Learning Objectives

After a thorough discussion on Mood disorders, the student will be able to:
• define mood disorders
• identify the two major categories and related disorders of mood disorders
• explain the etiology and psychodynamic theories of mood disorder
• identify treatments and interventions for mood disorders
• explain the signs and symptoms of bipolar disorder
• explain the treatment and interventions for bipolar disorder
• explain dynamics of suicide and its interventions

MOOD DISORDERS
• Also called affective disorders, are pervasive alterations in emotions that are manifested by depression,
mania or both
• Interferes with a person’s life
• With accompanying self-doubt, guilt and anger which alter life activities
Categories
• Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other
symptoms
• Bipolar disorder (formerly called “manic- depressive illness”): mood cycles of mania and/or
depression and normalcy and other symptoms
Related Disorders
• Dysthymia: sadness, low energy, but not severe enough to be diagnosed as major depression disorder
• Cyclothymia: mood swings not severe enough to be diagnosed as bipolar disorder
• Substance-induced mood disorder
• Mood disorder due to a general medical condition
• Seasonal affective disorder (SAD) -mood affected by seasons
Symptoms can be: increased sleep or insomnia, increased appetite or loss of appetite, weight gain,
interpersonal conflict, irritability
• Postpartum or “maternity” blues-frequent normal experience after delivery of a baby characterized by
labile mood and affect, crying spells, sadness, insomnia and anxiety
• Postpartum depression-meets all the criteria for a major depressive episode with onset within 4 weeks
of delivery
• Postpartum psychosis
Etiology
• Biologic theories
• Genetics - first degree relatives (3%-8%)
➢ -identical twins (2-4x higher risk than fraternal twins
• Neurochemical theories -deficits of serotonin occur in people with depression
 ➢ -norepinephrine maybe deficit in depression and increased in mania
KINDLING-process by which seizure activity in a specific area of the brain is initially stimulated by reaching a
threshold of the cumulative effects of stress

• Psychodynamic theories
1. Freud- self-depreciation of people with depression
2. Bibring-idealistic ego frustrated
3. Jacobson- ego is a powerless, helpless child victimized by the superego
4. Meyer-reaction to a distressing life experience 5.Horney- children raised by rejecting or unloving
parents were prone to feelings of insecurity and loneliness
6.Beck-results from specific cognitive distortions in susceptible people.

MAJOR DEPRESSIVE DISORDER (MDD)

• 2X IN WOMEN
• MORE ON DIVORCED
• 2 WEEKS
• HALLMARK SIGNS: ANHEDONIA & SAD MOOD Endogenous Depression- NO precipitating factor
(external); maybe due to biochemical imbalances MAJOR DEPRESSIVE DISORDER (MDD)
At least 5 of the following symptoms present during the 2 week period (IN SAD CAGES)
IN – Interest is lacking in most everything.
S -Sleep is hard to come by.
A - Appetite is very often depressed.
D –Depressed people can be very tearful.
C – Concentration is often lacking.
A – Activity is decreased.
G – Guilt may bring a negative view of self, world or future.
E –energy level is decreased.
S – suicide precautions are mandatory.

Nursing diagnoses may include:

• Risk for Suicide
• Imbalanced 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
Intervention (smart c)
Safety -Providing for the client’s safety and the safety of others
Medications -Managing medications
ADLs- Promoting activities of daily living and physical care
Relationship -Promoting a therapeutic relationship Teaching -Providing client and family teaching
Communication -Using therapeutic communication
BIPOLAR DISORDER
• Occurs almost equally among men and women
• It is more common in highly educated people
• The mean age for a first manic episode is the early 20s
• Involves mood swings of depression (same symptoms of major depressive disorder) and mania.
Major symptoms of mania include:
I - Inflated self-esteem or grandiosity F -Flight of ideas

S - Sleep decreased P - Pressured speech

A -Agitation (Psychomotor) D -Distractibility
E -Excessive involvement in pleasure-seeking activities with a high potential for painful consequences

