Bipolar Disorders and Depressive disorders

1- Sarah is a 42-year-old married woman who has a long history of both depressive and hypomanic
episodes. Across the years she has been variable diagnosis as having major depression,
borderline personality disorder, and recently, bipolar disorder. Review of symptoms indicates
that she indeed have multiple episodes of depression beginning in her late teens, but that clear
hypomanic episodes later emerged. Her elevated interpersonal conflict, hyper-sexuality and
alcohol use during her hypomanic episodes led to the provisional borderline diagnosis, but in
the context of her full history, bipolar disorder appears the best diagnosis. Sarah notes that she
is not currently in a relationship and that she feels alienated from her family. She has been
taking mood stabilizers for the last year, but continues to have low level symptoms of
depression. In the past, she has gone off her medication multiple times, but at present she says
she is” tired of being in trouble all the time” and wants to try individual psychotherapy.

1A- After going through the case study, do you consider Sarah as having Bipolar I or Bipolar II?
Please support your answer
In order to be diagnosed with bipolar I
-At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.
-The occurrence of the manic and major depressive episode(s) is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other
specified or unspecified schizophrenia spectrum and other psychotic disorder.
Whereas the criteria for bipolar II
-Criteria have been met for at least one hypomanic episode and at least one major depression
episode.
-There has never been a manic episode.
-The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other unspecified schizophrenia spectrum and other psychotic disorder.
-The symptoms of depression or the unpredictability caused by frequent alteration periods of
depression and hypomania causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Looking back to the case of sarah she meets the criteria of bipolar II (episode of hypomania,
never has a manic episode)

1B- What is the nurse’s role when dealing with patient with Bipolar disorder?
1) The nursing role starts with assessment
a) Physical Health Assessment(Biologic)
-Health Status
- Physical examination
- Physical function
-Pharmacologic
b) Psychogical Assessment:
-Mood: disturbed mood (grandiose, irritated, or agitated)
-Cognitive: impaired judgement by extremely rapid, disjointed, and distorted thinking.
-Thought disturbance: Psychosis commonly occurs in patients with bipolar, specially during
mania. Hallucination and delusional thinking are part of the clinical picture.
-Risk assessment: high risk for injury to themselves and others
-Stress and Coping: A stressful event often, but not always, triggers a manic or depressive
episode. Negative coping skills (substance use, aggression) should be identified and replaced by
positive coping skills.
c) assessment of social
-Patient’s interaction with others in the family and community.
-Functional Status
-Social System.
-Spiritual Assessment
-Occupational Status
-Economic Status
- Quality of Life
2)Then setting nursing diagnosis based on the finding eg: Sleep Deprivation, Imbalanced
Nutrition: Less than body requirements, Deficient Fluid Volume, Disturbed Personal identity,
Defensive coping, Risk for Suicide
4) setting outcomes
5)Establish a therapeutic relationship
6)Then do interventions
-Establishing Recovery and Wellness goals: during the acute phase, patients have poor judgment
and erratic behavior. During the recovery phase, nursing interventions will focus on recovery
and wellness goals like: managing the long term illness and supporting well-being; preventing
relapse including managing stress.
-Self-Care: adequate hydration and nutrition; sleep hygiene; limiting stimuli to decrease
agitation and promote sleep.
- Protecting patients with mania is always a priority. (harming self or others).
- Wellness challenges: developing skills for coping with stress; seeking pleasant environments
that support well-being. Developing a sense of connection, belonging and support system.
7) evaluate outcomes

1C- Sarah is continuing to have low level symptoms of depression, do you think the
psychiatrist should add some antidepressant medications with the mood stabilizer
medication? Why or Why not?
Medications are essential in bipolar disorder to achieve two goals: rapid control of symptoms
and prevention of future episodes or, at least, reduction in their severity and frequency.
Antidepressant therapy is not recommended in persons with bipolar depression because of a
risk of switching from depression to mania.
We can do another therapy like Family therapy, Support groups
2- Tala is a 29 years old woman who was admitted voluntary to the AUBMC psychiatry floor with
depression and suicidal ideation. She is married and have 3 children ages 9,5 ,and 3 years. Her
sister died as a result of drowning 6 months ago. She has been telling her husband that she just
wants to go to sleep and not wake up. According to her husband, Tala has neglected her self-
care and that of her children since her sister’s death. She has not been eating because she is not
hungry and has lost 10 kg over the past 6 weeks. She is also not sleeping well. She wakes up
during the middle of the night and can’t go back to sleep He is afraid to leave her alone and the
children are suffering.

