MOOD DISORDER

DEPRESSION AND BIPOLAR

DISORDER
 In any given 1-year period, 9.5 percent of the
population, or about 18.8 million American
adults, suffer from a depressive illness.
 The economic cost for this disorder is high,
but the cost in human suffering cannot be
estimated.
 Studies indicate that the incidence of
depressive disorder is higher in women than it
is in men by about 2 to 1.
 The incidence of bipolar disorder is equal,
with a 1.2 to 1 ratio of women to men.
 More than twice as many women (6.7 million) as men (3.2
million) suffer from major depressive disorder each year.
 Major depression can occur at any age including childhood,
the teenage years and adulthood.
 All ethnic, racial and socioeconomic groups suffer from
depression.
 About three-fourths of those who experience a first
episode of depression will have at least one other episode
in their lives.
 Some individuals may have several episodes in the course
of a year.
 If untreated, episodes commonly last anywhere from six
months to a year.
 Left untreated, depression can lead to suicide
 Mood is a pervasive and sustained feeling
tone that is experienced internally and that
influences a person's behavior and perception
of the world.
 Affect is the external expression of mood.
 Mood can be normal, elevated, or depressed.
Healthy persons experience a wide range of
moods and have an equally large type of
affective expressions; they feel in control of
their moods and affects.

 Mood disorders are a group of clinical

conditions characterized by a loss of that
sense of control and a subjective experience
of great distress
 Patients with elevated mood demonstrate
expansiveness, flight of ideas, decreased
sleep, and grandiose ideas.
 Patients with depressed mood experience a
loss of energy and interest, feelings of guilt,
difficulty in concentrating, loss of appetite,
and thoughts of death or suicide.
 Other signs and symptoms of mood disorders
include :
 change in activity level, cognitive abilities,
speech, and vegetative functions (e.g., sleep,
appetite, sexual activity, and other biological
rhythms).

 These disorders always result in impaired

interpersonal, social, and occupational
functioning.
 Patients with only major depressive episodes
are said to have major depressive disorder or
unipolar depression.
 Patients with both manic and depressive
episodes or patients with manic episodes
alone are said to have bipolar disorder.
 The terms “unipolar mania” and “pure mania”
are sometimes used for patients who are
bipolar, but who do not have depressive
episodes.
 Three additional categories of mood
disorders are:
 hypomania,
 cyclothymia,
 and dysthymia
 Hypomania is an episode of manic symptoms
that does not meet the full text revision of the
fourth edition of Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR)
criteria for manic episode.
 . Cyclothymia and dysthymia are defined by
DSM-IV-TR as disorders that represent less
severe forms of bipolar disorder and major
depression
 DSM-IV-TR Classification of Mood Disorders

Mood disorders are classified under two major

categories: depressive disorders and bipolar
disorders.
 Major Depression
 According to DSM-IV-TR, a major depressive
disorder occurs without a history of a manic,
mixed, or hypomanic episode.
 Major depressive disorder (MDD) is
characterized by depressed mood or loss of
interest or pleasure in usual activities.
Evidence will show impaired social and
occupational functioning that has existed for
at least 2 weeks, no history of manic
behavior, and symptoms that cannot be
attributed to use of substances or a general
medical condition.
 A major depressive episode must last at least 2
weeks, and typically a person with a diagnosis of
a major depressive episode also experiences at
least four symptoms from a list that includes:
 changes in appetite and weight,
 changes in sleep and activity,
 lack of energy,
 feelings of guilt,
 problems thinking and making decisions,
 recurring thoughts of death or suicide.
S&S Depression
 Persistent sad, anxious, or "empty" mood
 Feelings of hopelessness, pessimism
 Feelings of guilt, worthlessness, helplessness
 Loss of interest or pleasure in hobbies and activities that were
once enjoyed, including sex
 Decreased energy, fatigue, being "slowed down"
 Difficulty concentrating, remembering, making decisions
 Insomnia, early-morning awakening, or oversleeping
 Appetite and/or weight loss or overeating and weight gain
 Thoughts of death or suicide; suicide attempts
 Restlessness, irritability
 Persistent physical symptoms that do not respond to treatment,
such as headaches, digestive disorders, and chronic pain
 Mania
 A manic episode is a distinct period of an :
 abnormally and persistently elevated,
expansive, or irritable mood lasting for at least
1 week.
 A hypomanic episode lasts at least 4 days and
is similar to a manic episode except that it is
not sufficiently severe to cause impairment in
social or occupational functioning, and no
psychotic features are present.
 Both mania and hypomania are associated
with inflated self-esteem,
 decreased need for sleep,
 distractibility,
 great physical and mental activity,
 and over involvement in pleasurable behavior
Mania S&S
 Abnormal or excessive elation
 Unusual irritability
 Decreased need for sleep
 Grandiose notions
 Increased talking
 Racing thoughts
 Increased sexual desire
 Markedly increased energy
 Poor judgment
 Inappropriate social behavior
 Bipolar Disorders

