Mood Disorders

1. Concepts and principles:
   1. Self-limiting factors - most depressions are self-limiting disturbances, making it important to look for a change in functioning and behavior.
   2. Theories of cause of depression:
      1. Aggression turned inward - self-anger.
      2. Response to separation or object loss.
      3. Genetic or neurochemical basis - impaired neurotransmission of monoamine oxidase (MAO); high levels of catecholamines.
      4. Cognitive - negative mind-set of hopelessness toward self, world, future; overgeneralizes; focuses on single detail rather than whole picture; draws conclusions on inadequate evidence.
      5. Personality - negative self-concept, low self-esteem affect belief system and appraisal of stressors; ambivalence, guilt, feeling of failure.
      6. Learned helplessness - dependency; environment cannot be controlled; powerlessness.
      7. Behavioral - loss of positive reinforcement; lack of support system.
      8. Integrated - interaction of chemical, experiential, and behavioral variables acting on diencephalon.
      
      
2. General assessment:
   1. Physical: early-morning awakening, insomnia at night, increased need for sleep during the day, fatigue, constipation, anorexia with weight loss, loss of sexual interest, psychomotor retardation, physical complaints, amenorrhea.
   2. Psychological: inability to remember, decreased concentration, slowing or blocking of thought, all-or-nothing thinking, less interest in and involvement with external world and own appearance, feeling worse at certain times of day or after any sleep, difficulty in enjoying activities, monotonous voice, repetitive discussions, inability to make decisions due to ambivalence, impaired coping with “practical problems”.
   3. Emotional: loss of self-esteem, feelings of hopelessness and worthlessness, shame and self-derogation due to guilt, irritability, despair and futility (leading to suicidal thoughts), alienation, helplessness, passivity, avoidance, inertia, powerlessness, denied anger; uncooperative, tense, crying, demanding, and dependent behavior.
   
   
3. Analysis/nursing diagnosis:
   1. Risk for violence toward self (suicide) related to inability to verbalize emotions.
   2. Sleep pattern disturbance (insomnia or excessive sleep) related to unresolved fears and anxieties, biochemical alterations (decreased serotonin).
   3. Impaired social interaction/social isolation/withdrawal related to decreased energy/inertia, inadequate personal resources, absence of significant purpose in life.
   4. Altered nutrition related to lack of interest in food.
   5. Self-care deficit related to disinterest in activities of daily living.
   6. Chronic low self-esteem with self-reproaches and blame related to feelings of inadequacy.
   7. Altered feeling states and meaning patterns (sadness, loneliness, apathy) related to overwhelming feeling of unworthiness, hopelessness, and dysfunctional grieving.
   
   
4. Nursing care plan/implementation:
   1. Promote sleep and food intake: take nursing measures to ensure the physical well-being of the client.
   2. Provide steady company to assess suicidal tendencies and to diminish feelings of loneliness and alienation.
      1. Build trust in a one-to-one relationship.
      2. Interact with client on a nonverbal level if that is his or her immediate mode of communication; this will promote feelings of being recognized, accepted, and understood.
      3. Focus on today, not the past or far into the future.
      4. Reassure that present state is temporary and that he or she will be protected and helped.
   3. environment nonchallenging and nonthreatening.
      1. Use a kind, firm attitude, with warmth.
      2. See that client has favorite foods; respond to other wishes and likes.
      3. Protect from overstimulation and coercion.
   4. Postpone client’s decision making and resumption of duties.
      1. Allow more time than usual to complete activity (dressing, eating) or thought process and speech.
      2. Structure the environment for client to help reestablish a set schedule and predictable routine during ambivalence and problems with decisions.
   5. Provide nonintellectual activities (e.g., sanding wood); avoid activities such as chess and crossword puzzles, because thinking capacity at this time tends to be circular.
   6. Encourage expression of emotions, denial, hopelessness, helplessness, guilt, regret; provide outlets for anger that may be underlying the depression; as client becomes more verbal with anger and recognizes the origin and results of anger, help client resolve feelings - allow client to complain and be demanding in initial phases of depression.
   7. Discourage redundancy in speech and thought: redirect focus from a monologue of painful recounts to an appraisal of more neutral or positive attributes and aspects of situations.
   8. Encourage client to assess own goals, unrealistic expectations, and perfectionist tendencies.
      1. May need to change goals or give up some goals that are incompatible with abilities and external situations.
      2. Assist client to recapture what was lost through substitution of goals, sublimation, or relinquishment of unrealistic goals - reanchor client’s self-respect to other aspects of his or her existence; help him or her free self from dependency on one person or single event or idea.
   9. Indicate that success is possible and not hopeless.
      1. Explore what steps client has taken to achieve goals and suggest new or alternative ones.
      2. Set small, immediate goals to help attain mastery.
      3. Recognize client’s efforts to mobilize self.
      4. Provide positive reinforcement for client through exposure to activities in which client can experience a sense of success, achievement, and completion to build self-esteem and self-confidence.
      5. Help client experience pleasure; help client start good relationships in social setting.
   10. Long-term goal: to encourage interest in external surroundings, outside of self, to increase and strengthen social relationships.
       1. Encourage purposeful activities.
       2. Let client advance to activities at own pace (graded task assignments).
       3. Gradually encourage activities with others.
   11. Health teaching: explain need to recognize highly stressful situation and fatigue as stress factor; advise that negative responses from others be regarded with minimum significance; explain need to maintain positive self-attitude; advise occasional respite from responsibilities; emphasize need for realistic expectation of others.
   
   
5. Evaluation/outcome criteria: performs self-care; expresses increased self-confidence; engages in activities with others; accepts positive statements from others; identifies positive attributes and skills in self.


6. Critical Pathway: Depressed Client.