UNIT TWO
SEVERE MENTAL DISORDERS
CHAPTER TWO
MOOD (AFFECTIVE) DISORDERS
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CHAPTER 2: MOOD (AFFECTIVE)
DISORDERS
DEFINITIONS
Mood
 Mood is a pervasive and sustained emotion that
may have a major influence on a person’s
perception of the world (Examples of mood
include depression, joy, elation, anger, and
anxiety)
Affect
 Affect is described as the emotional reaction
associated with an experience
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EPIDEMIOLOGY
 Studies have shown no consistent relationship
between race and affective disorder, All races,
all ages, both sexes are susceptible to
depression episodes, but some are more
susceptible than others
 Depression is the fourth leading cause of
disability in the USA, and is expected to be the
second leading cause of disability by 2020
 Depression is sometimes called by some
researchers as the common cold of psychiatric
disorders and this generation as an age of
melancholia
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 The incidence of depression is higher in young
women and has a tendency to decrease with
age
 The opposite has been found in men, with the
prevalence of depressive symptoms being lower
in younger men and increasing with age. This
can be related to:
1. Gender differences in social roles and economic and
social opportunities and the shifts that occur with
age.
2. The construction of gender stereotypes, or gender
socialization, promotes typical female characteristics,
such as helplessness, passivity, and emotionality,
which are associated with depression
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 The highest incidence of depressive symptoms
has been indicated in individuals without close
interpersonal relationships and in persons who
are divorced or separated
 There are lower rates of depressive symptoms
among married men and higher rates among
married women and single men
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PRIMARY RISK FACTORS FOR MOOD
DISORDERS
1. History of prior episodes of depression
2. Family history of depressive disorder,
especially in first degree relatives
3. History of suicide attempts and/or family
history of suicide
4. Female gender
5. Age 40 years or younger
6. Postpartum period
7. Medical illness
8. Absent of social support
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9. Negative, stressful life events
10. Active alcohol or substance abuse
TYPES OF MOOD DISORDERS
 Mood disorders are classified under two major
categories:
1. Depressive disorders
2. Bipolar disorders
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A. DEPRESSIVE DISORDERS
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1. MAJOR DEPRESSIVE DISORDER
(MDD)
DEFINITION OF DEPRESSION
Depression is an alteration in mood that is
expressed by feelings of sadness, despair, and
pessimism. There is a loss of interest in usual
activities, and somatic symptoms may be
evident. Changes in appetite and sleep patterns
are common
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DESCRIPTION OF DEPRESSION
 The course of MDD is variable
 Patients with MDD experience substantial pain
and suffering and psychological, social, and
occupational disability during their depression
 The symptoms often interfere with the patients’
social and occupational functioning and
sometimes may include psychotic features
 Delusional or psychotic major depression is a
severe form of Mood Disorder that is
characterized by delusions or hallucinations
 Depression affects almost 10% of the population
worldwide
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 At least 60% of those people can expect to have
a second episode
 People who have had a second episode of MDD
have 70% chance of having a third episode
 Those who have three episodes have a 90%
chance of more future episodes
 The DSM IV TR diagnosis will identify:
 The degree of severity of symptoms (mild,
moderate, or severe
 If there is evidence of psychotic or catatonic
features
 If there is a seasonal pattern of the episode
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The DSM-IV-TR diagnostic criteria for major
depressive disorder
A. Five (or more) of the following symptoms have
been present during the same Two-Week
period and represent a change from previous
functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of
interest or pleasure
1. Depressed mood most of the day, nearly every
day, as indicated by either subjective report
(e.g., feels sad or empty) or observation made
by others (e.g., appears tearful). NOTE: In
children and adolescents, can be irritable
mood.
