Mood Disorders
Depression and Mania
Mood Disorders : Depression and Mania
Historical perspectives
Disturbances in mood have been recognized for many years.It is thought that the term melancholia was first coined by Hippocrates when he described changing temperament. In 1896 Kraepelin distinguished between dementia praecox (now known as schizophrenia)and manic depression .He described dementia praecox as a chronic illness with progressive deterioration in the clients functioning. Kraepelin (1913-1921) saw manic depression as cyclical abnormalities of mood, marked by a family history of similar disorders and caused by innate physical factors. This differentiation served as a primary underpinning for modern approaches to understanding and diagnosing mood disorders. Freud (1957) differentiated between maladaptive depression and grief in his famous paper"Mourning and Melancholia",detailing the psychodynamic genesis of depression.Leonhard, a German psychiatrist, proposed the separation of manic-depressive illness two types: bipolar and monopolar . This differentiation is the basis for current clinical depiction of bipolar and unipolar mood disorders.
Mood : is a feeling state reported by the client that can vary with external and internal changes .Mood disorders are defined by a pattern of episodes over time and by a pattern of symptoms in each episode.
Every one experiences mood fluctuation, depressionand elation.
Normal mood: every person experiences from time to time a change in his mood, which is related to everyday life events.
* This is considered normal as long as it is appropriate to the event.
* Mood fluctuation is often normal response to experiences and events that influence the human capacity for feeling .
* Grief and sadness in response to loss of a loved one is normal, adaptive response
* Most people experience sadness and depression with losses ( e.g., loved ones, jobs, status, possessions ).This sadness may persist for days, weeks or longer as the individual grieves the loss.
* Mood is considered abnormal when it is excessively depressible or related out of proportion to the life experience.
* The mood will be accompanied by affecting cognitive, behavioral, spiritual,
social and physiologic functioning.
Mood disorders: previously known as affective disorders, are a group of disorders characterized by disturbance in regulation of emotion, ranging from intense elation or irritability to severe depression.
* These disorders often result in personal suffering, family distress, interpersonal and occupational impairment, an untold social costs.
Classification of mood disorders
1- Depressive Disorders:
A. major Depression Disorder (unipolar depression or clinical depression)
* Atypical depression
* Catatonic depression
* Melancholic depression
* Postpartum depression
* Psychotic major depression
* Seasonal affective disorders
B. Dysthymia (double depression)
C. Depressive disorders not otherwise specified:
* Recurrent brief depression
* Minor depressive disorder
2- Bipolar Disorders (manic depression):
A. Bipolar I
B.Bipolar II
C. Cyclothymia
D.Bipolar disorder not otherwise specified
3- Substance-induced mood disorders:
A. Alcohol-induced mood disorders.
B. Benzodiazepine-induced mood disorders.
Epidemiology
* 2% of the general population develops a mood disorder.
* Major depression fourth leading cause of disease burden in the world (WHO 2002).
* 21% of women and 13% of men develop major depression.
* Ratio 2:1 Major depression in female >male
* Age of onset for major depression disorder is mid to late twenties.
* Depression occurs more frequently in lower socioeconomic groups.
*Averageage of onset of bipolar disorder is twenties.
* Prevalence of bipolar disorder ≈ 1% . Ratio M:F ≈ 2:3 .
Etiologic Factors Related to mood disorders
According to theories and researches we have the following factors:
1- Neurobiological factors:
* Altered neurotransmission (biochemical influences):
abnormalities in various neurotransmitters as decrease in norepinephrine, low levels of serotonin in the brain, decrease in dopamine
* Neuroendocrine dysregulation: hypothalamus, pituitary, adrenal, thyroid, and growth hormone.
* Genetic transmission (heredity):
First degree relatives with mood disorders. (At least 3 times higher).
* concordance between identical twins is high.
2- Psychological factors:
*Psychoanalytic theory: depression is a result of loss
* Mania is a defense against depression .
* Cognitive theory: depression is a result of negative processing of thoughts.
* Learned helplessness: depression is a result of aperceived lack of control over events.
* Life events and stress theory: significant life events cause stress, which results in depression or mania.
