Week 3 - Mood disorders Flashcards
Define mood
Subjective internal feeling experienced by the person through their emotions
Define affect
Objective observation of how a person outwardly presents
Define a mood disorder
- extreme fluctuation in a persons mood
- impacts their thinking, emotions and behaviour
- is chronic and persistent
Define major depressive disorder
experience of a depressed mood or loss of pleasure or interest in activities for at least 2 weeks which impacts on functioning
Identify the signs and symptoms of major depressive disorder
- depressed mood (most of the day, nearly every day)
- marked loss of interest in activities
- change in weight without weight loss attempt
- insomnia or hypersomnia
- observable psychomotor agitation or retardation
- loss of energy/fatigue
- feelings of worthlessness
- loss in concentration/ability to think
- recurrent suicidal ideation
Biological causes of major depressive disorder
Serotonin and norepinephrine (neutrotransmitters)
* decreased sensitivity of serotonin receptors
* decreased serotonin levels
* decreased release of norepinephrine into synaptic cleft
Dopamine (neurotransmitter)
* decreased dopaminergic activity
HPA axis (hormones)
* Increased HPA axis activity -> chronic stress
* increased cortisol levels
Genetic predisposition and family history (in combination with environmental factors)
Structural variations in the emotion-regulating regions of the brain (smaller hippocampus)
Sleep
* decreased amount of deep sleep
* increased nocturnal arousal (insomnia)
Presence of comorbid chronic illnesses
Psychological causes of major depressive disorder
Negative thinking
* thinking style which focuses on inability or inadequacy to get through life events
Rumination
* makes a person more likely to develop depression
* also contributes to a person experiencing an episode of depression for longer as they ruminate on their depression
Environmental causes of major depressive disorder
- Stress of life events (relationship breakdown, loss of employment, death of a loved one)
- substance misuse
- loneliness and isolation
- family trauma and childhood trauma
- cultural aspects (migration, distrimination, loss of identity)
- giving birth
SSRIs
selective serotonin reuptake inhibitors
First line treatment for major depressive disorder
MOA: inhibits the reuptake of serotonin at the synaptic cleft to increase serotonin activity
takes 2-4 weeks to take therapeutic effect
eg. prozac, zoloft, lexapro, luvox
Side effects: fatigue, hot flashes, insomnia, headache, tremor, sexual dysfunction
Avoid concurrent administraation with other SSRIs, MAOIs and St John’s Wort
SNRIs
serotonin-noradrenaline reuptake inhibitors
MOA: Inhibit the reuptake of serotonin and norepinephrine at the synaptic cleft, increasing the activity of these neutrotransmitters in the brain
Takes 2-4 weeks to take therapeutic effect
eg. Duloxetine
Side effects: dry mouth, fatigue, naursea and vomiting, diarrhoea and constipation
Avoid concurrent administration with SSRIs, MAOIs, and St Johns Wort
TCAs
Tricyclic antidepresssants
second line of treatment for major depressive disorder
MOA: Inhibit the reuptake of serotonin and norepinephrine at the synaptic cleft, increasing the activity of these neurotransmitters in the brain (are more selective to one or the other than SNRIs)
Takes 2-4 weeks to take therapeutic effect
eg. Amitriptilyne, Imipramine
Side effects: sedation, postural hypotension, arrhythmias, urinary retention, disorientation/confusion in elderly
Avoid concurrent administration with SSRIs, alcohol, antipsychotics, and MAOIs
MOAIs
Monoamine oxidase inhibitors
Not widely used due to significant side effects
MOA: ihnibits monoamine oxidase from metabolising serotonin, norepinephrine and dopamine (monoamines)
Takes 2-4 weeks to take therepeutic effect
Side effects: hypertensive crisis
* MOAIs also inhibit the metabolism of tyramine, which can build up in the bloodstream to cause a hypertensive crisis
* requires diet control for many spoiled/aged/fermented products
Side effects of antidepressant medications
Serotonin syndrome
* fatal excessive concentration of serotinin in the CNS
* agitation, tremor, fever, shivering, muscle spasms, ataxia, diaphoresis, hyperreflexia, changes in mental state
* perceptual disturbances, blood pressure changes, loss of coordination, N+V
Antidepressant discontinuation syndrome
* withdrawal after abruptly ceasing or changing antidepressant
* non-life threatening
* irritation, anxiety, nausea, anorexia, diaphoresis, paraesthesia, sleep disturbances, headache, vertigo
* engage in monitored titration to wean antidepressants and understand the dosage and half life of the drug
Suicidality
* significantly increased incidence in suicidal thoughts, feelings and behaviours
Identify and explain non pharmacological treatments for major depressive disorder
Early intervention
Cognitive behavioural therapy
Behavioural strategies
Cognitive strategies
Talk therapy and group therapy
Exercise
Identify and explain last resort physical treatments for major depressive disorder
Electroconvulsive therapy
* supervised medical procedure
* brief electrical stimulation of the brain under anaesthesia
* number of sessions dependent on clinical response
* consent as per mental health act 2014
Indications
* MDD
* psychotic symptoms
* responded well to ECT previously
* limited/poor response to other treatment
* suicidal
Describe the role of the nurse through the process of ECT
