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Mood DisordersDepressive

and Bipolar DO

Mary Vercoutere, RN, MSN

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Introduction

Mood DODepressive DO disabling due to effect on thoughts, emotions, behaviors.Bipolar DOCoexisting DisordersPrevalence

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Topics of Discussion

DSM IV Definition of Mood DO: Major Depression Or Unipolar DiseaseBipolar Disease Theory of cause: Genetic,Gender, Biological, Psychological, Situational.Assessing Suicide Potential.Nursing Interventions.

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DSM IV Criteria

Major Depression A change in functionClinical distress,impairedsocial, occupational, or other

important areas of functioning.

Five or more of the following most days for 2 weeks:

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Major DepressionDepressed Mood,every dayAnhedoniaSignificant weight gain or lossSleep disturbancesIncreased / decreased motor activityAnergia (lethargy)Feelings of guilt, helplessness, hopelessnessPoor concentration Recurrent thoughts of death/suicide

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Theory of Cause

Presence evaluated on a spectrum.Genetic abnormalities,

Activated (Shine)Dormant-normal development

The occurrence of stressful events.Difficult ongoing life situations with

a depletion of neurotransmitters.Grief-Support and coping skills

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Genetic Basis• Depression• 20% have one episode only.• An individual with a first-degree

relative has up to 40%-50% chance with an 8% vulnerability in the general population.

• Multiple genes are involved in Depression, more prevalent in women.

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Genetic Influence

Bipolar disease85% of risk inheritedMultiple genes involved in disease.

• Up to 60% chance of having the disease in identical twins.More prevalent in men.

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Spectrum of Mood Disorders

DysthymicCyclothymicSchizoaffective Post-partumCo-morbid Disorders

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Biochemical Basis of Mood DO

The neural networks of the brain and the prefrontal cortex.Limbic System: the emotional brain.Altered neurotransmitters: serotonin (5HT), dopamine, norepinephrine, acetylcholine (a critical neurotransmitter in brain plasticity).

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Neurobiology

Depression and PTSD have shown to damage the hippocampus.Hypercortisolemia: majority of unipolar and bipolar individuals have elevated cortisol levels.This causes neurotoxic effects: hippocampal atrophy.

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Organic Causes• Endocrine disorders:Diabetes, Cushing’s disease• Neurologic diseases:Parkinson’s and Alzheimer’s

disease Metabolic disturbances:Hypoxia and hypercalcemia• Cardiovascular diseases:Heart failure, Open Heart OR• Pulmonary disorders:COPD

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Drugs can cause depressionAntihypertensivesPsychotropicsAntiparkinsonian drugsAnalgesicsCardiovascular drugsSteroidsChemotherapeutic agentsCimetidine (Tagamet)Alcohol

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Symptom AssessmentSymptoms:

Client may report feeling “down in the dumps”.

• Change in appetite• Sleep disturbances• Difficulty concentrating and

easy distractibility• Low self-esteem• Poor coping and problem

solving skills

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Assessment Interview

You may notice agitation (wringing hands, restlessness)OrPsychomotor retardation (slow movement)With severe depression persons may have delusions of persecution or guilt.

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Nursing Assessment and Interventions

Assess for suicidalityStay alert for clues to suicidal

thoughts, stay with client.Findings:A preoccupation with death.Previous suicide attempts.Presence of a plan.

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Assessment FindingsPresence of Significant risk factorsProfound hopelessness.Concurrent medical illness.Substance abuse.

ALERT Mental Health staff!!!!

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Pharmacological Interventions

Antidepressants Prescribed: Variety of antidepressants that alter specific neurotransmitters.

Often 4 –6 weeks until a therapeutic result, if none another tried or added to initial

medication tried.

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Non-Pharmacological Therapies

Electroconvulsive Therapy-ECTAlternative Therapy.LifestyleNutritionalHerbal: SAMe St. John’s Wort

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Maintaining a Healthy Brain

A key to activating neuroplasticity:Paying Attention.

Learn something new.Evoking a mental picture will increase metabolic activity.Repeated activation strengthens areas of the brain.Exercise creates new capillaries to the brain.

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Integrative Medicine

CBT (cognitive behavioral therapy) modifies sensitivity to anxiety.Family Focused Therapy: problem solving for the family and psychosocial pressuresNational Alliance for the Mentally ill

NAMIEach client needs to be an involved

member of the team.

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Bipolar DisordersDepression is a low, sad state in which life seems dark and its challenges overwhelming,Bipolar is a pattern of alternating between moods.

Mania, the opposite of depression, is a state of breathless euphoria, and a frenzied energy.People have the mistaken belief that the world is theirs.

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Bipolar I and Bipolar II

Bipolar I is most severePatient has manic episodes and major depression.Bipolar IINot a severe mania, a milder one such as hypomania/ alternating with major depressive episodes.

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Incidence

Close to 3 million people have bipolar in the USA.www.manicdepression.orgCauseOnset in 20’ and 30’sMost patients have recurring episodes throughout their lifespan.

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Genetic Influence

Bipolar Disease has an 85% inheritable risk.Multiple genes involved.More prevalent in men.

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Neurobiology

Bipolar DO:Ventricular enlargementSmaller hippocampus (critical

for memory and emotional regulation) amygdala, temporal lobe.

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Mania

Elation, euphoria, agitation or irritability, hyper-excitability, hyperactivity, rapid thought and speech, exaggerated sexuality, decreased sleep.Psychotic symptomsHypomania:An expansive, elevated, or agitated mood. Similar to mania but is less intense, no psychotic symptoms.

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Treatment for Bipolar Disorders

Mood Stabilizers.Anticonvulsants.Medications combined until therapeutic effect achieved.Quality of life is always important.Compliance is always important.The difficulty in treating women who are pregnant.

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TreatmentTreatment of bipolar I requires medicationLithium still a major therapy.Narrow range of safety as can be toxic (0.5-1mEq/L) Therapeutic blood levels in 7-10 days.Risk for Toxicity is high in patients with renal, heart disease, dehydration, salt depletion, on diuretics.

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Nursing Symptom Assessment

BehaviorAffectInterpersonal RelationshipsCultureAge-specific considerationsFunctionLife-specific considerations

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Assessment Interview

Rapid speechDifficulty sitting in a chair.Physical condition: weight loss, dehydration, poor ADL’sEvidence of psychosisSafety interventions

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Nursing InterventionsDuring manic phase, provide physical needs, ADL’s.Ensure safety with minimal stimulation.Provide emotional support.Limit setting and staff safety.Psycho education.Behavioral therapy re-educates in social skills, with attitude change.Group therapy.

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Case Study

Client historyCurrent problemsClient’s PerceptionYour Perception and Assessment: non-emotional, non-judgmental, using inductive reasoning.Nursing Diagnosis.