 Bipolar disorder is characterized by mood

swings from profound depression to extreme
euphoria (mania), with intervening periods of
normalcy
 Bipolar disorders:

 The DSM-IV-TR divides bipolar disorders into

three major groups:
 bipolar I (periods of major depressive, manic, or
mixed episodes);
 bipolar II (periods of major depression and
hypomania).
 cyclothymic disorder (periods of hypomanic
episodes and depressive episodes that do not
meet full criteria for a major depressive episode)
 A mixed episode is a period of at least 1
week in which both a manic episode and a
major depressive episode occur almost daily.
 Dysthymia and Cyclothymia
 Dysthymic disorder and cyclothymic disorder are
characterized by the presence of symptoms that are
less severe than those of major depressive disorder
and bipolar I disorder,.

 Cyclothymic Disorder:
 The essential feature of cyclothymic disorder is a
chronic mood disturbance of at least 2-year duration,
involving numerous episodes of hypomania and
depressed mood of insufficient severity or duration to
meet the criteria for bipolar I or bipolar II disorders.
 Dysthymic Disorder:
 is a milder but more chronic form of major
depressive disorder. The DSM-IV-TR criteria for
dysthymic disorder are depressed mood for most
days for at least 2 years and two or more of the
following symptoms: poor appetite or
overeating; insomnia or oversleeping; low
energy or fatigue; low self-esteem; poor
concentration or difficulty making decisions; and
feelings of hopelessness.
 Other DSM-IV-TR diagnoses are:
 premenstrual dysphoric disorder
 mood disorder due to a general medical
condition
 substance-induced mood disorder
 minor depressive disorder,
 recurrent brief depressive disorder.

 bipolar disorder not otherwise specified,

 depressive disorder not otherwise specified,
 and mood disorder not otherwise specified
 . These categories are designed to broaden
the recognition of mood disorder diagnoses,
 to describe mood disorder symptoms more
specifically than in the past,
 and to facilitate the differential diagnosis of
mood disorders.
Summary
 Major depressive disorder (MDD) is
characterized by depressed mood or loss of
interest or pleasure in usual activities.
Evidence will show impaired social and
occupational functioning that has existed
for at least 2 weeks, no history of manic
behavior, and symptoms that cannot be
attributed to use of substances or a general
medical condition.
 A major depressive episode must last at least 2
weeks, and typically a person with a diagnosis
of a major depressive episode also experiences
at least four symptoms from a list that
includes:
 changes in appetite and weight,
 changes in sleep and activity,
 lack of energy,
 feelings of guilt,
 problems thinking and making decisions,
 recurring thoughts of death or suicide.
:Dysthymic Disorder

 is a milder but more chronic form of major

depressive disorder. The DSM-IV-TR criteria for
dysthymic disorder are depressed mood for
most days for at least 2 years and two or more
of the following symptoms: poor appetite or
overeating; insomnia or oversleeping; low
energy or fatigue; low self-esteem; poor
concentration or difficulty making decisions;
and feelings of hopelessness.
Summary--Mania

 A manic episode is a distinct period of an :

 abnormally and persistently elevated,
expansive, or irritable mood lasting for at least
1 week,
 A hypomanic episode lasts at least 4 days and
is similar to a manic episode except that it is
not sufficiently severe to cause impairment in
social or occupational functioning, and no
psychotic features are present.
 mania summary
 Mania disorder is a lifelong illness. Episodes of mania and depression
eventually can occur again, if you don't get treatment. Many people
sometimes continue to have symptoms, even after getting treatment
for their bipolar disorder. Here are the types of bipolar disorder:
 Bipolar I disorder involves periods of severe mood episodes from
mania to depression.