* Personality theory: personality characteristics predispose an individual to mood disorders.
3- Social and environmental factors:
* Adverse childhood experiences lead to depressive disorders in adult life.
* Depression is more common in divorced men.
* Women, who were caring for 3 or more children under the age of 11, unemployed and without a confiding relationship, were at high risk of having depression.
* High rates of depression are seen in clients with chronic or painful physical illnesses.
Co morbiditywith Other Disorders
* Symptoms of anxiety are common in depressive disorder.
* Depressive features are quite frequent in: generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, schizophrenia, schizoaffective disorder, eating disorder and personality disorder.
* Substance-use disorders are common in person with mood disorder.
* The incidence of depressive disorder is quite high in medical illness such as: chorea, parkinson's disease, epilepsy, stroke, migran, myocardial Infraction, endocrinal disorders, viral infections and rheumatoid arthritis.
First:Depressive Disorders
Patient will have only episodes of depression with no manic or hypomanic episodes (unipolardepression).
A. Major depressive disorder (MDD): (unipolar or clinically depression)
Is condition characterized by along-lasting depressed mood or marked loss of interest or pleasure (anhedonia) in all or nearly all activities.
Children and adolescents with MDD may be irritable instead of sad.
Symptoms of Depression: “Space Drugs"
Sleep disturbance: insomnia or hypersomnia nearly everyday.
Pleasure/interest: (lack of) anhedonia in things that normally enjoy.
Agitation: psychomotor agitation nearly everyday.
Concentration:diminished ability tothink or concentration, or indecisiveness.
Energy: fatigue or loss of energy nearly everyday
Depressed mood: most of day
Retardation movement: psychomotor retardation nearly everyday
Appetite disturbance: decreased or increased appetite and weight change.
Guilt: feeling of worthlessness or excessive or inappropriate guilt.
Suicidal thought: recurrent thoughts of death and suicidal ideation.
Mental Status Examination:
General appearance: psychomotor retardation, decreased activity level, spontaneous movements, stooped posture and sad facial expression.
Mood/Affect: depressed mood and he sees the world through dark glasses.
Speech: slow, monotonous, answers in brief,
Perception: Hallucination, and illusions may occur in depression
Thought: negative thought about themselves, the world and the future.
preoccupation with thoughts of loss, worthlessness, guilt and death.
suicidal ideation is present in 2/3 of patients.
The patient may have delusions of guilt or poverty.
process: thinking is slow and difficult, the patient may take along time to answer a question.
Orientation: usually oriented to place, time and person
Memory: most of patients complain of forgetfulness and poor concentration.
Judgment/Insight: depressed patients emphasize their symptoms, they are said to have excessive insight into their condition.
Reliability: Information from depressed patients tends to emphasize the bad and minimize the good.
Impulse control: 2/3 of depressed patients have suicide thoughts, and about 10-15% actually completes suicide.
Paradoxical suicide :is suicide in adepressed patient after starting antidepressant treatment and improvement in his activity level .
It is wrong to give a severly depressed patient a large amount of pills to take at home.
Diagnostic criteria: DSM IV criteria for major depression:
A. During the same 2-week period, five or more of the following symptoms including either 1 or 2 have been present (must be a change in functioning).
1. Depressed mood most of the day, nearly everyday.
2. Diminished interest or pleasure in all, or almost all, activities.
3. Significant changes in appetite and/or weight.
4. Significant changes in sleep patterns.
5. Psychomotor retardation or agitation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness or inappropriate guilt.
8. Diminished ability to concentrate or make decisions.
9. Recurrent thoughts or death or suicide.
B. The criteria do not meet criteria for a Mixed Episode.
C.Thesymptoms cause clinically significant distress or impairment in functioning
D. Not due to a general medical condition or substance.
E. The symptoms are not better accounted for by Bereavement.
Subtypes of Major depressive disorder:-
Atypical depression: is characterized by mood reactivity (ability to react to positive stimuli) and significant weight gain increased appetite, hypersomnia, a sensation of heaviness in limbs (leaden paralysis), and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
Melancholic depression: is characterized by a loss of pleasure in most or allactivities, a failure of reactivity to pleasurable stimuli, a worsening of symptoms in the morning hours, early morning waking, psychomotor, retardation, excessive weight loss, excessive guilt.
