NURS 5602 Mood Disorders 2024 SC(Vicky) PDF

Mood Disorders Concept: Cognition & Perception 2024  Explore theories that contribute to the understanding of the aetiology (causes) of mood disorders Gain...

Mood Disorders Concept: Cognition & Perception 2024  Explore theories that contribute to the understanding of the aetiology (causes) of mood disorders Gain an understanding of mood changes associated with major depressive and bi-polar disorders Gain an understanding of Learning Outcomes the impact of mood disorders and nursing considerations for working with people who are experiencing major mood disorders Gain an understanding of the common psychopharmacology used in the treatment of mood disorders. 2 Recovery: Remember CHIME Therapeutic optimism Defined as “self reported, specific expectancies regarding client outcomes in a clinical setting “ (cited by Proctor et al, 2014 p 12) Supporting the aspiration is to live, work, and love in a community in which one makes a contribution (citizenship) Supporting reconnection with social life and meaningful activities – including gaining employment. Having roles and routines and sense of purpose and enhance coping skills to 4 Mood Disorders Mood disorders are among the most common form of mental illness and can cause much distress. Mood disorders are divided into: Depressive Disorders Bipolar Affective Disorders (I and II) 5 Prevalence (Ministry of Health, 2023). In 2022/23, one in eight adults (11.9%) reported experiencing high or very levels of psychological distress, with the rate being higher in women (13.2%) than men (10.2%). One in five (21.2%) young people aged 15–24 years experienced high or very high levels of psychological distress in 2022/23, up from 5.1% in 2011/12. After adjusting for age and gender differences, Māori and Pacific adults were 1.5 and 1.2 times as likely to have experienced psychological distress as non-Māori and non-Pacific adults, respectively. Adults living in the most deprived neighbourhoods were 2.4 times as likely to have experienced psychological distress as those in the least deprived neighbourhoods, after adjusting for age, gender and ethnicity. In 2022/23, 35.9% of disabled adults experienced high or very high psychological distress in the four weeks prior to the survey, compared to 9.5% of non-disabled adults. 6  There is unlikely to be only one factor that is wholly responsible for depression; rather, it is a combination of factors interacting that causes the illness. Causation Theories The diathesis–stress model attempts to explain a disorder as the result of an interaction between a predisposition to vulnerability and stress caused by life experiences. 10  Diathesis-stress model PRESDISPOSITIO STRESSORS: N: Trauma, poverty, poor Increased  Genetic links living vulnerabilit  Hormonal + conditions, family = y factors conflict, social for mental isolation, physical distress  Neuro-chemical illness, some  Historical prescription Causation: Genetic links There are likely to be several different genes involved in the development of mood disorders. It is thought that genetic mutations cause dis- regulation of neurotransmitters Family studies have shown a strong probability of a heredity component to this condition. This genetic pattern may interact with pre-natal environmental factors (e.g., stress in utero). Children who have a parent with bipolar disorder may have a 20% chance of developing the disorder (Athanasos, 2017: Clark & Temmhoff, 2021) 12 Causation: Hormonal factors Important among these systems are the hypothalamic- pituitary-adrenal (HPA) axis (which controls the release of cortisol and thyroid hormones) and the overall circadian rhythms (the body’s 24-hour cycle of brainwave activity, hormone production and cell regeneration). Cortisol and thyroid hormone levels have been found to be elevated in clients during manic episodes The immune system by way of pro-inflammatory cytokines (to produce an inflammatory response) may underpin many of these mechanisms (Athanasos, 2017: Clark & Temmhoff, 2021) 13 Causation: Neurochemical 1965 theory was depression was a a consequence of low levels of serotonin or other neurotransmitters (monoamines) in