| | Evidence-based treatment of mood disorders
There is growing interest among mental health nurses and other clinicians in providing interventions with demonstrated efficacy and effectiveness in vast practice settings [1]. This movement to develop and implement treatment modalities extends beyond traditional outcomes, such as adherence to treatment and exacerbation of symptoms, and includes helping patients reach an optimal level of functioning and quality of life. Providing empirically based treatment is crucial in the treatment of mood disorders.
Mood disorders can occur at any age and to people of any race, ethnic group, or social class. In the United States, more than 19 million adults have depression. Depression has a lifetime prevalence of 24% for women and 15% for men [2], [3]. Among developed nations, including the United States, major depression is the leading cause of disability for individuals age 5 and older. Also near the top of the list of disabilities in the United States and throughout the world is bipolar disorder [2]. Also called manic depressive disorder, bipolar disorder affects 1%, or more than 2 million, of American adults. An equal number of men and women experience bipolar disorder. It is inherited, and it is found to occur more frequently in some families. There is also a seasonal relationship, with more “highs” or mania occurring in the spring and fall, whereas depression often occurs in winter [2], [4]. Abnormalities in the brain biochemistry and in the communication of certain brain circuits are responsible for the shifts experienced in mood disorders [5], [6]. Although there are a variety of mood disorders, this article addresses major treatment issues, including differential diagnosis, pharmacologic and nonpharmacologic approaches, and the role of the nurse caring for patients, in major depression and bipolar disorders.
Definitions  The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM IV-TR) [7], describes major depressive disorder as a constellation of symptoms that last for at least 2 weeks, are not the patient's normal behavior, and include at least five of the following:
•Sad or depressed mood
•Psychomotor agitation or retardation
•Appetite disturbances with subsequent weight gain or loss
•Fatigue
•Decreased libido
•Concentration disturbances
•Anhedonia or loss of interest in things that were once pleasurable
Dysthymia-type depression is defined as a chronically sad or blue mood, which may include physical symptoms of poor appetite or overeating, insomnia or hypersomnia, fatigue, and mental difficulty concentrating or making decisions and emotional feelings of hopelessness or powerlessness and spiritual feelings of worthlessness, as though life has no meaning. These symptoms may last for years and be chronic in nature, or they may have a sudden onset. The persistence, duration, date of first symptoms, and severity differentiate between the two distinct depression diagnoses. The second group of mood disorders is bipolar-type disorder. Also called manic depressive disorder, bipolar I disorder is another distinct illness. It includes periods of major depressive symptoms, with at least one manic episode in the person's history. Mania is different. The essential characteristics of mania are the following:
•Physical arousal, with high energy and much activity
•Emotional irritability, anger, reactivity
•Increased or expansive mental thinking with fast or racing thoughts
•Rapid speech
•Sleep disturbances, such as decreased need for sleep
•Delusions of grandeur
•Increased risk-taking behaviors that have potential negative consequences
These extremes sometimes are interspersed with periods of normal moods, but the cycle inevitably goes up into mania at least once in the person's life and alternately moves down into depression. Each person's rhythm of cycles between up and down mood and periods of normalcy is personal and individual, perhaps lasting days, weeks, months, or years. The distinction of bipolar I disorder includes a history of at least one episode of mania; when the patient presents for the first interview, he or she may be in either mood state. This cyclical swing between major depressive disorder and mania is the defining characteristic of bipolar I disorder [2], [8], [9]. Major symptoms of bipolar II disorder include a history of primarily “low” down moods, with a history of at least one hypomanic episode, but this episode never developed into a full mania, as defined earlier. History of hypomania could be determined by questioning about brief periods of silly, happy, fidgety, or irritable behaviors [2], [8], [9]. A major treatment issue concerning a mood disorder is making an accurate diagnosis. Of the cases reviewed in a 2002 survey, a correct diagnosis of bipolar disorder was missed 69% of the time [10]. This survey pointed to the necessity for the psychiatric clinician to rule out bipolar disorder confidently along with other diagnostic rule out considerations before making a diagnosis. The most frequent misdiagnosis given was depression in 60% of the cases in the survey [10]. Diagnosis and assessment The following case history shows classic symptoms of major depression. It is important for the nurse to perform a complete assessment, including a mental status examination. Major aspects of a psychiatric assessment include the following:
•Identifying information
•Chief complaint
•Current medications/over-the-counter preparations, side effects
•Presenting problems
•Past psychiatric history
•Medical history, allergies
•Family, personal, social, military history
•Drugs, alcohol, gambling, smoking
•Legal history, problems
•Spiritual, and cultural beliefs
