Module 8: Stressors Affecting Mood (Depression and Bipolar Disorder)

Introduction

Mood disorders like Major Depressive Disorder (MDD) and Bipolar Disorder are among the leading causes of disability worldwide. In 2008, MDD was the third leading cause of disease burden globally, and it is projected to rank first by 2030【8†L94-L102】. These illnesses profoundly impact a person’s emotional state, energy, functioning, and quality of life. This module provides an in-depth exploration of depression and bipolar disorders – their definitions, causes, neurobiology, clinical presentation, and management – with a​annals-general-psychiatry.biomedcentral.comannals-general-psychiatry.biomedcentral.comle in assessment, care planning, and patient education. We will also examine evidence-based tools for assessment, special considerations (cultural, developmental, and gender-related), and present case studies with nursing care plans to illustrate practical application.

Major Depressive Disorder (MDD)

Overview: Major Depressive Disorder is a common and serious mood disorder characterized by persistent low mood and loss of interest in activities (anhedonia), along with a range of emotional and physical symptoms【21†L144-L152】【21†L155-L163】. These symptoms represent a change from previous functioning and cause significant distress or impairment. MDD has an estimated lifetime prevalence around 12% (affecting nearly twice as many women as men)【13†L188-L196】【13†L190-L198】. It can occur at any age but often begins in young adulthood. Depression is more than normal sadness – it is a clinical syndrome that requires careful assessment and treatment.

Etiology and Risk Factors of MDD

MDD arises from a complex interplay of biological, genetic, psychosocial, and environmental factors【11†L151-L159】. No single cause exists, but several contributing factors are recognized:

DSM-5-TR Diagnostic Criteria for MDD

According to the DSM-5-TR, a major depressive episode is defined by at least 5 of the following 9 symptoms present most of the day, nearly every day, for a minimum of 2 weeks (and representing a change from prior functioning). One of the symptoms must be either depressed mood or loss of interest/pleasure (anhedonia)【9†L1-L4】:

These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The episode is not attributable to physiological effects of a substance or another medical condition【23†L829-L838】【23†L833-L839】. Importantly, there must be no history of a manic or hypomanic episode – if such history is present, the diagnosis would shift to bipolar disorder【9†L1-L4】.

Persistent Depressive Disorder (PDD): Also known as dysthymia, this is a related disorder characterized by a chronically depressed mood (often more days than not) for at least 2 years, but with symptoms that are fewer or less severe than major depression【9†L7-L12】. A person with PDD may have low-grade depression that persists over a long period, sometimes punctuated by episodes of major depre​cssrs.columbia.educssrs.columbia.edun”). PDD is mentioned here for completeness, though the primary focus of this module is on MDD and bipolar spectrum disorders.

Differential Diagnosis of Depression

A careful evaluation is required to distinguish MDD from other conditions that can mimic depression:

In practice, nurses must maintain a broad differential and assess for medical contributions or other dis​ncbi.nlm.nih.govncbi.nlm.nih.govesents with depressive symptoms【23†L837-L845】【23†L847-L855】. This ensures accurate diagnosis and appropriate treatment.

Pathophysiology and Neurobiology of Depression

Depression involves widespread changes in brain chemistry, circuitry, and even immune and endocrine function. Key aspects of its pathophysiology include:

Understanding these biological underpinnings helps in explaining to patients why medications or other treatments are needed (e.g., “to correct chemical imbalances and support your brain health”) and combats the stigma that depression is a “personal weakness.” It also underscores that effective treatment often requires a combination of pharmacological and therapeutic approaches to address both the neurobiology and psychosocial aspects of depression.

Bipolar Disorders

Overview: Bipolar disorder (previously called manic-depressive illness) is a chronic psychiatric illness characterized by mood swings between two poles: depressive lows and manic or hypomanic highs【15†L94-L100】【15†L96-L100】. These mood episodes are episodic, typically lasting weeks to months, with intervening periods of euthymia (normal mood). Bipolar disorder is a major cause of disability and is among the top 10 causes of lost years of healthy life globally【15†L92-L100】. The condition usually begins in late adolescence or early adulthood – over 70% of cases manifest by age 25【17†L191-L199】. Unlike depression, males and females are affected in roughly equal numbers overall【17†L193-L200】, though there are some gender differences in presentation (notably, women tend to experience more depressive and rapid-cycling episodes)【5†L199-L207】. The bipolar spectrum includes Bipolar I, Bipolar II, and Cyclothymic Disorder, as well as some subthreshold conditions. It is often misdiagnosed, especially early on, because patients might seek help only for depression and not recognize their past manic symptoms as illness. On average, it can take 6–10 years from first mood episode to arrive at the correct bipolar diagnosis【18†L231-L239】.

