16.1 Depressive Disorders
Learning Objectives
By the end of this section, you will be able to:
- Describe the spectrum and presentations of mood disorders
- Explain the approaches for treating mood disorders
Mood disorders comprise a category of mental health conditions with significant disturbances in mood, emotions, and overall affect. These disorders profoundly affect an individual’s emotional well-being and functioning. In addition, mood disorders often significantly influence relationships, work or academic performance, and overall quality of life. Accurate diagnosis and classification of these disorders according to established guidelines are crucial for effective treatment planning and improving the well-being of individuals affected by these conditions (American Psychiatric Association, 2022).
Unfolding Case Study
Depression: Part 1
The nurse is assessing a seventy-six-year-old male who has been admitted to the inpatient psychiatric unit accompanied by his son.
| PMH | Client is a seventy-six-year-old male who is recently widowed and living in an assisted living community. He has a medical-surgical history of prostatitis, hypertension, and hyperlipidemia. He has a surgical history of a right knee replacement in 2017. Family History: Client reports a family history of depression and anxiety. Per the client, his brother had been diagnosed with bipolar II disorder and he died in 2010 from a heart attack. His mother and father both appeared to have depression throughout their lives, but never sought treatment. His sister had two suicide attempts when she was in her mid-thirties. Social History: Client is widowed for three years and has four children, all adults, as well as three grandchildren. He lives in an assisted living community and one of his sons lives about thirty miles away. The rest of his children live out of state. He worked for the postal service for forty years until he retired six years ago. He states that his son visits him once a week, but that he otherwise feels lonely and isolated at the assisted living community, and he misses his wife. He denies alcohol or drug use. He is not a smoker or a former smoker. He and his wife used to attend church, but since moving to the assisted living community, he has been unable to go to services. He does listen to them through his computer occasionally. Current Medication: Carvedilol 25mg BID, Atorvastatin 20mg daily, Tamsulosin 0.4mg daily, Sertraline 12.5mg daily, and no known allergies. |
| Nursing Notes | 1345: Admission Assessment Physical examination: Client clean and appropriately dressed, alert and oriented ×4, stooped posture, unsteady gait and utilizing a cane. He appears thin. HEENT: Pupils equal, reactive to light (PERRL), mucus membrane dry, pharynx without lesions, palate intact. No thyroid enlargement. Lymphatic: Tonsillar and cervical lymph nodes noted but not enlarged; no enlargement of right axillary or inguinal nodes, no pain or tenderness noted. Respiratory: Clear to auscultation bilaterally, no stridor, no crackles or murmur. Cardiovascular: Regular rate and rhythm, slight edema to lower extremities, peripheral pulses 2+. Abdomen: Bowel sounds present but slowed in all four quadrants, no organomegaly or tenderness. Musculoskeletal: Within normal limits, unsteady gait with assistive device. Skin: Dry and intact. No skin injuries noted. Mental assessment: Client appears anxious, passive suicidal ideation, blunted affect, depressed mood, mood congruent with affect, denies AVH. Blood pressure: 145/92 mmHg. Heart rate: 89 beats/minute. Respiratory rate: 18 breaths/minute. Temperature: 98.5°F (36.9°C). Oxygen saturation: 99% on room air. Pain: Denies. |
| Flow Chart | 1345: Admission Assessment The client is a seventy-six-year-old male who is recently widowed and living in an assisted living community. He has a medical-surgical history of prostatitis, hypertension, and hyperlipidemia. He has a surgical history of a right knee replacement in 2017. He reports a decreased and depressed mood for the past month, with low energy and periods of feeling sad. His appetite is diminished, and he has experienced weight loss of approximately nine pounds in the past month. He uses nutritional supplement shakes for his meal replacement due to his low appetite. He reports that he has not been participating in any of the activities of the assisted living because he has lost enjoyment and pleasure in being around people, including visits from his son. He states he has suicidal thoughts but does not have a plan to act on them; rather, he would just like to go to sleep and not wake up in the morning. Current Medication: Carvedilol 25mg BID, Atorvastatin 20mg daily, Tamsulosin 0.4mg daily, Sertraline 12.5mg daily, and no known allergies. |
| Provider’s Orders | Complete admission assessment CMP/CBC Close observation |
The Spectrum of Mood Disorders
As defined by the DSM-5, the most common mood disorders include depression, bipolar disorder, and dysthymia. Mood disorders are characterized by disturbances in mood that are intense, persistent, and interfere significantly with an individual’s daily life. These disorders can have severe repercussions on one’s physical health, interpersonal relationships, and overall quality of life (Sekhon & Gupta, 2020).