Manic
Mood elevated
A grandiose delusion
Need for sleep, eat decreased
Inappropriate Clanging, loud vulgar

Depressed Out for suicide

Won’t sleep, eat
Negative

Mania Vs Depression
Mania Depression
Appearance Colorful, Sad and gray
flamboyant
Behavior Psychomotor Psychomotor
agitation retardation
Communication Pressured Monotonous
speech speech
Stuttering
Cluttering

Mania Vs Depression
Mania Depression
Nx Risk for Injury Risk for injury (self)
(others) suicidal precaution

Nursing Safety and Safety and

priority nutrition Nutrition
Nutrition Finger foods and Increased in
high in calories nutrients
Treatment Lithium; ECT TCA; SSRI; MAOI’s
ECT
 Mania Vs Depression
Mania Depression

Milieu Non-stimulating Stimulating

environment

Appropriate Quiet type; non- Monotonous;

activity competitive Non-competitive

Attitude Matter of fact Kind firmness;

therapy active
friendliness

PHARMACOLOGY MOMENTS ANTIDEPRESSANTS TRICYCLIC

ANTIDEPRESSANTS TCAs:
ANTIDEPRESSANTS (TCA’s) =15
“MAMA, DEDE NA ACO, PARA TATABA DIVA?” (GENERIC)

M-MAPTROPTILINE (LUDIOMIL) M- MIRTAZAPINE (REMERON)

D- DOXEPIN (SINEQUAN)
D-DESIPRAMINE (NORPRAMIN)

N- NORTRIPTYLINE (AVENTYL, PAMELOR) A-AMOXAPINE (ASENDIN)

C- CLOMIPRAMINE (ANAFRANIL)…best for OCD

P-PROTRIPTYLINE (VIVACTIL) T-TRAZODONE (DESYRYL)

T-TRIMIPRAMINE (SURMONTIL) B- BUPROPION (WELLBUTRIN)

D-DULOXETINE(CYMBALTA) I-IMIPRAMINE (TOFRANIL)

V-VENLAFAXINE (EFFEXOR) … (SNRI) A- AMITRIPTYLINE (ELAVIL)
SSRIs
Flouxetine (Proxac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)
MAOIs
Moclobemide (Manerix)- reversible Phenelzine (Nardil)
Tranylcypromine
(Parnate)
Isocarboxacid
(Marplan)
ANTIMANIC
Carbamazepine (Tegretol) Lithium Carbonate (Eskalith) Valproic Acid (Depakene)
TCAs:
Contains three hydrocarbon rings
Inhibits neurotransmitter reuptake (NE and SE)
Intended Effects

S-sedative/hypnotic
T-treatment of chronic pain
D-decreased symptoms of depression

T-treatment of anxiety associated with depression, alcoholism, neurotic disorders

I- improved appetite-weight gain
T-treatment of panic attacks and phobic attacks

SIDE OR ADVERSE EFFECTS

W- Weight gain
A-Agitation I-Insomnia S-Sedation

A-Arrhythmias
C-Confusion (esp.elderly)
O-Orthostatic hypotension

A-Anticholinergic effects Pharmacological Effects (TCA)

Serum level of amines in the depressed person is low

TCA blocks reuptake of amines

✓ Greater neurotransmitter availability
✓ Prolonged stimulating action
✓ Alleviates symptoms
✓ ABSORPTION
✓ Absorbed well in the GIT
✓ Metabolized in the liver
✓ Binds with plasma proteins
✓ Peak plasma concentrations reached at 2-4 hours
✓ Inhibits amine reuptake

Side Effects
PNS side Effects-
orthostatic hypotension

CNS side effects:

A-nticholinergic effects
D-isorientation D-elusions
S-edation

C-onfusion A-gitations
S-eizure threshold lowered
H-allucinations
Lower doses or OD for elderly, alcoholics, history of hepatitis
Connection to suicide: depressed people are also suicidal but antidepressants may cause the “lifting” in these
patients which may warrant close monitoring/suicide precaution
Drug interactions with TCAs Teaching patients:
OTC avoided-to prevent drug interactions