The mental status examination includes the following:
•Appearance (dress, hygiene)
•Mood (up, down)
•Affect (flat, animated, incongruent)
•Speech (rate, volume, foreign language)
•Perception (distorted/hallucinations)
•Sensorium (orientation to time, date, place, season)
•Memory (remote, recent)
•Calculation (spell “world” backward, serial 7s)
•Abstract reasoning (interpret proverb/simile)
•Thoughts (linear, logical)
•Judgment (taxes, driving, risk taking)
•Insight (about self/mental health)
Case history: patient with major depression Mr. Dawson was sitting in the mental health triage lobby waiting to be seen. He rose slowly from his chair and walked, without assistance, down the hallway. He had uncombed gray hair and clean clothes—Levis, a flannel shirt, and tennis shoes, no jewelry. He politely said hello, then was quiet. He spoke comfortably with a normal rate and volume. He said he was depressed. He'd lost interest in his usual hobbies and had lost weight because he wasn't interested in food. He often woke up during the night but for most of the night and into the day, he stayed in bed sleeping or resting. Mr. Dawson denied and showed no evidence of having hallucinations, paranoia, or delusional thinking. Feeling he had made mistakes, he explained that he was discouraged with life and was unable to find peace with himself. He answered the specific first question by giving a convincing statement of having no intention of hurting or killing himself or another [2], [9], [11], [12]. Risk of danger to self and others (suicide risk) Because of the high risk of suicide among patients with mood disorders, the nurse needs to assess initially and continuously for suicide and homicide. Questions about suicidal thoughts, plan, intent, and means are crucial aspects of the assessment and treatment process. If the patient describes a well-developed, specific, possible, and immediate plan for suicide, the clinician is obligated to initiate crisis interventions planning to save the patient's life. To provide the highest protection for a suicidal, depressed patient, it is necessary to hospitalize the patient in a locked psychiatric facility under direct supervision of caring staff. Each state has slightly different laws, and it is the clinician's duty to be informed of the exact phrasing of the laws of his or her state. If the patient's suicidal thoughts are of moderate or mild intensity, and there is no current intention to take action, the assessment can proceed. Mental status examination The mental status assessment constitutes the major part of the interview. There is a general description of the individual's appearance. In the case history presented, Mr. Dawson is clean but uncombed and basic in his clothing. He is a quiet man, with a flat affect, polite behavior, and a depressed mood. He describes a decreased interest or enjoyment in his previous activities. He has an unintentional weight loss because of a lack of appetite and little eating. He experiences a change in his sleep pattern, stays in bed for many hours, but he continues to feel tired. He says he feels worthless, feels guilty about past situations, has a current feeling of hopelessness, and feels powerless to create change. His speech is slow in rate and quiet in volume. It is noted that his cognition is slowed, and he takes time responding. He denies hearing or seeing things that are not there. He denies a feeling that his senses are tricking him. He denies paranoia. He denies delusional or grandiose thinking. He denies any episodes of high energy, risk taking, or excessive irritability. He says that he gets along fine with other people. He reveals his level of insight by saying that although he is aware these depressed feelings have been with him for several days, he does not know why they started. He has never sought mental health care previous to this conversation and has never been hospitalized in a psychiatric facility. He denies any family history of mental illness. To assess the patient's degree of depression and cognition difficulties, standardized tests, such as the Zung Self Rating Depression Scale, the Hamilton Depression Scale, the Geriatric Depression Scale, and the Mini Mental Status Exam, can be given to the patient. These tests are available on the Internet [2], [13], [14]. Biopsychosocial assessment The next step is to obtain a medical history, including a list of the patient's prescription medications and over-the-counter medications. Medical disorders can mimic mental disorders. Laboratory tests may be ordered or reviewed to rule out medical illness and to evaluate physical health before making a diagnosis and choosing a treatment. In the case history, Mr. Dawson answers that he takes no medications. The next questions focus on alcohol dependency and substance abuse. What is the patient's history with alcohol? When did he or she last drink? How much and what type of alcohol did he or she choose? A Breathalyzer could be used to test levels of alcohol intoxication during the visit. The clinician then asks about the use of street drugs, and a urine-screening test may be requested for verification. Addiction to gambling and resultant financial losses may be a precipitating factor. Sexual addictions or other behaviors may have precipitated this depression. Has the patient experienced situational losses recently, or is this anniversary time for a previous loss or traumatic event? Is the patient isolated? Does he or she ask for help? Will the patient sign a release so that the clinician may ask for help from family or friends on his or her behalf? Information gathering from other sources often proves beneficial. The patient may be neither a good historian