Caring for Patients with Mood Disorders

Caring for Patients with Mood Disorders

Objectives

* Identify the two major types of mood disorders and subtypes. * Identify key features of depression and bipolar disorder. * Summarize effective measures to utilize when caring for a patient with a mood disorder.

Mood disorders are categorized as conditions that affect the emotional state. Patients may experience long periods of extreme happiness, extreme sadness or both. Certain mood disorders involve other persistent emotions, such as anger and irritability. For a mood disorder diagnosis, symptoms must be present for several weeks or longer. Mood disorders can cause changes in behavior and can affect the ability to perform routine activities, such as work or school. Let's look at key features of two major types of mood disorders.

Depressive Disorders

There are several different subtypes related to depression.

Major depression — typically lasts for at least two weeks and often longer than four weeks.Seasonal affective disorder — occurs at certain times of the year, typically with a change of season. Persistent depressive disorder — a long-term form of depression that causes feelings of sadness, emptiness and often hopelessness. Disruptive mood dysregulation disorder — a diagnosis used for children and teenagers. It features constant, serious and lasting testiness with frequent temper outbursts that are not consistent with the age of the child.

Depression subtypes continued...

Premenstrual dysphoric disorder — features mood changes, hopelessness and feelings of being overwhelmed or out of control. These symptoms occur in the 10 days before a menstrual period and go away within a few days after a period begins.Depression related to a medical condition — features a great loss of pleasure in most or all activities due to the physical effects of another medical health problem. Depression related to substance or medicine use — features depression symptoms that start during or soon after using a street drug or medicine, or after withdrawal from these substances.

Click on the radio button relative to your role for effective strategies in working with patients experiencing depression.

RN

BHS

Electroconvulsive therapy (ECT) is a highly effective treatment for depression. Click on the radio buttons for information and reminders.

Safety and comfort

Fast facts

Medication information for RNs

Communication tips for patients with depression

• Acceptance acknowledges a patient’s emotions or message and affirms they have been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “I hear what you are saying.

• Clarification asks the patient to further define what they are communicating.

• Focusing narrows in on a point of interest to discuss the information further.

• Exploring gathers more information about what is being communicated.

• Open questions and offering general leads provides keywords to “open” the discussion while also seeking more information.

• Paraphrasing rephrases the patient’s words and key ideas to clarify their message and encourage additional communication.

Communication tips for patients with depression (continued)

• Restating uses different word choices for the same content to encourage elaboration.

• Reflecting asks patients what they think they should do, encourages them to be accountable for their own actions, and helps them come up with solutions.

• Silence is a powerful communication tool and allows quiet time for self-reflection and/or processing.

• Offering hope may provide much needed encouragement to persevere and be resilient.

• Summarizing demonstrates active listening to patients and allows us to verify information. Ending a discussion with a phrase such as “Does that sound correct?” gives patients explicit permission to make corrections if they are necessary.

Bipolar Disorders

Bipolar disorders feature mood swings that include emotional highs (manic or hypomanic episodes), and lows, called depressive episodes. These highs and lows are usually continuous. They also can change from high to low or low to high — or shift into a normal mood. Sometimes both the highs and lows might occur together. This is a mixed episode. Subtypes of bipolar disorder include:

• Bipolar I disorder — features a constantly elevated mood that lasts for at least one week. This is a manic episode. It affects one's overall ability to function and makes it more likely to take part in risky behavior,

• Bipolar II disorder — features constantly elevated moods — called hypomanias — that last at least four days and less than one week. There may be risky behaviors, but usually hypomania does not greatly affect the ability to function. Other people may notice that something is different,

• Cyclothymia — features shifts from emotional highs to emotional lows that can affect the ability to function. The emotional ups and downs are not as extreme as those in bipolar I or II disorder,

Bipolar subtypes continued...

• Bipolar related to a medical condition — features symptoms that are the same as bipolar disorder, but they can be due to a medical condition. For example, Cushing's disease, multiple sclerosis, stroke and traumatic brain injury can cause bipolar mania or hypomania, and

• Bipolar related to the use of certain substances — features symptoms that are the same as bipolar disorder, but they can be due to alcohol, street drugs or medicine.

Click on the radio button relative to your role for effective strategies in working with patients experiencing bipolar disorder.

RN

BHS

Communication tips for patients with bipolar disorder

• Use a firm and matter-of-fact tone and calm approach.
• Use simple, concise, very short explanations (the attention span may be short with difficulty focusing).
• Reinforce verbal limit setting on behaviors with personal boundaries (patient may be impulsive and distracted with limited insight and inappropriate behaviors towards others).
• Utilize therapeutic communication techniques, such as redirecting, active listening, distraction, clarification, or restating; avoid exploring because the thought process is too expansive.
• Avoid the use of jargon, jingles, jokes, proverbs, or cliches (the patient is already overstimulated).
• Remain neutral with careful choice of words to avoid “power struggles”.
• Intervene early with verbal de-escalation skills during phases of escalation.
• Avoid arguing or challenging grandiose ideas.

