Nursing Management Of Patient

With Mood Disorders

MS SONALI GUPTA
MOOD DISORDERS
• Mood disorders are characterized by a disturbance of mood, accompanied
by a full or partial manic or depressive syndrome, which is not due to any
other physical or mental disorder. The prevalence rate of mood disorders
is 1.5 percent, and it is uniform throughout the world.
ICD-11 Classification of Mood Disorders

Bipolar or related disorders include the following:

• 6460: Bipolar type I disorder

• 6A61: Bipolar type II disorder
• 6462: Cyclothymic disorder
• 6A6Y: Other specified bipolar or related disorders
 Cyclothymic disorder is
Bipolar I disorder is an Bipolar II disorder is
characterized by a
episodic mood an episodic mood
persistent instability of
disorder defined by disorder defined by the
mood over a period of
occurrence of one or occurrence of one or
at least 2 years
more manic or mixed more hypomanic
involving numerous
episodes. episodes and at least
periods of hypomania
one depressive
and depressive
episode.
symptoms
 MANIC EPISODE

• Mania refers to a syndrome in which the central features are over-activity,

mood change (which may be towards elation or irritability) and self-
important ideas. The lifetime risk of manic episode is about 0.8–1%. This
disorder occurs in episodes lasting usually 3–4 months, followed by complete
recovery.
 ETIOLOGY
1. NEUROTRANSMITTER AND 2. GENETIC CONSIDERATIONS
STRUCTURAL HYPOTHESES
• Monozygotic (identical) twins
• Manic episodes are related to have a higher rate of incidence
excessive levels of than normal siblings and other
norepinephrine and dopamine, close relatives. Siblings and close
an imbalance between relatives have a higher incidence
cholinergic and noradrenergic of manic-depressive illness than a
systems or a deficiency in general population, and
serotonin. cyclothymic characteristics are
common among family members
of bipolar patients
3. PSYCHODYNAMIC THEORIES
• Developmental theorists have hypothesized that faulty family dynamics during
early life are responsible for manic behaviors in later life. Another
psychodynamic hypothesis explains manic episodes as a defense against or
denial of depression.
CLINICAL FEATURES
Four Euphoria (Stage I): Increased sense of psychological well-
being and happiness not in keeping with ongoing events
Stages
Of Elation (Stage II): Moderate elevation of mood with increased
psychomotor activity
Elevated
Mood Exaltation (Stage III): Intense elevation of mood with
delusions of grandeur

Ecstasy (Stage IV): Severe elevation of mood, intense sense of

rapture or blissfulness seen in delirious or stuporous mania
PSYCHOMOTOR ACTIVITY SPEECH AND THOUGHT
There is an increased Flight of ideas: Thoughts racing in mind,
psychomotor activity ranging rapid shifts from one topic to another
from over activeness and Pressure of speech: Speech is forceful, strong
restlessness to manic excitement. and difficult to interrupt. Uses playful
The person involves in ceaseless language with punning, rhyming, joking,
activity. These activities are goal- teasing and speaks loudly
oriented and based on external  Clang association: These are ideas that are
environment cues related only by similar or rhyming sounds
rather than actual meaning
Delusions of grandeur

 Delusions of persecution

Distractibility
OTHER FEATURES

Increased sociability's

Impulsive behavior

Disinhibition

Hypersexual and promiscuous behavior

Poor judgment

Dressed up in gaudy and flamboyant clothes although in severe mania there may be poor self-care

Decreased need for sleep Decreased food intake due to over-activity

Decreased attention and concentration

Absent insight
SYMPTOMS OF HYPOMANIA

 persistent mild elevation of mood

 increased sense of psychological well-being
 happiness not in keeping with ongoing events
 irritability,
 conceit,
 boorish behavior
 usual euphoric sociability
DIAGNOSIS
• Psychological tests such as young Mania Rating Scale

• ICD11 diagnostic criteria Based on signs and symptoms

TREATMENT MODALITIES
• ELECTROCONVULSIVE THERAPY (ECT)
PHARMACOTHERAPY
• ECT can also be used for acute manic
• Lithium: 900–2100 mg/day excitement if not adequately responding
to antipsychotics and lithium.
• Carbamazepine: 600–1800
mg/day • PSYCHOSOCIAL TREATMENT

• Sodium valproate: 600–2600 • Family and marital therapy is used to

mg/day decrease intrafamilial and interpersonal
difficulties and to reduce or modify
• Lamotrigine: 25–200 mg/day stressors. The main purpose is to ensure
continuity of treatment and adequate
• Other drugs: Clonazepam, drug compliance
calcium channel blockers, etc.
• NURSING DIAGNOSIS I • NURSING DIAGNOSIS II

