Mood & Adjustment Disorders PDF

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Mood & Adjustment Disorders 1. Identify the major groupings of mood disorders according to the DSM-V. - Co-morbidities commonly linked to Mood Disorders o Dementia o Medical Conditions o Chronic Pain o Diabetes o Terminal Illness o Changes to thyroid function o MS o Strokes o AIDS o Huntington's Disease o Cancer o Heart Disease - Mood disorders can occur in response to: o Stress o Illness o medication – antihypertensives - Secondary medical concerns can occur o Chronic pain o IBS o Migraines o Fibromyalgia Bipolar Disorder

Previously known as Manic-Depression, bipolar disorder is characterized by episodes of significantly elevated mood, arousal, and/or energy levels (mania) often interspersed with contrasting episodes of low mood (depression). It is often noted that there is a significant association between bipolar disorder and creativity

Clinical Depression

Also known as Major Depressive Disorder or Unipolar Depression, this type of recurrent depression is characterized by an all-encompassing low mood, diminished self-esteem, and a loss of interest in normally enjoyable activities. Often misunderstood as being something that individuals should be able to overcome by will-power alone, major depression often requires antidepressant medication such as an SSRI (Selective Serotonin Reuptake Inhibitor).

2. Describe presenting behaviours for depression, adjustment, and bipolar disorders. - Major Depressive Disorder o Symptoms present for 2 weeks or more o Mood depressed, sad, empty, numb o Anhedonia- loss of normal interest o Sadness, crying, numbness, disinterest, disconnect o Anxiety, irritability or anger o Loneliness, helplessness or hopelessness o Flat/constricted affect, minimal expression o Must have at least 5 of these symptoms for more than 2 weeks

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o An adjustment disorder is what happens right after a stressor has occurred (treated with anti-depressant/anti-anxiety meds) but once the stressor and situation is resolved, the adjustment disorder usually subsides BUT if the symptoms continue, then it’s leading into a major depression o Adjustment disorder can look like a depressive disorder or an anxiety disorder Dysthymic Disorder o Chronic, low-level depression o Symptoms present for two years or more o Depressed mood, poor appetite or overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration, difficulty making decisions, feelings of hopelessness o It’s become part of their personality, negative, low energy o Adults must have at least 3 symptoms for 2+ years o Children must have at least 3 symptoms for 1+ years o To be diagnosed, you must have at least 6 months of no manic states o Other types of depressive disorders: seasonal depression, post-partum depression (you can also have post-partum psychosis/mania), atypical depression (people will have hyper insomnia, hyperphasia [increased appetite], lots of interrelationship difficulties) o Depression is very gradual, symptoms are severe, much more intense level than us just going through PMS, or feeling depressed Mania o Symptoms present for at least one week o Mood abnormally elevated, expansive, or irritable o Inflated self-esteem o Decreased need for sleep o More than usual talkativeness o Racing thoughts o Distractibility o Increase in goal-directed activity- they say they’re gonna do something and they literally go out and do it o Excessive involvement in pleasurable and risky activities o You feel a sense of euphoria, you require less sleep, very talkative, active, distractible o They can feel grandulose illusions o These patients are very vulnerable, they usually come to emergency with physical problems (foot pain d/t walking a lot even maybe with bare feet, electrolytes are off balance and they’re dehydrated because they most likely haven’t eaten anything and they have so much energy) o Very likely to be aggressive, physical b/c of their impulsivity Hypomania o Elevated mood without decreased functioning o Extremely happy & agreeable o Ease with social conversation o Humorous o Productive o They don’t need to always be brought into the hospital b/c they don’t have psychosis/manic symptoms and they are aware that they haven’t had a lot of sleep

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o To get a diagnosis, it’s a huge change from a person’s normal functioning within 4 days o There is typically some awareness with individuals with hypomania o Could be aggressive/physical but not as common compared to mania Bipolar Disorder o Bipolar I Disorder– major depressive episode alternate with manic episode  Most significant- you alternate between a full manic episode to a full depressive episode, over a period of time, not within a dayà and between those different episodes, you get periods of normal/no symptoms o Bipolar II Disorder– presence of at least one depressive episode and one hypomanic episode  you get more depressive episodes rather than full manic episodes o Cyclothymic Disorder- chronic mood disturbance of at least 2 years, symptoms are less severe or intense than they would be in other diagnoses

3. Apply the nursing process to individuals experiencing mood and adjustment disorders. -

Refer to Case Studies.

