Mood Disorders PowerPoint Presentation

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Mood Disorders Davaar Consultancy Training & Development Pty. Ltd Learning with integrity, passion & fun

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1 CNE point

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What is mood? mood is a pervasive and sustained emotion that influences one’s perception normal variations in mood occur as responses to specific life experience normal mood variations, such as sadness, euphoria and anxiety are time limited but when there is a sustained mood - mood disorder (2 weeks)

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Types of mood disorders primary mood disorders include both depressive disorders (unipolar) and manic-depressive (bipolar) disorders mood disorder due to a medical condition substance induced mood disorders

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Incidence WHO predict that for the 21st century mood disorders will be the number one health problem (WHO predicts depression will be 2nd largest cause of death and disability in world by 2020) major depression is currently the number one cause of disability worldwide 300 million people in world today affected by depression 20-30% of people with depression have a resistive depression - prolonged disability (loss) and 25% suicide

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

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Depression Depression categorised as: ICD10 mild - moderate DSMIV dysthymic disorders – major depression

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Depressive Subtype Clinical feature Psychotic melancholia Non-psychotic melancholia Non-melancholic depression (major depression) Psychotic features Psychomotor disturbances Mood disorder ___________ Neurotransmitter DA NA 5-HT The Black Dog Institute Hierarchical Model Internet. May 2005 Non-melancholic depression = underpinned by serotenergic dysfunction Melancholic & psychotic depression = increased and more dominant noradrenergic /dopaminergic contributions respectively

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More than 2 weeks Social impairment Non-melancholic depression Individuals with NMD tend to exhibit the following features: absence of psychomotor disturbances depressed mood is reactive no morning changes in mood/energy

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Melancholic Depression Social impairment Psychomotor disturbance (retardation, agitation & cognitive disturbance) Key features: anhedonia non-reactive mood mood & energy worse in the morning profound & uncharacteristic “emptiness & inactivity” observable psychomotor disturbance

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risk of depressive disorder range from 7-12% in men and 20-25% in women 2,500 youth suicide a year second most common death in adolescence depression is often associated with a variety of medical conditions: (endocrine, cardiovascular, neurological, autoimmune, viral and substance abuse) prevalence is unrelated to ethnic or cultural backgrounds 25% experience recurrence in first six months after episode 50-75% have recurrence in five years Epidemiology

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Risk Factors depression is so common that it is sometimes difficult to identify the risks prior history of depression family history lack of social support stressful life event current substance abuse medical comorbidity

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Causes Three major causes of depression often cited: genetics, biochemical and environmental Genetics: emphasis placed on the role of dominant of faulty genes in the production of various modes of depression Biochemical: emphasis placed on the role of decreased numbers of neurotransmitters at receptor sites in brain

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Environmental: emphasis placed on the extent to which various clusters of factors in a person's physical and social environment come together to produce the symptoms Diet – according to Sanchez Villegas et al, (2009) a Mediterranean diet may protect against depression. This diet is high in vegetables, fruits and nuts, cereals, legumes and fish, has a high monounsaturated to saturated fatty acids ratio and includes moderate amounts of alcohol. The Mediterranean diet is thought to reduce inflammatory and metabolic processes that may be involved in depression

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Other models have also been proposed: disease model, psychodynamic (personality), behavioural and social / learning model (McLoughlin, 2002; Parker & Ray, 2002) Behavioural position holds that depression occurs primarily as the result of a severe reduction in rewarding activities or an increase in unpleasant events in one’s life manifesting the mood disturbance Learnt responses: some people exposed to repeated losses or stresses may learn that life is difficult and often feel helpless and depressed

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Personality Anxious / worrying: reflecting high levels of internalised, on-going anxiety Irritability: reflecting high levels of externalised, ongoing anxiety Social avoidance: individuals avoid socialising Personal reserve: individuals are uncomfortable about sharing their feelings or opening up to others Self-criticism: reflecting ongoing low self-esteem and self-worth Perfectionism: reflecting self-imposed high standards Interpersonal sensitivity: sense of self worth is highly dependent on how they see other people reacting to them Self-focused: focus more on own needs than on the needs of others (Black Dog Institute, 2005)

