SEMINAR ON

MOOD
DISORDERS

SUBMITTED TO SUBMITTED BY

MRS.SUSHMA SAGARI MADAM J.SUNITHA

ASSISTANT PROFESSOR MSC(N) 2ND YEAR

KIMS COLLEGE OF NURSING KIMS COLLEGE OF NURSING

NARKETPALLY NARKETPALLY

S.NO CONTENT PAGE NO

1. Introduction 1
2. Definition 2

3. Characteristics and benefits of assertive training 3

4. Assertive communication 4

5. Benefits of assertive communication 5

6. Basic human rights 6

7. Bills of assertive rights 6

8. Response patterns 7

9. Assertive behavior 8

10 High assertiveness 8

11. Definition of aggressiveness 9

12. Characteristics of aggressive behavior 9

13 Passive aggressive behavior 9

14 Characteristics of Passive aggressive behavio 10

OBJECTIVES

GENERAL OBJECTIVES- At the end of the seminar students able to gain knowledge

regarding mood disorders at its management

SPECIFIC OBJECTIVES- At the end of seminar students will be able to

 introduce the topic
 define the mood disorders
 enlist the characteristics and benefits of assertive training
 defineassertive communication
 explain about benefits of assertive communication
 enumerate basic human rights
 list down the bills of assertive rights
 narrate the response patterns
 define assertive behavior
 explain about high assertiveness
 define the aggressiveness
 list out the characteristics of aggressive behavior
 narrate the passive aggressive behavior
 enlist the characteristics of passive aggressive behavior
 STUDENT PROFILE

NAME - J. SUNEETHA

SUBJECT - MENTAL HEALTH NURSING

COURSE - MSC 2 ND YEAR

TOPIC - MOOD DISORDERS

GROUP - BSC 3 RD YEAR

VENUE - B.SC 3 RD YEAR

METHOD OF TEACHING - LECTURER-CUM DISCUSSION

A.V. AIDS - OHP,PPT,CHART,FLIPCARDS,BLACKBOARD

NAME OF THE INSTRUCTOR - MRS T.SUSHMA SAGARI MADAM

ASSISTANT PROFESSOR

KIMS COLLEGE OF NURSING

NARKETPALLY.

NALGONDA
INTRODUCTION

Mood is a prevailing internal emotional state and Affect is the external display of
feelings Mood disorders are a category of illnesses that describe a serious change in mood.
Mood disorders previously referred to as affective disorders. Mood disorders encompass a
large group of disorders; characterized by pervasive dysregulation of mood and
psychomotor activity and by related biorhythmic and cognitive disturbances. Mood
disorders are one of the most commonly occurring psychiatric-mental health disorders. By
the year 2020, mood disorders are estimated to be the second most important cause of
disability worldwide. The prevalence rate of mood disorders is 1.5 percent, and it is
uniform throughout the world

HISTORY

About 400 BCE, Hippocrates - alignment of the planets caused the spleen to secrete black
bile, which then darkened the mood = melancholia.
• Around 30 AD, the Roman physician Celsus : melancholia - work De re medicina - as a
depression caused by black bile.
• In 1854, Jules Falret - folie circulaire - alternating moods of depression and mania.
• In 1882, the German psychiatrist Karl Kahlbaum - cyclothymia, described mania and
depression as stages of the same illness
.• In 1899, Emil Kraepelin : – manic-depressive psychosis using most of the criteria -
bipolar I disorder – differentiated it from dementia praecox (as schizophrenia was then
called) – involutional melancholia = a form of mood disorder that begins in late adulthood

DEFINITION

1. Mood disorders or affective disorders are mental health problems such as

depression, bipolar disorder and mania.
 2. Mood disorder is a Pervasive and sustained Feeling tone that is expressed internally
that influences a person’s behaviour and perception of the world distinguished from
affect the external expression of mood

3. Mood disorders are a group of clinical conditions characterised by loss of the sense
of control & a subjective experience of great distress.

4. Mood disorders are characterized by a disturbance of mood, accompanied by a full

or partial manic or depressive syndrome, which is not due to any other physical or
mental disorder.

5. Mood Disorder or Mood change is the main psycho pathological feature. The
abnormality is more intense and persistent than normal variation in mood and often
lead to problems in occupational and social functioning.

6. Mood disorder is a condition whereby the prevailing emotional mood is distorted or

inappropriate to the specified circumstances.

7. Affective disorders are group of disorders in which fundamental disturbances or

changes in mood occur accomplished by overall change in level of activity

8. Mood disorder is a clinical condition in which mood change is predominant and

persistent, associated with cognitive, psychomotor, psycho-physiological and
behavioural difficulties accomplished by a full or partial manic or depressive
syndrome, and occurrence of such manifestations based on client's mood.

Etiology

The etiology of mood disorders is currently unknown.