nor self-observant of his or her own external mood and behavior. Others are often good observers, however, noticing small emotional and behavioral changes, which are helpful to the process of making an accurate assessment and diagnosis. The answers to these questions help with interim planning and are part of future psychotherapy work. Data from the assessment reveals that Mr. Dawson has been feeling intensely depressed without identifying any recent situations that precipitated this feeling. He denies history of hyperactivity, participating in risky behaviors, or agitation. He is not suicidal and is willing to take medications. He is willing and able to participate in a cognitive approach to therapy to gain a more hopeful outlook to his life. When the nurse completes the assessment, a diagnosis is made. The criteria for the diagnoses are listed as signs and symptoms in the DSM IV-TR and restated in many sources [2], [7], [8], [9]. Accurate diagnosis is essential, and by necessity it precedes the initiation of treatment. Mr. Dawson meets the criteria for the diagnosis of major depressive disorder. Persons with major depressive disorder suddenly experience overwhelming feelings of depression, which have been present for a few weeks and are preceded by a normal mood for at least the previous 2 months. Case history: patient with bipolar disorder Ms. Nicolai came through the doors to the mental health department and immediately was drawing the attention of others in the reception area. She was wearing a brightly colored outfit in purples and pinks, large earrings, and at least three rings on each hand. She requested to be seen as a walk-in patient and soon was telling quips to the secretaries and generating laughter for her humorous stories. As she walked into the interview room, she pulled papers out of her disheveled purse, which she identified as her “soon-to-be-published journal.” She was unable to stay seated and walked about the interview room, talking nonstop. She said she was “only coming in here to placate my family and show them nothing is wrong with me.” Risk of danger to self and others (suicide risk) Ms. Nicolai denies having any current intention of suicide or homocide. She denies having fleeting thoughts or past ideation of self-harm. She denies having a suicide plan for the future, and she denies having an accumulated means for self-harm. Mental status examination Ms. Nicolai is colorfully dressed, with much jewelry and makeup. Her speech is noticeably fast and continuous. Her tone and volume of voice are normal. It is difficult to redirect her or interrupt her to ask a question for history gathering. Her mood is jovial, and her affect is easily irritable. She denies seeing or hearing things that are not present and denies paranoid feelings. She is distracted by the sound of laughter in the hallway. She is oriented to time and place; she states the name of the clinic and the city and state in which she lives. She is thinking rapidly, yet answering questions correctly. She denies having previous episodes similar to this. She is reluctant to accept help and is irritated that her sister and brother-in-law insisted that she come into the clinic. She has little insight into her mental health problems. She is delusional about the possibility of successfully writing journal entries for publication, yet she is enthusiastic about the project. She is amenable to taking the Mood Disorder Questionnaire to verify the extent of affective and behavioral symptoms in her history [2], [4]. Biopsychosocial assessment The next step is to obtain a medical history, including current and past medical history and a list of current medications and over-the-counter medications. Ms. Nicolai reports that she is healthy and is not taking any prescription medications. She volunteers information about her use of over-the-counter multivitamins and minerals. Ms. Nicolai denies drinking alcohol except occasionally with dinner. She denies having an eating disorder. She denies using unprescribed drugs or drugs of abuse. She denies using mood-elevating substances. She denies an interest in gambling. She denies smoking cigarettes. Ms. Nicolai is willing to do routine blood tests, including a complete blood count, platelet count, liver function test, and urinalysis to test for drugs of abuse. All are normal, confirming her health, healthy liver, normal thyroid-stimulating hormone, normal thyroxine, and drug-free status [15]. She is willing to sign a release of information to allow a conversation with her sister. With the call on speakerphone, all the parties are informed that they could hear and be heard. The sister says that the patient's home was a jumbled mess with papers on all surfaces. She also reports that the patient has been calling several times during the day or night, leading the family to believe she was not sleeping well. The patient had never been like this before. She had never been diagnosed or treated for mood disorder in the past. No other family members had been treated for mood disorders, although a maternal aunt had always been “different.” The sister corroborates saying Ms. Nicolai had never indicated she was thinking of hurting herself and had never taken action to hurt herself in her past. Ms. Nicolai meets the criteria for a diagnosis of bipolar I disorder, manic episode. She is in a distinct period of abnormally and persistently optimistic, expansive, and irritable mood, which has lasted at least 1 week. The exact diagnostic criteria are found in the DSM IV-TR and other sources [8], [9], [16]. Treatment planning Treatment planning for the patient with a mood disorder stems from the nurse and health team