BIPOLAR AND RELATED (MOOD) DISORDERS
Jeffrey S. Jones
Vickie L. Rogers
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Identify the common disorders affecting mood
2. Discuss the history and epidemiology of mood disorders
3. Analyze current theories related to the etiology of bipolar and related disorders, including proposed neurobiological and psychodynamic theories
4. Identify the controversial aspects of psychopharmacology as applied to this population
5. Discuss suicide and its relation to bipolar and related disorders
6. Describe common nursing assessment strategies for individuals with mood disorders
7. Demonstrate effective therapeutic use of self and application of the nursing process when caring for an individual with mood disorders and experiencing suicidal thoughts
8. Explain various treatment modalities including those that are evidence-based practice (EBP) for the person demonstrating signs and symptoms of mood disorders and/or is suicidal
Most people experience transient periods of depressed moods in their life. Fluctuations in MOOD (a person’s overall emotional status), especially during times of loss, change, and other social stressors, are normal as one’s mood is not static. However, fluctuations occurring for a sustained period of time or a depressed mood that does not change are suggestive of a more serious problem. A mood disorder, a term frequently used interchangeably with depressive or bipolar disorders, predominantly involves a persistent or chronic disturbance in mood. Mood disorders also influence a person’s thoughts, emotions, and behavior. Some of these disorders include major depressive disorder; persistent depressive disorder (dysthymia); disruptive mood dysregulation disorder; premenstrual dysphoric disorder; bipolar disorder types I and II, and cyclothymic disorder; and substance/medication-induced bipolar and depressive disorder. The more common ones you are likely to encounter are discussed later in the chapter. Psychiatric-mental health nurses need to be able to understand these different types of mood disorders when caring for individuals.
This chapter addresses the historical perspectives and epidemiology of mood disorders. Suicide, often a symptom of mood disorders, is also addressed. Current proposed psychosocial and biological/etiological influences of mood disorders are addressed along with current treatment modalities. Application of the nursing process from an interpersonal perspective is presented, including a nursing plan of care for a patient with a depressive disorder who is suicidal.
Mood disorders were described as early as the fourth century BCE in Greek medical literature. Hippocrates used the term MELANCHOLIA (black bile) to describe sad or dark moods noted in patients with depression and the term MANIA to describe mental disturbances such as elevated mood, grandiosity, difficulty with attention span, and sometimes even psychosis.
During the 17th and through the 18th centuries, Europeans continued to use the term melancholia for a range of mental illnesses. The depressed were less burdensome to the community, especially in large crowded cities, and were usually ignored. Thus, they suffered alone with no hope of a cure. However, manic and psychotic persons were more likely to be locked up in “insane or lunatic asylums.” Conversely, the wealthy frequented the famous European spa towns to “take the waters” in the hope that these experimental treatments would relieve their symptoms.
By the end of the 19th century, practitioners had begun to experiment with hypnosis as a treatment for “nervous” complaints. Influenced by this method, Sigmund Freud proposed that childhood experiences, particularly with the mother figure, and buried memories were the cause of DEPRESSION in adult life. So he used hypnosis to assist the patient to unlock these suppressed memories in order to deal with the effects of the past experience on their present life (Freud, 1920). Hypnosis as a treatment remained popular in Europe and the United States during and after World War II. By 1938, electroconvulsive therapy (ECT) was being used because it was found to lessen depressive symptoms. It is still used today although the method of delivery has changed drastically. During the 1950s, psychopharmacology became prominent with the trial of antidepressants. Tricyclic antidepressants were first (i.e., Elavil), followed by the monoamine oxidase inhibitors (MAOIs) such as Parnate. The MAOIs are rarely used today due to risk and potential life-threatening side effects. In the late 1970s, serotonin reuptake inhibiters (SSRIs) such as Prozac were developed. Newer medications targeting various other neurotransmitters, such as dopamine and norepinephrine, are constantly being tested and approved for use in treatment of mood disorders, such as the serotonin/norepinephrine reuptake inhibitors (SNRIs; i.e., Cymbalta). Talk therapies, such as cognitive behavioral therapy (CBT), are still used to treat affective disorders. New studies validate that talk therapy is as effective, if not greater in efficacy than medication, for treatment of mood disorders (DeRubeis, Siegle, & Hollon, 2008).