1. Biological Theories

A. Genetic Hypothesis: Genetic factors are very important in predisposing an individual

to mood disorders. The lifetime risk for the first-degree relatives of patients with mood
disorder is 25% and of normal controls is 7%.The lifetime risk for the children of one
parent with mood disorder is 27% and of both parents with mood disorder is 74%.The
concordance rate for monozygotic twins is 65% and for dizygotic twins is 15%.

B. Biochemical theories: Increased amounts of nor-epinephrine, serotonin and dopamine

activity cause an elevation in mood and the two phases of bipolar disorder whereas
decreased amounts lead to depressed mood.

C. Neuro-endocrine Disturbance: Mood is also affected by the thyroid gland.

Approximately 5%-10% of clients with abnormally low level of thyroid hormones suffer
form a chronic mood disorder. Clients with a mild, symptom-free form of hypothyroidism
are more vulnerable to depressed mood than the average person. Abnormalities of Neuro-
endocrine such as decreased nocturnal secretion of melatonin, decreased levels of
prolactin, follicle- stimulating hormone, testosterone and somatostatin and sleep-
stimulation of growth hormone cause mood disorders in clients.

2. Psychological theories

A. Psychoanalytic theory : According to Freud depression results due to loss of a 'loved

object' and fixation in the oral sadistic phase of development. In this model, mania is
viewed as a denial of depression.

B. Behavioral theory : This theory of depression connects depressive phenomena to the

experience of uncontrollable events. According to this model, depression is conditioned by
repeated losses in the past.
C. Cognitive theory: According to this theory depression is due to negative cognitions
which includes Negative expectations of the environment, Negative expectations of the
self, Negative expectations of the future. These cognitive distortions arise out of a defect in
cognitive development and cause of the individual to feel inadequate, worthless and
rejected by others.

 D. Sociological theory: Stressful life events such as the loss of parent or spouse, financial
hardship, illness, perceived or real failure, and midlife crisis etc are factors contributing to
the development of a mood disorders. Certain populations of people including the poor,
single persons, or working mothers with young children seem to be more susceptible than
others to mood disorders.

• Brain chemical imbalance

• Medical condition
• Substance abuse
• Life events
• Hereditary factors

Symptoms

 Common symptoms of mood disorders

 Symptoms of heightened mood that may accompany mood disorders
 Serious symptoms that might indicate a life-threatening condition

Common symptoms of mood disorders

 Body aches
 Changes in appetite
 Difficulty concentrating
 Difficulty sleeping
 Fatigue
  Feelings of sadness, hopelessness, helplessness or inadequacy
 Guilt
 Hostility or aggression
 Irritability and mood changes
 Loss of interest in daily life
 Problems interacting with loved ones
 Unexplained weight gain or loss

Symptoms of heightened mood that may accompany mood disorders

 Abnormally high energy level

 Decreased sleep
 Feelings of omnipotence
 Impulsive behaviors such as spending sprees
 Poor judgment
 Racing thoughts
 Talking fast or switching conversational topics rapidly

Serious symptoms that might indicate a life-threatening condition

 Being a danger to yourself or others including threatening, irrational or suicidal

behavior.
 Feelings of wanting to die
 Hearing voices or seeing things that do not exist
 Inability to care for your basic needs
 Suicidal thoughts or expression of suicidal thoughts

Classification of mood disorders: According to the ICD-10, the mood disorders are
classified as follows:
F30-F39 : Mood Disorder

 F30 - Manic episodes

 F31 - Bipolar mood (affective) disorder
 F32 - Depressive mood (affective) disorder
 F33 - Recurrent depressive disorder
 F34 - Persistent mood disorder (including cyclothymia and dysthymia)
 F38 - Other mood disorders (including mixed affective episode and recurrent brief
depressive disorder)
 F39 - Unspecified mood disorders

1. MANIC EPISODES

It is a psychotic medical condition in which client manifests a clinical syndrome

characterized by extremely elevated mood, energy, hyperactivity, unusual thought process
with flight of ideas and acceleration in speaking process.

Life-time risk: 0.8-1.0% tends to occur in episodes lasting usually 3-4 months
followed by complete clinical recovery, future episodes (manic/depressive/mixed)

Incidence

0.6 – 1 per cent adults will have mania during their life time. Onset is most common
in late adolescence or early adulthood. Incidence is more in Unmarried, separated or
divorced cases and Urban, upper socioeconomic groups Positive family history,
monozygotic twins. Drug induced manic disturbance Male and Female ratio 1:1 (Bipolar
disorder; males tend to have manic episode first, cycling with depressive episode; females
tend to have depressive episode first circle with mania later).
Classification of Mania

 F30 Manic episode

 F30.0 Hypomania
 F30.1 Mania without psychotic symptoms
 F30.2 Mania with psychotic symptoms
 F30.8 Other manic episodes
 F30.9 Manic episode, unspecified

Hypomania : It is mild form of mania. Hypomania is not severe enough to cause marked
impairment in social or occupational functioning or to require hospitalization and it does
not include psychotic features.

