Mood Disorder and Suicide


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Psychiatric and Mental Health Nursing

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Mood Disorder and Suicide

  2. 2. <ul><li>Mood disorders are among the most common psychiatric disorders, so students are likely to encounter persons with depression or bipolar disorder during their clinical experience. </li></ul><ul><li>Clients whose symptoms are moderate or those who have begun to respond to treatment are often a better choice. </li></ul>
  3. 3. <ul><li>This chapter provides an overview of mood disorders, categories of mood disorders, and current theories of etiology. Symptoms, treatment, and application of the nursing process are presented in depth for major depressive disorder and bipolar disorder. A sample care plan for a client with depression is included. </li></ul>
  4. 4. <ul><li>The topic of suicide is described in terms of populations at risk, interventions, responses of the family and the nurse, legal and ethical considerations, and community care. Self-awareness issues for the nurse are included for clients who are depressed, manic, and/or suicidal. </li></ul>
  5. 5. <ul><li>CURRENT ISSUES RELATED TO THE TOPIC </li></ul><ul><li>Euthanasia and assisted suicide are hotly debated topics in our society. Should either be legal? Under what circumstances? How should these issues be decided? </li></ul><ul><li>Some people struggle with the idea of whether suicide can ever be the decision of a rational person or whether being suicidal is always a sign of mental illness. </li></ul><ul><li>Suicide rates remain high for adolescents and the elderly (over age 80). </li></ul><ul><li>Is that a sign of despair and hopelessness? What is society’s response to these two populations? </li></ul>
  6. 6. <ul><li>It can be frustrating to try to engage a severely depressed client in therapeutic communication, and it can be frightening to encounter the client in a severe manic state. </li></ul><ul><li>Therefore, it may be best to avoid assigning students to severely ill clients. </li></ul>
  7. 7. <ul><li>Mood Disorders </li></ul><ul><li>Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to live life </li></ul>
  8. 8. <ul><li>Categories </li></ul><ul><li>Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms </li></ul><ul><li>Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy and other symptoms </li></ul>
  9. 9. Major Depressive Disorder
  10. 11. Related Disorders <ul><li>Dysthymia: sadness, low energy, but not severe enough to be diagnosed as major depression disorder </li></ul><ul><li>Cyclothymia: mood swings not severe enough to be diagnosed as bipolar disorder </li></ul><ul><li>Substance-induced mood disorder </li></ul><ul><li>Mood disorder due to a general medical condition </li></ul>
  11. 12. Related Disorders (cont’d) <ul><li>Seasonal affective disorder (SAD) </li></ul><ul><li>Postpartum or “maternity” blues </li></ul><ul><li>Postpartum depression </li></ul><ul><li>Postpartum psychosis </li></ul>
  12. 13. Etiology <ul><li>Biologic theories </li></ul><ul><li>Genetics </li></ul><ul><li>Neurochemical theories </li></ul><ul><li>Neuroendocrine or hormonal fluctuations </li></ul><ul><li>Theories of Cause of depression: </li></ul><ul><li>Aggression turned inward- self anger </li></ul><ul><li>Response to separation of object loss </li></ul><ul><li>Genetic of nuerobiochemical basis-impaired neurotransmission system, especially serotonin regulation. </li></ul>
  13. 14. Etiology (cont’d) <ul><li>Psychodynamic theories </li></ul><ul><li>Self-reproach to anger turned inward </li></ul><ul><li>Inability to achieve personal ideals </li></ul><ul><li>Powerless ego </li></ul><ul><li>Manic episodes are a “defense” against depression </li></ul><ul><li>Reaction to a distressing life experience </li></ul><ul><li>Rejecting or unloving parents </li></ul><ul><li>Resulting from specific cognitive distortions </li></ul>
  14. 15. Cultural Considerations <ul><li>Other behaviors considered age-appropriate can mask depression </li></ul><ul><li>Somatic complaints are a major manifestation among cultures that avoid verbalizing emotions </li></ul><ul><ul><li>Asians who are anxious or depressed are more likely to have somatic complaints of headache, backache, or other symptoms </li></ul></ul><ul><ul><li>Latin cultures complain of “nerves” or headaches </li></ul></ul><ul><ul><li>Middle Eastern cultures complain of heart problems </li></ul></ul>