Resources

Chand, S. P., Arif, H., & Kutlenios, R. M. (2023). Depression (Nursing). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568733/ Ernstmeyer, K., & Christman, E. (2022a). Chapter 8 Bipolar Disorders. In www.ncbi.nlm.nih.gov. Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK590048/ Ernstmeyer, K., & Christman, E. (2022b). Table 2.3b, [Nontherapeutic Responses [],[]]. Www.ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK590036/table/ch2communication.T.nontherapeutic_respon/ Ernstmeyer, K., & Christman, E. (2022c). Therapeutic Communication and the Nurse-Client Relationship. In www.ncbi.nlm.nih.gov. Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK590036/ Mayo Clinic. (2024, January 31). Mood disorders - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mood-disorders/symptoms-causes/syc-20365057

Thank You!

Meds to prioritize before ECT:

• Cardiac Meds
• GERD Meds

Good choices for anxiety pre-ECT:

• Olanzapine
• Seroquel
• Clonidine
• Tenex

Meds to HOLD until after ECT:

• Anticonvulsants
• Benzodiazepines
• Short acting insulins and oral antidiabetic agents

Meds to HOLD after ECT:

• Ibuprofen held for 6 hours after Toradol

• Monitor for suicidal risk and complete observation precautions as ordered.
• Keep the environment safe by eliminating sharp objects and items that could be used to harm self.
• Encourage the patient to do as much as possible for themself. They may need more direction with activities of daily living if depression is severe.
• Use sleep hygiene to encourage sleep.
• Engage the patient in a therapeutic relationship.
• Use empathy (rather than sympathy) when communicating. Empathy fosters connection and focuses on sharing feelings whereas sympathy conveys feelings of sorrow or pity for someone's misfortunes or losses.
• Reinforce elements of treatment such as challenging negative thoughts about self, the world, and the future.
• Encourage participation in activities and groups on the unit.
• Have the patient list their own positive characteristics.
• Have patient set a realistic goal for the day and review goal attainment.
• Review and evaluate coping strategies and support systems.
• Monitor eating patterns and encourage nutritional intake.

• Include the family and other support systems in care when possible.

ECT: Fast Facts

• It usually takes at least 6 treatments to feel

better

• Side effects are most common after the

first few treatments

• Patients are under general anesthesia and

sometimes don’t remember having treatment Setting Up for Success The day before...

• Encourage hydration for an easier IV

start and a bedtime snack to reduce AMhunger

• Clear patient's room of food at midnight
• Talk to your team: Can patient maintain

NPO without eyesight?

• Monitor for suicidal risk. Complete the Columbia Suicide Severity Rating Scale
• Keep the environment safe by eliminating sharp objects and items that could be used to harm self.
• Encourage patient to do as much as possible for self. The patient may need more direction with activities of daily living if depression is severe.
• Use sleep hygiene to encourage sleep.
• Engage the patient in a therapeutic relationship.
• Use empathy (rather than sympathy) when communicating. Empathy fosters connection and focuses on sharing feelings whereas sympathy conveys feelings of sorrow or pity for someone's misfortunes or losses.
• Reinforce elements of treatment such as challenging negative thoughts about self, the world, and the future.
• Encourage participation in activities and groups on the unit.
• Facilitate the medication education group tailored for Adult 3.
• Have patient list positive characteristics about themself.
• Have patient set a realistic goal for the day and review goals attained.
• Review and evaluate patient coping strategies and support systems.
• Monitor eating patterns and encourage nutritional intake.
• Monitor medications for effectiveness and side effects.
• Include the family and other support systems in care when possible.

• Maintain observation precautions as ordered

• Complete the Columbia Suicide Severity Rating Scale

• Monitor for impulsive behavior and set expectations to help prevent manipulation and pushing limits

• Utilize Krames in eStar to deliver health education developed for patient use

• Educate about mood stabilizers and other medications with expected time frames for improvement. Facilitate Adult 3's medication education psychoeducational group

• Open medication packaging in front of the patient

• Observe for signs of medication toxicity, especially related to lithium

• Decrease unit stimuli to the extent possible and provide structure

• Encourage engagement in unit activities- facilitate psychoeducational groups

• Set limits with personal boundaries

• Utilize finger-foods for patients unable to sit for periods at a time or refusing entire meals

• Maintain observation precautions as ordered

• Monitor for impulsive behavior and set expectations to help prevent manipulation and pushing limits

• Utilize Krames in eStar to deliver health education developed for patient use

• Observe for signs of medication toxicity, especially related to lithium

• Decrease unit stimuli to the extent possible and provide structure

• Facilitate psychoeducational groups according to your unit's schedule and plan

• Encourage engagement in unit activities and groups

• Utilize finger-foods for patients unable to sit for periods at a time or refusing entire meals

• Set limits with personal boundaries

Ways to make treatment day smoother

• Clear liquids are OK until 4 AM, small sips OK until 6 AM. After these times, drinking can cause serious complications or death.
• Appointment times are an estimate. ECT staff work to minimize wait times but some days there may be delays. Reassure your patient that they will be seen as quickly as possible.
• Encourage toileting before leaving the unit and consider offering Depends.

Upon return to the unit

• Falls risk may be increased, evaluate on

return from ECT.

• Encourage hydration. IV fluids are no longer

routinely used in ECT.

• Common side effects include headache,

generalized soreness, and jaw pain. Consideribuprofen or acetaminophen as ordered.

• Short term memory loss may occur.
• Report fever, rigidity, and change in

consciousness to your charge RN/MD.