2. Markedly diminished interest or pleasure in all,
or almost all, activities most of the day, nearly
every day (as indicated either by subjective
account or observation made by others)
3. Significant weight loss when not dieting or
weight gain (e.g., a change of more than 5% of
body weight in a month), or a decrease or
increase in appetite nearly every day. NOTE:
In children, consider failure to make expected
weight gains
4. Insomnia or hypersomnia nearly every day
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5. Psychomotor agitation or retardation nearly
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every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or
guilt about being sick)
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by
subjective account or as observed by others),
recurrent thoughts of death (not just fear of
dying)
9. Recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for
committing suicide
B. There has never been a manic episode, a
mixed episode, or a hypomanic episode that
was not substance or treatment induced or due
to the direct physiological effects of a general
medical condition
C. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning
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D. The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism)
E. The symptoms are not better accounted for by
bereavement (i.e., after the loss of a loved
one), the symptoms persist for longer than 2
months or are characterized by marked
functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
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MAJOR DEPRESSIVE DISORDER (MDD)
SUBTYPES
1. MDD with psychotic features
 indicates the presence of delusion such as
delusions of guilt, or being punished for sins,
somatic delusions of horrible disease or body
rotting, delusions of poverty or going bankrupt
 Or the presence of hallucinations usually
auditory, voices berating person for sins or
shortcomings
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2. MDD with Postpartum onset
 Onset within 4 weeks of childbirth
 Can present with or without psychotic features
 Severe rumination or delusional thoughts about
infant increased risk of harm to infant
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3. MDD with seasonal characteristics
(Seasonal Affective Disorder SAD)
 Indicates that episodes mostly begin in Autumn
or Winter and remit in Spring
 Characterized by anergia, hypersomnia,
overeating, weight gain, and a craving for
carbohydrates
 Responds to phototherapy (light therapy)
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 Phototherapy treats seasonal affective disorder
(SAD) by stimulating the production of retinal
dopamine and suppressing the production of
retinal melatonin (hormone of darkness)
4. MDD with chronic feature
 Indicates MDD lasting 2 years or longer
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2. DYSTHYMIA DISORDER (DD)
DESCRIPTION
 Characteristics of DD are similar to those of
major depressive disorder but milder
 Individuals with DD describe their mood as sad
or “down”
 In DD, there is no evidence of psychotic
symptoms
 The essential feature of DD is a chronically
depressed mood (Irritable mood in children or
adolescents) for most of the day, more days than
not, for at least 2 years (1 year for children and
adolescents).
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 The diagnosis is identified as:
1. Early onset: Occurring before age 21 years
2. Late onset: Occurring at age 21 years or
older
 Although DD patients suffer from social and
occupational distress, it is usually not severe
enough to need hospitalization unless the
patient become suicidal
 DD patients are at risk of developing MDD as
well as other psychotic disorders
 Differentiating MDD from DD is difficult because
both have similar symptoms
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 The main differences are in the duration and the
severity of the symptoms
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DYSTHYMIA DISORDER (DD) SUBTYPES
1. DD and MDD with atypical features
 Indicate mood reactivity:
 Can be cheered with positive events
 Rejection sensitivity (pathological sensitivity to
perceived interpersonal rejection)
 These features present throughout life and result
in functional impairment
 Other symptoms include: hypersomnia and
hyperphagia
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OTHER DEPRESSIVE DISORDERS
 DESCRIPTION
 The following disorders have no DSM-IV-TR
official diagnostic category
 It provides a set of research criteria to promote
further study of these disorders
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1. PREMENSTRUAL DYSPHORIC DISORDER
 PDS characterized by more severe symptoms
than Premenstrual Syndrome (PMS)
 Symptoms begin toward last week of luteal
(secretory) phase and are absent in the week
following menses (it is the latter phase of the
menstrual cycle that begins with the formation
of the corpus luteum and ends in either
pregnancy or luteolysis
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 The essential features include:
1. Markedly depressed mood
2. Excessive anxiety
3. Mood swings
4. Persistent and marked anger or irritability
5. Anergia
6. Overeating
