Mood Disorders

Mood Disorder Continuum

Well Neurotic Psychotic

Sadness
Grief

Dysthymic
Cyclothymic

MDD
Bipolar

14 million Americans have major affective disorder. incidence in younger women & older men.

 Dysthymia = Down in the Dumps

Chronically depressed mood x 2 years Energy Anhedonia Feelings of hopelessness Insomnia or Hypersomnia

Related Mood Disorders

Social Withdrawal

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 infants health (Over concern) Risk injury to infant & Mom Therapy:

Medication & Hospitalization

 Presence of the following symptoms > 2 weeks:

Sadness Anhedonia- inability to feel pleasure Psychomotor retardation / Appetite & weight Energy Level / Sleeping Hopelessness Self-Esteem Concentration Decision Making Worthlessness Guilt Anxiety Recurrent thoughts of death or suicide

Major Depressive Disorder MDD

 Genetic Transmission via different genes (# 6 or # 11) Risk of incidence 25% 1st degree relative Hereditability 50 % Bipolar Disorder
75% identical twins

MDD Etiology

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 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 Active Substance Abuse

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

MDD 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

MDD Nursing Interventions

Assist with Grief Process
Encourage verbalization to acknowledge loss Patience-build trust & convey acceptance Identify secondary gains Encourage participation in support group

Enhance Self-Esteem
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

MDD 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

MDD 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) Desipramine (Norpramin) Imipramine (Tofranil) Amoxapine (Asendin) Doxepin (Sinequan) Nortriptyline (Pamelor)

TCA Side Effects Dose related = dose = SE Start low & go slow Potentially lethal if 3x Max therapeutic dose
Not responsive to dialysis = fatal!

TCA Contraindications Cardiac HX (MI) Hepatic or Renal insufficiency Closed <) glaucoma

Seizures

TCA Side Effects

Anticholinergic
Dry mouth Urinary retention Blurred vision Photophobia Diaphoresis CHF

Cardiovascular
Orthostatic BP HR Arrhythmias Prolonged QRS QT

TCA Side Effects Cont.

Neurological
Sedation Concentration Fatigue Muscle Weakness N &V Motility Constipation

Gastrointestinal
Heartburn

Tremors & Seizures

Paralytic Ileus

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

Selective Serotonin Reuptake Inhibitors SSRIs

Citalopram (Celexa) Escitalopram (Lexapro)

Fluxoxetine(Prozac)
Sertraline (Zoloft)

Paroxetine (Paxil)

Block reuptake of 5-HT = availability

Mood elevation SE: Anticholinergic, cardiac & sedating
Nausea Nervousness Agitation Dizziness Sexual Dysfunction Weight HA

Serotonin Syndrome Risk with MAOIs, Tryptophan or St. Johns Wort

SSRIs inhibit P450 enzymes
levels of un-metabolized drugs

Clinical Signs:

Mental status
Restlessness Temp Diaphoresis Diarrhea HR Chills

Confusion
Agitation RR Ataxia

Hypomania
Myoclonus BP

Abdominal cramps

Nausea

Bupropion (Wellbutrin)

Selective DA & NE reuptake inhibitor (No affect on 5-HT) SE: Seizures Weight Nicotine craving

Atypical Antidepressants
Sexuality

Duloxetine (Cymbalta)* Nefazodone (Serzone) *** Venlafaxine (Effexor) *****

Mirtazapine (Remeron)** Trazodone (Desyrel)****

Blocks 5-HT & NE receptors & reuptake

SE: * BP

HR

N&V

SE: ** Sedation

Weight

Serum Cholesterol (LDL & HDL)

SE:*** Inhibits P450 system = drug toxicity & hepatic failure

SE: **** Priapism Orthostaic BP

Sedation

SE: *****Low anticholinergic

BP @ doses

Monoamine Oxidase Phenelzine Inhibitors MAOIs Isocarboxiazid (Marplan) (Nardil)

Tranylcypromine (Parnate) Moclobemide (Menerix)

Last choice due to fatal SE & drug interactions Irreversibly Inhibits monoamine oxidase (MAO)
MAO deactivates NE, DA & 5-HT & tyramine inactive products

NE

DA tyramine = BP

Hypertensive Crisis Lethal dose = 6-10x daily dose!

