MOOD

DISORDERS
AND
SUICIDAL
BEHAVIOR

Overview of mood
disorders
and
suicidal behavior

Key concepts:
Mood disorder are characterized by disturbances in feelings,
thinking and behavior that tend to occur on a continuum
ranging from severe depression to severe mania.
Depression is an emotional state characterized by sadness,
discouragement, guilt and feelings of helplessness and
hopelessness.
Mania is an emotional state characterized by high optimism,
increased energy and an exaggerated sense of importance
and invincibility.
Unipolar depression is a mood disturbance with only
depression but no occurrence of mania.
Bipolar disorder is a mood disturbance in which the
symptoms of mania have occurred at least one time.

Grief is a normal response to loss, grief is differentiated

from depression by the following factors:
1. Acute grieving may occur up to 3 months after a
significant loss.
2. Grief resolution is characterized by the grieving persons
ability to remember both the pleasures and disappointments
associated with the loss.
3. Maladaptive grief response can lead to a mood disorder.
4. Loss of self esteem in the grieving person is not
characteristics of normal grieving and may indicate a mood
disorder.

Suicidal behavior involves thoughts of taking ones

own life.
A. Suicidal Threat- a suicidal intent that is usually
accompanied by behavior changes: includes a plan
and the means to execute the plan.
B. Suicidal Gesture- refers to a self-destructive act
that does not involve serious injury, however it may
be followed by a more serious attempt.
C. Suicidal attempt- is a self destructive act that
has a potential outcome of death.

Common Risk factors

associated with
Mood disorders and Suicidal
behavior:
-Sex
-Age
-Mental status
-Family History
-Precipitators (recent life
events)
-Other factors

TYPES OF MOOD
DISORDERS

A. Major depressive disorder

1) Includes at least four of the following symptoms of
depression:
a. Increase or decrease in appetite
b. Increase or decrease in sleep
c. Psychomotor agitation or retardation
d. Fatigue and loss of energy
e. Decrease In ability to think and concentrate
f. Recurrent thoughts of suicide

2) DSM-IV TR specifiers or subtypes of major depressive disorder

include:
A. Melancholic features: the client experiences either anhedonia
in relation to all activities or lack of mood reactivity to usually
pleasurable activities; this specifiers is also characterized by waking
early in the morning, feeling worse in the morning, and excessive
guilt.
B. Atypical Features: the client exhibits mood reactivity,
increase levels of anxiety, changes in appetite and sleep, and
increased sensitivity to interpersonal rejection.
C. Psychotic features: depression is accompanied by delusions
and hallucinations.
D. Postpartum Onset: onset of symptoms occurs within 4 weeks
of delivery.
E. Seasonal Pattern Specifier (SAD): is currently not classified
as diagnostic category in DSM-IV TR, It is included as specifier.
-commonly occurs in the fall and winter and is associated
with the decrease in sunlight.
-symptoms include hypersomnia, overeating and

B. Dysthymia
1) Characterized by a chronically depressed mood occurring most of the day.
2) This disorder usually does not affect social or occupational functioning.

C. Bipolar Disorder
1) Bipolar I disorder is characterized by one or more manic or mixed episodes.
Symptoms of manic episode
a. Inflated self esteem or grandiosity
b. Decreased need for sleep
c. Increased or pressured speech
d. Flight of ideas
e. Distractibility
f. Increased involvement in goal directed activities.
g. Excessive involvement in pleasurable activities that have a high potential
for painful consequences.
2) Bipolar II disorder is characterized by one or more major depressive
episodes accompanied by at least one hypomanic episode.
*A Hypomanic episode is one in which at least three or more of the symptoms
of mania are present.

D. Cyclothymia is characterized by at least

2 years of several periods of hypomanic
symptoms not as severe as those in a manic
episode.
E. Pseudodementia is a disorder
associated with depression in elderly clients.
1) The clinical presentation of depression is
similar to symptoms associated with a
cognitive impairment disorder.
2) Treatment of depression that is successful
in eliminating the symptoms of dementia
will establish the diagnosis.

