Chapter 15Chapter 15
Mood Disorders
Part I
IntroductionIntroduction
Depression is the oldest and most frequently described psychiatric illness.
Transient symptoms are normal, healthy responses to everyday disappointments in life.
Introduction (cont.)Introduction (cont.)
Pathological depression occurs when adaptation is ineffective.
EpidemiologyEpidemiology
Affects almost 10 percent of the population, or 19 million Americans, in a given year
Considered to be the “common cold” of psychiatric disorders
Epidemiology (cont.)Epidemiology (cont.)
Gender prevalence Higher in women than in men by about 2 to 1 Incidence of bipolar disorder is roughly equal
Epidemiology (cont.)Epidemiology (cont.)
Age Depression more common in young
women than in older women; has a tendency to decrease with age
Opposite is true for men Studies of bipolar disorder suggest median
age at onset of bipolar disorder is 18 years in men and 20 years in women
Epidemiology (cont.)Epidemiology (cont.)
Social class: There is an inverse relationship between social class and report of depressive symptoms; the opposite is true with bipolar disorder.
Seasonality: Affective disorders are more prevalent in the spring and in the fall.
Epidemiology (cont.)Epidemiology (cont.)
Race: No consistent relationship between race and affective disorder reported
Marital status: Single and divorced people more likely to experience depression than married people
Types of Mood DisordersTypes of Mood Disorders
Depressive disorders Major depressive disorder Dysthymic disorder Premenstrual dysphoric disorder
Bipolar disorder Bipolar I disorder Bipolar II disorder Cyclothymia
Major Depressive DisorderMajor Depressive Disorder
Characterized by depressed mood Loses interest or pleasure in usual activities Social and occupational functioning impaired
for at least 2 weeks No history of manic behavior Cannot be attributed to use of substances or
a general medical condition
Dysthymic DisorderDysthymic Disorder Sad or “down in the dumps” No evidence of psychotic symptoms Essential feature is a chronically depressed
mood for Most of the day More days than not For at least 2 years
Premenstrual Dysphoric DisorderPremenstrual Dysphoric Disorder Essential Features
Depressed mood Anxiety Mood swings Decreased interest in activities
Symptoms occur during the week prior to menses and subside shortly after onset of menstruation
Bipolar DisordersBipolar Disorders
Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy
Delusions or hallucinations may or may not be part of clinical picture
Onset of symptoms may reflect seasonal pattern
Bipolar I DisorderBipolar I Disorder
Individual is experiencing, or has experienced, a full syndrome of manic or mixed symptoms
May also have experienced episodes of depression
Bipolar II DisorderBipolar II Disorder
Recurrent bouts of major depression Episodic occurrences of hypomania Has not experienced an episode that meets the
full criteria for mania or mixed symptomatology
Other Mood DisordersOther Mood Disorders
Due to general medical condition Substance-induced mood disorder
Etiological Implications-Depressive DisordersEtiological Implications-Depressive Disorders
Biological theories Genetics: Hereditary factor may be
involved Biochemical influences: Deficiency of
norepinephrine, serotonin, and dopamine has been implicated
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Biological theories (cont.) Neuroendocrine disturbances
Possible dysfunction within the hypothalamic-pituitary-adrenocortical axis
Possible diminished release of thyroid-stimulating hormone
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Physiological influences Medication side effects Neurological disorders Electrolyte disturbances Hormonal disorders Nutritional deficiencies
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Physiological conditions (cont.)
Secondary depression related to: Collagen disorders (e.g., SLE) Cardiovascular disease Infections (e.g., hepatitis, pneumonia, syphilis) Metabolic disorders (e.g., diabetes mellitus)
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Psychosocial theories
Psychoanalytical theory (Freud) Mourning Melancholia Follows loss of a loved object
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Learning theory Learned helplessness: Repeated failure to
control life, leading to defeat and dependence on others, resulting in predisposition to depression
Etiological Implications-Depressive Disorders (cont.) Etiological Implications-Depressive Disorders (cont.)