During the 1940s, electroconvulsive therapy was used to treat depression. The use of medications to treat affective disorders arose during the 1950s and continues through today.
Statistics and prevalence for affective disorders according to the National Institute of Mental Health’s (NIMH) website (NIMH, 2013) and derived from the 2004 U.S. census reveal that approximately 20.9 million American adults, or about 9.5% of the population of the United States aged 18 years and older in a given year, have a mood disorder, with an average age of onset of 30 years. Statistics related to specific affective disorders show the following:
Depressive disorders often co-occur with anxiety disorders and substance abuse disorders.
Major depressive disorder is the leading cause of disability in the United States for individuals between the ages of 15 and 44 years, affecting approximately 14.8 million American adults, or about 6.7% of the U.S. population aged 18 years and older in a given year.
While major depressive disorder can develop at any age, the median age at onset is 32 years.
Major depressive disorder is more prevalent in women than in men.
Dysthymic disorder affects approximately 1.5% of the U.S. population aged 18 years or older, or approximately 3.3 million American adults, with an average age of onset of 31 years.
Bipolar disorder affects approximately 5.7 million American adults, or about 2.6% of the U.S. population aged 18 years and older in a given year, with a median age of onset of 25 years.
Approximately 33,300 (about 11 per 100,000) people died by suicide in the United States in 2006.
More than 90% of people who kill themselves have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder.
The highest suicide rates in the United States are found in White men older than age 85 years.
Four times as many men as women die by suicide; however, women attempt suicide two to three times as often as men (NIMH, 2013).
Major depressive disorder is a leading cause of disability in the United States, affecting greater numbers of women than men.
DIAGNOSTIC ASPECTS AND KEY FEATURES
Major Depressive Disorder
A patient with major depressive disorder has experienced a change from previous functioning with evidence of a depressed mood or decreased interest or pleasure in his or her usual activities. This change in mood lasts most of the day for more than 2 weeks. The patient can report this mood change or it can be observed by others. The change in mood can be so severe and prolonged that it begins to affect daily functioning, and work, school, and personal/family life begin to suffer. Hopelessness can set in, which can lead to suicidal ideation, or the thoughts of ending one’s own life, in an effort to stop the emotional pain (American Psychiatric Association [APA], 2013).
Persistent Depressive Disorder (Dysthymia)
Dysthymic disorder involves depressive symptoms that are chronic and must be present for at least 2 years for adults or 1 year for children and adolescents. Dysthymia is considered a milder form of depression. The patient experiences a depressed mood, which can be self-reported, such as “feeling sad or down in the dumps,” or observed. This diagnosis differs from major depression in that these individuals usually can maintain adequate functioning in work and school, and so on. However, because of the chronic low-level mood, they can be perceived as negative or isolative, thus impacting social aspects of their life (APA, 2013).
Bipolar I Disorder
Bipolar I disorder is characterized by the occurrence of one or more manic episodes or mixed episodes (mania and major depression), and often one or more major depressive episodes. Mixed episodes may present as extreme irritability and/or agitation at times. A patient experiencing a mixed episode may also be experiencing psychotic features and will most likely require hospitalization to prevent harm to self or others. This type of bipolar disorder is what used to be termed manic depression. That is because of the extremes in the mood. This type of mood disorder is classified as bipolar because it has a cycle and ranges significantly from one extreme to the other. This individual may be stable for several weeks or several months. The cycle usually begins with a shortening of the sleep cycle until the individual is full of energy and requires very little if any sleep. They may be up for days. As they become manic they may begin doing bizarre things such as booking trips to Mexico at 3:00 a.m. or deciding to re-wallpaper their whole house on the spur of the moment. They may become hypersexual and engage in reckless behavior. They may spend money impulsively and put themselves and family in a financially compromised position. Then the mania passes (usually after 3–7 days) and the depression sets in. Now, filled with remorse and embarrassment and feeling a sense of being out of control, the person swings into a deep depression, so profound that he or she usually cannot even function. The person may not go to work or school and may literally shut himself or herself in the bedroom for days until the depressed episode passes (APA, 2013).