CAUSES OF MOOD DISORDERS

A. Key concepts
1) These disorders result from complex interactions. Among a
variety of factors.
2) Implicating factors include genetic predisposition,
neurochemical imbalances, certain medications and
psychosocial and environmental processes.
B. Genetic predisposition
1) Major depressive disorder
a. Twin studies reveal a higher rate of concordance in
monozygotic twins than dizygotic twins, indicating a genetic
component.
b. Researchers are currently investigating a defective gene
on chromosomes 4; those with this defective gene are 26
times more likely to be hospitalized for severe depression and
suicide attempt; research is also focused on genes on
chromosomes 11, 18, and 21.
2) The risk of developing bipolar disorder increases 4% to 24%
in first degree relatives of people with bipolar disorder.

C. Neurotransmission dysregulation
1) Biogenic amine theory,
norepinephrine and serotonin are deficient in individuals with
a depressive disorder;
whereas these neurotransmitters are increase in those with a
bipolar disorder; changes in quantity and sensitivity of
receptor sites are also important.
2) Kindling theory,
external environmental stressors activate internal physiologic
stress responses,
which trigger the first episode of a mood disorder,
the first episode then creates electrophysiologic sensitivity to
future episodes so that less stress is required to evoke another
episode.

D. Neuroendocrine dysgeneration
1) Hypothalamic Pituitary Adrenal (HPA) axis
indicates that some individuals with depressive disorders
exhibits increased cortisol level,
resistance of cortisol to suppression by dexamethasone and
blunted adrenocorticotropin hormone response to
corticotrophin-releasing factor challenge as compared to
normal controls.
2) Subclinical hypothyroidism
blunting of response of thyroid-stimulating hormone to
thyrotropic-releasing factor has been found in about 25% of
euthyroid individuals with depressive disorders.
3) Circadian rhythm changes
indicating abnormal sleep EEG activity in many individuals
with mood disorders.

E. Medication use and medication conditions

1) Medications known to produce depression as a side effect:
a.Hormones (oral contraceptives, glucocorticoids)
b.Cardiovascular drugs
c.Psychotropics
d.Anti-inflammatory and anti-inefective drugs
e.Antiulcer medications
2) Nonpsychiatric general medical condition:
a.Cerebrovascular accident
b.Cognitive impairment disorder
c.Diabetes
d.Coronary artery Disease
e.Cancer
f.Chronic fatigue syndrome
g.Acquired immune deficiency syndrome (AIDS).

Common negative cognition

-Overgeneranalization
-All-or-nothing thinking
-Should statements
-Labeling
-Mind reading
-Fortune telling

MANAGING MOOD DISORDERS

A. Acute, psychiatric, hospital-based care

Clients with suicidal behavior require hospitalization for
protection, so they can receive:
a. Supportive psychotherapy and milieu management
b. Cognitive-behavioral therapy
c. Medication with antidepressants, neuroleptics or mood
stabilizing agents.
Electroconvulsive therapy may be recommended for severe
depression that is unresponsive to anti depressants therapy.

B. Community-Based treatment
1) Primary prevention may be accomplish through identification of
at risk population and teaching self care measures to decrease
occurrence of mood disorders; self care measure may include:
a. Adequate exercise and rest.
b. Good nutrition
c. Stress management
d. Use of Support system
e. Verbalizing rather than Internalizing feelings
f. Assertiveness training programs

2) Case finding occurs when health care practitioners

identify individuals in the community who have symptoms
of a mood disorder but are not in treatment.
3) Crisis Intervention Services should be use for those
individuals with suicidal behavior
4) Medication management may include the use of
antidepressants mood stabilizer or antipsychotics.
Ultraviolet light therapy may also be used for those with
seasonal affective disorder.
5) Cognitive behavior therapy is the recommended
type of psychotherapeutic approach for a client with a
mood disorder

CLASSIFICATION

DRUG

RATIONALE FOR USE

Antidepressants
Tricyclic
antidepressant(TCAs)

amitriptyline (Elavil)
clomipramine
(Anapranil)
desipramine
(Norpramin)
nortriptyline (Pamelor)

Act by blocking reuptake

of neurotransmitters at
presynaptic neuron;
provide elevation of
mood, increase activity
level, and appetite
stimulation

Monoamine oxidase
inhibitors (MAOIs)

isocarboxazid (Marplan)
phenelzine (Nardil)
tranylcypromine
(Parnate)

Act by inhibiting the

enzyme monoamine
oxidase. When enzyme
is inhibited, increased
amounts of
neurotransmitters
remain at the synapse
and act to elevate mood
and increase activity
level.

