Mood Disorders

C. Baker-Burke
MScN, BScN, RN

Mood Disorders
Mood Disorders are mental
disorders in which the prevailing
symptoms are pathological
mood changes of
sadness/depression, elation/
mania or both.

Depressive disorders (DSM 5)

Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)-

lasts more than 2 yrs.

Premenstrual Dysphoric Disorder- symptoms
appear in final week before onset of most
menses, then improve (eg. lability, irritability,
anxiety, depressive mood)
Disruptive Mood Dysregulation Disorder
diagnosed before age 10 (temper tantrums,
irritability, anger)

Depressive disorders (DSM 5)

Substance Medication-Induced Depressive

Disorder
Other Specified Depressive Disorder
-With Anxious distress
-Peripartum onset (includes during/following
pregnancy)
Unspecified Depressive Disorder-e.g.
insufficient information

Diagnostic criteria Major Depressive

Disorder
At least one of the following three abnormal
moods that significantly interferes with the
person's life:
Depressed mood
Loss of interest & pleasure
Irritable mood (under 18 yrs)
Occurring most of the day, nearly every day,
for at least 2 weeks

Diagnostic criteria
At least five of the following symptoms should have

been present during the same 2 weeks as

depressed mood:
Loss of interest & pleasure
Appetite/weight disturbance (gain/loss)
Sleep disturbances
Fatigue/loss of energy
Guilt
Poor concentration
Morbid thoughts of death

Diagnostic criteria
The symptoms are not due to
Physical

illness, alcohol,
medication, or drug use.
Bipolar Disorder
Delusional or Psychotic
Disorders

Bipolar disorder
Bipolar 1 Disorder -1 or more manic or

mixed episodes
-Exclusions physical, substance abuse,
psychosis
Bipolar 11 -1 or more major depressive
episodes accompanied by at least 1
manic episode
Cyclothymic Disorder

Mania
At least 5 of the foll.
Increased physical & mental activity &

energy
Heightened/ elevated mood, exaggerated optimism and self-confidence
Excessive irritability, aggressive
behavior
Decreased need for sleep without
experiencing fatigue

Mania
Grandiose delusions, inflated sense of

self-importance
Racing speech & thoughts, flight of
ideas
Impulsiveness, poor judgment,
distractibility
Reckless behavior
In severe cases, delusions &
hallucinations

Prevalence
International studies

Major depression - 3-16%

Bipolar disorder 0.3-1.5%

Caribbean

4.9% (PAHO 2005)

Depression with physical illness 25-45%
Trinidad 14% (Bandhan et al 2005)
Community prevalence and risk factors for mood
disorders are generally unknown (Hickling 2005 )

Aetiology
Depression is often triggered by

stressful life events

Contributing factors:
Intensity and duration of these
events
individuals genetic endowment
coping skills

Aetiology
Social support network depression &

many other mental disorders are

described as the product of a complex
interaction between biological and
psychosocial factors
The importance of biological &
psychosocial factors may vary across
individuals & different types of
depression.

Aetiology
Biological factors
Alterations in brain function
Abnormal

concentrations of
neurotransmitters & their metabolites in
urine, plasma, & cerebrospinal fluid
Overactivity of the HPA (hypothalamuspituitary-adrenal) axis - stress
Major depression is associated with a
dysfunction of the serotonergic activity
and the hypothalamic-pituitary-adrenal
(HPA) axis

Aetiology
Biological factors
Dysfunction in 5-HT(1A)
receptor activity could be due
to a hypersecretion of cortisol
Antidepressants

directly
regulate HPA axis function.

HYDROXYTRYTAMINE- MODULATE
NEUROTRANSMITTERS

Monoamine Hypothesis
Prevailing hypothesis - depression is caused by an

absolute or relative deficiency of monoamine

transmitters in the brain
Evidence that reserpine used to treat hypertension,
caused depression by depleting the brain of both
serotonin and the three principal catecholamines
(dopamine, norepinephrine, and epinephrine).
monoamine hypothesis has been found insufficient to
explain the complex etiology of depression. One
problem is that many other neurotransmitter systems
are altered in depression

Monoamine Hypothesis
monoamine hypothesis remains

important for treatment purposes.

Many currently available pharmacotherapies that relieve depression or
mania, or both, enhance monoamine
activity.
One of the foremost classes of drugs for
depression, SSRIs, increase the level of
serotonin in the brain.

Psychosocial and Genetic Factors in

Depression
Social, psychological, and genetic

factors act together to predispose

to, or protect against, depression.
Depression may be associated
with some sort of acute or chronic
adversity

Psychosocial and Genetic

Factors in Depression
Past

parental neglect, physical and

sexual abuse, and other forms of
maltreatment impact on both adult
emotional well-being and brain function
Early disruption of attachment bonds
can lead to enduring problems in
developing and maintaining
interpersonal relationships and
problems with depression and anxiety

Cognitive factors
How individuals view and interpret stressful

events contributes to whether or not they

become depressed.

