Depressive Disorders
Objectives
• At the end of this lesson, the SPN will:
• 1. Define mood and affect
• 2. Define and differentiate depression, euphoria, and mania
• 3. Define and describe the s/s, incidence and treatment for major
depressive disorder, seasonal affective disorder, dysthymia, and
premenstrual dysphoric disorder
• 4. Define and describe the s/s, incidence, and treatment for
Bipolar disorder
• 5. Apply the nursing process to a client with Bipolar Disorder
Mood and Affect Defined
• Mood is an emotion that is prolonged to the point that it colors an individual’s
entire psychological thinking. The feelings are changeable depending on the
person’s perception of sensory stimuli.
• Affect describes the facial expression an individual displays in association with
the mood (e.g. smiling when happy, grimacing when angry)
• Alterations in mood can range from mild to severe
Mood alterations
• When the mood alterations are mild, the person may experience minor changes
in daily routine with minimal impairment in functioning
• Severe mood alterations can result in significant impairment of the person’s
ability to function
• The prolonged inability to regain a sense of emotional balance is considered
abnormal. A depressed mood is one in which sadness is intensified and continues
longer than would normally be expected in a particular situation
Depression, Euphoria, Mania
• Depression is described as a persistent and prolonged mood of sadness that
extends beyond 2 weeks’ duration or longer
• In the depressive disorders, there is a distinctive change in the affect and
cognition, with the sadness being severe enough to interfere with the individual’s
functional activity
• In contrast, excessive feeling of happiness or elation is seen in euphoria
• A euphoric state can escalate to a frenzied unstable mood of mania in which the
person may be out of touch with reality.
Major Depressive Disorder
• Occurs when a person experiences a depressed mood or loss of interest in most
activities for most of each day for a period of 2 weeks
• Can occur as a single episode or recurrent depressive episodes
• The depressive episode may have a precipitating circumstance, such as chronic
pain, loss of a job, lack of support system, financial difficulties, or conflict with a
friend or loved one
Major Depressive Disorder
• Incidence and Etiology• More common in females and those who have a familial tendency for the
disorder
• Adolescents between 14 and 16 and adults older than 65 have a higher
incidence
• May develop over days or weeks and last for several months
• A common theory about the cause of major depression is that it is related to
functional deficits of neurotransmitters in the brain that lead to a chemical
imbalance
Major Depressive Disorder- Signs and
Symptoms
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Mood of worry, anxiety, hopelessness and worthlessness
Guilt and self-blame
Crying episodes
Fatigue, Anergia (a marked decrease in energy level)
Sleep disturbances
Weight and appetite changes
Decreased sex drive
Poor concentration and memory lapse
Signs and Symptoms Con’t.
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Decreased productivity
Difficulty making decisions
Irritability
Extreme sadness with sad affect
Physical complaints
Anhedonia- a lack of pleasure in things previously enjoyed
Thoughts of death or suicide
Major Depressive Disorder-Treatment
• CBT
• Antidepressants-SSRI’s, tricyclics
Major Depressive Disorder with Seasonal
Pattern
• Indicates that episodes mostly begin in fall or winter and remit in
spring.
• Characterized by anergia, hypersomnia, overeating, weight gain, and
craving for carbohydrates
• Responds to light therapy
Persistent Depressive Disorder (Dysthymia)
• A recurrent state of depression over a period of at least 2 years
• Depressive symptoms become a part of the person’s day-to-day
experience, never disappearing for more than 2 months at a time
• The symptoms of persistent depressive disorder are less severe than
those of major depression, but the disorder tends to be more chronic
Persistent Depressive Disorder (Dysthymia)
• Incidence and Etiology
• Occurs two to three times more frequently in women than men
• More likely to occur in first-degree biologic relatives with
depressive disorders
• There is usually an early-onset beginning anytime from childhood
through early adulthood
Persistent Depressive Disorder (Dysthymia)Signs and Symptoms
• Chronic depression symptoms
• Feelings of inadequacy, failure, emptiness
• Hopelessness
• Negativism-a learned sense of helplessness characterized by feelings
of failure, and emptiness that often results in a pessimistic attitude
toward most aspects of the person’s existence
• Maladaptive coping skills
• Sleep difficulties
Persistent Depressive Disorder (Dysthymia)Signs and Symptoms
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Increased or decreased appetite
Fatigue
Low self-esteem
Difficulty concentrating
Decreased decision-making ability
Dysthymic Disorder- Treatment
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Psychotherapy
Behavioral Therapy
Group therapy
Pharmacologic treatment- SSRI’s, tricyclics
Premenstrual Dysphoric Disorder
• A condition in which a woman has severe depression symptoms, irritability, and
tension before menstruation
• Symptoms typically occur about 5 to 11 days before a woman starts her monthly
menstrual cycle
• Symptoms usually stop when, or shortly after, her period begins
Premenstrual Dysphoric Disorder
• Etiology and Incidence
• Many women who have this disorder, also have anxiety, severe depression, and depressive
disorder with a seasonal pattern
• Other factors that may play a role include: alcohol or substance abuse, thyroid disorders,
overweight, having a mother with the disorder, lack of exercise
Premenstrual Dysphoric Disorder
• Signs and Symptoms
• Lack of interest in daily activities and relationships
• Fatigue or low energy
• Sadness or hopelessness, possibly thoughts of suicide
• Anxiety
• Out of control feeling
• Food cravings or binge eating
• Mood swings with bouts of crying
• Panic attacks
Premenstrual Dysphoric Disorder
• Signs and Symptoms Con’t.
