Mood Disorders

1
Chapter 15

• Mood Disorders
• Part I

2
Introduction

• Depression is the oldest and most frequently
  described psychiatric illness.
• Transient symptoms are normal, healthy responses
  to everyday disappointments in life.

3
Introduction (cont.)

• Pathological depression occurs when adaptation is
  ineffective.

4
Epidemiology

• Affects almost 10 percent of the population, or
  19 million Americans, in a given year
• Considered to be the common cold of psychiatric
  disorders

5
Epidemiology (cont.)

• Gender prevalence
• Higher in women than in men by about 2 to 1
• Incidence of bipolar disorder is roughly equal

6
Epidemiology (cont.)

• Age
• Depression more common in young women than in
  older women has a tendency to decrease with age
• Opposite is true for men
• Studies of bipolar disorder suggest median age at
  onset of bipolar disorder is 18 years in men and
  20 years in women

7
Epidemiology (cont.)

• Social class There is an inverse relationship
  between social class and report of depressive
  symptoms the opposite is true with bipolar
  disorder.
• Seasonality Affective disorders are more
  prevalent in the spring and in the fall.

8
Epidemiology (cont.)

• Race No consistent relationship between race and
  affective disorder reported
• Marital status Single and divorced people more
  likely to experience depression than married
  people

9
Types of Mood Disorders

• Depressive disorders
• Major depressive disorder
• Dysthymic disorder
• Premenstrual dysphoric disorder
• Bipolar disorder
• Bipolar I disorder
• Bipolar II disorder
• Cyclothymia

10
Major Depressive Disorder

• Characterized by depressed mood
• Loses interest or pleasure in usual activities
• Social and occupational functioning impaired for
  at least 2 weeks
• No history of manic behavior
• Cannot be attributed to use of substances or a
  general medical condition

11
Dysthymic Disorder

• Sad or down in the dumps
• No evidence of psychotic symptoms
• Essential feature is a chronically depressed mood
  for
• Most of the day
• More days than not
• For at least 2 years

12
Premenstrual Dysphoric Disorder

• Essential Features
• Depressed mood
• Anxiety
• Mood swings
• Decreased interest in activities
• Symptoms occur during the week prior to menses
  and subside shortly after onset of menstruation

13
Bipolar Disorders

• Characterized by mood swings from profound
  depression to extreme euphoria (mania), with
  intervening periods of normalcy
• Delusions or hallucinations may or may not be
  part of clinical picture
• Onset of symptoms may reflect seasonal pattern

14
Bipolar I Disorder

• Individual is experiencing, or has experienced, a
  full syndrome of manic or mixed symptoms
• May also have experienced episodes of depression

15
Bipolar II Disorder

• Recurrent bouts of major depression
• Episodic occurrences of hypomania
• Has not experienced an episode that meets the
  full criteria for mania or mixed symptomatology

16
Other Mood Disorders

• Due to general medical condition
• Substance-induced mood disorder

17
Etiological Implications-Depressive Disorders

• Biological theories
• Genetics Hereditary factor may be involved
• Biochemical influences Deficiency of
  norepinephrine, serotonin, and dopamine has been
  implicated

18
Etiological Implications-Depressive Disorders
(cont.)

• Biological theories (cont.)
• Neuroendocrine disturbances
• Possible dysfunction within the
  hypothalamic-pituitary-adrenocortical axis
• Possible diminished release of thyroid-stimulating
  hormone

19
Etiological Implications-Depressive Disorders
(cont.)

• Physiological influences
• Medication side effects
• Neurological disorders
• Electrolyte disturbances
• Hormonal disorders
• Nutritional deficiencies

20
Etiological Implications-Depressive Disorders
(cont.)

• Physiological conditions (cont.)
• Secondary depression related to
• Collagen disorders (e.g., SLE)
• Cardiovascular disease
• Infections (e.g., hepatitis, pneumonia, syphilis)
• Metabolic disorders (e.g., diabetes mellitus)

21
Etiological Implications-Depressive Disorders
(cont.)

• Psychosocial theories
• Psychoanalytical theory (Freud)
• Mourning
• Melancholia
• Follows loss of a loved object