Bipolar disorders are episodic but recurrent conditions. Without ongoing treatment, most individuals will have multiple episodes over their lifetime – the five-year relapse​ncbi.nlm.nih.govncbi.nlm.nih.gov】【24†L25-L33】. Effective management therefore involves long-term strategies to reduce frequency and severity of episodes. Importantly, bipolar disorder carries a high risk of suicide; about 25–60% of bipolar patients will attempt suicide at least once, and suicide completion rates are higher than in MDD, particularly during mixed episodes or depressive phases. Thus, early recognition and intervention are critical.

Types of Bipolar Disorder (DSM-5-TR Definitions)

Bipolar disorders are classified based on the presence and duration of manic or hypomanic episodes and the presence of depressive episodes【19†L274-L283】【19†L279-L287】:

Mania causes severe impairment in social or occupational functioning, often necessitates hospitalization to prevent harm, or includes psychotic features (delusions or hallucinations)【20†L359-L364】【20†L312-L320】. By definition, if psychosis is present, the episode is manic (not hypomanic)【20†L312-L320】. In Bipolar I, a depressive episode is common but not required for diagnosis as long as mania has occurred【5†L149-L158】. Most Bipolar I patients do experience major depression at some point (depressive episodes typically last ≥2 weeks)【5†L149-L158】, but the manic episode is the hallmark. Untreated mania can last weeks to months and often has a more abrupt onset than depression.

In addition to type, episodes can have specifiers describing their features. For example, episodes can be labeled “with mixed features” if depressive and manic symptoms occur together (e.g. a manic episode with some depressive symptoms)【19†L316-L321】【20†L316-L324】, “with rapid cycling” if ≥4 episodes occur in 12 months【19†L307-L314】, “with psychotic features”, “with catatonia”, “with anxious distress”, “with seasonal pattern”, or “with peripartum onset” (if onset is around childbirth)【19†L299-L307】. These specifiers help guide treatment and prognosis. For instance, rapid cycling and mixed features often indicate a more difficult course and may influence medication choices (e.g., avoid antidepressants which can worsen rapid cycling【26†L684-L692】【26†L686-L694】).

Mania vs. Hypomania – A Closer Look

Both mania and hypomania involve elevated or irritable mood and increased energy, but differ in severity and duration【60†L297-L305】:

In summary: Mania is hypomania on overdrive – more intense, longer, and dangerous. Mania requires clinical intervention due to safety risks, whereas hypomania might not, though it still needs medical evaluation because it can progress or alternate with depression (signifying Bipolar II). Table 1 below summarizes key differences:

(Both mania and hypomania are most commonly seen in bipolar disorders. They can occasionally be caused by medical conditions (e.g., hyperthyroidism) or substances (e.g., stimulant drugs), in which case the diagnosis would be mania/hypomania due to another cause rather than bipolar.)

Etiology and Risk Factors of Bipolar Disorder

Bipolar disorder has a strong genetic component and complex pathophysiology:

In summary, bipolar disorder is thought to result from an inherited vulnerability in brain systems that regulate mood, arousal, and circadian rhythms, combined with environmental stressors that precipitate episodes【17†L155-L163】【17†L157-L165】. The disease’s episodic nature suggests that aafp.orgaafp.orgn normally at baseline, but certain triggers cause the system to go out of balance – producing mania or depression – before eventually resetting. This understanding guides both medicatio​aafp.orgaafp.orgze the biological rhythms and neurotransmitters) and psychotherapy (to manage stress and maintain routines).

Nursing Assessment for Mood Disorders

Assessment is the first step of the nursing process and is critical in mood disorders to establish safety and identify needs. Key areas for a nurse to assess in patients with depression or bipolar disorder include:

(Use of these tools should complement, not replace, a thorough clinical assessment. Positive screens or concerning scores should prompt immediate safety measures and referral to mental health professionals.)

After gathering assessment data, the nurse synthesizes information to identify priority nursing problems and to formulate nursing diagnoses as part of the care plan.

Nursing Diagnoses in Mood Disorders

Nursing diagnoses for patients with depression or bipolar disorder should be individualized, but commonly observed problems include:

For Major Depression:

For Mania/Hypomania (Bipolar):

Many of the above nursing diagnoses map to the DSM symptoms (for example, “fatigue” and “sleep disturbance” in depression, or “impaired social interaction” in mania). Safety-related diagnoses (suicide or injury risk) take highest priority. It’s important to set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) for each nursing diagnosis. For instance, for Risk for Injury in mania, a goal might be: “Patient will remain free from injury throughout hospitalization, as evidenced by no falls or self-harm, with assistance of envir​cssrs.columbia.educssrs.columbia.edu and supervision.” For Hopelessness in depression: “Patient will verbalize at least two hopeful statements about the future after 1 week of therapy and nursing interventions.” These goals guide the selection of interventions.

Next, we discuss therapeutic interventions in detail, divided by those addressing depression and those addressing mania, given the differing needs.

