AFFECTIVE DISORDERS

Depression, Nursing the Depressed Patient Mania, Nursing the Overactive Patient

INTRODUCTION

The Affective Disorders are those disorders where the MOOD [Affect] is the dominant feature of the illness. The mood may be either very Low with Unhappiness (Depression) or very raised with Happiness and Over activity (Mania).

All of are sometimes happy or sad. Affective states become disorders if they interfere with out daily lives, have no apparent cause, the response is not appropriate to the cause, or the reaction goes on for too long.

DEPRESSION

Depression is the commonest mental disorder. Studies in the United Kingdom and the USA (Ingram, 1981. Paykel & Rowan, 1979) have found that about I in 10 of the population will be affected by depression at some time in their life. The incidence of depression is higher in young women and decreases with age. The opposite pattern occurs with men.

Depression may be divided into :

1. REACTIVE DEPRESSION(Exogenous,Neurotic)

In Reactive Depression it is usually clear that the person is Reacting to a LOSS or a set of circumstances. Someone close to the patient may have died or become seriously ill, there may be a broken love affair, the husband may have taken another wife. Other causes may include unemployment or financial loss. In many of these cases the patient will have lost Self-Esteem and feel a failure.

In Reactive Depression the patient retains INSIGHT (they know that they are ill). Psychotic Symptoms such as Hallucinations and Delusions are absent. They do not have PSYCHO-MOTOR RETARDATION, though they complain of constant tiredness and be unable to Concentrate.

They will often find it Difficult To Go To Sleep, but when they do go to sleep they find it difficult to get up in the morning. They will often feel better in the morning and get worse as the day goes on.

2. ENDOGENOUS DEPRESSION(Psychotic)

In Endogenous Depression there is no Obvious cause for the depression. There is a very strong Genetic link to Endogenous Depression.

In some patients there is a pattern where the individual has severe Mood Swings, from Deep Depression a very Elated Mood; this is called MANIC DEPRESSIVE PSYCHOSIS or BI-POLAR AFFECTIVE DISORDER. Other individuals have a Mood Swing from Very Depressed to Normal and back to Very Depressed;

PSYCHO-MOTOR RETARDATION is the main characteristics of Endogenous Depression. Mental Function and Behavior are slowed down. The patient. looks sad and unhappy with shoulders hunched over.

PSYCHOTIC SYMPTOMS may include DELUSIONS of Guilt, Unworthiness, Poverty. Nihilistic Delusions may also be present. HALLUCINATIONS may be present, especially Auditory Hallucination, where voices may tell them that they are wicked and should kill themselves.

SLEEP PATTERNS may be disturbed. They can get off to sleep easily. but they wake up in the middle of the night and cannot get back to sleep. They tend to feel worse in the Morning and get better towards the Evening. They will often complain of Physical symptoms such as Constipation, Headaches and Muscle Pains.

PHYSICAL TREATMENT

Three Groups of Drugs used in the treatment of Depression are:

A. TRICYCLIC ANTIDEPRESSANTS

1. Amitriptyline (Tryptizol)
2. Imipramine (Tofranil);
3. Clomipramine (Anafranil)

Tricyclics take about 2-3 Weeks to have maximum effect. Patients need to be told this otherwise they may feel that the treatment is failing. It is important to remember that the patient may recover their energy and motivation before the mood begins to improve, so the Risk of Suicide is increased.

COMMON SIDE EFFECTS include Dry Mouth, Dizziness. Hypertension, Constipation, Retention of Urine and, rarely, Blood Dyscrasias.

B. MONOAMINE OXIDASE INIHBITORS (MAOIs):

1. Phenelzine (Nardil)
2. Tranylcypromine (pamate)

MAOIs are rarely used because of the serious side-effects. There may be a reaction between the Amino acid TYRAMINE and MAOIs. This reaction can cause a HYPERTENSIVE CRISIS leading to a Stroke or Death. A Card is always given to patients on MAOIs telling them what Foods to Avoid which include: Cheese, Alcohol, Meat Extracts (Bovril) Yeast Extracts (Marmite), Broad Beans.