22
Etiological Implications-Depressive Disorders
(cont.)

• Learning theory
• Learned helplessness Repeated failure to control
  life, leading to defeat and dependence on others,
  resulting in predisposition to depression

23
Etiological Implications-Depressive Disorders
(cont.)

• Object loss theory
• Experiences loss of significant other during
  first 6 months of life
• Early loss or trauma may predispose client to
  episodes of depression in response to losses
  later in life

24
Etiological Implications-Depressive Disorders
(cont.)

• Cognitive theory Beck
• Primary disturbance in depression is cognitive
  rather than affective
• Three cognitive distortions serve as basis for
  depression
• Negative expectations about
• Environment
• Self
• Future

25
Etiological Implications-Depressive Disorders
(cont.)

• Theoretical Integration
• Etiology of depression likely due to multiple
  influences of
• Genetics
• Biochemical
• Psychosocial

26
Developmental Implications

• Childhood Depression
• Symptoms
• ltage 3 feeding problems,
• tantrums, lack of playfulness and
• emotional expressiveness
• Ages 3 to 5 accident proneness, phobias,
  excessive self-reproach
• Ages 6 to 8 physical complaints, aggressive
  behavior, clinging behavior
• Ages 9 to 12 morbid thoughts and excessive
  worrying

27
Developmental Implications (cont.)

• Childhood Depression (cont.)
• Precipitated by a loss
• Focus of therapy alleviate symptoms and
  strengthen coping skills
• Parental and family therapy

28
Developmental Implications (cont.)

• Adolescence
• Symptoms include
• Anger, aggressiveness
• Running away
• Delinquency
• Social withdrawal
• Sexual acting out
• Substance abuse
• Restlessness apathy

29
Developmental Implications (cont.)

• Adolescence (cont.)
• Best clue that differentiates depression from
  normal stormy adolescent behavior
• A visible manifestation of behavioral change that
  lasts for several weeks
• Most common precipitant to adolescent suicide
  perception of abandonment by parents or close
  peer relationship

30
Developmental Implications (cont.)

• Senescence
• Bereavement overload
• High percentage of suicides among elderly
• Symptoms of depression often confused with
  symptoms of dementia
• Treatment
• Antidepressant medication
• Electroconvulsive therapy
• Psychosocial therapies

31
Developmental Implications (cont.)

• Postpartum Depression
• May last for a few weeks to several months
• Associated with hormonal changes, tryptophan
  metabolism, or cell alterations
• Treatments antidepressants and psychosocial
  therapies
• Symptoms include
• Fatigue
• Irritability
• Loss of appetite
• Sleep disturbances
• Loss of libido
• Concern about inability to care for infant

32
Nursing Process/Assessment

• Transient depression
• Symptoms at this level of the continuum not
  necessarily dysfunctional
• Affective The blues
• Behavioral Certain amount of crying

33
Assessment

• Transient depression (cont.)
• Cognitive Some difficulty getting mind off ones
  disappointment
• Physiological Feeling tired and listless

34
Assessment (cont.)

• Mild depression
• Symptoms with normal grieving are identified by
  clinicians as associated with normal grieving
• Affective Anger, anxiety, sadness
• Behavioral Tearful, regression

35
Assessment (cont.)

• Mild depression (cont.)
• Cognitive Preoccupied with loss self-blame and
  blaming of others
• Physiological Anorexia or overeating, sleep
  disturbances, somatic symptoms

36
Assessment (cont.)

• Moderate depression
• Symptoms associated with dysthymic disorder
• Affective Helpless, powerless
• Behavioral Slow physical movement, slumped
  posture, limited verbalization

37
Assessment (cont.)

• Moderate depression (cont.)
• Cognitive Retarded thinking processes,
  difficulty with concentration
• Physiological Anorexia or overeating, sleep
  disturbances, somatic symptoms, feeling best
  early in morning and worse as the day progresses

38
Assessment (cont.)

• Severe depression
• Includes symptoms of major depressive disorder
  and bipolar depression
• Affective Feelings of total despair,
  worthlessness, flat affect, apathy, anhedonia
• Behavioral Psychomotor retardation, curled-up
  position, no interaction with others

