This lecture is focused on mood disorders and suicide. We will differentiate the clinical presentation of clients experiencing mood disorders, explore the role of the nurse caring for clients experiencing mood disorders, and apply the nursing process. Mood disorders are also called effective disorders. They are pervasive alterations and emotions that are manifested by depression or mania or both. They interfere with a person's life often causing them drastic and long-term sadness, agitation, or elation. From early history, people have suffered with mood disturbances. Until the mid 1950s, no treatment was available to help people with serious depression or mania. We now know mood disorders are the most common psychiatric diagnoses associated with suicide. Depression is one of the most important risk factors for it. The primary mood disorders are major depressive disorder and bipolar disorder. A major depressive episode lasts at least 2 weeks during which the person experiences a depressed mood or loss of pleasure in nearly all activities. There are many symptoms that result in significant distress or impairment of social, occupational, or other important areas of functioning. Bipolar disorder is diagnosed when a person's mood fluctuates to extremes of mania and/or depression. Mania is a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable. Bipolar disorder are often described as bipolar one disorder or bipolar 2 disorder. In bipolar one disorder, this is characterized by one or more manic or mixed episodes, usually accompanied by major depressive episodes. For bipolar 2 disorder, there is one or more major depressive episode accompanied by at least one hypomomanic episode. And hypomomania is a period of abnormally and persistently elevated expansive or irritable mood and some other milder symptoms of mania. The difference is that hypomomanic episodes do not impair the person's ability to function and there are no psychotic features such as delusions or hallucinations. Other disorders classified with similarities to mood disorders are listed on the screen. We're not going to focus on those as much. Various theories for the ideology of mood disorders exist. Most recent research focuses on chemical, biologic imbalances as the cause. However, psychosocial stressors and interpersonal events appear to trigger certain physiological and chemical changes in the brain. This significantly alters the balance of neurotransmitters. Effective treatment addresses both biologic and psychosocial components of mood disorders. Therefore, nurses need a basic knowledge of both perspectives when working with clients experiencing these mood disorders. In terms of cultural considerations, while there are many tools or multiple tools to assess depression, the Hamilton rating scale for depression is considered the gold standard and has been studied to determine whether general depression questions were valid and reliable across diverse cultures. And they the researchers determined that symptoms related to general depression were reliable. that is depressed mood, guilt, loss of interests, slowing or retardation, suicide, and psychological anxiety. In addition, often times sematic ailments or physiological complaints can accompany depression. This manifestation varies among cultures and may be more apparent in cultures that avoid verbalization of emotions. For example, some people may report physical problems such as a backachche or headache rather than being able to verbalize their feelings or emotions. It is also important to consider cultural attitudes toward mental illness. There may be a reluctancy to disclose struggles or that the admission of the need for help. The individual could fear losing a job, fear the loss of custody of children, fear of the loss of relationships, etc. The nurse needs to communicate respectfully and empathetically with the client to asssure that disclosure of symptoms to the nurse will not lead to rejection, bias, or stigma. Pause here and consider, is the following statement true or false? Depression is one of the most important risk factors for suicide. The answer is true. Major depressive disorder typically involves two weeks or more of a sad mood or lack of interest in life activities with at least four other symptoms of depression such as anhidonia, changes in weight, sleep, energy, concentration, decision making, self-esteem, and goals. Major depression is twice as common in women and has a 1 and a half to three times greater incidence in firstdegree relatives than the general population. An untreated episode of depression can last from a few weeks to months or even years, though most episodes clear in about 6 months. Some people have a single episode of depression while 50 to 60% of people will have a recurrence. Approximately 20% will develop a chronic form of depression. Depressive symptoms can vary from mild to severe. Some people with severe depression can experience psychotic features such as delusions and hallucinations. Major categories of anti-depressants include cyclic anti-depressants, monoamine oxidase inhibitors or MAIs, selective serotonin reuptake inhibitors or SSRIs, and atypical anti-depressants. The choice of which anti-depressant to use is based on the client's symptoms, their age, and physical health needs. Drugs that have or have not worked in the past or that have worked for a blood relative with depression and other medications that the client is taking are all taken into