Major depressive disorder and bipolar disorder are mood disorders characterized by disturbances in mood and behavior ranging from depression to mania. Major depressive disorder involves at least two weeks of depressed mood or lack of interest in activities along with other symptoms. Bipolar disorder involves extreme mood swings between episodes of mania and depression. Both have genetic and biological factors and are treated with medication and psychotherapy. Accurate assessment and monitoring of symptoms is important for nursing care.

2. Mood Disorder
• Characterized by disturbances in feelings,
thinking, and behavior that tend to occur on a
continuum, ranging from severe depression to
severe mania (hyperactivity).
• Is the most common psychiatric diagnoses
associated with suicide.
• Two Categories:
a. Major Depressive Disorder
b. Bipolar Disorder (Manic-Depressive Illness)

3. 1. Major Depressive Disorder
• Characterized by at least two weeks of a depressed mood or
loss of interest in pleasure and activities.
• Also includes at least 4 of the following symptoms of depression:
a. Increase or decrease in appetite
b. Increase or decrease in sleep
c. Psychomotor agitation or retardation
d. Feelings of worthlessness or guilt
e. Fatigue and loss of energy
f. Decreased ability to think and concentrate
g. Recurrent thoughts of suicide
• These symptoms must be present everyday for 2 weeks and result in
significant distress or impair important areas of functioning.
• Referred to as PSYCHOTIC DEPRESSION if combined with delusions and
hallucinations.

4. 2. Bipolar Disorder
• Diagnosed when a person’s mood cycles between
extremes of mania and depression.
• Mania – an emotional state characterized by elation, high
optimism, increased energy, and an exaggerated sense of
importance and invincibility.
• May last for about 1 week but may be longer for some individuals.
• At least 3 of the following symptoms accompany the manic
episode:
a. Inflated self-esteem or grandiosity
b. Decreased need for sleep
c. Pressured speech
d. Flight of ideas
e. Distractibility
f. Increased involvement in goal-directed activity or
psychomotor agitation
g. Excessive involvement in pleasure-seeking activities with a
high-potential for painful consequences

5. 2. Bipolar Disorder
• HYPOMANIA – a period of abnormally and persistently
elevated, expansive, or irritable mood lasting for days
and including 3 or 4 of the additional symptoms
described earlier.
• MIXED EPISODE
- Diagnosed when the person experiences both mania and
depression nearly everyday for at least 1 week.
- A person with mixed episodes experiences both mood "poles"--
mania and depression--simultaneously or in rapid sequence.
• BIPOLAR I DISORDER – one or more manic or mixed episodes
usually accompanied by major depressive episodes.
• BIPOLAR II DISORDER – one or more major depressive episodes
accompanied by at least one hypomanic episode.

6. Related Disorders
• Dysthymic Disorder - Characterized by at least 2 years of
depressed mood for more days than not with some
additional, less severe symptoms that do not meet the
criteria for a major depressive episode.
- This disorder usually does not affect social or
occupational functioning.
• Cyclothymic Disorder – characterized by at least 2 years of several
periods of hypomanic symptoms not as severe as those in a manic
episode.
• Substance-Induced Mood Disorder – characterized by a prominent
and persistent disturbance in mood that is judged to be a direct
physiologic consequence of ingested substances.
• Mood Disorder due to a general medical condition
- Characterized by a prominent and persistent disturbance in
mood that is judged to be a direct physiologic consequence of a
medical condition.

7. Other Disorders
• Seasonal Affective Disorder (SAD) – 2 Subtypes:
- WINTER DEPRESSION OR FALL-ONSET SAD: people experience
increased sleep, appetite and carbohydrate cravings; weight gain;
interpersonal conflict; irritability; and heaviness in the
extremities beginning in late autumn and abating in spring and
summer.
- SPRING-ONSET SAD: less common; with symptoms of insomnia,
weight loss, and poor appetite lasting from late spring or early
summer until early fall.
• Postpartum or “Maternity” Blues
- Frequent, normal experience after delivery of a baby.
- Symptom begin approximately 1 day after delivery, usually peak
in 3 to 7 days, and disappear rapidly with no medical treatment.