 Bipolar II disorder is a milder form of mood elevation, involving

milder episodes of hypomania that alternate with periods of severe
depression.

 Cyclothymic disorder describes periods of hypomania with brief

periods of depression that are not as extensive or long-lasting as seen
in full depressive episodes.
 Types of Bipolar Disorder
 There are several kinds of bipolar disorder. Each kind is
defined by the length, frequency and pattern of episodes
of mania and depression.
 Bipolar I Disorder
 Bipolar I disorder is characterized by one or more manic
episodes or mixed episodes (symptoms of both a mania
and a depression occurring nearly every day for at least
one week) and one or more major depressive episodes.
Bipolar II Disorder
 While bipolar I disorder is characterized by one or more
manic episodes or mixed episodes and one or more
major depressive episodes; bipolar II disorder is
diagnosed after one or more major depressive episodes
and at least one episode of hypomania.
 Etiology

 Biological Factors
 neurotransmitters—norepinephrine, dopamine,
serotonin, and histamine—were the main focus
of theories and research about the etiology of
these disorders.
 norepinephrine and serotonin are the two
neurotransmitters most implicated in the
pathophysiology of mood disorders.
 Increased Nor = mania
 Decrease Nor = depression
Serotonin plays a role in emotions, cognition,
sensory perceptions, and essential biologic
functions, such as sleep and appetite. Serotonin is
also involved in the control of food intake, hormone
,secretion, sexual behavior
Depression and insomnia have been associated with
decreased levels of Serotonin where as mania has
been associated with increased serotonin
Some of the most well-known antidepressant .
medications, such as Prozac and Zoloft, function by
raising serotonin levels within certain areas of the
CNS
Alterations of Hormonal Regulation

Abnormal secretions have been linked to

psychological disorders
– Example: cortisol release is related to
anxiety and mood disorders
 alterations in neuroendocrine and behavioral
responses can result from severe early stress.
 Animal studies indicate that even transient
periods of maternal deprivation can alter
subsequent responses to stress.
Alterations of Sleep Neurophysiology

 Depression is associated with a premature loss of

deep sleep and an increase in nocturnal arousal.
 The latter is reflected by four types of disturbance:
 (1) an increase in nocturnal awakenings,
 (2) a reduction in total sleep time,
 (3) increased phasic rapid eye movement (REM)
sleep,
 (4) increased core body temperature.
Structural and Functional Brain Imaging

 The most consistent abnormality observed in

the depressive disorders is increased
frequency of abnormal hyperintensities in
subcortical regions, such as
 1) periventricular regions,
 2)the basal ganglia,
 3) the thalamus.
 . More common in bipolar I disorder and
among the elderly
 Genetic Factors-Family Studies-
 Family data indicate that if one parent has a
mood disorder, a child will have a risk of
between 10 and 25 percent for mood
disorder. If both parents are affected, this risk
roughly doubles.
 The risk is greater if the affected family
members are first-degree relatives rather
than more distant relatives. A family history
of bipolar disorder conveys a greater risk for
mood disorders in general.
Psychosocial Factors
Life Events and Environmental Stress

 stressful life events more often precede

first, rather than subsequent, episodes of
mood disorders.
 This association has been reported for both
patients with major depressive disorder and
patients with bipolar I disorder.
 Some clinicians believe that life events play
the primary or principal role in depression;
 others suggest that life events have only a
limited role in the onset and timing of
depression.
 The most compelling data indicate that the
life event most often associated with
development of depression is losing a
parent before age 11.
 The environmental stressor most often
associated with the onset of an episode of
depression is the loss of a spouse.
 Another risk factor is unemployment;
persons out of work are three times more
likely to report symptoms of an episode of
major depression than those who are
employed.
Personality Factors

