NUR20002

Mood/Affective Disorders

CRICOS 00111D, TOID 3059

 Mood Disorders
At completion of this lecture & with further study you should be able to:

State the DSM 5 diagnostic criteria (characteristic features) for mood disorders.
List causative theories of mood disorders.
Discuss the comprehensive psychiatric assessment of a patient with depression.
Differentiate between mood and affect.
Distinguish between grief and depression.
Differentiate between the different types of mood disorders.
Discuss the management (including related pharmacology) of a patient with depression.
List the major anti-depressants and indicate some of the major side effects, contraindications
of the drugs and their mode of action.
 Mood Disorders
At completion of this lecture & with further study you should be able to:

State the DSM 5 diagnostic criteria (characteristic features) for bipolar disorder.
Discuss the comprehensive psychiatric assessment of a patient with bipolar disorder.
Differentiate between the different types disorders on the bipolar spectrum.
Discuss the management (including related pharmacology) of a patient with bipolar disorder (manic
phase).
State causative theories, risk factors and indicators for suicide
Identify primary suicide prevention strategies
List and discuss the steps involved in the process of assessing a patient at risk of suicide and/or
deliberate self harm.
Differentiate between deliberate self-harm and suicide
Distinguish between suicidal ideation, intent, threat, gesture and attempt
Discuss nursing interventions to maintain a suicidal patients’ safety
Discuss nursing interventions to maintain the safety of a patient at risk of deliberate self-harm
Describe a post-intervention program for bereaved survivors of a completed suicide
Define key terms and acronyms related to suicide and deliberate self –harm.
 Diagnostic Criteria – DSM5
DISORDER→ Bipolar 1 Bipolar 1 Bipolar 1 Bipolar 2 Bipolar 2 Cyclothymic Substance ind. BP
Feature ↓

Mania   Past Hx.  or  Past Hx.  or   - Mild, Mod. or severe.

 

Hypomania   Past Hx.  or  Past Hx.  or   - Mild, Mod. or severe.

 

Euthymia
(Normal)
Depression  or  or  - Mild,  or  - Mild, Mod. or  (Mild)  - Mild, Mod. or severe.
  Mod. or  severe
severe.

Mood Elevated Same as Depressed Same as Either: Elevated, Either Depressed or Elevated, irritable &/OR
Irritable BPAD 1 & BPAD 1 & grandiose & ▲ risk hypomanic sx’s with an depressed.
Labile not as not as beh. OR absence of sx’s ≤ 2/12’s. Labile
disabling obvious. Depressed

Minimum [B] ≥ 3 [B] ≥ 3 [A] ≥ 5 [B] ≥ 3 [A] ≥ 5 Chronic fluctuating mood Delirium excluded from Dx.
DSM 5 criteria with symptoms for Dep / Mood Sx’s must be in
Hypomania context of substance
needed
use /med’s.

Duration of ≥ 1/52 ≥ 4/7’s ≥ 2/52’s ≥ 4/7’s ≥ 2/52’s >2 yr. adult & >1yr. Ch / Not specified, however
Symptoms. Adolescent. must occur after substance
use
 Diagnostic Criteria – DSM5
DISORDER→ Disruptive Mood Dysregulation Major Depressive Persistent Premenstrual Dysphoric Sub. Induced Dep.
D/O Disorder Depressive Disorder Disorder
Feature ↓
(DYSTHYMIA)

Euthymia
(Normal)

Depression Possible (secondary)  - Mild, Mod. or  - Mild, Mod. or   - correlating with

severe. severe. sub. use

Mood Angry – inconsistent with Mainly depressed, Depressed most Angry, irritable, Depressed; during
age & severe (Temper sad with of the day for depressed &/or use or withdrawal
Tantrums) anhedonia. most days (Sub & anxious.
obj account)

Minimum DSM 5 ≤18 age. Recurrent [A] ≥ 5 [B] ≥ 2 during dep. [B] ≥ 1 with extra from [B] 1, 2 or both.
criteria needed outbursts – Verbal &/or No previous episodes [C] to total ≥ 5.
physical for excessive episode of hypo /
time & intensity. mania

Duration of ≥12/12 : ≥ 3 times per ≥ 2/52’s >2 yr. ad. & >1yr. Sx’s are present 1/7 Occur during or
Symptoms. week. Ch / Adole. prior, during & shortly shortly after intake
after menses. of meds / subs

Other Factors in Dx: 2 of 3 settings: home, Similar to DSM IV Different to MDD Cannot be Delirium exempt
school or play. Dx. cannot but grief included as PDD sx’s may exacerbation of other from dx. criteria
exist with IED, ODD or be continuous. disorder.
BPAD.
 Epidemiology of Mood Disorders
“In 2007 the Australian Bureau of Statistics conducted the second ‘National Survey of Mental Health and
Well-being…[finding]… 20 per cent of Australians had experienced a mental illness in the 12 months
before…” (Henderson in Edward, Munro, Robins & Welch 2011)

The most common and prevalent mood disorder is Depression and although there is recognition of
mood disorders contributing to suicide rates, acknowledgement by the Australian Bureau of Statistics
[2009] advise that suicide is rarely the result from one factor & is complex by nature.
(www.mindframe-media.info, 2011)

According to Headspace, “Depression is the most common mental health problem for young Australians.
About one in every four people aged 12 to 25 will experience depression.”
(http://www.headspace.org.au/media/22527/depression_web.pdf, 2011)
 Statistics of mood disorders
According to the Australian Bureau of Statistics [2007] from “…3.2 million people who had a 12-month mental disorder…
6.2% (995,900) had a 12-month Affective disorder.”
From this figure, Depression was the most common at 4.1%, followed by BPAD at 1.8% & Dysthymic disorders at 1.3%.
Women have a higher prevalence for mood disorders than men with 7.1% compared to 5.3%.
Concerning Depression, Women experienced a higher rate than men, 5.1% compared with 3.1%.
Studies into mental health consistently report lower socio-economic status have higher prevalence of developing
mental illness with a high proportion suffering from Depression.

