Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 17 Mood Disorders and Suicide

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 17

Mood Disorders and Suicide

Chapter 17

Mood Disorders and Suicide


Mood DisordersMood 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


Mood Disorders (cont.)Mood Disorders (cont.)

• Most common psychiatric diagnosis associated with suicide

– Depression one of the most important risk factors for it


Categories of Mood DisordersCategories of Mood Disorders• Major depressive disorder

• Bipolar disorder

• Related disorders– Dysthymic disorder– Cyclothymic disorder– Substance-induced depressive or bipolar disorder– Seasonal affective disorder– Postpartum depression, psychosis, premenstrual

dysphoric disorder– Nonsuicidal self-injury


EtiologyEtiology

• Biologic theories

– Genetic theories

– Neurochemical theories: serotonin, norepinephrine; possibly acetylcholine and dopamine

– Neuroendocrine influences: hormones


Etiology (cont.)Etiology (cont.)

• Psychodynamic theories

– Freud: self-deprecation

– Bibring: ideal ego

– Jacobson: superego over powerless ego

• Mania: defense against underlying depression


Cultural ConsiderationsCultural 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


QuestionQuestion

• Is the following statement true or false?

• Depression is most commonly associated with suicide.


AnswerAnswer

• True

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


Major Depressive DisorderMajor Depressive Disorder

• Incidence: women to men 2:1

– 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


Major Depressive Disorder (cont.)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


PsychopharmacologyPsychopharmacology

• Selective serotonin reuptake inhibitors (see Table 17.1)

• Cyclic antidepressants (see Table 17.2)

• Atypical antidepressants (see Table 17.3)

• Monoamine oxidase inhibitors (MAOIs) (see Table 17.4)


Other Medical Treatments and PsychotherapyOther 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


Major Depressive Disorder and Nursing Process ApplicationMajor 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)


Major Depressive Disorder and Nursing Process Application (cont.)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


QuestionQuestion


• Patients with depression often exhibit anhedonia.


AnswerAnswer

• 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.



• Data analysis/nursing diagnoses

• Outcome identification– Free from self-injury

– Improved mood and energy

– Return to previous functional level

– Medication compliance



• Intervention– Providing for safety (suicide precautions)– Promoting therapeutic relationship– Promoting ADLs, physical care– Using therapeutic communication– Managing medications– Patient, family teaching

• Evaluation


Bipolar DisorderBipolar 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


Treatment 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


Bipolar Disorder and Nursing Process Application 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)


Bipolar Disorder and Nursing Process Application (cont.)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


QuestionQuestion

• 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


AnswerAnswer

• 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.


Bipolar Disorder and Nursing Process Application (cont.)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


SuicideSuicide

• Intentional act of killing oneself

• Suicidal ideation: thinking about killing oneself

• Warning signs: risk for suicide (see Box 17.4)


Suicide (cont.)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 17.4); risky behavior

– Lethality assessment

• Data analysis/nursing diagnoses



• Outcome identification

– Safety, free from self-harm

• Intervention– Authoritative role

– Safe environment: suicide precautions; no suicide/no self-harm contract

– Support system list



• Family response

– Suicide as ultimate rejection of family, friends

– Families react with guilt, shame, anger


Suicide (cont.)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


Legal and Ethical Considerations 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


QuestionQuestion


• When dealing with a patient who is suicidal, the nurse needs to assume a dependent role.


AnswerAnswer

• False

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


Elder Considerations 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


Community-Based Care 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


Community-Based Care (cont.) Community-Based Care (cont.)

• Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment


Mental Health Promotion 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


Mental Health Promotion (cont.) 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


Self-Awareness IssuesSelf-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

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 17 Mood Disorders and Suicide