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 aannals-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:
Neurochemical Factors: Early theories focused on neurotransmitter deficiencies (especially serotonin, norepinephrine, and doncbi.nlm.nih.govression【11†L151-L159】. Low levels of serotonin metabolites have been linked to suicidal ideation【11†L153-L161】. Newer research highlights dysregulation in broader neural circuits and neuroregulatory systems rather than a single neurotransmitter defect【11†L158-L164】【11†L159-L167】. For example, reduced gamma-aminobutyric acid (GABA, an inhibitory neurotransmitter) and altered glutamate signaling have been observed in depressed patients【11†L163-L171】. The success of novel treatments like ketamine (an NMDA-glutamate receptor antagonist) in alleviating depression supports the role of the glutamatergic system【11†L165-L172】.
Neuroendocrine and Neurobiology: Chronic stress can dysregulate the hypothalamic-pituitary-adrenal (HPA) axis, leading to elmy.clevelandclinic.orgmy.clevelandclinic.orgt damage neurons and alter brain structure over time. Severe early-life stress and trauma are associated with an increased risk of depression later in life【13†L169-L177】【13†L174-L182】. Imaging studies in depression show functional and structural changes: for instance, reduced metabolic activity in the left frontal cortex and subtle brain volume reductions have been noted【13†L174-L182】. There is also evidence of decreased neurotrophic factors (like brain-derived neurotrophic factor, BDNF) which impairs neuroplasticity and resilience of neuronal circuits (the neurotrophic hypothesis of depression).
Genetics: Depression can run in families. First-degree relatives of individuals with MDD have about 3 times higher risk of developing depressioblogs.bcm.edublogs.bcm.eduation【45†L149-L157】. Twin studies show high concordance rates, especially in monozygotic twins【13†L177-L184】. However, genetics are not destiny – many people with no family history develop depression, and not all with familial risk will develop it, indicating gene-environment interactions.
Psychosocial Factors: Adverse childhood experiences (such as abuse or neglect) and cumulative life stressors significantly increase depression risk【11†L169-L172】【11†L179-L186】. Certain personality traits or cognitive styles can predispose individuals – for example, the learned helplessness theory and Beck’s cognitive theory posit that people who develop depressive thinking patterns (e.g. persistent negative views of self, world, and future) are more vulnerable to depression【13†L179-L186】. Lack of social support, loneliness, or major losses (job loss, divorce, death of loved one) are common triggers for depressive episodes.
Medical Illness and Other Risk Factors: Chronic medical conditions (e.g. diabetes, heart disease, cancer) and chronic pain are associated with higher rates of depression, especially in older adults【13†L199-L207】. Certain medications and substances can contribute to depressive symptoms (for example, alcohol or sedative abuse, corticosteroids, interferon therapy). Women have approximately 2x higher incidence than men, possibly due to hormonal fluctuations (e.g. childbirth, menstrual cycle), as well as psychosocial differences and gender roles【13†L190-L198】. Socio-demographic factors like lack of close relationships or being divorced/widowed are also linked to higher depression rates【13†L199-L207】.
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】:
Depressed mood (sad, empty, or hopeless feelings; in children/teens, this may present as irritable mood).
Markedly diminished interest or pleasure in all/almost all activities.
Significant weight loss or gain (without dieting) or changes in appetite【8†L95-L102】【8†L121-L129】.
Insomnia or hypersomnia (difficulty sleeping or sleeping excessively).
Psychomotor agitation or retardation (observable restlessness or slowing of movements and speech).
Fatigue or loss of energy.
Feelings of worthlessness or excessive/inappropriate guilt.
Diminished ability to think or concentrate, or indecisiveness.
Recurrent thoughts of death, suicidal ideation, or suicide attempt.
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 deprecssrs.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:
Grief vs. Clinical Depression: Bereavement due to loss of a loved one can cause deep sadness, tearfulness, and insomnia, but in normal grief the predominant affect is a sense of loss with preserved self-esteem, and painful feelings tend to occur in waves tied to reminders of the deceased. In MDD, mood and negative thoughts are more persistent and pervasive, often coupled with feelings of worthlessness【23†L863-L871】. The DSM-5-TR recognizes that grief can precipitate a depressive episode, but typical grief is not labeled MDD unless criteria are met beyond what is culturally expected for the bereavement period【43†L268-L274】.
