MS. RITIKA SONI ASSOCIATE PROFESSOR SNC, SHIMLA.

1. MOOD DISORDERS
PRESENTEDBY: MS RITIKA SONI

2. INTRODUCTION
EMOTIONS
AFFECT:
Short-lived, emotional
Response to an event
MOOD:
Sustained and pervasive

3.  Mood disorders are characterized by a
disturbance of mood, accompanied by a full or
partial manic or depressive syndrome, which is not
due to any other physical or mental disorder .
 Mood disorders are a group of clinical
conditions(syndrome) which are characterized by a
sense of loss of control over one’s mood and
subjective sense of distress, impaired
interpersonal, social and occupational
functioning.
 The prevalence rate of mood disorder is 1.5 %, and
it is uniform throughout the world.

4. HISTORY
 Hippocrates (400 B.C.) used the terms
mania and melancholia to describe mental
disturbances, it was Aretaeus who first
described mania and depression.
 Roman physician (30 A.D.) described
melancholia as depression caused by black
bile

5.  In 1854, Jules Farlet described a condition
called folie circulaire: alternating moods of
depression and mania
 In 1899, Emil Kraepelin described manic-
depressive psychosis using most of the
criteria that psychiatrists use now.

6. CLASSIFICATION( F30-F39)
 F30: Manic Episode
 F31: Bipolar (Affective) Disorder
 F32: Depressive Episode
 F33: major depressive disorder, single episode
 F34: Persistent Mood (affective) Disorder (cyclothymia
and dysthymia)
 F39: Unspecified mood disorder

7. MANIC EPISODE
Introduction:
 Life time risk – 0.8-1%
 Occurs in episodes- lasting usually 3-4 months, followed by clinical recovery.
 Future episodes can be manic, depressive or mixed.
 The manic episode is characterized by the following features( which should last for
at least 1 week and cause disruption in occupational and social functioning)
Definition:
 Mania refers to a syndrome in which the central features are over-activity, mood
change( which may be towards elation or irritability)and self- important ideas.
 Mania : an alteration in mood that is expressed by feelings of elation, inflated self-
esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

8. CLASSIFICATION: F30- MANIC EPISODE
 F30.0- HYPOMANIA
 F30.1- MANIA WITHOUT PSYCHOTIC
FEATURES
 F30.2- MANIA WITH PSYCHOTIC FEATURES
 F30.8- OTHER MANIC EPISODES
 F30.9- MANIC EPISODES UNSPECIFIED

9. MANIA: CLINICAL FEATURES
 Core features
 Elevated, expansive or irritable mood
 Increased speech
 Decreased need for sleep
 Increased psychomotor activity
 Psychotic features
 Delusions
 Hallucinations
(Mood incongruent psychotic features)
 Others
9

10. 1. Core features:
2. 1. Elevated, Expansive or Irritable mood
3. Stages/Degrees :
o Euphoria/ Grade 1 (mild elevation of mood): increased sense
of psychological well being and happiness, not in keeping with
ongoing events. Usually seen in hypomania.
o Elation/ Grade 2(moderate elevation of mood): feeling of
confidence and enjoyment, along with increased psychomotor
activity. Classically seen in mania.
o Exaltation/ Grade 3 (severe elevation of mood):intense elation
with delusions of grandiosity. Seen in severe mania
o Ecstasy/ Grade 4 (very severe elevation of mood): intense
sense of rapture or blissfulness. Typically seen in delirious or
stuporous mania. 10

11. 2. Increased speech and thought
o Volubility
o Acceleration
o Pressured speech- difficult to interrupt
o Flight of ideas- shift from topic to topic with cues
o Clang association
o Delusion of grandeur
o Delusion of persecution
o Distractibility
3. Increased psychomotor activity
Increased psychomotor activity ranging from over
activeness and restlessness to manic excitement.
The activities are goal oriented.
o Over activity/ restlessness
o Excitement
o Stupor ( rarely) 11

12. 4. PSYCHOTIC SYMPTOMS
 Delusions: grandiose, love( Erotomania),
persecutory.
 Hallucinations.
5. GOAL-DRECTED ACTIVITY:
-The person is unusually alert, trying to do many
things at one time.
-In hypomania, the ability to function becomes much
better and there is marked increase in productivity
and creativity.
-In mania, there is marked increase in activity with
excessive planning and, at times, execution of
multiple activities.

