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Purpose:

Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.

Scenario:

Kel is a 42-year-old certified public accountant (CPA) who dreams each year that she will board a cruise ship the day after Tax Day and go somewhere, anywhere, except Portsmouth, Virginia. Each year the dream, like the ocean, ebbs and flows, but this year she is not even going to think about such a “ridiculous idea.” In fact, she does not even have the energy to dream; getting out of bed and preparing to go to work is simply too labor intensive.

Each evening Kel retires to bed with a lack of energy to complete her normal tasks such as readying her clothes for work and making a lunch. She lacks the energy to shop in the evening; consequently, she eats mostly crackers and canned soup. She is not hungry, and her scale reflects this. She has lost 15 pounds over the last 2 months. She does not attend to her makeup or clothes; she finds both too taxing. The clothes she selects are drab and not ironed. At work she makes no effort to talk with her co-workers and does not initiate new contacts with clients. The normal work of filing taxes and writing reports, which she used to enjoy, are overwhelming, and she feels too disorganized to complete them. Telephone calls and e-mail messages from friends are ignored. Attendance at work is spotty.

Sue, her sister, becomes alarmed with Kel’s unanswered telephone calls and e-mails. Worried, she decides to visit her sister at home. She finds the apartment unclean and in disarray. Kel is unkempt, disheveled, and looks sad. Her voice is monotone and flat. Kel tells Sue that she feels “sad and hopeless. Nothing is ever going to change. I am a bad person and I can’t even do my work right. Although I sleep for many hours, I am still tired all the time.” Sue is alarmed at the changes in her sister and arranges for Kel to visit a health care worker at the medical clinic.

Questions:

Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers.

Describe the presenting problems.

Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.

Formulate and prioritize a treatment plan.

Identify and discuss appropriate screening instruments for a patient who has suicidal ideation.