4. Identify the major groupings of antidepressant and mood stabilizing medications. - Antipsychotic Medications o Conventional antipsychotics (typical)à block D2 receptors in the limbic region of the brain o Unconventional antipsychotics (atypical)à lower potential for extrapyramidal effectsà Antipsychotic medications commonly produce extrapyramidal symptoms as side effects. The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome o Antipsychotics medications are used to treat psychosis including schizophrenia, schizo-affective disorders, and delusional disorders o For individuals taking antipsychotic meds (Adverse Effects & Nursing Management)  Ensure you are monitoring drug levels to avoid drug toxicity  Antipsychotic meds block Dopamine, Histamine, Cholinergic, Alpha, and Serotonin receptors so it can result in extrapyramidal and other side effects Receptor Blocked Side Effects Dopamine - Extrapyramidal side effects - Prolactin Histamine - Sedation - Weight gain Cholinergic - Dry mouth - Blurred vision - Sinus tachycardia - Constipation - Impaired memory & cognition Alpha - Orthostatic hypotension - Reflex tachycardia

Serotonin

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Weight gain GI upset Sexual dysfunction

o Neuroleptic Malignant Syndrome (NMS)  This is a medical emergency, patient presents with decrease LOC, increased muscle tone (rigidity), and autonomic dysfunction (hyperpyrexia, labile HTN, tachycardia, tachypnea, drooling)  Large amounts of myoglobin get released from muscle tissue and cause kidney damage o Mood Stabilizers (Lithium)  The oldest psych med that’s out there  Huge side effects, lithium is a salt so it bind to Na+ in the body  Anyone on lithium is at risk for lithium toxicity  They should be drinking 1.5 L of water a day, ensure that they’re having the same amount of sodium everyday  If fluid levels are high = lithium level is low  If fluid levels are low = lithium level is high  So ensure that the patient is drinking enough fluids  One of the first signs of lithium toxicity is:  Diarrhea  Fever  Someone who looks like they’re drunk (slurred speech, peeing a lot, sometimes nauseous)  Mild Toxicity  Fine tremor  GI upset  Mild polyuria (lots of urine) and polydipsia (abnormal thirst)  Muscle weakness and lethargy  Persistent Effects  Fine tremor  Mild polyuria and polydipsia  Increased white blood cell count  Exacerbation of psoriasis  Acne  Alopecia  Weight gain  Moderate Toxicity  Lithium level 1.5 mEq/L  Coarsening of tremor  Reappearance of GI symptoms  Confusion  Sedation and lethargy  As levels increase: ataxia (loss of control of bodily movements), dysarthria (unclear articulation of speech), mental status deterioration  Severe Toxicity  Lithium level 2.5 mEq/L  Seizures  Coma  Cardiovascular collapse  Death  Other mood stabilizers include:

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Valproateà anticonvulsant med effective for manic episodes, first-line treatment for rapid-cycling bipolar disorder  Carbamazepineà alternative treatment for acute bipolar mania in place of lithium, elevates mood in some depressed patients  Oxcarbazepineà as effective as Carbamazepine for treating bipolar disorder, an alternative for patient who can’t tolerate Carbamazepine  Lamotrigineà effective for the treatment of bipolar depression disorder and rapid-cycling bipolar disorder  Topiramateà used to treat epilepsy, used as an adjunctive therapy o Anticonvulsants  They work on the mood pathway  Carbamazepime, toperimate, lamotragine  It controls those manic symptoms  Effects liver function, GI problems o Other: atypical antipsychotics, electroconvulsive therapy Anti-Depressants o Indications  Mostly used to treat major depression, but also used for:  Anxiety  Obsessive-compulsive disorders  Panic disorders  Bulimia  Anorexia nervosa  PTSD  Bipolar depression  Neuropathic pain  Migraine headache  Smoking cessation  Autism o Tricyclic antidepressants (TCAs)  Rarely used anymore JUST for depression  Used to treat sleep disorders, nerve pain  It’s very easy to take an overdose (not recommended for patients who are suicidal), and they have a lot of side effects (especially cholinergic side effects)  Dry mouth  Blurred vision  GI upset  Constipation  Urinary retention  Confusion  Sedating effects, usually taken at bedtime  Reuptake of Serotonin and norepinephrine are blocked  TCAs also act on other receptors causing antihistaminic effects, anticholinergic effects, and effects on cardiac conduction  TCAs can cause cardiotoxicity, so patient gets an ECG before initiation of treatment, can also cause orthostatic hypotension so be careful especially with elderly patientsà tell them to rise slowly to avoid dizziness/falls