• Delusions and hallucinations • High-risk for violence; self-

High-risk for injury related to directed or directed at others
extreme hyperactivity and related to manic excitement,
impulsive behavior, evidenced by delusional thinking and
lack of control over purposeless hallucinations. Objective: Patient
and potentially injurious will not harm self or others
movements. Objective: Patient
will not injure self
DEPRESSION
• DEPRESSIVE EPISODE • Depression occurs twice as
Depression is a widespread frequently in women as in men.
mental health problem affecting The median age at onset of
many people. The lifetime risk of bipolar disorder is 18 years in
depression in males is 8–12% men and 20 years in women. The
and in females it is 20–26%. highest incidence of depressive
symptoms has been indicated in
individuals without close
interpersonal relationships and
in persons who are divorced or
separated.
CLASSIFICATION OF DEPRESSION (ICD11)

• 6A70: Single episode depressive disorder

Depres • 6A71: Recurrent depressive disorder
sive • 6A72: Dysthymic disorder
disorde • 6A73: Mixed depressive and anxiety disorder
rs
• 6A7Y: Other specified depressive disorder:
include
the
followi
ng:
 • Recurrent depressive disorder is
• Depressive disorders are characterized by a history of at least
characterized by depressive mood or two depressive episodes separated
loss of pleasure accompanied by by at least several months without
other cognitive, behavioral or significant mood disturbance.
neurovegetative symptoms that
• Dysthymic disorder is characterized
significantly affect the individual's
ability to function. A depressive by a persistent depressive mood
episode should not be diagnosed in lasting 2 years or more.
individuals who have ever • Mixed depressive and anxiety
experienced a manic, mixed or disorder is characterized by
hypomanic episode which would symptoms of both
indicate the presence of a bipolar anxiety and depression
disorder.
 ETIOLOGY
• BIOLOGICAL THEORIES The etiology of
depression has been biologically attributed • ENDOCRINE THEORIES Normally, the
to alterations in neurochemical, genetic, hypothalamic-pituitary-adrenal (HPA) axis
endocrine and circadian rhythm functions. is a system that mediates the stress
response. However, in some depressed
• NEUROCHEMICAL Research findings people this system malfunctions and
suggest that depression results when levels creates cortisol, thyroid and hormonal
of norepinephrine and serotonin are abnormalities.
decreased and dysregulation of
• CIRCADIAN RHYTHM THEORIES Circadian
acetylcholine and GABA.
rhythms are responsible for the daily
• GENETIC THEORIES Major depressive regulation of wake-sleep cycles, arousal and
disorders occur more often in first degree activity patterns, and hormonal secretions.
relatives than they do in the general
• CHANGES IN BRAIN ANATOMY Loss of
population Studies of identical twins show
that when one twin is diagnosed with neurons in the frontal lobes, cerebellum and
major depression basal ganglia has been identified in
depression
• PSYCHOSOCIAL THEORIES • Cognitive theory: According to
Psychoanalytic theory: According this theory, depression is due to
to Freud (1957) depression negative cognitions which
results due to loss of a ‘loved includes:
object’, and fixation in the oral
sadistic phase of development. • Negative expectations of the
environment
• Behavioral theory: This theory of
depression connects depressive • Negative expectations of the self
phenomena to the experience of • Negative expectations of the
uncontrollable events. future
 TRANSACTIONAL MODEL OF
STRESS/ADAPTATION
According to transactional
model of
stress/adaptation,
depression occurs as a
combination of
predisposing factors Maladaptive coping
(family history and Because of weak ego mechanisms used are
biochemical alterations), strength, patient is unable denial, regression, All these factors lead to
past experiences (object to use coping mechanisms repression, suppression, clinical depression
loss in infancy, defect in effectively. displacement and
cognitive development) isolation.
and existing conditions
(lack of adequate support
system, inadequate coping
skills, other physiological
conditions).
CLINICAL FEATURES
• Depressed mood: Sadness of mood • Suicidal thoughts: Ideas of hopelessness
or loss of interest and loss of are often accompanied by the thought
pleasure in almost all activities that life is no longer worth living and that
(pervasive sadness), present death had come as a welcome release.
throughout the day (persistent • Psychomotor activity: Psychomotor
sadness). retardation is frequent. The retarded
patient thinks, walks and acts slowly.
• Depressive cognitions: Hopelessness
(a feeling of ‘no hope in future’ due to • Psychotic features: Some patients have
pessimism), helplessness (the delusions and hallucinations (the
patient feels that no help is possible), disorder may then be termed as
worthlessness (a feeling of psychotic depression); these are often
mood congruent, i.e. they are related to
inadequacy and inferiority), depressive themes and reflect the
unreasonable guilt and self-blame patient's dysphoric mood.
over trivial matters in the past
OTHER FEATURES

Vague physical symptoms

Difficulties in thinking Menstrual or sexual such as fatigue, aching
Subjective poor memory
and concentration disturbances discomfort, constipation,
etc.
DIAGNOSIS

• 1. Psychological tests—Beck depression inventory. Hamilton rating scale for

depression to assess severity and prognosis.
• 2. Dexamethasone suppression test showing failure to suppress cortisol
secretions in depressed patients.
• 3. Toxicology screening suggesting drug-induced depression.