Nursing Interventions and Care Planning

A combination of pharmacologic and non-pharmacologic interventions is used to treat mood disorders. Nurses play a key role in administering and monitoring treatments, providing education, and using therapeutic communication to help patients cope. Ensuring safety is the founda​nurseslabs.comnurseslabs.comlarly in acute phases. Below we outline interventions for depression and mania, including rationales:

Nursing Interventions for Depression

For a patient with MDD, the nursing care focuses on providing a safe environment, promoting self-care and coping, and assisting with symptom relief. Key interventions include:

By combining these interventions, nurses address both the psychological and physical needs of depressed patients. The overall goals are to keep the patient safe, start alleviating symptoms, help them resume normal daily functions, and instill hope for recovery. Improvement is often gradual – nurses should celebrate small gains (like eating a full meal or engaging in conversation) to encourage the patient.

#​my.clevelandclinic.orgmy.clevelandclinic.orgor Mania When caring for a patient in an acute manic episode (as seen in Bipolar I, or a hypomanic patient in Bipolar II if significantly symptomatic), the priorities are to prevent harm, reduce stimuli, and aid the patient in regaining control over behavior. Manic patients can be exuberant and intrusive, but also can become angry or psychotic, so a structured, calm approach is needed. Key nursing interventions include:

The goals of nursing interventions in mania are to quickly decrease the patient’s hyperactivity, ensure safety, and promote stabilization of mood. As the acute phase passes (often with medication), the patient may become exhausted and possibly depressed. The nurse should then help ease the transition to a more normal level of activity and address any shame or embarrassment the patient might feel about their manic behaviors (when insight returns, patients can feel bad about what they did while ill). Throughout, maintaining a respectful and dignified approach is key – even when setting limits – as these patients are still individuals deserving empathy, not just “disruptions.” In fact, frequent staff meetings are often held when managing manic patients to ensure consistency and to support staff, because these patients can be very taxing (interrupting, testing limits, etc.). Consistency and compassion are the therapeutic cornerstones in managing mania.

Pharmacologic Treatments: Psychopharmacology in Mood Disorders

Medications are a mainstay of treatment for depressive and bipolar disorders. They help correct underlying neurochemical imbalances and stabilize mood. Below is a summary of key medication classes, their actions, and nursing considerations:

Antidepressants (for Depression): Antidepressants target neurotransmitters in the brain to improve depressive symptoms. The major classes include:

Mood Stabilizers (for Bipolar Disorder): Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They include lithium, anticonvulsants, and some atypical antipsychotics used as mood stabilizers.

Patient Education and Medication Adherence: Nurses should educate patients and families that bipolar disorder usually requires lifelong medication even when feeling well, to prevent relapse【24†L25-L33】【24†L27-L31】. This can be challenging because once mood is stable, patients might be tempted to stop meds (especially in bipolar, where they miss the highs or dislike side effects). Emphasize the importance of maintaining a mood chart perhaps – tracking mood, meds, sleep can help identify early warning signs of relapse. Provide strategies to remember meds (daily pill box, phone reminders). If side effects are a reason for nonadherence, encourage the patient to discuss with prescriber – oftentimes regimens can be adjusted (for example, switching to a weight-neutral med, or adding a medication to manage a side effect like propranolol for lithium tremor). The nurse’s nonjudgmental inquiry into why someone stopped a med can reveal problems to solve (e.g., “Lithium made me feel dull” – perhaps dose was high, or they valued their creativity – so integrate psychotherapy to help them channel creativity without mania, etc.).

Non-Pharmacologic Treatments

In addition to medication, a comprehensive treatment plan for mood disorders includes psychotherapy and other somatic therapies. Nurses should be aware of these modalities to reinforce their importance and to assist in referrals or implementation.

Nurses should encourage participation in therapy and reinforce therapy learnings on the unit. For instance, if a depressed patient learned in CBT to counteract “all-or-nothing” thinking, the nurse can prompt them to use that skill when they express a black-and-white thought. In bipolar, if interpersonal issues are a trigger, the nurse can help patient rehearse asking an employer for accommodations or a family member for support, aligning with therapy goals.

In summary, optimal treatment often combines medication + psychotherapy. For example, medication might treat the neurochemical aspect while therapy treats the psychological contributors and teaches coping skills. Somatic therapies like ECT or TMS are there for more severe or refractory cases. Nurses ensure all these modalities work in concert: helping with scheduling therapy appointments, reinforcing therapist’s recommendations on the unit, monitoring and managing medication, and encouraging healthy lifestyle changes.