consideration. In clients who have acute depression with psychotic features, an antiscychotic can be used in combination with an anti-depressant. The antiscychotic treats the psychotic features. Several weeks into treatment, the client is reassessed to determine whether the medication can be withdrawn and the anti-dopressant maintained. In addition to the use of medication, non-farmacologic treatments can be used. Cognitive behavioral therapy or CBT usually involves meeting with a trained therapist who empowers the client to change behavior by changing their thinking. Electrocomvulsive therapy or ECT is administered to a client who may have had treatment refractory depression. Transcranial magnetic stimulation or TMS uses magnetic pulses to stimulate focal areas of the cerebral cortex. Unlike ECT, no anesthesia is used in TMS. A veagal nerve stimulator is implanted through an outpatient procedure in the left chest wall. For deep brain stimulation or DBS, implants are surgically implanted electrodes into the brain to stimulate underactive regions. This is more invasive than the VNS and is implanted surgically. Light therapy can be used for those clients who experience seasonal affective disorder because of the lack of sunshine. Other alternative therapies such as St. John's wart could be used by the patient. It's important that a patient understand that St. John's wart should not be taken with SSRIs. When gathering an assessment as part of the nursing process, it's important to note the nurse can collect assessment data from the client, from family or significant others, from previous chart information, and any others involved in the support or care of the client. It may take several periods to complete the assessment because clients who are severely depressed feel exhausted and overwhelmed. It can take time for them to process your question and or to formulate a response. It's important that we try not to rush them because this will lead to frustration and incomplete assessment data. To assess the client's perception of the problem, it's important to ask about behavioral changes, when they started, what was happening when they started, their duration, and what the client has tried to do about them. It's also important to determine any previous episodes, any previous treatment, and the client's response to said treatment. The nurse should also ask about family history of mood disorders, suicide, or attempts. In terms of general appearance and motor behavior, often times many people with depression look sad. Sometimes they just look ill. The posture is often slouched with head down, and they may make minimal eye contact. Consider cultural differences when it comes to eye contact. There may be slow body movements, slow cognitive processing, and slow verbal interaction. They may also demonstrate psychoot agitation. That is increased body movements and thoughts, which includes things like pacing, accelerated thinking, and argumentativeness. In terms of mood and affect, clients with depression may describe themselves as hopeless, helpless, down, or anxious. They may also say they are a burden on others or a failure. They experience anidonia, losing any sense of pleasure from activities they formerly enjoyed. They may be apathetic, that is not caring about themselves, activities, or much of anything. Clients with depression in terms of their thought processes thought processes and content experience slow thinking and their thinking seems to occur in slow motion. With severe depression, they may not respond verbally to questions. They may tend to be negative and pessimistic in their thinking. They may believe they will always feel this bad and things will never get better. They may ruminate which is repeatedly going over the same thoughts. Often clients with depression have thoughts of dying or um taking their own life by suicide. It's important to assess suicidal ideiation by asking about it directly such as the nurse may ask are you thinking about suicide or are you thinking about killing yourself? Most clients will readily admit to suicidal thinking. We'll discuss suicide more later. In terms of sensorium and intellectual processes, some clients with depression are oriented to person, place, and time. Others experience difficulty with orientation. Memory impairment is probably the most common. Continuing on with the nursing process phase of assessment. In terms of judgment and insight, clients with depression often experience impaired judgment because they cannot use their cognitive abilities to solve problems or make decisions. Their sense of self-esteem is greatly reduced. Oftent times um they may use phrases such as good for nothing, a failure, or just feeling worthless to describe themselves. They may feel guilty about not being able to function and often personalize events or take responsibility over which they have no control. Clients with depression often have difficulty fulfilling roles and responsibilities. The more the more severe the depression, the greater the difficulty. This may include problems going to work or school. Uh they seem unable to carry out their responsibilities. This is also true when it comes to family responsibilities. Depression can cause great strain in relationships. Clients with depression often experience pronounced weight loss because of lack of appetite or disinterest in eating. They may experience sleep disturbances. They lose interest in sexual activities. Some clients may neglect personal