Depressive Disorders
Bipolar Related Disorders
Week 4
NUR 530 Psychopathology
St. Thomas University
Outline
• Understanding Mood and Bipolar Disorders
• Prevalence of Mood and Bipolar Disorders
• Causes of Mood and Bipolar Disorders
• Treatment of Mood and Bipolar Disorders
• Suicide
Prevalence of Mood Disorders
• Worldwide lifetime prevalence
• 16% for major depression
• 6% have experienced major depression in last year
• Sex differences
• Females are twice as likely to have major depression
• Bipolar disorders approximately equally affect males and
females
• Women more likely to experience rapid cycling
• Women more likely to be in depressive period
Prevalence of Mood Disorders
• Occurs less often in prepubertal children
• Rapid rise in adolescents
• Adults over 65 have about 50% less prevalence than general
population
• Bipolar same in childhood, adolescence, and adults
• Prevalence of depression seems to be similar across subcultures
Life Span
Developmental
Influences on
Mood Disorders
• Three-month-olds can show depressive
symptoms
• Young children typically don’t show classic
mania or bipolar symptoms
• Mood disorder may be misdiagnosed as ADHD
• Children are being diagnosed with bipolar at
increasingly high rates
• Depression in elderly between 14% and 42%
• Co-occurrence with anxiety disorders
• Less gender imbalance after 65 years of age
Mood Disorders:
Familial and
Genetic
Influences
• Twin studies
• Concordance rates are high in identical twins
• Two to three times more likely to
present with mood disorders than a
fraternal twin of a depressed cotwin
• Severe mood disorders have a strong genetic
contribution
• Heritability rates are higher for females
compared to males
• Twin studies
• Vulnerability for unipolar or bipolar disorder
• Appears to be inherited separately
• Some genetic factors are common for mood
and anxiety disorders
• Family studies
• Rate is high in relatives of probands
• Relatives of bipolar probands are more likely to
have unipolar depression
• Marital relations
• Marital dissatisfaction is strongly related to
depression
• This relation is particularly strong in males
Mood Disorders:
Social and
Cultural
Considerations
• Social support
• Extent of social support is related to
depression
• Lack of social support predicts late onset
depression
• Cultural differences exist
• Hopi say they are “heartbroken”
• Native American population have four times
the rate of depressive disorders as the
general population
• Women account for 7 out of 10 cases of major
depressive disorder
Gender
Differences in
Mood
Disorders
• Recall that women also have higher rates of
anxiety disorders
• Possible explanations for gender disparity
• Women socialized to have stronger
perception of uncontrollability
• Parenting style makes girls less independent
• Women more sensitive to relationship
disruptions (e.g., breakups, tension in
friendships)
• Women ruminate more than men
Major Depressive Disorder (MDD)
Epidemiology
• Incidence of major depression within any 12 month time period is 7%
• 18% will suffer from major depression some time during their lifetime
• There are marked differences in depression as a function of age, with 18-29 year old individuals having a 3-fold
higher prevalence compared to patients 60 years or older
Assessment
• History and Physical – assess using the following mnemonic
• SIGECAPS (Acronym) for Depression: Sleep disturbance, Interest impaired, Guilt, Energy impaired,
Concentration impaired, Appetite decreased (more common) or increased, Psychomotor impairment , Suicide
(thoughts, ideation, attempt)
• Lab test: complete blood count (CBC), chemistry profile, thyroid function tests, or B12, and folate levels, drug
screen
Major Depressive Disorder (MDD)
Treatment
• Psychotherapy
• Cognitive Behavioral Therapy
• Interpersonal Therapy
• Psychodynamic Therapy
• Medication Management
• Selective serotonin reuptake inhibitors (SSRIs).
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Atypical antidepressants.
• Tricyclic antidepressants.
• Monoamine oxidase inhibitors (MAOIs)
• Atypical antipsychotics
• Electroconvulsive Therapy
Major Depressive Disorder (MDD)
Diagnostic Criteria
At least 5 of the following symptoms have to have been present during the same 2-week period (and
at least 1 of the symptoms must be diminished interest/pleasure or depressed mood) [2] :
1.Depressed mood: For children and adolescents, this can also be an irritable mood
2.Diminished interest or loss of pleasure in almost all activities (anhedonia)
3.Significant weight change or appetite disturbance: For children, this can be failure to achieve
expected weight gain
4.Sleep disturbance (insomnia or hypersomnia)
5.Psychomotor agitation or retardation
6.Fatigue or loss of energy
7.Feelings of worthlessness
8.Diminished ability to think or concentrate; indecisiveness
9.Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide
attempt or specific plan for committing suicide
Persistent Depressive Disorder: An Overview
