CH 17 - Mood Disorders and Suicide

Elder Considerations:

Depression common among the elderly; marked increase when elders are medically ill; Suicide increased among elderly Psychotic features more frequent than in younger people with depression Increased intolerance of side effects of medications ECT more commonly used for treatment; more rapid response

Tyramine Containing Foods:

All cheese, aged meats (pepperoni, salami, sausage, mortadella, beef logs), fava, tofu, banana peel, avocado, sauerkraut, soy sauce, marmite, yogurt, sour cream, peanuts, MSG containing products, soybeans, figs, dried or cured fish, , yeast products, beer, chianti wine, chocolate, caffeinated beverages

Suicide: Legal and Ethical Considerations

Assisted suicide is a as topic of national legal and ethical debate; Oregon was the first state to adopt assisted suicide into law. Nurse often cares for terminally or chronically ill people with poor quality of life; Nurse's role is to provide supportive care for clients and family as they work through decision-making process.

Bipolar Disorder: Data Analysis, Nursing Dx, Outcome, Intervention, Evaluation

Dx: Disturbed Thought Processes: Disruption in cognitive operations and activities Outcome: No injury to self or others; Balance of rest, sleep, and activity; Socially appropriate behavior Intervention: Providing for safety; Meeting physiological needs; Providing therapeutic communication; Promoting appropriate behaviors; Managing medications; Providing client and family teaching Evaluation: Has client achieved desired outcomes? (Safety issues, mood/affect between treatment, adherence to treatment regimen, improvement of QoL, achievement of specific goals)

Mood Disorders: Related Disorders

Dysthymic Disorder: chronic, persistent mood disturbance; insomnia, loss of appetite, low energy, low self-esteem, difficulty concentrating, sadness, hopelessness (milder than depression Cyclothymic Disorder: mood swings between hypomania and depression w/o loss os social or occupational functioning Substance-Induced Depressive or Bipolar Disorder: disturbance in mood that is a direct physiological consequence of ingested substances (alcohol, drugs, toxins) Seasonal Affective Disorder (SAD): two subtypes; winter depression/fall-onset, experience increased sleep, appetite, wt gain, interpersonal conflict, irritability, heaviness in extremities; and spring-onset, insomnia, wt loss, poor appetite; often treated with light therapy Postpartum Blues, Depression, Psychosis: (Blues) first several days after delivery of baby; crying spells, sadness, insomnia, anxiety (Depression) most common after pregnancy, consistent with depression, onset 4 weeks after delivery (Psychosis) severe/debilitating, acute onset; beings with fatigue, sadness, confusion; progresses to hallucinations, poor insight and judgement, and loss of contact with reality; requires emergency medical treatment. Premenstrual Dysphoric Disorder: severe form of premenstrual syndrome; occurs the week before menses; affects 20-30% of women Nonsuicidal Self-Injury: deliberate, intentional cutting, burning, scraping, hitting or interference with wound healing; if engaged in self-injury is called self-mutilation.

Mental Health Promotion:

Education to address stressors contributing to depressive illness and efforts to improve primary care treatment of depression Prevention and early detection, treatment for adolescents; Screening for early detection of risk factors: Family strife; Parental alcoholism or mental illness; History of fighting; Access to weapons in the home

Other Medical Treatments and Psychotherapy

Electroconvulsive therapy (ECT): shock therapy, nurse must monitor for amnesia and headache (similar to grand mal seizure); usually done when medication treatment fails or SE are intolerable. Psychotherapy (combined with medications): most effective treatment for depressive disorders; goal of combined therapy is remission, psychosocial restoration, relapse prevention. Interpersonal therapy: relationship difficulties Behavior therapy: increase positive reinforcement of interactions, decreasing negative interations. Cognitive therapy: focus on cognitive distortions (how think about self, others, future, and interprets his/her experiences) New and Investigational treatments: transcranial magnetic stimulation (TMS); USFDA approved treatment for major depression in treatment resistant clients.

Bipolar Disorder:

Extreme mood swings, episodes of mania and depression; second only to major depression as cause of worldwide disability Lifetime risk is at least 1.2%, risk of completed suicide for 15% Occurs almost equally among men and women; more common in highly educated people NEED to take medication for LIFE!!!!