Australian Bureau of Statistics, 2008

“Suicide is the main cause of premature death among people with a mental illness. More than 10% of people with a
mental illness die by suicide within the first 10 years of diagnosis (SANE, 2008)”.
Australian Bureau of Statistics, 2008
 Clinical Manifestations – Depression (Major & Persistent types)
Depressive disorders are diagnosed when at least five of the nine criteria listed below are present during the same fortnight and represent
a change from previous functioning: (# 1 or 2 – must be present to diagnose condition)

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in all, or most activities, most of the day, nearly every day.
3. Significant weight changes [loss or gain] when not dieting. (≥ 5% in 1/12)
4. Insomnia or Hypersomnia nearly every day.
5. Psychomotor agitation or retardation, nearly every day.
6. Physical fatigue or loss of energy every day.
7. Feelings of worthlessness, excessive or inappropriate guilt nearly every day (Can be delusional).
8. Diminished ability to concentrate or give enough attention, ambivalence or indecision nearly every day.
9. Recurrent thoughts of death or suicidal ideation.

Subjective or objective accounts are considered in diagnosis.

Issues of bereavement, grief and significant loss are included in current DSM. Depression is additional to these factors.

DSM–5 (A.P.A. 2013)

 Clinical Manifestations – Bi-Polar 1: Mania
Diagnostic criteria of a manic episode include: elevated, expansive, labile or irritable mood, abnormal / incongruent and persistent
goal directed activity, lasting minimum of one week and most of the day with ≥ 3 of the following;

Grandiosity or inflated self-esteem.

Decreased need for sleep [feels rested after a couple of hours of sleep]
More talkative than usual & difficult to interrupt. (or marked pressure of speech)
Flight of ideas or subjective account of thoughts racing.
Easily distracted towards irrelevant stimuli.
Increase in goal directed activity or Psychomotor agitation.
Excessive involvement in pleasurable activities that have a high potential for painful consequences.

The mood disturbance causes impairment in functioning or require hospitalisation to address risks to self / others. Psychosis
can occur to the patient.
At least one manic episode is required for accurate diagnosis.

DSM–5 (A.P.A. 2013)

 Clinical Manifestations – Bi-Polar 1: Hypomania
Diagnostic criteria of a manic episode include: elevated, expansive, labile or irritable mood, abnormal / incongruent and persistent goal
directed activity, lasting minimum of Four consecutive days and most of the day with ≥ 3 of the following;

Grandiosity or inflated self-esteem.

Decreased need for sleep [feels rested after a couple of hours of sleep]
More talkative than usual & difficult to interrupt. (or marked pressure of speech)
Flight of ideas or subjective account of thoughts racing.
Easily distracted towards irrelevant stimuli.
Increase in goal directed activity or Psychomotor agitation.
Excessive involvement in pleasurable activities that have a high potential for painful consequences.

The mood disturbance is not severe enough to cause impairment in functioning and not severe enough to require hospitalisation to
address risks to self / others. Psychotic features can occur to the patient.
Criteria A-F (as condensed) constitute a hypomanic episode and are common in BPAD1.

DSM–5 (A.P.A. 2013)

 Clinical Manifestations – Bi-Polar 2: Hypomania
Exactly the same criteria as set out for Bi-Polar 1 – Hypomanic Episode (Slide 13) and for
Major Depressive Episode (Slide 11);

In order to diagnose this condition, there must be at least one hypomanic episode & one
major depressive episode.
Additionally, there must never have been a manic episode.
The episode can be classed as “partial or full” remission and “mild, moderate or severe”.
Impulsivity is a feature of BPAD 2. Risks of suicide and substance use are common.
The initial presentation is usually depressive with hypomania occurring at later periods.

DSM–5 (A.P.A. 2013)

 Clinical Manifestations – Cyclothymic Disorder:
Diagnostic criteria of a Cyclothymic disorder includes:

A. For at least 2 years (1 for Child and Adolescent) periods of hypomanic symptoms that do not meet diagnosis of hypomania and the
same applies to depressive symptoms.

B. During the period, the symptoms of each mood disturbance have been present for ≥ half the time and the absence of symptoms
cannot be present more than 2 months at a time.

C. Criteria for major depressive, manic nor hypomanic episodes have never occurred.

D. The symptoms are not better explained by conditions such as schizo-affective disorder or any other psychotic condition

E. The symptoms are not the result of substance / medication use or another medical condition.

F. The symptoms impact on social, occupational or other areas of functioning and cause significant distress, clinically.

DSM–5 (A.P.A. 2013)

 Clinical Manifestations – Premenstrual Dysphoric Disorder
A. In most menstrual cycles, >5 symptoms must occur in the week before menses, start improving within a few days after menses onset,
and minimal or absent symptoms when menses cycle ends.

