Mood Disorder
• Also called affective disorders, are
pervasive alterations in emotions that
are manifested by depression, mania or
both.
• They interfere with a persons life,
plaguing him or her with drastic and
long-term sadness, agitation or elation.
• The most common psychiatric
diagnoses associated with suicide.
• Categories of Mood Disorders
MAJOR DEPRESSIVE DISORDER
• Last at least 2 weeks during which the
person experiences a depressed mood
or loss of pleasure in nearly all activities.
BIPOLAR DISORDER (formerly called manic-
depressive illness)
• Is diagnosed when a person’s mood
fluctuates to extremes of mania and/or
depression or irritable.
Types:
• Bipolar I – one or more manic or mixed
episodes usually accompanied by major
depressive episodes
• Bipolar II – one or more major
depressive episodes accompanied by at
least one hypomanic episode
Related Disorders
Persistent depressive (dysthymic)
disorder
• Is a chronic, persistent mood
disturbance characterized by symptoms
such as insomnia, loss of appetite,
decreased energy, low self-esteem,
difficulty concentrating, and feelings of
sadness and hopelessness that are
milder than those of depression.
Disruptive Mood Dysregulation
Disorder
• A persistent angry or irritable mood,
punctuated by severe, recurrent temper
outbursts that are not in keeping with
the provocation or situations, beginning
before age 10 years.
Cyclothymic Disorder
• Characterized by mild mood swings
between hypomania and depression
without loss of social or occupational
functioning
Substance-induced depressive or
Bipolar Disorder
• Characterized by a significant
disturbance in mood that is a direct
physiologic consequence of ingested
substances such as alcohol, other drugs
or toxins.
Seasonal Affective Disorder (SAD)
Winter Depression or fall-onset SAD
• Experience increase sleep, appetite and
carbohydrate cravings; weight gain;
interpersonal conflict; irritability and
heaviness in the extremities beginning
in late autumn and abating in spring and
summer
Spring-onset SAD
• Less common
• With symptoms of insomnia, weight
loss, and poor appetite lasting from late
spring or early summer until early fall.
Postpartum or “maternity”Blues
• A mild predictable mood disturbance
occurring in the first several days after
delivery of a baby
• Symptoms: fluctuations of mood and
affect, crying spells, sadness, insomnia
and anxiety
• Symptoms just subside without
treatment
Postpartum Depression
• The most common complication of
pregnancy in developed countries.
 • The symptoms are consistent with those
of depression with onset within 4 weeks
of delivery.
Postpartum Psychosis
• A severe and debilitating psychiatric
illness with acute onset in the days
following childbirth
• Symptoms: fatigue, sadness, emotional
lability, poor memory and confusion
and progress to delusions,
hallucinations, poor insight and
judgment, and loss of contact with
reality.
Premenstrual Dysphoric
• A recurrent, moderate psychological
and physical symptoms that occur
during the week before menses and
resolve with menstruation.
• Symptoms: labile (fluctuation) of mood,
irritability, increased interpersonal
conflict, difficulty concentrating, feeling
overwhelmed or unable to cope and
feelings of anxiety.
Nonsuicidal Self-injury
• Involves deliberate intentional cutting,
burning, scraping, hitting or
interference with wound healing.
Demographic Variables Associated
with Mood Disorder
ETIOLOGY
Genetic Theories
• Genetic studies implicate the
transmission of major depression in
first-degree relatives, who are as twice
the risk for developing depression
Neurochemical Theories
• Serotonin and norepinephrine are the 2
major biogenic amines implicated in
mood disorders.
• Serotonin has many roles in behavior…
there is deficit in people with
depression.
• Norepinephrine levels is deficient in
depression and increased in mania
Neuroendocrine Influences
• Hormonal fluctuations are being studied
in relation to depression.
• Mood disturbances have been
documented in people with endocrine
disorders
DEPRESSIVE DISORDERS
Types
Major Depressive Disorder
 Characterized by one or more major
depressive episodes, which are defined
as at least 2 weeks of depressed mood
or loss of interest accompanied by at
least 4 additional symptoms of
depression.
• Types
Dysthymic Disorder
 is constant and is less severe than major
depression.
 is a continuous long-term (chronic) form
of depression.