13. 6. OTHER SYMPTOMS
o Over religiosity
o Over spending/ expansive ideas
o Over familiarity/ disinhibition
o Dressed up in gaudy and flamboyant cloths but poor
self care.
o Appetite may be increased, but decreased food intake
due to over-activity
o Decreased need for sleep
o Impulsive behavior
o Increased sociability
o Poor judgement
o Absent insight

14.  TRIAD SYMPTOMS OF MANIA
HYPERACTIVITY
INCREASED SPEECH FLIGHT OF IDEAS
PRODUCTION

15. ETIOLOGY
 Neurotransmitter and structural hypothesis:
Manic episodes are related to excessive levels of
nor-epinephrine and dopamine, an imbalance
between cholinergic and noradrenergic systems.
(Serotonin is decreased).
- structural hypothesis:
Biological findings suggest that lesions are more
common in this population in areas of the brain
such as the right hemisphere or bilateral sub
cortical and periventricular grey matter.
- Sleep studies:
Sleep abnormalities are common in mood
disorders(eg: decreased need for sleep in mania)

16.  Genetic consideration:
Monozygotic twins have a higher rate of incidence
than normal siblings and other close relatives.
- Siblings and close relatives have a higher incidence
of manic-depressive illness than a general
population.
- First degree relative – 5-10% chance
- Identical twin with bipolar disorder about 40-70%
chance.
o Psychodynamic theories:
Developmental theorists have hypothesized that
faulty family dynamics during early life are
responsible for manic behaviors in later life.
.

17. DIAGNOSIS OF MANIA
 Psychological tests such as Young Mania Rating Scale
 ICD-10 Diagnostic criteria
 Based on sign and symptoms

18. 18
TREATMENT MODALITIES
PHARMACOTHERAPY
 Lithium- 900-2100 mg/dl
 Carbamazepine : 600-1800 mg/dl
 Sodium valproate- 600-2600 mg/dl
 Other drug- clonazepam

19. ECT
 It can be used for acute cases of mania if not
responding to mood stabilizer and antipsychotic.
PSYCHOSOCIAL TREATMENT
Family therapy and Marital therapy is used to
decrease interfamilial and interpersonal difficulties
and reduce or modify stressor.

20. NURSING MANAGEMENT OF MANIA
Nursing assessment
 Assessing the severity of the disorder
 Forming an opinion about the causes
 Assessing the patients resources and judging the effects
of patient’s behavior on other people.

21.  Assess for mood and affect
 Thinking and perceptual ability
 Sleep disturbance
 Changes in energy level
 Speech pattern
 Motor activity
 Speech production

22. NURSING DIAGNOSIS-1
 High risk for injury R/T hyperactivity and impulsive
behavior as evidence by lack of control over purposeful
and injurious movements.
Nursing intervention
 Keep environmental stimuli to minimum; assign single
room, limit interaction, keep lighting and noise level low
 Remove hazardous objects
 Engage patient in activities such as drawing, writing and
physical exercise
 Stay with patient as hyperactivity increases
 Administer medication as prescribed by physician

23. NURSING DIAGNOSIS- 2
 High risk for violence ; self directed or directed at others R/T
manic excitement, delusional thinking and hallucinations
Nursing intervention
 Maintain low of stimuli
 Observe patient’s behavior every 15 minutes
 Ensure all sharps, glasses or mirrors, belts, ties have been
removed from patients environment
 Avoid arguing with patient
 Encourage verbal expression of feeling
 Maintain and convey a calm attitude to the patient
 Have sufficient staffs to control the patient
 Administer tranquilizers
 Follow application of restrain
 Remove restrain gradually once at a time