B. At least one of the following symptoms are present:

1. Marked affective lability (e.g., mood swings, sensitivity to events).
2. Marked irritability, anger and/or interpersonal conflicts.
3. Marked depressed mood, hopelessness or self-deprecating thoughts.
4. Marked anxiety, tension, and/or feeling edgy.

C. At least one of the following symptoms which must additionally to criterion B, reach a minimum of 5 symptoms;
5. Decreased interest in usual activities – home, school, social outings, hobbies.
6. Subjective difficulty in concentration.
7. Lethargy, easily fatigued or marked lack of energy.
8. Insomnia or Hypersomnia.
9. Sensation of being overwhelmed or out of control.
10. Physical symptoms of breast swelling, joint or muscle pain, “bloating” or weight gain.

The symptoms interfere with regular functioning, cause distress and the disorder is not the result of another disorder exacerbated.
DSM–5 (A.P.A. 2013)
 Nursing care of the depressed client.

Comprehensive psychiatric assessment incorporating physical assessment applies.

Rationale is that many physical conditions mimic or influence Depression.

Physical conditions such as Hypothyroidism can mimic depressive symptoms.

Chronic pain syndromes can influence the severity, frequency & intensity of depressive symptoms. Anxiety commonly
occurs with Depression and moods rarely remain static.

Certain conditions such as Cancer, Cardiovascular diseases & Diabetes Mellitus are frequently linked with depression in
clients.

Some medical treatments can result in Depression as a side effect or interfere with Anti-depressant treatments. Some
examples; steroids, antibiotics, CNS & dermatological medications.

Mental State Examination [M.S.E] needs to be conducted with frequency to correlate with the clients condition. (Risk
assessment will occur at the same time & will be discussed later.)

Any M.S.E changes must be handed over within the team & documented. Abrupt changes in mood are of particular
concern as clients are resourceful & can take advantage of complacency from nursing staff. (e.g., handovers, meal
breaks, shift changes)
 Nursing care of the depressed client; cont.
Therapeutic relationship with the client should be established & maintained with encouragement to approach staff with concerns.

Education on the condition & management is of vital importance to the client & carers.

Risk assessment is vital & includes the following;

– Suicide risk: Depression represents the greatest risk factor in thoughts, intent & plans.
– Self Harm risk [Deliberate & Accidental] - DSH can be viewed as a better outcome rather than coping with current mood & ASH
commonly results from impaired cognition.
– Aggression to others (NB: Post Natal Depression – Infanticide)
– Neglect: Hygiene & grooming overt signs.
– Substance abuse: Common for clients to ‘self medicate’ in order to cope.
– Compliance: Can be impaired or passive acceptance of treatment.

Risk management consists of;

– Identification of risks
– Enhancing protective mechanisms
– Gauge the clients thoughts, intent, plan & assess past history of attempts
– Determine level of risk with a plan to address & resolve risk
– Document the assessment, degree of risk and plan of action.
(Henderson in Edward, Munro, Robins & Welch 2011)
 Nursing care of the depressed client; cont.
Attention to physical state needs monitoring with focus on;
– Nutrition & Elimination (F.B.C. with monitoring at meal times)
– Energy levels.
– Sleep.
– Attention to ADL’s & grooming.

Maintain a physical presence. The client require observation, reassurance, opportunities to discuss their concerns, be validated and
promote self esteem. Empathy is crucial for these clients.

Encouragement is valuable. Clients profoundly depressed should be gradually increasing their independence & expanding their self
care. Start with basics & try not to overwhelm clients with activities. Positive statements for achievements should occur.

Even if the client does not engage, persist as depression is an illness of isolation & ongoing contact reinforces nursing concerns for their
welfare.

Monitor for evidence of ETOH &/or Drug abuse. Also consider withdrawal regime if the client has been abusing substances prior to
admission.
 Nursing care of the client with Bi-Polar Affective Disorder.
Comprehensive psychiatric assessment applies. This can be difficult as cooperation from clients in a manic phase varies and does not
last for long periods. Part of the assessment consists of data gathering from others.

Physical conditions such as Hyperthyroidism can mimic mania. Illicit substances such as Amphetamines can induce a mania.

Some medical treatments can result in Mania as a side effect. Corticosteroids are an example of medication induced mania. Some
medications can have Euphoric effects for clients (Benzhexol).

Mental State Examination [M.S.E] needs to be conducted with frequency to correlate with the clients condition. (Risk assessment will
occur at the same time & will be discussed later.)

Any M.S.E changes must be handed over within the team & documented. Abrupt changes in mood are of particular concern, Mood
swings are common in clients with B.P.A.D.

Clients should be nursed in a low stimulus environment. As they are easily distracted and have a limited concentration & attention span,
short & simple statements with limit setting needs to occur - frequently.

(Henderson in Edward, Munro, Robins & Welch 2011)

 Nursing care of the client with Bi-Polar Affective Disorder; cont.

Monitor ADL’s & start to promote rest, sleep, adequate nutrition + hydration.

Attitude of nurses with ability to communicate is important. Characteristics should be; approachable, tolerant, patient, open, honest,
non-judgemental, compassionate, consistent, kind & non-punitive.