the brain. This is the ‘monoamine hypothesis’ More recent research suggested monoamines modulate a range of other neurobiological systems to produce major depression. However, the process is more complex than a simple increase or decrease in monoamines (Hillhouse & Porter, 2015). Neurotransmitter systems (serotonin, noradrenaline, gabaminergic and glutamatergic) impact on hormonal systems to produce major depression. (Athanasos, 2017: Clark & Temmhoff, 2021) 14 Causation: Trauma Emotional and psychological trauma can be caused by both one- off and ongoing events. (e.g., accident, natural disaster, or an attack.) On-going trauma can result from relentless stressful events, such as childhood sexual, emotional or physical abuse. Emotional responses include: numbness, emotions such as shock, denial, guilt or self-blame, extreme sadness, mood changes, difficulty concentrating, repeating memories, triggers. Physical symptoms: changes in eating or sleeping and use of alcohol or drugs. Many of these feelings are a normal part of recovering from any trauma, but sometimes these feelings go on for a long time and may lead to depression. (Athanasos, 2017: Clark & Temmhoff, 2021) 15 Causation: Personality and Stress Personality types: pessimistic explanatory style; catastrophic thinking; rumination Learned helplessness from stressful life events Depression can be triggered or exacerbated by stressful conditions, particularly by cumulative stressors. The concept of resilience refers to our capacity to adapt to stress and move forward with our development despite adversity. Resilience can be learned (reframing) (Athanasos, 2017: Clark & Temmhoff, 2021) 16 Causation: Environmental Stress Environmental events surrounding pregnancy and birth have been linked to an increased development of mental illness in offspring: Obstetric birth complications Maternal infections Gestational exposure to alcohol or drugs Such factors are thought to affect specific areas of neurodevelopment Studies confirm that stress can precipitate both manic and depressive episodes (Athanasos, 2017: Clark & Temmhoff, 2021) 17 Major Depressive Disorder The main symptoms of depression are depressed mood most of the day, nearly every day as indicated by self-report or observations made by others. The other main symptom is loss of enjoyment and pleasure in life. For diagnosis: Five or more symptoms will have been present during the same two-week period and represent a change from previous functioning, and... The symptoms are not better accounted for by bereavement, and... The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. (APA, 2013) 18  Depressive symptoms Moderate Mild Severe Persistent low Feeling “blue “or Unable to function. mood. Able to “down” Suicidality. function.  Other types of depression Persistent depressive disorder (Dysthymia) – depressed mood most of the day, for more days than not, for at least 2 years. Perinatal (ante natal and postpartum depression). Includes depressed mood, excessive anxiety, insomnia and change in weight. Premenstrual dysphoric disorder (PMDD). Extreme fatigue, feeling sad, hopeless, or self-critical. Severe feelings of stress or anxiety mood swings. Seasonal affective disorder (SAD). Disturbance in the normal circadian rhythm of the body. More common in areas further from the equator. Older person’s mental health – increasing client group. (Clark & Temmhoff, 2021) 20 Activity: Living with depression: Watch the video Ngaro's story | https://www.youtube.com /watch?v=6xRONDGpzYQ Identify aspects important to their experience and recovery using Te Whare Tapa Whā. Nursing considerations: Depression Develop a therapeutic rapport Encourage person to express feelings Ascertain person's strengths and negotiate small manageable goals to increase sense of achievement Structure the day – gently support person to become involved in regular brief social and recreational activities Encourage regular meals and activities of daily living (sleep, exercise and mindfulness). Listen so client feels heard and understood; acknowledge distress 22 Nursing considerations: Depression Assess for thoughts of suicide and self-harm Avoid Alcohol and other drugs