hygiene because they lack interest or energy and constipation is common um due to a decreased food and fluid intake as well as from inactivity. There are multiple depression rating scales that are available to help the client selfassess and also clinician rating scales such as the Hamilton rating scale. All of these tools will help us to assess the severity of depression. Consider whether the following statement is true or false. Clients with depression often exhibit anhidonia. The answer is true. Anhidonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression. The next step in the nursing process is to analyze the assessment data and determine priorities to establish a plan of care. Common problems for the client with depression include risk for suicide, inadequate nutrition, anxiety, ineffective coping, hopelessness, inability to fulfill life roles and responsibilities, self-care deficits, low self-esteem, disrupted or poor quality sleep, and impaired social interaction. So if we think of those being any um problems in our plan of care or the P in our ADPI, next we would identify outcomes or what are the goals for our clients with depression. For example, some outcomes we might identify would be the client will not injure themsel or they'll remain free from self-injury. The client will independently carry out activities of daily living. The client will establish a balance of rest, sleep, and activity. The client will evaluate sal self attributes realistically. The client will establish a balance of adequate nutrition, hydration, and elimination. The client will socialize with staff, peers, and family or friends. The client will maintain medication compliance and verbalize symptoms of recurrence. Next in the nursing process is actions or nursing interventions. Our priority is always providing for safety. This includes safety of the client and safety of others. This may mean that we need to institute suicide precautions as indicated. If indicated, it's important to begin and promote a therapeutic relationship by spending time with the client. We want to promote completion of activities of daily living by assisting the client only as necessary. We want to establish adequate nutrition, hydration, promote sleep and rest. Engage the client in activities. Encourage the client to verbalize and describe their emotions. work with the client to manage medications and side effects and provide client and family teaching. In the evaluation phase, we're really evaluating the plan of care based on the achievement of individualized client outcomes based on our assessment for this particular patient. It's essential that the client feels safe and no longer experiences uncontrollable urges um to die by suicide. Participation in therapy and medication compliance produces more favorable outcomes for clients with depression. Bipolar disorder involves extreme mood swings from episodes of mania to episodes of depression. Bipolar disorders are characterized by having trouble processing thoughts, speaking quickly but not necessarily thoughtfully, confused thought content, and decreased cognitive functioning. I would encourage you to review the graphic depiction of mood cycles, figure 17.1 in your vitbeck text. Bipolar disorder ranks second only to major depression as a cause of worldwide disability. The lifetime risk for bipolar disorder is about 2% in both adults and children. It occurs almost equally among men and women and is more common in highly educated people. Mild cycling between hypomomania and mild depressive symptoms is called psychic disorder. A client who experiences extremely high levels of mania may be diagnosed with bipolar one disorder. The diagnosis The diagnosis of a manic episode or mania requires at least one week of unusual and incessantly heightened grandiose or agitated mood in addition to three or more other symptoms. Bipolar one disorder requires at least one episode of mania not better explained by another diagnosis. A client who has bipolar 2 disorder may have less mania but more profound depression. Treatment for bipolar disorder involves a lifetime regimen of medications either an antimanic agent called lithium or anticonvulsant medications used as mood stabilizers. Bipolar disorder is the only psychiatric disorder in which medications can prevent acute cycles of the bipolar behavior. If a client in the acute stage of mania or depression exhibits psychosis, an antiscychotic agent is often administered in addition to the bipolar medications. In addition to psychopharmarmacology, psychotherapy can be useful. It is often useful when patients are in a mildly depressive or normal quote unquote portion of bip of the bipolar cycle. It is not useful during manic stages. However, conducting an assessment and taking a history with the client in the manic phase often proves difficult. The client may jump from subject to subject making it difficult for the nurse to follow along. Obtaining data in several short sessions as well as talking to family members and consulting the chart uh may be necessary. The nurse can obtain much information, however, by watching and listening. Clients with mania experience psychoot agitation and seem to be in perpetual motion. Sitting still is difficult. In the manic phase, the client may wear clothes that reflect the elevated mood such as brightly colored, flamboyant, attentiong, and perhaps sexually suggestive clothing. They may move, think, and talk fast. They may experience pressured