Selective serotonin
reuptake inhibitors
(SSRIs)

fluoxetine (Prozac)
fluovoxamine (Luvox)
paroxetine (Paxil)
sertraline(Zoloft)

Act specifically on
serotonin, preventing its
reuptake; because they
are selective, SSRIs do
not have the side effects
of TCAs and MAOIs

Atypical Antidepressants bupropion (Wellbutrin)

mirtazaphine (Remeron)
nefazadone (Serzone)
trazodone (Desyrel)
venlafaxine (Effexor)

Act similar to TCAs.

Antidepressant effects
are not yet well
understood; however
these drug produce
fewer side effect than
TCAs.

Herbal Remedies

May relive mild to

moderate depression;
however research has
not consistently
supported the result.

hypericum perforatum
(St. Johns wort)

Mood Stabilizers
Antimanic

lithium carbonate
(Eskalith,Lithobid,Lithon
ate)

Acts by interfering with

a neuropathway in the
limbic system, which
helps to stabilize
neurochemical
regulation in the brain
thereby stabilizing
mood.

Anticonvulsants

carbamazephine
(Tegretol)
gabapentin (Neurontin)
lamotrigine (Lamictal)
topiramate (Topamax)
valproic acid (Depakote)

Act by affecting sodium

and calcium channels
thereby decreasing
release of
neurotransmitters;
thought to inhibit the
process kindling.

olanzahine (Zyprexa)

Act as a mood stabilizer;

the FDA recently
approve this drug for
use in bipolar disorder.

Atypical antipsychotic

THE NURSING PROCESS OVERVIEW :

ASSESSMENT
When caring for clients with mood disorders, nurses must
maintain awareness of their own personal reactions to the client
and the ways in which these reactions can affect the nurseclient relationship and subsequent care.
Clients experiencing mood disorders are in emotional pain.
They are unable to change their emotional state at will. These
clients need validation that their emotional state is not their
fault, that they are experiencing a psychiatric disorder. They
should be approached with acceptance and respect.
It is important that nurses appear confident, straightforward,
and hopeful. It is appropriate to convey hope with comments
such as, '' I've known many clients with depression, and they
have felt better within several weeks of starting on their

 Communication Nurses need to be simple, clear, direct,

and firm.
Information from the client may be minimal or
inaccurate because of their cognitive impairment,
altered mood, or behavioral disturbances. A significant
other can be an important source of information when
the client is not reliable .
Assessment of the client with depression or mania
includes information about his or her presenting
problem and mental status, past psychiatric history,
social and developmental history, family history, and
physical health history.


ANALYSIS AND DIAGNOSIS

1. Analyze the clients predominant mood, anxiety level, degree of self

esteem, and severity of symptoms:
a. Activity intolerance
b. Anxiety
c. Fatigue
d. Hopelessness
e. Imbalanced nutrition : less than body requirements
f. Imbalanced nutrition : more than body requirements
g. Powerlessness
h. Self-care deficit , bathing /hygiene
i. Self-care deficit , dressing /grooming
j. Self-care deficit , feeding
k. Disturbed sleep pattern
l. Social isolation
m. spiritual distress

PLANNING :
Recent information about the epidemiology and
recurrent course of depression and mania provides the
basis for caring for clients with mood disorders in the
hospital and in the community. Nursing care addresses
the acute episodes of the disorder and the client's risk for
recurrent episodes. Interventions during the acute
depressive or manic episodes can be effective, but too
often the client is left with little understanding of the
importance of long-term management and self-care
strategies. Interventions must be planned for each client
based on his or her particular behaviors and concerns.
Planning care not only involves the client but may also
include the client's significant others and additional
health care providers .

IMPLEMENTATION :
The plan of action for clients with mood disorders varies
depending on whether the client is depressed or manic. Mood
disorders, although primarily disturbances in emotional regulation,
affect the whole person physically , cognitively , socially , and
spiritually .
Short-term interventions in the hospital or community address
priority issues such as preventing self-harm , promoting physical
health ( e.g., adequate nutrition , bathing , grooming , sleep ) ,
monitoring effects of medications , and assisting with altered thought
flow and impaired communication . Other concern to be addressed
include promoting social interaction , self esteem , understanding of
the disorder and its treatment , treatment compliance , and planning
for discharge and continuation or discontinuation of services .

