Mood Disorders
Fall 2012 M. Motyka
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Major Depressive Disorder History of one or more major
depressive episodes No history of manic or hypomanic episodes
Symptoms interfere with social or occupational functioning May
include psychotic features
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Major Depressive Disorder Subtypes Psychotic features
Melancholic features Atypical features Catatonic features
Postpartum onset Seasonal features seasonal affective disorder
(SAD)
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Proposed Subtypes Premenstrual dysphoric disorder Mixed
anxiety-depression Recurrent brief depression Minor depression
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Dysthymic Disorder Chronic depressive syndrome Present for most
of the day More days than not At least 2 years
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Epidemiology Leading cause of disability in the United States
Children and adolescents Older adults Comorbidity
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Etiology Biological factors Genetic Biochemical Alterations in
hormonal regulation Diathesis-stress model
Psychological factors Cognitive theory Learned helplessness7
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Nursing Process Assessment Self-assessment Unrealistic
expectations of self Feeling what the patient is feeling Assessment
tools Assessment of suicide potential Key assessment findings
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Nursing ProcessContinued
Areas to assess Affect Thought processes Mood Feelings Physical
behavior Communication Religious beliefs and spirituality
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Which question would be a priority when assessing for symptoms
of major depression?
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a. Tell me about any special powers you believe you have. b. You
look really sad. Have you ever thought of harming yourself? c. Your
family says you never stop. How much sleep do you get? d. Do you
ever find that you dont remember where youve been or what youve
done?Elsevier items and derived items 2010, 2006 by Saunders, an
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Nursing ProcessContinued
Nursing Diagnosis Risk for suicide safety is always the highest
priority Hopelessness Ineffective coping Social isolation Spiritual
distress Self-care deficit
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Nursing ProcessContinued
Outcomes Identification Recovery model Focus on patients
strengths Treatment goals mutually developed Based on patients
personal needs and values
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Nursing ProcessContinued
Planning Geared towards Patients phase of depression Particular
symptoms Patients personal goals
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Nursing ProcessContinued
Implementation Three phases Acute phase (6 to 12 weeks)
Continuation phase (4 to 9 months) Maintenance phase (1 year or
more)
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Nursing ProcessContinued
Basic Level Interventions Counseling and communication Health
teaching and health promotion Promotion of self-care activities
Milieu therapy
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Nursing ProcessContinued
Advanced Practice Interventions Psychotherapy Cognitive
behavioral therapy (CBT) Interpersonal therapy (IT) Time-limited
focused psychotherapy Behavior therapy
Group therapy
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Psychopharmacology Antidepressants Selective serotonin reuptake
inhibitors (SSRIs) First-line therapy Indications Adverse reactions
Potential toxic effects
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PsychopharmacologyContinued
Tricyclic antidepressants (TCAs) Neurotransmitter effects
Indications Adverse effects Contraindications
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PsychopharmacologyContinued
Monoamine oxidase inhibitors (MAOIs) Neurotransmitter effects
Indications Adverse/toxic effects Interactions Drug Food
Contraindications
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Other Treatments for Depression Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation Vagus nerve stimulation Light
therapy St. Johns wort Exercise
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Nursing ProcessContinued
Evaluation Short-term indicators and outcome criteria Reassess
and reformulate care plan as necessary Future of treatment
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Suicide A significant public health problem in the United States
In 2008 Eleventh leading cause of death 32,000 completed
suicides
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Psychiatric disorders Alcohol or substance use disorders Male
gender Increasing age Race Religion Marriage Profession Physical
health
Suicide Risk Factors
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Biological Factors Suicidal behavior tends to run in families
Low serotonin levels are related to depressed mood
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Freud aggression turned inward Menninger The wish to kill The
wish to be killed The wish to die
Psychosocial Factors
Aaron Beck central emotional factor is hopelessness Recent
theories combination of suicidal fantasies and significant
lossElsevier items and derived items 2010, 2006 by Saunders, an
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Protective factors
Cultural Factors
African Americans Religion, role of the extended family
Hispanic Americans Roman Catholic religion and importance of
extended family
Asian Americans Adherence to religions that tend to emphasize
interdependence between the individual and society
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Oregons Death with Dignity Act of 1994 terminally ill patients
allowed physicianassisted suicide Netherlands nonterminal cases of
lasting and unbearable suffering Belgium nonterminal cases when
suffering constant and cannot be alleviated Switzerland assisted
suicide legal since 1918 Massachusetts- vote in NovemberElsevier
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Societal Factors
Assessment: Overt Statements I can't take it anymore. Life isn't
worth living anymore. I wish I were dead. Everyone would be better
off if I died.
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Assessment: Covert Statements It's okay, now. Soon everything
will be fine. Things will never work out. I won't be a problem much
longer. Nothing feels good to me anymore and probably never will.
How can I give my body to medical science?Elsevier items and
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Assessment: Lethality of Suicide Plan Is there a specific plan
with details? How lethal is the proposed method? Is there access to
the planned method? People with definite plans for time, place, and
means are at high risk.
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Assessment Tools: SAD PERSONS ScaleUses 10 major risk factors to
assess suicidal potential1. Sex (male) 2. Age 25 to 44 or 65+ years
3. Depression 4. Previous attempt 5. Ethanol use 6. Rational
thinking loss 7. Social supports lacking or recent loss 8.