Give culturally specific care Medication and/or other treatment (ECT) Risks and side effects of medication Hospitalisation may be necessary 23 Electro Convulsive Therapy (ECT) ECT is sometimes prescribed for severe depression, catatonia and mania. The most common reason for prescribing ECT for people in New Zealand is severe depression. In some cases of severe depression ECT is prescribed because the standard treatments have not worked ECT is always given as a course of treatments rather than just once. One course of treatments can involve between six and twelve individual treatments. Very occasionally, ECT is prescribed for people experiencing mania. In these few cases, it is prescribed when the illness has become life-threatening or dangerous. 24 Electro Convulsive Therapy (ECT) The Neurotransmitter theory suggests that ECT works in a similar way to antidepressant medication. ECT causes a seizure that increases the amount of neurotransmitters available for communication between neurons. At the same time, it also makes the brain cells more responsive to the neurotransmitters. Side effects include loss of memory about the events immediately before and after ECT, heart rhythm disturbances, low blood pressure, headaches, nausea, sore muscles, aching jaw and confusion. (Fisher et al, 2017) 25  Bipolar Affective Disorder Muzina DJ, Colangelo E, Manning JS, et al. Differentiating bipolar disorder from depression in primary care. Cleve Clin J Med 2007;74:95–9. Cited in BPJ Issue 62 Bi-polar Disorder: Identifying and supporting patients in Primary 26 Care Bipolar Affective Disorder A recurrent mood disorder featuring one or more episodes of mania, or mixed episodes of mania and depression The DSM-5 (APA, 2013) classifies bipolar disorder into bipolar 1 disorder and bipolar 2 disorder. Affects approximately 1.2% of population. Onset is usually between ages 15-30, and type i bipolar disorder is about equally common in men and women. Bipolar I disorder involves 1+ episodes of mania and often depression (but does not require diagnosis of depression) Bipolar II disorder involves episodes of 1+ depression and a less severe form of mania called hypomania (Clark & Temmhoff, 2021) 27  Mania is characterised by three main features: Persistently elevated mood, which may be one of elation or irritability; Increased activity; Mania And poor judgement (Athanasos, 2017: Clark & Temmhoff, 2021) 28 Diagnostic criteria for mania Three (or more) of the following symptoms have persisted and have been present to a significant degree; Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility Increase in goal directed activity (either socially, at work, sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (APA, 2013) 29 In Bipolar Disorder A moderate to severe depression usually follows mania Usually characterised by reversed-vegetative symptoms Depressive episodes tend to last longer than manic episodes (median length about 6 months), though may last longer in the elderly With increasing age, the frequency and duration of episodes generally increases Hypomania has similar symptoms to mania, with the following exceptions: There is no significant impairment in social or occupational function; There are no psychotic features A mixed episode is where features of mania and depression such as agitation, anxiety, fatigue or irritability occur simultaneously or in short succession. E.G. Racing thoughts during a depressive episode or tears during a manic episode. Cyclothymia- at least 2yrs of hypomanic periods that do not meet criteria for other disorders (Athanasos, 2017: Clark & Temmhoff, 2021) 30. Activity: Watch: Living with Bipolar: https://www.talkingminds.co.nz/sto ries/reverend-imoa In pairs/threes: Identify three actions a RN can take to address stigma 31 Nursing considerations: Mania Monitor and document sleeping patterns due to insomnia Client’s may become exhausted from excessive psychomotor activity and lack of sleep, consider prn sedative to assist sleep and/or reduce agitation If client cannot tolerate meals, offer regular small snacks throughout the day to maintain dietary requirements Avoid coffee and coke or other stimulants Medications (Mood