39
Assessment (cont.)

• Severe depression (cont.)
• Cognitive Prevalent delusional thinking, with
  delusions of persecution and somatic delusions
  unable to concentrate confusion
• Physiological A general slow-down of the entire
  body, anorexia, insomnia, feels worse early in
  morning and somewhat better as the day progresses

40
Diagnosis/Outcome Identification

• Risk for suicide related to
• Depressed mood
• Feelings of worthlessness
• Anger turned inward on the self
• Misinterpretations of reality

41
Nursing Diagnosis

• Dysfunctional grieving related to
• Real or perceived loss
• Bereavement overload, evidenced by denial of loss
• Inappropriate expression of anger
• Idealization of or obsession withlost object

42
Nursing Diagnosis (cont.)

• Low self-esteem related to
• Learned helplessness
• Feelings of abandonment by significant others
• Impaired cognition fostering negative view of
  self

43
Nursing Diagnosis (cont.)

• Powerlessness related to
• Dysfunctional grieving process
• Lifestyle of helplessness, evidenced by feelings
  of lack of control over life situation

44
Nursing Diagnosis (cont.)

• Spiritual distress related to
• Dysfunctional grieving over loss of valued object
  evidenced by anger toward God
• Questioning meaning of own existence
• Inability to participate in usual religious
  practices

45
Nursing Diagnosis (cont.)

• Social isolation/Impaired social interaction
  related to
• Developmental regression
• Egocentric behaviors
• Fear of rejection or failure of the interaction

46
Nursing Diagnosis (cont.)

• Disturbed thought processes related to
• Withdrawal into self
• Underdeveloped ego
• Punitive superego
• Impaired cognition fostering negative perception
  of self or environment

47
Other Nursing Diagnoses

• Imbalanced nutrition less than body requirements
• Disturbed sleep pattern
• Self-care deficit

48
Criteria for Measuring Outcomes

• The client
• Has experienced no physical harm to self
• Discusses the loss with staff and family members
• No longer idealizes or obsesses about the lost
  object

49
Outcomes

• The client (cont.)
• Sets realistic goals for self
• Is no longer afraid to attempt new activities
• Is able to identify aspects of self-control over
  life situation

50
Outcomes (cont.)

• The client (cont.)
• Expresses personal satisfaction with and support
  from spiritual practices
• Interacts willingly and appropriately with others
• Is able to maintain reality orientation
• Is able to concentrate, reason,and solve
  problems

51
Planning/Implementation

• Nursing Interventions are aimed at
• Maintaining client safety
• Assisting client through grief process
• Promoting increase in self-esteem
• Encouraging client self-control and control over
  life situation
• Helping client to reach out for spiritual support
  of choice

52
Client/Family Education

• Nature of the illness
• Stages of grief and symptoms associated with each
  stage
• What is depression?
• Why do people get depressed?
• What are the symptoms of depression?

53
Client/Family Education (cont.)

• Management of the illness
• Medication management
• Assertive techniques
• Stress management techniques
• Ways to increase self-esteem
• Electroconvulsive therapy

54
Client/Family Education (cont.)

• Support services
• Suicide hotline
• Support groups
• Legal/financial assistance

55
Nursing Process/Evaluation

• Evaluation of the effectiveness of nursing
  interventions is measured by fulfillment of the
  outcome criteria.

56
Evaluation

• Has self-harm to the client been avoided?
• Have suicidal ideations subsided?
• Does the client know where to seek assistance
  outside the hospital when suicidal thoughts
  occur?

57
Evaluation (cont.)

• Has the client discussed the recent loss with the
  staff and family members?
• Is he or she able to verbalize feelings and
  behaviors associated with each stage of the
  grieving process and recognize own position in
  the process?

58
Evaluation (cont.)

• Has obsession with and idealization of the lost
  object subsided?
• Is anger toward the lost object expressed
  appropriately ?
• Does client set realistic goals for self?

59
Evaluation (cont.)

• Is he or she able to verbalize positive aspects
  about self, past accomplishments, and future
  prospects?
• Can the client identify areas of life situation
  over which he or she has control?