The DSM-5 defines depression as feelings of sadness and/or loss of interest in activities once considered enjoyable (Torres, 2020). By contrast, bipolar disorder is a recurrent illness that involves changes in mood and energy that may be severe and involves both depression and mania, or hypomania (Howland & El Sehamy, 2021). Previously known as dysthymia, persistent depressive disorder is a milder, but longer lasting form of depression (John Hopkins Medicine, 2019). Additionally, mania is a condition in which a person’s mood is abnormally elevated and is accompanied by high energy or activity.
Mood disorders have traditionally been viewed in categorical terms. This means that an individual either meets the specific criteria for a diagnosis or they do not. Recent research, however, indicates a shift toward understanding these disorders on a spectrum or continuum (Mason et al., 2016) (Figure 16.2). This shift in perspective allows for a more nuanced understanding of mood disorders, acknowledging the diversity and complexity of symptom presentations.
A more inclusive and flexible approach to understanding, diagnosing, and treating these conditions, the spectrum model of mood disorders acknowledges the variability in symptom presentations and offers a framework for individualized care. By moving away from rigid categorical definitions, it allows for a broader understanding of the diverse experiences of those with mood disorders (McIntyre et al., 2018). For example, the spectrum model accommodates those with atypical or mixed features. An individual might exhibit symptoms of both depression and mania but not meet the full criteria for bipolar disorder. In a categorical model, this could lead to challenges in diagnosis and treatment. Yet by understanding these symptoms as existing on a continuum, health-care professionals can offer tailored interventions that address the specific needs of the individual (Zimmerman et al., 2015).
Varying moods are a natural and expected part of the human experience. Everyone, at different points in their life, will experience fluctuations in their mood, feeling elated at times and downcast at others. These mood variations can be influenced by a myriad of factors, ranging from environmental stimuli, interpersonal relationships, stress, physiological changes, or hormonal fluctuations (Karl et al., 2018). It is when these mood variations begin to interfere with an individual’s daily functioning that they may be indicative of a mood disorder. The distinction between normal mood variations and clinically significant mood disturbances is primarily based on their duration, intensity, and impact on daily functioning (American Psychiatric Association, 2022). For instance, feeling sad or down after a negative life event, like the loss of a job or the end of a relationship, is expected. If this sadness persists for weeks, impairs one’s ability to perform daily tasks, affects relationships, or leads to thoughts of self-harm or suicide, it may be indicative of major depressive disorder (American Psychiatric Association, 2022).
Life-Stage Context
Age Considerations in Clients Diagnosed with Mood Disorders
Age plays a significant role in the presentation, diagnosis, treatment, and outcomes of mood disorders. Age-related considerations are pivotal in the accurate diagnosis and effective treatment of mood disorders. Recognizing the varied presentations across age groups, understanding the unique challenges posed by each age group, and tailoring interventions accordingly can lead to optimal client outcomes (American Psychiatric Association, 2022). Table 16.1 compares mood disorders among age groups.
