mood disorders elisa a. mancuso rnc, ms, fns professor

Mood DisordersMood Disorders

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

Mood Disorder ContinuumMood Disorder Continuum

WellWell NeuroticNeurotic PsychoticPsychotic

SadnessSadness Dysthymic Dysthymic MDD MDD

GriefGrief Cyclothymic Cyclothymic Bipolar Bipolar

14 million Americans have major affective 14 million Americans have major affective disorder.disorder.

↑ ↑ incidence in younger women & older men.incidence in younger women & older men.

Related Mood DisordersRelated Mood Disorders

Dysthymia Dysthymia = “Down in the Dumps”= “Down in the Dumps” Chronically depressed mood x 2 yearsChronically depressed mood x 2 years ↓ ↓ EnergyEnergy AnhedoniaAnhedonia Social WithdrawalSocial Withdrawal Feelings of hopelessnessFeelings of hopelessness Insomnia or HypersomniaInsomnia or Hypersomnia ↓ ↓ Self-Esteem ↓ Worthlessness ↓ ConcentrationSelf-Esteem ↓ Worthlessness ↓ Concentration Symptoms never disappear for more than 2 mos Symptoms never disappear for more than 2 mos

@ a time@ a time ↑ ↑ Incidence to develop MDDIncidence to develop MDD 15 % commit suicide15 % commit suicide


CyclothymiaCyclothymia– Cycles of mild depression & hypomania x 2 Cycles of mild depression & hypomania x 2

yearsyears– Hypomania 4 days of persistent up moodHypomania 4 days of persistent up mood

DepressionDepression HypomaniaHypomania↓ ↓ Self-EsteemSelf-Esteem Inflated self-Inflated self-

esteemesteem↑↑ ↑↑ SleepingSleeping ↓↓ Sleeping↓↓ SleepingSocial WithdrawalSocial Withdrawal People seekingPeople seeking↓↓ ↓↓ ProductivityProductivity ↑↑ Productivity↑↑ Productivity


Seasonal Affective Disorder SADSeasonal Affective Disorder SAD– ↑ ↑ Depression with shortened daylight in fall & Depression with shortened daylight in fall &

winterwinter– Disappears during spring & summerDisappears during spring & summer– Episodes occur @ same time of year Episodes occur @ same time of year

2 years in a row2 years in a row– Hypersomnia & daytime drowsinessHypersomnia & daytime drowsiness– ↑↑ ↑↑ Appetite for carbs & sugars = ↑ wt. gainAppetite for carbs & sugars = ↑ wt. gain

Seasonal Affective Disorder SADSeasonal Affective Disorder SAD

Etiology:Etiology:– ↓ ↓ Exposure to light & ↓ MelatoninExposure to light & ↓ Melatonin– Failure of body to adjust to stressorsFailure of body to adjust to stressors– Disrupted circadian rhythms due to head traumaDisrupted circadian rhythms due to head trauma

Therapy:Therapy:– Timed exposure to special light (4-6H/d)Timed exposure to special light (4-6H/d)– Synchronizes circadian rhythmsSynchronizes circadian rhythms– ↑↑ ↑↑ Melatonin production =Melatonin production =– Euthymia (normal mood & usual behaviors)Euthymia (normal mood & usual behaviors)


Postpartum DepressionPostpartum Depression– Onset within 1Onset within 1stst 30 days 30 days → 12 months.→ 12 months.– 10-15 % incidence with abrupt onset.10-15 % incidence with abrupt onset.– Severe labile mood symptoms:Severe labile mood symptoms:

TearfulnessTearfulness DespondencyDespondency Anxiety Anxiety ↓ Concentration↓ Concentration

– Delusional thoughts of infant’s health (Over Delusional thoughts of infant’s health (Over concern)concern)

– ↑ ↑ Risk injury to infant & MomRisk injury to infant & Mom– Therapy:Therapy:

Medication & HospitalizationMedication & Hospitalization

Major Depressive Disorder MDDMajor Depressive Disorder MDD Presence of the following symptoms > 2 weeks:Presence of the following symptoms > 2 weeks:

– ↑↑ ↑↑ SadnessSadness – AnhedoniaAnhedonia- inability to feel pleasure- inability to feel pleasure – Psychomotor retardationPsychomotor retardation– ↓↓/↑ Appetite & weight/↑ Appetite & weight– ↓ ↓ Energy Level Hopelessness ↓ Self-EsteemEnergy Level Hopelessness ↓ Self-Esteem– ↓↓/↑ Sleeping ↓ Concentration/Decision Making/↑ Sleeping ↓ Concentration/Decision Making– Worthlessness & guiltWorthlessness & guilt– Recurrent thoughts of death or suicideRecurrent thoughts of death or suicide

MDD EtiologyMDD Etiology GeneticGenetic

– Transmission via different genes (# 6 or # 11)Transmission via different genes (# 6 or # 11)– ↑ ↑ Risk of incidence 25% 1Risk of incidence 25% 1stst degree relative degree relative– ↑ ↑ Hereditability 50 % Bipolar DisorderHereditability 50 % Bipolar Disorder

75% identical twins 75% identical twins BiochemicalBiochemical

– Deficiency of neurotransmitters AChDeficiency of neurotransmitters ACh– ↓↓↓↓ NE, ↓↓ 5-HT, ↓ DA & ↑↑ GABA NE, ↓↓ 5-HT, ↓ DA & ↑↑ GABA – ↑ ↑ Cortisol RT ↓ response to CRFCortisol RT ↓ response to CRF

PsychosocialPsychosocial– Anger turned inwardAnger turned inward– Unresolved trauma or early life loss.Unresolved trauma or early life loss.– Learned Helplessness = Powerless EgoLearned Helplessness = Powerless Ego– Early stress contributes to self-defeating patternEarly stress contributes to self-defeating pattern– ““Glass is ½ empty” View in a negative manner Glass is ½ empty” View in a negative manner

MDD Risk FactorsMDD Risk Factors

Hx of Depression (self or family)Hx of Depression (self or family) Female onset @ age 40Female onset @ age 40 Stressors:Stressors:

– ↓ ↓ Financial resources/UnemployedFinancial resources/Unemployed– > 3 children @ home> 3 children @ home– ↓ ↓ Social supportSocial support– Sexually abusedSexually abused– Co-Morbidity DM, HTN, CA, CADCo-Morbidity DM, HTN, CA, CAD

Prior suicide attempts!Prior suicide attempts!

Clinical SymptomsClinical Symptoms

Suicidal IdeationSuicidal Ideation– Negative thoughts of self-hate & hostilityNegative thoughts of self-hate & hostility– Recurrent thoughts of deathRecurrent thoughts of death– ↓ ↓ Social & personal resourcesSocial & personal resources– Verbalize desire to die Verbalize desire to die – Patient getting better =↑↑↑ RiskPatient getting better =↑↑↑ Risk – ↑ ↑ LethalityLethality = Describe specific plan & access! = Describe specific plan & access!

Need immediate intervention!Need immediate intervention!

– All depressed patients are potentially suicidal!All depressed patients are potentially suicidal! 80% of 30,000 suicides/year80% of 30,000 suicides/year

Nursing InterventionsNursing Interventions

Promote Safety!Promote Safety!– Suicide precautionsSuicide precautions– Vigilant observations q 15 minutesVigilant observations q 15 minutes– Quiet, warm accepting attitudeQuiet, warm accepting attitude– Monitor for hoarding medicationsMonitor for hoarding medications

√ √ clothes, mattress, personal belongingsclothes, mattress, personal belongings Promote Physical Well-being.Promote Physical Well-being.

– Nutrition & elimination √ I & ONutrition & elimination √ I & O– Personal hygiene needsPersonal hygiene needs– Schedule regular mealtimes & stay with pt Schedule regular mealtimes & stay with pt – Establish regular hours for sleep Establish regular hours for sleep – Encourage participation in regular exerciseEncourage participation in regular exercise


Assist with Grief ProcessAssist with Grief Process– Encourage verbalization to acknowledge lossEncourage verbalization to acknowledge loss– Patience-build trust & convey acceptancePatience-build trust & convey acceptance– Identify secondary gainsIdentify secondary gains– Encourage participation in support groupEncourage participation in support group