8. Other Disorders
• Postpartum Depression
- Meets all the criteria for a major depressive episode,
with onset within 4 weeks of delivery.
• Postpartum Psychosis
- A psychotic episode developing within 3 weeks of
delivery and beginning with fatigue, sadness,
emotional lability, poor memory, and confusion and
progressing to delusions, hallucinations, poor insight
and judgment, and loss of contact with reality.
- Considered a medical emergency that requires
immediate treatment.

9. Etiology
BIOLOGIC THEORIES
• Major Depressive Disorder
- 3 times more common among first-degree
biological relatives.
- Twin studies reveal a higher rate of concordance
in monozygotic twins than dizygotic twins.
• Bipolar Disorder
- The risk increases 4% to 24% in first-degree
relatives of people with bipolar disorder.
- Twin studies of monozygotic twins indicate a
65% concordance rate.

10. Etiology
NEUROCHEMICAL THEORIES
• Biogenic Amine Theory
- Depressive Disorder: ↓ NE and serotonin
- Bipolar Disorder: ↑ NE and serotonin
• 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.

11. Etiology
NEUROENDOCRINE INFLUENCES
Depression
• Increased cortisol secretion in 40% of clients.
• Increased thyroid-stimulating hormone in 5% to 10% of clients.
PSYCHODYNAMIC THEORIES
• Freud: looked at the self-depreciation of people with
depression and attributed that self-reproach to anger turned
inward related to either a real or perceived loss. (Introjection)
• Bibring: believed that one’s ego aspired to be ideal and that to
be loved and worthy, one must achieve these high standards.
Depression results when, in reality, the person was not able to
achieve these ideals all the time.

12. Etiology
PSYCHODYNAMIC THEORIES
• Jacobson: ego is a powerless, helpless child victimized by the
superego.
• Mania episodes: “defense” against underlying depression, with
the id taking over the ego acting as an undisciplined hedonistic
being.
• Meyer: depression as an reaction to a distressing life experience
• Horney: children raised by rejecting or unloving parents were
prone to feelings of insecurity and loneliness, making them
susceptible to depression and helplessness.
• Beck: depression results from specific cognitive distortions in
susceptible people; involves magnification of negative events
and minimization of anything positive.

13. Major Depressive Disorder
• Involves 2 or more weeks of a sad mood or lack of
interest in life activities with at least 4 other
symptoms of depression.
• Twice as common in women than men.
• Has 1.5 to 3 times greater incidence in first-degree
relatives than in the general population.
• Its incidence decreases with age in women and
increases with age in men; single and divorced
people have the highest incidence.

14. Major Depressive Disorder
Symptoms:
a. Depressed mood
b. Anhedonism
c. Unintentional wight change of 5% or more in a month.
d. Change in sleep pattern
e. Agitation or psychomotor retardation
f. Tiredness
g. Worthlessness or guilt inappropriate to the situation
h. Difficulty thinking, focusing or making decisions.
i. Hopelessness, helplessness, and/or suicidal ideation.

15. Major Depressive Disorder
Onset and Clinical Course
• An untreated episode of depression can last 6 to 24
months before remitting.
• 50% to 60% of people who have one episode of
depression will have another.
• After a second episode, there is 70% chance of
recurrence.
Treatment and Prognosis
• Psychopharmacology (TCAs, MAOIs, SSRIs, Atypical
Antidepressants)

16. Major Depressive Disorder
• Psychotherapy
- Interpersonal Therapy: focuses on difficulties in
relationships, such as grief reactions, role
disputes, and role transitions.
- Behavior Therapy: seeks to increase the
frequency of the client’s positively reinforcing
interactions with the environment and to
decrease negative interactions.
- Cognitive Therapy: focuses on how the person
thinks.