| Age Group | Presentation | Differential Diagnosis |
|---|---|---|
| Children and adolescents | May not exhibit classic symptoms but may exhibit irritability, academic difficulties, or behavioral problems (Cleveland Clinic, 2018). | Attention-deficit hyperactivity disorder or conduct disorders |
| Adults | Classic symptoms, such as persistent sadness, anhedonia, changes in sleep and appetite, and feelings of guilt or hopelessness (American Psychiatric Association, 2022). | Bipolar disorder and other mood-related conditions (American Psychiatric Association, 2022) |
| Older adults | Somatic complaints, cognitive disturbances, or a decreased ability to function, rather than typical depressive symptoms (Devita et al., 2022). | Age-associated memory impairment or other neurocognitive disorders (Devita et al., 2022). In older adults, mood disorders, such as depression, can sometimes mimic symptoms of neurocognitive disorders. |
Mood disorders encompass a wide range of conditions that can affect an individual’s mood regulation. To provide a nuanced understanding of these disorders, the DSM-5 introduces specifiers. Specifiers are descriptors that can be added to the core diagnosis to offer more specific information about the presentation of the disorder (American Psychiatric Association, 2022).
For major depressive disorder (MDD), some of the key specifiers include:
- With Anxious Distress: Describes individuals who exhibit two or more symptoms of anxiety (e.g., feeling on edge, experiencing restlessness)
- With Mixed Features: Signifies the presence of at least three manic symptoms, though not enough for a full-blown manic or hypomanic episode
- With Melancholic Features: Characterized by profound anhedonia or lack of reactivity to positive stimuli, along with other symptoms, such as early morning awakening or significant weight loss
- With Atypical Features: Includes mood reactivity (i.e., mood brightens in response to positive events) and two or more additional symptoms, such as increased appetite or hypersomnia (American Psychiatric Association, 2022)
For bipolar disorders, specifiers can be used to detail the nature of the current or most recent episode (manic, hypomanic, or depressed). Some specifiers for bipolar disorders include:
- With Rapid Cycling: Indicates the occurrence of at least four mood episodes (depressive, manic, or hypomanic) within a twelve-month period
- With Mixed Features: Can be applied to manic, hypomanic, or depressive episodes if there are symptoms from the opposing mood polarity present
- With Anxious Distress: As with MDD, denotes the presence of two or more symptoms of anxiety (American Psychiatric Association, 2022)
The DSM-5 includes other specifiers applicable to both MDD and bipolar disorders, such as “With Psychotic Features,” which suggests the presence of delusions or hallucinations, and “With Catatonia,” which describes a range of psychomotor symptoms like mutism or posturing (American Psychiatric Association, 2022).
Approaches to Treating Mood Disorders
Mood disorders are serious mental health conditions with potentially debilitating effects. A comprehensive understanding of these conditions and their management strategies is paramount for health-care professionals to provide effective client care. It is equally essential to foster an empathetic and nonjudgmental approach when working with these clients, promoting their mental health and overall well-being (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022).
Treating mood disorders involves a combination of medication, psychotherapy, and lifestyle changes. Pharmacological treatment is currently considered an essential component in managing mood disorders. Health providers may prescribe antidepressants, mood stabilizers, and antipsychotic medications depending on the specific diagnosis and symptom severity. These medications can help balance brain chemistry, reduce the severity of symptoms, and improve quality of life.
Cognitive behavioral therapy, interpersonal therapy (IPT), and other forms of psychotherapy are often used to help individuals understand and manage their symptoms. These therapies can provide strategies for managing stress, improving relationships, and promoting healthier thinking patterns.
Electroconvulsive therapy is a medical procedure that involves the passage of a controlled electric current through the brain, inducing a brief seizure while the client is anesthetized (Salik & Marwaha, 2020). Historically, ECT has been the subject of controversy due to its portrayal in popular media and concerns about adverse effects (Cabrera et al., 2021). In recent years, however, it has gained recognition as an effective and safe intervention for specific psychiatric disorders, particularly when other treatments have failed. Mood disorders, such as MDD and bipolar disorder, can be debilitating. In some instances, clients do not respond adequately to traditional treatments like pharmacotherapy or psychotherapy. For these individuals, ECT can be a valuable alternative (American Psychiatric Nurses Association, 2021).