Hypomania is a period of abnormality and persistently mild elevation of mood,

increased energy and activity, and - usually marked feelings of well being and both
physical and mental efficiency lasting 4 days and including three or four of the additional
symptoms (e.g. Increased sociability, talkativeness, over familiarity, increased sexual
energy, and decreased need for sleep are often present but not to the extent that they lead
to severe disruption of work or result in social rejection but do not impair the person's
ability to function and there is no psychotic features (delusions and hallucinations).

Mania without psychotic symptoms: In mania without psychotic symptoms, mood is

predominantly elevated, expensive, or irritable, accompanied by increased energy,
resulting in over activity, pressure of speech, a decreased need for sleep, lost in social
inhabitation, - marked distractibility in addition Self esteem is inflated, and definitively
abnormal for the individual concerned for at least 1 week leading to severe interference
with personal functioning of daily living without psychotic symptoms.

Mania with psychotic symptoms: The episode meets the criteria for mania without
psychotic symptoms and hallucination or delusions. The commonest examples are those
with grandiose, self- referential, or persecutory content. The episode is not attributable to
psychoactive substance use or to any organic mental disorder.

Clinical features:

 Elevated, expansive or irritable mood

 Psychomotor activity
 Speech and thought
 Goal-directed activity
 Other features
 Absence of underlying organic cause (which should last for at least 1 week
and cause disruption in occupational & social activities)

The elevated mood can pass through 4 stages:

 Euphoria (mild elevation of mood): it is an increased sense of psychological well-

being and happiness Hypomania (stage I)
 Elation (mod elevation of mood): it is a feeling of confidence and enjoyment,
increase in psychomotor activity Mania (stage II)
 Exaltation (severe elevation of mood): it is an intense elation with delusion of
grandeur Severe mania (stage III)
 Ecstasy (very severe elevation of mood): it is an intense sense of rapture or
blistfullness Stupurous mania (stage III)

Speech and thought in Manic episode

• More talkative than usual

• Describes thoughts racing in mind

• Develops pressure of speech

• Uses playful language (joking/teasing)

 • Speaks loudly

• Flight of ideas

• Delusion of grandeur

• Delusion of persecution

• Hallucinations, often with religious content Since these psychotic symptoms are in
keeping with the elevated mood state, these are called mood-congruent psychotic
features

Diagnosis

 Proper history taking

 Mental status examination (positive criteria or mania)
 ICD 10 Diagnostic Criteria of Hypomania, Mania without and with psychotic
symptoms

Diagnostic criteria for Hypomania (ICD 10 diagnostic criteria) : The mood is elevated
or irritable to a degree that is definitely abnormal for the individual concerned and
sustained for at least 4 consecutive days. At least three of the following signs must be
present, leading some interference with personal functioning in daily living and Increased
activity or physical restlessness , Increased talkativeness.

– Distractibility or difficulty in concentration

– Decreased need for sleep

– Mild overspending of reckless or irresponsible behavior

– Increased sexual energy

– Increased sociability or over familiarity.

– The episode does not meet the criteria for mania, bipolar affective disorder, depressive
episode, cyclothymia, or anorexia nervosa.

– The episode is not attributable to psychoactive substance use or to any organic mental
disorder.

Diagnostic criteria for Mania without psychotic Symptoms: Mood must be

predominantly elevated, expensive, or irritable, and definitively abnormal for the
individual concerned. The mood change must be prominent and sustained for at least 1
week. At least three of the following signs must be present, leading to severe interference
with personal functioning of daily living. There are no hallucinations or delusion, although
perceptual disorders may occur. The episode is not attributable to psychoactive substance
use or to any organic mental disorder. The mood disturbance is sufficient to cause
impairment at work or danger are present to the patient or other.

Diagnostic criteria for Mania with psychotic symptoms: The episode meets the criteria
for mania without psychotic symptoms and hallucination or delusions.

Treatment

A. Pharmacotherapy

1. Lithium – Lithium is the drug of choice for the treatment of manic episode (acute
phase) as well as for prevention of further episodes in bipolar mood disorder. The usual
therapeutic dose range is 900-1500 mg of lithium carbonate per day.

Nursing Consideration: Lithium treatment needs to be closely monitored by repeated

blood levels, as the difference between the therapeutic and lethal blood levels is not very
wide (narrow therapeutic index).

- Therapeutic blood lithium = 0.8-1.2 mEq/L

- Prophylactic blood lithium = 0.6 – 1.2 mEq/L

• A blood lithium level of > 2.0 mEq/L is often associated with toxicity, while a level of
more than 2.5-3.0 mEq/L may be lethal.

2. Antipsychotics: Antipsychotics are an important adjunct in the treatment of mood

disorder. The commonly used drugs Include Risperidone, Olanzapine, Quetiapine,
Haloperidol, And Aripraxole.