stabilisers, Antipsychotics). Discuss side effects 32 Nursing considerations: Mania Safety – prevent manic patients from hurting themselves or others. Provide a low-stimulus environment – quiet rooms with limited activities or stimuli Set clear limits on behaviour with brief and simple directions. Do not argue with the client Consistent team approach to reduce staff splitting, blaming and limit testing Reinforce reality if needed Hospitalisation is often necessary to prevent harm to self or others, maintain dignity and to manage a psychosis that may develop 33 Psycho -pharmacology The main classes of Selective serotonin When psychotic reuptake inhibitors medication used to features are evident treat major (SSRIs) are the (with either major more popular class depression and depression or bipolar disorder are of antidepressants, bipolar disorder), an and lithium and antidepressants antipsychotic may and mood sodium valproate be required. are common mood stabilisers. stabilisers. 34 Anti-depressant medication SSRIs (selective SNRIs (serotonin and serotonin reuptake The main groups of noradrenaline reuptake inhibitors) antidepressants are: inhibitors) e.g. fluoxetine, e.g. venlafaxine citalopram These medications have Monoamine Oxidase Tricyclic Antidepressant not been shown to differ Inhibitors (MAOIs) (TCAs) substantially in their effectiveness, but they e.g., phenelzine e.g. amitriptyline do differ in their side effect profiles. Neurotransmitters and depression Noradrenaline Serotonin Dopamine Stress hormone Effects tends to be Plays a major role in Affects amygdala. inhibitory. reward-motivated Effects on attention Modulates mood, behaviour. and responding anxiety, nausea, Modulates anger, 36 actions. sexual libido, perception, motivation, Alertness, arousal, temperature control, cognition, movement and influences on blood pressure, and and kidney function. the reward system. sleep/wakefulness Most types of reward 36 increase the level of  SSRI: Mode of action Serotonin and noradrenaline are released into the synapse. On the pre-synaptic side there are re-uptake sites that reabsorb the chemicals very quickly. SSRIs and SNRIs act by blocking these sites (or channels) so again result in more of the chemical being available in the synapse for a longer period of time. SSRIs administered normally 1x a day Absorbed in stomach (80-90% in GI tract) Binds to plasma protein Metabolised in liver – long half life. Fluoxetine very long (up to 16 days)Excreted by kidney Half life has to be taken into account when switching antidepressants as can interact. Side effects include GI effects: nausea, vomiting, diarrhoea, dyspepsia, weight loss or weight gain, Sexual: loss of libido, (Almand & Trimmer, sexual function, Sleep disturbance; insomnia and weird dreams, 2021) Temperature disturbance: fever, Dry mouth. Headache, dizziness, Increased anxiety, suicidality, Bleeding abnormalities – clotting cascade 38 Serotonin syndrome Neuromuscular effects Autonomic effects Mental state changes  Hyperreflexia  Hyperthermia:  Agitation mild, < 38.5°C;  Clonus severe ≥ 38.5°C  Hypomania  Myoclonus  Tachycardia  Anxiety  Shivering  Diaphoresis  Confusion  Tremor  Flushing  Hypertonia/rigidity  Mydriasis 39 SSRI discontinuation syndrome Flu-like symptoms (nausea, vomiting, diarrhoea, headaches, sweating). Sleep disturbances (insomnia, nightmares, constant sleepiness). Sensory and movement disturbances have also been reported, including imbalance, tremors, vertigo, dizziness. Electric-shock-like experiences in the brain “brain zaps”. Mood disturbances (anxiety, or agitation are also reported). Cognitive disturbances such as confusion and hyperarousal. (Almand & Trimmer, 2021) 40 Mood Stabilisers  Sodium Valproate: Mood of Action First used as treatment for epilepsy in 1960s (Epilum). Anticonvulsant Gamma-aminobutyric acid (GABA) agonist. Anti-kindling: reducing sensitivity to electrical impulses in the brain and irregular firing of neurons. Direct membrane stabilizing effect altering cation (+ charge) transport (K, Na and Ca). Side effects: GI effects: nausea, vomiting, diarrhoea, dyspepsia, weight loss or weight gain. Endocrine: amenorrhea, menstrual disturbance, polycystic