 Anticholinergic CNS

Dry mouth, Blurred vision, Constipation

MAOIs SE

Drowsiness, Restlessness, Tremors & HA

Cardiac

Orthostatic BP, Heart failure Urinary Retention, Orgasms

GU

Selegine Transdermal System (STS)

Transcutaneous skin patch Bypasses liver & GI tract No tyramine breakdown = No hypertensive crisis

Monoamine Oxidase Inhibitors MAOIs

Avoid food, drinks & meds that contain tyramine!
3 days before starting, during and 14 days after med DCd

Dietary restrictions = tyramine content

Cheese aged & processed Beer Red wine Caffeine Cola/Coffee Chocolate Cold cuts Sour cream Yogurt Smoked Fish MSG Peanuts Fava Beans

Tofu Yeast Avocado

 Hypertensive Crisis

MAOIs SE

Explosive HA (Occipital Frontal) BP (Sudden Elevation = CVA) HR , Palpitations = Chest Pain Temp, Diaphoresis, Dilated pupils = Photophobia

Nursing Interventions VS q 5 mins Cooling Blanket Meds

High Fowlers Position Hold MAOI med!

Thorazine 100mg IM ( Blocks NE & DA) Procardia 10 mg PO/IV ( Vasodilator) BP Regitine IV (Vasodilator) BP

 Severe Depression, Bipolar (Psychotic)

When medications are ineffective 6 -15 treatments (3x/week) Response rate = 90% in 1-2 weeks

Electroconvulsive Therapy ECT

Jump Start neurotransmitter receptors

NE 5-HT DA

SE
Transient confusion Short term memory loss

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
Mood extremes, 1 or more manic episodes Sudden onset early 20s

risk with highly educated = 2 million/year

substance abuse & suicide (10-15%) Etiology
Altered Family Dynamics Expressed emotion Child Abuse NE & DA Receptor oversensitivity Intracellular Na & Ca = Serum Na & Ca
Neuronal Irritability

5-HT remains low

Bipolar Disorder
Manic Episode
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 Dont 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

Medications Lithium (Eskalith, Lithobid, Lithane)

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 < 1.5 mEq

Fine hand tremors Metallic taste Weight Fatigue/Drowsiness Polyuria Transient nausea Blurred Vision
Lightheadedness Mild Thirst

Li Toxicity >1.5 mEq ( Na & Li)

Dizziness Ataxia Mental COnfusion Persistent N & V Diarrhea Severe BP Coarse Hand tremors EKG Cardiac Arrest Seizures Coma

 Na or overdose of Li

Lithium Toxicity

Diuretics = Na & Li renal clearance Renal functioning 3 Ds (Diarrhea, Diaphoresis & Dehydration)
Fluid & Electrolyte loss

Therapy
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) Divalproex (Depakote) Gabapentin (Neurontin)

Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)

Topiramate (Topamax)

Carbamazepine (Tegretol) Rate of impulse transmission Serum level 8-12 ug/mL

Suicide
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
Mood Disorders Hopelessness Schizophrenia Command Hallucinations Substance Abuse Resources ($, social) Anxiety Insomnia European American > 65 years Mondays in the Spring Prior suicide attempts

Suicide
80% of attempts Pts give clues! Behavioral
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
Ambivalence (between life & death) Loss of emotional attachments Desolation Guilt Shame Sudden Happiness or relief

 Cognitive

Suicide

Poor problem solvers Fantasy Reunion Wish = meeting dead relatives Command Hallucinations Suicidal Ideation = Thought: How to method

Nursing Interventions
Take all gestures seriously! Assess suicidal intent Stay c Pt and maintain safety Establish a No harm contract

 Explore feelings & motive

Suicide Interventions

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 RT:
Significance of loss & degree of dependence

Behaviors
Tears Overwhelming feelings of loss Social withdrawal Concentration Dizziness HA Anorexia/ GI symptoms Anger Anxiety Guilt Lethargy Feel Drained

Grief
Unresolved Grief
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 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