MOOD AND MOOD DISORDERS

A. HISTORICAL PERSPECTIVE
Depression have been documented since the ancient times
Egyptian papyrus (1500 BC) contains a discourse on old age and says
“the heart grows heavy and remembers not yesterday”
King Saul = alternate moods of elation and depression
Emil Krapelin (1896) identified bipolar disorder as MANIC-DEPRESSIVE
PSYCHOSIS
Hippocrates (460-375? BC) knew the symptoms of depression well and
believed that it resulted from a surplus of black bile which is termed
melanchole in the Greek language
Treatment of mood disorders were not effective until the development of
the convulsion-producing drug pentylenetetrazol (Metrazol) by Meduna
followed by the introduction of ECT by Cerletti and Bini in 1938

B. GRIEF & LOSS

LOSS
Change in status of a significant other
Any change in individual’s situation that reduces the probability of
achieving implicit or explicit goals
An actual or potential situation in which a valued object, person, or other
aspect is inaccessible or changed so that it is no longer perceived as
valuable
Types:
1. sudden
2. gradual
3. predictable
4. unexpected
5. perceived
6. anticipatory

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 7. temporary
8. permanent
GRIEF
Normal, appropriate emotional response to an external and consciously
recognized loss
Time-limited and subsides gradually
Is all-consuming, having a physical, social, spiritual, and psychological
impact on an individual that may impair daily functioning
Feelings vary in intensity; does not necessarily follow a particular pattern,
and the time spent in the grieving process varies considerably, from
weeks to years
Mourning – individual’s outward expression of grief regarding the loss of a
love object or person
Bereavement – process of grief; feelings of sadness, insomnia, poor
appetite, deprivation or desolation
Anticipatory grief
refers to the reactions that occur when an individual family, significant
other, or friends are expecting a loss or death to occur; allows the
individual and others to get used to the reality of the loss or death and to
complete the unfinished business
Unresolved or Dysfunctional grief
could occur if the individual is unable to work through the grief process
after a reasonable time
usually an actual or perceived loss of someone or something of great
value to a person
include expressions of distress or denial of the loss, changes in eating and
sleeping habits, mood disturbances (anger, hostility, crying), and
alterations in activity levels including libido

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 idealizes the lost person or object, relives past experiences, loses the
ability to concentrate, and is unable to work purposefully because of
developmental regression
may exhibit symptoms of anxiety, depression, or psychosis

GRIEF
- disturbance in mood that is
normal, universal,
necessary in the life experience
of an individual
- reaction to the real loss of a
highly valued object that may be
tangible or intangible
- self-limiting and gradually
diminishes over a period of
about a year, except in the
elderly
GRIEF
- has different phases
DEPRESSION
- disturbance in mood that is a
and pathological elaboration of grief;
related to grief but not the same
- reaction to the actual,
threatened, or imagined loss of
a valued object, tangible or
intangible; an overwhelming
response to what the individual
considers a catastrophic loss
- not self-limiting, goes beyond
grief in duration and intensity;
prolonged and severe
DEPRESSION
- does not enter the phase of
restitution within a few weeks or
months; professional help is
often required

DIFFERENT STAGES OF GRIEF

STAUDACHER (2000) WESTBERG (2004) KUBLER-ROSS (1969)
Shock Shock Denial
Disorganization Expressing emotion Anger

3
 Reorganization Depression and Bargaining
loneliness Depression
Distress Acceptance
Panic
Guilt feelings
Anger and resentment
Resistance
Hope
Affirming reality

DIFFERENT STAGES OF GRIEF

BOWLBY HARVEY (1998) RODEBAUGH et al
(1999)
Numbness and denial of Shock, outcry, denial Reeling
loss Intrusion of thoughts Feeling
Emotional yearning for Confiding in others Dealing
the loved one Healing
Cognitive disorganization
and emotional despair
Reorganizing and
reintegrating sense of
self

KUBLER-ROSS
1. Denial
“No, it can’t be”, “It isn’t possible”, “Not me”
Displays disbelief in the prognosis of inevitable death
Stage serves as a temporary escape from reality

