Transcript Mood Disorders

Overview and Treatments
By: Aiza Espanol
July 13, 2009
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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
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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
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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
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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
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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
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?
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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.
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.
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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
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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
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.
The following physiological and somatic and related
symptoms frequently accompany depression:
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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.
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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.
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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.
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.
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.
DOMAIN
DEPRESSION
MANIA
Affective
Sadness, unhappiness,
apathy, anxiety,
brooding
Elation, grandiosity,
irritability
Cognitive
Pessimism, guilt,
inability to concentrate,
suicidal thoughts
Flighty and pressured
thoughts, lack of focus,
poor judgment
Behavioral
Low energy, neglect of
personal appearance,
agitation
Overactive, speech
difficult to understand,
talkative
Physiological
Poor/increased
appetite, constipation,
sleep disturbances
High levels of arousal,
decreased need for
sleep
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.
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.
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.
MOOD
DISORDER
LIFETIME
GENDER
PREVALENC DIFFERENC
E (%)
ES
AGE OF
ONSET
COURSE
MAJOR
DEPRESSIVE
8.0-19.0
HIGHER IN
FEMALES
ANY AGE;
AVG. 20S
6+ MO; MAY
END/RECUR
DYSTHYMIA
6.0
HIGHER IN
FEMALES
CHILDHOOD
/ADOLESCE
NCE
CHRONIC;
PRECEDE
MAJOR DEP.
BIPOLAR I
0.4-1.6
NO MAJOR
DIFFERENCE
ANY AGE;
AVG. 20S
MANIC EPI.
USUALLY
RECURRING
BIPOLAR II
0.5
HIGHER IN
FEMALES
ANY AGE
HYPOMANIC
EPI.
NO
DIFFERENCE
ADOLESCEN
CE
CHRONIC
HYPOMANIC
CYCLOTHYM 0.4-1.0
IA
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.
 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
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Actions
• Recommended for patients w/symptoms of moderate to
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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
 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
 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
 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
 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
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Planning
• Review data collected to identify patient’s strength and
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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
 Planning
• Identify areas in which the patient is capable of input
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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
 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
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Implementation
• Nursing interventions must be individualized and based
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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
 Implementation
• Throughout course of treatment, discuss meds and
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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
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Risk for self-directed violence (indication)
Hopelessness (indication)
Dysfunctional grieving (indication)
Ineffective coping (indication)
Social isolation (indication)
Disturbed sensory perception, visual or auditory
(indication)
 Cleopatra
 Kurt Cobain
 Ernest Hemingway
 Adolf Hitler
 Jim Jones
 David Koresh
 Marilyn Monroe
 Freddie Prinze
 King Saul
 Samson
 Virginia Woolf
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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
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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