speech which is one of the hallmark symptoms evidenced by unrelenting rapid and often loud speech without pauses. In terms of mood and a effect, mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a full sense of well-being. Cognitive ability or thinking is can be confused and jumbled with thoughts racing one after another which is often referred to as a flight of ideas. Clients may not be able to connect concepts as they jump from one subject to another. Clients who are experiencing mania may be oriented to person and place but rarely to time. Intellectual functioning is difficult to assess during the manic phase. Clients may claim to have many abilities they do not actually possess, and their ability to concentrate or pay attention is grossly impaired. Individuals in the manic phase are often impulsive and rarely think before acting or speaking, making their judgment poor. Insight is limited because they often believe they are fine and have no problems. They may blame difficulties on others. Clients with mania often portray an exaggerated self-esteem. They believe they can accomplish anything. Sometimes they even have grandiose thoughts like they believe they are sent by God or something like that. They rarely discuss their self-concept realistically. Clients in the manic phase can rarely fulfill role responsibilities. They often have trouble at work or school, even if they are attending, and are too distracted and hyperactive to pay attention. Although they may begin, many tasks or projects they often complete, few if any. They have a great need to socialize, but little understanding of their excessive, overpowering, and often confrontational social interactions. Although the usual mood of people with mania is elation, emotions can be unstable and can fluctuate readily between euphoria and hostility. Clients with mania can go days without sleep or food and not really even realize they're hungry or tired. They may be on the brink of physical exhaustion, but are unwilling or unable to stop, rest, or sleep. They often ignore their own personal hygiene as they have more important things to do. The nurse analyzes and prioritizes problems to establish a plan of care. Problems commonly identified for clients who are in the manic phase include risk for violence or unintended injury, inadequate nutrition, ineffective coping, non-compliance, unable to fulfill roles, self-care deficits, low self-esteem, and inadequate rest and sleep. Let's pause here for a question. Which medication would be most appropriate for the treatment of mania associated with bipolar disorder? The answer is lithium. Lithium is an anti-imic agent which would be most appropriate for treating a manic client with bipolar disorder. The other medications are anti-depressants. Many of the nursing interventions or actions for a client with bipolar disorder are similar to those with major depressive disorder. And as you can recall, bipolar disorder includes depression. So, we're really going to focus more on um the manic side of bipolar disorder. And so, again, your priority is always providing for safety. We also want to meet physiological needs of the client, provide therapeutic communication, and promote appropriate behaviors, manage medications, and provide client and family teaching. There is a nice plan of care for a client with mania in your textbook. And some examples for therapeutic communication as well are listed throughout um this section of the textbook. And then for evaluation, we're always evaluating, right, whether our interventions are effective. And when we're evaluating the treatment of bipolar disorder, this could include any safety concerns or issues. um comparison of mood and affect between the start of treatment and the current time, adherence to the regimen of medication and psychotherapy, changes in the client's perception of quality of life and achievement of specific goals including new coping methods. And so evaluation again is always reassessing are my interventions effective and then adjusting the plan of care as needed. Next, we're going to discuss suicide. Clients who are profoundly depressed may express an interest in stopping the emotional turmoil they are feeling through self harm. Suicide is defined as death caused by self-directed injurious behavior with intent to die as a result of the behavior. A suicide attempt is a non-fatal, self-directed, potentially injurious behavior with intent to die as a result of the behavior. A suicide attempt might not result in injury. Suicidal ideiation refers to thinking about, considering, or planning suicide. Those who cause death through a suicide attempt should not be referred to as a successful suicide as it has a tragic outcome, which is death. Um so it's important to consider our language when we're talking about suicide. Similarly, we wouldn't want to use the word commit suicide. And you'll notice um you might notice that language in the vitbec text. But when I'm speaking in this um recorded lecture, I'm ch I'm trying to catch that and changing the language. Um because we often relate commit to something negative. um such as you know committed a sin, committed a crime. Um so it's important to consider our language when we're discussing suicide. It's important to classify suicide as a behavior and not itself a disorder. There are warning signs um for the risk for suicide including myths and facts in your textbook. Uh you can see box 17.2. I would encourage you to review