Adjustment Disorder with depressed mood: If depressive symptoms occur in response to an identifiable stressor but do not meet full criteria for MDD (fewer than 5 symptoms or shorter duration), an adjustment disorder may be diagnosed【23†L823-L831】【23†L825-L833】. Adjustment-related depression is usually milder and resolves within 6 months once the stressor or its consequences are addressed.
Bipolar Depression: A depressive episode in bipolar disorder can be clinically indistinguishable from unipolar MDD. Clues pointing to bipolar depression include a history of past manic/hypomanic symptoms (even subtle), depression onset at a younger age (<25), multiple recurrent depressive episodes, psychotic depression, or a family history of bipolar disorder【18†L237-L245】【19†L267-L275】. It’s crucial to screen for past elevated mood episodes, because treating bipolar depression with antidepressants alone can trigger mania (see Bipolar Disorder section). MDD diagnosis should be reconsidered if any manic or hypomanic episode emerges【9†L1-L4】.
Medical conditions: Many medical illnesses can present with depressive-like symptoms or precipitate depression. Endocrine disorders (hypothyroidism, Cushing’s syndrome), neurological conditions (Parkinson’s disease, stroke, mncbi.nlm.nih.govncbi.nlm.nih.gov, vitamin deficiencies (B12, vitamin D), chronic infections (like HIV), or autoimmune diseases are some examples【23†L829-L838】【23†L833-L839】. A tncbi.nlm.nih.govncbi.nlm.nih.govical exam and lab tests such as TSH for thyroid function, etc.) is essential to rule out depression due to another medical condition. For example, undiagnosed hypothyroidism can manifest as fatigue, low mood, and cognitive slowing – symptoms overlapping with MDD【23†L831-L839】【23†L833-L838】.
Substance/Medication-induced depression: Depressive symptoms can be caused by alcohol or substance abuse (depressants), or as withdrawal effects from stimulants. Certain medications (e.g. some antihypertensives, corticosteroids, isotretinoin, interferon) may induce depressive symptoms in susceptible individuals【23†L847-L855】【23†L849-L853】. The timing of mood change with substance use/cessation helps differentiate this; if the mood disturbance is *diblogs.bcm.edublogs.bcm.edusubstance effects, it is diagnosed as a substance-induced depressive disorder, not MDD.
Other psychiatric disorders:
Dysthymia/Persistent depressive disorder (discussed above) involves chronic but milder depression.
Bipolar disorder must be ruled out by absence of mania/hypomania.
Borderline personality disorder (BPD) can present with episodic depression but is distinguished by pervasive patterns of unstable relationshipsncbi.nlm.nih.govncbi.nlm.nih.govy; mood shifts in BPD are usually more transient (minutes to hours) and reactive to interpersonal triggers, whereas MDD episodes last weeks and are more autonomous【5†L173-L182】【5†L185-L192】.
Attention-deficit/hyperactivity disorder (ADHD) in children can sometimes be mistaken for depression if irritability and concentration problems are prominent. However, in childhood depression, irritability is pervasive and accompanied by other depressive signs (anhedonia, sleep/appetite change), whereas ADHD’s core is attentional and behavioral regulation issues. Both can co-exist, and careful history is needed【23†L853-L861】.
Normal mood fluctuations or sadness that do not meet full criteria should not be pathologized. Feeling “down” in response to life events is part of the human experience. Clinicians diagnose MDD only when a cluster of symptoms is present with sufficient severity (≥5 symptoms), duration (≥2 weeks), and impairment【23†L863-L871】.
In practice, nurses must maintain a broad differential and assess for medical contributions or other disncbi.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:
Monoamine Dysregulation: The classic monoamine hypothesis implicates deficiencies or imbalance of neurotransmitters like serotonin, norepinephrine, and dopamine in the synapses. Antidepressant medications that boost these transmitters (such as SSRIs and SNRIs) can alleviate depression, supporting this theory【11†L153-L161】【11†L155-L163】. However, it’s now understood that the story is more complex. Rather than an absolute “lack” of serotonin, depression may involve abnormal function of receptors, changes in signal transduction, or downstream effects in neural circuits that regulate mood (like the limbic system and prefrontal cortex)【11†L158-L164】【11†L159-L167】.
Glutamate and GABA: Beyond monoamines, the balance of excitatory and inhibitory neurotransmission is disrupted in many depressed patients. GABA (an inhibitory neurotransmitter) levels are often low in plasma, cerebrospinal fluid, and brain of those with MDD【11†L163-L171】. GABA normally has a mood-stabilizing effect by inhibiting excessive neuronal firing; low GABA may thus remove a braking mechanism on negative mood circuits【11†L165-L172】. Glutamate, the primary excitatory neurotransmitter, also appears to be involved – drugs that modulate glutamate (like ketamine/esketamine, which antagonize NMDA glutamate receptors) can produce rapid antidepressant effects in treatment-resistant depression【11†L165-L172】. This has led to increased research on glutamate-targeting therapies.