Enhance Self-EsteemEnhance Self-Esteem– Schedule regular meeting times = Pt importanceSchedule regular meeting times = Pt importance– Redirect to focus on present problemsRedirect to focus on present problems– Identify (+) attributes & achievementsIdentify (+) attributes & achievements– Have pt make an antidepressant kitHave pt make an antidepressant kit– ↑ ↑ Social interaction via group activitiesSocial interaction via group activities– Assign responsibilities (arrange chairs in dayroom Assign responsibilities (arrange chairs in dayroom

for meetings)for meetings)


Assist Pt to take control over lifeAssist Pt to take control over life– Support decision making attemptsSupport decision making attempts– Encourage problem solvingEncourage problem solving– Have Pt develop a daily scheduleHave Pt develop a daily schedule– Allow sufficient time to think & act.Allow sufficient time to think & act.– Clearly communicate expectationsClearly communicate expectations

Attendance @ mealtimes, group meetings, etc.Attendance @ mealtimes, group meetings, etc.

– ↑ ↑ Autonomy for longer periods of timeAutonomy for longer periods of time


Confront anger turned inwardConfront anger turned inward– Identify feelings of anger & possible triggersIdentify feelings of anger & possible triggers– Offer acceptable alternatives of releasing Offer acceptable alternatives of releasing

angeranger Ripping paper, throwing nerf ball, yellingRipping paper, throwing nerf ball, yelling Physical exercise –walking releases Physical exercise –walking releases

tensiontension– Expressing emotions viaExpressing emotions via

–JournalingJournaling–Painting, drawingPainting, drawing

MedicationsMedications

TriCyclic Antidepressants –TCAsTriCyclic Antidepressants –TCAs– Formerly 1Formerly 1stst choice choice – Delayed onset of action 2-3 weeksDelayed onset of action 2-3 weeks

Optimal response in 1 monthOptimal response in 1 month

– Need adequate dose & duration 4-9 monthsNeed adequate dose & duration 4-9 months– Blocks reuptake of NE, 5-HT & DABlocks reuptake of NE, 5-HT & DA– ↑↑ ↑↑ Receptor sensitivityReceptor sensitivity– ↑↑ ↑↑ NE, 5-HT & DA available @ receptor siteNE, 5-HT & DA available @ receptor site– ↑ ↑ mood ↑ appetite mood ↑ appetite ↑activity & regular ↑activity & regular

sleep patternssleep patterns

TCA MedicationsTCA Medications

Amitriptyline (Elavil)Amitriptyline (Elavil) Amoxapine (Asendin)Amoxapine (Asendin)Desipramine (Norpramin) Desipramine (Norpramin) Doxepin (Sinequan)Doxepin (Sinequan)Imipramine (Tofranil)Imipramine (Tofranil) Nortriptyline (Pamelor) Nortriptyline (Pamelor)

Moderate – Severe depressionModerate – Severe depression

TCA Side EffectsTCA Side Effects– Dose related = Dose related = ↓ dose = ↓ SE↓ dose = ↓ SE– Start low & go slowStart low & go slow– Potentially lethal if 3x Max therapeutic dosePotentially lethal if 3x Max therapeutic dose

Not responsive to dialysis = fatal!Not responsive to dialysis = fatal!

TCA Side EffectsTCA Side Effects

AnticholinergicAnticholinergic CardiovascularCardiovascularDry mouthDry mouth Orthostatic ↓ BPOrthostatic ↓ BPUrinary retention Urinary retention ↑ HR↑ HRBlurred vision Blurred vision ArrhythmiasArrhythmiasPhotophobiaPhotophobia Prolonged QRS Prolonged QRS

& QT & QT↓ ↓ DiaphoresisDiaphoresis CHFCHF

TCA Side Effects Cont.TCA Side Effects Cont.

NeurologicalNeurological GastrointestinalGastrointestinal

SedationSedation HeartburnHeartburn

↓ ↓ ConcentrationConcentration N & VN & V

FatigueFatigue ↓ Motility↓ Motility

Muscle WeaknessMuscle Weakness ConstipationConstipation

Tremors & SeizuresTremors & Seizures Paralytic IleusParalytic Ileus

TCA Side Effects ContTCA Side Effects Cont

OtherOther– RashesRashes– PhotosensitivityPhotosensitivity– ↓ ↓ Sexual PerformanceSexual Performance

↓ ↓ Orgasm & ImpotenceOrgasm & Impotence TCA ContraindicationsTCA Contraindications

