Mood Disorders. Highs

(1)

Alterations in Mental Health

Mood Disorders

Highs

Lows Lows

(2)

Grief: The normal response to a

significant loss

(3)

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Normal vs Dysfunctional

• 12-24 Months • Somatic distress • Prolonged response • Delayed response • Preoccupation • Guilt/Anger • Exaggerated symptoms of normal Gu / ge • Behavior Changes • Reorganization grief Reorganization • Pp. 615-616 (Varcarolis) (Varcarolis)

(4)

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Factors effecting grief response

• Level of dependency in the relationship

• Degree of ambivalence in relationship

Degree of ambivalence in relationship

• Age of the deceased +/or grieving person

B

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• Bereaved person’s support system

• Physical and psychological health of the

bereaved individual

(5)

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Nursing Actions

• Goal

– Mourning is complete

• Interventions

– Allow privacy and when the bereaved

can remember

realistically both the

provide support

– Always offer and allow viewing of deceased realistically both the

pleasures and

disappointments of the lost relationship;

viewing of deceased – Recognize cultural

needs the lost relationship;

and begin to form new interests and

– Acknowledge feelings – Simply allowing

talking can release

relationships. talking can release

(6)

M d Di

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Mood Disorders

• Manic mood: Bipolar I • Hypomanic mood:

Bipolar II; Cyclothymic Disorder • Euthymic mood: normal • Dysthymic mood: – moderate: Dysthymic M j – severe:Major Depressive Disorder

(7)

Characteristics of Depressive

Disorders

• Depressed mood • Anhedonia • Feelings of worthlessness & • Decreased concentration/difficul inappropriate guilt • Suicidal thoughts ty making decisions • Negative thinking re • Anger, irritability • Vegetative signs: self, environment, future P h t – disturbance in eating, sleeping; loss of energy libido; • Psychomotor agitation/retardation energy, libido; constipation

(8)

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Types of Mood Disorders

• Dysthymic Disorder

– Chronic depression (at

• Cyclothymic Disorder – Chronic fluctuating least 2 years) – Mild to moderate degree of depression mood

– Hypomanic & mild to moderate depression degree of depression – Able to function – Depression is moderate depression • Substance -induced – Depressed or elevated p “normal”

– High risk for major depression

Depressed or elevated mood disturbance

within a month of substance intox or

depression substance intox or

(9)

Types of mood disorders: due to

General Medical Condition

• Medication SE (Steroids, Antihypertensives • Prevalence of Comorbid Depression: Stroke 22 50% Antihypertensives, Oral Contraceptives) • Medical conditions: – Stroke 22-50% – Cancer 18-39% – MI 15-19% Medical conditions: Endocrine, Hormonal (PMS), Post-viral syndrome Tumors MI 15 19% – HIV 8-10% – In-pt 12% syndrome, Tumors, Diabetes • (Varcolis p 328) – Out-pt 2-15% (Varcolis p.328)

(10)

Depression vs Dementia

Depression Dementia Depression • Onset gradual or in response to a crisis Dementia

• Slow incidious onset • Impaired memory, • Impaired concentration, focus, attention D d Impaired memory, judgment, agnosia • Function deteriorates as th d • Decreased energy, motivation, early am

awakening; morning is their

the day progresses – “sundowning”

• Affect flat, anxious

g g

“bad time”

• Affect sad, blunted, irritable

S h l fl l

Affect flat, anxious • Speech contains

confabulation &

i i li

(11)

M j D

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Major Depressive Disorder

• 17%Lifetime prevalenc • >25% rate in Nsg H’s • 15% Suicide rate • 2x rate in womena e o e • “Masked” by somatic complaints,

hyperactivity & poor school performance • Comorbid anxiety

(12)

Major Depressive Disorder, with

…..(Specifiers)

• Psychotic features (Mood congruent)

• Catatonic features(Psychomotor

Catatonic features(Psychomotor

disturbance)

• Melancholic features(Vegetative signs)

• Seasonal Affective Patterns

• Postpartum onset

– Severe depression occurring within 4 weeks of delivery/30-50% risk of recurrence with each subsequent delivery

(13)

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Etiology of Depression

• Biologic Theories

– Genetic: 1.5-3x in 1st

• Cognitive Theories: identify, refute and

degree

relatives/>incidence in alcohol dep. & ADHD

replace negative thoughts

P h l ti

in alcohol dep. & ADHD – Biochemical: Seratonin;Neurepinep h i / l ti hi t • Psychoanalytic: Aggression turned inward hrine/ relationship to stress regulation

– Sleep: REM latency

inward

• Learned Helplessness

(14)

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Risk Factors for Depression

• Chronic Illness • Female Gender • Bereavement • Perfectionistice ec o s c

• Situational stressors • Previous HistoryPrevious History

• Family History • Social IsolationSocial Isolation

(15)

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Nursing Assessment

• Where/ Who? ALL clients in ALL settings

• Affect: Sad blunted tearful

Affect: Sad, blunted, tearful

• Thought Process: Slow, negative,

indecisive poor memory&concentration

indecisive, poor memory&concentration

• Feelings: Worthless, guilty, sad, helpless &

hopeless angr & irritable

hopeless, angry & irritable

• Physical: Disturbance in grooming, eating ,

sleeping, energy, elimination, activity

(16)

S i id A

Suicide Assessment

• 75-80% give clues • Verbal clues – overt statements – covert statements – Behavioral clues – sudden changes i i – giving away possessions

(17)

S i id A

Suicide Assessment

• Assessing risk factors: – Is there a plan?