Neuroendocrine Factors: Dysregulation of the stress hormone system is common in depression. Many depressed individuals have hyperactivity of the HPA axis, resulting in elevated cortisol levels that can damage neurons (especially in the hippocampus, which is involved in mood and memory). Thyroid hormone disturbances are also linked – even subclinical hypothyroidism can contribute to depressive symptoms, and thyroid funcncbi.nlm.nih.govncbi.nlm.nih.govin some mood disorder patients【11†L167-L170】. This is why thyroid tests are often part of the depression workup【13†L221-L229】. Additionally, inflammatory cytokines (molecules of the immune system) are elevated in a subset of depressed patients, leading to the “inflammation hypothesis” of depression. Though not fully understood, inflammation might affect neurotransmitter metabolism and neural plasticity.
Structural and Functional Brain Changes: Chronic depression is associated with measurable brain changes. MRI studies have shown reduced volume in the hippocampus and prefrontal cortex in some individuals with long-term depression, possibly due to the toxic effects of cortisol and lack of neurotrophic support. Functional neuroimaging (PET, fMRI) often reveals hypoactivity in the dorsolateral prefrontal cortex (associated with executive function and emotional regulation) and hyperactivity in limbic regions like the amygdala (which processes fear and negative emotion)【13†L174-L182】. Increased deep white matter ncbi.nlm.nih.govncbi.nlm.nih.goveen observed in depressed populations, especially in late-life depression, suggesting microvascular changes or demyelination in subcortical regions【13†L174-L182】. These changes correlate with certain symptom profiles (e.g., executive dysfunction in depression with prominent frontal deficits).
Neuroplasticity: Emerging evidence points to impairment in neuroplasticity (the brain’s ability to form new connections and adapt) in depression. Levels of neurotrophic factors such as BDNF are often low in depressed patients, and antidepressant treatments tend to increase BDNF over time, promoting the growth and survival of neurons and synapses. This aligns with the observation that antidepressants typically take weeks to achieve full effect – time needed for downstream changes like new protein synthesis, neural growth, and circuit remodeling to occur, beyond immediate neurotransmitter changes. In summary, depression can be seen as a state where strncbi.nlm.nih.govncbi.nlm.nih.govhave caused the brain’s mood-regulation networks to “malfunction,” and treatment seeks to reset and heal these networks over time.
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 relapsencbi.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】:
Bipolar I Disorder (BD-I): Characterized by at least one manic episode, which may have been preceded or followed by depressive or hypomanic episodes【19†L279-L287】. A manic episode is a distinct period of abnormally elevated, expansive, or irritable mood and increased energy/activity lasting at least 1 week (or any duration if hospitalization is required)【20†L335-L343】【20†L337-L345】. During mania, there are ≥3 of the following symptoms (≥4 if mood is only irritable)【20†L335-L343】【20†L337-L345】:
Inflated self-esteem or grandiosity
Decreased need for sleep (e.g., feeling rested after only a few hours)
More talkative than usual or pressured speech
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity (socially, at work/school, sexually) or psychomotor agitation
Excessive involvement in risky activities (unrestrained buying sprees, sexual indiscretions, reckless driving, foolish investments)
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.
Bipolar II Disorder (BD-II): Defined by at least one hypomanic episode and at least one major depressive episode, with no full manic episodes ever【19†L279-L288】【19†L283-L289】. Hypomania involves similar symptoms to mania but is milder and shorter: the mood disturbance lasts at least 4 days in a row【20†L371-L379】 and is observable by others though not severe enough to cause marked functional impairment or require hospitalization【60†L297-L305】【60†L299-L307】. In hypomania, psychotic features do not occur (if psychotic symptoms arise, that automatically qualifies as mania)【20†L312-L320】. Patients with hypomania often feel very good, productive, or creative and may not perceive anything is wrong, but family/friends notice the change in mood and behavior【60†L300-L307】. Bipolar II patients spend more time in depression overall, and their depressive episodes can be just as severe and impairing as in Bipolar I. In fact, Bipolar II is often more debilitating than Bipolar I long-term because of the burden of frequent or chronic depression【5†L155-L163】【5†L157-L160】. Hypomanic episodes in Bipolar II often last a few days to weeks and may confer a temporary increase in functioning (unlike mania, which causes impairment).