24. NURSING DIAGNOSIS- 3
 Imbalanced nutritional pattern less than body
requirement R/T hyperactivity as evidenced by
weight loss , refusal or inability to sit still enough to
eat .
Nursing intervention
 Assess the nutritional pattern of patient
 Find out patient’s likes and dislikes
 Provide high protein, calorie, nutritious foods and
drinks
 Provide 6-8 glasses of fluids per day
 Maintain accurate records of intake and output.
 Supplement with vitamins and minerals
 Walk and sit with patient while he eats
 Finger foods

25. NURSING DIAGNOSIS-4
 Impaired social interaction R/T egocentric and
narcissistic behavior as evidenced by inability to
develop satisfying relationship and manipulation of
others for own desires
Nursing intervention
 Recognize that manipulative behavior helps to
decrease feeling of insecurity by increasing the
feeling of power and control
 Set limits on manipulative behavior. Explain the
consequences if limits are violated.
 Ignore attempts by patient to argue or bargain his
way-out of setting limits.
 Give reinforcement for non- manipulative behaviors.
 Helps patient identify positive aspects about self

26. OTHER DIAGNOSIS
 Disturbed sleep pattern related to hyperactivity as
evidenced by lack of sleep(hrs)
 Altered family process R/T euphoric mood,
manipulative behaviors

27. DEPRESSIVE EPISODE
 Life time risk in males is 8-12% and in
females is 20-26%.
 However, the life time risk- 8%
 Typical depressive episode is
characterized by the following features(
which would last for at least 2 weeks for
the diagnosis to be made)

28. DEFINITION
 An alteration in mood that is expressed by feelings of
sadness, despair, and pessimism. There is a loss of interest in
usual activities, and somatic symptoms may be evident.
Changes in appetite and sleep patterns are common.
Classification of Depression:
 F32: Depressive episode
 F32.0: Mild Depressive episode
 F32.1: Moderate Depressive episode
 F32.2: severe Depressive episode without psychotic
symptoms
 F32.3: severe Depressive episode with psychotic
symptoms
 F32.8: other depressive episode- Atypical depression
 F32.9: depressive episode, unspecified
 F33: recurrent Depressive episode.

29. TYPES OF DEPRESSIVE DISORDER
 Major depressive disorder(MDD):
MDD is characterized by depressed mood or loss of interest or
pleasure in usual activities.
Impaired social and occupational functioning that has been
existed for at least 2 weeks.
o Dysthymic Disorder/ chronic or long term depression:
Chronically depressed mood (possibly an irritable mood) for
most of the day, more days than not, for at least 2 years.
o Others:
- Mood disorder (depression) due to a general medical
condition.
- Substance-induced mood disorder.

30. CLINICAL FEATURES
1. Depressed Mood:
 Pervasive and persistent sadness of mood
 Pervasive sadness: loss of interest / pleasure in almost all
activities leads to social withdrawal, decreased ability to
function in occupational and interpersonal functioning.
 Persistent sadness: sadness present throughout the day.
 This sadness of mood is Quantitatively as well as
qualitatively different from sadness encountered in
‘normal’ depression or grief
 Sadness of mood varies little from day to day and is often
unresponsive to environmental stimuli.
 In severe depression, there may be complete Anhedonia.

31. 2. Anhedonia:
 Loss of interest or pleasure in almost all
activities/ earlier pleasurable activities
 Results in social withdrawal
 Decreased ability to function in occupational and
interpersonal areas

32. 3. Anergia:
 Easy fatigability
 Increased effort to perform simple tasks

33. 4. Depressive ideation/ Cognition:
 Hopelessness (There is no hope in the future)
 Helplessness( no help is possible now) TRIAD
 Worthlessness( feeling of inadequacy and inferiority)
 Feelings of guilt
 Death wishes
 Suicidal ideas
 In severe cases, delusions of nihilism.(e.g.: ‘world is coming to an end, ‘there is no
brain in my head, my intestines have rotted away’) may occur.