OUTCOME IDENTIFICATION
Client will:
1. Remain safe and free from harm.
2. Verbalize absence of suicidal or homicidal intent or
plans.
3. Express desire to live and not harm others.
4. Make decisions based on examination of options and
problem solving
5. Report absence of hallucinations / delusions.
6. Engage in activities and behaviors that promote
confidence, belonging, and acceptance.
7.Identify medications, including action, dosage, side
effects, therapeutic effects, and self-care issues.

Nursing Interventions:
1. Conduct a suicide assessment as necessary to ensure the client's safety
and prevent harm to self or others.
2. Maintain a safe, harm free environment through close and frequent
observations to minimize the risk of violence.
3. Establish rapport and demonstrate respect for the client to facilitate the
client's willingness to communicate thoughts and feelings.
4. Assist the client in verbalizing feelings to promote a healthy , expressive
form of communication.
5. Identify the client's social support system and encourage the client to use
it to minimize isolation and loneliness as possible precursors to hopelessness.
6. Praise the client for attempts at alternate activities and interactions with
others to encourage socialization.
7. Monitor the client's fluid intake and output, food intake, and weight to
ensure adequate nutrition and hydration and adequate weight for body size
and metabolic need.
8. Promote self-care activities, such as bathing, dressing, feeding, and
grooming , to ascertain the client's level of functioning and increase selfesteem.

9. Assist the client in establishing daily goals and expectations to

promote structure and minimize confusion/anxiety.
10. Plan self-care activities around those times when the client may
have more energy to increase activity tolerance and minimize
fatigue.
11. Encourage the client to attend therapeutic groups that provide
feedback regarding thinking to reframe thinking with the support of
others.
12. Provide simple, clear directives/communication in a low-stimulus
environment to assist with focus, attention and concentration with
minimal distractions.
13. Gradually increase levels of activity and exercise to minimize
fatigue and increase activity tolerance.
14. Educate the client with depression about the disorder and
symptoms as appropriate to lessen feelings of inadequacy, minimize
guilt, and increase the knowledge base about the effects of the
illness.
15.Educate the client with mania about the disorder and symptoms
as appropriate to lessen feelings of inadequacy, minimize guilt, and
increase the knowledge base about the effects of the illness.

Outpatient Discharge Criteria

Client will:
a. Verbalize plans for the future , including absence of imminent suicidal
intent or behavior.
b. Verbalize plan for seeking help. if suicidal thoughts become intensified
or if thoughts progress to plans.
c. Demonstrate ability to manage basic self-care needs, such as personal
hygiene, or verbalize strategies to acquire assistance.
d. Describe mood state and demonstrate ability to identify changes from
euthymic mood.
e. Identify psychosocial or physical stressors that may have negative
influences on mood and thinking.
f. State positive and helpful strategies to cope with threats, concerns, and
stressors. Identify signs and symptoms of the mood disorder, including
prodromal ( early ) signs that might indicate the need to seek help.
g. Describe how to contact appropriate sources for validation and / or
intervention when necessary.
h. Use learned techniques and strategies to prevent or minimize
symptoms.
i. Verbalize knowledge about medication treatment and necessary selfcare strategies.

- Family Intervention
Mood disorders affect the entire family, not just the client who is
experiencing the depression or mania, Most often the family or
significant others become known to the nurse during the client's
acute episode of depression or mania.
Nurses in both the hospital and community interact with the
client's family, who often appreciate the opportunity to vent feelings
of confusion, anger, concern, or frustration. Teaching family members
about the client's disorder, especially the biologic untrue of the
disorder, allows them to reframe the situation and minimize blame on
the client. They also find it helpful to know that the client's behavior
is not a personal affront to other family members but may be part of
the symptomatology of depression or mania.

-Group Intervention:

Group intervention can provide multiple benefits to

clients with mood disorders, including socialization,
education about their disorder and more useful coping
mechanisms, the opportunity to vent feelings, the
establishment of personal goals, and the realization
that others have similar problems, thus reducing
isolation and hopelessness.
Certain types of group may be less structured and less
imposing to clients than formal group therapy.
Clients often need to debrief or discuss their
experiences and reactions after the completion of a
group.