– Cardiac HX (MI)Cardiac HX (MI)– Hepatic or Renal insufficiencyHepatic or Renal insufficiency– Closed <) glaucomaClosed <) glaucoma– SeizuresSeizures

TCA Drug InteractionsTCA Drug Interactions

MAO InhibitorsMAO Inhibitors– 14 day waiting period TCA- MAOI14 day waiting period TCA- MAOI

Cardiac MedsCardiac Meds– √ √ BP may ↑ or ↓BP may ↑ or ↓

AntacidsAntacids– Inhibit TCA absorptionInhibit TCA absorption

AntipsychoticsAntipsychotics– Potentiate anticholinergic effects, EPS, Potentiate anticholinergic effects, EPS,

sedation & seizuressedation & seizures

Atypical AntidepressantsAtypical AntidepressantsBupropion (Wellbutrin)Bupropion (Wellbutrin)

Selective DA reuptake inhibitor (No affect on 5-HT)Selective DA reuptake inhibitor (No affect on 5-HT)SE: SE: ↑ Seizures ↓ Weight↑ Seizures ↓ Weight ↓ Nicotine craving↓ Nicotine craving ↑ Sexuality ↑ Sexuality

Mirtazapine (Remeron)Mirtazapine (Remeron)Blocks 5-HT receptorBlocks 5-HT receptorDissolves orally Dissolves orally SE: SE: ↑ Sedation ↑ Weight↑ Sedation ↑ Weight ↑Serum Cholesterol (LDL & HDL) ↑Serum Cholesterol (LDL & HDL)

Nefazodone (Serzone) *Nefazodone (Serzone) * Trazodone (Desyrel)**Trazodone (Desyrel)**5-HT reuptake inhibitor & receptor blocker5-HT reuptake inhibitor & receptor blockerSE: SE: * Inhibits P450 system = drug toxicity & hepatic failure* Inhibits P450 system = drug toxicity & hepatic failure ** Priapism, Orthostaic ** Priapism, Orthostaic ↓ BP, Sedation↓ BP, Sedation

Venlafaxine (Effexor)Venlafaxine (Effexor)Selective 5-HT & NE reuptake inhibitorSelective 5-HT & NE reuptake inhibitorSE: Low anticholinergic SE: Low anticholinergic ↑ BP @ ↑ doses↑ BP @ ↑ doses

Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors SSRIsSSRIs

Citalopram (Celexa) Fluxoxetine(Prozac)Citalopram (Celexa) Fluxoxetine(Prozac)

Paroxetine (Paxil)Paroxetine (Paxil) Sertraline (Zoloft) Sertraline (Zoloft) Block reuptake of 5-HT = Block reuptake of 5-HT = ↑↑ availability↑↑ availability Mood elevationMood elevation SE: ↓ Anticholinergic, cardiac & sedatingSE: ↓ Anticholinergic, cardiac & sedating

– NauseaNausea Nervousness Nervousness Agitation Agitation HAHA– DizzinessDizziness Sexual Dysfunction ↓ WeightSexual Dysfunction ↓ Weight

Serotonin SyndromeSerotonin Syndrome

↑↑ ↑↑ Risk with MAOIs, Tryptophan or St. John’s WortRisk with MAOIs, Tryptophan or St. John’s Wort SSRIs inhibit P450 enzymesSSRIs inhibit P450 enzymes

– ↑↑ ↑↑ levels of un-metabolized drugslevels of un-metabolized drugs

Clinical Signs:Clinical Signs: ↓↓Mental status ConfusionMental status Confusion HypomaniaHypomania HAHA RestlessnessRestlessness AgitationAgitation Myoclonus/Myoclonus/

HyperreflexiaHyperreflexia ↓↓DiaphoresisDiaphoresis ChillsChills Abdominal crampsAbdominal cramps DiarrheaDiarrhea NauseaNausea AtaxiaAtaxia

Monoamine Oxidase Inhibitors Monoamine Oxidase Inhibitors MAOIsMAOIs

Isocarboxiazid (Marplan) Phenelzine (Nardil)Isocarboxiazid (Marplan) Phenelzine (Nardil)Tranylcypromine (Parnate) Tranylcypromine (Parnate) Moclobemide (Menerix)Moclobemide (Menerix) 33rdrd choice due to fatal SE & drug interactions choice due to fatal SE & drug interactions IrreversiblyIrreversibly Inhibits monoamine oxidase (MAO) Inhibits monoamine oxidase (MAO)

– MAO deactivates NE, DA & 5-HT & tyramine MAO deactivates NE, DA & 5-HT & tyramine → inactive → inactive productsproducts

No MAO = ↑↑ NE ↑↑ DA ↑↑ tyramine = ↑↑ BP No MAO = ↑↑ NE ↑↑ DA ↑↑ tyramine = ↑↑ BP Hypertensive CrisisHypertensive Crisis Lethal dose = 6-10x daily dose!Lethal dose = 6-10x daily dose!