Psychotic major depression: major depressive episodes, where the patient experiences psychotic symptoms such as delusions, hallucinations.
Catatonic depression: is a rare and severe form of major depression involving disturbances motor behavior, stupor, immobile.
Post-partum depression: depression following the birth of a child, usually occurs within 4 weeks of the birth and having symptoms of depression.
Seasonal affective disorder (winter depression): some people have a seasonal pattern, a depressive episodes coming on in the autumn or winter, and resolving in spring, the diagnosis is made if at least 2 periods have occurred in colder months with none at other times over a two-year period or longer.
B. Dysthymic Disorder (double depression):
Chronic mood disorder includes low level depression lasting most of the day for most days for 2 years in adults and 1 year in children and adolescents.
Diagnosis:
1- Depression for most of day for a period not less than 2 years.
During the period of depression 2 or more of the following symptoms:-
* loss or increase appetite.
*Insomnia or hypersomnia.
* loss of energy or exhaustion.
* low self esteem and inadequacy.
* feelings of hopelessness .
* Difficulty with concentration, memory, and decision making.
2- Absence of episodes of mania, mixed, hypomania or major depression.
3- The symptoms cause clinical problems, social and vocational.
Notice:
* It is difficult to differential between major depression and dysthymia because the symptoms are the same. In major depression the performance of person is decreasing significantly, but in dysthymia less severe and its effect on the performance is less and may continue for years.
It is believed that 50% of dysthymic pt. will have major depression later.
C. Depressive Disorder not otherwise specified:
Any depressive disorder that does not meet the criteria for a specific disorder. It includes:
Recurrent brief depression: depressive episodes once per month at least one year, with individual episodes lasting less than 2 weeks and typically less than 2-3 days.
Minor depressive disorder: depression that does not meet full criteria for major depression but in which at least two symptoms are present for 2 weeks.
Premenstrual dysphoric disorder .
Post psychotic depression of schizophrenia .
Second:Bipolar Disorders (manic depression)
A mood disorder described by alternating periods of mania or hypomania and depression over time.
Mania: It is mood disorder characterized by abnormal elevated expanded or irritable mood accompanied by hyperactivity, grandiosity, and loss of reality .
Onset of mania usually rapid, the patient is unaware of his inappropriate behavior without regard to social or moral conventions.
How to Diagnosis: DSM IV criteria
1. Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week
2. During the mood disturbance, 3 or more of the following symptoms have persisted (4 or more if the mood is only irritable):
* Inflated self-esteem or grandiosity.
* Decreased need for sleep.
* More talkative than usual, or pressure to keep talking.
* Racing thoughts (“flight of ideas”).
* Distractibility.
* Increase in goal-directed activity.
* Excessive involvement in pleasurable activities that have the potential for negative consequences.
3. The symptoms do not meet criteria for a Mixed Episode.
4. The symptoms cause significant impairment in functioning or necessitate hospitalization to prevent harm to self or others.
5. Not due to a general medical condition or substance.
Mental state examination:
General appearance:hyperactive, dress in colorful but inappropriate clothes
Mode/Affect: mood is elevated, expensive, express feeling without restraint, Elation, Euphoria, and grandeur.
Speech: pressure speech, rapid and difficult to interrupt.
Thought: Delusions of grandiosity and persecution, thinking is rapid, flight of idea.
Perception: Hallucination may occur, as religious or sexual type.
Orientation: oriented to time, place and person.
Concentration: poor and are easily distracted by environmental stimuli.
Memory: is usually intact.
Insight/Judgment: is impaired
impulse control: Impulsive behavior is common, suicide sometimes.
Reliability: Information not reliable.
Hypomanic Episode:
The same symptoms of mania but with different in period and severity (hypomania is less severity and longer period) it is characterized by:
1. Adistinct period of persistently elevated, expensive, or irritable mood, continues for at least 4 days, that is clearly different from the usual non depressed mood.