17. Major Depressive Disorder
Electroconvulsive Therapy
- Involves application of electrodes to the head of the
client to deliver an electrical impulse to the brain; this
causes a seizure.
- It is believed that the shock stimulates brain chemistry
to correct the chemical imbalance of depression.
- A series of 6 to 15 treatments is scheduled 3 times a
week.
- The client receives a short-acting anesthetic so he or she
is not awake during the procedure.
- A muscle relaxant is given to relax all muscles that will
greatly reduce the outward signs of the seizure.

18. Major Depressive Disorder
Electroconvulsive Therapy
- After the therapy:
a. The client may be confused; provide frequent orientation and
reassurance.
b. Assess the gag reflex prior to giving the client fluid, foods, or
medication.
- Potential Side Effects:
a. Major side effects with bilateral treatment are confusion,
disorientations, and short-term memory loss.
b. The client may be confused and disoriented on awakening.
c. Memory deficits may occur, but memory usually recovers
completely; although some clients have memory loss lasting
up to six months.

19. Application of the Nursing Process
Depression
Assessment
• History
- It may take several short periods to complete the assessment
because clients who are severely depressed feel exhausted and
overwhelmed.
- Nurses must not rush the client because it can lead to
frustration and incomplete assessment data.
- Nurses must ask about the behavioral changes, previous
episodes of depression, treatment, and client’s response to
treatment; and family history if suicide.
• General Appearance and Motor Behavior
- Looks sad and ill; slouched posture, makes minimal eye contact.
- Psychomotor retardation, latency of response, psychomotor
agitation.

20. Application of the Nursing Process
Depression
Assessment
• Mood and Affect
- Anhedonia
- Affect: sad or depressed or may be flat with no emotional
expression.
- They are overwhelmed by noise and people who might
make demands on them, so they withdraw from the
stimulation of interaction with others.
• Thought Process and Content
- Slowed thinking process; negative and pessimistic, makes
self-depreciating remarks; tends to ruminate.
- Has thoughts of dying or committing suicide.

21. Application of the Nursing Process
Depression
Assessment
• Sensorium and Intellectual Process
- Others are oriented, but others experience difficulty.
- Has limited ability to respond to questions.
- Memory impairment is common.
- Has extreme difficulty concentrating or paying attention.
• Judgment and Insight
- Cannot make decisions or choices because of their extreme
apathy or their negative belief that it “doesn’t matter
anyway.”
• Self-Concept
- Low self-esteem
- “good for nothing”; “worthless”

22. Application of the Nursing Process
Depression
Assessment
• Roles and Relationships
- Inability to fulfill their roles
- Withdraw from relationships
• Physiologic and Self-Care Considerations
- Pronounced weight loss due to lack of appetite or
disinterest in eating.
- Sleep disturbances are common.
- Lose interest in sexual activity
- Neglect personal hygiene
- Constipation commonly results

23. Application of the Nursing Process
Depression
Data Analysis
• Risk for Suicide
• Imbalance Nutrition: Less Than Body Requirements
• Anxiety
• Ineffective coping
• Hopelessness
• Ineffective Role Performance
• Self-Care Deficit
• Chronic Low Self-Esteem
• Disturbed Sleep Pattern
• Impaired Social Interaction

24. Application of the Nursing Process
Depression
Outcome Identification
The client will:
• Not injure himself or herself.
• Independently carry out ADLs
• Establish a balance of rest, sleep, and activity.
• Establish a balance of adequate nutrition, hydration, and
elimination.
• Evaluate self-attributes realistically.
• Socialize with staff, peers, and family/friends.
• Return to occupation or school activities.
• Comply with antidepressant regimen.
• Verbalize symptoms of a recurrence.

25. Application of the Nursing Process
Depression
Interventions
• Encourage the client to express sadness or anger and
allow adequate time for verbal responses.
• Spend short periods of time throughout the day with
the client.
• Sit in silence with the client who is not verbalizing.
• Avoid a cheerful attitude.
• Assess for suicide clues and intervene to provide
safety precautions as necessary.
• Assist with activities of daily living if the client is
unable to perform them.

26. Application of the Nursing Process
Depression
Interventions
• Provide activities for easy mastery to increase self-
esteem and help in alleviating guilt feelings.
• Provide activities that do not require a great deal
of concentration (simple card games, drawing)
• Offer small, high-calorie, high-protein snacks and
fluids throughout the day.
• Encourage to dress and stay out of bed during the
day.

