Depression, Bipolar Disorder, Suicide

Mood Disorders

• Occasional bouts of the "blues" are normal responses to life's disappointments and are typically short-lived.
• Mood disorders are characterized by ineffective adaptation that interferes with functioning.
• Individuals from throughout history, for example Abraham Lincoln, Queen Victoria, Lady Gaga, and Michael Phelps, have had mood disorders.
• Before the mid-1950s, there were no available treatments for serious depression or mania.
• Mood disorders are the most common psychiatric diagnosis associated with suicide.
• Depression involves pervasive feelings of sadness, pessimism, and worthlessness.
• Bipolar disorder involves switches from depression to normal mood, to manic episodes.

Etiology of Mood Disorders

• Genetics play a role in the development of mood disorders.
• Neurotransmitter imbalances, such as low serotonin, norepinephrine (NE), and dopamine can impact mood.
• Hormonal imbalances, including thyroid hormones and cortisol, can also play a role.
• Psychodynamic theory suggests depression involves self-depreciation, while bipolar disorder is seen as a defense against underlying depression.
• Traumatic experiences or the death of loved ones can be factors.

Major Depressive Disorder

• Depression is defined as an alteration in mood expressed by feelings of sadness, despair, and pessimism.
• To meet diagnostic criteria one must experience symptoms for at least 2 weeks. -One must have at least five symptoms to be diagnosed.
• A specified symptom must be either a depressed mood or anhedonia
• Additional symptoms may include things like significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness, diminished ability to concentrate, and recurrent thoughts of suicide.

Epidemiology of Depression

• Females have twice the risk of depression.
• Higher concentrations of monoamine oxidase (MAO) are found in females.
• Hormonal changes during menses, postpartum, and menopause can impact mood.
• Unequal power and status for females is also a consideration.
• Poverty and unemployment increase the risk of depression.
• Single and divorced individuals have a higher incidence of depression.
• The lack of social connectedness is a significant aspect of the depression.
• Having a first-degree relative with depression increases the risk.

Psychopharmacology of Depression

• Antidepressants categories include; selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, atypical antidepressants, and monoamine oxidase inhibitors (MAOIs).
• MOAIs can cause hypertensive crisis and serotonin syndrome.
• Antidepressant can take 2-4 weeks to take effect
• Fewer relapses occur with 18-24 months of antidepressant therapy.
• Antidepressants should be tapered before discontinuing.
• Suicidal tendencies may increase after starting antidepressants.

Other Medical Treatments and Psychotherapy for Depression

• Electroconvulsive therapy (ECT) is used for severe, treatment-resistant depression.
• Esketamine is used for treatment-resistant depression and is administered as a spray by a professional.
• Psychotherapy is combined with medications.
• Interpersonal therapy addresses relationship difficulties.
• Behavior therapy uses positive reinforcement.
• Cognitive therapy addresses cognitive distortions.
• Family therapy restores adaptive family functioning.
• Group therapy uses peer support.
• Deep brain stimulation and vagal nerve stimulation are other somatic therapies.

Major Depressive Disorder and Nursing Process Application

• Assessment includes history, general appearance, motor behavior, mood and affect, thought process and content, sensorium, and intellectual processes.
• The client should not be rushed during the assessment.
• Information may be gathered from secondary sources.
• Psychomotor retardation, latency of response, and agitation may be noted.
• Anhedonia, apathy, a sad or depressed mood, or a flat affect may also be observed.
• Ruminations and thoughts of suicide are considerations.
• Impaired memory and difficulty concentrating can occur.

Major Depressive Disorder, Continued Nursing Considerations

Assessing Judgment and Insight

• Cognitive disabilities or apathy can contribute to impaired judgment.

Assessing Self-Concept

• Feelings of worthlessness should be noted.

Assessing Roles & Relationships

• The greater the difficulty, the more severe the depression.

Assessing Physiological and Self-Care Considerations

• Lack of appetite, sleep disturbances, self-care deficit, and constipation from decreased food, fluid intake, and inactivity are points to consider.

Depression Rating Scales

• Zung Self-Rating Depression Scale and Hamilton Rating Scale are useful tools.

Nursing Process: Outcome Identification

• Outcome identification includes freedom from self-injury, ability to carry out activities of daily living, balance of rest, sleep, and activity, realistic self attributes, socialization, returning to occupation or school, medication compliance, and verbalizing symptoms of recurrence.

Nursing Actions: Safety

• Actions include providing safety from suicide.
• The goal includes the patient not harming themself.
• The patient will reach out to staff when feeling the urge to harm themself.
• Interventions include removing harmful objects.
• Supervise closely during meals and intake of medicines.
• Question suicidal ideations and intentions, for example asking "Have you thought about killing yourself?" or "If so, what do you plan to do?"
• Encouraging the patient to participate in a "safety contract" is useful along with encouraging the patient to reach out to staff when having the urge to harm themself .