Two-four weeks –before full therapeutic effects occur

Eye pain-report immediately (narrow angle glaucoma) Adjustment- to medication can lessen some side effects
Slow discontinuation- to avoid nausea, headache and malaise

Individual TCAs
AMITRIPTYLINE(ELAVIL)
-prescribed often but not for the elderly
-Highly anticholinergic
-one of the most sedating and cardiotoxic antidepressants
-parenteral form and in fixed dose combination with antipsychotics Perphenazine (Triavil)
AMOXIPINE (ASENDIN)
-metabolite of g drug loxapine
-blocks dopamine receptors
-potential for tardive dyskinesia;
-not for elderly

DESIPRAMIN (NORPRAMIN)
-metabolite of imipramine
-Good choice for elderly patients who are sensitive to anticholinergic side effects
-minor anticholinergic effects
-activating antidepressant (for apathetic, lethargic, hypersomic)
-less sedating
-therapeutic to panic attacks and dysthymia DOXEPIN (SINEQUAN)
-potentiates serotonin; sedating, has anticholinergic activity; high antianxiety effects
-Few cardiovascular effects but can have orthostatic hypotension and weight gain
-may have antiulcer properties

IMIPRAMINE (TOFRANIL)
-oldest TCA; more effective
-for children enuresis
-first-line drug in the treatment of panic disorder
-the standard by which newer antidepressants are measured
-care with children due to its cardiovascular effects

MAPROTILINE (LUDIOMIL)
-potentiates norepinephrine
-with anticholinergic effects; sedating
-a strong antianxiety effect
-no cardiovascular risk

NORTRIPTYLINE (AVENTYL, PAMELOR)

-for people with history of unfavorable responses to antidepressants
-for elderly; less orthostatic hypotension
-sedating; for agitated and insomnia

PROTRIPTYLINE (VIVACTIL)
-potentiates norepinephrine much more than serotonin
-greater incidence of tachycardia, cardiovascular problems and orthostatic hypertensions; has
anticholinergic effects

BUPROPION (WELLBUTRIN)
-inhibits dopamine reuptake
-minimal orthostatic hypotension, cardiovascular problems, anticholinergic effects and daytime sedation
-activating antidepressant
-contraindicated for patients with seizure disorders (lowers seizure threshold)
-can cause weight loss
-effective replacement for SSRIs
-reduces craving for cigarettes

NEFAZODONE (SERZONE)
-first line agent for depression
-inhibits serotonin and norepinephrine reuptake; blocks serotonin receptors
-does not cause insomnia, sexual dysfunction, nervousness

TRAZODONE(DESYREL)
-Potentiates serotonin not norepinephrine
-almost no anticholinergic effects
-few cardiac effects
-sedating; for insomnia
-absorption is increased right after a light meal
-adverse reaction is priapism (prolonged penile erection); nurse should stop the medication and notify the
prescriber

MIRTAZAPINE (REMERON)
-for major depression only
-blocks alpha2 receptors which increases norepinephrine and serotonin by utilizing the presynaptic feedback
system (signals need for more of these neurotransmitters
VENLAFAXINE (EFFEXOR)
-SNRI, norepinephrine reuptake inhibitor
-few anticholinergic, antihistaminic, or antiadrenergic side effects
-does not exaggerate the effects of alcohol
-maybe effective in treating SSRI-induced sexual dysfunction, panic disorders and OCD

SSRI
First choice for depression
Fewer anticholinergic, cardiovascular and sedating effects
OD dosing
Tolerated in the elderly

SIDE EFFECTS: DOWN D2

D-decreased libido O-orgasm decreased W-weight loss
N-nervousness,, D-diarrhea
D-dizziness,

TOXICITY: VITMN
V- vomiting I-irritability T-tremor
M-myoclonus (twitching of a muscle or group of muscles)
N-nausea