C. LITHIUM :Lithium Carbonate (Priadel)

Lithium is a MOOD STABILIZER and is used in Bi-Polar and Uni-Polar Affective Disorder. Patients who are given Lithium on a long term basis have Fewer and Less Extreme Mood Swings. There is a very narrow band between the Therapeutic and Toxic Blood levels. During your clinical assignment Find Out what the Therapeutic Blood Level is and how often the blood levels are checked. Also find out what advice you would give to the patient on his diet.

Toxic Effects Include: Weight Loss, Diarrheoa, Tremors, Slurred Speech, Vomiting, Confusion, Restlessness, Fits, Coma.

NURSING CARE

A patient who is depressed Will Recover. It is important, therefore, to give them Hope and to Prevent them from Harming themselves.

These patients have a very low Self¬-Esteem and expect to Fail. Therefore we must be careful to praise them and reinforce everything they do which is successful. Any tasks given to them should be within their ability and complicated tasks avoided.

Even if they do not react to you, take time to sit with them and talk to them. Make a special effort to try and involve them in activities but do not try to force them to take part in group activities.

Depressed patients will be Anorexic. To help them eat it is better to give small Frequent Meals. At first the patient may prefer to eat on their own. Being with a lot of people, especially if they are noisy and happy, may make them more depressed.

They may need help with personal hygiene and should be encouraged to take physical exercise. Patients with Reactive Depression may want to talk about their problems, and this should be encouraged. If there are specific problems such as family arguments these need to be settled.

REMEMBER THE GREATEST RISK OF SUICIDE IS WHEN THE PATIENT IS GETTING BETTER

KEY POINTS:

I) In Affective Disorders the MOOD (Affect) is the dominant feature of the illness.

2) The mood may be either very Low. Depression of very raised, Mania. ¬

3) Reactive Depression is a Reaction to a LOSS or a set of circumstances

4) Endogenous Depression has no obvious cause. There is a very strong Genetic link to Endogenous Depression.

5) Endogenous Depression may be Bi-Polar or Uni-Polar.

6) In Reactive Depression the patie11t retains INSIGHT. They do not have PSYCHO¬MOTOR RETARDATION. They will often find it DifflCul1 to Go to Sleep. They will often feel better in the morning and get worse as the day goes on.

7) PSYCHO-MOTOR RETARDATION is the main characteristic of Endogenous Depression. PSYCHOTIC SYMPTOMS may include DELUSIONS and HALLUCINATIONS.

8) In Endogenous Depression they can get off to sleep easily, but they wake up UI the middle of the night and cannot get back to sleep. They tend to fell Worse in the Morning and get Better towards the Evening.

9) The Three Groups of Drugs used UI the treatment of Depression are Tricyclic Antidepressants, Monoamine Oxidase Inhibitor_ (MAOIs) and Lithium.

10) There may be a reaction between the Amino Acid TYRAMINE and MAOIs causing a HYPERTENSIVE CRISIS. A card is given to patie11ls on MAOIs telling them what? Foods to A void.

11) Lithium is a MOOD STABILIZER and is use in Bi-Polar and Uni-Polar Affective Disorder. There is a Very narrow band between the Therapeutic and Toxic Blood Level.

12) A patient who is depressed will Recover. It is very' important to Prevent them from Harming Themselves.

13) These palie1ltS have a very' low Self-Esteem. Therefore praise everything they do which is successful

14) Even if they do not react to you. take time to sit with them and talk to them.

15) Give Small Frequent Meals. At fist the patient may prefer to eat on their own.

16) They may need help with personal hygiene and should be encouraged to take physical exercise.

17) Patients with Reactive Depression may want to talk about their problems, and this should be encouraged.

18) THE GREATEST RISK OF SUICIDEI( WHEN THE Patient is getting better