34. SUICIDAL RISKS: SOME IMPORTANT FACTORS
Suicidal risk is much more in the presence of following factors:
a) Presence of marked hopelessness
b) Males ; age > 40; unmarried, divorced/widowed
c) Written/verbal communication of suicidal intent/or plan
d) Early stages of depression
e) Recovering from depression
f) Period of 3 months of recovery

35. 5. Psychomotor Activity:
 Younger patients (less than 40): slowed thinking and
activity, decreased energy, monotonous voice.
 Older patients (e.g. post- menopausal): agitation, marked
anxiety, restlessness, subjective feeling of unease.
 Severe depression: stupor
 Anxiety, irritability, frustration in day to day activities-
unusual anger at the noise made by children at home.

36. 6. PHYSICAL SYMPTOMS
 Multiple physical symptoms:
 Heaviness of head
 Vague multiple aches
 General aches and pains
 Hypochondriacal features.

37. 7. Biological functions/ somatic syndrome:
 Insomnia
 Loss of appetite and weight
 Loss of sexual drive
 Early morning awakening (at least 2 hrs before
usual time of awakening)
 Loss of reactivity to pleasurable stimuli.

38. 8. Psychotic Symptoms:
 Delusions of guilt, Nihilism
 Hallucinations
9. suicide:
suicidal ideas in depression should always be
taken very seriously.

39. OTHER SYMPTOMS
 Difficulty in concentration
 Forgetfulness
 Low self-esteem
 Decreased self-confidence

40. 40
ETIOLOGY
Biological theories
1.Genetic factors
- Twin studies
- Family studies
- Adoption studies
2. Neurotransmitter theories-
o Serotonin- decreased in depression and vice versa
3. Neuroendocrine theories:
Mood symptoms are prominently seen in disorder like,
hypothyroidism, Cushing’s disease and Addison’s disease.
 Hypothalamic-Pitutory- Adrenocortical Axis:
Endocrine function is often disturbed in depression, with cortisol
hypersecretion.

41. HYPOTHALAMIC-PITUTORY- THYROID AXIS:
 Thyrotropin- releasing factor (TRF) from the hypothalamus
stimulates the release of thyroid –stimulating hormone (TSH)
from the anterior pituitary. Diminished TSH response is
observed in approximately 25 % of depressed persons.
4. Physiological influences:
 Secondary depression: depressive symptoms that occur as
a consequence of a non-mood disorder or as an adverse
effect of certain medications are called secondary
depression.
 Secondary depression may be related to medication side
effects, neurological disorders, electrolyte or hormonal
disturbances, nutritional deficiencies and other physiological
or psychological conditions.

42. 5. Neuroimaging and anatomy
 Ventricular dilatation, white matter hyper- intensifies and
changes in blood flow & metabolism in several parts of
brain( prefrontal cortex).
6. Sleep studies:
Insomnia and frequent awakenings in depression).
7. Circadian Rhythm Theories:
Circadian rhythm are responsible for the daily regulation of
wake-sleep cycles, arousal and activity patterns and
hormonal secretions. Individual experiencing circadian
rhythm changes are at increased risk for developing
depressive symptoms and other mood symptoms.
These changes might be caused by medications,
nutritional deficiencies, physical or psychological
illnesses, hormonal fluctuations.

43. 43
CONTD-
Psychosocial theories:
1.Life events and stress
o Play a formative role in depression; precipitating in mania
 Psychoanalytical Theory:
In depression, loss of libidinal object, introjections of the
lost object, fixation in oral sadistic phase.

44. DIAGNOSIS FOR DEPRESSION
 Psychological tests- Beck depression inventory, Hamilton
rating depression scale to assess severity and prognosis
 Dexamethasone suppression test showing failure to
suppress cortisol secretion in depressed patient.
 Based on ICD- 10
 Toxicology screening suggesting drug induced depression(e.g
anticonvulsive drugs, hormonal agents, antipsychotics)

45. TREATMENT MODALITIES
1. Psychopharmacology
 Selective serotonin reuptake inhibitor (SSRIs)-
Citalopram, Fluoxetine, Sertraline
 Tricyclic antidepressant- clomipramine,
imipramine
 Monoamine oxidase inhibitors- Isocaboxazid,
Phenelzine
 Other newer antidepressants:
Bupropion,Maprotiline.