Cyclothymic Disorder: A chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms (that do not meet full criteria for a hypomanic episode) and periods of depressive symptoms (not meeting full criteria for major depression) for at least 2 years (1 year in youth)【19†L283-L291】. The person experiences these ups and downs at least half the time and has not been symptom-free for >2 months at a stretch【19†L285-L293】. While the symptoms are milder than full bipolar episodes, cyclothymia causes noticeable instability in mood and may progress to a full bipolar disorder in some cases. It can be thought of as the “temperamental” form of bipolar – mood swings are less extreme but more persistent. Individuals may be regarded as overly moody, unpredictable, or impulsive. Cyclothymic disorder has a lifetime prevalence of about 0.4–1%【17†L199-L202】【17†L193-L199】.
Other Specified or Unspecified Bipolar and Related Disorder: These categories are used for bipolar-like presentations that do not neatly fit the above diagnoses (e.g., short-duration hypomania that doesn’t reach 4 days, hypomanic episodes without depression, or episodes with insufficient symptoms)【19†L291-L299】. Essentially, if a person has clinically significant mood elevation symptoms but doesn’t meet full criteria for Bipolar I, II, or cyclothymia, these categories apply. They acknowledge the spectrum nature of bipolar disorders.
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】:
Mania: Lasts ≥7 days (or any duration if hospitalization is needed). Causes severe functional impairment, often includes psychosisnurseslabs.comnurseslabs.comabnormal to others. For example, an individual in mania might max out credit cards on impulsive purchases, drive recklessly, engage in inurseslabs.comnurseslabs.com, or believe they have special powers or destiny (grandiose delusions). They may require hospitalization for their own safety or that of others【60†L299-L307】. Insight is usually impaired.
Hypomania: Lasts ≥4 days, and by definition does not cause marked impairment in social or occupational functioning【60†L300-L307】. No psychotic symptoms. The person may appear “amped up,” overly enthusiastic or irritable, but can still function – perhaps even be highly productive or charming. Often the hypomanic person does not recognize the state as abnormal, though those around them notice a change in mood or behavior【60†L301-L307】. If hypomania escalates (e.g., becomes more severe or prolonged), it may cross into mania.
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:
Duration: Mania ≥ 7 days; Hypomania ≥ 4 days
Severity: Mania causes major impairment, possible psychosis, often hospitalized; Hypomania causes mild to moderate symptoms, no psychosis, no hospitalization required by criteria.
Insight: Often absent in mania (may have delusional beliefs); often partially intact in hypomania (person may just nursetogether.comnursetogether.comive).
Outcome: Mania almost always necessitates treatment; hypomania will also eventually require treatment in context of bipolar disorder, primarily to prevent depression or further escalation.
(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:
Genetics: Bipolar disorder is one of the most heritable psychiatric disorders. Heritability estimates are as high as 80–90%. Family studies show that first-degree relatives of bipolar patients have a greatly elevated risk of mood disorders; twin studies indicate a high concordance in identical twins【17†L157-L165】. Multiple gene loci are implicated – it’s a polygenic condition. The first gene associations were found on chromosome 11 in 1987, andnursetogether.comnursetogether.comloci (related to neurotransmitter regulation, ion channels, circadian rhythms, etc.) have been linked to increased bipolar risk【17†L157-L165】【17†L159-L163】. No single “bipolar gene” exists; rather, many gene variants each contribute a small amount to vulnerability.
Life Stress and Psychosocial Triggers: Like depression, stressful life events can precipitate bipolar episodes. In fact, more than 60% of bipolar patients report a significant stressor in the 6 months prior to an episode (be it manic or depressive)【17†L165-L173】【17†L167-L170】. Childhood maltreatment (especially emotional abuse or neglect) is linked to earlier onset and a more severe course of bipolar disorder【17†L163-L170】. Other triggers canursetogether.comnursetogether.com (childbirth is a known trigger of bipolar episodes or postpartum psychosis), loss of relationships, job stress or loss, sleep deprivation (e.g., shift work, crossing time zones), and substance use【6†L25-L28】【17†L165-L173】. It’s important to note that while stress can precipitate episodes, it doesn’t cause bipolar disorder in someone who isn’t already predisposed. The current view is the diathesis-stress model: individuals inherit a biological vulnerabiaafp.orgaafp.orgg significant stress or disruption (environmental factors), leads to the onset of symptoms.