Not first line of treatment, defs last line of treatment People are on these only if they’ve been on it for a long time and it seems to be working, if people have tried everything else and this is their last resort, or people with atypical depression o Monoamine Oxidase Inhibitors (MAOIs)  The neurotransmitters norepinephrine, serotonin, and dopamine are monoamines  MAOIs inhibit the enzyme called monoamine oxidase, therefore increasing the availability of these neurotransmitters  Used for treatment of atypical depression, major depression, or depressive disorders resistant to TCAs  Patients on MAOIs must follow a strict diet  Prohibited (foods high in tyramine) o Aged cheeses o Ripe avocados o Anchovies o Broad beans (e.g. fava, Italian) o Liver o Fermented foods  Allowed in moderation o Beer and ale o White wine o Cottage cheese and cream cheese o Coffee (2 cups a day) o Chocolate o Soy sauce o Yogurt and sour cream o Spinach, raisins, tomatoes, eggplant, and plums  Side effects  Orthostatic hypotension  Edema  Sexual dysfunction  Weight gain  Insomnia  Although these drugs do not have direct effects on cholinergic receptors, anti-cholinergic type side effects occur such as dry mouth, urinary hesitancy, and constipation o Selective Serotonin Reuptake Inhibitors (SSRIs)  making sure that the serotonin passes that synapse and get used up, inhibits the reuptake of serotonin therefore increasing serotonin in the CNS  There is a risk for serotonin syndrome b/c your body is not used to this change (sweating, High BP, then go into a hypertensive crisis then as it progresses, they get muscle shifting, tremors, seizures)  Drug interactions between SSRIs and MAOIs can cause serotonin syndrome  Clinical signs of serotonin syndrome: o Confusion o Hypomania o Restlessness o Myoclonus- spasmodic jerky contraction of groups of muscles  

o Hyperreflexia o Diaphoresis o Shivering o Tremor o diarrhea  there’s no way of testing for serotonin syndrome, it’s all about observation and recognition  the first-line drug therapy for treating depression  side effects of SSRIs  side effects are mild, more severe when initiating therapy but patient’s body becomes used to it and tolerates the medication and symptoms lessen with time and use  GI upset  Insomnia  Restlessness  Irritability  Headache  Sexual dysfunction  SSRIs also associated with dystonia, bradykinesia  Overdose of SSRIs are not lethal so that is an advantage compared to TCAsà if a patient is suicidal, SSRIs is a better choice that TCAs o Atypical Anti-depressants  Atypical antidepressants are considered “atypical” because these agents do not fit into any of the other classes of antidepressants. Each medicine in this category has a unique mechanism of action in the body. However, like other antidepressants, atypical antidepressants affect the levels of dopamine, serotonin, and norepinephrine in the brain.  Brintellix and Viibryd inhibit reuptake of serotonin but also act on serotonin receptors.  Atypical antidepressants include bupropion (Wellbutrin), mirtazapine (Remeron), nefazodone (Serzone), trazodone (Desyrel, Oleptro), vilazodone (Viibryd), and vortioxetine (Brintellix).  Since medications in this class have unique properties, their side effect profile also varies. Some common side effects include dry mouth, constipation, dizziness, and lightheadedness.  Mirtazapine and trazodone cause drowsiness and are usually taken at bedtime.  Bupropion generally does not cause weight gain or sexual problems. Bupropion may also be used to help quit smoking.  Viibryd is not associated with significant weight gain or sexual dysfunction. o Other Anti-depressants  Duloxetineà selective serotonin and norepinephrine reuptake inhibitor, used for major depression  Venlafaxineà selective serotonin and norepinephrine reuptake inhibitor, does not cause anticholinergic and antihistaminic side effects, used for anxiety disordersà side effects include GI upset, increased BP, insomnia, restlessness, h/a, irritability  Trazodoneà an SSRI, used an an agent to counteract insomnia

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Bupropionà norepinephrine and dopamine reuptake inhibitorà side effects include nervousness, h/a, insomnia, seizures Mirtazapineà increases both norepinephrine and serotonin in the synapseà side effects include sedation, weight gain, constipation

5. Discuss the various treatments used in managing depression and bipolar disorders. Major Depression: - Treatment includes counselling, cognitive behavioural therapy, antidepressants -

Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. Performed under anesthesia, this procedure is thought to impact the function and effect of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.

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Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair, awake, with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks

Bipolar Disorder: - Treat symptoms of lithium toxicity and then stop lithium - Prevention is key – functioning is always a little less after a full manic episode. - Pharmacology -

Cognitive behavioral therapy. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. It can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.

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Psychoeducation. Counseling to help you learn about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder. Knowing what's going on can help you get the best support and treatment, and help you and your loved ones recognize warning signs of mood swings.

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Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleep, wake and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.

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Other therapies. Other therapies have been studied with some evidence of success. Ask your doctor if any other options may be appropriate for you....