• At least 2 years of depressive symptoms
• Depressed mood most of the day on more than 50% of days
• No more than 2 months symptom free
• Symptoms can persist unchanged over long periods (≥20 years)
• May include periods of more severe major depressive symptoms
• Major depressive symptoms may be intermittent or last for the majority or
entirety of the time period
Persistent Depressive Disorder: An Overview
• Types of PDD
• Mild depressive symptoms without any major depressive episodes (“with
pure dysthymic syndrome”)
• Mild depressive symptoms with additional major depressive episodes
occurring intermittently (previously called “double depression”)
• Major depressive episode lasting 2+ years (“with persistent major
depressive episode”
Bipolar I Disorder: An Overview
• Overview and defining features
• Alternations between full manic episodes and major
depressive episodes
• Facts and statistics
• Average age of onset is 15 to 18 years
• Can begin in childhood
• Tends to be chronic
• Suicide is a common consequence
Mania
Epidemiology
• Mania is the diagnostic criteria for bipolar I disorder
• The lifetime prevalence of bipolar disorder is about 4 per cent.
• Men and women are equally likely to be affected
• The median age of onset of is around age 25. Men typically have an earlier age of onset than women.
• Two-thirds of bipolar patients have at least 1 close relative who was also diagnosed with the disease
or with unipolar depression.
Assessment
• Assess safety and level of functioning
• History and Physical – assess using the following mnemonic
• DIG FAST -Distractibility, Irresponsibility or Irritability, Grandiosity, Flight of ideas, increased Activity, decreased
Sleep and excessive Talkativeness.
• Extensive evaluation to rule out other differentials: complete blood count (CBC), complete metabolic panel
(CMP), thyroid panel, and a urine drug screen
• Brain imaging in the form of a CT or MRI
• (Dailey & Saadabadi, 2020)
Mania
Diagnostic Criteria
• A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally
and persistently goal-directed behavior or energy, lasting at least 1 week and present most of the day,
nearly every day (or any duration if hospitalization is necessary).
• B. During the period of mood disturbance and increased energy or activity, three (or more) of the
following symptoms have persisted (four if the mood is only irritable) are present to a significant degree
and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments)
Mania
Treatment
• The first-line pharmacological treatment for more severe manic or mixed episodes is
• Lithium + an antipsychotic or
• Valproate (Depakote) + an antipsychotic
• For less ill patients, monotherapy with lithium, valproate, or an antipsychotic such as
olanzapine may be sufficient
• Short-term adjunctive treatment with a benzodiazepine may also be helpful
• For mixed episodes, valproate may be preferred over lithium.
• Atypical antipsychotics are preferred over typical antipsychotics because of their more
benign side effect profile [I], with most of the evidence supporting the use of olanzapine
or risperidone.
• Alternatives include carbamazepine or oxcarbazepine in lieu of lithium or valproate
• Antidepressants should be tapered and discontinued if possible.
• If psychotherapy approaches are used, they should be combined with pharmacotherapy.
•
Shah, Grover & Rao, 2017)
Hypomania
Diagnostic Criteria
• A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day,
nearly every day.
• B. During the period of mood disturbance and increased energy or activity, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent
a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported
or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Substance, A., & Mental, H. S. A. (2016)
Hypomania
Epidemiology
• May be a long or recent history of depression or a mix of hypomania
combined with depression
• Can affect both adults and younger patients
• Commonly surfaces in the mid to late teens
• 5% to 15% of individuals experiencing hypomanic episodes will eventually
develop a manic episode.
Assessment
• Assess safety: suicidal or homicidal ideation
• Assess the level of functioning
• Complete History and Physical
• Lab: complete blood count (CBC), complete metabolic panel (CMP), thyroid
panel, B12 and a urine drug screen
• Brain imaging in the form of a CT or MRI
Hypomania
Treatment
• Monotherapy Pharmacotherapeutic options for hypomania are similar to those for mania.
• with mood stabilizers with or without adjunctive benzodiazepines can be used for the initial
treatment of hypomanic episodes.
• Pharmacotherapy with an antipsychotic drug, or combination therapy with 2 mood stabilizers or
mood stabilizers combined with antipsychotic drugs, is generally reserved for cases of poor response
to monotherapy.
Bipolar II Disorder: An Overview
• Overview and defining features
• Alternations between major depressive and hypomanic
episodes
• Facts and statistics
• Average age of onset is 19 to 22 years