Monoamine Oxidase Inhibitors Monoamine Oxidase Inhibitors MAOIsMAOIs

Avoid food, drinks & meds that contain tyramine!Avoid food, drinks & meds that contain tyramine!– 3 days before starting, during and 14 days after med 3 days before starting, during and 14 days after med

DC’dDC’d

Dietary restrictions =Dietary restrictions =↑↑ tyramine content↑↑ tyramine content– Cheese –aged & processedCheese –aged & processed– BeerBeer Red wine Red wine Caffeine Caffeine Cola/CoffeeCola/Coffee– ChocolateChocolate Cold cutsCold cuts YeastYeast– Sour cream Smoked FishSour cream Smoked Fish

MAOIs SEMAOIs SE

Lethal Dose = 6-10x daily dose!Lethal Dose = 6-10x daily dose! AnticholinergicAnticholinergic

– Dry mouth, Blurred vision, ConstipationDry mouth, Blurred vision, Constipation CNSCNS

– Agitation, Restlessness, Tremors & HAAgitation, Restlessness, Tremors & HA CardiacCardiac

– Orthostatic Orthostatic ↓ BP, Heart failure↓ BP, Heart failure GUGU

– Urinary Retention, Urinary Retention, ↓ Orgasms↓ Orgasms

MAOIs SEMAOIs SE

Hypertensive CrisisHypertensive Crisis– Explosive HA (Occipital Explosive HA (Occipital → Frontal)→ Frontal)– ↑↑ ↑↑ BPBP (Sudden Elevation = CVA)(Sudden Elevation = CVA)– ↑↑ ↑↑ HR , Palpitations = Chest PainHR , Palpitations = Chest Pain– ↑↑ ↑↑ Temp, Diaphoresis, Temp, Diaphoresis, – Dilated pupils = PhotophobiaDilated pupils = Photophobia

Nursing InterventionsNursing Interventions– VS q 5 minsVS q 5 mins High Fowlers PositionHigh Fowlers Position– Cooling BlanketCooling Blanket Hold MAOI med!Hold MAOI med!– MedsMeds

Thorazine 100mg IM ( Blocks NE & DA)Thorazine 100mg IM ( Blocks NE & DA) Procardia 10 mg PO/IV ( Vasodilator)↓↓ BPProcardia 10 mg PO/IV ( Vasodilator)↓↓ BP Regitine IV (Vasodilator) ↓↓ BPRegitine IV (Vasodilator) ↓↓ BP

Electroconvulsive Therapy ECTElectroconvulsive Therapy ECT

Severe Depression, Bipolar, SchizophreniaSevere Depression, Bipolar, Schizophrenia– When medications are ineffective When medications are ineffective – 6 -15 treatments (3x/week)6 -15 treatments (3x/week)– Response rate = 90%!Response rate = 90%!

““Jump Start” neurotransmitter receptorsJump Start” neurotransmitter receptors– ↑ ↑ NE ↑ 5-HT ↑ DANE ↑ 5-HT ↑ DA

SE SE – Transient confusion Transient confusion – Short term memory lossShort term memory loss

ECTECT Out Pt. ProcedureOut Pt. Procedure

– Complete PE & HX Complete PE & HX Contraindications: Brain tumor, Contraindications: Brain tumor, ↑ ICP, ↑ ICP,

CVA, ↑ BPCVA, ↑ BP– Informed consent & NPO 6-8 hours Informed consent & NPO 6-8 hours – Assess mood & thought processAssess mood & thought process– Remove prosthesis & void a ECTRemove prosthesis & void a ECT– Current (70-125 volt) applied to frontal lobeCurrent (70-125 volt) applied to frontal lobe

Induces seizure for 25 -90 secondsInduces seizure for 25 -90 seconds– Post procedure- Post procedure-