  15. 16. Major Depressive Disorder <ul><li>Twice as common in women and more common in single or divorced people </li></ul><ul><li>Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least four other symptoms: </li></ul><ul><ul><li>Changes in appetite or weight, sleep, or psychomotor activity </li></ul></ul><ul><ul><li>Decreased energy </li></ul></ul><ul><ul><li>Feelings of worthlessness or guilt </li></ul></ul><ul><ul><li>Difficulty thinking, concentrating, or making decisions </li></ul></ul><ul><ul><li>Recurrent thoughts of death or suicidal ideation, plans, or attempts </li></ul></ul><ul><li>Untreated, can last 6 to 24 months; recurs in 50% to 60% of people </li></ul><ul><li>Symptoms range from mild to severe </li></ul>
  16. 17. Treatment and Prognosis <ul><li>Antidepressants </li></ul><ul><li>SSRIs (Prozac, Zoloft, Paxil, Celexa) prescribed for mild and moderate depression </li></ul><ul><li>TCAs (Elavil, Tofranil, Norpramin, Pamelor, Sinequan) used for moderate and severe depression </li></ul><ul><li>Atypical antidepressants (Effexor, Wellbutrin, Serzone) </li></ul><ul><li>MAOIs (Marplan, Parnate, Nardil) used infrequently because interaction with tyramine causes hypertensive crisis </li></ul>
  17. 18. <ul><li>Electroconvulsive therapy (ECT) is used when medications are ineffective or side effects are intolerable. </li></ul><ul><ul><li>6 to 15 treatments scheduled three times a week </li></ul></ul><ul><ul><li>Preparation of a client for ECT is similar to preparation for any outpatient minor surgical procedure </li></ul></ul><ul><ul><li>The client will have some short-term memory impairment </li></ul></ul><ul><li>Psychotherapy in conjunction with medication is considered most effective treatment; useful therapies include behavioral, cognitive, interpersonal therapy </li></ul>
  18. 19. Application of the Nursing Process: Major Depressive Disorder <ul><li>Assessment </li></ul><ul><li>History: the client’s perception of the problem, behavioral changes, any previous episodes of depression, treatment, response to treatment, family history of mood disorders, suicide, or attempted suicide </li></ul><ul><li>General appearance and motor behavior: slouched posture, latency of response, psychomotor retardation or agitation </li></ul><ul><li>Mood and affect: hopeless, helpless, down, anxious, frustrated, anhedonia, apathetic; affect is sad, depressed, or flat </li></ul><ul><li>Thought processes and content: slowed thinking processes, negative and pessimistic, ruminate, thoughts of dying or committing suicide </li></ul>
  19. 20. Application of the Nursing Process: Major Depressive Disorder (cont’d) <ul><li>Assessment (cont ’ d) </li></ul><ul><li>Sensorium and intellectual processes: oriented, memory impairment, difficulty concentrating </li></ul><ul><li>Judgment and insight: impaired judgment, insight may be intact or limited </li></ul><ul><li>Self-concept: low self-esteem, guilty, believe that others would be better off without them </li></ul>
  20. 21. Application of the Nursing Process: Major <ul><li>Roles and relationships: difficulty fulfilling roles and responsibilities </li></ul><ul><li>Physiologic considerations: weight loss, sleep disturbances, lose interest in sexual activities, neglect personal hygiene, constipation, dehydration </li></ul><ul><li>Depression rating scales: Zung Self-Rating Depression Scale, Beck Depression Inventory, the Hamilton Rating Scale for Depression </li></ul>
  21. 22. Application of the Nursing Process: Major Depressive Disorder (cont’d) <ul><li>Data Analysis </li></ul><ul><li>Nursing diagnoses may include: </li></ul><ul><li>Risk for Suicide </li></ul><ul><li>Imbalanced Nutrition: Less Than Body Requirements </li></ul><ul><li>Anxiety </li></ul><ul><li>Ineffective Coping </li></ul><ul><li>Hopelessness </li></ul><ul><li>Ineffective Role Performance </li></ul><ul><li>Self-Care Deficit </li></ul><ul><li>Chronic Low Self-Esteem </li></ul><ul><li>Disturbed Sleep Pattern </li></ul><ul><li>Impaired Social Interaction </li></ul>
  22. 23. Application of the Nursing Process: Major Depressive Disorder (cont’d) <ul><li>Outcomes </li></ul><ul><li>The client will: </li></ul><ul><li>Not injure himself or herself </li></ul><ul><li>Independently carry out activities of daily living (showering, changing clothing, grooming) </li></ul><ul><li>Establish a balance of rest, sleep, and activity </li></ul><ul><li>Establish a balance of adequate nutrition, hydration, and elimination </li></ul><ul><li>Evaluate self-attributes realistically </li></ul><ul><li>Socialize with staff, peers, and family/friends </li></ul><ul><li>Return to occupation or school activities </li></ul><ul><li>Comply with antidepressant regimen </li></ul><ul><li>Verbalize symptoms of a recurrence </li></ul>
  23. 24. Application of the Nursing Process: Major Depressive Disorder (cont’d) <ul><li>Intervention </li></ul><ul><li>Providing for the client’s safety and the safety of others </li></ul><ul><li>Promoting a therapeutic relationship </li></ul><ul><li>Promoting activities of daily living and physical care </li></ul><ul><li>Using therapeutic communication </li></ul><ul><li>Managing medications </li></ul><ul><li>Providing client and family teaching </li></ul>