Bipolar II Disorder
Bipolar II disorder is characterized by recurring/chronic depressive episodes and at least one hypomanic (not a full-blown mania) episode. The patient has never experienced symptoms that meet the criteria for a manic or mixed episode. These individuals are often misdiagnosed with major depression because the hypomanic episodes are misinterpreted as getting better. Most often, the person experiences bursts of energy and increased feelings of motivation. This lasts for a short period of time, 2 to 4 days. Then the person returns to a depressive state (APA, 2013).
Cyclothymic disorder is defined by chronic fluctuations of mood from numerous periods of both depressive symptoms and HYPOMANIA. A diagnosis is not made unless the patient has been free of major depression, manic, or mixed episodes for at least 2 years. This individual rarely experiences a state of “normal.” His or her moods chronically shift from a little bit up, then a little bit down, over and over again, on and on and on (APA, 2013).
Probably nowhere else in the area of mental health will you be challenged on a personal level other than when dealing with the subject matter of suicide. The mere mention of the word triggers opinions, emotions, and beliefs. Most people have been touched by this phenomenon, either in that they knew someone who took his or her own life (a family member or a friend), or have found themselves in that dark passageway of depression and have had thoughts of “I wonder if things would be better if I were not here.” The act of ending one’s own life has been around since the beginning of time. Beliefs and opinions around this differ from culture to culture and generation to generation. Some feel very strongly that this is a sin, based on a theological basis, while others may grant that in cases of terminal illnesses a person has a right to chose when to end the suffering. Several states now allow physician-assisted euthanasia in such cases. Box 12-1 explains what we know about this phenomenon as of today.
People who kill themselves exhibit one or more warning signs, either through what they say or what they do. The more warning signs, the greater the risk.
ETIOLOGY OF AFFECTIVE DISORDERS
At this time in history there is no single scientific theory that explains the cause of mood disorders. Many theorists suggest multiple causes as an explanation for the development of affective disorders.
A number of psychosocial/psychological theories suggest that psychodynamic influences play a role in causing affective disorders. For example, learned helplessness theory is based on studies performed by Seligman (1992) dealing with dogs and avoidable shock (see Chapter 10 for an expanded discussion of Seligman’s work). Cognitive theory (Beck, Rush, Shaw, & Emery, 1979) is based on the premise that negative and faulty thoughts lead to negative feelings and behaviors. Freud and other therapists have posited that anger turned inward can lead to depression. He believed that a loss of a love object, either real, such as through death, or perceived, such as by rejection or loss of value to the person, led to melancholia. Childhood temperament is thought to be a factor. Stress for prolonged periods of time has been studied as a factor leading to affective disorders. Several of these theories are summarized in Table 12-1.
There are numerous theories suggestive of a biological basis for depression and bipolar disorders. While none of them have been fully accepted as a definitive or exact cause, research continues to provide us with new knowledge about these illnesses and some are discussed in the following section.
The most common theories addressing neurobiological influences involve the neurotransmitters serotonin, dopamine, and norepinephrine. It is proposed that patients who are experiencing affective disorders, especially the depressive symptoms, have an altered level of these neurotransmitters or dysfunction at the receptor sites. However, the exact role of the neurotransmitters is not known. In fact, many of these neurobiological theories are now under scrutiny. There are very little actual scientific data to support that depression has anything to do with altered levels of serotonin, norepinephrine, or dopamine. To date there are no double-blind, placebo-controlled studies to support these theories. There is also mounting evidence that by and large the various classes of antidepressant medications do nothing more than produce varying degrees of anesthesia, which in turn is then interpreted as “correction of the chemical imbalance.” The person believes he or she is better because the person no longer experiences the discomfort of depression and anxiety; rather, what actually happens is that the person is “numb” to the discomfort. Whatever is driving the symptoms (relationship problems, troubled childhood, daily stressors, etc.) still exists. Now the client just does not care (Whitaker, 2011).
BOX 12-1: SIGNS OF POSSIBLE PENDING SUICIDAL ACTIVITY
If a person talks about:
• Killing himself or herself
• Having no reason to live
• Being a burden to others
• Feeling trapped
• Unbearable pain
A person’s suicide risk is greater if a behavior is new or has increased, especially if it is related to a painful event, loss, or change.
• Increased use of alcohol or drugs
• Looking for a way to kill himself or herself, such as searching online for materials or means
• Acting recklessly
• Withdrawing from activities
• Isolating from family and friends
• Sleeping too much or too little
• Visiting or calling people to say goodbye
• Giving away prized possessions
People who are considering suicide often display one or more of the following moods.