Suicide Responses:

Family Response: Suicide as ultimate rejection of family and friends; Families react with guilt, shame, and anger; Families can disintegrate. Nurse's Response: Need for unconditional positive regard for person; Avoidance of client blame; Nonjudgmental approach, tone; Belief that one person can make a difference in another's life; Possible devastation of staff if client commits suicide

Mood Disorders: Etiology

Genetic Theories: focuses on immediate family; if first-degree relatives have it, clients are 7 times more likely to develop major depression. Neurochemical Theories: serotonin, norepinephrine, possibly acetylcholine and dopamine Norepinephrine levels may be deficient in depression and increased in mania. Neuroendocrine influences: hormone fluctuation (thyroid, adrenal, parathyroid, pituitary) possibly related to depression. Psychodynamic Theories: Self-deprecation: self-reproach and "anger turned inward" related to either a real or perceived loss. Ideal ego: to be loved and worthy, must achieve these high standards Rejecting or unloving parents: feelings of insecurity and loneliness Cognitive distortions: Early experiences shape distorted ways of thinking about oneself, the world, and the future Mania as defense against underlying depression and Depression as reaction to life experience

Bipolar Disorder: Nursing Process - Assessment

History: if in manic phase, may be difficult to obtain info; General Appearance and Motor Behavior: clothes reflecting elevated mood (flamboyant, attention-grabbing, sexually suggestive); think, move, and talk fast Mood and Affect: periods of euphoria, grandiosity, false sense of well-being, mood is labile (severe mood swings with emotional reactions) Thought Process and Content: Circumstantial thinking: client eventually answers a question but only after giving excessive, unnecessary detail Tangential thinking: wandering off the topic and never providing the information requested (never reaching the point) Sensorium and Intellectual Processes: disoriented to time (may be oriented to person and place); impaired concentration Judgment and Insight: easily angered and irritated, impulsive, don't think before speak; insight limited, believe their "fine" Self-Concept: exaggerated self-esteem, believe can accomplish anything. Roles and Relationships: in manic phase can rarely fulfill role responsibilities Physiological and Self-Care Considerations: manic clients go days without sleeping and eating, won't realize hungry or tired. Ignores hygiene and daily activities, may physically injure self and be unaware of health needs. Lithium is an anti-mania medication, will use when a patient cannot tolerate side effects of lithium, will use mood stabilizers (anticonvulsants) Medication requires lab work to be completed.

Major Depressive Disorder: Assessment

History: when they started, what was happening when they began, their duration, and what the client has tried to do about them General Appearance and Motor Behavior: Psychomotor retardation: slow body movements, cognitive processing, verbal interactions; Latency of response: take up to 30 seconds to respond; Psychomotor agitation: increased movements/thoughts, pacing, accelerated thinking, argumentative Mood and affect: anhedonia (inability to feel pleasure), hopeless, down, helpless, anxious Thought Process and Content: rumination (repeatedly going over same thought), thoughts of suicide, self-criticism, focus on failures Sensorium and Intellectual Processes: impaired memory; disoriented to person, time, place Judgment and Insight: impaired judgment; inability to solve problems or make decision Self-Concept: feelings of worthlessness; Roles and Relationships the more severe the depression, the greater the difficulty to fulfill roles; strained relationships Physiological and Self-Care Considerations: self neglect of personal hygiene and daily activities (eat, sleep, work) Depression Rating Scales Self-rating scales: Zung Self-Rating Depression Scale and Beck Depression Inventory Clinician rating scale: Hamilton Rating Scale for Depression; done by psychologist

Self-Awareness Issues:

Importance of dealing with own feelings about suicide; Frustration and exhaustion possible when working with depressed or manic clients; Journaling to help deal with feelings or talking with colleagues is often helpful.

Major Depressive Disorder: Data Analysis/Nursing Dx

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Suicide:

Intentional act of killing oneself; men commit approximately 72% of suicides. Suicidal Ideation: thinking about killing oneself Warning Signs: risk for suicide; suicide involves ambivalence (simultaneous conflicting reactions or feelings); Ex: fatal accidents may be impulsive suicides.