2. During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable):
* Inflated self esteem or grandiosity.
* Decreased need for sleep
* Distractibility
* Flight of ideas
* More talkative than usual
* Increase in goal-directed activity or psychomotor agitation.
* Excessive involvement in pleasurable activities that have a high potential for painful consequence.
3. The episode is associated with an unequivocal in functioning that is un characteristic of the person when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, and there are no psychotic feature.
6. The symptoms are not due to the direct physiological effects of a
substance.
Subtypes of Bipolar disorder:
1. Cyclothymic Disorder:
Chronic mood disturbance of at least 2 years' duration with many periods of hypomanic symptoms, depressed mood and anhedonia .
There symptoms are less severe or intense than those in major depression or manic episode.
2. Bipolar I:is distinguish by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes.
3. Bipolar II:consisting of recurrent intermittent hypomanic and depressive episodes.
4. Bipolar disorder not otherwise specified: indicates that the patient suffers from some symptoms in the bipolar spectrum but does not fully quality for any of the three formal bipolar mentioned above.
Third:Substance- induced mood disorders
Mode disorders occur due to direct physiologic effects of psychoactive drug, or other chemical substance, substance intoxication or withdrawal.
Alcohol- induced mood disorders: Alcoholism.
Benzodiazepine induced mood disorders: longterm (chronic) used.
Management of mood disorders
1- Hospitalization: is indicated in:-
a. If there is a need for diagnostic procedures.
b. Risk of suicide or homicide.
c. Retarded patients or disorganized hyperactive manic patients who can not care for themselves.
d. History of rapid progression of symptoms with no family or social support.
2- Psycho pharmacotherapy:
* Antidepressant:
1. Tricyclic Antidepressants (TCAs ) as Imipramine
2. Monoamine Oxidase Inhibitors (MAOs) as Nardil
3. Selective Serotonin Reuptake Inhibitors (SSRIs) as Prozac
* Mood stabilizer: as Lithium carbonate to prevent recurrent
* Antipsychotic and Anxiolytics
* Others as Tegretol, Depakin
3- Psychosocial Therapy:
Studies indicated that a combination of drug therapy and psychotherapy is the most effective type of treatment.
* Psychoanalytic psychotherapy: aims to make a change in the personality structure, to improve trust and develop coping mechanisms.
* Family therapy: is indicated if there is relation between the patients symptoms and family interactions.
Family therapy examines the role of the patient in the family and how family is maintaining the patient s depression.
* Cognitive-Behavioral therapy: aims to help the patient identifies and tests negative cognition about his self, world and future, and develops more flexible and positive ways of thinking .
*Interpersonal and social therapy: helping the patient socially and solving his social problems and establishing appropriate environmental changes to decrease his suffering.
4-Electroconvulsive Therapy (ECT): involves the induction of brain seizures by the application of electrical current to the skull, It is an effective therapy for severe depression accompanied by suicidal ideation.
Course and prognoses of mood disorder
* Depressive episode usually last for 6 months.
* The presence of residual symptoms such as somatic symptoms and poor sleep increase the risk of recurrence.
* The death rate in clients with depressive disorder is higher.
* 11-17% of client with severe depression eventually commit suicide
* Clients with younger age of onset show better recovery.
* The length of manic episode varies from 3-13 months
* Prognosis is much better with treatment
*The most serious complication is suicide, and substance abuse.
Nursing Interventions
* Maintaing supportive contact with the client
* provide quite, non-stimulating environment.
* encourage client to actively engage in life and relationships.
* assist with ADL'S / hygiene / grooming as needed.
* Assist client to identify previous coping skills
* Identify client's needs
* Remove harmful objects/protect from self-harm, others.
* Assist with problem solving / decision making.
* Assist client to set limits on own behavior.
* educate about disorder and medication compliance.
* Monitoring for side effects of drugs.
References:
** Katherine M. Fortinasl and Patricia A. Holoday-worret (1996) psychiatric Mental Health Nursing, Newyork, Toronto, 1st edition.
** Rob Newell and Kevin Gournay. (2009) Mental Health Nursing, New York, Toronto, 2nd edition.
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