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 Subsides when the client realizes that someone will help him or her
to express feelings while accepting reality
2. Anger
“Why me?”, “Why now?”, “It’s not fair”
May appear difficult, demanding, and ungrateful during this time
3. Bargaining
“If I promise to take my medication, will I get better”, “If I get better,
I’ll never miss church ever again”
Dying client acknowledges his or her fate but is not quite ready to
die at this time
Bargaining to prolong one’s life
Cline is ready to take care of unfinished business or begins to
anticipate various losses, including death
4. Depression
Watching the depressed client mourn for future losses
Dying patient is about to lose not just one loved person but
everyone he has ever loved and everything that has been
meaningful to him
5. Acceptance
“I’m ready”
Client has achieved inner and outer peace to a personal victory
over fear
May want only one or two significant people to sit quietly by the
client’s side, touching and comforting him or her

RESPONSES AND SYMPTOMS OF THE GRIEVING CLIENT

COGNITIVE Disruption of assumptions and beliefs
Questioning and trying to make sense of the loss
Attempting to keep the lost one present
Believing in the afterlife as though the lost one is the

5
 guide
EMOTIONAL Anger, sadness, anxiety
Resentment
Guilt
Feeling numb
Vacillating emotions
Profound sorrow, loneliness
Intense desire to restore bond with lost one or object
Depression, apathy, despair during phase of
disorganization and despair
Sense of independence and confidence as phase of
reorganization evolves
SPIRITUAL Disillusioned and angry with God
Anguish of abandonment or perceived abandonment
Hopelessness, meaningless
BEHAVIORAL Functioning “automatically”
Tearful sobbing, uncontrollable crying
Great restlessness, searching behaviors
Irritability and hostility
Seeking and avoiding places and activities shared with
lost one
Keeping valuables of lost one while wanting to discard
them
Possibly abusing drugs or alcohol
Possible suicidal or homicidal gestures or attempts
Seeking activity and personal reflection during phases
or reorganization
PHYSIOLOGIC Headaches, insomnia
Impaired appetite, weight loss
Lack of energy

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 Palpitations, indigestion
Changes in immune and endocrine system

COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE

1. TODDLER
No specific concept of death and thinks only in the terms of the
living
Reacts more to pain and discomfort of illness and immobilization
Separation anxiety
Interventions:
a. Focus on parents
b. Assist parents to deal with their feelings
c. Encourage parents’ participation in child’s care
2. PRESCHOOLER
Death is a kind of SLEEPING; form of punishment
Life and death can change place with one another
If a pet dies, may request “funeral” and “burial”
Interventions:
a. Utilize play for expressing thoughts and feelings
b. Explain what is death that it is final and not sleep
c. Permit a choice of attending a funeral
3. SCHOOL AGE
Death is personified
Child fears mutilation and punishment
Anxiety is alleviated by nightmares and superstition
Death is perceived as a final process
Interventions:
a. Accepts regressive or protest behavior
b. Encourage verbalization of feelings
4. ADOLESCENT

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 Mature understanding of death
May have strong emotions about death, silent, withdrawn, angry
Worry about physical changes
Interventions:
a. Support maturational crisis
b. Encourage verbalization of feelings
c. Respect need for privacy and personal expression of
anger, sadness or fear
5. ADULT
Death is a disruption of lifestyle
Death is viewed on terms of its effect on significant others
6. OLDER ADULT
Emphasis is on religious beliefs for comfort. A time of reflection, rest and
peace

INTERVENTIONS FOR THE CLIENT WHO IS GRIEVING

1. Explore client’s perception and meaning of his or her loss
2. Allow adaptive denial
3. Encourage or assist the client to reach out for and accept support
4. Encourage client to review personal strengths and power
5. Encourage client to care for himself or herself
6. Use therapeutic communication
7. Establish rapport and maintain interpersonal skills
8. Provide an open accepting environment
9. Provide various diversional activities
10. Provide teaching about common symptoms of grief
11. Reinforce goal-directed activities
12. Bring together similar aggrieved persons, to encourage communication,
share experiences of the loss and to offer companionship, social and
emotional support