Further limit setting must occur as Hypomanic clients can dress & behave provocatively. This can be the result of increased libido & the
client can regret their behaviour when their mood stabilizes.

Limit visitors and length of visits, reduce environmental stimulus – Light, noise & group activity. Replaced with drawing, painting,
relaxation music & 1:1 contacts. Nursing staff should be relaxed & calm around the client.

When mood stabilizes, provide psycho-education on the illness, treatment & early warning signs of relapse.

Take active measures to prevent exhaustion & diurnal variation. Consider P.R.N. medications to promote appropriate wake/sleep cycle.

(Henderson in Edward, Munro, Robins & Welch 2011)

 Nursing care of the client with Bi-Polar Affective Disorder; cont.
Risk assessment is vital & includes the following;
– Suicide risk: These clients have a higher rate of suicide than the general population.
– Self Harm risk: [Deliberate & Accidental] DSH is possible during depressive phases & ASH commonly results from hypomanic / manic
phase due to impaired judgement.
– Aggression to others: Risk varies, irritability & lability of mood factors to consider.
– Risk of harm from others: Due to impaired judgement & insight, ↑’ed risk taking behaviours occur. Impulsivity factors heavily into this
risk.
– Neglect: Deprivation of sleep, eating, drinking & self-care deficits factor into this domain.
– Compliance: Can be impaired or absent due to lack of insight or desire to keep feelings of euphoria.
– Vulnerability: Financial & sexual. Sufferers have been known to lose large amounts of $.

Risk management consists of;

– Identification of potential & actual risks.
– Enhancing protective mechanisms.
– Gauge the clients thoughts, intent, plan & assess past history of attempts.
– Determine level of risk with a plan to address & resolve risk.
– Document the assessment, degree of risk, effectiveness of interventions and plan of action.

(Henderson in Edward, Munro, Robins & Welch 2011)

 Nursing care of the client with Bi-Polar Affective Disorder; cont.
Attention to physical state needs monitoring with focus on;
– Nutrition & Elimination (F.B.C. with monitoring at meal times)
– Energy levels.
– Sleep & rest with emphasis on balance.
– Attention to ADL’s & grooming

When hypomanic, clients should be offered “finger foods” and nutritional supplements as they are difficult to direct & remain seated for meals.

Maintain a physical presence. The client require observation, redirection, opportunities to discuss their concerns, be validated and promote
responsibility. Empathy is crucial for these clients.

Encouragement is valuable for the client to make healthy choices about their treatment & welfare.

Even if the client does not agree, Mania or Depression is not a personal choice. Empowerment occurs when clients choose how they manage
it .

Monitor for evidence of ETOH &/or Drug abuse. Also consider withdrawal regime if the client has been abusing substances prior to admission.

Develop a relapse plan with focus on early warning signs of relapse & an alert system for their supports – Clinical & personal.
 Pharmacological interventions - Depression
The perceived action of antidepressants is based on the belief they have an effect on neurotransmitters in the brain. The reduction or
absence of these correlate in cases of depression.

The 3 neurotransmitters involved are;

1. Serotonin
2. Noradrenaline (Norepinephrine)
3. & Dopamine

Not all clients with depression benefit from antidepressant therapy & someone who has experienced a depressed mood after a
stressful event over a brief period, usually recovers without needing medications.

Additionally, chronic mild cases of depression may be warranted with antidepressant therapy when other interventions are exhausted.

Family history of depression & recurrent depressive episodes are more likely to warrant antidepressant therapy. There are currently
(2012) 122 antidepressants listed on MIMS online.
(Maude & Edward in Edward, Munro, Robins & Welch 2011)

All antidepressants can potentially lead to manic episodes.

 Pharmacological interventions - Depression

Antidepressant families:
Tricyclic Antidepressants [TCA’s]
Mono-Amine Oxidase Inhibitors [MAOI’s]
Reversible Mono-Amine Oxidase Inhibitor [RIMA]
Selective Serotonin Reuptake Inhibitors [SSRI’s]
Serotonin – Noradrenaline Reuptake Inhibitors [SNRI’s]

Tricyclic Antidepressants;
The first of the current range of antidepressants used with Imipramine in 1956.
Generally seen as more effective in treating depression, however more potent side effects & lethal in over dosage.
Usually administered at night due to sedative properties.
Amitryptyline, Dothiepin & Doxepin are commonly used in pain disorders given their propensity to bind to nociceptors [pain
receptors] and enhance efficacy of analgesia.
Imipramine commonly used on children with enuresis >5 years

(Maude & Edward in Edward, Munro, Robins & Welch 2011)

(MIMS online, 2011)
 Pharmacological interventions – Depression
Tri Cyclic Antidepressants [TCA’s]

Generic Name Trade Name/s

Amitriptyline hydrochloride * Endep *

Clomipramine hydrochloride Anafranil, Placil

Dothiepin hydrochloride * Dothep, Prothiaden *

Deptran, Sinequan *
Doxepin hydrochloride *
Tofranil
Imipramine
Allegron
Nortriptyline hydrochloride
Surmontil
Trimipramine

Tetracyclics Lumin, Tolvon

Mianserin Avanza, Axit, Mirtazon, Remeron

Mirtazapine
(MIMS online, 2011)
 Pharmacological interventions – Depression
MonoAmine Oxidase Inhibitor - Antidepressants [MAOI’s]

Generic Name Trade Name/s

Nardil
Phenelzine sulfate
Parnate
Tranylcypromine sulfate

Fermented foods / beverages, pickled foods, aged & cured meats,

Banana skins, Avacado, broad bean pods. Stock cubes & packet
Precautions with MAOI’s – all foods containing soups, Soy sauce & sour cream
tyramine

Amira, Aurorix, Clobemix, Mohexal

Reversible MAOI
Moclobemide

(MIMS online, 2011)

 Pharmacological interventions – Depression
Selective Serotonin Reuptake Inhibitors [SSRI’s]

• Most commonly used Antidepressants currently used since introduction in 1987.