• 4. Based on ICD11 criteria

 SYMPTOMS OF DEPRESSION
COMMON OTHER
FATIGUE
APATHY

THOUGHTS OF
DEPENDENCY
DEATH
ANGER SADNESS

SLEEP
HELPLESSNESS
DISTURBANCES
DECREASED
PASSIVENESS
LIBIDO

WORTHLESSNESS HOPELESSNESS SPONTANEOUS

CRYING
MAJOR CATEGORIES OF ANTIDEPRESSANTS ARE:

2. Tricyclic
Antidepressants
1. Selective (TCAs) 3. Monoamine
Serotonin Reuptake Amitriptyline oxidase inhibitors 4. Other Newer
Inhibitors (SSRIs) (Elavil), (MAOIs). Antidepressant
Citalopram (Celexa), Clomipramine Isocarboxazid drugs Bupropion,
Fluoxetine (Prozac), (Anafranil), (Morplan), Maprotiline
Sertraline (Zoloft) Imipramine Phenelzine (Nardil)
(Tofranil), Doxepin
(Adapin, Sinequan)
PHYSICAL THERAPIES
• Electroconvulsive therapy (ECT): Severe depression with suicidal risk is
the most important indication for ECT
• Light therapy: Sometimes called phototherapy involves exposing the
patient to an artificial light source during winter months to relieve
seasonal depression. The light source must be very bright, full-spectrum
light, usually 2,500 lux
• Repetitive Transcranial Magnetic Stimulation (TMS) and Vagus Nerve
Stimulation (VNS) directly affect brain function by stimulating the nerves
that are direct extensions of the brain
PSYCHOSOCIAL TREATMENT
• 1. Psychotherapy: Psychotherapy based on • 5. Family therapy: Family therapy
psychoanalytic interventions emphasizes helping
patients gain insight into the cause of their is used to decrease intrafamilial
depression. and interpersonal difficulties and
• 2. Cognitive therapy: It aims at correcting the to reduce or modify stressors,
depressive negative cognitions like hopelessness,
worthlessness, helplessness and pessimistic ideas, which may help in faster and
and replacing them with new cognitive and more complete recovery.
behavioral responses.
• 3. Supportive psychotherapy: Various techniques • 6. Behavioral therapy: It includes
are employed to support the patient. They are
reassurance, ventilation, occupational therapy, social skills training, problem
relaxation and other activity therapies. solving techniques, assertiveness
• 4. Group therapy: Group therapy is useful for mild training, self-control therapy,
cases of depression. In group therapy negative
feelings such as anxiety, anger, guilt, despair are
activity scheduling and decision-
recognized and emotional growth is improved making techniques
through expression of their feelings.
BIPOLAR MOOD DISORDER (BIPOLAR AFFECTIVE
DISORDER, MANIC DEPRESSIVE DISORDER

• This is characterized by recurrent episodes of mania and depression in the

same patient at different times.
• Typically, the patient experiences extreme highs (mania or hypomania)
alternating with extreme lows (depression), interspersed between the highs
and lows are periods of normal mood.
• Onset usually occurs between ages 20 and 30.
Signs and symptoms of bipolar disorders
Manic Phase Depressive Phase
Expansive, grandiose, or hyperirritable mood Low self-esteem

Increased psychomotor activity, such as agitation Overwhelming inertia Feelings of hopelessness,

pacing or hand-wringing apathy, or self-reproach

Excessive social extroversion Rapid speech with Difficulty concentrating or thinking clearly (without
frequent topic changes obvious disorientation or intellectual impairment)

Decreased need for sleep and food Psychomotor retardation

Impulsivity Anhedonia

Impaired judgment Suicidal ideation

 Bipolar disorder—Good and poor prognostic
factors
Good Prognostic Factors Poor Prognostic Factors
Double depression
Abrupt or acute onset
Comorbid physical disease, personality disorders or alcohol
dependence
Severe depression