Bipolar Phases:

Manic Phase: clients are euphoric, grandiose, energetic, and sleepless, have poor judgment and rapid thoughts, actions, and speech Depressed Phase: mood, behavior, and thoughts are the same as in people diagnosed with major depression

Psychopharmacology

Most common type of treatment; major categories of antidepressants include: Selective serotonin reuptake inhibitors (SSRIs): most frequently prescribed; effective for most clients Tricyclic: oldest antidepressant; not used too often because of side effects with MAOI medications. Atypical: used when client has inadequate response to or side effect from SSRI's Monoamine Oxidase Inhibitors (MAOI): infrequently used because of potentially fatal SE and interactions with both prescription and OTC drugs. Hypertensive crisis: serious SE from taking MAOIs and ingesting tyramine containing foods; MAOI-tyramine interaction symptoms w/in 20-60 minutes. Serotonin syndrome: occurs when there is an inadequate washout period between taking MAOI and SSRIs or when combined with meperidine. Adequate washout periods of 5-6 weeks are recommended between the time that the MAOI is discontinued and another class of antidepressant is started. Limit prescription and refills in limited amounts of MAOI and tricyclic drugs due to lethality of overdose.

Instructor Input:

Must Know for Test and NCLEX: Dysthymia: persistent depression (chronic mood disturbance for at least 2 years) Major depression: recurring depression (goes and comes) Dysphoria: a state of feeling uneasy, unhappy or unwell. Psychogenic: mild mood swings

Community-Based Care:

Nurses as first health care professionals to recognize behaviors consistent with mood disorders Documenting and reporting behaviors helps clients get treatment. Successful treatment of depression in community by psychiatrists, psychiatric advanced practice nurses, and primary care physicians

Mood Disorders: Cultural Considerations

Other behaviors considered age appropriate can mask depression Children: school phobia, hyperactivity, learning disorders, failing grades, antisocial behaviors Adolescents: substance abuse, gangs, risky behaviors, dropping out of school Adults: substance abuse, eating disorders, compulsive behaviors Somatic complaints (multiple physical problems, backaches, headache, heart problems) and major manifestation among cultures that avoid verbalizing emotions

Major Depressive Disorder: Outcome, Intervention, Evaluation

Outcome: Free from self-injury; Independently carry out activities of daily living; Balance of rest, sleep, and activity; Evaluate self-attributes realistically; Socializing; Return to occupation or school activities; Medication compliance; Verbalize symptoms of recurrence Intervention:Providing for safety (suicide precautions); Promoting a therapeutic relationship; Promoting ADLs and physical care; Using therapeutic communication; Managing medications; Client and family teaching Evaluation: achieved outcomes? satisfied with QoL?

Suicide: Outcome, Intervention

Outcome: Safe from harming self and others; No-suicide contract; List of positive attributes Intervention: Using an authoritative role; Providing a safe environment; Creating a support system list

Suicide: Nursing Process - Assessment

Previous suicide attempts (the first 2 years after is the highest risk period, especially the first 3 months); relative who committed suicide Warnings of Suicidal Intent: most people send direct or indirect signal about intent to self-harm; never ignore hints of SI. Risky Behavior: few people who commit suicide give no warning Lethality Assessment: client admits to having a "death wish" or suicidal thoughts, the next step is to determine potential lethality Ask specific questions; Ex: Does you have a plan to kill ourself? If so, what is it? Is the plan specific? Are means available to carry out this plan? (patient wants to shoot himself, does he own or have access to a gun?) Has the client made preparations for death (giving away prized possessions, suicide note, talking to friends one last time? Clients believing a method to be lethal poses a significant risk.

Mood Disorders: Categories

Primary mood disorders are major depressive disorder and bipolar disorder Major Depressive Episode: lasts at least 2 weeks Bipolar Disorder: mood fluctuates from mania (persistently elevated, expansive, or irritable mood (hypomania)) and last about 1 week -to- depression Mixed episodes of both mania and depression nearly every day for at least one week (rapid cycling) is classified as: Bipolar I: one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II: one or more major depressive episodes accompanied by at least one hypomanic episode

Bipolar Disorder: Treatment

Psychopharmacology: lifetime regimen of medications; ONLY disorder medication can prevent acute cycles of bipolar behavior. Lithium (0.5-1.5): 70-80% response in acute mania; can stabilize bipolar disorder by reducing the degree/frequency of cycling or elimination of episodes. Anticonvulsant drugs: used when client doesn't respond or has difficulty with SE of lithium. Psychotherapy: useful in mildly depressive or normal portion of bipolar cycle; Not useful during manic stages because of reduced attention span. Combined therapy can reduce risk of suicide and injury.