• Very effective in treating depression with a better side effect profile and less toxic in overdose.
• Also effective with social phobias & anxiety disorders.
• Broad usage to the extent of prescription for erectile dysfunction [Fluoxetine]
• Fluoxetine was marketed under the trade name ~ PROZAC until removal of that trade name in
many countries. Recently reinstated as a trade name in some countries, including Australia.
• Common side effects are; Dry mouth, headache, drowsiness, dizziness, tremors, diarrhoea,
loss of appetite.
• SSRI’s are less sedating than earlier antidepressants.
• Sertraline & Venlafaxine [SNRI] are believed to have an impact on adolescent suicide rates in
UK with subsequent bans enforced. Worldwide controversy surrounding its use exists
presently with Australia discouraging its use with adolescents
 Pharmacological interventions – Depression
Selective Serotonin Reuptake Inhibitors [SSRI’s]

Generic Name Trade Name/s

Citalopram Celopram, Celica, Ciazil, Cipramil,
Citalobell, Talam

Escicor, Esipram, Lexapro, Loxalate

Escitalopram

Fluohexal, Fluoxebell, Lovan, Zactin

Fluoxetine

Faverin, Luvox, Movox

Fluvoxamine

Aropax, Extine, Paxtine

Paroxetine

Eleva, Xydep, Zoloft

Sertraline
 Pharmacological interventions – Depression
Selective Serotonin - Noradrenaline Reuptake Inhibitors [SSNRI’s]

Generic Name Trade Name/s

Desvenlafaxine Pristiq

Duloxetine Cymbalta

Venlafaxine Efexor, Efexor XR

Reboxetine [Selective Noradrenaline Edronax

Reuptake Inhibitor]
 Pharmacological interventions – Mania / Hypomania
Mood Stabilizers

Generic Name Trade Name

Lithium Carbonate [LiCO³] • Lithicarb, Quilonum SR

• Epilum, Valpro
Sodium Valproate [Na+Val]
• Tegretol, Tegretol CR
Carbamazepine
• Lamictal, Lamidus, Lamogine

Lamotrigine • Topamax

Topiramate
 Medication - Considerations
Antidepressants -
• These medications are not addictive.
• Antidepressants do not change personality.
• When changing antidepressants, Cross titration is of a shorter period since the newer antidepressants require less time to “washout”.
• Antidepressants are utilised for a variety of general & psychiatric disorders. Fibromyalgia, pain disorders, premature ejaculation,
migraines, neuropathy, nocturnal enuresis …

Mood Stabilisers –
These medications are also used for neuralgic pain & to manage epilepsy. [not LiCo3]
Lithium can cause an upset stomach & affected clients are advised to take dose with milk .
Serum levels are taken >12 hours post dosage. The advantage of serum levels is the monitoring of compliance.
Lithium is most recommended mood stabiliser for clients having ECT, the others are anticonvulsants.
Two different mood stabilisers can be administered at the same time & antidepressants can be added during depressive phases.
LiCO3 toxicity usually results in clients requiring dialysis treatment as the majority of the drug is excreted via kidneys.
 Therapeutic interventions – Mood disorders
Electro – Convulsive Therapy (E.C.T.) – is a treatment for depression and there are more strict protocols governing its use in accordance
with the Victorian M.H.A [2014].
The advantages to ECT are;
[1] If a depressed client refuses to eat or drink, ECT works more rapidly than conventional treatments.
[2] Their safety is compromised due to a poor response to medications or due to intense suicidal ideation, ECT has a high success rate [~
80%].
[3] More appropriate for clients with long standing, treatment resistant depression & catatonic presentations (Schizophrenia or
Depression), Schizo-affective Disorder (S.A.D).
[4] Can be used in hypomania / mania, when other treatments are of minimal or no effect.
[5] Electrical current administered (Uni or Bi-Laterally) and titrated according to response.
[6] Regular Consultant psychiatrist reviews in accordance with relevant MHA;
The adverse effects are;
[A] Poor public perception of the use of ECT.
[B] Brief period of headache
[C] Cognitive impairment – Poor STM, impaired attention & concentration, brief disorientation. (This can be exacerbated by depressive
state with the client)
[D] Potential for complications consistent with use of IV anaesthetic agents & considered an invasive procedure.
 Therapeutic interventions – Mood disorders
Psychotherapies: Are a non-invasive treatment for mood disorders that are effective and increasing in popularity. They aid in the
prognosis of clients with mood disorders and can be used over the short or long term.