27. Application of the Nursing Process
Depression
Evaluation
Participation in therapy and medication
compliance produce more favorable
outcomes for clients with depression.

28. Bipolar Disorder
• Involves extreme mood swings from episodes of
mania to episodes of depression.
• During manic phases, clients are euphoric, grandiose,
energetic, and sleepless; they have poor judgment,
rapid thoughts, actions, and speech.
• Onset and Clinical Course
- Occurs in the early twenties or in adolescence; or in
ages older than 50.
- Manic episodes typically begin suddenly, with rapid
escalation of symptoms over a few days, and last
from a few weeks to several months.
- They tend to be briefer and to end more suddenly
than depressive episodes.

29. Bipolar Disorder
Typical symptoms of Mania:
• Heightened, grandiose, or agitated mood
• Exaggerated self-esteem
• Sleeplessness
• Pressured speech
• Flight of ideas
• Reduces ability to filter out extraneous stimuli; easily
distractible
• Increased number of activities with increased energy
• Multiple, grandiose, high-risk activities, using poor
judgment, with severe consequences

30. Bipolar Disorder
Treatment
Psychopharmacology
• Lithium:
- For bipolar mania but could also partially or completely
mute the cycling toward bipolar depressions.
- Contraindicated during pregnancy.
• Anticonvulsant Drugs
- Exact mechanism is unknown but may raise the brain’s
threshold for dealing with stimulation.
- Given to clients who have problems in lithium therapy
(SEs, drug interactions, renal disease)
- Carbamazepine, Valproic Acid, Clonazepam

31. Bipolar Disorder
Treatment
Psychotherapy
• Useful in the mildly depressive or normal
portion of the bipolar cycle. It is not useful
during acute manic stages because the person’s
attention span is brief and he or she can gain
little insight during times of accelerated
psychomotor activity.

32. Application of the Nursing Process
Bipolar Disorder
Assessment
•History
- Taking history can be difficult
- Obtain data in several short sessions, talking to
family members may be necessary.
• General Appearance and Motor Behavior
- Psychomotor agitation (sitting still id difficult)
- Wears brightly-colored, flamboyant, attention-
getting, and perhaps sexually suggestive clothes.
Exhibit pressured speech.

33. Application of the Nursing Process
Bipolar Disorder
Assessment
• Mood and Affect
- Mood is labile (loud laughter/episodes of tears)
- Projection of an all-knowing and all-powerful image
may be an unconscious defense against underlying
low self-esteem.
• Thought Process and Content
- Thinking is confused and jumbled with thoughts
racing one after another.
- Starts many projects at one time but cannot carry any
to completion.
- Some experience psychotic features during mania

34. Application of the Nursing Process
Bipolar Disorder
Assessment
• Sensorium and Intellectual Process
- Oriented to person and place, but rarely to time.
- They may claim to have abilities they do not possess.
- Impaired ability in concentration or in paying
attention.
- If also psychotic, hallucinations may be present.
• Judgment and Insight
- Impulsive; poor judgment
- False sense of well-being masks difficulties with
chronic low self-esteem.

35. Application of the Nursing Process
Bipolar Disorder
Assessment
• Roles and Relationships
- They are too distracted and hyperactive to pay attention to
children or ADLs.
- Begins many tasks/projects but completes few.
- Excessive, overpowering, and confrontational social
interactions.
- Invades the intimate space and personal business of others.
- Labile emotions that fluctuate between euphoria and hostility.
•Physiologic and Self-Care Considerations
- Can go on days without sleep or food and not even realize they
are hungry or tired.
- They may even physically injure themselves or be unaware of
health needs.