• Loss of interest
• Anxiety (www.afsp.org)
HERE IS WHAT YOU CAN DO AS A NURSE
Many suicidal individuals report feeling alone and disconnected from others. Remembering and thinking about Travelbee’s continuum of suffering (as illustrated in Chapter 2), you could begin by focusing on the following points:
1. Establish and maintain a therapeutic relationship with the client. It is imperative that you come across as honest and real.
2. Manage your own feelings (transference and countertransference) about the subject matter and be nonjudgmental.
3. Convey a calm, caring attitude and try to understand from an empathic standpoint where the client’s emotional pain is coming from.
4. Take the time you need to be able to sit and talk. Sometimes just allowing the client to cathart (vent) and cry about the pain is enough to avert a crisis.
5. Explore issues of safety (does the person have a plan and the means to carry it out?). You will only learn this once you have gained his or her trust.
6. Do you need to take immediate steps to avert an attempt (put on suicide watch, remove potentially harmful objects, etc.)? If so, this must be done as an act of caring, not as a punishment!
American Foundation for Suicide Prevention (2015).
Learned helplessness (Seligman, 1992)
Harnessed canines exposed to a sustained electrical shock could not escape. Additional experiments followed with the same dogs, unharnessed and exposed to the electrical shock; despite being free to escape or avoid the shock these canines did not
Adaptation of experiments to humans: added the human dimension of attribution of meaning (cognitive explanations) to negative events in a person’s life using an optimistic versus pessimistic lens (self-explanation)
Proposed that prior inescapable negative events, negative cognition, and locus of control are important contributors to depression in humans
Cognitive theory (Beck et al., 1979)
Cognitive distortions (negative expectations of environment, self, and future) as the underlying mechanism leading to negative, defeatist attitudes
Distortions develop because of a defect in the development of cognition, leaving the person to feel inadequate and worthless
Pessimistic and hopeless attitude for the future
Psychoanalytical theory (Freud, 1920)
Melancholia developing after loss of an identified love object, leaving the person feeling ambivalent
Rage resulting from the loss directed inward resulting in depression
Neurobiological theories of depression are driven largely by the pharmaceutical companies and there is very little evidence to support their validity.
Most researchers agree that there seems to be a familial connection for developing mood disorders. Depressive disorders tend to “run in families,” and an association has been established. Much research has been conducted regarding genetics. Numerous investigators have documented that susceptibility to a depressive disorder is twofold to fourfold greater among the first-degree relatives of patients with mood disorder than among other people. The risk among first-degree relatives of people with bipolar disorder is about six to eight times greater. Some evidence indicates that first-degree relatives of people with mood disorders are also more susceptible than other people to anxiety and substance abuse disorders (Tsuang & Faraone, 1990). So while genetics continues to be an explosive field for research, some still question: “Is it nature or is it nurture?” Are children from depressed families more likely to show signs of depression due to genetic predisposition (nature) or is this due to learned behavior (nurture)?
Primarily on inpatient units, an interdisciplinary-team approach is used to treat patients with mood disorders regardless of the setting. Nurses’ role in the treatment team varies from facility to facility but usually is of major importance as they are often the professionals who spend the most time with the patient.
Various treatment options are available for patients who are diagnosed with mood disorders or who have suicidal thoughts. They include but are not limited to individual therapy, group therapy, psychopharmacological options, inpatient treatment, and outpatient partial- or day-treatment programs. There are even some Internet support groups that some find helpful. Chapter 25 goes into this topic in depth. Evidence-Based Practice 12-1 highlights a comparison of face-to-face and Internet therapy related to self-disclosure. Research has indicated that although all options are viable depending on the severity of the illness, the inclusion of psychotherapy or “talk therapy” usually results in the best outcomes (NIMH, 2009).
Psychopharmacology is a treatment option usually reserved for patients suffering from moderate to severe depression and/or bipolar I or II disorder. Medications used to treat patients with affective disorders include antidepressants and mood stabilizers:
Tricyclic antidepressants such as amitriptyline, imipramine, amoxapine, and doxepin
SSRIs such as fluoxetine, paroxetine, sertraline, and escitalopram
SNRIs such as duloxetine and venlafaxine