Some types of psychotherapies appropriate for use with mood disordered clients include:
1. Cognitive Behavioural Therapy [CBT] –
Useful for all mood & anxiety disorders as a primary or secondary form of treatment.
The aim is to challenge negative or irrational thought patterns.
Extreme thoughts = extreme emotions. CBT aims to reduce the intensity of these emotions
Feelings result from attitudes, thoughts & beliefs, not the external situations
Harmony between thoughts, emotions and behaviour is the desired result

Thoughts

Behaviour Emotions
 Therapeutic interventions – Mood disorders
Milieu Therapy –
• This refers to the quality of the environment believed to have benefits for clients with mental
illnesses. This environment is not restricted to wards or hospitals and can be applied to
community settings.
• In the situation of a client with BPAD, the reduction of sensory stimulation is viewed as
appropriate given the disorganized thought processes of the client. For a depressed client, a
safe environment is essential.
• Elder, Evans & Nizette (2009) advise the components are; “…participation of the patients [and]
staff in decision-making…use of a multidisciplinary treatment team…Open communication…
Individualised goal-setting with patients.” [p.393] as vital ingredients to success in treatment.
• Accurate definition of the therapy is difficult given the comprehensive nature of applying care.
• Conceptually Milieu therapy accounts for social, emotional, interpersonal, professional and
the management of these factors.
 Therapeutic interventions – Mood disorders
Interpersonal Therapy (IPT)
• Focus is given to the strength of the clinical relationship.
• Like CBT, IPT does not resolve every problem; more driven to problem solve & grounded in the
present.
• The relationship and interactions of carers / family are seen as catalysts to change unhelpful
thoughts & behaviours.
• Useful in hypomanic and depressive disorders.
Financial counselling
• Warranted for client with manic episodes, as some of these clients excessively spend, placing
themselves and / or family members at risk.
• It is common for hypomanic clients to experience Delusions of Grandeur, consideration for
Guardian and/ or Administration order should be given.
• Proactive measures should be recommended when the client is well such as Advance
statements and Nominated persons.
 Discharge Planning – Mood disorders
Educating the client & carers about the disorder, early warning signs [EWS] of relapse & treatments with the need to adhere to
treatments. Potential side effects to psychotropic medications and to remain compliant with them even when feeling improvements.

Encouraging the client to keep appointments with GP, clinical professionals & social contacts. Accurate reporting of current
situation & side effects to medications are important, mood diary can be of benefit, if memory poor.

Advising the client of fluctuations in mood are common & discouraging the use of ETOH or mood altering illicit substances.

Management of stress is important and techniques to minimise or avoid stressful situations can be warranted.

Empowerment of clients is vital to maintain a therapeutic relationship. Honesty & openness assists in this area.
 Discharge Planning – Mood disorders
Identify support networks & inform them of discharge plans & care arrangements. Also the identification of potential relapse triggers
and strategies to manage them. [e.g, limiting time at stressful family functions].

Provide crisis contact details should regression of illness occur. Vital that the client is informed that – early proactive contact is viewed
as a success rather than a failure.

Information should be given verbally & in writing to the client. Different states have management plans for the clients &/or carers.
These plans should be reviewed with the client on a regular basis.

Encourage a graduated return to premorbid functioning. The common mistake from high functioning clients is a need to rapidly
return to their pre-illness level. The nurse should display an approachable demeanour and active listening for the client to initiate
discussions about their concerns and fears. The client needs to own the illness and benefit from successful treatment.
 Final thoughts to consider:
It is a common feature that mood instability will lead to suicidal thinking,
plans and in many cases behaviours therefore ongoing risk assessments,
documentation and interventions are crucial components of the nursing role.

The importance of MHN’s cannot be underestimated during these periods.

 Suicide
According to Usher, Foster & Luck in Elder, Evans & Nizette (2009);
“Suicide: the deliberate and conscious attempt to kill oneself. May be either completed (results in death)
or attempted…
Self-harm or injury/deliberate self-harm [D.S.H.] : any intentional damage to the persons body, without
a conscious intention to die. Includes the use of cutting, burning, carving, branding, head-banging,
scratching, biting, bruising, abrasions and pulling skin and hair. [Excludes psychosis]…
Parasuicidal behaviour: actions that are intended to cause self-injury but not intended to be lethal…”
(p.418).

According to Morrison in Elder, Evans & Nizette (2013);

– “… not all suicides or attempted suicides are by individuals with a clinical diagnosis of depression. Stressful
and negative life events can become triggers for suicidal ideation and attempts” (p.166).
 Suicide - Epidemiology
A taskforce set up by the Victorian Government in 1997 to publically investigate suicide factors came to these conclusions:
[1] Each suicide is a tragic and unique event. Death by suicide reflects an intensely personal set of circumstances for the individual, their
family and loved ones. The tragic reality is that every two days, three Victorians end their lives by suicide.
[2] Suicide is now the leading cause of death due to injury in Australia, ahead of motor vehicle accidents and homicide.
[3] It is estimated that each week in 1995, an average of two young people in Victoria died by suicide. Of the 107 young people aged
between 15 and 24 years who died by suicide in that year, 74 per cent were young men.

Although the overall rate of suicide in Australia has remained constant for 100 years, the rate of suicide for young men has tripled
since 1960.