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

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Findings from Parker & Ray (2002), two dominant factors correlated to presentation of depression – “anxious worrying and intraversion” Anxious worrying/intraversion usually evidenced where family hx of anxiety Individual demonstrated behavioural inhibition shyness in childhood - high lifetime rate of both formal anxiety disorder and anxious/fearful personality characteristics

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Taking a closer look at some of those symptoms – usually seen in a major depression The physical, cognitive, emotional and psychotic

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Physical change in appetite (weight gain/loss) sleep disturbance (initial, middle, terminal insomnia) sexual dysfunction decreased motivation/interest psychomotor retardation / agitation

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Cognitive worthlessness, guilt, recurrent thoughts of death, suicidal ideation thoughts and or plan sadness, hopelessness, anxiety preoccupation with death loss of sense of self-control poor concentration / memory loss

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Mood sad “depressed” “black hole” “crying” “numb”

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delusional thinking hallucinations thought disorders (blocking, retardation, insertion etc) (Moyle 2002) Psychotic Symptoms

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Famous Folks Abraham Lincoln, Adam Ant, Billy Joel, Heath Ledger Harrison Ford, J.K. Rowling, Tennesse Williams, Vincent van Gough

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Treatment of depression often treated in community hospitalisation only occurs when symptoms are such to cause concern for family, GP, psychiatrists, patient (inability to function, suicidal thoughts / intent)

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Scenario Consider 3 stages of management: Acute Stabilising Follow up

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Goals of inpatient care - acute maintain safety, reduce signs & symptoms of depression restore level of functioning Routine Mental State Assessment Maintain safety Adequate sleep Hydration and nutrition Exercise Diversion Therapeutic use of self

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Stabilising Monitoring medication regime (effects / side effects) Ongoing support: Individual counselling Group Support Psycho education (signs, symptoms, triggers, intervention) Sleep, diet, safety

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

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Pharmacology depression is often considered to be caused by an over response or under response somewhere in the process of neurotransmission antidepressant pharmacology effects process of cell to cell communication at the synapse in specialised medians - release, blockade, receptor sensitivity, blocked re uptake within neurotransmitters

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Pharmacology Mono-axine oxidase inhibitor (MAOI’s) successful in 39% pop –(increases noradrenaline and serotonin in the brain – Parnate, Marplan) Tricyclic antidepressants (TCA)(introduced in the 1950’s - Prothiaden, Amitriptyline, Clomipramine, Doxepin, Imipramine) Selective Serotonin Reuptake Inhibitors (SSRI’s)(Citalopram, Fluoxetine, Paroxetine, Sertraline) Serontin and Noradrenaline Reuptake Inhibitour (SRI) (Venlafaxine, Nefazodone, Tramadol)

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Cognitive Behavioural Therapy CBT teaches skills which help people cope with events components include recognising there is a connection between thought, mood, and behaviour. Learning to monitor negative self talk ie “I can’t do this” challenge thinking, interpret situations so that reactions are more realistic

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E.C.T. & T.M.S Electro Convulsive Therapy initially used in the 1930’s usual course 6-12 treatment (3 x weekly) procedure does not cause brain injury in adults uni or bilateral consent form Famous folks who have had ECT: Janet frame, Judy Garland, Ernest Hemingway, Sylvia Plath, Lou Reed, Yves Saint-Laurent, Vivien Leigh Transcranial Magnetic Stimulation noninvasive method to excite neurons in the brain, weak electrical currents are induced in the tissue by rapidly changing magnetic fields

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Questions to consider Why is this person depressed? (personality type, Hx) What type of depression? Why now? (life events, triggers) Are they safe? (risk assessment) What needs to be done now? (priorities) How well do I know the patient? (therapeutic alliance) Who else is there for them (supports available) Who else do I need to involve? (referral needs)