Nursing Interventions

• Maintain close observation of the patient through constant visual observation every 15 minutes, check at irregular intervals, especially at night, shift changes, and other predictable times.
• Place the client close to the nurses' station.
• Spending time and silence with the patient can be therapeutic.
• It is important to express to the patient that they are a worthwhile person.

Actions: Promoting Independence

• Actions include promoting independence, self-care, and self-esteem.
• This exhibits feelings of self-worth & supports participation in activities of daily living.
• Interventions involve focusing patients on strengths and accomplishments.
• Promote attendance in group therapy and encourage independence in doing ADLs while supporting them if assistance is needed.
• Break down global tasks into simple steps.

Communication

• Acknowledge independent accomplishments of the patient.
• Use active communication strategies, for example saying "'it's time to eat lunch" rather than "would you like to eat".
• A strict record of food and fluid intake, promote sleep (back rub, warm bath, soft music, relaxation exercise) can aid in recovery.
• Therapeutic communication can also be useful.
• Do not attempt to fix the clients difficulties nor use cliches that invalidate the patient's feelings.
• It is vital to continually assess risk.

Medication Management & Education

• Antidepressant can improve mood and energy.
• Follow up appointments with the therapist is important.
• Provide education regarding medication side-effects & compliance.
• Provide education that identifies early signs of potential relapse.

Bipolar Disorder

• Bipolar disorder consists of extreme mood swings that cycle between episodes of depression, periods of normalcy, and mania (euphoric, grandiose, energetic, sleepless).
• It is second only to major depression as a cause of worldwide disability.
• The lifetime risk is about 2%.
• It occurs almost equally among men and women.
• The age of onset is typically 25 years old.
• It is more common in highly educated and socioeconomic people.

Types of Bipolar Conditions

• Bipolar mixed: cycles alternate between periods of mania, normal mood, and depression.
• Bipolar type one: consists of manic episodes with at least one depressive episode.
• Bipolar two: Recurrent depressive episodes with at least 1 hypomanic episode.

Mania

• Mania involves a distinct period of elevated or irritable mood, and abnormally increased energy lasting at least 1 week.
• Having three or more symptoms is required.
• Symptoms include inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas or racing thoughts, distractibility, and excessive involvement in activities that have a high potential for painful consequences, among other symptoms.

Treatment of Bipolar Disorder

• Psychopharmacology typically involves lithium and anticonvulsant drugs.
• Psychotherapy is useful in the mildy depressive or normal portion of the bipolar cycle but not as useful during manic stages.
• Assessment findings of a client with Bipolar d/o indicate flamboyant clothes reflecting elevated mood, excessive jewelry, and can, in some cases be sexually suggestive.
• The client can also be verbally aggressive.
• Hallmarks also consist of flight of ideas, circumstancially, tangentiality, impulsivity, and grandiosity.

Bipolar Assessment

• Starts many projects but does not complete them.
• Grandiose notions of being President, famous movie star, or even God.
• Poor judgement and insight.
• Exaggerated self-esteem.
• Rarely fill roles and responsibilities while being hyperactive and impulsively distracted.
• Can go for days without sleep or food and not even realize they are hungry or tired.
• No injury to self or others.
• Balance of rest, sleep, and activity are necessary goals of recovery.
• Socially appropriate behavior is vital.

Safety Measures for Bipolar

• Provide safety from risk of violence toward self or others.
• Patient will recognize signs of increasing agitation & reach out to staff.
• The patient will not harm self or others.
• Maintain a non-stimulating environment through low ambient sounds.
• Remove all dangerous objects from the patients environment.
• Agitation; address at first sign of aggression or increased anxiety, use distraction activities, anti-anxiety meds and restraints only as a last resort.

Client Care

• Goals also include consuming sufficient foods.
• Interventions include, finger foods that are nutritious.
• Avoid drinks with caffeine, give tepid bath, back rub, soft music to decrease stimuli & aid rest.

Other Nursing Actions with Bipolar Patients

• Providing therapeutic communication, for example, acknowledging the pressured speech and telling them "please speak more slowly".
• Promoting appropriate behaviors.
• Do not scold or chastise the client.
• Address with matter of fact and non-judgemental manner.

Other Nursing Considerations

• Set boundaries and limits using matter of fact verbiage like "Let's go to your room and find a sweater".
• State what is expected behavior and consequences if limits are violated.
• Confront patient as soon as possible.
• Provide positive reinforcements for good behaviors.
• Manage medications and observe for Lithium toxicity.

