Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 17 Mood Disorders and Suicide
Apr 01, 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 17
Mood Disorders and Suicide
Chapter 17
Mood Disorders and Suicide
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mood DisordersMood Disorders
• Affective disorders
– Pervasive alterations in emotions manifested by depression, mania, or both
– Interference with life; long-term sadness, agitation, or elation
• Individuals with mood disorders throughout history
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Mood Disorders (cont.)Mood Disorders (cont.)
• Most common psychiatric diagnosis associated with suicide
– Depression one of the most important risk factors for it
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Categories of Mood DisordersCategories of Mood Disorders• Major depressive disorder
• Bipolar disorder
• Related disorders– Dysthymic disorder– Cyclothymic disorder– Substance-induced depressive or bipolar disorder– Seasonal affective disorder– Postpartum depression, psychosis, premenstrual
dysphoric disorder– Nonsuicidal self-injury
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EtiologyEtiology
• Biologic theories
– Genetic theories
– Neurochemical theories: serotonin, norepinephrine; possibly acetylcholine and dopamine
– Neuroendocrine influences: hormones
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Etiology (cont.)Etiology (cont.)
• Psychodynamic theories
– Freud: self-deprecation
– Bibring: ideal ego
– Jacobson: superego over powerless ego
• Mania: defense against underlying depression
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Cultural ConsiderationsCultural Considerations
• Masking of depression by other behaviors considered age appropriate – School phobia, hyperactivity, learning disorders,
failing grades, antisocial behaviors
– Substance abuse, gangs, risk behaviors, eating disorders, compulsive behaviors
• Somatic complaints– Major manifestation among cultures that avoid
verbalizing emotions
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QuestionQuestion
• Is the following statement true or false?
• Depression is most commonly associated with suicide.
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AnswerAnswer
• True
• Rationale: Depression is considered the most common diagnosis that results in suicide.
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Major Depressive DisorderMajor Depressive Disorder
• Incidence: women to men 2:1
– Decreases with age in women; increases with age in men; highest in single, divorced people
• 50% to 60% will suffer recurrence
• Approximately 20% will develop a chronic form of depression
• Symptoms range from mild to severe
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Major Depressive Disorder (cont.)Major Depressive Disorder (cont.)
• Symptoms: sad mood, lack of interest in life activities (2 weeks or more), and at least four other symptoms:– Changes in eating habits → weight gain or loss– Hypersomnia or insomnia– Impaired concentration, decision making, or problem
solving– Worthlessness, hopelessness, despair, guilt– Thoughts of death/suicide– Overwhelming fatigue, negative thinking
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PsychopharmacologyPsychopharmacology
• Selective serotonin reuptake inhibitors (see Table 17.1)
• Cyclic antidepressants (see Table 17.2)
• Atypical antidepressants (see Table 17.3)
• Monoamine oxidase inhibitors (MAOIs) (see Table 17.4)
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Other Medical Treatments and PsychotherapyOther Medical Treatments and Psychotherapy• Electroconvulsive therapy (ECT)
• Psychotherapy (combined with medications)– Interpersonal therapy: relationship difficulties– Behavior therapy: reinforcement of positive
interactions– Cognitive therapy: correction of cognitive distortions
(see Table 17.5)
• Investigational treatments
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Major Depressive Disorder and Nursing Process ApplicationMajor Depressive Disorder and Nursing Process Application
• Assessment – History– General appearance, motor behavior (psychomotor
retardation, latency of response, psychomotor agitation)
– Mood, affect (anhedonia)– Thought process, content (rumination, suicide)– Sensorium, intellectual processes (impaired memory)
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Major Depressive Disorder and Nursing Process Application (cont.)Major Depressive Disorder and Nursing Process Application (cont.)
• Assessment (cont.)– Judgment, insight (impairment)– Self-concept (worthlessness)– Roles, relationships (difficulty in this area)– Physiologic, self-care considerations– Depression rating scales
• Self-rating scales: Zung, Beck• Clinician rating scale: Hamilton Rating Scale
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QuestionQuestion
• Is the following statement true or false?
• Patients with depression often exhibit anhedonia.
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AnswerAnswer
• True
• Rationale: Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression.
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Major Depressive Disorder and Nursing Process Application (cont.)Major Depressive Disorder and Nursing Process Application (cont.)
• Data analysis/nursing diagnoses
• Outcome identification– Free from self-injury
– Improved mood and energy
– Return to previous functional level
– Medication compliance
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Major Depressive Disorder and Nursing Process Application (cont.)Major Depressive Disorder and Nursing Process Application (cont.)