• Keys Features of Depressive Disorders
 At least a 2 week period of maladaptive
functioning is present
 At least 5 of the following symptoms is
present during the 2 week period
1. Depressed mood
2. Inability to experience pleasure, or
markedly diminished interest in
pleasurable activities
3. Appetite disturbance with weight change
(loss or gain of more than 5% of body weight
within 1 month)
4. Sleep disturbance
5. Psychomotor disturbance
- Emotional distress
- Restlessness
- Pacing around the room
- Wringing the hands
- Uncontrolled tongue movement
- Pulling off clothing and putting it back
on
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or
inappropriate guilt
8. Diminished ability to concentrate or
indecisiveness
9. Recurrent thoughts of death or suicidal
ideation
• Other symptoms of depression
 Fatigue
 Thoughts of death
 Decreased libido
 Ruminations of inadequacy
 Psychomotor agitation
 Verbal beratings of self
 Spontaneous crying
 Dependency, passiveness
• Facts about Depression
 It is estimated that 5-10% of the
population at any given time suffering
from identifiable depression need
psychiatric treatment or psychosocial
intervention.
 The lifetime risk of developing
depression is 10-20% in females and
slightly less in males.
 Nearly 5-10% of person in a community
at any given time are in need of help for
depression.
 As much as 8-10% of persons carry the
risk of developing depression during
their lifetime.
 The average age of the onset of major
depression is between 20 and 40 years.
 An episode of depression, on average,
lasts about 20 weeks, 12 weeks if
treated, and up to 52 weeks if
untreated.
 Most individuals suffering from a first
episode of major depression will have
another episode ( the average is five or
six episodes over a lifetime)
 Some patients never recover from the
first episode
 Stress plays a role in the onset and
exacerbation of depression
 Early life stress can change brain
structure and function, thus lowering
the threshold for adult depressive
episodes.
DYSTHYMIC DISORDER
• Is diagnosed when a person has a
depressed mood for at least 2 years.
• Dysthymic disorder is a disorder of
chronicity, whereas severity is the
distinguishing factor for MDD.
Criteria
• Depressed mood for most of the days,
for more days than not
• Presence of two or more of the
following:
 Poor appetite or overeating
 Insomnia or hypersomnia - is a sleep
disorder characterized by excessive
daytime sleepiness, excessive sleep
periods each day (usually taken to mean
more than 10 hours) and/or an inability
to achieve the feeling of refreshment
that sleep usually brings.
 Low energy or fatigue
 Low self-esteem
 Poor concentration or difficulty making
a decision
 Feelings of hopelessness
Assessment for Depression
- For accurate assessment of depression the
following should be addressed.
1. History of inset of symptoms
2. Presence of co-morbid substance,
alcohol, and medication use
 3. Physical examination to rule out the
presence of medical conditions
4. Presence of non mood psychiatric
disorders
5. Patient resources and social support
systems
6. Interpersonal and coping abilities
7. Level of stressors
8. Presence or level of suicidal ideation
-Nurses can be instrumental in collecting all of
this information
• Psychotherapeutic Management
I. Nurse-Patient Relationship
II. Psychopharmacology
III. Milieu Management
• I. Nurse-Patient Relationship
1. Depressed individuals suffer from low
self-esteem.
Ex. Smelly clothes, untidy appearance
 Accept pt as they are (negative
attitude and all)
 Help them focus on the positive
 Provide successful experiences
with positive feedback
 Keep self-help strategies simple
• Help patients avoid embarrassing social
blunders
• The objective is to provide specific
principles of therapeutic
communication for nurses who work
with depressed pts.
• Best approach is to bolster self-esteem
2. Development of a meaningful relationship in
which depressed individual are valued as human
beings.
 It is important for the nurse to
be honest and to work on
developing trust.
Example:
• Pt wish to tell something but does not
want the nurse to share the
information. Nurse build trust by
sharing only to staff members who have
a need to know.
• Pt trust as a professional whose concern
is pts best interest
3. The nurse must have sincere
concern for depressed patients
and be emphatic.
4. The nurse acknowledges the
emotional pain and suffering
conveyed by patients
5. Offers to help patients work
through the pain
6. Sitting beside the patient…
introduce self and encourage
patient to tell something… do
not force.
4. The nurse can point out small visible
accomplishments and strength.
Ex. Comb hair; taking a bath
5. Depressed individuals are typically
dependent.
 Nurse ask client to perform
global task
 The nurse should reward even
small decisions and
independent actions.
Task – getting dressed, if cant let choose what to
wear, then instruct to put it on
6. The nurse should not attempt to embarrass
patients out of being depressed.
7. Never reinforce hallucinations, delusions or
irrational beliefs
 The nurse cannot agree and
argue seems to reinforce them
 The nurse should state his or
her perception of reality, voice
doubt about the patient’s
perceptions
8. Depressed individuals tend to be angry.
 It is important for the nurse to
learn to handle hostility
therapeutically by recognizing
the anger, not taking it
personally, and not retaliating
in word, deed, or some passive-
aggressive form
  Encouraging verbal expressions
of anger helps release patient’s
tension
9. The nurse can help withdrawn patients
emerge from their social isolation
 Spending time with them –
even without speaking
 Providing a nonthreatening
one-to-one relationship
 Practicing assertive interactions
 Showing acceptance
10. Depressed individuals can have difficulty
making even simple decisions.