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BIPOLAR AFFECTIVE DISORDER Melancholia Hypomania Mania

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MANIA

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

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

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Mood during manic episodes the individuals mood is euphoric (overly cheerful, excessively enthusiastic and presents as “high”) may exhibit a wide range of mood swings labile laughing/crying becoming irritable and angry when desires are thwarted infectious quality about mood / unwarranted optimism Consider: there may be a feeling of inadequacy and inferiority that lurks behind his euphoria (psychoanalytical perspective)

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Cognition thought processes in mania are accelerated easily distracted pressured speech …. flight of ideas communication may be humorous (full of jokes, puns, play on words) may become theatrical sounds rather than meaning govern word choice (clanging) grandiose thoughts (I’m the queen, “I have close links with Jesus”) judgment & insight impaired may give away valued possessions (thinking they no longer need / want them)

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Social self-esteem unrealistically inflated over-confidence in one’s ability increased social activity intrusive, domineering approach to others often involved in excessive planning and multiple activities

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Pressure on partners “being alone together” (van der Voort, et al 2009) experienced heavy burdens and difficulty coping ( being solely responsible, being alone with one’s feelings) absence of sex and intimacy – worry about the future being forced to give up their work perform new roles in the relationship feeling exhausted choose to leave relationship

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Spiritual in mania individuals may come to value the “highs” in their lives may choose not to take their medication (preferring to be high / or because of side effects) life more bearable when high rather than when depressed

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Interventions Maintain safety

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Interventions Pharmacology: mood stabilisers (lithium, valporate, carbamazepine) anti depressents (effexor, cipramil, MAOI’s parnate, imipramine) antipsychotics (olanzapine, clozapine, risperidone, quetiapine) be mindful of interactions, side effects of medications

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limit set on inappropriate behaviour reduce environment stimuli supervise administration of medications ensure adequate sleep and nutrition help client focus on one topic during conversation ignore, distract from grandiose thinking present reality (time place & person) consider one staff member involved in discussions provide information about diagnosis, medication and treatments (when patient demonstrating insight) promote a realistic sense of self-esteem

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Famous Folks Richard Dreyfuss Carrie Fisher Marilyn Munroe Charles Dickens Robert Louis Stevenson Mark Twain Ozzy Osbourne Winston Churchill Florence Nightingale Issac Newton

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Suggested readings Gomez, G.E. (2001), Lithium Treatment. Present & Future. Journal of Psychosocial Nursing, 39 (8), 31-36. Pebbles, C., & Porter, R. (2002). New treatments for bipolar disorder. Current Therapies, Oct 21-26 Scheick, D.M. (1995). Therapeutic Insight: From family to practice. Journal of Psychosocial Nursing, 33 (7), 31-33. References Black Dog Institute (2005). Internet: www.blackdoginstitiute.org.au DSM IV McLoughlin, G. (2002). Is depression normal in human beings? A critique of the evolutionary perspective. International Journal of Mental Health Nursing, 11, 170-173. Moyle, W. (2002). Unstructured interview: challenges when participants have a major depressive illness. Journal of Advanced Nursing, 39 (3), 266-273 Parker, G., & Roy, E. (2002). Examining utility of a temperament model for modelling non- melancholic depression. Acta Psychiatrica Scandinavia, 106, 54-61 Sanchez Villegas, A., et al. (2009)..... Archives of General Psychiatry, 66, 1090-1098 van der Voort, T.Y.G., Goossens, P. J.J., & van der Bijl, J.J. (2009). Alone together: A grounded theory study of experienced burden, coping and support needs of spouses of persons with a bipolar disorder. International Journal of Mental Health Nursing, 18, 434-443.

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Websites www.sane/org/snapshots

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Davaar details Davaar Consultancy Training & Development Pty. Ltd. PO Box 37, Laidley, Qld. 4341 Web: www.davaar.com.au Email: wendy@davaar.com.au colleen@davaar.com.au (m) Wendy: 0411385573 Colleen: 0431655702