VS, Maintain airway, √ Gag reflex, VS, Maintain airway, √ Gag reflex, Reorient & Assess mood/behaviorReorient & Assess mood/behavior

ECT MedicationsECT Medications

Glycopyrrolate (RobinulGlycopyrrolate (Robinul) 0.2-0.4 mg IM 30 ) 0.2-0.4 mg IM 30 mins amins a ↓ ↓ secretions & blocks vagal reflex = HR secretions & blocks vagal reflex = HR

remains WNL remains WNL

Methohexital (Brevital)Methohexital (Brevital) 1.5 mg/kg IV 1.5 mg/kg IV Anesthetic = ↓ RR ↓ BP & ↓↓ COAnesthetic = ↓ RR ↓ BP & ↓↓ CO

Succinylcholine CL (Anectine)Succinylcholine CL (Anectine) 0.75 mg/kg IV 0.75 mg/kg IV Muscle relaxant & prevents generalized Muscle relaxant & prevents generalized

Gran mal seizure Gran mal seizure Apnea & Respiratory depression Apnea & Respiratory depression

Bipolar DisorderBipolar Disorder

Mood extremes, 1 or more manic episodesMood extremes, 1 or more manic episodes Sudden onset early 20’sSudden onset early 20’s ↑ ↑ risk with highly educated = 2 million/yearrisk with highly educated = 2 million/year ↑ ↑ substance abuse & ↑ suicide (10-15%)substance abuse & ↑ suicide (10-15%) EtiologyEtiology

– Altered Family Dynamics Altered Family Dynamics – ↑↑↑↑ AmbivalenceAmbivalence– ↑↑ ↑↑ NE & DANE & DA– ↑↑ ↑↑ Intracellular Na & Ca = ↓↓ Serum Na & CaIntracellular Na & Ca = ↓↓ Serum Na & Ca

Neuronal IrritabilityNeuronal Irritability

– 5-HT remains low5-HT remains low

Bipolar DisorderBipolar Disorder

Manic EpisodeManic Episode– ↑ ↑ Self Esteem = GrandiositySelf Esteem = Grandiosity– Pressured speech & IntrusivePressured speech & Intrusive– Euphoria Euphoria – Aggressive, Sarcastic & Manipulative Aggressive, Sarcastic & Manipulative – Flight of ideas & DistractibleFlight of ideas & Distractible– Dress Bizarrely & ↑↑ MakeupDress Bizarrely & ↑↑ Makeup– ↑ ↑ Psychomotor agitation = ↓ Work production Psychomotor agitation = ↓ Work production – ↓ ↓ Sleep only 1-2 hours/daySleep only 1-2 hours/day– ↓ ↓ Nutritional Status RT Don’t eat or drinkNutritional Status RT Don’t eat or drink– ↑ ↑ Pleasure seeking activities = ↑ SexualityPleasure seeking activities = ↑ Sexuality


SafetySafety– ↓ ↓ Environmental stimuliEnvironmental stimuli– Protect from harm to self or othersProtect from harm to self or others– Consistent limit settingConsistent limit setting

Restoration of Nutritional BalanceRestoration of Nutritional Balance– 6 small meals/day 6 small meals/day Finger foods Finger foods – ↑ ↑ Fluids ↑ Cal ↑ ProteinFluids ↑ Cal ↑ Protein √ I & O√ I & O

Improve Social BehaviorsImprove Social Behaviors– Reinforce reality Focus on 1 idea Reinforce reality Focus on 1 idea – Simple concise explanationsSimple concise explanations– Appropriate hygiene & dressAppropriate hygiene & dress

Channel EnergyChannel Energy– Redirect activities to “work off energy”Redirect activities to “work off energy”– Exercise Walking Exercise Walking Avoid competitive gamesAvoid competitive games– JournalsJournals Creative outlets- Drawing, Painting, MusicCreative outlets- Drawing, Painting, Music

MedicationsMedications

Lithium (Eskalith, Lithobid)Lithium (Eskalith, Lithobid)– Alters Na transport in nerves & cellsAlters Na transport in nerves & cells– ↓ ↓ Intracellular Na & CaIntracellular Na & Ca– Enhances reuptake of NE & 5-HTEnhances reuptake of NE & 5-HT– ↓↓ ↓↓ NE & 5-HT = ↓↓ HyperactivityNE & 5-HT = ↓↓ Hyperactivity– Li competes with Na for absorptionLi competes with Na for absorption

