias
Prolonged QRS
& QT
CHF
TCA Side Effects Cont.
Neurological
Sedation
↓ Concentration
Fatigue
Muscle Weakness
Tremors & Seizures
Gastrointestinal
Heartburn
N&V
↓ Motility
Constipation
Paralytic Ileus
TCA Side Effects Cont
 Other
– Rashes
– Photosensitivity
– ↓ Sexual Performance
 ↓ Orgasm & Impotence
 TCA Contraindications
– Cardiac HX (MI)
– Hepatic or Renal insufficiency
– Closed <) glaucoma
– Seizures
TCA Drug Interactions
 MAO Inhibitors
– 14 day waiting period TCA- MAOI
 Cardiac Meds
– √ BP may ↑ or ↓
 Antacids
– Inhibit TCA absorption
 Antipsychotics
– Potentiate anticholinergic effects, EPS,
sedation & seizures
Atypical Antidepressants
Bupropion (Wellbutrin)
Selective DA reuptake inhibitor (No affect on 5-HT)
SE: ↑ Seizures ↓ Weight
↓ Nicotine craving
↑ Sexuality
Mirtazapine (Remeron)
Blocks 5-HT receptor
Dissolves orally
SE: ↑ Sedation ↑ Weight
↑Serum Cholesterol (LDL & HDL)
Nefazodone (Serzone) * Trazodone (Desyrel)**
5-HT reuptake inhibitor & receptor blocker
SE: * Inhibits P450 system = drug toxicity & hepatic failure
** Priapism, Orthostaic ↓ BP, Sedation
Venlafaxine (Effexor)
Selective 5-HT & NE reuptake inhibitor
SE: Low anticholinergic ↑ BP @ ↑ doses
Selective Serotonin Reuptake Inhibitors
SSRIs
Citalopram (Celexa) Fluxoxetine(Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
 Block reuptake of 5-HT = ↑↑ availability
 Mood elevation
 SE: ↓ Anticholinergic, cardiac & sedating
– Nausea
– Dizziness
Nervousness
Agitation HA
Sexual Dysfunction ↓ Weight
Serotonin Syndrome
 ↑↑ Risk with MAOIs, Tryptophan or St. John’s Wort
 SSRIs inhibit P450 enzymes
– ↑↑ levels of un-metabolized drugs
Clinical Signs:
 ↓Mental status Confusion
 Restlessness Agitation
 ↓Diaphoresis Chills
 Diarrhea
Nausea
Hypomania
HA
Myoclonus/Hyperreflexia
Abdominal cramps
Ataxia
Monoamine Oxidase Inhibitors
MAOIs
Isocarboxiazid (Marplan) Phenelzine (Nardil)
Tranylcypromine (Parnate)
Moclobemide (Menerix)
 3rd choice due to fatal SE & drug interactions
 Irreversibly Inhibits monoamine oxidase (MAO)
– MAO deactivates NE, DA & 5-HT & tyramine → inactive
products
 No MAO = ↑↑ NE ↑↑ DA ↑↑ tyramine = ↑↑ BP
 Hypertensive Crisis
 Lethal dose = 6-10x daily dose!
Monoamine Oxidase Inhibitors
MAOIs
 Avoid food, drinks & meds that contain tyramine!
– 3 days before starting, during and 14 days after med
DC’d
 Dietary restrictions =↑↑ tyramine content
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Cheese –aged & processed
Beer
Red wine
Caffeine
Cola/Coffee
Chocolate
Cold cuts
Yeast
Sour cream Smoked Fish
MAOIs SE
 Lethal Dose = 6-10x daily dose!
 Anticholinergic
– Dry mouth, Blurred vision, Constipation
 CNS
– Agitation, Restlessness, Tremors & HA
 Cardiac
– Orthostatic ↓ BP, Heart failure
 GU
– Urinary Retention, ↓ Orgasms
MAOIs SE
 Hypertensive Crisis
– Explosive HA (Occipital → Frontal)
– ↑↑ BP (Sudden Elevation = CVA)
– ↑↑ HR , Palpitations = Chest Pain
– ↑↑ Temp, Diaphoresis,
– Dilated pupils = Photophobia
 Nursing Interventions
– VS q 5 mins
High Fowlers Position
– Cooling Blanket
Hold MAOI med!