7. Difficulty concentrating
8. Feeling of being out of control or
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overwhelmed
9. Decreased interest in activities during the
week prior to menses and subsiding shortly
after the onset of menstruation
 Somatic complaints, such as headache, edema,
backache, and breast tenderness, as well as
changes in appetite and sleep patterns, are
common
 There is no DSM-IV-TR Diagnostic criteria for
Premenstrual Dysphoric Disorder (PDD), only
research criteria
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2. MIXED ANXIETY DEPRESSION
 Prevalence of 5%
 Characterized by significant functional disability
 Criteria include at least 1 month of persistent
Dysphoric mood, with possible hypervigilance,
difficulty concentrating, fatigue, low-self esteem,
irritability,
 All these symptoms causing significant distress
or impairment in functioning
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3. RECURRENT BRIEF DEPRESSION
 Meets criteria for depressive episode, but
episodes last 1 day to 1 week
 Depressive episode must reappear at least once
per month over 12 months or more
 Carries a high risk for suicide
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4. MINOR DEPRESSION
 Characterized by sustained depressed mood
without the full depressive syndrome
 Pessimistic attitude and self-pity are required for
the diagnosis
 Maybe chronic and maybe complicated by a
superimposed major depressive episode
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TREATMENT OF DEPRESSIVE
DISORDERS
ANTIDEPRESSANTS
INDICATIONS:
 Antidepressant medications are used in the
treatment of the following disorders:
1. Major depression with melancholia or psychotic
symptoms
2. Depressive phase of bipolar disorder
3. Depression accompanied by anxiety
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4. Dysthymia Disorder
5. Depression associated with organic disease,
alcoholism, schizophrenia, or mental
retardation
Effects of treatment with Antidepressants
1. Elevate mood
2. Increase physical activity
3. Increase mental alertness
4. Improve appetite and sleep
5. Restore interest or pleasure in usual daily
activities previously enjoyed
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MODE OF ACTION
1. Depression results from a decrease in the
concentration of the following monoamine
neurotransmitter to a level insufficient to
stimulate Norepinephrine (Noradrenalin)
2. Serotonin (5 Hydroxytriptamine)
3. Dopamine
 he receptors
 Research indicates that by inhibiting the
breakdown of the monoamine neurotransmitters
or inhibiting their reuptake to the pre-synapses
at the neuron level in the brain, mood can be
effectively elevated and improved.
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CONTRAINDICATIONS/PRECAUTIONS
 Hypersensitivity to antidepressants
 Acute recovery phase of myocardial infarction
 Individuals with angle-closure glaucoma
(Narrow-Angle Glaucoma)
 Special attention and close observations should
be given to elderly people with hepatic, renal, or
cardiac insufficiency when starting them on
Antidepressants
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Caution: As these drugs take effect, and mood
begins to improve, the individual may have
increased physical energy enough to carry out a
suicide that he planned when he was
depressed. Suicide potential often increases as
the level of depression decreases. The nurse
should be particularly alert to sudden
improvement in mood
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CLASSIFICATIONS OF ANTIDEPRESSANT
Antidepressants generally fall into five types:
1. Tricyclic Antidepressants (TCAs)
2. Monoamine Oxidase Inhibitors (MAOIS)
3. Serotonin-Specific Reuptake Inhibitors (SSRIs)
4. Serotonin-Norepinephrine-Reuptake Inhibitors
(SNRI)
5. Hetrocyclic Antidepressants
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 TRICYCLICS ANTIDEPRESSANTS
1. Amitriptyline (Elavil)
2. Imipramine (Tofranil)
3. Clomipramine (Anafranil)
4. Trimipramine (Surmontil)
Side effects most commonly occur with
Tricyclic Antidepressants:
 Blurred vision, Constipation, Urinary retention,
Orthostatic hypotension, Tachycardia;
arrhythmias, Photosensitivity, Weight gain,
Reduction of seizure threshold
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MONOAMINE OXIDASE INHIBITORS (MAOIS)
Commonly used MAOIs:
1. Isocarboxazid (Marplan)
2. Phenelzine (Nardil)
Side effects most commonly occur with
MAOIs:
1. Hypertensive crisis:
 A 14-day interval is recommended between use
of Tricyclic Antidepressants drugs and MAOIs
drugs
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 Life threatening hypertensive crisis may occur
with concurrent use of certain medications and
certain foods substances that contain Tyramine
High Tyramine containing foods:
 Aged cheeses (cheddar)
 Red wines
 Smoked and processed meats (salami,
pepperoni)
 Caviar
 Corned beef
 Chicken or beef liver
 Soy sauce,
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Moderate Tyramine containing foods:
 Yogurt
 Avocados
 Bananas
 Beer
 White wine, coffee, colas, tea, hot chocolate
 Chocolate
Low Tyramine containing foods:
 Cream cheese
 Figs
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Symptoms of hypertensive crisis include:
1. Severe occipital headache
2. Palpitations
3. Nausea & vomiting
4. Fever & sweating
5. Marked increase in blood pressure
6. Chest pain and coma.
Treatment of hypertensive crisis:
1. Discontinue drug immediately
2. Monitor vital signs
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3. Administer short-acting antihypertensive
medication
4. Use external cooling measures to control
hyperpyrexia
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIS)
Most commonly used SSRIs:
1. Citalopram (Celexa)
2. Fluoxetine (Prozac)
3. Fluvoxamine (Luvox)
4. Sertraline (Zoloft)
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Side effects most commonly occur with SSRIs:
1. Hypertensive crisis can occur if SSRIs are
used within 14 days of MAOIs.
2. Insomnia and agitation
3. Headache
4. Weight loss (may occur early in therapy)
5. Sexual dysfunction
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Serotonin syndrome:
 Occurs when treating with two drugs that
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increase the availability of Serotonin in the brain.
Most frequent symptoms include changes in
mental status, restlessness, hyperreflexia,
tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.
 Treatment: Discontinue the drug immediately.
The physician will prescribe medications to block
serotonin receptors, relieve hyperthermia and
muscle rigidity, and prevent seizures. Artificial
ventilation may be required. The condition will
usually resolve on its own once the offending
medication has been discontinued.
 However, if the medication is not discontinued, the
condition can progress to a more serious state and
become fatal
SEROTONIN NOREPINEPHRINE REUPTAKE
INHIBITORS (SNRIs)
Most commonly used SNRIs:
1. Venlafaxine (Effexor)
2. Duloxetine (Cymbalta)
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HETROCYCLIC ANTIDEPRESSANTS
Most commonly used Heterocyclic
Antidepressants:
1. Bupropion (Zyban; Wellbutrin)
2. Maprotiline (Ludiomil)
3. Mirtazapine (Remeron)
4. Trazodone (Desyrel)
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NURSING CARE PLANNING FOR PATIENTS
RECEIVING ANTIDEPRESSANTS
Diagnoses
 Example of nursing diagnoses may be
considered for clients receiving therapy with
antidepressant medications:
 Risk for suicide related to depressed mood
 Risk for injury related to side effects of sedation,
lowered seizure threshold, orthostatic
hypotension, photosensitivity, arrhythmias,
hypertensive crisis, or serotonin syndrome.
 Constipation related to side effects of the
medication.
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Planning/Implementation
 The plan of care should include monitoring for
the following side effects from antidepressant
medications:
 Dry mouth: offer the client sugarless candy, ice,
frequent sips of water. Strict oral hygiene is very
important
 Sedation: request an order from the physician
for the drug to be given at bedtime. Request that
the physician decrease the dosage or perhaps
order a less sedating drug. Instruct the client not
to drive or use dangerous equipment while
experiencing sedation.
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 Nausea: medication may be taken with food to
minimize GI distress.
Discontinuation syndrome:
 All classes of antidepressants have varying
potentials to cause discontinuation syndromes.
 Abrupt withdrawal following long-term therapy
with SSRIs may result in dizziness, lethargy,
headache, and nausea.