Other Mood stabilizers

i. Sodium valproate: For acute treatment of mania and prevention of bipolar mood
disorder. Particularly useful in those patients who are refractory to lithium. The dose range
is usually 1000-3000mg/day (the therapeutic blood levels are 50-125 mg/ml). It has a
faster onset of action than lithium, therefore it can be used in acute treatment of mania
effectively.

ii. Carbamazepine: For acute treatment of mania and prevention of bipolar mood
disorder. – Particularly useful in those patients who are refractory to lithium and valproate.
The dose range of carbamazepine is 600-1600 mg/day ( the therapeutic blood levels are 4-
12 mg/ml).

iii. Benzodiazepines : Lorazepam (IV or orally) and clonazepam are used for the treatment
of manic episode alone rarely; however, they been used more often as adjuvant to
antipsychotics.

 B. ECT :(Electro-Convulsive Therapy) : ECT can also be used for acute mania
excitement if it is not adequately responding to antipsychotic and lithium.

C. Psychosocial treatment:

 Cognitive Behavior Therapy

 Interpersonal Therapy
 Psychoanalytic Therapy
 Behaviour Therapy
  Group Therapy
 Family and Marital therapy

Nursing Interventions

 Encouraging taking medications.

– Explain to the client and his family members the importance of medicine and
contribution of medication as per prescription and treatment plans, effects or
complications, if not consuming drugs, etc. in an understanding and simple manner, it is a
good to convey the message in their own language.

– Administer the drugs according to doctors order and monitor for side effects, record and
report the drugs administered, and if any side effects observed.

– Administer the drugs according to doctors order and monitor for side effects, record and
report the drugs administered, and if any side effects observed.

– While the client is on lithium prescription, monitor the level of serum lithium levels
periodically, advice salt restrictions diet.

– Encourage the client to perform productive activities

– Provide calm and quiet environment.

 Prevent from injury

– Establish calm and quiet, non-productive or non-stimulating environment.
– Keep sharp instruments away from the client.
– Provide supportive environment.
– Keep the client aside from stressful environment.
– Do not provoke or argue with the client or others in the client's unit.
– Protect the client by engaging in useful activities.
 Divert the client's by engaging in useful activities.
– Divert the client's mind by asking him to participate in calm activities like watching
TV, playing with children, reading spiritual materials or interest of his own.
– Never allow violent patients stay together or nearby place in same environment.
– Establish reliable, framed environment, set priorities and goals for everyday
activities.
 Educate the client the coping strategies and deep relaxation techniques to
overcome aggressive feelings.

– Never leave client all alone, one person has to accompany to observe and guide or
assist the patient to perform useful activities. Observe the client's interaction and
restrict him to involve in group destructive activities.

– Keep the music volume low and dim light in client's room.

– Avoid slippery floor to prevent accidents.

 Prevent for violence resulting causing harm himself or to others related to manic
excitement and perceptual disturbance.
– Provide peaceful, safe, environment, establish and maintain low stimuli in client's
unit.
– Monitor the client's behavior every 15 minutes once and maintain process recording
of it, report if to appropriate health care professional.
– Remove all hazardous material in client's unit.

 Motivate the client to verbalize his feelings openly, thereby internal conflicts and
hesitation will be reduced.
– Encourage the client to perform deep breathing exercises, medication and interested
activities in a desirable manner.
– Promote physical outlet for violent behavior.
 – Accept the client's feelings, be with him, show positive attitude, concern, and make
him to understand that nurses are their well wishers and caretakers. Be brief, clear,
direct speech in conversation, make the client to ventilate the emotions.

 Administer the drugs as per order and explain to the client and his relatives its
importance.
– Always some nursing staff should be ready to handle the client in the time of need
(violent behavior or exciting if needed placement of restraints may be necessary.
– If restraints are placed, gradually remove one by one by observing his behavior.
– Maintain adequate distance with the violent client and be ready to exit during violent
behaviour.
 Exhibit consistency behaviour at all times.
– Never hurt inner feeling of the client, do not do any unhealthy comparisons.
– Review the incident with client after he gained control over his behavior.
– Restrict or limit the client's negative feeling or activities.
– Define specified tasks, schedule it, orient and reinforce the client to perform his
scheduled activities without postponing , insist for implementation of activities.
– Encourage the client to participate in group activities and in small discussions.
– Provide minimum furniture

2. BIPOLAR MOOD (AFFECTIVE) DISORDER

Introduction

Bipolar disorder is mood disorder characterized by mood swings from manic

episodes to depressive episodes in the same patient at different times and usually
accomplished by abnormalities in thinking, perception and behavior arising out of mood
disturbances. It was formerly known as "Manic Depressive Psychosis" (MDP). During
manic phases, client are euphoric, grandiose, energetic and sleepless. They have poor
judgment and rapid thoughts, actions and speech. During depressed phases, mood behavior
and thoughts are the same as persons diagnosed with major depression. Bipolar mood
disorder has an earlier age of onset i.e. third decade and an average episode last for 3-4
months while a depressive episode lasts from 4-6 months. With rapid institution of
treatment, the major symptoms of mania are controlled within 2 weeks and of depression
within 6-8 weeks.