46. 2. Physical therapies/ Somatic therapies :
 ECT- severe depression with suicidal thoughts
 Light therapy: can be given in cases of seasonal depression
 Repetitive transcranial magnetic stimulation ( TMS) ,
Vagus nerve stimulation( VNS)

47. 3. PSYCHOLOGICAL TREATMENT
 PSYCHOTHERAPY
 COGNITIVE THERAPY
 SUPPORTIVE THERAPY
 GROUP THERAPY
 FAMILY THERAPY
 BEHAVIOURAL THERAPY

48. NURSING MANANAGEMENT OF MAJOR
DEPRESSIVE DISORDER
 Nursing assessment:
 Judging the severity of the disorder i.e.
1. Risk for suicide
2. Identifying the possible cause
3. Social resources available to the patient
4. Effect on other people
5. Assess the sign and symptoms like:
hopelessness, helplessness, worthlessness,
decreased appetite, sleep, decreased motor
activity etc.

49. NURSING DIAGNOSIS-1
 High risk of self directed/other directed violence
related to depressed mood, feeling of
worthlessness and anger directed inwards

50. NURSING INTERVENTION
 Ask the patient directly ‘ have you thought of
harming yourself in any way’? If so, what do you plan
to do? Do you have the means to carry it out?
 Create safe environment for patient
 Formulate a short term verbal or written contract that
the patient will not harm himself.

51.  It may be desirable to place the patient near the
nursing station
 Close observation is specially required
 Do not allow the patient to bolt the room
 If the patient becomes unusually happy or gives
clues of suicide, immediately inform
 Encourage to express feelings including anger.

52. NURSING DIAGNOSIS-2
 Dysfunctional grieving R/T real or perceived loss,
as evidenced by denial of loss, inappropriate
expression of anger, inability to carry out activities
of daily living
Nursing intervention
 Assess the stage of fixation in grief process
 Be accepting to the patient and spend time with
him. Show sympathy, care and unconditional love,
positive regard
 Explore feelings of anger and help patient direct
them towards the intended object or person
 Provide simple activities.

53. NURSING DIAGNOSIS- 3
 Powerlessness R/T dysfunctional grieving process,
life style of helplessness as evidenced by feeling of
lack of control over life situation and decreased
psychomotor activities.

54. NURSING INTERVENTION
 Allow patient to take decisions regarding own care.
 Ensure that the goal are realistic and that patient is able
to identify life situation.
 Encourage the patient to verbalize feelings about areas
that are not in his ability to control.
 Family therapy

55. NURSING DIAGNOSIS-N 4
 low Self esteem R/T learned helplessness,
impaired cognition, worthlessness as evidenced by
feeling of inferiority, negative view towards self.

56. NURSING INTERVENTION
 Be accepting to the patient and spend time with him/her
 Focus on strengths and accomplishments and minimize
failure.
 Provide him with simple and easily achievable activity.
 Encourage patients to recognize areas of change and
provide assistance towards effort.
 Teach assertiveness and coping skills

57. NURSING DIAGNOSIS-5
 Disturbed sleep and rest R/T depressed mood, early
morning awakening as evidenced by restlessness,
irritation .

58. NURSING INTERVENTION
 Plan daytime activities according to the patients interest,
do not allow him to sit idle
 Ensure a quiet and peaceful environment when patient is
preparing to sleep
 Provide comfort measures ( back rub, warm milk, tipid
bath)
 Do not allow patient to sleep for long time during day
 Give medicine as prescribed

59. OTHER DIAGNOSIS
 Imbalanced nutritional status R/T depressed mood,
lack of interest in food as evidenced by weight loss.
 Self care deficit R/T depressed mood, feeling of
worthlessness as evidenced by poor hygiene and
grooming.

60. 60
BIPOLAR MOOD (AFFECTIVE) DISORDER
 Earlier known as manic depressive psychosis
(MDP)
 Characterized by recurrent episodes of mania
and depression in same patient at different
times.