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C. MOOD DISORDERS
Previous referred to as affective disorders
Encompass a large group of disorders involving pathological and related
disorders
Can occur in any age
Two main categories:
1. Depressive disorders
2. Bipolar disorders
ETIOLOGY
A. Genetic Theory
Higher correlations of mood disorders between depressed
adoptees and biologic parents than adoptive parents
Twins – identical twin has mood disorder = other twin 70% of
having the disorder
Dominant gene may influence or predispose a person to react more
readily to experiences of loss or grief
B. Biochemical Theory
Norepinephrine and serotonin regulate mood, control drives such
as hunger, sex, and thirst – if at receptor sites can cause mood
elevation, if can lead to depression
Dopamine if depressed, if in mania
1. Neuroendocrine Regulation
cortisol levels
Normally cortisol peaks in the early morning, level off during
the day, and reach the lowest point in the evening
Also affected by thyroid gland
Decreased nocturnal secretion of melatonin; decreased
levels of prolactin, FSH and testosterone; sleep-induced
stimulation of growth hormone

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C. Biologic Theory
Biologic relation between depression and various medical
conditions
1. Neurodegenerative Diseases
Alzheimer’s disease, Parkinson’s disease, Multiple Sclerosis
Prognosis of the disease
Degenerative changes in the neural system
2. Immunotherapy
Cytokine therapy
Pancreatic tumors
Cancer drugs
3. Medical Conditions
Hypothalamic-pituitary-adrenal axis
4. Pain
Pain that is biologic in origin leads to psychomotor agitation,
agitation leads to irritability, irritability leads to aggression,
aggression leads to depression and more pain, often
resulting in disability
D. Psychodynamic Theory
Bereavement normally produces symptoms resembling a mood
disorder
Any loss or disappointment later in life reactivates a delayed grief
reaction that is accompanied by self criticism, guilt, and anger
turned inward
Mania = defense mechanism
E. Behavioral Theory : Learned Helplessness
Form of acquired or learned behavior
Little positive reinforcement = withdrawn, overwhelmed, passive,
giving up hope, shunning responsibility

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 Depressed mood could improve if client develops sense of control
and mastery of the environment
F. Cognitive Theory
Thoughts are maintained by reinforcement, thus contributing to a
mood disorder
G. Life Events and Environmental Theory

RISK FACTORS FOR MOOD DISORDERS

1. Prior episodes of depression
2. Family history of depressive disorders
3. Prior suicide attempts
4. Female
5. Age of onset younger than 40 years
6. Pospartum period
7. Medical comorbidity
8. Lack of social support
9. Stressful life events
10. Current alcohol or substance abuse
11. Presence of anxiety, eating disorder, OCD, somatization disorder,
personality disorder, grief, and adjustment reactions

DEPRESSIVE DISORDERS
1. Mild Depression
Affective symptoms of sadness
Less responsive to the environment and may complain of physical
discomfort
2. Moderate Depression (dysthymia)
Symptoms are less severe than those experienced in major
depressive disorders
No psychotic features

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 Verbalize feelings of guilt, inadequacy, and irritability
Lack if interest and productivity
Clinical symptoms usually persist for 2 years or more and may
occur continuously or intermittently with normal mood swings for a
few days or weeks
3. With Psychotic Features
Impairment of reality testing
4. Melancholic Type
Loss of interest in all activities
Depression is worse in he morning
Prior history of major depressive episodes having responded well to
somatic anti-depressant therapy
5. Seasonal Pattern (Seasonal Affective Disorder)
Has been (at least) 3 years pattern of onset of depressive disorder
beginning between the early part of October and end of November
and ending between February and mid April
Two subtypes:
a. Fall-onset SAD (increased sleep, appetite, carbohydrate
cravings; weight gain; interpersonal conflict; irritability;
heaviness in the extremities)
b. Spring-onset SAD (insomnia, weight loss, poor appetite)
6. Postpartum or Maternity Blues
Normal after birth
Labile mood and affect, crying spells, sadness, insomnia, anxiety
Begin approximately 1 day after delivery, usually peak in 3-7 days
and disappear with no medical treatment
7. Postpartum Depression
Meets all criteria for a major depressive disorder, with onset within
4 weeks of delivery
8. Postpartum Psychosis