Epidemiology

In case of depressive episodes, nearly 40% of depressives with episodic course

improve in 3 months, 60% in 6 months and 80% improve within a period of one year, 15-
20% of patients develop chronic course of illness, which may last for two or more years.

Definition

a. Bipolar mood or affective disorder is characterized by recurrent episodes of mania

and depression in the same patient at different times. Earlier known as manic
depressive psychosis (MDP)
b. Bipolar disorder, also known as manic- depressive illness, is a brain disorder that
causes unusual shifts in mood, energy, activity levels, and the ability to carry out
day-to-day tasks.

Etiology-The etiology of mood disorders is not known currently.

A. Biological Theories

1. Genetic Hypothesis -The life-time risk for the first degree relatives of bipolar mood
disorder patients is 25%, and of recurrent depressive disorder patients is 20% .The life-
time risk for the children of one parent with bipolar mood disorder is 27% and of both
parents with bipolar mood disorder is 74%.
 The concordance rate in bipolar disorders for monozygotic twins is 65% and for
dizygotic twins is 20%.

2. Biochemical Theories : An abnormality in nor-epinephrine, dopamine, serotonin,

Acetylcholine and GABA are involved in bipolar mood disorders. The side effects of
antidepressants and mood stabilizers also cause bipolar mood disorders.

3. Neuroendocrine Theories : Endocrine function is often disturbed in depression such as

hypothyroidism, Crushing's disease, and Addison's disease.

4. Sleep studies: Sleep abnormalities are common in mood disorders e.g. decreased need
for sleep in mania insomnia and frequent awakening in depression. In depression, the
commonly observed abnormalities include decreased REM latency ( i.e. the time between
falling asleep and the first REM period is decreased), increased duration of the first REM
period, and delayed sleep onset.

5. Brain Imaging: In mood disorders, brain imaging studies; findings include ventricular
dilatation, white matter hyper-intensities, and changes in the blood flow and metabolism in
several parts of brain (such as prefrontal cortex, anterior cingulated cortex, and caudate).

B. Psychosocial Theories

1. Psychoanalytic Theories : In depression, loss of a libidinal object, introjections of the

lost object, fixation in the oral sadistic phase of development, and intense craving for
narcissism or self-love are some of the postulates of different psychodynamic theories.
Mania represents a reaction formation to depression according to the psychodynamic
theory.

2. Stress- Increased number of stressful life events before the onset or relapse has a
formative rather than a precipitating effect in depression though they can serve a
precipitant in mania. Increased stressors in the early period of development are probably
more important in depression.
 -

3. Cognitive and Behavioral Theories The mechanisms of causation of depression,

according to these theories, include depressive negative cognition, learned helplessness
and anger directed inwards.

Classification of Bipolar Disorders

1. Bipolar I Disorder

2. Bipoalar II Disorder

3. Cyclothymia

4. Bipolar Disorder Not otherwise Specific (BP- NOS)

1. Bipolar I Disorder-Bipolar I disorder is characterized by at least one manic

episodes or mixed episodes and one or more major depressive episodes. These
episodes last for at least one week but may continue for months. Between episodes,
there may be periods of normal functioning. Bipolar I disorder is the most severe
form of the illness. The manic symptoms are sometimes so severe that the person
may require immediate hospital admission.
2. Bipolar II Disorder - Bipolar II Disorder is characterized by one or more major
depressive episodes with at least one hypo-manic episode (Not requiring
hospitalization). Between episodes, there may be periods of normal functioning.
Bipolar II disorder is believed to occur more frequently in women than in men.
3. Cyclothymic Disorder - Cyclothymic Disorder refers to a persistent instability in
mood between mild depression and mild elation lasting more than 2 years. Milder
form of bipolar disorder the periods of both mild depressive and hypo-manic
symptoms are shorter, less severe and do not occur with regularity.
 4. Bipolar Disorder Not Otherwise Specified (BP-NOS): diagnosed when symptoms
of the illness exist but do not meet diagnostic criteria for either bipolar I or II.
However, the symptoms are clearly out of the person’s normal range of behavior.

Treatment

A. Mood stabilizers (Lithium)-Mood stabilizers are usually the first choice to treat bipolar
disorder. Lithium also known as is an effective mood stabilizer for treating both manic
and depressive episodes.

Other mood stabilizers

1. Sodium valproate – For acute treatment of mania and prevention of bipolar mood
disorder. Particularly useful in those patients who are refractory to lithium. The dose range
is usually 1000-3000mg/day (the therapeutic blood levels are 50-125 mg/ml). It has a
faster onset of action than lithium, therefore, it can be used in acute treatment of mania
effectively.