INTERACTIONS SEROTONIN SYNDROME

✓ Potentially fatal with SSRI + MAOI
✓ Hyperreflexia, hyperthermia, myoclonus, NMS
✓ Should:
✓ Be aware that a period of 14 days is required between stopping a MAOI and starting a SSRI
✓ Be aware of a period of 5 weeks is required between stopping an SSRI Flouxetine (Prozac) and
starting a MAOI
✓ Be aware that MAOIs and clomipramine (Anafranil) should not be given concomintantly

INDIVIDUAL SSRIs
1. FLOUXETINE (PROZAC)
-first SSRI; treatment for bulimia
2. SERTRALINE (ZOLOFT)
-potent inhibitor of serotonin reuptake than flouxetine
-inhibit ejaculation in men and orgasm in women; orgasmic ability returns after 2-3 days after drug
cessation
3. PAROXETINE(PAXIL)
-most potent SSRI
-Treatment of panic attacks; prevention of depression relapse
-side effect: nausea
-delays or inhibits orgasm
4. FLUOVOXAMINE(LUVOX)
-for OCD

MAOI
✓ Administered to hospitalized patients
✓ Derivative of isoniazid, iproniazid (Anti-TB)
✓ Blocks monoamine oxidase
✓ Effect from 10 days to 2 weeks
✓ Causes decreased heart rate, decreased vasoconstriction and hypotension (slowed release of
norepinephrine in PNS)
✓ Inhibits MAO in the liver, leads to elevated levels of other drugs metabolized in the liver by MAO
✓ Side effects: cardiovascular and anticholinergic effects
✓ Blood counts and liver function tests before therapy

TYRAMINE INTERACTION
✓ Amino acid, tyramine (precursor of dopamine, epinephrine and norepinephrine)
✓ Foods: (principle: foods aged, left to spoil) A-alcohol/avocado
B-bananas
C-chicken liver/caffeinated coffee/colas/ chocolate D-dairy products/dried fish
S-salami/sausage/soy sauce T-tea
Symptoms of hypertensive crisis:,,, D-Dilation of pupils
C-Chest tightness
H-high blood pressure P-Palpitation
D-Diaphoresis,
I-Increased heart rate, S-Stiff neck
H-Headache (throbbing, radiating )

TEACHING PATIENTS:
✓ Hypertensive crisis symptoms must be reported immediately
✓ OTC drugs (some) must be avoided
✓ Tyramine-rich foods, avoid except for reversible MAOI
✓ SSRI + MAOI is fatal, so avoid
✓ Ten days-4 weeks before full therapeutic effects occur
✓ Driving avoided due to drowsiness

IRREVERSIBLE MAOIs PHENELZINE (NARDIL)

-most effective MAOI, most sedative
-deterrent to cocaine abuse and for panic attacks

TRANYLCYPROMINE (PARNATE)
-for severe reactive depression
-most stimulating
-contraindicated to elderly REVERSIBLE MAOI

MOCLOBEMIDE (MANERIX)
-inhibition lasts only 24 hours
-taken after meals to reduce tyramine-related responses

ANTI- DEPRESSANT (Review))

A. TCA
“ knock! Knock! Who’s there? SEVANA to gagah!”--
------ (Sinequam, Elavil, Vivactil, Ascendin, Norpramin, Aventyl, Tofranil)
B. SSRI
Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv mo ko!” (PRAXIL, PROZAC, ZOLOFT,
LUVOX)
C.MAO
“Naman, parnate ko pa”
(NARDIL, MANERIX, PARNATE)