 Not therapeutic to badger
patients in making a decision
 Therapeutic to provide decision-
making opportunities as
patients is able to comply.
 When possible the nurse helps
guide patients to appropriate
decisions by using problem
solving technique
 Initially, nurse might need to
make decision for the pt.
“taking a bath”
Technique: identifying options, advantages and
disadvantages of the options; potential
consequences
• II. Psychopharmacology
• Selective Serotonin Reuptake Inhibitors
(SSRI)
• Tetracylic Antidepressants
• Atypical Antidepressants
• Monoamine Oxidase Inhibitors (MAOI)
• Important Points for Administering
Antidepressant Drugs
• Most antidepressants have a lag time of
2 to 4 weeks before a full clinical effect
occurs.
• Many reports suggest that these drugs
might provoke suicidal ideation and
behavior
• Be aware of the drug-drug and food-
drug interactions associated with MAOIs
• Observe for early signs of toxicity:
 TCAs: drowsiness, tachycardia,
mydriasis, hypotension,
agitation, vomiting, confusion,
fever, restlessness, sweating
 MAOIs: dizziness, vertigo,
fatigue
 SSRIs: have a low probability for
causing toxicity
• Monitor sexual side effects of selective
SSRI because they occur frequently and
lead to noncompliance
• Monitor v/s of patients who take TCAs
and MAOIs
 TCAs can cause orthostatic
hypotension, reflex tachycardia,
and arrhythmias.
 MAOIs have the potential for
triggering a hypertensive crisis.
• III. Milieu Management
General Principles
For patients with low self-esteem
 Encourage pts with low self-esteem to
participate in activities, including group
activities
- Is an important dimension of the psychiatric
nursing care of depressed pts.
- Patient will experience accomplishment and
receive positive feedback
 Provide assertiveness training.
(assertiveness -the quality of being self-assured
and confident without being aggressive)
 The training will make them
take care of their needs and to
express their feeling along the
way
 Help patients avoid embarrassing
themselves through socially
unacceptable appearance or behavior.
For withdrawn patients
 Keep contacts brief but frequent.
 Many patients are insistent about going
to their rooms to lie down.
- Nurse should intervene or else they will stay in
the room whole day… lock the room during the
day.
For anorectic patients
 The nursing staff must take
responsibility for ensuring that
depressed patients eat.
- Encourage them to eat by placing tray in front
of pt.
 Allow patients to participate in selecting
preferred foods from the menu.
 Promote a proper diet, adequate fluids,
and exercise.
 A diet with adequate fiber content and
sufficient fluids is important.
- Pt may experience constipation - a side effects
of drugs
For patients with sleep disturbances
 The nursing staff should record the
amount and quality of patient’s actual
sleep.
Insomnia/fatigue is real – check patient if asleep
or just isolating
 Eliminate self defeating behaviors such
as daytime napping and drinking
stimulants increases the likelihood of
nighttime sleep
BIPOLAR DISORDERS
• Bipolar disorder involves extreme mood
swings from episodes of mania to
episodes of depression.
• During manic phases, clients are
euphoric, grandiose, energetic, and
sleepless.
• They have poor judgment and rapid
thoughts, actions, and speech.
• During depressed phases, mood,
behavior, and thoughts are the same as
in people diagnosed with major
depression.
- if a person’s first episode of bipolar is a
depressed phase, might be diagnosed with
major depression; then bipolar will diagnose
after manic s/s
• Facts about Bipolar Disorder
• Average of age of onset is early twenties
for both men and women.
• Bipolar 1 disorder occurs equally in men
and women.
• Up to 50% are noncompliant with
medications
• Over 1.2 % of the adult population
suffers from Bipolar 1 disorder in a
given year.
• Over 2.6% of the adult population
suffers from all bipolar disorders in a
given year.
• About 15% of bipolar patients will
commit suicide.
• About 37% of bipolar pts will relapse in
the 1st year, and only 24% regain a
“normal life”.
• Untreated, a person might experience
10 or more episodes over a lifetime.
• Bipolar disorder runs in families.
• 60% experience chronic interpersonal
and occupational difficulties.
• Risk Factors
• More than two-thirds of people with
bipolar disorder have at least one close
relative with the illness or with unipolar
major depression.
• When one parent is affected, a child has
a 15% to 30% risk of developing the
disease. The risk this increases to 50%
to 75% if both parents have it.