those. And then um just know that suicide really involves the client getting to a place of ambivalence. We know that a history of previous suicide attempts increases the risk for suicide. The first two years after an attempt represent the highest risk period, especially the first 3 months. Those with a relative who has died by suicide are at increased risk. The closer the relationship, the greater the risk. Many people with depression who have suicidal ideiation lack the energy to implement suicide plans. The natural energy that accompanies increased sunlight in spring is believed to explain why many suicides occur in the spring. Additionally, it's important to consider when starting on an anti-depressant, especially if the patient has major depression, um, that as they start to feel better and their mood is starting to slightly increase, they're actually at high risk for, um, suicide due to having the energy to carry out their plan. Most people with suicidal ideiation send either direct or indirect signals to others about their intent to harm themselves. It's important that the nurse never ignore any hint of suicidal ideiation, regardless of how trivial or subtle it may seem. Asking clients directly about thoughts of suicide is imperative. A few people who die by suicide give no warning sides signs. Some artfully hide their distress and suicide plans. Others act impulsively by taking advantage of a situation to carry out the desire. Some risk factors individually include having made a previous attempt, mental illness, lacking social support, legal problems, financial problems, risky and impulsive behaviors, job loss, serious medical illness, use of substances, history of having been abused or neglected as a child, history of been bullied, family history of suicide, personal relationship problems, sexual violence, barriers, to access to healthcare. Cultural and religious and/or religious beliefs such as a belief that suicide is noble resolution to a personal problem, community cluster of suicides, stigma associated with mental illness or helpseeking, access to lethal weapons, medications, etc., and media portrayals of suicide. It's important that we complete a lethality assessment. When a client admits to having um suicidal thoughts, the next step is to determine potential lethality. It includes in it includes asking you know the client directly does the client have a plan? If so, what is it? Is the plan specific? Are the means available to carry out the plan? If the client carries out the plan, is it likely to be lethal? Has the client made preparations for death, such as giving away prized possessions, writing a note, or talking to friends one last time? Where and when does the client intend to carry out the plan? And is the intended time a special date or anniversary that has meaning for the client? Suicide prevention involves treating the underlying disorder such as mood disorder or psychosis. The overall goals are first to keep the client safe and later to help them develop new coping skills that do not involve self harm. Example of outcomes for a suicidal person include the client being safe from harming themsel or others. The client will engage in a therapeutic relationship. The client will honestly report suicidal ideiation. The client will create a list of positive attributes. The client will generate, test, and evaluate realistic plans to address underlying issues. Actions or nursing interventions to prevent suicide or manage suicidal ideiation become the first priority of nursing care. The nurse must assume an authoritative role to help clients stay safe. This is a crisis situation, and in this crisis situation, clients see few or no alternatives to resolve their problems. The nurse lets the client know their safety is the primary concern and takes precedence over other needs or wishes. For example, a client may want to be alone in their room and this is not allowed while they are at an increased risk for suicide. We also want to ensure we're providing a safe environment and creating a support system list. Suicide is often felt as the ultimate rejection of family and friends. Implicit in the act is the message to others that their help was incompetent, irrelevant, or unwelcome. Families and significant others may feel guilty for not knowing how desperate the suicidal person was, angry because the person did not seek their help or trust them, ashamed that their loved one ended their life with a socially unacceptable act. and/or sad about being rejected. Consider also that suicide is often newsworthy and there may be whispered gossip and even news coverage. Families can disintegrate after a suicide. It's important that as nurses um we are there to support the family as best we can as well. When dealing with a client who has suicidal ideiation or attempts, the attitude of the nurse must indicate unconditional positive regard for the person and their desperation. The ideas or attempts are serious signals of a desperate emotional state. The nurse must convey the belief that the person can be helped and can grow and change. Trying to make clients feel guilty for thinking of or attempting suicide is never helpful. They already feel incompetent, hopeless, and helpless. It is not the nurse's job to blame clients or act judgmentally when asking about the details of a planned suicide. Rather, we use a non-judgmental tone of voice and self-monitor our body language and facial expressions to make sure we're not conveying