• How lethal? How lethal? • How available?

– Support system

– Severe life stressorsS

– Men over 65

– Previous attempts increase risk

– As meds lift depression, it may allow for energy to act

(18)

Analysis

Nursing Diagnoses

• Risk for Suicide

• Hopelessness /Ineffective Individual

Hopelessness /Ineffective Individual

Coping

• Altered Nutrition / Disturbed Sleep Pattern

• Impaired Social Interaction

• Chronic Low Self-esteem

• Disturbed Thought Processes

g

• Interrupted Family Processes

(19)

Pl

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Planning

• Short term goals

– safety needs met

– physiologic needs met

• Long Term Goals

– improved coping l

– resume role expectations

(20)

Nursing Interventions

In the Hospital

• Remove harmful items • Support self-care

• Educate client and family re S&S of activities

• Monitor food, fluid,

depression and management of meds P id t t weight, sleep, elimination • Provide structure – 1:1 relationship Socialization as • Support and encourage M it ff t f t – Socialization as tolerated

– Support coping skills

(21)

Suicide Precautions in the

Hospital

• Safe environment:

Check on admission, • Levels of suicide precaution (p.739, after passes and after

visitors A i t

Varcarolis)

– q 15-30” checks

Cl b ti

• Assign to room near the nursing station with other clients

– Close observation, accompany to BR – 1:1 - Arms-length 24

with other clients • Change of shift

• No suicide contract

1:1 Arms length 24 hours/day

(22)

Nursing Interventions in the

Community

• Work with the client and their family to:

– Make the home safe (weapons, pills, etc.)Make the home safe (weapons, pills, etc.) – Assess for Substance Abuse

– Develop a routine for taking meds and Develop a routine for taking meds, and establishing structure for self-care

– Relieve isolation and reestablish social tiesRelieve isolation and reestablish social ties – Establish healthy methods to express feelings

(23)

Treatments for Depression

Electroconvulsant Therapy -ECT

• 90% efficacy • seizure occurs • Informed consent • Short procedure • 6-12 treatments • Refractory – NPO – Atropine, Brevital, A i O2 e ac o y depression, suicidal, psychotic depression Anectine, O2 – Short-term side effects: confusion • Medical conditions contraindicating d effects: confusion, disorientation meds

(24)

Selective Seratonin Reuptake

Inhibitors (SSRI)

• Block neuronal

reuptake of seratonin, • Prozac, Paxil, Zoloft, Luvox, Celexa, Lexapro enhancing action of seratonin at synapse E il t l t d • Side Effects: – GI complaints • Easily tolerated • Tx of PMS Depression OCD – Anxiety/agitation – Insomnia/Somnolence Sexual dysfunction PMS,Depression,OCD, Bulimia • Effective in 2 4 weeks – Sexual dysfunction – Appetite increase or decrease • Effective in 2-4 weeks • Less toxic in overdose

(25)

Tricyclic Antidepressants

TCA

• Inhibit reuptake of NE

& Seratonin by • Side Effects:– Anticholinergic

presynaptic neurons • Effects in 2 weeks, full

ff t 4 8 k – Sedation – Changes in appetite C di i i ll effects 4-8 weeks • Dangerous in overdose due to – Cardiotoxic in small percent: Dysrhythmias, tachycardia, MI, Heart

overdose due to

cardiotoxic effects / only give 1 week

y , ,

block

– Elavil, Norpramin, Tofranil(panic

only give 1 week

(26)

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Atypical Antidepressants

• Desyrel (Trazadone):

Used for mild- • Wellbutrin: Used to treat refractory moderate depression/

commonly used for treating sleep

depression and

marketed for smoke cessation (Zyban) treating sleep disturbance • Xanax: cessation (Zyban). Greater incidence of seizure activity and • Xanax:

Benzodiazepine used to treat anxious

mild-seizure activity and fewer sexual SE

to treat anxious mild moderate depression

(27)

Monoamine Oxidase Inhibitors

(MAO Inhibitors)

• MAO is an enzyme that

breaks down • Diet restrictions: Aged cheeses & tyramine, therefore,

these drugs create a risk for hypertensive

wines, yeast, salami, pepperoni, game meat herring soy sauce

risk for hypertensive crisis resulting from too much tyramine

herring, soy sauce,

organ meats, bananas, figs, raisins, etc.

too much tyramine

• Tx atypical depression • Nardil Parnate

figs, raisins, etc. • Many drug-drug

interactions Nardil , Parnate,

Marplan

(28)

Seratonin/NE Reuptake

Inhibitors

• Inhibit both Seratonin

and NE without the • Serzone: sedating_{• Effexor: Short half-life} number of SE of TCA’s _{• Remeron: Increases}

appetite, fewer drug interactions

(29)

Nursing Interventions R/T

Antidepressant Medications

• Assess for Effects & SE

• Encourage use for at least 4 weeks

• Assess for suicide potential

• Assess for substance 4 weeks

• Assess for use of over the counter drugs (Herbal

remedies)

• Assess for substance abuse • Assess client’s understanding and remedies) • Seratonin Syndrome: agitation, flushing, understanding and compliance with prescribed regimen diaphoresis, diarrhea, mental status change,tremors • Encourage psychotherapy in addition to drug tx