2. Carbamazepine – For acute treatment of mania and prevention of bipolar mood

disorder. Particularly useful in those patients who are refractory to lithium and valproate.
Particularly effective when EEG is abnormal (although this is not necessary for the use of
carbamazepine). The dose range of carbamazepine is 600-1600 mg/day ( the therapeutic
blood levels are 4-12 mg/ml).

3. Lamotrigine – Lamotrigine is particularly effective for bipolar depression and is

recommended by several guidelines.

4. T3 and T4 as adjuncts for the treatment of rapid cycling mood disorder and resistant
depression.
B. Atypical antipsychotics drugs such as risperidone, olanzapine, quetiapine are
sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken
with other medications, such as antidepressants.

C. Antidepressants such as Fluoxetine, paroxetine, sertraline, and bupropion; are

sometimes used to treat symptoms of depression in bipolar disorder.

D. Psychotherapy

 Cognitive behavioural therapy (CBT), which helps people with bipolar disorder
learn to change harmful or negative thought patterns and behaviors.
 Family-focused therapy, which involves family members. It helps enhance family
coping strategies, such as recognizing new episodes early and helping their loved
one. This therapy also improves communication among family members, as well as
problem-solving. Interpersonal and social rhythm therapy, which helps people
with bipolar disorder improve their relationships with others and manage their daily
routines. Regular daily routines and sleep schedules may help protect against manic
episodes
 Psycho-education: which teaches people with bipolar disorder about the illness and
its treatment. Psycho-education can help to recognize signs of an impending mood
swing so they can seek treatment early, before a full-blown episode occurs. It may
also be helpful for family members and caregivers.

E. Electroconvulsive Therapy (ECT)- Electroconvulsive therapy (ECT) may be

useful for patient with severe bipolar disorder who have not been able to recover with
other treatments.

Nursing interventions

 Provide a safe Environment for the client.

 Decrease environmental stimuli whenever possible. Respond to cues of increased
restlessness agitation by removing stimuli and perhaps isolating the client.
 Provide a consistent, structured environment. Let the client know what is expected
of him or her’.
 Determine the appropriate level of suicide precautions for the client.
 Ask the client if he or she has a plan for suicide. Attempt to ascertain how detailed
and feasible the plan is.
 The client’s room should be centrally located, preferably near the nurses’ station
and within view of to staff
 Decrease environment stimuli.
 Provide consistent structure environment.
 Give simple direct explanations
 Reorient the client to person, place, and time as indicated. Spend time with the
client.
 Decrease environmental stimuli whenever possible. Respond to cues of increased
restlessness or agitation by removing stimuli and perhaps isolating the client
 Set and maintain limits on behavior that is destructive or adversely affects others.
 If necessary, assist, the client with personal hygiene, including mouth care, bathing,
dressing, and laundering clothes.
 Encourage the client to meet as many of his or her own needs as possible.
 Monitor the client’s eating patterns and fluid intake. You may need to record intake
and output can carry with him or her
 Teach the client and family or significant others about manic behavior, bipolar
disorder, and other problems as indicated.
 Inform the client and family or significant others chemotherapy: Dosage, the need
to take the medication only as prescribed
 Provide a safe environment for the client
 Continually assess the client’s potential for suicide.
 Reorient the client to person, place, and time as indicated.
 When first communicating with the client, use simple, direct sentences
  Initially, interact with the client on a one – to one basis
 Convey that you care about the client and that you believe the client is worthwhile
human being.
 Encourage the client to express his or her feelings; convey your acceptance of the
client’s feelings.
 Help the client identify positive aspects about himself or herself.

MANAGEMENT OF VIOLENCE:

 A person who loses control of his anger becomes violent. We must develop the
ability to deal with violent behavior in a way that minimizes the danger.
 Prevention of violence is preferable if it is possible. The intense anxiety associated
with violent feelings is communicated interpersonally.
 Accept the patient as he is, without retaliation or judgement.
 Allow the patient to verbalize his annoyance.
 Don’t’ hurt the patient for his aggressiveness

Rehabilitation: Rehabilitation is the process of enabling the individual to return to his

highest possible level of functioning. The goal is usually to reach the pre-illness functional
level. This may be achieved by assisting the patient, to regain their strengths, re-learning
their old skills or learning new skills,

FOLLOW – UP AND HOME CARE AND REHABILITATION-Educate the family

about the impact of untreated mood disorders on the individual’s life and functional
ability. Tell the client and family to report any worsening signs of depression or suicidal
thoughts.

Educate the client and family about mood disorders as illnesses that are not their
“fault”. Teach clients and families about the “lag time” between starting antidepressants
and onset of therapeutic effect. Inform the client that several strategies exist to manage
uncomfortable side effects including reduced dosages, additional medications, or
switching to another medication. Tell clients about the need to continue medication and
discuss with their prescriber any desire to stop it.