Typical clinical features Chronic ongoing stress

Well-adjusted premorbid personality Poor drug compliance

Good response to treatment Marked hypochondriacal features or mood-incongruent psychotic

features
ETIOLOGY
• Precise cause unknown • DIAGNOSIS

• Genetic, biochemical and • Based on signs and symptoms

psychological factors may play a
role • ICD11 criteria

• May be triggered by stressful

events, antidepressant use
• Sleep deprivation and
hypothyroidism
• TREATMENT • COURSE AND PROGNOSIS OF
MOOD DISORDERS
• Lithium Valproic acid
• An average manic episode lasts
• Carbamazepine for 3–4 months, while a
• Antidepressants Antipsychotics depressive episode lasts for 4–9
(if necessary) months
• RECURRENT DEPRESSIVE
DISORDER PERSISTENT MOOD DISORDER

• This disorder is characterized by F34.0 Cyclothymia

recurrent depressive episodes.

The current episode is specified F34.1 Dysthymia

as mild, moderate and severe,

without psychotic symptoms, F34.8 Other persistent mood disorders

severe with psychotic symptoms

F34.9 Persistent mood disorder, unspecified
• CYCLOTHYMIA

• Cyclothymic disorder is • ETIOLOGY

characterized by short periods of
mild depression alternating with • Genetic factors (most likely cause)—
short periods of hypomania; Family history of bipolar disorder,
between the depressive and manic major depression, substance abuse, or
episodes, brief periods of normal suicide in many patients
mood occur. Both depressive and
hypomanic phases are shorter and
less severe than those in bipolar I or
II disorder.
CLINICAL FEATURES
HYPOMANIC PHASE DEPRESSIVE PHASE
• Insomnia • Insomnia or hypersomnia

• Hyperactivity and physical • Feelings of inadequacy

restlessness • Decreased productivity
• Irritability or aggressiveness • Social withdrawal
• Grandiosity or inflated self- • Loss of libido or interest in
esteem pleasurable activities
• Increased productivity • Lethargy

• creativity • Suicidal ideation

• DIAGNOSIS • TREATMENT MODALITIES

• Based on ICD11 criteria Rule out • Lithium

physical and psychiatric
disorders that can mimic • Carbamazepine
cyclothymic disorder, for • Valproic acid
example, endocrine disorders,
uraemia, vitamin deficiency, • Verapamil
epilepsy, borderline personality
disorder, mood disorders caused • Various antidepressants
by substance abuse, etc. • Individual psychotherapy

• Couple or family therapy

DYSTHYMIA
• Dysthymic disorder, or • ETIOLOGY
dysthymia, refers to mild
depression that lasts at least 2 • Below-normal serotonin levels
years in adults or 1 year in • Increased vulnerability when
children. It is twice as common in multiple stressors and
women as in men and more personality problems are
prevalent among the poor and combined with inadequate
unmarried coping skills
CLINICAL FEATURES
PSYCHOLOGICAL SYMPTOMS DIAGNOSIS
• Persistent sad, anxious, or empty mood • Careful psychiatric examination and
medical history
• Excessive crying
• Based on ICD11 criteria
• Increased feelings of guilt,
TREATMENT
• helplessness, or hopelessness
• Short-term psychotherapy
PHYSIOLOGIC SYMPTOMS
• Behavioral therapy
• Weight or appetite changes
• Group therapy
• Sleep difficulties
• Antidepressants, such as SSRIs or TCAs,
• Reduced energy level especially for patients who exhibit
pessimism
Differences between somatic (major/endogenous
depression/melancholia) and neurotic depression (reactive)
Endogenous Depression Neurotic Depressio

Endogenous Depression Neurotic Depression

• Caused by factors within the • Caused by stressful events
individual
• Premorbid personality: anxious,
• Premorbid personality: Cyclothymic or obsessive
or dysthymic
• Difficulty in falling asleep (early
• Early morning awakening (late
insomnia) Difficulty in falling asleep
insomnia)
(early) • Patient feels sadder in the
• Patient feels sadder in the morning evening
• Feels better when alone • Feels better when in a group
Differences between somatic (major/endogenous
depression/melancholia) and neurotic depression (reactive)
Endogenous Depression Neurotic Depressio

Endogenous Depression Neurotic Depression

• . Psychotic features like • Usually, psychomotor agitation
psychomotor retardation, and no other psychotic features
suicidal tendencies, delusions etc.
are common • Relapses are uncommon

• Relapses are common • Psychotherapy and

antidepressants are used for
• . ECT and antidepressants are management
used for management
• Insight is present
• Insight is absent
NURSING INTERVENTIONS
• Provide supportive measures, such as reassurance, warmth, availability,
and acceptance
• Teach patient about the illness

• Encourage positive health habits