SUICIDE
• The intentional act of killing oneself
• Suicidal Ideation- means thinking about oneself
• Passive suicidal ideation (e.g. reckless driving, heavy smoking, overeating, self-mutilation, drug abuse)
• Active suicidal ideation-when a person thinks about and seeks to commit suicide.
SAD PERSON’S SCALE
S-Sex Men kill themselves 3x more than women though women make attempts 3x more often than men
A-Age High risks groups:19 years or younger; 45 years or older, especially the elderly 65 and above
D-Depression Studies report that 35-79% of those who attempt suicide manifested a depressive syndrome
P-Previous Attempts Of those who commit suicide, 65- 70% have made previous attempts
E-ETOH Alcohol is associated with up to 65% of successful suicides
R-Rational Thinking Loss People with functional or organic psychoses are more apt to commit suicide than
those in the general population
S-Social Supports Lacking A suicidal person often lacks significant others, meaningful employment and
religious supports
O-Organized Plan The presence of a specific plan for suicide signifies a person at high risk
N-No Spouse repeated studies indicate that persons who are widowed, separated, divorced or single at
greater risk than those who are married
S-Sickness Chronic, debilitating and severe illness is a risk factor

Scoring
0-2 Home with follow up care
3-4 Close follow up and possible hospitalization 5-6 Strongly consider hospitalization
7-10 Hospitalize

Theories of SUICIDE
• Psychodynamic theories - describe suicide as a wish to be at peace with the internalized significant
person. Wish to be reunited with a deceased loved object
Suicide is an attempt to escape from an intolerable situation or intolerable state of mind

• Sociological Theories
Durkheim-pioneer of sociological research in the study of suicide
3 Principal types:
Egotistic suicide-occurs when a person is insufficiently integrated into society
Anomic suicide-occurs when a person is isolated from others through abrupt changes in social
norms/status Altruistic suicide- occurs as a response to societal demands (deaths of Buddhist monks who
set themselves on fire to protest the Vietnam war)

Precipitating factors
• Social isolation- have difficulty forming and maintaining relationships

Norman Cousins Story: a woman who committed suicide had written in her diary everyday during the week
before her death “Nobody called today.
Nobody called today. Nobody called today. Nobody called today…”
 • Severe life’s events-divorce, death, sickness, legal problems, interpersonal discord
• Sensitivity to Loss-may react tragically to separation or loss of a loved one (had insecure or unreliable
childhood experiences)

ASSESSING VERBAL & NONVERBAL CLUES

Verbal Clues:
Overt Statements: “I can’t take it anymore!”; “Life’s isn’t worth living anymore.”; “I wish I were dead.”;
“Everyone will be better off if I am dead.”
Covert Statements: “It’s ok now, soon everything will be fine,” “Things will never work out.” “I won’t be a
problem much longer.” “Nothing feels good to me anymore.” “How can I give my body to medical science?”
Nonverbal Clues
BEHAVIORAL CLUES: sudden behavioral changes especially when depression is lifting and when the person
has more energy available to carry out the plan Signs: giving away prized possessions, writing farewell notes,
making out a will and putting personal affairs in order
SOMATIC CLUES: physiological complaints can mask psychological pain and internalized stress Headaches,
muscle aches, trouble sleeping, irregular bowel habits, unusual appetite or weight loss EMOTIONAL CLUES
Social withdrawal, feelings of hopelessness and helplessness, confusion, irritability and complaints of
exhaustions

Suicide Precautions
B-Be alert for cries for suicide
E-Expression of feelings
S-Safe environment
T-Teaching-disturbance in the brain chemistry and is treatable