Nurses role
* check paperwork
* recovery follow up
* monitoring physical obs
* monitoring side effects post procedure
* risk and MSE
Identify nursing interventions and rational for caring for the person with MDD
Monitor symptoms
Psychoeducatio
Therapeutic relationship and communication
Support
Encourage coping/soothing strategies
MSE and referral
Medicaiton PRN
monitoring and addressing side effects
Encouraging exercise and activities as tolerated
Perinatal depression
Woman experiences depression along the childbearing continuum
- rarely dissolves without treatment
- baby blues –> PND –> PPP
- symptoms typically present within 4 weeks postnatally
Treatment includes
* medication
* psychotherapy
* counselling
* hospitalisation and initial mother/baby separation
* enhanced maternal nurse support
* facilitating mother baby bonding afterwards
Define Bipolar disorder I and II
A disorder causing severe disturbances in mood characterised by
BPDI - episodes of mania and often depression
* requires hospitalisation
* may experience psychosis
BPDII - episodes of hypomania and depression
* symptoms lower in intensity
* may not require hospitalisation
* never experiences psychosis
What are the signs and symptoms of bipolar disorder
Depressive episodes
* similar symptoms to depression
Must show 3 or more of these symptoms
must last at least 1 week presenting most of the day nearly every day
Manic episodes
* increased energy feeling ‘wired’
* racing thoughts, flight of ideas
* talkative - pressured speech
* grandiosity
* insomnua
* risky/reckless behaviour/impulsivity
* euphoria or extreme irritaation
* impaired judgement
* sexual disinhibition
* +/- psychosis symptoms
Hypomanic episodes
* less severe manic symptoms
* 4 days long
Biological causes of bipolar disorder
Family history - 10x more likely
proposed a cause connecting circadian, infradian rhythms with neutotransmitter issues in the brain
Psychological causes of bipolar disorder
- Ability to manage stress
- childhood trauma
- head injury
Environmental causes of bopolar disorder
- substance misuse
- prenatal impacts like maternal infection
Distinguish between mania and hypomania
Mania
* persistent, elevated, irritable mood
* lack of need for sleep
* engagement in goal directed activity
* may include psychosis
* prolonged
Hypomania
* mood elevation similar to mania but less intense
* no need for hospitalisation
* no psychosis
* shorter in duration
Mixed episode - experiencing symptoms of mania and depression at the same time
Signs and symptoms of an episode of mania or hypomania
Mania symptoms must last at least 1 week and present for most of the day, nearly every day
Must have 3 or more:
* Increased energy/feeling ‘wired’ to an abnormal extent
* Racing thought and flight of idea
* Pressured speech - more talkative
* Inflated confidence/self esteem/grandiosity
* Distractibility
* Decreased need for sleep
* Risky or reckless behaviour
* Increased goal directed behaviour
* Euphoria or extreme irritation
* Impaired judgement or decision making ability
* Impulsivity
* Disinhibition
* +/- psychosis symptoms
* Physical health deficits due to lack of sleep
Signs and symptoms of hypomania
Similar to mania, must be experienced for 4 consecutive days
Less intense
Mood stabilisers
Lithium
Address both mood extremes - depression and mania
Lithium
MOA: unknown
antiepileptics
MOA: slow down abnormal electrical discharges in the brain. These abnormal discharges are linked to seizures and an imbalance of brain chemicals (neurotransmitters), which can cause mania in bipolar disorder.
Side effects:
* Nausea and diarrhoea
* metallic taste
* hypothyroidism - monitor thyroid function
* polyuria - monitor renal function
* weight gain
* drowsiness
* headache
* GIT disturbance
Antidepressants
Addresses depressive symptoms of BD
But lifts mood to point where risks triggering manic episode
Antipsychotics
- some clinical efficacy in reducing psychotic symptoms associated with mania
- can also provide sedation and emotional calming
- effective in managing agression
Benzodiazepines
- Calms and promotes rest
- sedative effect eg. temazepam
Identify and explain non pharmacological treatments for bipolar disorder
- CBT - focuses on how thoughts, feelings and beliefs influence actions and then finds ways of coping to deal with problems more productively
- ACT - encourages acceptance of situation and a commitment to working with these situations in a positive or productive way
- Behavioural strategies
- mindfulness
Lithium toxicity
and other side effects
Potentially fatally high serum concentration levels of lithium in the blood
Signs and symptoms:
* blurred vision
* tremor
* nausea, vomiting, diarrhoea
* slurred speech
* muscle twitching/seizures
* altered consciousness (disoriented, confused)
Nursing management:
* manage dehydration - fluid resuscitation and maintenence fluid
* stop lithium administration immediately
* urine output
* monitor lithium levels
Recovery and relapse prevention
Identify nursing interventions and rationale to care for the person experiencing bipolar disorder
- Low stimulus environment
- providing structure and engagement to the persons day
- medication managemtn
- risk and MSE
- sensory modulation
- mindfulness techniques
- safely maintain dignity related to sexual disinhibition
- establishing and maintaining adequate nutrition, healthy sleep, personal hnygeine
- limiting activity
- protecting reputation during manic episodes