  24. 25. Application of the Nursing Process: Major Depressive Disorder (cont’d) <ul><li>Evaluation </li></ul><ul><li>Does the client feel safe? </li></ul><ul><li>Is the client free of uncontrollable urges to commit suicide? </li></ul><ul><li>Is the client participating in therapy and medication compliance? </li></ul><ul><li>Can the client identify signs of relapse? </li></ul><ul><li>Will the client agree to seek treatment immediately upon relapse? </li></ul>
  25. 26. Bipolar Disorder <ul><li>Occurs almost equally among men and women </li></ul><ul><li>It is more common in highly educated people </li></ul><ul><li>The mean age for a first manic episode is the early 20s </li></ul>
  26. 27. Bipolar Disorder <ul><li>Involves mood swings of depression (same symptoms of major depressive disorder) and mania. Major symptoms of mania include: </li></ul><ul><ul><li>Inflated self-esteem or grandiosity </li></ul></ul><ul><ul><li>Decreased need for sleep </li></ul></ul><ul><ul><li>Pressured speech </li></ul></ul><ul><ul><li>Flight of ideas </li></ul></ul><ul><ul><li>Distractibility </li></ul></ul><ul><ul><li>Increased involvement in goal-directed activity or psychomotor agitation </li></ul></ul><ul><ul><li>Excessive involvement in pleasure-seeking activities with a high potential for painful consequences </li></ul></ul>
  27. 28. <ul><li>Treatment and Prognosis </li></ul><ul><li>Medication </li></ul><ul><li>Lithium; regular monitoring of serum lithium levels is needed </li></ul><ul><li>Anticonvulsant drugs are used for their mood-stabilizing effects: Tegretol, Depakote, Lamictal, Topamax, and Neurontin, as is Klonopin (a benzodiazepine) </li></ul><ul><li>Psychotherapy </li></ul><ul><li>Useful in mildly depressive or normal portion of the bipolar cycle. It is not useful during acute manic stages </li></ul>
  28. 29. Application of the Nursing Process: Bipolar Disorder <ul><li>Assessment </li></ul><ul><li>General appearance and motor behavior: psychomotor agitation; flamboyant clothing or makeup; think, move, and talk fast; pressured speech </li></ul><ul><li>Mood and affect: euphoria, exuberant activity, grandiosity, false sense of well-being, angry, verbally aggressive, sarcastic, irritable </li></ul>
  29. 30. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Assessment (cont’d) </li></ul><ul><li>Thought processes and content: flight of ideas, circumstantiality, tangentiality, possible grandiose delusions </li></ul><ul><li>Sensorium and intellectual processes: oriented to person and place but rarely to time, impaired ability to concentrate, may experience hallucinations </li></ul><ul><li>Judgment and insight: judgment poor, insight limited </li></ul><ul><li>Self-concept: exaggerated self-esteem </li></ul>
  30. 31. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Assessment (cont’d) </li></ul><ul><li>Roles and relationships: rarely can fulfill role responsibilities, invade intimate space and personal business of others, can become hostile to others, cannot postpone or delay gratification </li></ul><ul><li>Physiologic and self-care considerations: inattention to hygiene and grooming, hunger or fatigue </li></ul>
  31. 32. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Data Analysis </li></ul><ul><li>Nursing diagnoses may include: </li></ul><ul><li>Risk for Other-Directed Violence </li></ul><ul><li>Risk for Injury </li></ul><ul><li>Imbalanced Nutrition: Less Than Body Requirements </li></ul><ul><li>Ineffective Coping </li></ul><ul><li>Noncompliance </li></ul><ul><li>Ineffective Role Performance </li></ul><ul><li>Self-Care Deficit </li></ul><ul><li>Chronic Low Self-Esteem </li></ul><ul><li>Disturbed Sleep Pattern </li></ul>
  32. 33. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Outcomes </li></ul><ul><li>The client will: </li></ul><ul><li>Not injure self or others </li></ul><ul><li>Establish a balance of rest, sleep, and activity </li></ul><ul><li>Establish adequate nutrition, hydration, and elimination </li></ul><ul><li>Participate in self-care activities </li></ul><ul><li>Evaluate personal qualities realistically </li></ul><ul><li>Engage in socially appropriate, reality-based interaction </li></ul><ul><li>Verbalize knowledge of his or her illness and treatment </li></ul>
  33. 34. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Intervention </li></ul><ul><li>Providing for safety of client and others </li></ul><ul><li>Meeting physiologic needs </li></ul><ul><li>Providing therapeutic communication </li></ul><ul><li>Promoting appropriate behaviors </li></ul><ul><li>Managing medications </li></ul><ul><li>Providing client and family teaching </li></ul>