making an accurate diagnosis. The patient with major depression may require pharmacologic and nonpharmacologic interventions, such as antidepressant medication and cognitive therapy. The patient with bipolar disorder requires a mood stabilizer and an antidepressant with depressed and mixed episodes. Regardless of the diagnosis, the nurse must collaborate with the patient and family in the treatment process and explore issues such as past and future treatment responses of the patient and family members and social, spiritual, and cultural values [36]. Pharmacologic management of depression Most theories and research concerning mood disorders indicate dysregulation of various neurotransmitters, such as serotonin and norepinephrine; genetic, psychosocial, and environmental factors; and cognitive-behavioral distortions. Data also show the efficacy of various antidepressants and mood stabilizers in the treatment of mood disorders. There are many antidepressants available. First-line antidepressants are listed in Table 1 [5], [17], [18], [19], [20]. | | |  | | Comments | Neurotransmitters | |
|---|
| Fluoxetine (Prozac) 10–60 mg | Generic available, less costly | 5-HT | |
| Citalopram (Celexa) 10–40 mg | | 5-HT | |
| Paroxetine (Paxil) 20–60 mg | | 5-HT | |
| Sertraline (Zoloft) 50–200 mg | | 5-HT | |
| Bupropion (Wellbutrin) 150–450 mg | Lowers seizure threshold | NE | |
| Venlafaxine (Effexor) 75–375 mg | Change in blood pressure | 5-HT and NE | | | | |
Advice in initiating medications is to start with a low dose and slowly increase the dosage. This approach allows the patient to experience the fewest side effects, while achieving the desired effects of the medications (“start low, go slow”). The clinician should involve the patient in decisions concerning medications, informing the patient about possible choices for medication, potential side effects, and benefits, before the patient is asked to agree to take it. The medication should be given an adequate amount of time at an adequate dose before deciding to discontinue it. It is likely a patient will never return to a medication he or she believed was a failure, which failed only because it was given too short a trial. A third caution involves the patient's possible use of popular herbal antidepressants, which do have a slight benefit for mildly depressed patients [16], [21] but should not be taken together with prescribed serotonin medications. The oversupply of the neurotransmitter serotonin could cause serotonin syndrome, a potentially serious complication [22], [23]. If a patient successfully recovers from depression, the clinician and patient might feel relief and joy at the bright outlook and enthusiasm now visible, which were not present months earlier when the patient first came into the clinic. On resolution of a severely depressed state, when the patient has recovered his or her enthusiasm and ability to think clearly, the clinician should be most cautious. The patient now has regained the ability to plan and enact a self-destructive intention; this is a risky time in the recovery process [5]. What are the patient's intentions? Does the patient affirm an interest in getting well, staying well, and working toward managing this illness? What if the good feelings keep right on escalating? What if the patient recovers from depression and continues to take the serotonin medications and becomes not only recovered from depression, not only seeing the bright side of life, but giddy, grandiose, creative, and irritable, who does not sleep, who wants to do new things, and who lacks the judgment to know those adventuresome new interests are dangerous and life-threatening? Some of the serotonin pharmacologic treatments for depression could precipitate a manic episode if the patient actually has a bipolar-type disorder [5], [24]. Psychopharmacologic management of bipolar disorder Table 2 lists the most commonly used medications for mood stabilization and the most common dosage ranges. They are listed in order of preference, with depakote, lithium, and olanzapine first-line choices. The necessary laboratory tests before initiating treatment include liver function tests, complete blood count, platelet count, blood urea nitrogen/creatinine, glucose, thyroid-stimulating hormone, thyroxine, urine screening for drugs of abuse, and pregnancy test in women of reproductive age. These tests are used to rule out possible mimic disorders, thyroid disorder, diabetes, use of illicit drugs, and pregnancy. The tests also define baseline status of the body before initiating treatment. The periodic (3–6 months) laboratory tests required for safe monitoring of medication levels, liver, kidneys, and thyroid while taking medications are listed in Table 2 [10], [15], [25], [26], [27], [28], [29]. | | | | | Level | | |
|---|
| Divalproex (Depakote) 250–2500 mg | (50–110 mcg/mL) | ECG, CBC, platelets, divalproex level, LFT | |
| Lithium 300–2400 mg | (0.6–1.2 mcg/mL) | Thyroid panel, CBC, lithium level, BUN/Creatinine, ECG | |
| Carbamazepine (Tegretol) 200–1400 mg | (4–10 mcg/mL) | LFT, CBC, platelets carbamazepine level | |
| Olanzapine 2.5–20 mg | | ECG, glucose | |
| Quetiapine 25–600 mg | | | |
| Lamotrigine 25–400 mg | | | |
| Risperidone 0.5–6 mg | | | |
| Topiramate 25–400 mg (divided doses) | | | |
| Omega-3 fatty acids 6–9000 mg | | | | | | |
