Mood Disorders

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What is mood?

• mood is a pervasive and sustained emotion that influences one’s perception

• normal variations in mood occur as responses to specific life experience

• normal mood variations, such as sadness, euphoria and anxiety are time limited but when there is a sustained mood - mood disorder (2 weeks)

Types of mood disorders

• primary mood disorders include both depressive disorders (unipolar) and manic-depressive (bipolar) disorders

• mood disorder due to a medical condition

• substance induced mood disorders

Incidence• WHO predict that for the 21st century mood disorders

will be the number one health problem• (WHO predicts depression will be 2nd largest cause

of death and disability in world by 2020)• major depression is currently the number one cause

of disability worldwide• 300 million people in world today affected by

depression• 20-30% of people with depression have a resistive

depression - prolonged disability (loss) and 25% suicide

Diagnostic Tools

• DSMIV - defines a mood disorder as “recurrent disturbances or alterations in mood that cause psychological distress and behaviour impairment”

Depression

Depression categorised as:

ICD10 mild - moderate

DSMIV dysthymic disorders – major depression

Depressive Subtype Clinical feature

Psychoticmelancholia

Non-psychoticmelancholia

Non-melancholicdepression (major depression)

Psychoticfeatures

Psychomotordisturbances

Mood disorder

___________

Neurotransmitter

DA

NA

5-HT

The Black Dog Institute Hierarchical ModelInternet. May 2005

Non-melancholic depression = underpinned by serotenergic dysfunctionMelancholic & psychotic depression = increased and more dominant noradrenergic /dopaminergic contributions respectively

More than 2 weeks

Social impairment

Non-melancholic depression

Individuals with NMD tend to exhibit the following features:• absence of psychomotor disturbances• depressed mood is reactive• no morning changes in mood/energy

Melancholic Depression

Social impairment

Psychomotor disturbance(retardation, agitation & cognitive disturbance)

Key features:• anhedonia• non-reactive mood• mood & energy worse in the morning• profound & uncharacteristic “emptiness & inactivity”• observable psychomotor disturbance

• risk of depressive disorder range from 7-12% in men and 20-25% in women

• 2,500 youth suicide a year second most common death in adolescence

• depression is often associated with a variety of medical conditions: (endocrine, cardiovascular, neurological, autoimmune, viral and substance abuse)

• prevalence is unrelated to ethnic or cultural backgrounds

• 25% experience recurrence in first six months after episode 50-75% have recurrence in five years

Epidemiology

Risk Factors

• depression is so common that it is sometimes difficult to identify the risks

• prior history of depression• family history• lack of social support• stressful life event• current substance abuse• medical comorbidity

Causes

Three major causes of depression often cited: genetics, biochemical and environmental

Genetics: emphasis placed on the role of dominant of faulty genes in the production of various modes of depression

Biochemical: emphasis placed on the role of decreased numbers of neurotransmitters at receptor sites in brain

Environmental: emphasis placed on the extent to which various clusters of factors in a person's physical and social environment come together to produce the symptoms

Diet – according to Sanchez Villegas et al, (2009) a Mediterranean diet may protect against depression. This diet is high in vegetables, fruits and nuts, cereals, legumes and fish, has a high monounsaturated to saturated fatty acids ratio and includes moderate amounts of alcohol. The Mediterranean diet is thought to reduce inflammatory and metabolic processes that may be involved in depression

Other models have also been proposed:

disease model, psychodynamic (personality),

behavioural and social / learning model (McLoughlin, 2002; Parker & Ray, 2002)

Behavioural position holds that depression occurs primarily as the result of a severe reduction in rewarding activities or an increase in unpleasant events in one’s life manifesting the mood disturbance

Learnt responses: some people exposed to repeated losses or stresses may learn that life is difficult and often feel helpless and depressed

PersonalityAnxious / worrying: reflecting high levels of internalised,

on-going anxiety

Irritability: reflecting high levels of externalised, ongoing anxiety

Social avoidance: individuals avoid socialising

Personal reserve: individuals are uncomfortable about sharing their feelings or opening up to others

Self-criticism: reflecting ongoing low self-esteem and self-worth

Perfectionism: reflecting self-imposed high standards

Interpersonal sensitivity: sense of self worth is highly dependent on how they see other people reacting to them

Self-focused: focus more on own needs than on the needs of others (Black Dog Institute, 2005)

Developmental theorists postulate that depression may be the result of loss of parent or separation or lack of emotionally adequate parenting. Also developmental milestones (trust vs mistrust)