Cultural, Developmental, and Gender Considerations

Cultural Considerations: Culture deeply influences how individuals experience and express mood disorders, as well as how they seek help. Nurses must practice cultural sensitivity and awareness in assessment and care:

Overall, the nurse’s approach is to be curious and respectful: ask how the patient conceptualizes their illness, what it means to them, and what kind of help they trust. Cultural competence means not only awareness of differences but adapting care to fit the patient’s cultural context. For example, a nurse might facilitate involvement of the patient’s family elder in the treatment discussions if that is culturally appropriate and if the patient consents, since that could improve acceptance of care.

Developmental Considerations:

Adolescent Bipolar Disorder: This can be challenging to diagnose because teens normally have mood swings and irritability. Bipolar in teens often presents initially as severe depression or with mixed features (irritability, aggression). Some adolescents have frequent short-duration mood elevations – these may be classified as Bipolar (with rapid cycling) or as other specified bipolar (if not meeting full criteria). There is also Disruptive Mood Dysregulation Disorder (DMDD) – a diagnosis created to capture chronic severe irritability and temper outbursts in children, so as not to over-diagnose bipolar in every angry child【45†L113-L121】【45†L115-L123】. DMDD is characterized by non-episodic irritability (whereas bipolar is episodic). A teen in a manic state might be misidentified as having behavior problems, ADHD, or substance issues. Nurses dealing with adolescents should assess risk-taking behaviors, home environment stability, and school performance changes. Treatment of bipolar in adolescents often mirrors adults but doses are adjusted; family psychoeducation is particularly important to ensure med adherence and reduce stigma among peers. The developing brain also is more sensitive – so clinicians try to use the lowest effective med doses. Also, issues like birth control and pregnancy need addressing in teen girls on meds like valproate (which is very teratogenic – should be avoided in adolescent girls if possible for that reason, or ensure proper contraception and informed consent).

School context: Nurses (especially school nurses) might need to develop academic accommodations. Depressed students might qualify for a 504 plan or IEP for temporary supports (like reduced homework load during treatment, permission to see a counselor during school, etc.). Similarly, a teen recovering from mania might need tutoring to catch up.

Treatment differences: Older adults may be more sensitive to medication side effects (slower metabolism, more likely to be on multiple meds). Doses often start lower (“start low, go slow”), especially with TCAs or antipsychotics, due to fall risk and anticholinergic effects. SSRIs are generally first-line for geriatric depression (avoiding paroxetine in the elderly because of its anticholinergic load). ECT is actually very useful and fairly safe in the elderly for severe depression, often tolerated even better than multiple meds. Cognitive impairment from ECT in the elderly can be an issue, but severe depression itself greatly impairs cognition and quality of life, so the risk-benefit often favors ECT if meds fail.

Many older adults grew up in a time when mental illness was taboo, so they might resist labels. Framing depression as “this is common with the stresses of aging or after your heart surgery, and there are treatments that can improve your overall health” can help. Engaging them in reminiscence therapy (discussing past positive memories) or social activities at senior centers can combat isolation. Watch for elder abuse as a contributor to depression as well.

Gender Considerations: Gender can influence the prevalence, presentation, and management of mood disorders:

In any patient, understanding how their cultural background and gender role expectations impact their view of illness can guide a tailored care plan. For example, a middle-aged man who sees depression as “unmanly” might respond well if the nurse frames treatment as a way to “get back to feeling productive at work” (aligning with his value of providing), whereas a new mother with PPD might need reassurance that accepting help is okay and does not make her a bad mother. The nurse’s cultural and gender awareness ultimately fosters a therapeutic environment where the patient feels seen as an individual, not just a diagnosis.

Nursing Case Studies with Care Plans

Below are multiple case scenarios illustrating how to apply the above concepts in nursing practice. Each case includes a brief patient scenario followed by nursing diagnoses, goals, and example interventions with rationales.

Case Study 1: Major Depressive Disorder with Suicidal Ideation

Scenario: A 30-year-old female patient, A.B., is admitted to the behavioral health unit for severe depression. She has a 2-month history of worsening mood following a divorce. On admission, she presents with a flat affect, speaks quietly of feeling “hopeless” and “like a burden.” She has lost 15 pounds in 2 months, reports insomnia (initial and middle-of-the-night awakening), and expresses passive suicidal ideation, saying, “I sometimes wish I wouldn’t wake up.” No specific plan is stated, but she admits to thinking about her pain ending. She has no history of mania. A.B. has a young child whom her sister is caring for during her hospitalization. This is her first psychiatric admission.

Nursing Assessment Highlights: Patient endorses depressed mood, anhedonia (no interest in anything, “I don’t even enjoy playing with my child anymore”), significant weight loss and appetite loss, insomnia, fatigue, feelings of worthlessness, and passive death wish. Denies substance use. Physical exam: poor eye contact, slowed movements, appears unkempt. PHQ-9 score on admission was 22 (severe depression). No manic or psychotic symptoms noted. Columbia Suicide Scale administered: she answers “Yes” to wishing she were dead, “Yes” to thoughts of killing herself, but “No” to having a specific plan or recent intent【31†L39-L47】【31†L45-L53】. This indicates suicide risk is present and needs continuous monitoring, even though she hasn’t attempted.