Neurochemical Factors: Bipolar disorder involves dysregulation of multiple neurotransmitter systems, particularly monoamines. During mania, increased dopamine activity is thought to contribute to euphoria, hyperactivity, and psychosis; conversely, low dopamine in depressive phases may relate to low energy and anhedonia. Serotonin and norepinephrine imbalances are also implicated – many bipolar patients benefit from drugs that modulate these transmitters (e.g., SNRIs, mood stabilizers that have indirect effects)【17†L171-L175】. Notably, no single consistent neurotransmitter abnormality has been pinned down, highlighting that bipolar disorder is not just a “dopamine surplus” or “serotonin deficit” – it’s the overall regulatory systems that are unstable【16†L19-L27】【16†L13-L21】.
Pathophysiology and Neurobiology: Bipolar disorder’s pathophysiology is multifaceted:
Neuroplasticity and Cellular Resilience: Research shows alterations in cellular resilience factors. Levels of neurotrophic factors like BDNF, nerve growth factor (NGF) and others are found to change during mood episodes【18†L210-L218】【18†L212-L220】. In mania, there may be heightened oxidative stress and mitochondrial dysfunction in brain cells【18†L212-L220】. Mood stabilizer medications (like lithium and valproate) have neuroprotective effects – lithium, for instance, increases BDNF and anti-apoptotic proteins, promoting neuron health.
Brain Structure and Connectivity: Large neuroimaging studies (e.g., ENIGMA Bipolar Disorder project) have identified subtle but diffuse brain aafp.orgaafp.orgnts: slightly smaller subcortical volumes, thinner cortical gray matter in certain regions, and altered white matter connectivity compared to healthy individuals【17†L177-L185】【17†L179-L183】. Specifically, bipolar patients tend to have differences nursetogether.comnursetogether.comvolved in judgment and impulse control) and the amygdala (emotional processing). Post-mortem studies reveal loss of dendritic spines (synaptic connections) in the dorsolateral prefrontal cortex in bipolar brains【18†L217-L220】【18†L219-L220】, which could underlie some cognitive and mood-regulation deficits.
Functional Circuits: During mania, functional MRI often shows overactivity in emotion/reward circuits (like the striatum and amygdala) and underactivity in frontal regulatory circuits. The opposite pattern (low reward circuit activity, possibly high stress-circuit activity) may be seen in bipolar depression. There is also evidence for disruptions in circadian regulation – many bipolar patients have abnormal sleep-wake cycles and benefit from maintaining strict routines. This is the rationale behind Interpersonal and Social Rhythm Therapy (IPSRT), a therapy specifically designed for bipolar disorder that emphasizes maintaining consistent daily rhythms (sleep, meals, activity) to prevent mood episodes【50†L449-L457】.
Inflammatory and Hormonal: Similar to MDD, some bipolar research suggests immune system activation and inflammation during mood episodes. Thyroid function can influence bipolar course: thyroid abnormalities (even mild) can contribute to rapid cycling in bipolar patients【5†L199-L207】. Clinicians sometimes use high-dose thyroid hormone as an adjunct treatment in refractory bipolar depression or rapid cycling, highlighting the thyroid–mood connection.
Substance Use: Bipolar disorder and substance abuse commonly co-occur. Patients may use alcohol or drugs in attempts to self-medicate mood symptoms (e.g., stimulants to combat depression, sedatives to calm mania), but this often worsens the illness. Substance use can trigger or prolong episodes and increase impulsivity, thereby raising risks (violence, accidents, suicide)【57†L439-L447】【57†L441-L446】. Whenever a bipolar patient has active substance use, it becomes harder to manage their mood disorder, so integrated treatment for both is essential.
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 medicatioaafp.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:
Mental Status Examination (MSE): Evaluate the patient’s mood and affect (is the mood sad, euphoric, labile, irritable? Is affect congruent or flat?), speech (slow, soft speech in depression; rapid, pressured speech in mania【29†L109-L117】【29†L112-L115】), thought processes (logical vs. flight of ideas or racing thoughts in mania), and thought content (any suicidal or homicidal ideation, delusions such as grandiosity or guilt). Note any perceptual disturbances – e.g., depressed patients with psychotic features may have auditory hallucinations of derogatory voices, and manic patients may have hallucinations or delusions when severely ill【4†L101-L106】【4†L103-L111】. Assess insight and judgment – often markedly impaired in mania (patient may not recognize they are ill), and in depression patients may have distorted negative views of themselves.