P-Plan for Life”(list of warning signs of suicidal ideation and actions to take)
L-Listen with emotional support
A-Ask direct questions
N-No suicide contract
S-Structured schedule and involve in activities with others to increase self-worth and divert attention Suicide
Precautions
Always remember:
✓ That a suicidal person want to die only during the period of suicidal crisis-during this time the person is
ambivalent about living and dying
✓ Suicidal people gives warning
✓ Persons recovering from depression are high risk for 9-15 months after recovery
✓ Suicidal people are extremely unhappy but not always mentally ill
ANTIMANIC DRUGS
• LITHIUM (ESKALITH)
• CARBAMAZEPINE(TEGRETOL)
• VALPROIC ACID (DEPAKENE)
• LAMOTIGRINE (LAMICTAL)
LITHIUM
✓ Not much significant than sodium
✓ Treatment of manic depression
✓ Absorbed in the GIT, peak blood levels of 1-3 hours
✓ Not metabolized, excreted by the kidneys
unchanged
✓ Absorption of lithium and sodium are closely linked
✓ If dietary sodium intake increases, plasma lithium levels will drop (lithium excreted more rapidly)
✓ If NA in the diet decreases, lithium levels increase
✓ 7-10 days for therapeutic effects
✓ Maintenance level: 0.5-1.5 mEq/L (900- 1200mg/day)
✓ Side effects that subside: nausea, dry mouth, thirst, mild hand tremor, weight gain, insomnia, light-
headedness
✓ Side effects which will not subside: vomiting, severe tremors, sedation, muscle weakness, vertigo
✓ Contraindication: persons with cardiovascular diseases
✓ Interactions: diuretics-decreases lithium excretion, low-salt diet increases lithium levels
TEACHING PATIENTS:
T-try not to instill anxiety by preparing patients for expected side effects
R-report immediately side effects which will not subside (vomiting, severe tremors, sedation, muscle
weakness, vertigo)
E-Elevate feet to relieve ankle edema
M-maintain normal fluid balance of at least 3 liters of water per day
O-On side effects that subside, discuss them with the patient (nausea, dry mouth, thirst, mild hand tremor,
weight gain, insomnia, light-headedness)
R-Reduce nausea by taking lithium with meals S- Sodium intake must be maintained
CARBAMAZEPINE
✓ Antimanic, anticonvulsant
✓ Side effects: drowsiness ,dizziness, unsteadiness, upset stomach vomiting, headache, anxiety,
memory problems, diarrhea, constipation, heartburn dry mouth, back pain
✓ Can cause agranulocytosis and aplastic anemia VALPROIC ACID
✓ ANTIMANIC, ANTICONVULSANT
✓ Side effects: drowsiness, Dizziness, headache, diarrhea, constipation, heartburn, changes in
appetite, weight changes, back pain , unusual bruising or bleeding, tiny purple spots on the skin
✓ Can cause liver dysfunction, hepatic failure, blood dyscrasias including thrombocytopenia
✓ Teaching Patients
✓ Other medications should be prescribed to avoid adverse drug interactions
✓ Report bruising, can be thrombocytopenia
✓ Swallowed, not chewed, cut or crushed to avoid irritation
✓ Avoid machineries, driving due to drowsiness
✓ Liver and renal functions tests, CBCs to prevent serious complications
✓ Take with food to avoid nausea
Activities:
1. Study the Module
2. Supplement the module by reading e-
book by Videbeck - Psychiatric-Mental
Health Nursing,
3. Answer Module Assessment and do the self-
check using the module and e-book.
4. Answer the ONLINE QUIZ

Module Assessment Self-

Check True or False:

1. Males have a higher rate of

success in committing suicides than
females.
2. Single, widowed, divorced and
separated individuals have a greater risk of
committing suicide.
3. People who talk about suicide never
commit suicide.
4. Suicidal people only wanted to
hurt themselves not others.
5. Do not mention the word suicide to a
person you suspect to be suicidal.
6. Risk of suicide increases as the client’s
energy level is increased after taking the
medication for two weeks.
7. Presence of signs like sudden
cheerfulness, relief from guilt, giving away
personal belongings
indicates that the client has come
to a decision to commit suicide.
8. Risk of suicide increases when the
client’s time is unstructured.
9. Crying is a healthy way of expressing
feelings of sadness, hopelessness and despair.
10. SSRI’s are antidepressants drugs not
to be taken with tyramine rich foods as
hypertensive crises can result.
11. Norepinephrine is a neurotransmitter
that is deficient in Depressed individuals.
12. Flouxetine (Prozac) ans Sertraline
(Zoloft) are examples of Tricyclics Antidepressants.
13. Serotonin is elevated during depression.
14. Depression is a disorder of the mind.
15. E in the acronym sad person means
heavy alcohol or drug abuse.