Nursing Diagnoses:

Goals (Outcomes):

  1. Safety Goal: A.B. will remain safe and free from self-harm throughout hospitalization. (Short-term goal: She will inform staff promptly if she has any urge to harm herself.)

  2. A.B. will report a measurable improvement in hopefulness, as evidenced by rating her hope as higher on a subjective scale (e.g., from 2/10 to 5/10) or by expressing future-oriented statements (e.g., looking forward to an event) within 1 week of treatment.

  3. A.B. will consume at least 50% of all meals and regain 1-2 pounds by the end of week 2 of hospitalization. (Short term: each day she will eat small frequent meals or high-calorie snacks totaling >1500 calories.)

  4. A.B. will achieve a consistent sleep pattern of ~6-7 hours per night within one week (with aid of medication or sleep hygiene measures), improving her energy level. (This supports other goals but isn’t listed as a primary goal here.)

Interventions and Rationale:

Evaluation: After 1 week, A.B. no longer expresses active suicidal ideation, though she still has depressive thoughts. She has been complying with sertraline and reports fewer early-morning awakenings in the last two nights (with the help of trazodone). She gained 1 kg and is eating ~75% of meals. She attended three group therapy sessions, and while initially silent, she shared a little by the third session. She tells the nurse, “I do feel maybe a tiny bit less heavy inside than when I came in.” These are signs of progress. The nurse would continue to monitor for increasing hope and reduction in symptoms. By discharge, a successful outcome would be A.B. denying thoughts of self-harm, verbalizing a plan for ongoing therapy, and demonstrating use of at least one coping strategy (e.g., “When I start feeling overwhelmed, I will call my sister or use the deep breathing I learned”). Her care plan would then transition to the outpatient setting with close follow-up.

Case Study 2: Acute Mania in Bipolar I Disorder

Scenario: J.S. is a 25-year-old male with known Bipolar I disorder, brought to the hospital by his parents during an acute manic episode. Over the past two weeks, he became extremely energetic, went on a spending spree buying three expensive guitars despite little money, and only slept ~2–3 hours a night. He was fired from his job three days ago after yelling and cursing at his boss. On admission, J.S. is loud, hyperverbal with rapid speech, and grandiose – he claims he has a plan to record an album with famous artists (whom he has no connection to). He is easily irritable when interrupted. J.S. is pacing the unit corridors, unable to sit still. He denies suicidal ideation, but belittles others and made a sexually inappropriate remark to a female patient earlier. He has not taken his prescribed lithium for the past month, saying “I don’t need it; I feel better than ever.”

Nursing Assessment Highlights: Patient exhibits classic mania: elevated expansive mood alternating with irritability, inflated self-esteem (grandiose plans), hyperactivity, very little sleep, talkative (pressured speech), and high-risk behavior (impulsive spending, job loss from aggression). Though he denies intent to harm, his impaired judgment puts him at risk for accidental harm. He’s also potentially provocative to others (could trigger fights). No hallucinations or delusions besides grandiosity noted (he’s not overtly psychotic, though insight is absent). Vital signs: slightly elevated BP and heart rate (likely from agitation and lack of sleep). Labs pending for lithium level (likely low) and tox screen (to rule out stimulant use; family denies substance abuse).

Nursing Diagnoses:

Goals (Outcomes):

  1. J.S. will be free of injury throughout hospitalization: he will not physically harm himself (no falls or exhaustion-related incidents) or others (no aggressive altercations), as evidenced by requiring no emergency restraints.

  2. J.S. will demonstrate increased behavioral control and social appropriateness by (within 72 hours) cooperating with unit limits (e.g., refraining from sexual remarks, responding to redirection without escalation).

  3. J.S. will sleep at least 4–5 hours overnight by the third day (short-term goal: increase from 2 to 4 hours of sleep with treatment, moving toward a normal 6–8 hours as mania subsides).

  4. J.S.’s thought content will become more reality-based (e.g., reduction in grandiosity) and he will be able to engage in conversation with less flight of ideas within 4–5 days, indicating improvement in thought process organization.

  5. J.S. will adhere to his medication regimen in the hospital and verbalize an understanding of the need for continued mood stabilizer therapy by discharge (e.g., “I realize I need my lithium to stay well”).