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 Develops within 3 weeks of delivery
Fatigue, sadness, emotional lability, poor memory, and confusion
progressing to delusions, hallucinations, poor insight and judgment,
and loss of contact with reality

MAJOR DEPRESSIVE DISORDER

Single episode or recurrent loss of interest or pleasures in usual activities
and past time
Evidence of interference in social and occupational functioning for at least
2 weeks
A. SYMPTOMATOLOGY
AFFECT THOUGHT PHYSIOLOGIC VERBAL SOCIAL
CONTENT/PROCESS
Sadness Slow Weakness Limited Intense
Helplessness Difficult concentration Fatigue Content is focus on
Hopelessness Hallucination Irritability all about self
Gloomy Delusion Excessive life
Pessimistic eating/drinking regrets
Feeling of Anorexia
worthlessness Weight
gain/loss
Constipation
Urinary
retention
B. NURSING DIAGNOSES
1. Risk for violence, self-directed or directed at others
2. Impaired Verbal Communication
3. Decisional Conflict
4. Altered Role Performance
5. Hopelessness

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 6. Deficit in Diversional Activity
7. Fatigue
8. Self-care Deficit
9. Altered Thought Processes
10. Self-esteem Disturbance
11. Spiritual Distress
12. Anxiety
C. THERAPEUTIC NURSING MANAGEMENT
1. Safe Environment
2. Psychological therapy
3. Social Treatment
4. Psychopharmacologic and Somatic treatments
D. NURSING INTERVENTIONS
1. Priority for care is always the client’s safety
2. Use of behavioral contracts
3. Assess regularly for suicidal ideation or plan
4. Observe client for distorted, negative thinking
5. Assist client to learn and use problem-solving and stress
management skills
6. Avoid doing too much for the client, as this will only increase client’s
dependence and decrease self-esteem
7. Provide assessment and interventions related to appropriate
nutrition, fluids, sleep, exercise, and hygiene, and to provide health
education
8. Explore meaningful losses in the client’s life
9. Encourage daily exercise
10. Offer small, high-calorie, high-protein snacks and fluids throughout
the day
11. Stay with the client during meals
12. Weigh client weekly

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 E. CLIENT AND FAMILY EDUCATION
1. Discuss with the client and family the possible environmental or
situational causes, contributing factors, and triggers for serious
depression
2. Help client and family to identify the internal and external indicators
of major depressive disorder
3. Teach about:
a. Suicide prevention
b. Stress management and problem solving
c. Symptoms management
d. Medications
e. Family support,, understanding, coping
f. Social skills strengthening
g. Self-care assistance when needed
h. Grief resolution

BIPOLAR DISORDER
- formerly known as manic depression
- involves extreme mood swings from episodes of mania to episodes of
depression
- Bipolar I: characterized by one or more manic or mixed episodes in which
the individual experiences rapidly alternating moods accompanied by
symptoms of manic mood and a major depressive episode
- Bipolar II: characterized by recurrent major depressive episodes with
hypomanic episodes occurring with a particular severity, frequency, and
duration; has a presence or history of one or more major depressive
episodes alternating with at least one hypomanic episode
- Cyclothymic: identical to the symptoms of Bipolar II, except that they are
generally less severe; changes in mood are irregular, abrupt, sometimes
occurring within hours

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A. SYMPTOMATOLOGY (MANIA)
1. Mood that is abnormally and persistently elevated, expansive, or
irritable lasting at least 1 week
2. Inflated self-esteem or grandiosity
3. Insomnia
4. Increased talking or increased pressure to keep talking
5. Flight of ideas or subjective feeling of “racing thoughts”
6. Easily distractable
7. Increased goal-directed activity or psychomotor activity
8. Excessive overinvolvement in pleasurable activities usually
associated with a high potential for painful consequences
B. NURSING DIAGNOSES
1. High risk for violence, directed at self or others
2. Impaired Verbal Communication
3. Anxiety
4. Ineffective Individual Coping
5. Disturbance of Self-Esteem
6. Alteration in Thought Processes
7. Alteration in Sensory Perceptions
8. Self-Care Deficit
9. Sleep Pattern Disturbances
10. Alteration in Nutrition
C. THERAPEUTIC NURSING MANAGEMENT
1. Environment
2. Psychologial Treatment
3. Somatic and Psychopharmacologic Treatment
D. NURSING INTERVENTIONS
1. Remove hazardous objects from the environment
2. Assess client closely for fatigue
3. Use comfort measure to promote sleep