Lifestyle changes, such as regular physical exercise, a healthy diet, adequate sleep, and avoiding alcohol and illicit substances, also help in treating mood disorders. These changes can enhance the effectiveness of therapy and medication and improve overall health and well-being (Hollon et al., 2014).
Overview of Medications Used to Treat Mood Disorders
Medication is a critical component in treating mood disorders, managing symptoms, and restoring balance in brain chemistry. Antidepressants, mood stabilizers, and antipsychotic medications (see Schizophrenia Spectrum Disorder and Other Psychotic Disorders) commonly treat these disorders.
Antidepressants, such as SSRIs and SNRIs, frequently treat major depressive disorder and dysthymia. Antidepressants function by modulating the concentrations of neurotransmitters. These neurotransmitters, including serotonin, norepinephrine, and dopamine, play crucial roles in regulating mood, energy, sleep, and appetite (Moraczewski & Aedma, 2020).
Mood stabilizers, including lithium and certain anticonvulsants, are the cornerstone of treatment for bipolar disorder. These medications help to regulate mood swings and prevent episodes of mania and depression. Antipsychotic medications are indicated where psychotic symptoms, such as hallucinations or delusions, are present; such episodes can occur in severe depressive episodes or during manic episodes in bipolar disorder (Yatham et al., 2018).
Overview of Psychosocial Approaches to Treat Mood Disorders
Psychosocial interventions are essential in treating mood disorders, providing individuals with strategies to manage their symptoms, improve their functioning, and enhance their quality of life. CBT, IPT, and family-focused therapy (FFT) are among the most researched and commonly used psychosocial treatments (Chatterton et al., 2017).
CBT helps individuals identify and modify maladaptive thought patterns and behaviors that may contribute to their mood disorder. It also teaches coping strategies to manage stress and prevent future depressive episodes. IPT, on the other hand, focuses on improving interpersonal relationships and social functioning, which mood disorders often affect negatively. It helps individuals navigate relationship difficulties, role transitions, and unresolved grief that may contribute to their depressive symptoms (Rajhans et al., 2020).
FFT and DBT are commonly used in the treatment of bipolar disorder. FFT includes psychoeducation about the disorder, communication enhancement training, and problem-solving skills training. FFT aims to improve the family environment because a supportive family environment can often help manage bipolar disorder symptoms and prevent relapse (Guarnotta, 2023). DBT is a talk therapy focused on helping an individual deal with intense emotions. It revolves around how thoughts affect the emotions and eventual behavior of the individual (Cleveland Clinic, 2022). In addition to these structured therapies, psychosocial interventions may include self-help strategies and peer support, which can enhance the effectiveness of other treatments and improve the overall prognosis.
Overview of Lifestyle Changes That Help Treat Mood Disorders
While lifestyle changes alone may not replace the need for traditional treatments, they can significantly complement them and lead to enhanced mood stability and improved overall well-being in individuals with mood disorders (Ee et al., 2020). Engaging in regular physical activity has been linked to reduced symptoms of depression and anxiety. Exercise promotes the release of endorphins, which are natural mood elevators, and helps in regulating neurotransmitters like serotonin and norepinephrine that play a role in mood regulation (American Psychological Association, 2020). Likewise, consuming a well-balanced diet rich in fruits, vegetables, whole grains, lean protein, and omega-3 fatty acids can positively influence mood. For instance, omega-3 fatty acids, found in fish like salmon, have anti-inflammatory properties and are associated with a reduced risk of depression (Gómez-Pinilla, 2008). Maintaining a consistent sleep schedule and ensuring adequate rest is crucial for mood stability. Sleep disturbances, such as insomnia or oversleeping, can exacerbate symptoms of mood disorders. It is recommended to establish a regular bedtime routine, avoid electronics before sleep, and create a sleep-conducive environment (Saghir et al., 2018). Alcohol and certain drugs can interact with medications and can lead to mood swings or worsen depressive or manic symptoms. It is best to avoid these substances (World Health Organization, 2023).