• Can begin in childhood
• 10% to 25% of cases progress to full bipolar I disorder
• Tends to be chronic
Cyclothymic
Disorder: An
Overview
• Facts and statistics
• Average age of onset is 12 to 14 years
• More common among females
• Cyclothymia tends to be chronic and lifelong
• One third to one half develop full-blown
bipolar
Cyclothymic Disorder: An Overview
• Overview and defining features
• Chronic version of bipolar disorder
• Alternating between periods of mild depressive symptoms
and mild hypomanic symptoms
• Episodes do not meet criteria for full major depressive
episode, full hypomanic episode or full manic episode
• Hypomanic or depressive mood states may persist for long
periods
• Must last for at least 2 years (1 year for children and
adolescents)
• Eleventh leading cause of death in the United States
• Underreported; actual rate may be 2x to 3x higher
• Most common among white and native Americans
Suicide: Facts
and Statistics
• Particularly prevalent in young adults
• Third leading cause of death among teenagers
• Second leading cause of death in college students
• 12% of college students consider suicide in a given
year
• Gender differences
• Males complete more suicides than females
• Females attempt suicide more often than males
• Disparity is due to males using more lethal methods
• Exception: Suicide more common among women in
China
• May reflect cultural acceptability; suicide is
seen as an honorable solution to problems
Suicide: Epidemiology
Epidemiology
•
10th leading cause of death in the United States
•
the second leading cause of death (after accidents) for people aged 10 to 34
•
In 2019 in the United States over 47,000 people died by suicide and the rate of suicide has increased
every year since 2006
•
An estimated 1.3 million adults attempt suicide each year, according to the Centers for Disease Control
and Prevention (CDC)
•
More than one in five people who died by suicide had expressed their suicide intent
•
Men are more than three times more likely than women to take their lives. Firearms are the most
common method of suicide (used in about half of all suicides)
Assessment
•
Conduct a thorough psychiatric evaluation
•
Inquire bout suicidal thoughts, plans and behaviors
•
Establish a multiaxial diagnosis
•
Estimate a suicide risk
(APA, 2018); (Oquendo & Baca-Garcia, 2014)
The Nature of
Suicide: Risk
Factors
Risk factors include:
• Family history of attempted or completed
suicides
• Low serotonin levels
• Severe persistent mental illness
• Alcohol use and abuse
• Stressful life event, especially humiliation
• Past suicidal behavior
• Plan and access to lethal methods
Suicide: Diagnostic Criteria
Diagnostic Criteria
Determine risk factors
• Previous suicide attempt(s)
• A history of suicide in the family
• Substance misuse
• Mood disorders (depression, bipolar disorder)
• Access to lethal means (e.g., keeping firearms in the home)
• Losses and other events (for example, the breakup of a
relationship or a death, academic failures, legal difficulties,
financial difficulties, bullying)
• History of trauma or abuse
• Chronic physical illness, including chronic pain
• Exposure to the suicidal behavior of others
(Oquendo & Baca-Garcia, 2014)
Suicide
Treatment
• Establish and Maintain a Therapeutic Alliance
• Attend to the Patient’s Safety
• Determine a Treatment Setting
• Develop a Plan of Treatment
• Coordinate Care and Collaborate With Other Clinicians
• Promote Adherence to the Treatment Plan
• Provide Education to the Patient and Family
• Reassess Safety and Suicide Risk
• Monitor Psychiatric Status and Response to Treatment
• Obtain Consultation, if Indicated
References
• American Psychiatric Association (2010). PRACTICE GUIDELINE FOR THE Assessment and Treatment of
Patients With Suicidal Behaviors. Retrieved from
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf
• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5). Washington,DC: American Psychiatric Publishing ISBN: 978-0-89042-555-8
• American Psychiatric Association (2018). Suicide Prevention. Retrieved from
https://www.psychiatry.org/patients-families/suicide-prevention
• Dailey, M. W., & Saadabadi, A. (2020). Mania. StatPearls [Internet].
• Krishnan R (2016): Unipolar depression in adults: epidemiology, pathogenesis, and neurobiology.
In: UpToDate, Basow, DS (Ed), Waltham, MA. Cited 3/10/16.
• Oquendo, M. A., & Baca-Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM-5
classification system: advantages outweigh limitations. World psychiatry : official journal of the World
Psychiatric Association (WPA), 13(2), 128–130. https://doi.org/10.1002/wps.20116
• Shah, N., Grover, S., & Rao, G. P. (2017). Clinical practice guidelines for management of bipolar
disorder. Indian Journal of Psychiatry, 59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974
• Substance, A., & Mental, H. S. A. (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey
on Drug Use and Health.

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