– Meds
 Thorazine 100mg IM ( Blocks NE & DA)
 Procardia 10 mg PO/IV ( Vasodilator)↓↓ BP
 Regitine IV (Vasodilator) ↓↓ BP
Electroconvulsive Therapy ECT
 Severe Depression, Bipolar,
Schizophrenia
– When medications are ineffective
– 6 -15 treatments (3x/week)
– Response rate = 90%!
 “Jump Start” neurotransmitter receptors
– ↑ NE ↑ 5-HT ↑ DA
 SE
– Transient confusion
ECT
 Out Pt. Procedure
– Complete PE & HX
 Contraindications: Brain tumor, ↑ ICP,
CVA, ↑ BP
– Informed consent & NPO 6-8 hours
– Assess mood & thought process
– Remove prosthesis & void a ECT
– Current (70-125 volt) applied to frontal lobe
 Induces seizure for 25 -90 seconds
– Post procedure VS, Maintain airway, √ Gag reflex,
Reorient & Assess mood/behavior
ECT Medications
Glycopyrrolate (Robinul) 0.2-0.4 mg IM 30
mins a
 ↓ secretions & blocks vagal reflex = HR
remains WNL
Methohexital (Brevital) 1.5 mg/kg IV
 Anesthetic = ↓ RR ↓ BP & ↓↓ CO
Succinylcholine CL (Anectine) 0.75 mg/kg IV
 Muscle relaxant & prevents generalized
Gran mal seizure
 Apnea & Respiratory depression
Bipolar Disorder
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Mood extremes, 1 or more manic episodes
Sudden onset early 20’s
↑ risk with highly educated = 2 million/year
↑ substance abuse & ↑ suicide (10-15%)
Etiology
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Altered Family Dynamics
↑↑ Ambivalence
↑↑ NE & DA
↑↑ Intracellular Na & Ca = ↓↓ Serum Na & Ca
 Neuronal Irritability
– 5-HT remains low
Bipolar Disorder
 Manic Episode
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↑ Self Esteem = Grandiosity
Pressured speech & Intrusive
Euphoria
Aggressive, Sarcastic & Manipulative
Flight of ideas & Distractible
Dress Bizarrely & ↑↑ Makeup
↑ Psychomotor agitation = ↓ Work production
↓ Sleep only 1-2 hours/day
↓ Nutritional Status RT Don’t eat or drink
↑ Pleasure seeking activities = ↑ Sexuality
Nursing Interventions
 Safety
– ↓ Environmental stimuli
– Protect from harm to self or others
– Consistent limit setting
 Restoration of Nutritional Balance
– 6 small meals/day
Finger foods
– ↑ Fluids ↑ Cal ↑ Protein √ I & O
 Improve Social Behaviors
– Reinforce reality Focus on 1 idea
– Simple concise explanations
– Appropriate hygiene & dress
 Channel Energy
– Redirect activities to “work off energy”
– Exercise Walking
Avoid competitive games
– JournalsCreative outlets- Drawing, Painting, Music
Medications
 Lithium (Eskalith, Lithobid)
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Alters Na transport in nerves & cells
↓ Intracellular Na & Ca
Enhances reuptake of NE & 5-HT
↓↓ NE & 5-HT = ↓↓ Hyperactivity
Li competes with Na for absorption
 ↑ Na = ↓ Li
 ↑ Li = ↓ Na
↑↑ Na intake = ↓↓ Li available & ↓↓ serum Li
– √ Serum Li level (weekly)
 Therapeutic 0.5 -1.4 mEq/L
 Toxic 1.5 -2.0 mEq/L
 Lethal > 2.0 mEq/L
 Lithium Side Effects
– Fine hand tremors
Transient nausea
– Metallic taste
Diarrhea
– Blurred Vision
↑↑ Weight
– Fatigue/Drowsiness Lightheadedness
– Polyuria & Polydipsia
 Li Toxicity >1.5 mEq (↓↓ Na & ↑↑ Li)
– Dizziness Ataxia
– Persistent N & V
– EKG ▲ → Cardiac Arrest
– Seizures
Coma
+4 Reflexes
Severe ↓↓ BP
Lithium Toxicity
 Etiology
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↓↓ Na or overdose of Li
Diuretics = ↓↓ Na & ↓↓ Li renal clerance
↓ Renal functioning
3 Ds (Diarrhea, Diaphoresis & Dehydration)
 Fluid & Electrolyte loss
 Therapy