The impact of a stressor is moderated by the

personal meaning of the event or situation

Increased vulnerability to depression is linked

to cognitive patterns that predispose to

distorted interpretations of a stressful event

Genetic factors in depression &

Bipolar
Susceptibility to a depressive disorder is two to four

times greater among the first-degree relatives of

patients with mood disorder
The risk among first-degree relatives of people with

bipolar disorder is about 6 - 8 times greater.

this does not prove a genetic connection.

first-degree relatives typically live in the same
environment, share similar values and beliefs, and are
subject to similar stressors, the vulnerability to
depression could be due to nurture rather than nature

Management
50 to 70 percent of depressed patients who complete

treatment respond to either antidepressants or

psychotherapies
Surveys consistently show that a majority of
individuals with depression receive no treatment
The acute phase for medication typically requires 6 to
8 weeks

patients should be seen weekly or biweekly for

monitoring of symptoms, side effects, dosage
adjustments, and support

Psychotherapies during the acute phase for

depression typically consist of 6 to 20 weekly visits

Management
ECT Treatment in Depression
60 to 70 % response rate seen with ECT
effect of ECT occurs faster
Proposed to be useful with poor response to
meds & depression is accompanied by
potentially uncontrollable suicidal ideas and
actions

The most common adverse effects are

confusion and memory loss for events

surrounding the period of ECT treatment.

Management
Medication Depression

Antidepressants -Drugs that elevate mood by

increasing the levels of serotonin and

noradrenaline in the synaptic cleft
-antidepressant should be followed by at least 6
months of continued treatment)
SSRI - Fluoxetine 20mg daily

-Sertraline 50mg daily

-Paroxetine 20mg daily
Selective serotonin re-uptake
inhibitor

Management
Medication Depression (contd)
SNRI - Venlafaxine 37.5 mg daily
(serotonin & norepinephrine reuptake inhibitor)

Bupropion / Wellbutrin
TCAs - Amytryptilline 75mg daily
- Imipramine 75 mg daily
St Johns Wort
Tricyclic antidepressant

Management
Medication Bipolar Disorder
Antipsychotic
Some atypical antipsychotics are also used to help
control manic episodes (olanzapine, aripiprazole and
quetiapine
Olanzapine & aripiprazole affect dopamine and
serotonin.
Olanzapine prevents excessive activity of dopamine.
Quetiapine treats both manic and depressive
episodes.

Management
Antimanic /mood stabilizers are drugs used in

the long-term management of

bipolar disorder.
They are used to maintain a person's mood at
a reasonable level and help prevent future
episodes of low or high mood (mania).
There are three types of mood stabiliser:
The oldest and most widely used is lithium
(LiCO3)
.

Management
Some anticonvulsants proved to be effective

mood stabilisers ( valproate, carbamazepine

and lamotrigine
Lithium 200mg tid PO (Monitor lithium levels)
Carbamazepine 300mg tid PO
Valproic acid 250 mg tid PO (monitor liver

function)

Management
Anticonvulsants are thought to

work on the brain by: increasing the

amount of a natural nerve-calming
chemical called GABA
reducing the amount of a natural
nerve-exciting chemical called
glutamate

Management
Issues to consider when taking lithium

includes:
regular blood tests to monitor the level of
lithium in your blood (0.6 -1.2 is normal; >1.5
is toxic)
maintaining an adequate fluid intake &
avoiding dietary changes that suddenly
increase or reduce salt intake
potential problems of using other medications
at the same time (e.g. Diuretics).

Management - Side effects

Nausea, vomiting, and diarrhea.
Trembling.
Increased thirst & the need to urinate.
Weight gain in the first few months of use.
Drowsiness.
A metallic taste in the mouth (lithium)
With Carbamazepine and Lamotigine a major

side effect is Stevens-Johnson Syndrome

(rash, sore throat, fever, lesions skin & mm)

Psychosocial interventions
NICE Guidelines
Mild depression psychological
Moderate depression Medication or

Psychological
Severe depression CBT & medication

(CBT is best established treatment for

depressive mood disorders)

Nursing Management using

Nursing Process: Assessment
CC., HPI, PPH, PMH, SH, physical &

mental health status

attitudes, feelings, knowledge of pt. &
family re; illness
Degree & intensity of suicidal thinking
Issues of powerlessness, hopelessness,
social isolation
Sleeplessness, hyperactivity, risky
behaviours

Nursing diagnoses
Specific nursing diagnoses in
depressed individuals include:
chronic low self-esteem,
powerlessness,
hopelessness
Risk for suicide
Risk for self directed violence

Planning & outcome identification

Outcomes are pt. & family oriented
Planning develop written care

plan, establish short term & long

term goals

Implementation
Identify appropriate nursing Interventions with
rationale to address problems/ needs
Develop nurse- patient relationship
-therapeutic use of self
-apply roles of nurse in psychiatric setting
Administer medication
Educate Pt. & family re: illness, meds.,
adherence to treatment, follow up care, lifestyle
changes, stress reduction, activity, recreation

Evaluation
Formative achievement of short term

goals during care process

Summative at discharge- pts. ability to
establish long term goals and continue
therapy, referrals, follow up care, reintegration into family & community.

References
1. American Psychiatric Association (2013) Diagnostic

Statistical Manual 5th edition Arlington VA APA

2. Carson, V.B.(2000) Mental health nursing: the nurse-

patient journey 2nd ed. Philadelphia: W.B. Saunders

company
3. Kaplan, H.I., Sadock, B.J. (1996) Concise textbook

of clinical psychiatry 7th ed. Pennsylvania: Lippincott

Williams & Wilkins