 • Similarities between Bipolar 1 disorder Manic Episode
and Schizophrenia  Elevated mood
 Grandiosity, inflated self-esteem
 Irritability
BIPOLAR I SCHIZOPHRENIA
 Anger
 Insomnia
Gender Equal Equal  Anorexia
Affected  Flamboyant gestures
Mean age 20s 20s  Flight of ideas, racing thoughts
of onset  Distractibility
 Hyperactivity
Genetic Yes Yes  Involvement in pleasurable activities
factors  Loud, rapid speech; talkative
One 25% risk 15% risk  High energy
affected  Increased interest in sex
parent  High rate of suicide
 Excessive make up
Two 50% risk 35% risk Depressive Episode
parents  Withdrawal
 Passivity
Identical 40-48% 50%
 Insomnia, daytime sleepiness
twin
 Anorexia
Course Chronic chronic  Sluggish thinking
 Difficulty concentrating, distractibility
Suicide 15% 10%  Insertia
 Diminished interest in activities,
Cigarette Increased Increased inappropriate or excessive guilt
smoking  Decrease in speech
 Fatigue
Substanc Increased Increased  Decreased interest in sex
e abuse  High rate of suicide
Very Yes yes Hypomanic episodes is similar to the manic
sensitive episode but denotes a less severe level of
to stress impairment.
 A noticeable increase in energy,
hyperactivity and a decreased need for
sleep
 Rapidly moving on from activity to
activity without completion
 Talking in a rapid, forced or loud
manner
 Inflated self-esteem or grandiosity
Gender Differences

Bipolar Symptoms
 • There are key gender differences in
manifestation of the disease, symptoms
and comorbidities.
• Men experience earlier onset than
women, more severe episodes, a higher
incidence of manic episodes, are more
prone to aggressive behavior during
manic episodes and have a higher
incidence of co-occurring drug or
alcohol abuse.  treat seizures and manic or mixed
• Women have a higher incidence of
depressive episodes, greater likelihood
of simultaneous or overlapping
symptoms of mania and depression
(mixed episodes),
• are more likely to experience seasonal
episodes and have a higher incidence of
comorbid conditions such as thyroid
disease, eating disorders and anxiety
disorders.
Treatment
Psychotherapy
• The most effective therapies are
cognitive behavioral therapy, family-
focused therapy and interpersonal
therapy.
• Therapists may also recommend self-
help measures such as exercising
regularly, eating nutritious foods and
getting enough sleep.
• An approach that is effective for one
person may not work for another, so it
is important to try a number of options.
• Many people find that a combination of
the following therapies helps them
manage their symptoms.
• Alternative treatments including
acupuncture, yoga and mindfulness
meditation may also be helpful.
Bipolar Medications
The three major types of medications used to
treat bipolar disorder are mood stabilizers,
antidepressants and atypical antipsychotics.
• Lithium: Considered highly effective in
controlling mood swings, particularly
highs, lithium has been used for more
than 60 years to treat bipolar disorder.
- It can take a while for lithium to work, so it is
more effective for long-term treatment than for
acute hypomanic episodes.
• Depakote: Valproate drugs such as
Depakote are approved by the FDA to
episodes associated with bipolar
disorder.
• This drug works more rapidly than
lithium and can also be used for
prevention.
Family Treatment Programs and
Services
• Family treatment programs combine
support and education.
• These programs help loved ones play an
integral role in managing the disorder
and may reduce the likelihood of
symptom recurrence. 
The goal of treatment is to help family
members:
• Cope with symptoms that are present
even when medications are taken
• Stay on top of the individual, reminding
him or her to take medications as
prescribed and be proactively involved
in management of side effects
• Recognize and reinforce the importance
of the individual getting adequate sleep
each night
• Encourage and reinforce a healthy
lifestyle as key to overall recovery (e.g.
staying away from recreational drugs)
Clinical Example
• Elena is a 45 year old, well-educated,
intelligent woman who has been in and
out of therapy for a lone time (15 to 20
yrs). Elle grew up in Ilocos Norte with
two brothers and a very physically and
emotionally abusive father. Elena
 reports that, when she was quite young,
her mother left home and did not
return for several years.
• Elena left home at age 17 and was
married twice and separated shortly
after each marriage. She has a history
of depression, and she attempted
suicide 20 years ago. After many
turbulent years she started going to
bars in hopes “that I might get killed.”
She refers to this period as her
“pasaway days.” After emotional and
financial collapse, Elena has recently
returned to her father’s home. He
continues to control her life in every
way. She has commented that her life is
so futile that she would rather be dead.