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Mood Disorders

Mood Disorders. Objectives. Compare and contrast grief to depressive disorders Identify stages of the grieving (mourning)process Relate interventions appropriate to the grieving process Identify symptoms and behaviors associated with mood disorders

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Mood Disorders

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  1. Mood Disorders

  2. Objectives • Compare and contrast grief to depressive disorders • Identify stages of the grieving (mourning)process • Relate interventions appropriate to the grieving process • Identify symptoms and behaviors associated with mood disorders • Analyze predisposing factors and/or precipitating stressors to mood disorders • Apply the nursing process in the care of persons with mood disorders • Describe the treatment strategies for mood disorders and the implications for the nursing role

  3. Grief Reactions • Grief is universal • Grief is the subjective state that follows loss • A powerful emotional state that affects all aspects of a person’s life • Grief can continue for months, 1-2 years

  4. Loss • Types of loss • Particularly the loss of a loved one • Other types of loss • Physiologic • Safety • Security • Self-esteem • Self-actualization

  5. Types of Grief • Uncomplicated bereavement (normal grief) – this is not a disorder • Anticipatory grieving-grief associated with anticipation of predicted loss or death • Disenfranchised grief involves a loss not typically acknowledged by society (i.e., a pet, a home) • Chronic sorrow-grief associated with ongoing loss such as chronic mental or physical illness

  6. Kubler-Ross Stages of Grieving • Normal mourning process: • Denial • Anger • Bargaining • Depression • Acceptance

  7. Considerations for Interventions Individuals grieve in different ways Stage/phase of grief determines intervention Developmental stage effects grief process Nurses have role in helping persons who are grieving

  8. Maladaptive Responses to Loss:Complicated Bereavement • Excessive hostility and bitterness • Prolonged emptiness and numbness • Inability to weep or express emotion • Failure to resume activities, work, go on with their lives

  9. Nursing • Understanding • Promote expression and release of pain • Use of the therapeutic relationship/communication • Individualization of care, recognizing various beliefs and practices r/t loss such as death • Culture, religious practices, and spiritual beliefs

  10. Nursing interventions for grief • Identification of loss • Expression of feelings • Discuss prior losses • Empathetic statements about grief • Explore fears about loss • Elicit coping strategies • Promote cultural, religious, social customs • Use the term “dead” rather than euphemisms • Clarify misconceptions See Stuart 2013, p. 308, Box 18-9

  11. Additional Interventions • Grief counseling • Traumatic grief psychotherapy

  12. Grief vs. Major Depression • Grief can look very much like depression (overwhelming sadness, poor sleep, poor concentration, decreased appetite, somatic complaints) • Unlike depressed persons, the grieving person does not have poor self-attitude, worthlessness • Grief can progress to Major Depression

  13. Distinguishing Grief & Depression • Feelings of emptiness and loss • Pangs (or waves) of grief • Positive emotions and humor • Preoccupation with the deceased (loss) • Depressed mood and/or inability to anticipate happiness or pleasure • Persistent • Pervasive unhappiness • Pessimism GRIEF DEPRESSION

  14. Mood Disorders • Depressive Disorders • Major Depressive Disorder • Postpartum Depression • Seasonal Affective Disorder • Dysthymic Disorder • Cyclothymic Disorder • Bipolar Disorders I & II

  15. What is mood? • Mood - Pervasive and sustained emotion that colors one’s perspective of the world and how one functions in it

  16. Mood Disorders: • 20.9 million American adults (9.5% of the population) have a mood disorder in a given year • Median age of onset 30 years old • Depressive disorders often co-occur with anxiety and substance abuse

  17. Major Depressive Disorder (MDD) • 20% of people will experience depressive illness in their lifetime • Prevalence rates not affected by race • Leading cause of disability among ages 15-44 y.o. • Effects 14.8 million (6.7 % of the U.S. population) in a given year • Median onset is 32 y.o. • More prevalent in women than men, 2:1 • Incidence higher in young women, increasing in adolescents, increases with age among men

  18. Major Depressive Disorder (MDD) For at least 2 weeks a depressed, sad mood and/OR loss of interest & pleasure (anhedonia) with 4 of the following: • Appetite/weight change * • Sleep disturbance daily • Psychomotor agitation or retardation (observed by others) • Fatigue/low energy daily • Guilt or feelings of worthlessness daily • Poor concentration or indecisiveness daily • Recurrent thoughts of death, suicidal ideation