Interventions and Rationale:

Evaluation: Over the first 48 hours, J.S. required haloperidol IM twice for acute agitation, after which he slept 4 hours straight. By day 3 on the unit, with consistent limits, his shouting outbursts diminished; he was redirectable with a few prompts. He began sleeping ~5 hours at night with lorazepam. By day 5, he is no longer pacing constantly and can sit through a 30-minute community meeting (though he interrupts a few times). His speech is still rapid but less pressured. He admits, “Yeah, maybe I went a bit overboard,” indicating slight return of insight. He is taking lithium and even reminded the nurse of his evening dose (a great sign!). His lithium level is 0.9 mEq/L – therapeutic. J.S. still has grandiose plans but laughs about some when staff gently reality-test (“Okay maybe I won’t cut an album this month, but soon!”). The outcome is that he did not harm himself or others during the stay; he’s rehydrated and physically stable (labs normal, appetite improved with finger foods). At discharge (day 7 or so), he agrees to continue lithium and risperidone, and his parents will oversee medications at home. He will follow up with the outpatient bipolar clinic in 3 days and psychotherapy in one week. This case shows how acute mania management is aimed at ensuring safety, controlling symptoms quickly (often with medication and low stimuli), and then maintaining adherence to prevent relapse.

Case Study 3: Postpartum Depression (Moderate) with Impaired Bonding

Scenario: E.M. is a 28-year-old woman, 6 weeks postpartum after her first childbirth. She is referred to the home health psychiatric nurse by her OB due to concerns of depression. E.M. reports frequent crying spells, feelings of inadequacy as a mother, and excessive anxiety about her baby’s health. She has insomnia (can’t sleep even when the baby sleeps) and poor appetite. She admits she doesn’t feel the joy she expected with her newborn: “Sometimes I look at him and feel nothing… then I feel horrible guilt.” She has fleeting thoughts that her family might be better off if she weren’t around, but no specific suicidal plan. Her husband is supportive but works long hours; her mother stayed for 2 weeks then left. E.M. is breastfeeding. She has no history of depression and the pregnancy was desired and uncomplicated.

Nursing Assessment Highlights: This appears to be Postpartum Depression (PPD), presenting within 2 months of delivery, beyond the 2-week “baby blues” period【64†L7-L15】【64†L8-L15】. Symptoms: depressed mood, anhedonia (not enjoying baby), insomnia, anxiety, guilt, and passive death wishes. She denies any hallucinations or delusional thoughts about the baby (no signs of postpartum psychosis). Bonding assessment: E.M. cares for the baby’s basic needs but in a mechanical way; she states she feels disconnected. Risk assessment: she has passive suicidal ideation (thinking family might be better without her), which is concerning – nurse will monitor this closely and ensure she has emergency contacts. Protective factors: she acknowledges her feelings and sought help (via OB), husband is present (though busy), and she does have insight that these thoughts are not normal for her. She’s breastfeeding, which influences medication choices (if needed). The Edinburgh Postnatal Depression Scale (EPDS) score was 18 (consistent with PPD).

Nursing Diagnoses:

Goals (Outcomes):

  1. E.M. will identify positive traits or successful actions as a mother (at least one per day) after 2 weeks of intervention, indicating improving self-esteem and confidence in the maternal role.

  2. E.M. will demonstrate improved bonding with her infant, as evidenced by initiating at least one positive interaction (smiling, gentle touching, talking to baby) during each observed visit, within 1 month of support and therapy【68†L278-L286】【68†L280-L287】. (We’ll measure this by reports from her and her husband as well, e.g., she spends time holding the baby for pleasure, not just duty.)

  3. E.M.’s depressive symptoms will reduce: she will report a mood improvement (for example from 2/10 to 6/10 on a mood scale) and a decrease in guilt feelings at her follow-up OB visit in one month; EPDS score will drop below 10.

  4. E.M. will achieve adequate rest and nutrition: sleeping at least one 4-5 hour stretch (with husband’s help for a feeding) by 2 weeks, and eating 3 meals a day (even if small) by 2 weeks – evidenced by her verbal report and weight stabilization.

  5. Safety goal: E.M. will verbalize any suicidal thoughts promptly and will work with the nurse to create a safety plan. Ideally, by 2 weeks of treatment, she denies thoughts of being “better off dead” and expresses commitment to caring for herself for the baby’s sake.

Interventions and Rationale:

Evaluation: Over the next four weeks of nursing follow-ups, E.M. gradually shows improvement. By week 2, she reports she managed to get a 4-hour block of sleep when her husband took the night feeding – “I felt like a new person after that rest.” Her EPDS score reduced to 12 at week 3 (mild range). She is seen smiling at her baby when he coos – she says “I still don’t feel 100% connection, but I love when he makes that face.” She started attending a virtual PPD support group and realized “Other moms feel like this too; I’m not alone.” No suicidal thoughts after week 1 – she says she’s committed to getting better for her son. By week 4, she’s more confident in caring for the baby, accepting help without guilt, and practicing some CBT techniques to counter self-critical thoughts (she showed the nurse a thought record where she challenged “I am a bad mother” with “I am doing all I can and my baby is healthy”). She has started taking sertraline 25 mg daily as of week 3 (decided in consultation with her doctor due to ongoing symptoms and wanting to speed recovery) and hasn’t noticed side effects in herself or baby. At 6-week follow-up, her OB and nurse note she is brighter in affect, bonding better (e.g., she cuddles the baby proactively), and she rates her mood 7/10 better compared to initial 2/10. While she’s not completely symptom-free, the trajectory is positive. The nursing care plan is successful: goals met – no harm came to mom or baby, she’s engaging in bonding activities, sleeping more, and expressing hope. The plan moving forward is continuation of sertraline for at least 6-12 months, ongoing therapy, and plenty of support from family.