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 4. Provide frequent rest periods
5. Monitor the client’s sleep patterns
6. Provide a private room if possible
7. Administer a hypnotic or sedative as prescribed
8. Encourage verbalization of feelings
9. Use calm, slow interactions
10. Help the client focus on one topic during the conversation
11. Ignore or distract the client from grandiose thinking
12. Present reality to the client
13. Don’t argue with the client
14. Limit group activities and assess the client’s tolerance level
15. Provide high-calorie finger foods and fluids
16. Supervise the client’s choice of clothing
17. Reduce environmental stimuli
18. Set limits on inappropriate behaviors
19. Provide physical activities and outlets for tension
20. Avoid competitive games
21. Provide gross motor activities, such as walking
22. Provide structured activities or one-to-one activities with the nurse
23. Provide simple and direct explanations for routine procedures
E. CLIENT AND FAMILY EDUCATION
1. Discuss with the client and family the possible environmental or
situational causes, contributing factors, and triggers for a mood
disorder with recurrent episodes of depression and mania
2. Help the client and family to identify the internal and external
indicators of bipolar disorders
3. Teach about:
a. Self-monitoring
b. Medication therapy and importance of blood levels and
monitoring

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 c. Self-care, including adequate nutrition, hygiene and sleep
d. How to decrease stimuli and use other methods to control
symptoms and decrease anxiety
e. No harm to self or others
f. Use of self-help groups

D. SUICIDE
most common means are guns, explosives, hanging and poison
women make more attempts, but men actually commit suicide
A. HIGH-RISK GROUPS
1. History
2. Family history of suicide attempts
3. Adolescents
4. Elderly clients
5. Disabled or terminally ill clients
6. Clients with personality disorders
7. Clients with organic brain syndrome or dementia
8. Depressed or psychotic clients
9. Substance abusers
B. CLUES
1. Giving away personal, special, and prized possessions
2. Canceling social engagements
3. Making out or changing a will
4. Taking out or changing insurance policies
5. Positive or negative changes in behavior
6. Poor appetite
7. Sleeping difficulties
8. Feelings of hopelessness
9. Difficulty in concentrating
10. Loss of interest in activities

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 11. Client statements that indicate an intent to attempt suicide
12. Sudden calmness or improvement in a depressed client
13. Client questions about poisons, guns, or other lethal objects
C. ASSESSMENT
1. The plan
a. Does the client have a plan?
b. What is the plan, how lethal is the plan, and how likely is
death to occur?
c. Does the client have the means to carry out the plan?
2. Client history of attempts
a. Suicide attempts in the past and the outcomes
b. Was the client accidentally rescued?
c. Have the past attempts and methods been the same, or
have methods increased in lethality?
3. Psychosocial
a. Is the client alone or alienated from others?
b. Is hostility or depression present?
c. Do hallucinations exist?
d. Is substance abuse present?
e. Any recent losses or physical illness?
f. Any environmental or lifestyle changes?
D. IMPLEMENTATION
1. Initiate suicide precautions
2. Remove harmful objects
3. Do not leave the client alone
4. Provide one-to-one supervision at all times
5. Provide a nonjudgmental, caring attitude
6. Develop a contract that is written, dated, and signed and indicates
alternative behavior at times of suicidal thoughts

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 7. Encourage client to talk about feelings and to identify positive
aspects about self
8. Encourage active participation in own care
9. Keep the client active by assigning simple tasks
10. Check that visitors do not leave harmful objects in the client’s room
11. Identify support systems
12. Do not allow the client to leave the unit unless accompanied by
staff members
13. Continue to assess the client’s suicide potential