↑ ↑ Na = ↓ LiNa = ↓ Li ↑↑ Na intake = ↓↓ Li available & ↓↓ serum ↑↑ Na intake = ↓↓ Li available & ↓↓ serum LiLi

↑ ↑ Li = ↓ NaLi = ↓ Na

– √ √ Serum Li level (weekly)Serum Li level (weekly) Therapeutic 0.5 -1.4 mEq/LTherapeutic 0.5 -1.4 mEq/L Toxic 1.5 -2.0 mEq/LToxic 1.5 -2.0 mEq/L Lethal > 2.0 mEq/LLethal > 2.0 mEq/L

Lithium Side EffectsLithium Side Effects– Fine hand tremorsFine hand tremors Transient nauseaTransient nausea– Metallic tasteMetallic taste DiarrheaDiarrhea– Blurred VisionBlurred Vision ↑↑ Weight↑↑ Weight– Fatigue/Drowsiness Fatigue/Drowsiness LightheadednessLightheadedness– Polyuria & PolydipsiaPolyuria & Polydipsia

Li Toxicity >1.5Li Toxicity >1.5 mEq (↓↓ Na & ↑↑ Li) mEq (↓↓ Na & ↑↑ Li)– Dizziness Dizziness Ataxia Ataxia +4 Reflexes+4 Reflexes– Persistent N & VPersistent N & V Severe ↓↓ BPSevere ↓↓ BP– EKG EKG ▲ ▲ → Cardiac Arrest→ Cardiac Arrest– SeizuresSeizures ComaComa

Lithium ToxicityLithium Toxicity

EtiologyEtiology– ↓↓ ↓↓ Na or overdose of LiNa or overdose of Li– Diuretics = ↓↓ Na & ↓↓ Li renal cleranceDiuretics = ↓↓ Na & ↓↓ Li renal clerance– ↓ ↓ Renal functioningRenal functioning– 3 Ds (Diarrhea, Diaphoresis & Dehydration)3 Ds (Diarrhea, Diaphoresis & Dehydration)

Fluid & Electrolyte lossFluid & Electrolyte loss

TherapyTherapy– Rapid Assessments √ VS & √ LOCRapid Assessments √ VS & √ LOC– Hold all Li dosesHold all Li doses– ↑ ↑ Hydration (5-6 L/d) NS to promote excretionHydration (5-6 L/d) NS to promote excretion– Diuresis & HemodialysisDiuresis & Hemodialysis

AnticonvulsantsAnticonvulsants Used for mood stabilizing effectsUsed for mood stabilizing effects For Pts who failed to respond to LIFor Pts who failed to respond to LI

Or Li contraindicated (Pregnancy, Renal, Cardiac)Or Li contraindicated (Pregnancy, Renal, Cardiac)

Carbamazepine (Tegretol)Carbamazepine (Tegretol)– ↓ ↓ Rate of impulse transmission Rate of impulse transmission – Serum level 8-12 ug/mLSerum level 8-12 ug/mL– Dizziness Dizziness AtaxiaAtaxia– HepatotoxicityHepatotoxicity N & VN & V– AgranulocytosisAgranulocytosis AnemiaAnemia ThrombocytopeniaThrombocytopenia

Divalproex (Depakote)Divalproex (Depakote) Gabapentin (Neurontin)Gabapentin (Neurontin) Lamotrigine (Lamictal)Lamotrigine (Lamictal) Topiramate (Topamax)Topiramate (Topamax) Oxcarbazepine (Trileptal)Oxcarbazepine (Trileptal)

SuicideSuicide 30,000 year 230,000 year 2ndnd cause of death 15-34 age cause of death 15-34 age 5-6% occur in inpatient psych unit5-6% occur in inpatient psych unit 10-20 unsuccessful attempts q10-20 unsuccessful attempts q suicide suicide Risk factorsRisk factors