  19. Affective features • Helplessness • Hopelessness • Loneliness • Low self-esteem • Pessimism • Bitterness • Self-destructive thoughts/behaviors • Anger/irritability • Anxiety • Apathy • Withdrawal • Denial of feelings • Despondency • Loss of motivation • Guilt

  20. Physiological features of Depression • Sleep disturbances • Menstrual changes • Sexual problems • Weight change • Abdominal pain • Backache • Chest pain • Dizziness • Fatigue • Headache • GI disturbances

  21. Cognitive features of Depression • Ambivalence • Confusion • Inability to concentrate- “can’t think, can’t focus” • Indecisiveness and uncertainty • Cognitive distortions • Impaired (short-term)memory • Negative thinking (self-blame, –deprecation, –destructive) • May include psychosis

  22. Behaviors Associated with Depression • Aggressiveness/agitation • Alcohol/drug abuse • Altered activity level/psychomotor retardation • Over- dependency • Poor hygiene • Underachievement • Withdrawal

  23. Risk Factors for Depression • Prior episodes of depression • Family history of depression • Prior suicide attempts • Female gender • Postpartum period • Medical comorbidity • Lack of social support • Life stressors • Personal history of sexual abuse • Current substance abuse

  24. Models of Causation of Severe Mood Disturbances • Multifactorial: • Genetic/biological • Environmental- Life stressors, loss • Poor attachment in infancy/early childhood (object relations) • Learned helplessness/hopelessness

  25. Neurobiology of Depression • Decrease in monoamine neurotransmitters (Norepinephrine, Serotonin) in the synapse between neurons • Over-Activation of the HPA axis Stress hypothalamus secretes CRH  stimulates pituitary to release ACTH  stimulates adrenal cortex to release glucocorticoids  damages neurons  decrease in neurotransmitters  depression and anxiety

  26. PET scan

  27. Diagnosis of Depression • Psychiatric evaluation • Self-report of symptoms • Family report of symptoms • Signs of depression (decreased sleep, decreased appetite, etc) • Medical exam to rule out physical illness • Labs – TSH, T3, T4, CBC must rule out medical causes such as hypothyroidism • Screening tools

  28. Screening Instruments • Hamilton Rating Scale for Depression (HAM-D) (1967) • Primary Care-Screener for Affective Disorders (PC-SAD) • (Rogers et al, 1998) • Primary Care Evaluation of Mental Disorders (PRIME-MD) (Spitzer, et al., 1994) • Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) (Broadhead et al., 1995) • Beck Depression Inventory (BDI) 1988 • Child Depression Inventory • Zung Self-Rating Depression Scale (1965)

  29. Impact of Depression • Impaired relationships • Inability to perform usual activities • Loss of productivity • Alcohol and other substance abuse • Increased use of health care resources • Risk of suicide (about 15% of patients with severe depression commit suicide)

  30. Differences by sex: Women • More common in women • Hormones directly effect the brain • Vulnerability to postpartum depression • Premenstrual dysphoric disorder • Increased risk during transition to menopause • Additional stresses at work, home, caring for children and aging parents, abuse, poverty, relationship strains

  31. Postpartum Depression • 13% of all new mothers • Associated with drastic hormone changes • Higher risk with previous PPD, h/o mood disorder • Estradial for treatment

  32. Differences by sex: Men • May experience differently • Feel tired, irritability, anhedonic, poor sleep, get frustrated, angry • More likely to use alcohol/drugs • Avoid talking about it • Excessive work • Behave recklessly • More likely to complete a suicide

  33. Depression in Older adults • More medical conditions that are associated with depression (i.e., cardiac, Parkinson’s, stroke, cancer) • Medications with SE of depression • Older white males age 85 + have the highest suicide rate in the U.S. • Psychotherapy and medications are effective treatments

  34. Depression in Children • Children may pretend sick, refuse school, cling to a parent, worry about a parent dying • Older children may sulk, get into trouble, be negative and irritable, feel misunderstood • Before puberty, no difference in incidence based on sex • By age 15 y.o., girls twice as likely as boys

  35. Depression in Children • In the teen years, often co-occurs with anxiety, eating d/o’s, or substance abuse • Childhood depression often persists into adulthood, esp. if not treated

  36. Other Types of Depression • Mood disorder due to medical condition • Endocrine dysfunction • Hypo- or hyperthyroidism • Cushing’s disease • Degenerative/structural change • Parkinson’s • Huntington’s Disease • MS • TBI • Stroke • Substance-Induced Mood Disorder • Seasonal Affective Disorder (SAD) • Adjustment Disorder (situational)

  37. Seasonal Affective Disorder (SAD) • Less daylight during the fall and winter causes depression in some people. • Overproduction of melatonin disrupts our internal body clock leading to depressive symptoms. If you have had episodes of depression that clearly have an onset in fall or winter followed by remission of symptoms in the spring or summer, you may have SAD.