• Irritability or anger that affects other people
• Bloating, breast tenderness, headaches, and joint or
muscle pain
• Problems sleeping
• Trouble concentrating
Treatment of Depressive Disorders
• Treatment involves a combination of pharmacological and
psychotherapeutic approaches
• Antidepressants
• Individual psychotherapy to address past losses and stressors
• Short-term cognitive behavioral therapy to develop new strategies to
alter negative thinking
• Group therapy to address socialization and poor self-esteem
• For severe depression, ECT is sometimes suggested
Treatment of Depressive Disorders Con’t.
• Alternative Treatments:
• Light Therapy- special lights are used for certain amounts of time
during the day
• Herbal and Nutritional Therapy-Avoiding caffeine, sugar, and
alcohol or adding servings of whole grains and vegetable may help
a person with mild depression
• Herbs such as kava, gingko, and fish oil have been shown to
provide antidepressant effects in some patients with mild
depression
Bipolar Disorder
• Formerly known as manic depression
• There is a brain dysfunction that causes abnormal and erratic shifts in
mood, energy, and functional ability
• The episodes of alternate changes between extreme moods, ranging
from high manic episodes (euphoric, excessively happy, high energy)
to low depressive periods may occur rapidly, may be intermixed with
periods of normal functioning, or these can occur simultaneously in a
missed episode
Bipolar Disorder
• The rapid shifts in mood in a short period of time are known as labile,
or alternating from euphoria to dysphoria and irritability
• According to the DSM-5 criteria for bipolar disorder, the mood
changes must be accompanied by persistently increased activity or
energy levels that are obvious to those observing the person.
• The frequency of the mood swings between the two states is
unpredictable and varies from person to person
• The severity of the symptoms may vary from mild to severe
Bipolar Disorder
• If the person has four or more mood shifts within a year, the person is
said to be rapid cycling. This feature is more common in later stages
of the illness
• Incidence and Etiology• There seems to be a genetic factor that is shown by the familial
pattern of illness
• Evidence has linked bipolar symptoms to changes in the chemical
neurotransmitters in the brain
• Substance abuse and stressful life events have also been linked to
the episodes
Bipolar Disorder
• Incidence and Etiology
• Women are at greater risk than men for developing manic
episodes, which can occur at any time
• The average age of onset for a first manic episode is in the
early 20’s, but it can be as early as adolescence and as late
as age 50
• Manic episodes that occur in adolescence may lead to
school failure, behavioral problems, and substance abuse
Bipolar Disorder
• Signs and Symptoms• The first indications may be a state of mild to moderate mania called hypomania
that lasts for a period of at least 4 days.
• During the hypomania phase the person will have the following signs and
symptoms:
• Unusually cheerful with excessive energy and the ability to keep going long
after others are exhausted
• The need for sleep decreases to 3 or 4 hours
• There is an obvious inflated self-esteem or feeling of grandiosity during which
time the person may experience hallucinations or delusional thinking
Bipolar- Signs and Symptoms Con’t.
• During hypomania:
• An increase in goal-directed activity but with increased irritability and
moodiness
• The person usually talks incessantly with a flight of ideas or jumping from one
subject to another, and may describe thoughts as racing or pressured
• Attention is easily distracted to things in the environment that are
insignificant
• Irresponsible, impulsive behavior.
• A preoccupation with seductive thoughts often leads to sexual promiscuity
Bipolar- Signs and Symptoms Con’t.
• During hypomania:
• The changes in mood are obvious to others but not
usually severe enough to require hospitalization
• The person in hypomania does not experience
psychotic symptoms of delusions or hallucinations
Bipolar- Signs and Symptoms Con’t.
• During full-blown manic episodes:
• Symptoms are more extreme and pronounced
• Elevated mood lasts for at least a week and causes disruption in
the person’s ability to function- little need for sleep
• The person’s lack of insight and excessive level of activity
predispose him or her to a dangerous and volatile psychotic state
• The person may be offensive and violate the rights of others
• When his or her wishes are not fulfilled, the mood may shift from
extreme aggressive euphoria to extreme aggressive irritability
Bipolar- Signs and Symptoms Con’t.