Object loss theory Experiences loss of significant other during
first 6 months of life Early loss or trauma may predispose client
to episodes of depression in response to losses later in life
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Cognitive theory: Beck Primary disturbance in depression is cognitive
rather than affective Three cognitive distortions serve as basis for
depression Negative expectations about
Environment Self Future
Etiological Implications-Depressive Disorders (cont.)Etiological Implications-Depressive Disorders (cont.)
Theoretical Integration
Etiology of depression likely due to multiple influences of Genetics Biochemical Psychosocial
Developmental ImplicationsDevelopmental Implications
Childhood Depression Symptoms:
<age 3: feeding problems, tantrums, lack of playfulness and emotional expressiveness Ages 3 to 5: accident proneness, phobias,
excessive self-reproach Ages 6 to 8: physical complaints,
aggressive behavior, clinging behavior Ages 9 to 12: morbid thoughts and
excessive worrying
Developmental Implications (cont.)Developmental Implications (cont.)Childhood Depression (cont.) Precipitated by a loss Focus of therapy: alleviate symptoms and
strengthen coping skills Parental and family therapy
Developmental Implications (cont.)Developmental Implications (cont.)
Adolescence Symptoms include:
Anger, aggressiveness Running away Delinquency Social withdrawal Sexual acting out Substance abuse Restlessness; apathy
Developmental Implications (cont.)Developmental Implications (cont.)
Adolescence (cont.) Best clue that differentiates depression from
normal stormy adolescent behavior: A visible manifestation of behavioral change that
lasts for several weeks Most common precipitant to adolescent suicide:
perception of abandonment by parents or close peer relationship
Developmental Implications (cont.)Developmental Implications (cont.)
Senescence Bereavement overload High percentage of suicides among elderly Symptoms of depression often confused with
symptoms of dementia Treatment
Antidepressant medication Electroconvulsive therapy Psychosocial therapies
Developmental Implications (cont.)Developmental Implications (cont.)Postpartum Depression May last for a few weeks to several months Associated with hormonal changes, tryptophan
metabolism, or cell alterations Treatments: antidepressants and psychosocial
therapies Symptoms include:
Fatigue Irritability Loss of appetite Sleep disturbances Loss of libido Concern about inability to care for infant
Nursing Process/AssessmentNursing Process/Assessment
Transient depression Symptoms at this level of the continuum
not necessarily dysfunctional Affective: The “blues” Behavioral: Certain amount of crying
AssessmentAssessment
Transient depression (cont.) Cognitive: Some difficulty getting mind off
one’s disappointment Physiological: Feeling tired and listless
Assessment (cont.)Assessment (cont.)
Mild depression Symptoms with normal grieving are
identified by clinicians as associated with normal grieving
Affective: Anger, anxiety, sadness Behavioral: Tearful, regression
Assessment (cont.)Assessment (cont.)
Mild depression (cont.) Cognitive: Preoccupied with loss; self-
blame and blaming of others Physiological: Anorexia or overeating,
sleep disturbances, somatic symptoms
Assessment (cont.)Assessment (cont.)
Moderate depression Symptoms associated with dysthymic disorder Affective: Helpless, powerless Behavioral: Slow physical movement,
slumped posture, limited verbalization
Assessment (cont.)Assessment (cont.)
Moderate depression (cont.) Cognitive: Retarded thinking processes,
difficulty with concentration Physiological: Anorexia or overeating,
sleep disturbances, somatic symptoms, feeling best early in morning and worse as the day progresses
Assessment (cont.)Assessment (cont.)
Severe depression Includes symptoms of major depressive
disorder and bipolar depression Affective: Feelings of total despair,
worthlessness, flat affect, apathy, anhedonia
Behavioral: Psychomotor retardation, curled-up position, no interaction with others
Assessment (cont.)Assessment (cont.)