Findings from Parker & Ray (2002),two dominant factors correlated to presentation of depression – “anxious worryingand intraversion”

• Anxious worrying/intraversion usually evidenced where family hx of anxiety • Individual demonstrated behavioural inhibition shyness in childhood - high lifetime rate of both formal anxiety disorder and anxious/fearful personality characteristics

Taking a closer look at some of those symptoms – usually seen in a major depression

The physical, cognitive, emotional and psychotic

Physical

• change in appetite (weight gain/loss)

• sleep disturbance (initial, middle, terminal insomnia)

• sexual dysfunction

• decreased motivation/interest

• psychomotor retardation / agitation

Cognitive

• worthlessness, guilt, • recurrent thoughts of death, suicidal ideation

thoughts and or plan• sadness, hopelessness, anxiety preoccupation

with death• loss of sense of self-control• poor concentration / memory loss

Mood

• sad

• “depressed”

• “black hole”

• “crying”

• “numb”

• delusional thinking• hallucinations• thought disorders

(blocking, retardation,

insertion etc)

(Moyle 2002)

Psychotic Symptoms

Famous Folks

Abraham Lincoln, Adam Ant, Billy Joel, Heath LedgerHarrison Ford, J.K. Rowling, Tennesse Williams, Vincent van Gough

Treatment of depression

• often treated in community

• hospitalisation only occurs when symptoms are such to cause concern for family, GP, psychiatrists, patient (inability to function, suicidal thoughts / intent)

Scenario

Consider 3 stages of management:

Acute Stabilising Follow up

Goals of inpatient care - acute

• maintain safety, • reduce signs &

symptoms of depression

• restore level of functioning

• Routine Mental State Assessment

• Maintain safety • Adequate sleep• Hydration and

nutrition• Exercise• Diversion• Therapeutic use of

self

Stabilising

• Monitoring medication regime (effects / side effects)

• Ongoing support:– Individual counselling– Group Support– Psycho education (signs, symptoms, triggers,

intervention)– Sleep, diet, safety

• monitoring medication compliance / adverse effects • cognitive therapy• behavioural therapy• group therapy• family support and education• counselling• education

Follow up

Pharmacology

• depression is often considered to be caused by an over response or under response somewhere in the process of neurotransmission

• antidepressant pharmacology effects process of cell to cell communication at the synapse in specialised medians - release, blockade, receptor sensitivity, blocked re uptake within neurotransmitters

Pharmacology• Mono-axine oxidase inhibitor (MAOI’s) successful

in 39% pop –(increases noradrenaline and serotonin in the brain –

Parnate, Marplan)• Tricyclic antidepressants (TCA)(introduced in the

1950’s - Prothiaden, Amitriptyline, Clomipramine, Doxepin, Imipramine)

• Selective Serotonin Reuptake Inhibitors (SSRI’s)(Citalopram, Fluoxetine, Paroxetine, Sertraline)

• Serontin and Noradrenaline Reuptake Inhibitour (SRI) (Venlafaxine, Nefazodone, Tramadol)

Cognitive Behavioural Therapy

• CBT teaches skills which help people cope with events

• components include recognising there is a connection between thought, mood, and behaviour. Learning to monitor negative self talk ie “I can’t do this”

• challenge thinking, interpret situations so that reactions are more realistic

E.C.T. & T.M.S

Electro Convulsive Therapy •initially used in the 1930’s• usual course 6-12 treatment (3 x weekly)• procedure does not cause brain injury in adults• uni or bilateral • consent form

Famous folks who have had ECT: Janet frame, Judy Garland,Ernest Hemingway, Sylvia Plath, Lou Reed, Yves Saint-Laurent, Vivien Leigh

Transcranial Magnetic Stimulation• noninvasive method to excite neurons in the brain, weak electrical currents are induced in the tissue by rapidly changing magnetic fields

Questions to consider

• Why is this person depressed? (personality type, Hx)

• What type of depression? • Why now? (life events, triggers)• Are they safe? (risk assessment)• What needs to be done now? (priorities)• How well do I know the patient? (therapeutic

alliance)• Who else is there for them (supports available)• Who else do I need to involve? (referral

needs)

BIPOLAR AFFECTIVE DISORDER

Melancholia

Hypomania

Mania

MANIA

Manic behaviour is

• The opposite of depressed behaviour• motor activity is increased• hyperactivity• restlessness• increased spending• driving recklessly• foolish business investments • sexual disinhibition, increased libido