• During full-blown manic episodes:
• The person may perceive injustice and have delusional thoughts of
persecution that a threat of harm exists
• The constant shift in attention from one thought to another is
seen in flight of ideas
• Words may be strung together in rhyming phrases or clang
associations that have no connected meaning.
• The person projects an expanded thought pattern of grandiosity
with false beliefs of wealth, power, and identity
Bipolar- Signs and Symptoms Con’t.
• During full-blown manic episodes:
• Auditory and visual hallucinations may occur during the height of
the manic episode
• Females may dress bizarrely with bright flamboyant colors,
excessive jewelry, and inappropriate makeup
• Hygiene is often neglected as the thought processes escalate and
activity accelerates
• Items such as magazine pictures, containers, and food may be
collected and stockpiled as the hyperactivity absorbs the person’s
time
Bipolar Depressive Phase Symptoms
• Low self esteem
• Overwhelming inertia (sluggishness, a lack of activity)
• Social withdrawal
• Feelings of hopelessness, and apathy
• Difficulty concentrating or thinking clearly (without obvious
disorientation or intellectual impairment)
• Psychomotor retardation (sluggish physical movements and activity)
• Slowing of speech and responses
• Sexual dysfunction
Depressive Symptoms Con’t
• Sleep disturbances (such as difficulty falling or staying asleep or earlymorning awakening)
• Decreased muscle tone
• Weight loss
• Slow gait
• constipation
Bipolar Treatment
• Consists of drug therapy. Lithium is highly effective in both preventing
and relieving manic episodes. It curbs accelerated thought processes
and hyperactive behavior without the sedating effect of antipsychotic
drugs.
• The MD may also prescribe Depakote for rapid cyclers or for patients
who can’t tolerate lithium.
• Tegretol may also be prescribed for treating mania.
• Lamotrigine (Lamictal) may be prescribed. ***Monitor for StevensJohnson Syndrome)
• Newer anticonvulsants- Topamax and Trileptal may be prescribed
• Anxiolytics such as Klonopin and Ativan are useful for acute mania
Bipolar Treatment
• Second generation antipsychotics- Zyprexa, Risperdal, Abilify, and
Geodon may be prescribed to help with insomnia, anxiety, and
agitation
• ECT is used to subdue severe manic behavior
• Psychotherapy
• Cognitive Behavioral therapy
• Family-focused therapy
• Support groups
Nursing Care-Manic Phase
• Provide for the patient’s physical needs. Involve him in activities that
require gross motor movements
• Encourage the patient to eat. Offer high calorie finger foods,
sandwiches, and cheese and crackers to supplement his diet.
• Provide clear firm limits. Clearly define what is expected and what is
not allowed
• Maintain safety
Nursing Care Con’t
• Suggest short daytime naps, and help with personal
hygiene. As symptoms subside, encourage him to
assume responsibility for personal care
• Provide diversionary activities suited to a short
attention span
• Maintain a calm environment and protect the patient
from over-stimulation, such as from large groups, loud
noises, etc.
Nursing Care Con’t
• Provide emotional support and set realistic goals for
behavior
• Tactfully divert the conversation if it becomes
intimately involved with other patients or staff
• Avoid reinforcing socially inappropriate or suggestive
comments
• Set limits for the patient’s demanding, hyperactive,
manipulative, and acting-out-behaviors
Nursing Care Con’t
• Collaborate with other staff members regarding the
plan of care
• Monitor the medication regimen. Advise the patient
that Lithium needs to be taken with food or after
meals to avoid stomach upset
Nursing Care-Depressive Phase
• Provide for the patient’s physical needs. If he’s too
depressed to care for himself, help with personal
hygiene
• Encourage him to eat, or feed him if necessary. If
constipated, add high-fiber foods to his diet; offer
small, frequent meals; and encourage physical activity
• To help the patient sleep, give back rubs or warm milk
at bedtime
Nursing Care Con’t
• Provide a structured routine
• Avoid overwhelming the patient with expectations
• Remove harmful objects from the patient’s environment
• Observe the patient closely, and strictly supervise his
medications
• If the patient is taking an antidepressant, watch for signs and
symptoms of mania
Bipolar Disorder- Nursing Diagnosis
• What would be an appropriate nursing diagnosis for a
patient that presents with bipolar disorder?
• BE AWARE THAT YOU NEED TO RECOGNIZE WHAT
STATE OF BIPOLAR THE PATIENT IS IN. THE NURSING
DIAGNOSIS’ FOR DEPRESSION VS. THE NURSING
DIAGNOSIS’ FOR MANIA WILL BE DIFFERENT!!!!!!
Bipolar Disorder- Expected Outcomes
• What are the expected goals or outcomes for the
client in a depressed state?
• What are the goals for the client in a state of
hypomania or mania?
Bipolar Disorder- Nursing Interventions
• What are the interventions for a client in a depressed state?
• What are the interventions for a client in a state of mania or
hypomania?