Severe depression (cont.) Cognitive: Prevalent delusional thinking,
with delusions of persecution and somatic delusions; unable to concentrate; confusion
Physiological: A general slow-down of the entire body, anorexia, insomnia, feels worse early in morning and somewhat better as the day progresses
Diagnosis/Outcome IdentificationDiagnosis/Outcome Identification
Risk for suicide related to: Depressed mood Feelings of worthlessness Anger turned inward on the self Misinterpretations of reality
Nursing DiagnosisNursing Diagnosis
Dysfunctional grieving related to: Real or perceived loss Bereavement overload, evidenced by
denial of loss Inappropriate expression of anger Idealization of or obsession with
lost object
Nursing Diagnosis (cont.)Nursing Diagnosis (cont.) Low self-esteem related to:
Learned helplessness Feelings of abandonment by significant
others Impaired cognition fostering negative view
of self
Nursing Diagnosis (cont.)Nursing Diagnosis (cont.)
Powerlessness related to: Dysfunctional grieving process Lifestyle of helplessness, evidenced by
feelings of lack of control over life situation
Nursing Diagnosis (cont.)Nursing Diagnosis (cont.)
Spiritual distress related to: Dysfunctional grieving over loss of valued
object evidenced by anger toward God Questioning meaning of own existence Inability to participate in usual religious
practices
Nursing Diagnosis (cont.)Nursing Diagnosis (cont.)
Social isolation/Impaired social interaction related to: Developmental regression Egocentric behaviors Fear of rejection or failure of the interaction
Nursing Diagnosis (cont.)Nursing Diagnosis (cont.)
Disturbed thought processes related to: Withdrawal into self Underdeveloped ego Punitive superego Impaired cognition fostering negative
perception of self or environment
Other Nursing DiagnosesOther Nursing Diagnoses
Imbalanced nutrition less than body requirements
Disturbed sleep pattern Self-care deficit
Criteria for Measuring OutcomesCriteria for Measuring Outcomes
The client Has experienced no physical harm to self Discusses the loss with staff and family
members No longer idealizes or obsesses about the
lost object
OutcomesOutcomes
The client (cont.) Sets realistic goals for self Is no longer afraid to attempt new activities Is able to identify aspects of self-control
over life situation
Outcomes (cont.)Outcomes (cont.)
The client (cont.) Expresses personal satisfaction with and
support from spiritual practices Interacts willingly and appropriately with
others Is able to maintain reality orientation Is able to concentrate, reason,
and solve problems
Planning/ImplementationPlanning/Implementation
Nursing Interventions are aimed at: Maintaining client safety Assisting client through grief process Promoting increase in self-esteem Encouraging client self-control and control
over life situation Helping client to reach out for spiritual
support of choice
Client/Family Education Client/Family Education
Nature of the illness Stages of grief and symptoms associated
with each stage What is depression? Why do people get depressed? What are the symptoms of depression?
Client/Family Education (cont.) Client/Family Education (cont.)
Management of the illness Medication management Assertive techniques Stress management techniques Ways to increase self-esteem Electroconvulsive therapy
Client/Family Education (cont.) Client/Family Education (cont.)
Support services Suicide hotline Support groups Legal/financial assistance
Nursing Process/EvaluationNursing Process/Evaluation
Evaluation of the effectiveness of nursing interventions is measured by fulfillment of the outcome criteria.
Evaluation Evaluation
Has self-harm to the client been avoided?
Have suicidal ideations subsided? Does the client know where to seek
assistance outside the hospital when suicidal thoughts occur?
Evaluation (cont.) Evaluation (cont.)
Has the client discussed the recent loss with the staff and family members?
Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process?
Evaluation (cont.)Evaluation (cont.)
Has obsession with and idealization of the lost object subsided?
Is anger toward the lost object expressed appropriately ?
Does client set realistic goals for self?
Evaluation (cont.)Evaluation (cont.)
Is he or she able to verbalize positive aspects about self, past accomplishments, and future prospects?
Can the client identify areas of life situation over which he or she has control?