The therapeutic interventions provided by the clinician include assessment of the patient's health, review of systems, initiation of laboratory tests, and an electrocardiogram before initiation of medications. When considering the choices of medications, the clinician may consult algorithms that assist in medication decision making from available evidenced-based treatment guidelines [11], [12], [13], [30], [31]. Health education It is within the scope of practice and standard of care for the advanced practice psychiatric mental health nurse to teach the newly diagnosed patient and significant others about all aspects of the management of the illness [7], [32], [37], [38], [39]. The procedure of taking a 12-hour trough test for the level of mood stabilizers in the blood is new to the recently diagnosed patient. Verbally telling the patient and providing written instructions are helpful teaching methods [7], [32]. In addition to managed psychopharmacologic interventions, patients and their families benefit from a strong collaborative relationship with the health care provider. Nurses are well respected and trusted for the therapeutic alliance they establish with their patients [6], [33]. There are many educational resources available for patients. Traditional self-help learning is available in books, brochures, and community support groups. If the patient has access to a computer, he or she can learn about symptoms, join support groups, and get ideas for management from the Internet. Clinicians also can use the Internet to find resources for patient teaching [37], [39]. Psychiatric mental health advanced practice nurses conduct group and individual therapies and incorporate the many resources of learning into the psychotherapeutic process [6], [7], [9], [32]. Teaching incorporates the ideas that mood disorders and mental health problems are illnesses similar to medical illnesses, all of which require adaptation and management. Health insurers are increasingly including benefits for mental health care with medical health care. Because of past ostracism, many patients do not know about the many mental health resources, options, and choices that exist for them when they become consumers. When a patient is experiencing the first episode of illness, the clinician needs to maintain an awareness of the bigger picture, while informing the patient and family of possible pitfalls. Many patients with mood disorder have a propensity to think all is well when the symptoms subside. They may drop out of therapy or stop the medications when the symptoms resolve, only to return to therapy when the next cycle begins. Mood disorders tend to have recurrences. Patients and their families need to understand the illness and learn how to communicate with the psychiatric community [26], [34]. The illness is lifelong and requires lifelong management. As time passes, the patient begins to understand the long-term prognosis, as the clinician gives anticipatory guidance for managing the mood disorder over the lifetime. With the clinician's willingness to listen to the patient's experience and interests and the clinician's intention of establishing a collaborative, therapeutic relationship, the patient learns to participate in the management of his or her treatment. The clinician's dedication to an ongoing program of self-awareness and skill building is a major contributor to maintaining a therapeutic alliance [4], [6], [26], [27]. Evaluation and outcomes The clinician can adjust and make evaluations of progress along the path to recovery with every contact. With a two-pronged approach to treatment, the effects of psychopharmacologic and psychotherapeutic interventions are evaluated. When treatment plans are being written, the patient, the clinician, and the family choose the behaviors, emotions, and thoughts that are targeted for change. Now it is time to evaluate the outcomes. Is the medication taken regularly as ordered? Is the medication helping? Is the patient involved and participating in therapy? If the patient is not recovering a positive attitude or showing desired behavior change, the medications can be adjusted. There are many options to adjusting medications, increasing the dosage, augmenting with another medication, changing drugs within the same class of drugs, or changing classes of medications altogether. Clinical judgment, collegial relationships with peers, continuing education, and reports from the patient and the family all support the psychiatric mental health advanced practice nurse to make changes for the patient's recovery. In the realm of therapy, the chosen theory and the proficiency of the clinician influence the ability of the patient to change his or her outlook and see the world with new perspectives. The personal presentation, mental health, and conduct of the clinician influence and contribute to the progress of the patient. The clinician should not be satisfied with a partial recovery from disordered moods. There are many options to consider. The mind, body, emotions, and spiritual health of all concerned influence the whole system. The clinician and patient should keep working toward full recovery [6], [26], [34], [35]. Summary Currently, mental health care is seeking parity with medical health care for the first time. The readers of this article are informed, globally aware, expert clinicians. They have access to the latest resources for diagnostics and clinical guidelines for managing mental health problems. They can incorporate their use of self as a therapeutic agent to teach, listen, and negotiate effectively with patients and their families for optimal outcomes in treating the whole person, mind, body, emotions, and spirit. Advanced practice psychiatric mental health nurses are able to move with the changes in mental health care [7], [33], [35]. Acknowledgements The author acknowledges Rebecca Costell for her assistance in manuscript editing and her unwavering support. References [1].
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