61. CLASSIFICATION:
 F31.0:BAD, current episode
hypomania
 F31.1:BAD, current episode
mania, without psychotic
symptoms
 F31.2:BAD, current episode
mania, with psychotic symptoms
 F31.3:BAD, current episode
mild or moderate depression.
 F31.4:BAD, current episode
severe depression without
psychotic symptoms
 F31.5:BAD, current episode of
severe depression with psychotic
symptoms.

62.  The current episode in bipolar mood disorder is
specified as one of the following:
 Hypomania
 Mania without psychotic symptoms
 Mania with psychotic symptoms
 Mild or moderate depression
 Severe depression, without psychotic symptoms

63.  Severe depression with psychotic symptoms
 Mixed
 In remission

64. SUBTYPES OF BIPOLAR DISORDER
 Bipolar I
Characterized by episodes of severe mania and
severe depression
 Bipolar II
Characterized by episodes of hypomania ( not
requiring hospitalization) and severe depression

66.  Others :
 Cyclothymia or cyclothymic disorder -- is a
relatively mild mood disorder. In cyclothymic
disorder, moods swing between short periods of
mild depression and hypomania, an elevated mood.
It involve numerous episodes of hypomania and
depressed mood of insufficient severity ( means no
full manic episodes or full major depressive
episodes).
 Bipolar disorder NOS : sometimes called "sub-
threshold" bipolar, indicates that the patient suffers
from some symptoms in the bipolar spectrum (e.g.,
manic and depressive symptoms) but does not fully
qualify for any of the formal bipolar

68. OTHER BIPOLAR DISORDER
 Bipolar disorder due to a general medical condition
 Substance- induced bipolar disorder

69. ETIOLOGY
 Precise unknown cause
 Genetics, biochemical and psychological factors
 Stressful life events, antidepressant use chronically
 Sleep deprivation and hypothyroidism
DIAGNISIS:
Based on sign and symptoms
ICD-10 classification
TREATMENT:
- Lithium
- Valporic acid
- Carbamazepines
- Antidepressants
- Antipsychotics

70. 4. RECURRENT DEPRESSIVE
DISORDER
 Recurrent (at least 2 )depressive episodes
(unipolar depression)
 Episodes last between 3 to 12 months
 Recovery is usually complete
 Often precipitated by stressful life events

71. 5. PERSISTENT MOOD DISORDERS
 Persistent mood symptoms lasting for more than 2
years
 Chronic/ long term depression: Dysthymia
 Persistent instability of mood between mild
depression and elation: Cyclothymia

72. COURSE AND PROGNOSIS
 Average manic episode lasts for 3-4
months
 Average depressive episode lasts for 4-6
months
 Unipolar depression is usually longer than
bipolar depression
 As age advances, intervals between 2
episodes shorten; duration and frequency
increases

73. 73
EPIDEMIOLOGY
Prevalence
Unipolar depression- 6%
Bipolar disorder- 1%, milder forms often missed
Gender ratio
Equal prevalence among men and women
Manic episodes more common in men and depressive
episodes more common in women
Seasonality
Two prevalent period of seasonal involvement: one in
spring(march,april, may) and one in the fall (sep., oct, nov).
Large peak in the spring and a smaller one in october.

74. 74
Age of onset
Unipolar depression can occur from childhood
50% has age of onset 20-50
Bipolar begins a bit earlier, childhood to 50 years
Ranges from 5-50yrs; mean age 30yrs
Marital status
More common in divorced and single persons
Socioeconomic status
Higher than average incidence among upper socioeconomic
status

75. GERIATRIC CONSIDERATION
 Late onset bipolar disorder is rare
 Depression is common among elderly
 Have psychotic features particularly
delusions
 Suicide is doubles in older age people
above 65.
 Treated with ECT more frequently.

76.  Have increased tolerance to side effects of
antidepressants. However not able to tolerate high
doses.
 Accompanying stresses can put older adults at risk
for clinical depression

77. FACTORS RESPONSIBLE FOR CLINICAL
DEPRESSION AMONG OLDER ADULTS:
Factors
responsible
for clinical
depression
Worries about
being a burden
Loss of
physical and
mental ability
Physical illness
Death of
spouse, friend
and loved one
Concomitant
physical illness and
cerebral pathology
worsen prognosis
Retirement