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Chapter 17
Mood Disorders and Suicide
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Mood 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.)
• Most common psychiatric diagnosis associated with
suicide
– Depression one of the most important risk factors for
it
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Categories 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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Etiology
• Biologic theories
– Genetic theories
– Neurochemical theories: serotonin, norepinephrine;
possibly acetylcholine and dopamine
– Neuroendocrine influences: hormones
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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 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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Question
• Is the following statement true or false?
• Depression is most commonly associated with suicide.
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Answer
• True
• Rationale: Depression is considered the most common
diagnosis that results in suicide.
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Major 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.)
• 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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Psychopharmacology
• 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
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 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.)
• 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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Question
• Is the following statement true or false?
• Patients with depression often exhibit anhedonia.
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Answer
• 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.)
• 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.)
• 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 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
• 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
• 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.)
• 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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Question
• 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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Answer
•
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.)
• 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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Suicide
• 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.)
• 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.)
• 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.)
• Family response
– Suicide as ultimate rejection of family, friends
– Families react with guilt, shame, anger
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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
• 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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Question
• 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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Answer
• False
• Rationale: When dealing with a patient who is suicidal,
the nurse must take an authoritative role.
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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
• 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.)
• Bipolar disorder: referral to psychiatrist or psychiatric
advanced practice nurse for treatment
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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.)
• 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 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
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