  38. SAD sx’s • Depressed mood • Irritability • Hopelessness • Anxiety • Loss of energy • Social withdrawal • Oversleeping (feeling like you want to hibernate) • Loss of interest in activities you normally enjoy • Appetite changes, especially a craving for foods high in carbohydrates such as pastas, rice, bread and cereal • Weight gain • Difficulty concentrating and processing information

  39. Dysthymic Disorder • Characterized by chronic low-level depression experienced for at least 2 years • Not as severe as MDD, but can prevent normal functioning and feeling well • 1.5 % of the adult population in the U.S.

  40. Treatment of Depression • Safety - Environment free of harmful objects, safety plan • Pharmacology – antidepressants, sleep aids, short term anxiolytics • Psychotherapy – Cognitive Behavioral, Interpersonal, Solution Oriented, Supportive • Education- Coping skills, self esteem, illness, medications, resources • Phototherapy - Artificial bright light for SAD* • Electroconvulsive therapy (ECT)*

  41. Treatment of depression in children and adolescents • Unlike adults, children may not respond to tricyclics. • Children and adolescents do respond well to SSRIs and perhaps to other classes of antidepressants as well. • In 2003 a blackbox warning was implemented r/t increased suicide risk. More recent reports (June 2014) indicates an association between decrease rx and rise in child/teen suicide attempts

  42. Monoamine Oxidase Inhibitors (MAOIs) • Usual adult daily dosage ranges (not recommended for children): • Phenelzine (Nardil): 30-60mg • Tranylcypromine (Parnate): 20-60mg • Selegiline (Eldepryl, Atapryl) 10mg • Indications: may be useful in the treatment of depressed patients with marked anxiety or phobic symptoms. Selegiline is also used for the treatment of parkinsonism. • Because of the potential for serious adverse effects, MAOIs are not commonly used in clinical practice.

  43. Monoamine Oxidase Inhibitors (MAOIs) • Pharmacokinetics: antidepressant effects may take 3-6 weeks • Most frequent adverse effects: orthostatic hypotension, insomnia, weight gain, edema, and sexual dysfunction. • Rare side effect: tyramine-induced hypertensive crisis. Avoid foods that are preserved, pickled or aged (e.g., aged cheese, cured meats or fish, alcoholic beverages) • Potential for severe drug-drug interactions

  44. Tricyclic Antidepressants • Elavil (amitriptyline) • Norpramin (desipramine) • Pamelor (nortryptyline) • Pertofrane (desipramine) • Sinequan (doxepin) • Tofranil (imipramine) • Anafranil (clomipramine) - OCD

  45. Tricyclic Antidepressants (TCAs): Indications • Depression • Anxiety disorders • Obsessive-compulsive disorder • Clomipramine (Anafranil) • Chronic pain: • Neurogenic pain, Trigeminal neuralgia, Diabetic neuropathy, Sciatica, Fibromyalgia • Sleep Disorders • Insomnia, Cataplexy

  46. Tricyclic Antidepressants • Pharmacokinetics: therapeutic effects within 3-4 weeks; improved energy and sleep in 1-4 weeks • Adverse effects: • Anticholinergic: dry mouth, blurred vision, constipation, memory effects • Antiadrenergic: orthostatic hypotension • Antihistaminergic: sedation & weight gain • Cardiac: use in patients with conduction defects is contraindicated • Because of the potential for severe side effects and even death, TCAs are relatively contraindicated in the elderly, children, pregnant women and suicidal individuals.

  47. Selective Serotonin Reuptake Inhibitors (SSRIs) • Adolescents often receive adult dose, but doses are slightly less for children. • Fluoxetine (Prozac): 20-80mg/day for depression and anxiety disorders; 60-80mg/ day for bulemia. Prozac weekly: 90mg. • Fluvoxamine (Luvox): 100-300mg/day for OCD; 100-200 mg/day for depression • Paroxetine (Paxil): 20-50 mg/day • Sertraline (Zoloft): 50-200 mg/day • Citalopram (Celexa): 20-60mg/day • Escitalopram (Lexapro): 10-20mg/day

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