– Mood DisordersMood Disorders Hopelessness Hopelessness – Schizophrenia Schizophrenia Command HallucinationsCommand Hallucinations– Substance AbuseSubstance Abuse ↓ Resources ($, social)↓ Resources ($, social)– European American > 65 years European American > 65 years – Mondays in the SpringMondays in the Spring– Prior suicide attemptsPrior suicide attempts– ↑↑ ↑↑ Detailed Plan = ↑↑ Risk & ↑↑ LethalityDetailed Plan = ↑↑ Risk & ↑↑ Lethality

SuicideSuicide 80% of attempts Pts give clues!80% of attempts Pts give clues! BehavioralBehavioral

– Verbal cues- “The pain will be over soon”Verbal cues- “The pain will be over soon”– Obtaining a gun # 1 method.Obtaining a gun # 1 method.– Hoarding pills & getting multiple refillsHoarding pills & getting multiple refills– Give away prized personal belongingsGive away prized personal belongings– Suicidal gestures: Non-lethal self injury actsSuicidal gestures: Non-lethal self injury acts

AffectiveAffective– Ambivalence ( between life & death)Ambivalence ( between life & death)– Loss of emotional attachmentsLoss of emotional attachments– DesolationDesolation Guilt Guilt ShameShame– Sudden Happiness or reliefSudden Happiness or relief

SuicideSuicide

CognitiveCognitive– Poor problem solversPoor problem solvers– Fantasy “Reunion Wish” = meeting dead relativesFantasy “Reunion Wish” = meeting dead relatives– Command Hallucinations Command Hallucinations – Suicidal Ideation = Thought, “How to method”Suicidal Ideation = Thought, “How to method”

Nursing InterventionsNursing Interventions– Take all gestures seriously!Take all gestures seriously!– Assess suicidal intentAssess suicidal intent– Stay c Pt and maintain safetyStay c Pt and maintain safety– Establish a “No harm contract”Establish a “No harm contract”

Suicide InterventionsSuicide Interventions

Explore feelings & motiveExplore feelings & motive Focus discussion on events & activitiesFocus discussion on events & activities Encourage Encourage ↑ participation & attendance↑ participation & attendance ↑ ↑ Interaction with ↑ # of peopleInteraction with ↑ # of people Mobilize social support systemMobilize social support system Assess perception of the situationAssess perception of the situation Promote decision making & autonomyPromote decision making & autonomy Identify strengths & alternative coping skillsIdentify strengths & alternative coping skills

GriefGrief A subjective state that follows lossA subjective state that follows loss

– Object, relationship or situationObject, relationship or situation Grief Process = BereavementGrief Process = Bereavement

– Healthy, & necessary to dissolve bondsHealthy, & necessary to dissolve bonds– Reaction and final adjustment to new life depends Reaction and final adjustment to new life depends

on:on: Significance of loss & degree of dependenceSignificance of loss & degree of dependence

– BehaviorsBehaviors Tears Tears Overwhelming feelings of lossOverwhelming feelings of loss GuiltGuilt Social withdrawalSocial withdrawal Anorexia/ GI symptomsAnorexia/ GI symptoms Dizziness Dizziness HAHA ↓ Concentration↓ Concentration Anger Anger AnxietyAnxiety Lethargy “Feel Lethargy “Feel

Drained”Drained”

GriefGrief Unresolved GriefUnresolved Grief

– Prolonged griefProlonged grief Loss of self esteemLoss of self esteem– Unable to resume usual routine/ADLs Unable to resume usual routine/ADLs – Psychotic symptoms –Reclusiveness Psychotic symptoms –Reclusiveness – Psychosomatic DisordersPsychosomatic Disorders

Asthma Asthma IBDIBD RARA– ↑ ↑ Acting out behavior = ↑↑ HostilityActing out behavior = ↑↑ Hostility

TherapyTherapy– RN must 1RN must 1stst accept own mortality accept own mortality– Encourage expressions of feelings to identify the degree of Encourage expressions of feelings to identify the degree of

lossloss– Listening = single most important communication skill!Listening = single most important communication skill!– Maintain dignity & incorporate cultural/spiritual beliefsMaintain dignity & incorporate cultural/spiritual beliefs– Facilitate life review & saying good byFacilitate life review & saying good by– Accept loss emotionally & intellectuallyAccept loss emotionally & intellectually

Realistically remember (+) & (-) aspectsRealistically remember (+) & (-) aspects– Find new ways of sharing lifeFind new ways of sharing life

mood disorders elisa a. mancuso rnc, ms, fns professor

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