3. DEPRESSIVE MOOD (AFFECTIVE) DISORDER

Introduction

Everyone occasionally feels blue or sad. But these feelings are usually short-lived
and pass within a couple of days. When you have depression, it interferes with daily life
and causes pain for both you and those who care about you. Depression is a common but
serious illness.

Definition

a. Depression is a common mental disorder that presents with depressed mood, loss
of interest or pleasure, feelings of guilt or low self- worth, disturbed sleep or
appetite, low energy, and poor concentration.

(By WHO)

b. Depression is a very common, highly treatable, medical illness affects physical,

mental and emotional well-being and basic, everyday activities like eating and
sleeping. Affects how people think about things and feel about themselves.

c. Depression in contrast to the normal emotional experiences of sadness, loss, or

passing mood states, clinical depression is persistent and can interfere
significantly with an individual's ability to function. Give up like tendency.
Symptoms can last months or even years.
Epidemiology

According to WHO Globally more than 350 million people of all ages suffer from
depression. For the age group 15-44 major depression is the leading cause of disability in
the U.S. Women are nearly twice as likely to suffer from a major depressive disorder than
men are. With age the symptoms of depression become even more severe. About thirty
percent of people with depressive illnesses attempt suicide.

Etiology

 Genetic cause
 Environmental factors
 Biochemical factors : Biochemical theory of depression postulates a deficiency of
neurotransmitters in certain areas of the brain (nor-adrenaline, serotonin, and
dopamine).
 Dopaminergic activity : reduced in case of depression, over activity in mania.
 Endocrine factors - hypothyroidism, cushing’s syndrome etc

 Abuse of Drugs or Alcohol

 Hormone Level Changes
 Physical illness and side effects of medications
 Drugs like Analgesics, Antidepressants, Anti-hypertensive, Anti-convulsants,
Benzodiazipine withdrawal, Antipsychotics
 Physical Illness like Viral illness , Carcinoma, Neurological disorders, Thyroid
Disease, Multiple sclerosis, Pernicious Anaemia, Diabetes, Systemic lupus
Erythematosus, Addison’s disease
Types of depression

a. Major Depressive Disorder (MDD) Individuals with a major depressive episode or

major depressive disorder are at increased risk for suicide. Seeking help and treatment
from a health professional dramatically reduces the individual's risk for suicide.

b. Depressive Disorder- it includes

Atypical Depression (AD) - is characterized by mood reactivity (paradoxical

anhedonia) and positivity, significant weight gain or increased appetite, excessive sleep or
somnolence.

Psychotic Major Depression (PMD) - melancholic in nature - characterized by

delusion and hallucinations.

Non-melancholic Depression - Most common sub-type of depression - non-biological

in nature

 Catatonic Depression - is a rare and severe form of major depression involving

disturbances of motor behavior and other symptoms. The person is mute and almost
stuporose, and either is immobile or exhibits purposeless or even bizarre movements.
Depressive Disorder

 Post Partum Depression (PPD) - it refers to the intense, sustained and sometimes
disabling depression experienced by women after giving birth.

 Dysthymia - physical and cognitive problems are evident Depressive Disorder

 Double Depression - fairly depressed mood (dysthymia). Depressive Personality

Disorder (DPD) - is characterized by an ongoing and inescapable array of depressive
thoughts and actions. Depressive Disorder

  Recurrent Brief Depression (RBD) - characterized by frequently occurring brief

depressive episodes, lasting less than two weeks. Depressive Disorder
Clinical Manifestations

Depressions

 Thinking is pessimistic and in some cases suicidal.

 In severe cases psychotic symptoms such as hallucinations or delusions may be
present.
 Insomnia or hypersomnia, libido, weight loss, loss of appetite.
 Intellectual or cognitive symptoms include a decreased ability to concentrate,
slowed thinking, & a poor memory for recent events.

DIAGNOSIS-ICD 10 Diagnostic criteria for a depressive episode {WHO}

Usual Symptoms
 Depressed mood.
 Loss of interest and enjoyment.
 Reduced energy leading to increased fatiguability and diminished activity.
Common symptoms
 Reduced concentration and attention.
 Reduced self -esteem and self-confidence.
 Ideas of guilt and unworthiness.
 Bleak and pessimistic views of future .
 Ideas or acts of self harm or suicide.
 Disturbed sleep.
 Diminished appetite.
Mild Depressive Episode: For at least 2 weeks, at least two of the usual symptoms of a
depressive episode plus at least two common symptoms.
Moderate Depressive Episode: For at least 2 weeks, at least two or three of the usual
symptoms of a depressive episode plus at least three of the common symptoms.
 Severe Depressive Episode: For at least 2 weeks all three of the usual symptoms of a
depressive episode plus at least 4 of the common symptoms some of which should be of
severe intensity.
SIGECAPS Mnemonic for Symptom Criteria for Major Depressive Episode

 S – sleep disturbance (insomnia, hypersomnia)