 Fluoxetine is less likely to result in withdrawal
symptoms because of its long half-life.
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 Abrupt withdrawal from Tricyclic drugs may
produce hypomania, cardiac arrhythmias, and
panic attacks.
 The discontinuation syndrome associated with
MAOIs includes confusion, hypomania, and
worsening of depressive symptoms.
 All antidepressant medication should be
decreased gradually to prevent withdrawal
symptoms (weaning)
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Client/Family Education
 Patient Continue to take the medication even
though the symptoms have not subsided.
 The therapeutic effect may not be seen for as
long as 4 weeks. If after this length of time no
improvement is noted, the physician may
prescribe a different medication.
 Use caution when driving or operating
dangerous machinery. Drowsiness and
dizziness can occur. If these side effects
become persistent or interfere with activities of
daily living, the client should report them to the
physician. Dosage adjustment may be
necessary.
 Not stop taking the drug abruptly. To do so might
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produce withdrawal symptoms, such as nausea,
vertigo, insomnia, headache, malaise, and
nightmares.
 If taking a Tricyclic, use sun-block lotion and
wear protective clothing when spending time
outdoors. The skin may be sensitive to sunburn.
 Report occurrence of any of the following
symptoms to the physician immediately: sore
throat, fever, malaise, yellowish skin, unusual
bleeding, easy bruising, persistent nausea/
vomiting, severe headache, rapid heart rate,
difficulty urinating, anorexia/weight loss, seizure
activity, stiff or sore neck, and chest pain.
 Rise slowly from a sitting or lying position to prevent
a sudden drop in blood pressure.
 Take frequent sips of water, chew sugarless gum, or
suck on hard candy if dry mouth is a problem. Good
oral care (frequent brushing, flossing) is very
important.
 Not consume the following foods or medications
while taking MAOIs: aged cheese, wine (especially
Chianti), beer, chocolate, colas, coffee, tea, sour
cream, beef/chicken livers, canned figs, soy sauce,
overripe and fermented foods, pickled herring,
preserved sausages, yogurt, yeast products, broad
beans, cold remedies, diet pills. To do so could
cause a life-threatening hypertensive crisis.
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 Avoid smoking while receiving Tricyclic drugs.
Smoking increases the metabolism of Tricyclics,
requiring an adjustment in dosage to achieve the
therapeutic effect.
 Not drink alcohol while taking antidepressant
therapy. These drugs potentiate the effects of each
other.
 Not consume other medications (including over-thecounter medications) without the physician’s
approval while receiving antidepressant therapy.
Many medications contain substances that, in
combination with antidepressant medication, could
precipitate a life-threatening hypertensive crisis.
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 Notify the physician immediately if inappropriate or
prolonged penile erections occur while taking
Trazodone (Desyrel). If the erection persists longer
than 1 hour, seek emergency room treatment. This
condition is rare, but has occurred in some men who
have taken trazodone. If measures are not instituted
immediately, impotence can result.
 Be aware of possible risks of taking antidepressants
during pregnancy. Safe use during pregnancy and
lactation has not been fully established. These
drugs are believed to readily cross the placental
barrier; if so, the fetus could experience adverse
effects of the drug. Inform the physician immediately
if pregnancy occurs, is suspected, or is planned.
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 Be aware of the side effects of antidepressants.
Refer to written materials furnished by health care
providers for safe self-administration.
 Carry a card or other identification at all times
describing the medications being taken.
 Outcome Criteria/Evaluation
 The following criteria may be used for evaluating the
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effectiveness of therapy with antidepressant
medications:
 The patient has not harmed self.
 The patient has not experienced injury caused by
side effects such as hypertensive crisis,
photosensitivity, or serotonin syndrome.
 The patient exhibits vital signs within normal limits.
 The patient manifests symptoms of improvement in
mood (brighter affect, interaction with others,
improvement in hygiene, clear thought and
communication patterns).
 The patient willingly participates in activities and
interacts appropriately with others.
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