• in females make up may be excessive and poorly applied• both male and female wear bright coloured clothes may not match, (may be seductive)• decreased attention to personal hygiene• disruptions in the circadian rhythms therefore there is a perception of decreased need for sleep (even though the body may be exhausted)• disturbed sleep • excessive energy no time to sit and eat (the lack of sleep and failure to eat may become life threatening)

• individual fails to notice minor ailments or physical complaints – (may be susceptible to infection & illness)

Mood• during manic episodes the individuals mood is

euphoric (overly cheerful, excessively enthusiastic and presents as “high”)

• may exhibit a wide range of mood swings labile laughing/crying

• becoming irritable and angry when desires are thwarted

• infectious quality about mood / unwarranted optimism

Consider: there may be a feeling of inadequacy and inferiority that lurks behind his euphoria (psychoanalytical perspective)

Cognition

• thought processes in mania are accelerated

• easily distracted• pressured speech ….

flight of ideas• communication may be

humorous (full of jokes, puns, play on words)

• may become theatrical• sounds rather than

meaning govern word choice (clanging)

• grandiose thoughts (I’m the queen, “I have close links with Jesus”)

• judgment & insight impaired

• may give away valued possessions (thinking they no longer need /

want them)

Social

• self-esteem unrealistically inflated

• over-confidence in one’s ability

• increased social activity

• intrusive, domineering approach to others

• often involved in excessive planning and

multiple activities

Pressure on partners

• “being alone together” (van der Voort, et al 2009)• experienced heavy burdens and difficulty coping

( being solely responsible, being alone with one’s feelings)

• absence of sex and intimacy – worry about the future• being forced to give up their work• perform new roles in the relationship • feeling exhausted • choose to leave relationship

Spiritual

• in mania individuals may come to value the “highs” in their lives

• may choose not to take their medication (preferring to be high / or because of side effects)

• life more bearable when high rather than

when depressed

Interventions

Maintain safety

Interventions

• Pharmacology:– mood stabilisers (lithium, valporate,

carbamazepine)– anti depressents (effexor, cipramil, MAOI’s

parnate, imipramine)– antipsychotics (olanzapine, clozapine,

risperidone, quetiapine)– be mindful of interactions, side effects of

medications

• limit set on inappropriate behaviour

• reduce environment stimuli

• supervise administration of medications

• ensure adequate sleep and nutrition

• help client focus on one topic during conversation

• ignore, distract from grandiose thinking

• present reality (time place & person)

• consider one staff member involved in discussions

• provide information about diagnosis,

• medication and treatments (when patient demonstrating insight)

• promote a realistic sense of self-esteem

Famous Folks

• Richard Dreyfuss• Carrie Fisher• Marilyn Munroe• Charles Dickens• Robert Louis

Stevenson• Mark Twain

• Ozzy Osbourne• Winston Churchill• Florence Nightingale• Issac Newton

Suggested readings• Gomez, G.E. (2001), Lithium Treatment. Present & Future. Journal of Psychosocial Nursing, 39

(8), 31-36.• Pebbles, C., & Porter, R. (2002). New treatments for bipolar disorder. Current Therapies, Oct 21-

26• Scheick, D.M. (1995). Therapeutic Insight: From family to practice. Journal of Psychosocial

Nursing, 33 (7), 31-33.

References

• Black Dog Institute (2005). Internet: www.blackdoginstitiute.org.au DSM IV• McLoughlin, G. (2002). Is depression normal in human beings? A critique of the evolutionary perspective. International Journal of Mental Health Nursing, 11, 170-173.• Moyle, W. (2002). Unstructured interview: challenges when participants have a major depressive illness. Journal of Advanced Nursing, 39 (3), 266-273• Parker, G., & Roy, E. (2002). Examining utility of a temperament model for modelling non- melancholic depression. Acta Psychiatrica Scandinavia, 106, 54-61• Sanchez Villegas, A., et al. (2009)..... Archives of General Psychiatry, 66, 1090-1098 • van der Voort, T.Y.G., Goossens, P. J.J., & van der Bijl, J.J. (2009). Alone together: A grounded theory study of experienced burden, coping and support needs of spouses of persons with a bipolar disorder. International Journal of Mental Health Nursing, 18, 434-443.

Websites

• www.sane/org/snapshots

Davaar details

Davaar Consultancy Training & Development Pty. Ltd.

PO Box 37, Laidley, Qld. 4341

Web: www.davaar.com.au

Email: wendy@davaar.com.au

colleen@davaar.com.au

(m) Wendy: 0411385573

Colleen: 0431655702