36. Application of the Nursing Process
Bipolar Disorder
Data Analysis
• Risk for other-directed violence
• Risk for injury
• Imbalanced Nutrition: Less than body requirements
• Ineffective coping
• Noncompliance
• Ineffective role performance
• Self-Care deficit
• Chronic low self-esteem
• Disturbed sleep pattern

37. Application of the Nursing Process
Bipolar Disorder
Outcome Identification
The client will:
• Not injure self or others.
• Establish a balance of rest, sleep, and activity.
• Establish adequate nutrition, hydration, and
elimination.
• Participate in self-care activities.
• Evaluate personal qualities realistically.
• Engage in socially appropriate, reality-based
interaction.
• The client will verbalize knowledge of his or her
illness and treatment.

38. Application of the Nursing Process
Bipolar Disorder
Interventions
• Providing for Safety
-Provide a safe environment for clients and others.
-Assess directly for suicidal ideation.
- Set limits. Clearly identify the unacceptable behavior and the
expected, appropriate behavior.
- Remind the client to respect distances between staff and others.
• Meeting physiologic needs
-Decrease environmental stimulation; provide a quiet
environment.
-Establish a bedtime routine to help clients to calm down to rest.
-Provide “finger foods” or things clients can eat while moving
around to improve nutrition. (sandwiches, protein bars)

39. Application of the Nursing Process
Bipolar Disorder
Interventions
• Providing Therapeutic Communication
- Nurses must use clear simple sentences when
communicating.
- Clarify the meaning of client’s communication.
- Set limits regarding taking turns in speaking and listening.
• Promoting Appropriate Behaviors
- Direct the clients’ need for movement into socially
acceptable, large motor activities such as arranging chairs
or walking.
- Protect the client’s dignity when inappropriate behavior
occurs.

40. Application of the Nursing Process
Bipolar Disorder
Interventions
• Managing Medications
- Monitor serum lithium levels.
- Clients should drink adequate water and continue with the
usual amount of dietary table salt. (table)
- Too much salt and water = Lithium blood level is too low
- Too little salt and water = Lithium toxicity
- Monitor fluid balance by measuring I and O
- Monitor thyroid function tests and renal status.
• Providing Client and Family Teaching
- Client and family teaching for the client with mania

41. Application of the Nursing Process
Bipolar Disorder
Interventions
• Providing Therapeutic Communication
-Nurses must use clear simple sentences when communicating.
-Clarify the meaning of client’s communication.
-Set limits regarding taking turns in speaking and listening.
• Promoting Appropriate Behaviors
-Direct the clients’ need for movement into socially acceptable,
large motor activities such as arranging chairs or walking.
-Protect the client’s dignity when inappropriate behavior occurs.
• Managing Medications
-Monitor serum lithium levels.

42. Suicide
• The intentional act of killing oneself.
• The nurse caring for a depressed client always
considers the possibility of suicide.
• Commonly occurs in clients with:
- Psychiatric Disorders: depression, bipolar, schizo,
substance abuse, PTSD, and BPD.
- Chronic medical illness: Cancer, HIV, DM, CVA, head
and spinal cord injury.
- Environmental factors

43. Suicide
Assessment:
• A history of previous suicide attempts increases risk for
suicide. (The first 2 years after an attempt represent the
highest risk period, especially the first 3 months)
• Family history (the closer the relationship, the greater
the risk)
• Suicidal clues:
- Giving away personal, special, and prized possessions
- Cancelling social engagements
- Making out or changing a will

44. Suicide
Suicidal clues:
- Taking out or changing insurance policies
- Positive or negative changes in behavior
- Poor appetite
- Sleeping difficulties
- Feelings of hopelessness
- Difficulty in concentrating
- Loss of interest in activities
- Client statements indicating an intent to attempt suicide
- Sudden calmness or improvement in depressed client.
- Client inquiries about poisons, guns, or other lethal
objects.

45. Suicide
Interventions
• Remove harmful objects such as sharp objects,
shoelaces, belts, lighters, matches, pencils, pens and
even clothing with drawstrings.
• Clients must be in direct sight of and no more than 2
to 3 feet away from a staff member for all activities.
• Initiate a no-suicide contract
• Identify support systems
• Keep the client active by assigning achievable tasks.
• Encourage Active participation in own care.
• Continue to assess the client’s suicide potential.