PSYCHOPHARMACOLOGIC TREATMENT
A. SELECTIVE SEROTONIN REUPTAKE IINHIBITORS (SSRI)
Citalopram (Celexa) Paroxetine Hydrochloride (Paxil)
Fluoxetine (Prozac) Sertraline Hydrochloride (Zoloft)
Fluvoxamine (Luvox) Venlaxafine (Effexor)
Description:
- inhibit serotonin reuptake
- produce an antidepressant response
Side Effects:
Nausea & diarrhea Photosensitivity Headache
Dry mouth Insomnia Dizziness
CNS stimulation Nervousness Weight loss
Implementation:
1. Monitor vital signs
2. Monitor weight
3. Initiate safety precautions, particularly if dizziness occurs
4. Instruct the client to take a single dose in the morning to prevent insomnia
5. Administer with a snack or meal to reduce the risk of dizziness and
lightheadedness

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 6. Monitor the suicidal client, especially during improved mood and increased
energy levels
7. Instruct the client on fluoxetine (Prozac) to take the medication early in the
day to avoid interference with sleep
8. For the client on long-term therapy, monitor liver and renal function tests
9. Monitor WBC and neutrophil counts and discontinue the medication as
prescribed, if levels are below normal
10. If priapism occurs, discontinue the medication immediately and notify the
physician
11. Instruct the client to change positions slowly to avoid hypotensive effect
12. Instruct the client to avoid alcohol
13. Instruct the client to report any visual changes to the client
14. Instruct the client to take drugs exactly as prescribed
15. Instruct client to avoid operating hazardous machinery, including an
automobile, if drowsiness occurs
B. TRICYCLIC ANTIDEPRESSANTS (TCA)
(Pamelor) Nortriptyline Bupropion (Wellbutrin)
(Elavil) Amitriptyline Amoxapine (Asendin)
(Norpramin) Desipramine Hydrocholoride Maprotiline (Ludiomil)
(Tofranil) Imipramine Mirtazapine (Remeron)
(Anafranil) Clomipramine Trazodone (Desyrel)
(Sinequan) Doxepin Hydrochloride Nefazodone (Serzone)
Description:
- block the reuptake of norepinephrine and serotonin at the presynaptic
neuron
- used to treat depression
- may reduce seizure threshold
- may reduce effectiveness of antihypertensive agents
- concurrent use with alcohol or antihistamines can cause CNS depression
- concurrent use with MAOIs may cause hypertensive crisis

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Side Effects:
Anticholinergic effects Dilated pupils and blurred Orthostatic hypotension
Dry mouth vision Sedation
GI motility and Photosensitivity Weight gain
constipation CV disturbances Anxiety, restlessness,
Difficulty voiding Tachycardia, dysrhythmias irritability
or libido, with
ejaculatory and erection
disturbances
Implementation:
1. Instruct client that medication may take several weeks to produce the
desired effect (client response may not occur until 2-4 weeks after the 1st
dose)
2. Monitor the suicidal client, especially during improved mood and increased
energy levels
3. Instruct client to change positions slowly to avoid hypotensive effect
4. Monitor pattern of daily bowel activity
5. Assess for urinary retention
6. For the client on long-term therapy, monitor liver and renal function tests
7. Administer with food or milk if GI distress occurs
8. Administer the entire daily dose at one time, preferably at bed time
9. Instruct the client to avoid alcohol and nonprescription medications, to
prevent adverse medication interactions
10. Instruct the client to avoid driving and other activities requiring alertness
11. When the medication is discontinued, it should be tapered gradually
12. Instruct the client to avoid exercise and high temperatures
C. MONOAMINE OXIDASE INHIBITOR (MAOI)
(Parnate) Tranylcypromine Sulfate
(Marplan) Isocarboxazid
(Nardil) Phenelzine Sulfate