2A- What is the likelihood that Tala would actually kill herself, what questions should you ask?
Patients with major depressive disorder are at increased risk for suicide. The development of
suicide behavior is a complex phenomenon because symptoms are often hidden or veiled by
somatic symptoms. Suicidal ideation includes thoughts that range from a belief that others
would be better off if the person were dead or thoughts of death (passive suicidal ideation) to
actual specific plans for committing suicide (active suicidal ideation). The risk for suicide needs
to be initially assessed in patients who incur depressive disorders and look up for every key
word he/she says as well as reassessed throughout the course of treatment. She has suicidal
ideation, since she has warning signs like hopelessness, "I wants to go to sleep and not wake
up", recklessness
So, we must assess for the intent, severity, degree of planning.
So, we have to ask her:
Have you ever tried to harm or kill yourself? If yes what keeps you from killing yourself
Do you have thoughts of suicide at this time?
If yes do you have plans? tell me details, how often do you have these thoughts?, how long
do they last?, what is the distress that it causes to you?, can you dismiss they or do they return?,
do they increase in intensity and frequency?
Do you have the means to carry out the plan? Is it available? (ask about plan details)
Have you made preparation for your death
Has a significant episode in your life causes you to think this way?
What will be the impact of your death? Who is affected? Did you tell them?

2B- Compare and contrast a person with Major depression disorder and Dysthymic Disorder?
Which one Tala is having? Justify your answer.
Both disorder fall under the umbrella of Depressive Disorder they have common criteria
however they differ in major criteria.
In major depression disorder:
-Five (or more) of the following symptoms have been present during the same 2-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, empty, or hopeless) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day
3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite
nearly every day
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly everyday.
7. Feelings of worthlessness or excessive or inappropriate guilt(which may be delusional) nearly
every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
-The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
- The episode is not attributable to the physiological effects of a substance or another medical
condition.
- The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and
unspecified schizophrenia spectrum and other psychotic disorders.
- There has never been a manic episode or a hypomanic episode.
Whereas, criteria for Dysthymic Disorder
-Depressed mood for most of the day, for more days than not, as indicated by either subjective
account or observation by others, for at least 2 years.
- Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
-During the 2-year period of the disturbance, the individual has never been without the
symptoms in Criteria A and B for more than 2 months at a time.
-Criteria for a major depressive disorder may be continuously present for 2 years.
- There has never been a manic episode or a hypomanic episode, and criteria have never been
met for cyclothymic disorder.
- The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia,
delusional disorder, or other specific or unspecified schizophrenia spectrum and other psychotic
disorder.
- The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or other medical condition.
-The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning
So looking back at the case of tala the problem started 6month ago so this eliminates having
Dysthymic Disorder since she doesnt meet criteria A
So she is Major depression disorder (symptoms highlighted in the text above) however there
should be more details to check if she meets the rest of criteria
2C- Describe how you would approach the patient who doesn’t want to talk to you, like Tala?
One of the most effective tools for caring for any person with a mental disorder is the
therapeutic relationship
2D- Tala doesn’t seem inclined to talk about her depression. Describe the measures you would
take to initiate a therapeutic relationship with her.
For a person who is depressed, there are a number of effective approaches:
-Establishment and maintenance of a supportive relationship based on the incorporation of
culturally competent interventions and strategies
-Availability in times of crisis
-Vigilance regarding danger to self and others
- Education about the illness and treatment goals
-Encouragement and feedback concerning progress
- Guidance regarding the patient’s interactions with the personal and work environment
-Realistic goal setting and monitoring
-Support of individual strengths in treatment choices.
Interacting with depressed individuals is challenging because they tend to be withdrawn and
have difficulty expressing feelings and engaging in interpersonal interactions. The therapeutic
relationship can be strengthened through the use of cognitive interventions as well as the
nurse’s ability to win the patient’s trust through the use of culturally competent strategies in the
context of empathy
Cheerleading, or being overly cheerful to a person who is depressed, blocks communication and
can be quite irritating to depressed patients. Nurses should avoid approaching patients with
depression with an overly cheerful attitude. Instead, a calm, supportive empathic approach
helps keep communication open.
2E- Compare the side effects of the SSRIs, TCAs, and MAOIs.
SSRIs tend to be safer and have fewer side effects ( Gastrointestinal distress, Sedation,
Anticholinergic effects, Weight gain or loss in some people, Sexual dysfunction, Dizziness,
Diaphoresis).
TCAs ( Drowsiness, Anticholinergic effects effects like blurred vision/ dry mouth/ constipation/
urinary retention/ sinus tachycardia/ and decreased memory, Orthostatic hypotension, Impaired
coordination Diaphoresis, Weakness, Disorientation, Sexual side effects (impotence, changes in
libido) antihistaminic side effect like sedation and weight gain
anticholinergic side TCAs should not be prescribed for patients at risk for suicide (1g of TCA is
often toxic and may be fatal).
MAOIs: Dizziness, Headache, Nausea, Dry mouth, Constipation, Drowsiness, Sleep disturbance,
Orthostatic hypotension, blurred vision. Close attention to dietary restriction. Food containing
tyramine (aged cheese, beer, red wine) if taken with MAOIs can trigger a hypertension crisis that
may be life threatening.