This is not just a Victorian or an Australian problem. According to the World Health Organisation (WHO), suicide is now one of the 10
major causes of death in developed countries. Rises in suicide among young people, especially young men, is a growing international
trend.
Most young people successfully negotiate the transition from adolescence to become well-adjusted adults.
Obtaining & interpreting data is difficult due to delays in coronial inquests, multiple factors, a lack of set factors and other
complexities contributing to the suicide rate.
 Suicide – Risk Factors
Prior attempts & history of D.S.H. – This is widely recognized as a strong indicator for suicide.
Mental illness – Clients diagnosed with either any personality or mental disorder have a higher
prevalence to suicide. The accuracy of figures is difficult given under-reporting of MH issues,
however, Mind frame (2009) advises the risk increases after discharge from hospital or reduction
in treatment for a mental health.
Clients with Drug & ETOH problems – There is a correlation between substance abuse /
dependence and depression. This group are at a higher risk chronically than the general
population.
Indigenous males – particularly young males are more likely to suicide than Caucasian males
Incarcerated people – Regardless of ethnicity are more prone to suicide than others with 3x risk.
Social factors - Impacts on personal safety. Poor relationships, family discord, marital separation
and conflicts, legal proceedings, unemployment, finances, social welfare recipients, loss of partner,
sexual abuse, trauma, isolation & sexual orientations / preferences.
Physical state – Chronic disability, pain & terminal conditions increase personal safety concerns.
Combinations of the above groups.
 ParaSuicide
Para stems from the Greek language and means ‘Near’ .

Hence parasuicide refers to suicide attempts or gestures. Non-lethal in their

intent to die.

Despite this, risk of suicide is high and each presentation must be assessed
on its merits. Prior knowledge of the consequences aids in determining
parasuicide compared to D.S.H. i.e. clients that overdose on sub-lethal
quantities of prescription medication, aware that charcoal or Parvolex will be
activated to treat the OD.
 Deliberate Self Harm [D.S.H]
Distinct from suicidal behaviour given the intent is non-lethal, possibly impulsive & is targeted to alleviate emotional distress and
inflict injury to themselves. Tissue damage is a result of D.S.H. Also referred to as ‘Non-Suicidal Self Injury’ [N.S.S.I]

Rationale for D.S.H are complex & can be considered by healthcare professionals as a self destructive or negative behaviour.
However, the client can experience a release of tension & even empowerment by releasing internal tensions.

D.S.H. can be interpreted as a more preferable option compared to the clients internal anguish. Commonly depressed clients D.S.H.
in order to ‘feel something other than numb’.

A common myth is that D.S.H. is a result of the client “attention seeking” and this view is not correct.

It is common for clients with D.S.H. to have a history of abuse, depression / anxiety disorder, personality disorder or have a form of
psychological disturbance.

Clients with a history of D.S.H. are at chronic risk of suicide & each presentation needs to be considered on its merits. Suicide,
Parasuicidality & D.S.H are different phenomena.

Self destructive or high risk behaviours can be interpreted as D.S.H. – ETOH / Drug binges, provoking fights are good examples

Elder, Evans & Nizette (2009)

 Self-harm – Risk Factors
From the Victorian Government –D.H.S : Mental Health Branch (2003) came the following:
– “High-risk populations identified in the 1997 Victorian Task Force Report on Suicide Prevention included, elderly males, Aboriginal &
Torres Strait Islander people, young males aged 20–24 years, homeless people, people with HIV/AIDS, people in custody and gay and
lesbian young people. Although depression and prior suicidal behaviour or attempts remain the most significant clinical risk indicators
for suicide, a number of additional risk groups have been highlighted by Strategy initiatives. These include people suffering from co-
existing disorders, adolescents at the secondary and tertiary level, ex-prisoners and ex-psychiatric care patients.” (p.11)

These risk groups listed above were proactively identified as an emerging risk group.
Victorian Government (2003)

Currently recognized risk groups are as follows;

– Clients with intellectual impairment / disability.
– Psychotic disorders.
– Depressed &/or Anxious clients.
– Personality Disorder clients – Mainly Cluster B.
– Clients with a history of abuse.
– Intoxicated / recreational substance users.
– Combinations of the above groups.
Elder, Evans & Nizette (2013)
 Risk assessment
Risk assessment is essential to gauge risk – Please refer to Assessments lecture.

Suicidal ideation refers to thoughts or ideas of suicide. These may be vague with only a wish to die and no plan or
intent. Alternatively, the client may have firm plans, intent to act on the plan & the availability of means. (Mx’s, rope,
secluded area)

Suicidal ideation usually varies in the intensity, frequency & duration. Levels of subjective distress with the client also
may vary between passive acceptance to severe agitation.

The frequency of risk assessments depend on the clients current mental state & response to treatment and nursing
interventions.

The M.H.A. status of the client may need to be reviewed in order to protect the client. Consideration needs to be given
to the clients ability to make sound decisions and if all the Section 29 criteria for detention under the Victorian Mental
Health Act [2014] applies.
Elder, Evans & Nizette (2009)
 Risk assessment
Suicide - Risk Factors/Assessment
1. Do you feel that life is no longer worth living? (thoughts)
2. Have you felt like acting on this? (intent)
3. Have you made any plans to carry this through? (method + plan)
4. Have you ever tried to harm or kill yourself before (attempt, past history)
5. Suicidal ideas in absence of intention to act = low risk
6. Suicidal ideas + intention = mod risk
7. Suicidal ideas + intention to act + specific plans = high risk
8. Yes to Q4 Increased overall risk