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Description:
- inhibition of MAO enzymes thus metabolizes amines, norepinephrine, and
serotonin, and the concentrations of this amines
- used for depression in the client who has not responded to other
antidepressant therapies, including ECT
- concurrent use with amphetamines, antidepressants, dopamine,
epinephrine, guanethidine, levodopa, methyldopa, nasal decongestants,
norepinephrine, reserpine, tyramine-containing foods, or vasoconstrictors
= hypertensive crisis
- concurrent use with narcotic analgesics = hypertension, hypotension,
coma, seizures
Side Effects:
Orthostatic hypotension Dizziness Peripheral edema
Restlessness GI upset Anticholinergic effects
Insomnia Dry mouth CNS stimulation
Weakness, lethargy Weight gain Delay in ejaculations
Hypertensive Crisis:
Hypertension Fever and chills
Occipital headache Clammy skin
Neck stiffness and soreness Dilated pupils
Nausea and vomiting Palpitations, tachycardia, bradycardia
Sweating Constricting chest pain
- ANTIDOTE: Phentolamine (Regitine) 5-10 mg IVTT
Implementation:
1. Monitor blood pressure frequently for hypertension
2. Monitor for signs of hypertensive crisis
3. If palpitations or frequent headaches occur, discontinue the medication
and notify the physician
4. Administer with food if GI distress occurs

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 5. Instruct the client that the medication effect may be noted during the first
week of therapy, but maximum benefit may take up to 3 weeks
6. Instruct the client to report headache, neck stiffness, or neck soreness
immediately
7. Instruct client to change positions slowly to prevent orthostatic
hypotension
8. Instruct the client to avoid caffeine or OTC preparations
9. Monitor for compliance with medication administration
10. Instruct the client to carry a Medic-Alert card indicating that a MAOI
medication has been prescribed
11. Avoid administering the medication in the evening because insomnia may
result
12. MAOIs should be tapered and discontinued 7-14 days before surgery
13. When the medication is discontinued, it should be discontinued gradually
14. Instruct the client to avoid foods that require bacteria or molds fort heir
preparation or preservation or those that contain tyramine

FOODS TO AVOID
Cheese, especially aged, except Brewer’s yeast
cottage cheese Meat extracts and tenderizers
Sour cream Yogurt
Pickled herring Sausage, bologna, pepperoni, salami
Avocados Soy sauce
Bananas Raisins
Papaya Red wine, beer, sherry
Broad beans Beef or chicken liver
Figs Caffeine as coffee, tea, or chocolate
Overripe fruit
D. ANTIMANIC MEDICATIONS

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 Lithium Carbonate (Eskalith, Lithane, Lithobid)
Lithium Citrate (Cibalith-Si)
Description:
- affect cellular transport mechanism and alter both the presynaptic and
postsynaptic events affecting serotonin, thus enhancing serotonin
functioning
- use with diuretics, fluoxetine, methyldopa, or NSAIDS lithium
reabsorption by the kidney or inhibits lithium excretion = risk of lithium
toxicity
- acetazolamide, aminophylline, phenothiazines, or sodium bicarbonate =
renal excretion of lithium = ruedce drug effectiveness
- therapeutic drug level: 0.5 – 1.5 mEq/l
- maintenance level: 0.6 – 1.2 mEq/l
- lithium level = sodium intake, fluid and electrolyte loss associated with
severe sweating, dehydration, diarrhea, or diuretic therapy, illness, and
overdose
- serum lithium levels should be checked every 1 – 2 months or whenever
any behavioral change suggests an altered serum level
- blood samples to check serum lithium level should be drawn in the
morning 12 hours after last dose was taken
Side Effects:
Polyuria Weight gain Muscle weakness
Polydipsia Abdominal bloating Lethargy
Anorexia,nausea Soft stools or diarrhea Fatigue
Dry mouth Fine hand tremors Headache
Mild thirst Inability to concentrate Hair loss

Implementation:

25
 1. Monitor the suicidal client during improved mood and increased energy
levels
2. Administer the medication with food to minimize GI irritation
3. Instruct the client to maintain a fluid intake of 6-8 glasses per day
4. Instruct the client to avoid excessive amounts of coffee, tea, or cola, which
have a diuretic effect
5. Instruct the client to maintain an adequate salt intake
6. Do not administer diuretics while the client is taking lithium
7. Instruct the client to avoid alcohol
8. Instruct the client to avoid OTC medications
9. Instruct the client that he or she may take a missed dose within 2 hours of
the scheduled time; otherwise the client should skip the missed dose and
take the next dose at the scheduled time
10. Instruct the client not to adjust the dosage without consulting the
physician, because lithium should be tapered off and not discontinued
abruptly
11. Instruct the client in the signs and symptoms of toxicity
12. Instruct the client to notify the physician if polyuria, prolonged vomiting,
diarrhea, or fever occurs
13. Instruct the client that the therapeutic response to the medications will be
noted in 1-3 weeks
14. Monitor ECG, renal function tests, and thyroid tests
Lithium Toxicity
Description:
- occurs when ingested lithium cannot be detoxified and excreted by the
kidneys
- symptoms begin when serum lithium level is 1.5-2 mEq/l
Mild: Serum lithium level is 1.5 mEq/l
Apathy Diminished concentration Coarse hand tremors
Lethargy Mild ataxia Slight muscle weakness