any disgust, blame, or judgment. Nurses believe that one person can make a difference in another person's life. We must convey this belief when caring for people who are suicidal. It is important, however, to realize that no matter how competent and caring our interventions are, a few clients will still die by suicide. A client's suicide can be devastating to staff members who have worked with the client, cared for them. Um, especially if they've gotten to know the person and or their family and loved ones well even with therapy. There are legal and ethical considerations as well related to suicide. Assisted suicide or death with dignity is a topic of national legal and ethical debate. Oregon was the first state to adopt assisted suicide into law. However, there are at least nine or more US states and districts that have laws permitting um physician assisted death or medical aid in dying. Often nurses are caring for terminally or chronically ill people with a poor quality of life, such as those with the intractable pain of terminal cancer or severe disability or those kept alive by life support. It's not the nurse's role to decide how long these clients must suffer. It is the nurse's role to provide supportive care for clients and families as they work through the difficult emotional decision-making process. Pause and consider whether the following statement is true or false. When dealing with a client who is suicidal, the nurse needs to assume a dependent role. The answer is false. When dealing with a client who is suicidal, the nurse must take an authoritative role and maintain the patients safety. Let's review the age related considerations. The first disruptive mood dysregulation disorder or DMD is diagnosed in those 6 to 18 years old. The diagnosis was added to address concerns that bipolar disorder was overdiagnosed in children whose symptoms often differ from those of adults with bipolar disorder. Suicide is a leading cause of death among children. adolescence and young adults. Depression is common among older adults and marketkedly increased during med medical illnesses. Psychotic features are more frequent in older adults than in younger people with depression. There's an increased intolerance of side effects of medications for older adults and ECT is more commonly used for treatment with more rapid response. Suicide rate of older adults doubles that of younger adults. In terms of community-based care, it's important to note that nurses in any area of practice within the community are frequently the first health care professionals to recognize behaviors consistent with mood disorders. It's important that we document and report behaviors as this helps clients get the treatment that they need. People with depression can be treated successfully in the community by psychiatrists, psychiatric advanced practice nurses, and primary care physicians. People with bipolar disorder, however, should be referred to a psychiatric advanced practice nurse or a psychiatrist for treatment. The physician or nurse who treats a person with bipolar disorder must understand the drug treatment dosages, desired effects, therapeutic levels, and potential side effects so that they can answer questions and promote compliance with treatment. Promoting mental health and wellness includes education to address stressors contributing to depressive illnesses, efforts to improve primary care treatment of depression, and prevention and early detection which will lead to treatment for adolescents because suicide is a leading cause of death among adolescents. prevention, early detection, and treatment are um important. Screening for early detection of risk factors such as family strife, parental alcoholism, or mental illness, history of fighting, and access to weapons in the home can lead to referral and early intervention. In addition, bullying and cyber bullying require joint efforts of parents, families, and schools to decrease victimization of youth and prevent suicide among young people. As always, it's important to have a self-awareness. It's important to deal with our own feelings about suicide. Nurses working with clients who are depressed often empathize with them and can begin to feel sad or agitated. We may unconsciously start to avoid contact with these clients to escape feeling that way. It's important that we monitor our feelings and reactions closely when dealing with clients to be sure we can fulfill the responsibility of establishing a therapeutic nurse client relationship. Working with clients who are in a manic phase can be exhausting. They're so hyperactive that the nurse may feel spent or tired when carrying with them. It's important to remain patient and calm with the manic client. It is essential for the nurse to provide limits and redirection in a calm manner until the client can control their own behavior independently. Some health care professionals consider suicidal people to be failures, immoral or unworthy of care. These negative attitudes may result from several factors. Health care professionals may also feel inadequate and anxious dealing with suicidal clients or they may be uncomfortable about their own mortality. It's important to be effective that the nurse be aware of their own feelings and beliefs about suicide. It's important. Some tips um you know about dealing with some of these self-awareness issues include journaling to help deal with feelings around these topics and talking with trusted colleagues.