- Psychotherapeutic Intervention :
Although the effectiveness of
antidepressant and mood-stabilizing
medications is undisputed,
psychotherapeutic interventions are also
important in the treatment of mood
disorders.
These medications have major side
effects that create discomfort, interfere
with usual functioning, and promote
noncompliance.

Types of psychotherapy that have

been used to treat mood disorders
and associated psychosocial issues
include cognitive therapy,
behavioral therapy, interpersonal
relationship therapy, and
psychodynamic therapy.

A- Cognitive Therapy :
Clients are asked to identify their automatic thoughts, silent
assumptions and arbitrary inferences so that negative thoughts and
assumptions can be examined logically, challenged against realistic
attributes and subsequently validated or refuted.
Use of cognitive therapy also may increase the rate of symptom
improvement in depression , although longer term follow-up studies
fail to find differences over time.
B - Behavioral Therapy :
Behavioral Therapy, often used in conjunction with cognitive
therapy for treating mild to moderately depressed outpatients, is an
effective treatment for depression, comparing favorably with
medication and cognitive therapy.
The behavioral therapist works with clients to determine specific
behaviors to be modified and to identify the factors that evoke and
reinforce these behaviors.

C- Interpersonal Therapy :
The therapist using interpersonal therapy views depression as
developing from pathologic, early interpersonal relationship patterns that
continue to be repeated in adulthood.
The emphasis is on social functioning and interpersonal relationships,
with particular emphasis on the milieu. Life events, including change,
loss, and relationship conflict, trigger earlier relationship patterns; and
the client experiences a sense of failure decreased importance, and loss.
The goal of the therapy is to understand the social context of current
problems based on earlier relationships and to provide symptomatic relief
by solving or managing current interpersonal problems.
The client and therapist select one or two current interpersonal problems
and examine new communication and interpersonal strategies for more
effective management of relationships.

D- Psychodynamic Therapy :
Psychodynamic Therapy is derived from Freud's
psychoanalytic model. Depression is viewed as a result of
early childhood loss of a love object and ambivalence
about the object; introjection of anger onto the ego,
resulting in blockage of the libido; and unresolved
intrapsychic conflict during the oral or anal stage of
psychosexual development. Thus self-esteem is damaged
and eroded, with repetition of the primary loss pattern
occurring throughout life. Through the relationship with
the therapist, the client is helped to uncover repressed
experiences, experience catharsis of feelings, confront
defenses, interpret current behavior, and work through
early loss and cravings for love.

5- Self-Management Intervention
In the current health care environment with fewer financial
resources and difficulty with access to health care, more and more
clients must fend by self-managing their chronic illnesses. Selfmanagement approaches for chronic illnesses such as asthma and
cardiac disease have resulted in reduced health care costs and
improved longer term health outcomes.
Nurses have a major role in educating clients with mood
disorders about their illness and assisting them to develop strategies
for on-going management of the disorder and its impact on their
lives.
Clients can be taught self-management strategies such as
identifying prodromal symptoms of recurrence problem solving about
potential options for intervention, and building a repertoire of selfmanagement strategies that can be used during times of increased
stress and potential recurrence.

EVALUATION:
Nurses evaluate clients progress by measuring their achievement of identified
outcomes.
Evaluation occurs throughout hospitalization and may be continued by community
mental health providers after clients have been discharged
With decreasing lengths of stay in hospitals , nurses in inpatient psychiatric units may
not see dramatic changes in clients' symptoms.
However , they must see some clear progress related to priority short-term outcomes
such as absence of imminent suicidal intent , a plan for addressing the potential return
of suicidal ideation after discharge , the ability to conduct self-care activities , some
alleviation of the neurovegetative symptoms of depression ( sleep , loss of appetite ,
fatigue psychomotor retardation ) , alleviation of the severe hyperactive behavior of
mania , improvement in cognitive functioning and communication , and initial
understanding of the disorder and its treatment , including necessary self-care
management.
Referrals are made to therapists , psychiatrists , home care and community mental
health agencies , and partial hospitalization programs for continued care in the
community.
Clients with mania present a unique evaluative situation , because episodes of mania
may be followed by episodes of depression.

THANK YOU.. .