From this point, it is helpful to ask the client – “What needs to change to order to maintain your safety?”
If previous attempts at suicide / self harm have occurred, ask for particulars, “Were they alone?, Did they change their
mind or feel guilty?, Did they get medical treatment or Psychiatric care?, Did they get help?, What current factors are different?
& Was the help effective?”
 Risk assessment
Suicide -Risk Factors/Assessment Suicide: Use the Acronym SAD PERSONS

S - Sex. Males 4:1 Females

A - Age. Older > younger
D - Depression precedes in 70% of cases.
P - Previous attempts.
E - Ethanol use
R - Rational thinking loss
S - Social support deficit
O - Organised plan
N - No spouse
S - Sickness
 Risk management and Nursing care
Crisis lines are important – Crisis Support Services manages several specialist services;
– MensLine Australia 1800789978
– SuicideLine (VIC) 1300651251
– Suicide Call Back Service 1300659467
Lifeline 131144
Kids Helpline [5-25yrs.] 1800551800
beyondblue Information Line: 1300 22 46 36
Emergency – Nation wide 000

Provision of a safe & secure environment. Remove items that can be injurious to client / others.
Frequent observations & contacts with the client. The client may be specialled 1:1 should this intense level of nursing be warranted.
The nurse/client relationship is of high importance. The ATTITUDE of the nurse is crucial. Nurses who are judgemental, critical or
project their personal views toward these clients risk alienating them. Effective listening, sensitivity, empathy, respect, caring,
acceptance, encouragement and communication skills are personal attributes valued by clients in crisis.
Verbal contracts or “no suicide contracts”. Vary the time according to the clinical situation.
Nurses looking after these clients need clinical care from peers, a safe environment to discuss their concerns & supports to minimise
burnout & enhance coping skills.

Elder, Evans & Nizette (2009 & 2013)

 Risk management & Nursing care

Seclusion should be a last option when all other strategies are unsuccessful. The use of seclusion can be seen as
punitive & disempowering for the client. Should seclusion occur, the client must be debriefed at conclusion of the
intervention.

In the community, encourage the client to contact in times of crisis, reinforcing the success of this action by ‘owning’
the responsibility for personal safety. Do not use admission, MHA status or seclusion as a “threat” in order for the
client to comply with care.

Determine periods of crisis, Are mornings safer for the client? Respond according, If mornings are more difficult for
the client, visit them at these times.

Provide updates and stress any successes the client has made.

Continually assess the supports [Clinical & Emotional] & how they are coping.

Empower the client by providing options. N.B – With some clients this provokes more distress .
On a Lighter note…….
 Reference List
• American Psychiatric Association (A.P.A.) (2013) Diagnostic and Statistical Manual of Mental Disorders, 5 th ed. A.P.A.; Washington D.C.

• Barling, J. (2009). Assessment and Diagnosis. In R. Elder, K. Evans & D. Nizette. (Eds.), Psychiatric and Mental Health Nursing (2nd
edition) (pp. 173 - 200). Chatswood, N.S.W.; Elsevier.

Department of Health – Victoria (2012) A new Mental Health Act for Victoria – Summary of proposed reforms. Retrieved from
http://docs.health.vic.gov.au/docs/doc/128700DBBE24DDFDCA257C0B0079D75E/$FILE/mh reform.pdf

• Gaynor, N., Harder, K., Munro, I & Robins, A. (2011) Diagnostic Systems Used in Clinical Assessment. In K. Edward., I. Munro., A.
Robins & A. Welch. (Eds.) Mental health Nursing Dimensions of Praxis. (p 34.) South Melbourne; Oxford University Press

• Henderson, S. (2011) Mood and Anxiety Disorders. In K. Edward., I. Munro., A. Robins & A. Welch. (Eds.) Mental health Nursing
Dimensions of Praxis. (pp 169 – 183.) South Melbourne; Oxford University Press.
• Maude, P & Edward, K. (2011) Psychopharmacology. In K. Edward., I. Munro., A. Robins & A. Welsh. (Eds.) Mental health Nursing
Dimensions of Praxis. (pp 294 – 306.) South Melbourne; Oxford University Press.

• Morrison. S. (2013) Crisis and loss. In R. Elder., K. Evans & D. Nizette. (Eds.) Psychiatric and Mental Health Nursing (3rd edition) (pp.
173 - 200). Chatswood, N.S.W; Elsevier.
http://www.headspace.org.au/media/22527/depression_web.pdf (retrieved 20/12/11)
http://depressionet.org.au (retrieved 21/12/2011)
http://www.health.vic.gov.au/mentalhealth/suicide/suicide-prevention/task-force-report/chapt1.pdf (retrieved 4/1/2012)
http://www.health.vic.gov.au/mentalhealth/suicide/suicide-prevention/task-force-report/chapt2.pdf (retrieved 4/1/2012)
http://www.health.vic.gov.au/mentalhealth/suicide/suicide-prevention/task-force-report/chapt3.pdf (retrieved 4/1/2012)
http://www.health.vic.gov.au/mentalhealth/suicide/suicide-prevention/task-force-report/exsum.pdf (retrieved 4/1/2012)
http://www.mimsonline.com.au/search (retrieved 3/1/2012)
http://mindframe-media.info/client_images/826717.pdf (retrieved 4/1/2012)
State Government – Victoria. (2014). Mental Health Act (2014) Vic. No. 001. Retrieved from http://www.legislation.vic.gov.au/
www.mindframe-media.info/site/index.cfm?display=87222 (retrieved 5/1/2012)