Chapter 17: Mood Disorders and Suicide

1. Chapter 17: Mood Disorders and Suicide

2. Mood Disorders • Affective disorders • Pervasive alterations in emotions manifested by depression, mania, or both • Interference with life; long-term sadness, agitation, or elation • Individuals with mood disorders throughout history

3. Mood Disorders (cont.) • Most common psychiatric diagnosis associated with suicide • Depression being one of the most important risk factors for suicide

4. Categories of Mood Disorders • Major depressive disorder • Lasts at least 2 weeks • Bipolar disorder • Bipolar I, bipolar II • Related disorders • Dysthymic disorder • Cyclothymic disorder • Substance-induced depressive or bipolar disorder • Seasonal affective disorder • Postpartum blues, depression, psychosis, premenstrual dysphoric disorder • Nonsuicidal self-injury

5. Etiology • Biologic theories • Genetic theories • Neurochemical theories: serotonin, norepinephrine; possibly acetylcholine and dopamine • Neuroendocrine influences: hormones

6. Etiology (cont.) • Psychodynamic theories • Freud: self-deprecation • Bibring: ideal ego • Jacobson: superego over powerless ego • Mania: defense against underlying depression

7. Cultural Considerations • Masking of depression by other behaviors considered age appropriate • School phobia, hyperactivity, learning disorders, failing grades, antisocial behaviors • Substance abuse, gangs, risk behaviors, eating disorders, compulsive behaviors • Somatic complaints • Major manifestation among cultures that avoid verbalizing emotions

8. Question Is the following statement true or false? • Depression is most commonly associated with suicide.

9. Answer True • Rationale: Depression is considered the most common diagnosis that results in suicide.

10. Major Depressive Disorder • Incidence: women-to-men 2:1, 1.5 to 3 times greater incidence in first-degree relatives • Decreases with age in women; increases with age in men; highest in single, divorced people • 50% to 60% will suffer recurrence • Approximately 20% will develop a chronic form of depression • Symptoms range from mild to severe

11. Major Depressive Disorder (cont.) • Symptoms: sad mood, lack of interest in life activities (2 weeks or more), and at least four other symptoms: • Changes in eating habits → weight gain or loss • Hypersomnia or insomnia • Impaired concentration, decision making, or problem solving • Worthlessness, hopelessness, despair, guilt • Thoughts of death/suicide • Overwhelming fatigue, negative thinking

12. Psychopharmacology • Selective serotonin reuptake inhibitors (see Table 17.1) • Tricyclic antidepressants (see Table 17.2) • Atypical antidepressants (see Table 17.3) • Monoamine oxidase inhibitors (MAOIs) (see Table 17.4) • Serotonin syndrome • Anticonvulsants (see Table 17.6)

13. Other Medical Treatments and Psychotherapy • Electroconvulsive therapy (ECT) • Psychotherapy (combined with medications) • Interpersonal therapy: relationship difficulties • Behavior therapy: reinforcement of positive interactions • Cognitive therapy: correction of cognitive distortions (see Table 17.5) • Investigational treatments: transcranial magnetic stimulation (TMS)

14. Major Depressive Disorder and Nursing Process Application • Assessment • History • General appearance, motor behavior (psychomotor retardation, latency of response, psychomotor agitation) • Mood, affect (anhedonia) • Thought process, content (rumination, suicide) • Sensorium, intellectual processes (impaired memory)

15. Major Depressive Disorder and Nursing Process Application (cont.) • Assessment (cont.) • Judgment, insight (impairment) • Self-concept (worthlessness) • Roles, relationships (difficulty in this area) • Physiologic, self-care considerations • Depression rating scales • Self-rating scales: Zung, Beck • Clinician rating scale: Hamilton Rating Scale (see Box 17.1)

16. Question Is the following statement true or false? • Patients with depression often exhibit anhedonia.

17. Answer True • Rationale: Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression.

18. Major Depressive Disorder and Nursing Process Application (cont.) • Data analysis/nursing diagnoses • Outcome identification • Free from self-injury • Improved mood and energy • Return to previous functional level • Medication compliance

19. Major Depressive Disorder and Nursing Process Application (cont.) • Intervention • Providing for safety (suicide precautions) • Promoting therapeutic relationship • Promoting ADLs, physical care • Using therapeutic communication • Managing medications • Patient, family teaching • Evaluation