Key Points:

Studies have found a genetic component to mood disorders. The incidence of depression is up to three times greater in first-degree relatives of people with diagnosed depression. People with bipolar disorder usually have a blood relative with bipolar disorder. Only 9% of people with mood disorders exhibit psychosis. Major depression is a mood disorder that robs the person of joy, self-esteem, and energy. It interferes with relationships and occupational productivity. Symptoms of depression include sadness, disinterest in previously pleasurable activities, crying, lack of motivation, asocial behavior, and psychomotor retardation (slow thinking, talking, and movement). Sleep disturbances, somatic complaints, loss of energy, change in weight, and a sense of worthlessness are other common features. Several antidepressants are used to treat depression. SSRIs have the fewest side effects. Tricyclic antidepressants are older and have a longer lag period before reaching adequate serum levels; they are the least expensive type. MAOIs are used least because clients are at risk for hypertensive crisis if they ingest tyramine-rich foods and fluids while taking these drugs. MAOIs also have a lag period before reaching adequate serum levels. People with bipolar disorder cycle between mania, normalcy, and depression. They may also cycle only between mania and normalcy or between depression and normalcy. Clients with mania have a labile mood, are grandiose and manipulative, have high self-esteem, and believe they are capable of anything. They sleep little, are always in frantic motion, invade others' boundaries, cannot sit still, and start many tasks. Speech is rapid and pressured, reflects rapid thinking, and may be circumstantial and tangential with features of rhyming, punning, and flight of ideas. Clients show poor judgment with little sense of safety needs and take physical, financial, occupational, or interpersonal risks. Lithium is used to treat bipolar disorder. It is helpful for bipolar mania and can partially or completely eradicate cycling toward bipolar depression. Lithium is effective in 75% of clients but has a narrow range of safety; thus, ongoing monitoring of serum lithium levels is necessary to establish efficacy while preventing toxicity. Clients taking lithium must ingest adequate salt and water to avoid overdosing or underdosing because lithium salt uses the same postsynaptic receptor sites as sodium chloride does. Other antimanic drugs include sodium valproate, carbamazepine, other anticonvulsants, and clonazepam, which is also a benzodiazepine. For clients with mania, the nurse must monitor food and fluid intake, rest and sleep, and behavior with a focus on safety until medications reduce the acute stage and clients resume responsibility for themselves. Suicidal ideation means thinking of suicide. People with increased rates of suicide include single adults, divorced men, adolescents, older adults, the very poor or very wealthy, urban dwellers, migrants, students, whites, people with mood disorders, substance abusers, people with medical or personality disorders, and people with psychosis. The nurse must be alert to clues to a client's suicidal intent—both direct (making threats of suicide) and indirect (giving away prized possessions, putting his or her life in order, making vague goodbyes). Conducting a suicide lethality assessment involves determining the degree to which the person has planned his or her death, including time, method, tools, place, person to find the body, reason, and funeral plans. Nursing interventions for a client at risk for suicide involve keeping the person safe by instituting a no-suicide contract, ensuring close supervision, and removing objects that the person could use to commit suicide.

Major Depressive Disorder

Typically 2 weeks or more, untreated episode of depression can last weeks, months, or years; Most clear in about 6 months; twice as common in women 50% to 60% will suffer recurrence; approximately 20% will develop a chronic form of depression. Some people with severe depression have psychotic features. Symptoms: sad mood or lack of interest in life activities, with at least four other symptoms of depression such as anhedonia (Inability to experience pleasure in life) and changes in weight, sleep, energy, concentration, decision-making, self-esteem, and goals Anhedonia is a common symptom in depression

Mood Disorders:

also known as affective disorders; pervasive alterations in emotions manifested by depression or mania or both Most common psychiatric diagnosis associated with suicide; depression is one of the most important risk factors Interferes with life; long-term sadness, agitation, or elation Individuals with mood disorders throughout history; until the mid-1950s, no treatment available for serious depression or mania. Affect: outward expression of the clients emotional state