Suicide

• Suicide signifies the intentional act of killing oneself.
• Men commit approximately 72% of suicides.
• Suicidal ideation is just thinking about killing oneself.
• Males are between 3-4x more likely to commit suicide.
• Firearms are a most common means and then suffocation.

Myths about suicide

• People who talk about it don't actually do it.
• You cannot help someone who is suicidal, or once a person is suicidal, they are always suicidal.
• Improvement after severe depression means that a person is no longer at risk of suicide.
• People who make an attempt, are only doing it for attention.
• Suicide always happens during an impulsive moment, or Young children being incapable of committing suicide

Factors of Suicide

• People who take their own lives overdose by using drugs.
• That if an individual attempted suicide, they are less likely to attempt again.

Facts about Suicide

• Eight of 10 people who kill themselves show or give warnings about their suicidal intentions.
• Very subtle clues may be ignored or disregarded by others.
• Most suicidal people are very ambivalent about their feelings regarding living or dying.
• A suicidal person can lead a normal life with support.
• Many suicides occur within about 3 months after the beginning of “improvement,” when the individual has the energy to carry out suicidal intentions.
• A suicide by a close family member increases an individual's risk factor for suicide.
• They are unable at that point in time to see an alternative solution to what they consider an unbearable problem.
• Suicide attempts should be approached with the mindset that this person is issuing a call for help.
• Gunshot wounds are the leading cause of death among suicide victims.

Suicide, continued

• Between 50% and 80% of all people who ultimately kill themselves will have at least one previous attempt.
• People often contemplate, imagine, and make plans before the attempts
• Each year, 30 to 35 children younger than age 12 years take their own lives.
• Sex is a strong consideration for suicide.
• Death from suicide from men & attempts are predominated by women.

Additional Suicide Considerations

• Age; mostly 35–64 years old but varies with the gender.
• The state of widows/ widowers DOES NOT increase risk of suicidal tendencies.
• Sociological components such as financial strain & unemployment increase risk.
• Mental health history of depression, bipolar and / substance abuse.
• LGBGTQ individuals can be at a higher risk.
• Cyberbullying increases a person's risk of suicide.

Suicide Warning Signs

• Threatening to harm or end one's life, or seeking access to means: seeking pills, weapons, or other means.
• Other signs can include evidence of a suicide plan and expressing thoughts or ideations surrounding the wish to die or talking about suicide plans. Number of Warning Signs

Risk Level Assessment

• Assessing suicide risk: look at recent financial issues, divorse, and social isolation
• The level of risk associated with the client ranges from very high to low and corresponds with counseling recommendations.
• Number of Warning Signs.
• Prior dramatic or traumatic life events or abuse.
• Previous suicide behavior.
• Chronic mental illness.
• Chronic and debilitating physical illness.
• High Risk: seek help from mental health professional.
• Very High- levels of signs correlate with seeking immediate assistance from emergency medical staff.

Suicide Assessments

• Assessment is a key role in determining the right plan of care for the individual.
• Warning of suicidal thoughts and Intent is crucial.
• Lethality assessment is determining and identifying the risk of one carrying out plans to end one's life.
• Assess for demographics or risk factors associated with high risk for suicide that is present to the patient.

Suicide Verbal Cues

• Verbal ques include direct ("I want to die") and indirect ("This is the last time you'll see me", "I can't stand it anymore").
• Behavioral clues includes sudden lift in mood, giving away prized possessions, and getting financial affairs in order.

Suicide: Lethality Determination

• Find out plan, means, and timing of potentially fatal attempt: if it is a special time, or any trigger dates.
• Guns and suffocation are more risky.
• Assess for "taking two week supply of TCA". If intended, compare to taking 10 aspirin.
• Plan.
• Is it likely to be lethal.
  • If yes, what is the specific plan?
• Are the means available to carry out the plan?

Suicide Interventions

• Include, but are not limited to -safe from harming self and others.
• Engagement in a therapeutic relationship is recommended.
• Reporting any thought or ideations is a sign that they feel safe and trusting of staff.

Safety Considerations

• Maintain a safe environment.
• Take over and "pull rank" for safety reasons.
• Remove all items that can cause patients to harm to one self (belts and glass).
• Place patient in room near nurse's station to maintain in direct sight of staff.

Suicide, and Family

• Understand their emotions.
• It's okay for them to be upset due to betrayal or feeling overwhelmed.
• Family members may feel guilt, feel sad, and angry.
• Remind team mates of the importance of clear and accurate charting to ensure they are not liable.
• Suicide is the ultimate is often rejection by peers and family.
• Some suicides are done to place blame on others involved.
• They may have felt there wasn't a need for help/were irrelevant.