20. Bipolar Disorder • Extreme mood fluctuations from mania to depression (see Figure 17.1) • Second only to major depression as cause of worldwide disability • Onset usually in late teens, 20s, or 30s • Manic episodes begin suddenly, last from a few weeks to several months

21. Treatment • Psychopharmacology • Antimanic agent: lithium • Anticonvulsant agent used as mood stabilizer (see Table 17.6) • Agents helpful in reducing manic behavior, protecting against bipolar depressive cycles • Psychotherapy useful in mildly depressive or normal portion of bipolar cycle • Not useful during manic stages

22. Bipolar Disorder and Nursing Process Application • Assessment • History • General appearance, behavior (pressured speech, flamboyancy, sexually suggestive) • Mood, affect (euphoric, grandiose) • Thought process, content (circumstantiality, tangentiality) • Sensorium, intellectual processes (disoriented to time)

23. Bipolar Disorder and Nursing Process Application (cont.) • Assessment (cont.) • Judgment, insight • Self-concept (exaggerated) • Roles, relationships (labile emotions) • Physiologic, self-care considerations • Data analysis/nursing diagnoses • Outcome identification • Free from injury—med compliance • Meet basic needs and self-care • Socially appropriate behavior

24. Question • Which of the following would be most appropriate for the treatment of mania associated with bipolar disorder? A. Lithium B. Fluoxetine C. Citalopram D. Venlafaxine

25. Answer A. Lithium • Rationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic patient with bipolar disorder. • Fluoxetine, citalopram, and venlafaxine are antidepressants.

26. Bipolar Disorder and Nursing Process Application (cont.) • Intervention • Providing for safety • Meeting physiologic needs • Providing therapeutic communication • Promoting appropriate behaviors • Managing medications (see Tables 17.6 and 17.7) • Providing patient, family teaching • Evaluation

27. Suicide • Intentional act of killing oneself • Men commit approximately 72% of suicides • Suicidal ideation: thinking about killing oneself • Warning signs: risk for suicide (see Box 17.2)

28. Suicide (cont.) • Assessment: • Previous suicide attempts (first 2 years after—highest risk period, especially first 3 months); relative who committed suicide • Warnings of suicidal intent (see Box 17.2); risky behavior • Lethality assessment • Data analysis/nursing diagnoses

29. Suicide (cont.) • Outcome identification • Safety, free from self-harm • Intervention • Authoritative role • Safe environment: suicide precautions; no suicide/no self-harm contract • Support system list

30. Suicide (cont.) • Family response • Suicide as ultimate rejection of family, friends • Families react with guilt, shame, anger

31. Suicide (cont.) • Nurse’s response • Need for unconditional positive regard for person • Avoidance of patient blame • Nonjudgmental approach, tone • Belief that one person can make a difference in another’s life • Possible devastation of staff if patient commits suicide

32. Legal and Ethical Considerations • Assisted suicide as topic of national legal, ethical debate (Oregon, 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 to provide supportive care for patients, family as they work through decision-making process

33. Question Is the following statement true or false? • When dealing with a patient who is suicidal, the nurse needs to assume a dependent role.

34. Answer False • Rationale: When dealing with a patient who is suicidal, the nurse must take an authoritative role.

35. Elder Considerations • Depression common among the elderly; marked increase when elders are medically ill • Psychotic features common • Increased intolerance to medications • ECT more commonly used for treatment; more rapid response • Suicide increased among elderly

36. Community-Based Care • Nurses as first health-care professionals to recognize behaviors consistent with mood disorders • Successful treatment of depression in community by psychiatrists, psychiatric advanced practice nurses, primary care physicians

37. Community-Based Care (cont.) • Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment

38. Mental Health Promotion • Education to address stressors contributing to depressive illness • Efforts to improve primary care treatment of depression • Prevention and early detection, treatment for adolescents

39. Mental Health Promotion (cont.) • Screening for early detection of risk factors • Family strife • Parental alcoholism or mental illness • History of fighting • Access to weapons in the home

40. Self-Awareness Issues • Importance of dealing with own feelings about suicide • Frustration possible when working with depressed or manic patients • Exhaustion possible when working with manic patients • Journaling to help deal with feelings; talking with colleagues often helpful