 No single personality trait or type

uniquely predisposes a person to
depression;
 all humans, of whatever personality pattern,
can and do become depressed under
appropriate circumstances.
 .
 Persons with certain personality disorders—
OCD, histrionic, and borderline—may be at
greater risk for depression than persons with
antisocial or paranoid personality disorder.
The latter can use projection and other
externalizing defense mechanisms to protect
themselves from their inner rage

 patients with dysthymic disorder and

cyclothymic disorder are at risk of later
developing major depression or bipolar I
disorder
 Recent stressful events are the most
powerful predictors of the onset of a
depressive episode.
 From a psychodynamic perspective, the
clinician is always interested in the meaning
of the stressor.
 Research has demonstrated that stressors
that the patient experiences as reflecting
negatively on his or her self-esteem are more
likely to produce depression
Psychodynamic Factors in Depression
 The psychodynamic understanding of depression defined
by Sigmund Freud is known as the classic view of
depression. That theory involves four key points:
 (1) disturbances in the infant–mother relationship during
the oral phase (the first 10 to 18 months of life)
 (2) depression can be linked to real or imagined object
loss;
 (3) defense mechanism invoked to deal with the distress
connected with the object's loss;
 and (4) because the lost object is regarded with a
mixture of love and hate, feelings of anger are directed
inward at the self.
Psychodynamic Factors in Mania

 defense against underlying depression.

 such as the loss of a parent.
 intolerable self-criticism that is then replaced
by euphoric self-satisfaction
Cognitive Theory

 According to cognitive theory, depression

results from specific cognitive distortions
present in persons susceptible to depression.
perceive both internal and external data in
ways that are altered by early experiences
 . Aaron Beck postulated a cognitive triad of
depression that consists of
 (1) views about the self—a negative self-
precept;
 (2) about the environment—a tendency to
experience the world as hostile and
demanding, and
 (3) about the future—the expectation of
suffering and failure. Therapy consists of
modifying these distortions.
Learned helplessness theory

 person who internalizes the

belief that an unwanted event
is his own fault and that
nothing can be done to avoid
or change it is prone to
developing depression.
Seasonal Pattern

 Patients with a seasonal pattern to their

mood disorders tend to experience
depressive episodes during a particular
season, most commonly winter. The pattern
has become known as seasonal affective
disorder (SAD),
Medical Conditions

 Depression commonly coexists‫ مرافق‬with

medical conditions, especially in older
persons. When depression and medical
conditions coexist, clinicians must try to
determine whether the underlying medical
condition is pathophysiologically related to
the depression or whether any drugs that the
patient is taking for the medical condition are
causing the depression
Treatment Issues

 Complex issues treated by an

interdisciplinary team
 Priority issues:
 Safety from poor judgement and risk-taking
behaviors
 Risk for suicide during depressive disorders
 dealing with the consequences of
impulsive behavior
Nursing Management:
Biologic Domain

 Assessment
 Evaluation of mania symptoms
 Sleep may be nonexistent.
 Irritability and physical exhaustion
 Eating habits, weight loss
 Lab studies - thyroid
 Hypersexual, risky behaviors
 Pharmacologic (may be triggered by antidepressant),
alcohol use
 Nursing diagnosis
 Disturbed sleep pattern, sleep deprivation
 Imbalanced nutrition, hypothermia, deficit fluid balance
Nursing Interventions:
Biologic Domain

 Physical care
 Pharmacologic
 Electroconvulsive therapy
 Mood Stabilizers
 Lithium Carbonate (Eskalith)
 Mechanism of action: unknown
 Blood levels 0.5-1.2
 Side effects: GI, weight gain

 Divalproex Sodium (Depakote)

 Increase inhibitory transmitter, GABA
 Sedation, tremor

 Carbamazepine
 Other Medications Used
 Antidepressants
 Used during depressed phases
 Can trigger manic phase
 Antipsychotics
 Psychosis
 Mania
 Dosage usually lower
 Benzodiazepines

 Side effect monitoring important because taking more

than one medication and Drug-drug interactions
Nursing Management: Psychological, Social domain

sessment Nursing Diagnosis

 Mood  Disturbed sensory
 Cognitive perception
 Disturbed thought processes
 Thought Disturbances  Defensive coping
 Stress and coping factors  Risk for suicide
 Risk assessment  Risk for violence
 Social and occupational  Ineffective coping
changes  Ineffective role performance
 Cultural views of mental  Interrupted family processes
illness  Impaired social interaction
 Impaired parenting
:Nursing Interventions

 Protect from over-extending boundaries

 Support groups
 Family interventions
 Marital and family interventions
 Inpatient management – short-term
 Intensive outpatient programs
 Crisis telephone calls
 Family session
 Psychotherapy:
 Psychodynamic therapy assists
the patient to become aware of
unconscious anger directed
toward object loss and work
through‌these feelings to
alleviate depression.

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