  34. 35. Application of the Nursing Process: Bipolar Disorder (cont’d) <ul><li>Evaluation </li></ul><ul><li>Safety issues </li></ul><ul><li>Comparison of mood and affect between start of treatment and present </li></ul><ul><li>Adherence to treatment regimen of medication and psychotherapy </li></ul><ul><li>Changes in client’s perception of quality of life </li></ul><ul><li>Achievement of specific goals of treatment including new coping methods </li></ul>
  35. 36. Suicide <ul><li>Assessment </li></ul><ul><li>Men commit suicide three times the rate of women </li></ul><ul><li>Women are four times more likely than men to attempt suicide </li></ul><ul><li>Populations at risk </li></ul><ul><li>Men, young women, adults older than 65, and separated and divorced people </li></ul><ul><li>Clients with psychiatric disorders </li></ul><ul><li>Environmental factors include isolation, recent loss, lack of social support, unemployment, critical life events, and family history of depression or suicide </li></ul><ul><li>Behavioral factors include impulsivity, erratic or unexplained changes from usual behavior, and unstable lifestyle </li></ul>
  36. 37. <ul><li>Warnings of suicidal intent </li></ul><ul><li>Risky behaviors </li></ul><ul><li>Lethality assessment </li></ul><ul><ul><li>Does the client have a specific plan? </li></ul></ul><ul><ul><li>Are the means available to carry out this plan? </li></ul></ul><ul><ul><li>If the client carries out the plan, is it likely to be lethal? </li></ul></ul><ul><ul><li>Has the client made preparations for death? </li></ul></ul><ul><ul><li>Where and when does the client intend to carry out the plan? </li></ul></ul><ul><ul><li>Is the intended time a special date or anniversary that has meaning for the client? </li></ul></ul>
  37. 38. <ul><li>Outcomes </li></ul><ul><li>The client will: </li></ul><ul><li>Not injure self or others </li></ul><ul><li>Engage in a therapeutic relationship </li></ul><ul><li>Establish a no-suicide contract </li></ul><ul><li>Create a list of positive attributes </li></ul><ul><li>Generate, test, and evaluate realistic plans to address underlying issues </li></ul>
  38. 39. <ul><li>Intervention </li></ul><ul><li>Using an authoritative role </li></ul><ul><li>Providing a safe environment </li></ul><ul><li>Initiating a no-suicide contract </li></ul><ul><li>Creating a support system list </li></ul>
  39. 40. <ul><li>Family Response </li></ul><ul><li>Significant others may feel guilty, angry, ashamed, and sad </li></ul><ul><li>Nurse’s Response </li></ul><ul><li>The nurse does not blame or act judgmentally when asking about the details of a planned suicide. Rather, the nurse uses a nonjudgmental tone of voice and monitors his or her body language and facial expressions to make sure not to convey disgust or blame </li></ul><ul><li>Nurses must realize that no matter how competent and caring interventions are, a few clients will still commit suicide. A client’s suicide can be devastating to the staff members who treated the client </li></ul>
  40. 41. Legal and Ethical Considerations <ul><li>Often nurses must care for terminally or chronically ill people with a poor quality of life </li></ul><ul><li>The nurse’s role is to provide supportive care for clients and family </li></ul>
  41. 42. Elder Considerations <ul><li>Depression is common among the elderly and is markedly increased when elders are medically ill </li></ul><ul><li>Elders tend to have psychotic features, particularly delusions, more frequently than younger people with depression </li></ul><ul><li>Suicide among persons over age 65 is doubled compared with suicide rates of persons younger than 65 years </li></ul><ul><li>Elders are treated for depression with ECT more frequently than younger persons </li></ul><ul><li>Elder persons have decreased tolerance of side effects of antidepressant medications </li></ul>
  42. 43. Mental Health Promotion <ul><li>Education to address stressors contributing to depressive illness </li></ul><ul><li>Promotion of factors reducing suicide risk in adolescents (close parent–child relationships, academic achievement, family life stability, and connectedness with peers and others outside the family) </li></ul><ul><li>Screening for early detection of risk factors, such as family strife, parental alcoholism or mental illness, history of fighting, and access to weapons in the home </li></ul>
  43. 44. Self-Awareness Issues <ul><li>Nurses and other staff members need to deal with their own feelings about suicide </li></ul><ul><li>Depressed or manic clients can be frustrating and require a lot of energy to care for </li></ul><ul><li>Keeping a written journal may help deal with feelings; talking to colleagues is often helpful </li></ul>