Conclusion: These case studies underscore the nursing process in action for mood disorders. For each scenario – a severely depressed adult, an acutely manic patient, and a mother with PPD – the nurse used careful assessment, identifying hallmark signs (and risks) of the mood disturbance, then formulated nursing diagnoses that guided targeted interventions. Key themes include ensuring safety (especially regarding suicide or reckless behavior), using therapeutic communication to provide empathy and hope, involving support systems, and assisting with basic physical needs (sleep, nutrition) that are often disrupted in mood disorders. Medications are a critical component, and the nurse’s role in administration and education is vital for adherence and managing side effects. Equally important are the non-pharmacologic interventions – from cognitive-behavioral techniques and routine-setting to facilitating mother-infant bonding exercises – which address the psychosocial aspects. Culturally sensitive care and consideration of developmental stage or life role (like the postpartum period) ensure the interventions are tailored to the individual. By utilizing a holistic, evidence-based approach, nurses help patients not only find relief from acute symptoms but also equip them and their families with the knowledge and strategies to manage their condition long-term. The ultimate outcome is improved mood, functionality, and safety, enabling patients to move toward recovery and maintain their quality of life.

Visual Summary:

【5†L149-L158】【5†L155-L163】 Table: Bipolar Disorder Types and Features

【11†L163-L172】【11†L167-L172】 Diagram: Neurobiology of Depression – Depression involves changes in multiple neurotransmitters and pathways. Serotonin, norepinephrine, and dopamine levels tend to be low, contributing to sad mood, low energy, and anhedonia【11†L151-L159】. There is also reduced GABA (inhibitory) and potential overactivity of glutamate (excitatory) systems【11†L163-L171】. Chronic stress can lead to high cortisol which damages neurons (hippocampus) and lowers BDNF, resulting in atrophy in mood-regulating regions【13†L174-L182】. Antidepressants help reverse these changes by increasing monoamines and promoting neuroplasticity (e.g., SSRIs boost serotonin which over weeks increases BDNF and hippocampal volume). New treatments like ketamine target glutamate, rapidly improving synaptic connections【11†L165-L172】.

【26†L669-L677】【26†L673-L680】 Flowchart: Acute Mania Management1) Ensure safety: calm environment, limit setting, possible seclusion if needed. 2) Rapid tranquilization: e.g., IM antipsychotic or benzodiazepine for severe agitation【26†L675-L683】【26†L677-L680】. 3) Start mood stabilizer (Lithium or Valproate) and/or oral antipsychotic【26†L670-L678】【26†L672-L679】. 4) Promote sleep (medicate at night, reduce stimuli). 5) Monitor and hydrate/nourish. 6) Taper IM meds as oral regimen takes effect. 7) Ongoing: psychoeducation about adherence and follow-up. (This flow ensures mania is controlled quickly then handed off to maintenance treatment.)

【48†L391-L399】【48†L393-L401】 Image: Suicide Risk Assessment (Columbia Scale) – A few sample questions from the C-SSRS: “Have you wished you were dead or wished you could go to sleep and not wake up?”; “Have you had thoughts of killing yourself?”; “Have you done anything or started to do anything to end your life?”【31†L39-L47】【31†L45-L53】. Based on answers: No ideation = Low risk, Ideation without plan = Moderate risk (needs preventive measures, monitoring), Ideation with specific plan or prior attempt = High risk (needs possible hospitalization)【30†L21-L25】. Nurses use this tool to guide interventions – any “yes” warrants a safety plan and possibly higher level of care【31†L39-L47】.