ovary syndrome. Hyper-ammonaemia, CNS changes: lethargy, sedation tremor, Hair loss, Osteoporosis, Haematological – thrombocytopenia, bruising and haemorrhage. Leukopenia, Neutropenia, Agranulocytosis, Hepatic toxicity; pancreatitis (Almand & Trimmer, 2021) 42 Lithium Carbonate: Mood of Action Lithium carbonate is an inorganic compound; the lithium salt of carbonate with the formula Li2CO3. This white salt is widely used in the processing of metal oxides and treatment of mood disorders. Not metabolised; excreted by kidneys. Blocks ability of neurons to restore levels of the second message system. Lithium displaces K+ & Na+ possibly Ca+2 to occupy sites. Direct membrane stabilising effect altering cation transport (K, Na and Ca). Inhibits excitatory neurotransmitters such as dopamine and glutamate and promotes GABA-mediated neurotransmission. Side Effects: GI effects: nausea, vomiting, diarrhoea, dyspepsia, weight loss or weight gain, Haematological –leucocytosis, Hair loss, acne and psoriasis, Cardiac: ECG changes, Metabolic: weight gain, oedema and hypothyroidism, CNS changes: lethargy, sedation, tremor, Renal: polyurea or polydipsia. Long term kidney failure 43 (Almand & Trimmer, 2021)  Lithium toxicity Avoid sodium depletion or dehydration as can be toxic. Regular blood test to monitor serum levels; monitor kidney function. Overdose/toxicity: maintenance of fluid and electrolyte balance to prevent hyponatraemia; ecg monitoring, control of hypotension and seizures Therapeutic range: 0.7-1.2 mmol/l < 0.5 mmol/l no effect. > 1.5 risk of toxicity. 1.7-2.0 mmol/l: diarrhoea, nausea & vomitting, blurred vision, muscle weakness, tremor, ataxia & dysarthria. > 2.0 mmol: hyperreflexia & hyperextension, seizures, hypotension, renal & circulatory failure, confusion coma, death. 44 References American psychiatric association (APA). ( 2013). Diagnostic and statistical manual of mental disorders 5th ed. APA, Washington Almand B and Trimmer W (2021) Psychopharmacology A Handbook for New Zealand Health Professionals, Whitireia NZ Athanasos P., (2017) Mood Disorders in Evans, K., Nizette, D., & O’Brien, A. (Eds) Psychiatric and mental health nursing. 4th edition. Elsevier. Camann, M. (2010). The psychiatric nurse's role in application of recovery and decision- making models to integrate health behaviors in the recovery process august 2010 issues in mental health nursing 31(8):532-6 DOI: 10.3109/01612841003687316 Clark, G. And Temmhoff, S. (2021) Mood disorders in K. Foster (ed) Mental Health in Nursing Elsevier Hillhouse, T.M., & Porter, J. H, (2015) A brief history of the development of antidepressant drugs: from monoamines to glutamate. Experimental and clinical psychopharmacology 23(1):1–21 Kim, D.R., O’Teardon J. P., & Epperson, C.N. ( 2010) Guidelines for the management of depression during pregnancy. Current psychiatry reports 12(4):279–81 References Lehne, R. (2011) pharmacology for nursing care, 8th ed. Saunders Elsevier Fink, C. Md. (2008). Bipolar disorder & heredity – the genetic link. Http://blogs.Psychcentral.Com/bipolar/2008/07/bipolar-disorder-heredity-%e2%80%93-the- genetic-link-part-i/ Fisher, M., Morrison, J.,; Jones, P.,(2017) Electroconvulsive Therapy Practice in New Zealand. The Journal of ECT 33(2):p 134-137, | DOI: 10.1097/YCT.0000000000000364Ministry of Health (2022) : New Zealand health survey annual update of key results 2021/22: New Zealand Health Survey | Ministry of health NZ Ministry of Health (2023) Annual update of key results 202/23: : New Zealand Health Survey | Ministry of health NZ Procter, N.G., Froggatt, T., Mcgarry, D., Wilson, R., & Hamer, H., (2014) Mental Health : a person-centred approach.. : Cambridge UniversityPpress. Sorenson s., (2018). Labelling, recovery and therapeutic optimism https://mindthecaretraining.Com/2018/02/20/labelling-recovery-and-therapeutic-optimism Further Resources https://moodle.whitireia.ac.nz/mod/forum/discuss.php ?d=180951 Pharmacology - ANTIDEPRESSANTS - SSRIs, SNRIs, TC As, MAOIs, Lithium ( MADE EASY) – YouTube 2-Minute Neuroscience: Selective Serotonin Reuptake Inhibitors (SSRIs) – YouTube Lithium in Bipolar Disorder - One Minute Medical Scho ol - YouTube 47