 I – interest reduced (reduced pleasure or enjoyment)
 G – guilt and self-blame
 E – energy loss and fatigue
 C – concentration problems
 A – appetite changes (low appetite/weight loss or increased appetite/weight gain)
 P – psychomotor changes (retardation, agitation)
 S – suicidal thoughts

Investigations

 Rating Scales
o Beck Depression Inventory
o Hamilton Depression Rating Scale
 Dexamethasone Suppression Test

Treatment:

A) Anti-depressants
1. MAO inhibitors:
 Irreversible: Isocarboxazid, Iproniazid, Phenelzine and Tranylcypromine.
 Reversible: Moclobemide and Clorgyline.
2. Tricyclic antidepressants (TCAs)
 NA and 5 HT reuptake inhibitors: Imipramine, Amitryptiline, Doxepin,
Dothiepin and Clomipramine.
 NA reuptake inhibitors : Desimipramine, Nortryptyline, Amoxapine.
3. Selective Serotonin reuptake inhibitors: First line drug in depression. Relatively
safe and better patient acceptability. Some patients not responding to TCAs may
respond with SSRIs. SSRIs inhibit the reuptake mechanism and make more 5 HT
available for action.
• Fluoxetine, Fluvoxamine, Sertraline and Citalopram
4. Atypical antidepressants:
o Trazodone, Mianserin, Mirtazapine, Venlafaxine, Duloxetine, Bupropion

B) Psychotherapies:
 Supportive psychotherapy
 Interpersonal psychotherapy
C) Cognitive therapies: to modify patient’s faulty ways of thinking about life
situations
D) Behavioural therapies: Social skills training and Problem solving skills
 Cognitive Behavioral therapy (CBT) Identify automatic, maladaptive thoughts and
distorted beliefs that lead to depressive moods. Learn strategies to modify these
beliefs and practice adaptive thinking patterns. Use a systematic approach to
reinforce positive coping behaviours. 8-12 sessions
E) Interpersonal therapy- Identify significant interpersonal/relationship issues that
led to, or arose from, depression (unresolved grief, role disputes, role transitions,
social isolation). Focus on 1 or 2 of these issues, using problem-solving, dispute
resolution, and social skills training. 12-16 sessions

F) Electro-Convulsive Therapy

Indication:

 Depression with suicidal ideation

 Depression with psychotic symptoms
 Resistant depression- not responding to various drug combinations in full doses
Frequency & number of treatments:

 First 3 treatment on alternate day then twice a week

 6-12 depending upon response
 Mild to moderately severe MDD-psychotherapies are as effective as antidepressant
medications.
 Combined treatment with pharmacotherapy and psychotherapy-no more effective
than either therapy alone.
 Combined treatment-chronic or severe episodes, patients with co-morbidity, and
patients not responding to mono

Recommend lifestyle management for all patients with depression.

 Regular exercise
 Adequate housing
 Healthy regular meals
 Stress management strategies
 Sleep hygiene
 Engaging in at least one pleasurable activity a day
 Avoiding substance use
 Keeping a daily mood chart
 Assess and discuss self-management goals, challenges and progress.
 Provide patient education and self-management materials plus community
resources list.
 Review treatment plan and modify if no response to antidepressants after 3-4 weeks
 At least three follow-up visits in first 12 weeks of antidepressant treatment.
 At least one follow-up visit in first 12 weeks of referral for psychotherapy
 Continued antidepressant treatment for 6 months after remission, at least 2 years for
those with risk factors.
 Encourage adherence to continued treatment even and especially after remission.
  Discuss relapse risk factors, symptoms and prevention.
 Discuss and plan gradual discontinuation of antidepressants.
 Discuss need for social network of family, friends and community.

Conclusion:

Mood disorders are chronic & recurrent disorders. Mood disorders are common. Many
peoples suffer needlessly because their mood disorder is not diagnosed and treated.
Diagnosing mood disorders is straightforward. Drugs are effective and practical. Drugs are
effective and practical. Doctors should take the lead in recognizing and treating mood
disorders.

REFERENCES

1. R. Sreevani; a text book of mental health nursing, Jaypee publications; page no-417
to 430
2. Ram kumar Gupta; a text book of Mental health Nursing by PV publications; page
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3. Mary c townsend: a text book of mental health nursing jaypee publication; page no-
525-530
4. Ahuja and Vyas text book of post graduate psychiatry, 2nd edition, Jaypee brothers,
New Delhi, 2003.
5. Lalitha .k ,Mental health and Psychiatric nursing,, 2nd edition, Ganjana
publishers,Banglore,2004.
6. STUART,LARAIA, principles of psychiatric nursing,7th edition, Harcourt private
limited. New Delhi.
7. Bhatia. M.S, text book of psychiatric nursing,2nd ,edition, C BS publications, New
Delhi,2005
8. ICD-10 classification of mental and behavioural disorders, A.L.T.B.S publications,
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