Organized plan 9. No spouse 10. Sickness
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Nursing Diagnoses Risk for suicide Ineffective coping
Hopelessness Powerlessness Social isolation
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Levels of Intervention Primary activities that provide support,
information, and education to prevent suicide Secondary treatment
of the actual suicidal crisis Tertiary interventions with the
family and friends of a person who has committed suicide to reduce
the traumatic aftereffectsElsevier items and derived items 2010,
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Basic Level Interventions Milieu therapy with suicidal
precautions Counseling Health teaching and health promotion Case
management
Pharmacological interventions
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Survivors of Completed Suicide: Postintervention Surviving
friends and family Overwhelming guilt, shame Difficulties
discussing the often taboo subject of suicide
Staff Group support essential as treatment team conducts a
thorough postmortem assessment and reviewElsevier items and derived
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Advanced Practice Interventions Psychotherapy Psychobiological
interventions Clinical supervision Consultation
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A patient is hospitalized with major depression and suicidal
ideation. He has a history of several suicide attempts. For the
first 2 days of hospitalization, the patient eats 20% of meals and
stays in his room between groups. By the fourth day, the nurse
observes the patient is more sociable, is eating meals, and has a
bright affect. Which factor should the nurse consider? The
patient:Elsevier items and derived items 2010, 2006 by Saunders, an
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a. is showing improvement and may be ready for discharge. b. may
have decided to commit suicide; the nurse should reassess
suicidality. c. is feeling rested, supported by the therapeutic
milieu, and less depressed. d. is benefiting from the
antidepressant he has been taking for 4 days.
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Chapter 14Bipolar Disorders
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Clinical Picture Bipolar I Disorder Bipolar II Disorder
Cyclothymia
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EpidemiologyLifetime prevalence of bipolar disorder in the
United States is 3.9% Bipolar I more common in males Bipolar II
more common in females Cyclothymia usually begins in adolescence or
early adulthood
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Etiology Biological factors Genetic Neurobiological
Neuroendocrine
Psychological factors Environmental factors
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Assessment Mood Behavior Thought processes and speech patterns
Flight of ideas Clag associations Grandiosity
Cognitive functioning
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Self-Assessment Manic patient Manipulative Aggressively
demanding Splitting
Staff member actions Frequent staff meetings to deal with
patient behavior and staff response Set limits consistentlyElsevier
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Assessment Guidelines Bipolar Disorder Danger to self or others
Need for protection from uninhibited behaviors Need for
hospitalization Medical status Coexisting medical conditions
Familys understanding
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Nursing Diagnosis Risk for injury Risk for violence
Other-directed Self-directed
Risk for suicide
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Outcomes Identification Acute phase Prevent injury
Continuation phase Relapse prevention
Maintenance phase
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Planning Acute phase Medical stabilization Maintaining safety
Self-care needs
Continuation phase Maintain medication adherence
Psychoeducational teaching Referrals
Maintenance phase Prevent relapseElsevier items and derived
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Implementation Acute phase highest priority is always safety
Depressive episodes Manic episodes
Continuation phase Prevent relapse with follow-up care
Maintenance phase
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Pharmacological Interventions Lithium carbonate Indications
Therapeutic and toxic levels Therapeutic blood level 0.8 to 1.4
mEq/L Maintenance blood level 0.4 to 1.3 mEq/L Toxic blood level:
1.5 to 2.0 mEq/L
Maintenance therapy ContraindicationsElsevier items and derived
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Anticonvulsant Drugs Valproate (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
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Antianxiety Drugs Clonazepam (Klonopin) Lorazepam (Ativan)
Atypical Antipsychotics Olanzapine (Zyprexa) Risperidone
(Risperdal)
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Other Treatments Electroconvulsive therapy (ECT) Milieu
management Support groups Health teaching and health promotion
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Advanced Practice Interventions Psychotherapy
Cognitive-behavioral therapy (CBT) Interpersonal and social rhythm
therapy
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Evaluation Evaluate outcome criteria Care plan reassessed Care
plan revised if indicated
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Chapter 34Therapeutic Groups
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Therapeutic Factors Common to All Groups Instillation of hope
Universality Imparting of information Altruism Corrective
recapitulation of primary family group
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Therapeutic Factors Common to All GroupsContinued
Development of socializing techniques Imitative behavior
Interpersonal learning Group cohesiveness Catharsis Existential
resolution (Box 34-2)Elsevier items and derived items 2010, 2006 by
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Phases of Group Development Orientation phase Working phase
Termination phase
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Group Member Roles Task roles Maintenance roles
Individual roles
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Which of the following comments made by members of a group best
demonstrates a task role?
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a. I want to tell how my problems started. Im having more
trouble than anyone else in this group. b. Three people were late
for this group. Everyone is supposed to arrive on time. c. I cant
believe youre talking about your failed romantic relationships
again. d. We started out talking about guilt, but we have strayed
from that subject.
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Group Leadership Responsibilities Initiating Maintaining
Terminating
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Styles of Leadership Autocratic leader Democratic leader
Laissez-faire leader
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Basic Level Registered Nurse Psychoeducational groups Medication
education groups Health education groups Dual-diagnosis groups
Symptom-management groups Stress-management groups
Support and self-help groupsElsevier items and derived items
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Advanced Practice Nurse Group psychotherapy Psychodrama
groups
Dialectical behavior treatment
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Dealing with Challenging Member Behaviors Monopolizing member
Complaining member who rejects help Demoralizing member Silent
member
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