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Rapid Assessments √ VS & √ LOC
Hold all Li doses
↑ Hydration (5-6 L/d) NS to promote excretion
Diuresis & Hemodialysis
Anticonvulsants
 Used for mood stabilizing effects
 For Pts who failed to respond to LI
Or Li contraindicated (Pregnancy, Renal, Cardiac)
 Carbamazepine (Tegretol)
– ↓ Rate of impulse transmission
– Serum level 8-12 ug/mL
– Dizziness
Ataxia
– Hepatotoxicity
N&V
– Agranulocytosis
Anemia
Thrombocytopenia
 Divalproex (Depakote)
Gabapentin (Neurontin)
 Lamotrigine (Lamictal)
Topiramate (Topamax)
 Oxcarbazepine (Trileptal)
Suicide
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30,000 year 2nd cause of death 15-34 age
5-6% occur in inpatient psych unit
10-20 unsuccessful attempts q suicide
Risk factors
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Mood Disorders
Hopelessness
Schizophrenia
Command Hallucinations
Substance Abuse
↓ Resources ($, social)
European American > 65 years
Mondays in the Spring
Prior suicide attempts
↑↑ Detailed Plan = ↑↑ Risk & ↑↑ Lethality
Suicide
 80% of attempts Pts give clues!
 Behavioral
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Verbal cues- “The pain will be over soon”
Obtaining a gun # 1 method.
Hoarding pills & getting multiple refills
Give away prized personal belongings
Suicidal gestures: Non-lethal self injury acts
 Affective
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Ambivalence ( between life & death)
Loss of emotional attachments
Desolation Guilt
Shame
Sudden Happiness or relief
Suicide
 Cognitive
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Poor problem solvers
Fantasy “Reunion Wish” = meeting dead relatives
Command Hallucinations
Suicidal Ideation = Thought, “How to method”
 Nursing Interventions
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Take all gestures seriously!
Assess suicidal intent
Stay c Pt and maintain safety
Establish a “No harm contract”
Suicide Interventions
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Explore feelings & motive
Focus discussion on events & activities
Encourage ↑ participation & attendance
↑ Interaction with ↑ # of people
Mobilize social support system
Assess perception of the situation
Promote decision making & autonomy
Identify strengths & alternative coping skills
Grief
 A subjective state that follows loss
– Object, relationship or situation
 Grief Process = Bereavement
– Healthy, & necessary to dissolve bonds
– Reaction and final adjustment to new life depends
on:
 Significance of loss & degree of dependence
– Behaviors
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Tears
Overwhelming feelings of loss
Guilt
Social withdrawal
Anorexia/ GI symptoms
Dizziness
HA
↓ Concentration
Anger
Anxiety
Lethargy “Feel
Drained”
Grief
 Unresolved Grief
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Prolonged grief Loss of self esteem
Unable to resume usual routine/ADLs
Psychotic symptoms –Reclusiveness
Psychosomatic Disorders
 Asthma
IBD
RA
– ↑ Acting out behavior = ↑↑ Hostility
 Therapy
– RN must 1st accept own mortality
– Encourage expressions of feelings to identify the degree of
loss
– Listening = single most important communication skill!
– Maintain dignity & incorporate cultural/spiritual beliefs
– Facilitate life review & saying good by
– Accept loss emotionally & intellectually
 Realistically remember (+) & (-) aspects
– Find new ways of sharing life