• Intervention– Providing for safety (suicide precautions)– Promoting therapeutic relationship– Promoting ADLs, physical care– Using therapeutic communication– Managing medications– Patient, family teaching
• Evaluation
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Bipolar DisorderBipolar Disorder
• Extreme mood fluctuations from mania to depression (see Figure 17.1)
• Second only to major depression as cause of worldwide disability
• Onset usually in late teens, 20s, or 30s
• Manic episodes begin suddenly, last from a few weeks to several months
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Treatment Treatment
• Psychopharmacology – Antimanic agent: lithium – Anticonvulsant agent used as mood stabilizer (see
Table 17.6)– Agents helpful in reducing manic behavior, protecting
against bipolar depressive cycles
• Psychotherapy useful in mildly depressive or normal portion of bipolar cycle– Not useful during manic stages
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Bipolar Disorder and Nursing Process Application Bipolar Disorder and Nursing Process Application
• Assessment– History– General appearance, behavior (pressured speech,
flamboyancy, sexually suggestive)– Mood, affect (euphoric, grandiose)– Thought process, content (circumstantiality,
tangentiality)– Sensorium, intellectual processes (disoriented to
time)
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Bipolar Disorder and Nursing Process Application (cont.)Bipolar Disorder and Nursing Process Application (cont.)• Assessment (cont.)
– Judgment, insight– Self-concept (exaggerated)– Roles, relationships (labile emotions)– Physiologic, self-care considerations
• Data analysis/nursing diagnoses• Outcome identification
– Free from injury—med compliance– Meet basic needs and self-care– Socially appropriate behavior
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QuestionQuestion
• Which of the following would be most appropriate for the treatment of mania associated with bipolar disorder?
– A. Lithium
– B. Fluoxetine
– C. Citalopram
– D. Venlafaxine
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AnswerAnswer
• A. Lithium
• Rationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic patient with bipolar disorder.
– Fluoxetine, citalopram, and venlafaxine are antidepressants.
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Bipolar Disorder and Nursing Process Application (cont.)Bipolar Disorder and Nursing Process Application (cont.)
• Intervention– Providing for safety – Meeting physiologic needs– Providing therapeutic communication– Promoting appropriate behaviors– Managing medications (see Tables 17.6 and 17.7)– Providing patient, family teaching
• Evaluation
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SuicideSuicide
• Intentional act of killing oneself
• Suicidal ideation: thinking about killing oneself
• Warning signs: risk for suicide (see Box 17.4)
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Suicide (cont.)Suicide (cont.)
• Assessment: – Previous suicide attempts (first 2 years after—highest
risk period, especially first 3 months); relative who committed suicide
– Warnings of suicidal intent (see Box 17.4); risky behavior
– Lethality assessment
• Data analysis/nursing diagnoses
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Suicide (cont.)Suicide (cont.)
• Outcome identification
– Safety, free from self-harm
• Intervention– Authoritative role
– Safe environment: suicide precautions; no suicide/no self-harm contract
– Support system list
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Suicide (cont.)Suicide (cont.)
• Family response
– Suicide as ultimate rejection of family, friends
– Families react with guilt, shame, anger
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Suicide (cont.)Suicide (cont.)• Nurse’s response
– Need for unconditional positive regard for person
– Avoidance of patient blame
– Nonjudgmental approach, tone
– Belief that one person can make a difference in another’s life
– Possible devastation of staff if patient commits suicide
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Legal and Ethical Considerations Legal and Ethical Considerations
• Assisted suicide as topic of national legal, ethical debate (Oregon, the first state to adopt assisted suicide into law)
• Nurse often cares for terminally or chronically ill people with poor quality of life.
• Nurse’s role to provide supportive care for patients, family as they work through decision-making process
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QuestionQuestion
• Is the following statement true or false?
• When dealing with a patient who is suicidal, the nurse needs to assume a dependent role.
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AnswerAnswer
• False
• Rationale: When dealing with a patient who is suicidal, the nurse must take an authoritative role.
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Elder Considerations Elder Considerations
• Depression common among the elderly; marked increase when elders are medically ill– Psychotic features common
– Increased intolerance to medications
– ECT more commonly used for treatment; more rapid response
• Suicide increased among elderly
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Community-Based Care Community-Based Care
• Nurses as first health-care professionals to recognize behaviors consistent with mood disorders
• Successful treatment of depression in community by psychiatrists, psychiatric advanced practice nurses, primary care physicians
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Community-Based Care (cont.) Community-Based Care (cont.)
• Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment
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Mental Health Promotion Mental Health Promotion
• Education to address stressors contributing to depressive illness
• Efforts to improve primary care treatment of depression
• Prevention and early detection, treatment for adolescents
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Mental Health Promotion (cont.) Mental Health Promotion (cont.)
• Screening for early detection of risk factors
– Family strife
– Parental alcoholism or mental illness
– History of fighting
– Access to weapons in the home
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Self-Awareness IssuesSelf-Awareness Issues
• Importance of dealing with own feelings about suicide
• Frustration possible when working with depressed or manic patients
• Exhaustion possible when working with manic patients
• Journaling to help deal with feelings; talking with colleagues often helpful