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Moderate: Serum lithium level of 1.5-2.5 mEq/l
Nausea, vomiting Tinnitus
Severe diarrhea Blurred vision
Mild to moderate ataxia and incoordination Muscle twitching
Slurred speech Irregular tremor
Severe: Serum lithium level above 2.5 mEq/l
Nystagmus Oliguria or anuria
Muscle Fasciculations Impaired LOC
Deep tendon hyperreflexia Grand mal seizure or coma leading to
Visual or tactile hallucinations death
Implementation: (Lithium Toxicity)
1. Hold lithium and notify the physician
2. Monitor vital signs and LOC
3. Monitor cardiac status
4. Prepare to obtain lithium level; electrolyte, BUN, and creatinine counts;
CBC
5. Monitor for suicidal tendencies and institute suicide precautions

SOMATIC TREATMENT
ELECTROCONVULSIVE TTHERAPY (ECT)
Description:
- consists of inducing a grand mal (tonic-clonic) seizure by passing an
electric current through electrodes that are attached to the temples
- usual course is 6-12 treatments given two to three times per week
- maintenance ECT once a month may help to decrease the relapse rate for
the client with recurrent depression
- not necessarily effective in clients with dysrhythmic depression or those
with depression and personality disorders, those with drug dependence,
or those with depression secondary to situational or social difficulties

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 - at-risk clients include those with recent MI, CVA or cerebrovascular
malformation, or clients with intracranial mass lesion
Types:
1. Unmodified
2. Modified
Uses:
1. Clients with major depressive and bipolar disorders
2. Clients who have depression with marked psychomotor retardation and
stupor
3. Manic clients who are resistant to lithium and antipsychotic medications
4. Clients with schizophrenia, those with schizoaffective syndromes, and
psychotic clients
Indications for Use:
1. When antidepressants have no effect
2. When there is a need for a rapid definitive response
3. The client is in extreme agitation or stupor
4. The risks of other treatments outweigh the risks of ECT
5. Client has a history of poor medication response, a history of good ECT
response, or both
6. Client prefers it
Side Effects:
Memory loss Headache Hypertension
Difficulty learning new Weight gain Occasional cardiac
information Disorientation, confusion arrhythmias
Preprocedure:
1. Explain the procedure to the client
2. Encourage the client to discuss feelings, including myths regarding ECT
3. Teach the client and family what to expect
4. Informed consent must be obtained when voluntary clients are being
treated

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 5. For involuntary clients, when informed consent cannot be obtained,
permission may be obtained from the next of kin
6. NPO after midnight or at least 4 hours prior to treatment
7. Baseline V/S are recorded
8. The client is requested to void
9. Hairpins, contact lenses and dentures are removed
10. Administer pre-op meds if prescribed; Glycopyrolate (Robinul) or Atropine
sulfate
During the Procedure:
1. Attach client to cardiac monitor
2. An IV line is inserted, and EEG and ECG electrodes are attached
3. 100% oxygen by mask via positive pressure is administered throughout
the procedure
4. An airway or bite block is placed to prevent biting of the tongue
5. Electrical stimulus is administered, and the seizure should last 30-60
seconds
Postprocedure:
1. Client is transported to a recovery room with the cardiac monitor in place,
where oxygen, suction, and other emergency equipment is available
2. Once the client is awake, talk to the client and monitor V/S
3. Provide frequent orientation and reassurance
4. Client returns to the nursing unit when a 90% oxygen saturation level is
maintained, V/S are stable, and mental status satisfactory
5. Assess the gag reflex prior to giving the client fluids, food, or medication

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