References (411–460):

  1. Bains, N., & Abdijadid, S. (2023). Major Depressive Disorder. StatPearls. 【13†L174-L182】【13†L179-L186】

  2. Jain, A., & Mitra, P. (2023). Bipolar Disorder. StatPearls. 【17†L177-L185】【17†L179-L183】

  3. Cleveland Clinic. (2022). Bipolar Disorder – Symptoms & Treatment. 【5†L155-L163】【5†L157-L163】

  4. Marzani, G., & Neff, A. (2021). Bipolar Disorders: Evaluation and Treatment. Am Fam Physician, 103(4), 227-239. 【26†L669-L677】【26†L673-L680】

  5. Columbia Lighthouse Project. (2016). About the Columbia-Suicide Severity Rating Scale (C-SSRS). 【31†L39-L47】【31†L45-L53】

  6. UpToDate. (2023). PHQ-9 Depression Questionnaire: Scoring and Interpretation. 【58†L1-L8】

  7. MentalHealth.com. (2025). Cultural Effects on Depression. 【43†L253-L261】【43†L255-L263】

  8. Baylor College of Medicine. (2022). Expressing depression differs across cultures. 【38†L98-L107】【38†L100-L107】

  9. PsychDB. (2020). Differential Diagnosis of Depression. 【23†L829-L838】【23†L833-L839】

  10. PsychDB. (2019). Nursing Care – Depression. 【48†L391-L399】【48†L393-L401】

  11. StatPearls. (2023). Depression (Nursing). 【48†L403-L410】【48†L405-L413】

  12. StatPearls. (2023). Depression (Nursing) – Interventions. 【48†L414-L422】【48†L414-L418】

  13. StatPearls. (2023). Bipolar Disorder (Nursing) – (Open RN textbook example). 【57†L398-L406】【57†L401-L409】

  14. NurseTogether. (2022). Bipolar Disorder Nursing Care. 【52†L336-L344】【52†L338-L342】

  15. NurseTogether. (2022). Bipolar – Risk for injury interventions. 【52†L342-L349】【52†L344-L351】

  16. Nurseslabs. (2018). Postpartum Depression Nursing Care Plan. 【68†L278-L286】【68†L280-L287】

  17. Nurseslabs. (2018). Postpartum Depression – Nursing Interventions. 【68†L295-L303】【68†L295-L302】

  18. Psychiatry.org. (2022). DSM-5-TR Highlights: Bipolar and Related Disorders. 【19†L267-L275】【19†L269-L277】

  19. MedicalNewsToday. (2023). Mania vs. Hypomania Differences. 【60†L299-L307】【60†L300-L307】

  20. Hedya, S., et al. (2023). Lithium Toxicity. StatPearls. 【57†L445-L454】【57†L447-L455】

  21. Soreff, S., & Xiong, G. (2020). Bipolar Disorder and Aggression. (Referenced in Nurseslabs) 【57†L409-L418】【57†L415-L419】

  22. Florida BH Center. (2017). DSM-5 Criteria for MDD (PDF). 【9†L1-L4】 (Depressed mood or anhedonia + 5/9 symptoms criteria).

  23. Mayo Clinic. (2023). Postpartum Depression. 【64†L33-L38】【64†L35-L38】 (Sertraline safe in breastfeeding).

  24. Mayo Clinic. (2018). Premenstrual Dysphoric Disorder. 【45†L113-L121】 (Lists PMDD under depressive disorders).

  25. Hall, H. et al. (2016). Rapid effects of ketamine in major depression. 【11†L163-L172】 (Glutamate-NMDA link).

  26. Fico, G. et al. (2020). Aggression in Bipolar Disorder. (Noted in Nurseslabs) 【57†L415-L423】【57†L417-L419】

  27. Cox, J. et al. (1987). Edinburgh Postnatal Depression Scale (EPDS). (EPDS scoring: ≥13 indicates likely PPD).

  28. Nurseslabs. (2018). Bipolar Care Plan – Goals. 【55†L293-L301】【55†L295-L302】

  29. Joiner, T. (2017). Myths about suicide. (Men’s suicide rate higher).

  30. DBSA. (2021). Bipolar support – Patient and Family Education. (Emphasizes medication adherence and routines).

  31. Spinelli, M. (2020). Interpersonal Psychotherapy for PPD. (Therapy efficacy in PPD).

  32. Abdallah, C. (2022). Rapid antidepressant effect of ketamine. (Monoamine vs glutamate mechanism).

  33. Chaudron, L. (2018). Breastfeeding and antidepressants. (Sertraline is preferred).

  34. Geddes, J. (2019). Long-term lithium therapy. (Reduces suicide in bipolar). 【26†L673-L680】【26†L675-L683】

  35. Goodwin, G. (2016). Evidence-based treatment of Bipolar. (Combining mood stabilizer + antipsychotic in mania). 【24†L53-L61】【24†L55-L63】

  36. Beck, A. (1979). Cognitive Theory of Depression. (Cognitive distortions and CBT approach). 【48†L405-L413】【48†L408-L416】

  37. NIH. (2021). GABA and Glutamate in Depression. 【11†L163-L171】

  38. Melrose, S. (2010). Poverty, stigma and depression in rural mothers. (Social factors in depression).

  39. Mind.org.uk. (2021). Hypomania and mania – info for patients. 【60†L299-L307】

  40. NAMI. (2023). Depression fact sheet. (12 million women experience PPD globally per year, etc.)