Risk Assessment: Suicide risk is paramount in depression (and in mixed or depressive phases of bipolar). The nurse should ask directly about suicidal ideation, intent, and plan. Use clear, direct questions in a caring manner, for example: “Sometimes people with depression feel like life isn’t worth living – have you had any thoughts of harming yourself?”【31†L39-L47】【31†L69-L77】. If yes, follow up: “Do you have a plan? Have you taken any steps towards acting on these thoughts?”【31†L43-L50】【31†L69-L77】. Also assess for **homicaafp.orgaafp.org*, particularly in mania or if psychosis is present. A patient in mania may be at risk of accidentally harming self or others due to poor impulse control (e.g., driving recklessly) even if they have no intent to do harm【57†L401-L409】【57†L411-L419】. For bipolar patients, ask about risky behaviors (spending, sexual indiscretions, etc.) that could lead to injury or severe consequences.
Physical Health and Biological Functions: Depression often causes changes in sleep (insomnia or hypersomnia), appetite (loss of appetite and weight loss, or sometimes overeating in atypical depression), energy level (usually low, with fatigue), psychomotor activity (slowed movements in depression; accelerated in mania), and sexual interest (usually decreased in depression, increased or indiscriminate in mania). Take vital signs and note any significant weight change. In mania, patients may go for days with minimal sleep and not feel tired【52†L255-L263】【52†L259-L264】 – assess how many hours the patient has been sleeping and eating. Hydration and nutrition can be compromised in severe mania or depression, so evaluate intake. For example, a manic patient might be too hyperactive to sit and eat, and a depressed patient might lack appetite or energy to cook.
Medication and Treatment History: Determine if the patient is currently on any psychiatric medications or has taken any in the past. Non-adherence is common (especially in bipolar disorder during manic phases when patients feel “fine” and stop meds). Also ask about over-the-counter or herbal supplements (like St. John’s Wort for depression) and substances (alcohol, drugs) which can affect mood. For those on lithium or anticonvulsants, check if they’re getting regular blood level monitoring and any side effects (like lithium tremors, thyroid issues, etc.). If the patient has had therapy, ask what type and whether it was helpful.
Psychosocial Assessment: Explore the patient’s support system and living situation. Do they have family or friends involved and supportive? Are they socially isolated? Any recent conflicts or losses? How is their occupational or school functioning (missed work, drop in performance)? For adolescents, gather information from parents about behavior changes. For postpartum women, assess the relationship with the baby and availability of help at home. Cultural background should also be noted, as it may influence how symptoms are expressed (some may primarily report physical complaints rather than emotional distress【43†L253-L261】, see Cultural Considerations).
Use of Screening Tools: Nurses can employ standardized assessment tools to quantify symptoms:
The Patient Health Questionnaire-9 (PHQ-9) is a quick 9-item depression screening instrument that aligns with DSM-5 symptom criteria【27†L1-L9】. It can be used in primary care or hospital settings to screen for depression and monitor symptom severity over time. PHQ-9 scores range from 0–27; scores ≥10 indicate possible major depression (moderate to severe range)【27†L1-L9】【27†L7-L15】. Severity categories are: 5–9 = mild, 10–14 = moderate, 15–19 = moderately severe, and ≥20 = severe depression【58†L1-L8】. For example, a patient scoring 18 would be considered to have moderately severe depression, guiding the need for active treatment and possibly referral to a specialist.
The Young Mania Rating Scale (YMRS) is a clinician-administered scale used to assess the severity of manic symptoms. It has 11 items (rating mood, energy, sexual interest, sleep, irritability, speech, thought content, behavior, appearance, insight) scored via interview and observation【29†L78-L86】【29†L109-L117】. The YMRS score ranges from 0 to 60; higher scores indicate more severe mania. A score >25 is often used to denote a severe manic state【29†L117-L125】. Nurses might use the YMRS in inpatient psychiatric units to track a bipolar patient’s response to treatment across a manic episodnursetogether.comnursetogether.comSuicide Severity Rating Scale (C-SSRS)** is an evidence-based tool for suicide risk assessment. It uses a series of structured questions in plain language to evaluate suicidal ideation and behavior【31†L39-L47】. The C-SSRS asks about the wish to die, thoughts of suicide, presence of a plan, extent of preparation, and any past attempts【31†L39-L47】【31†L45-L53】. It helps determine the severity and immediacy of suicide risk and guides the level of intervention needed (e.g., one can classify risk as low, moderate, high based on answers)【30†L21-L25】. Nurses may administer a brief version of C-SSRS during intake or if a patient endorses suicidal thoughts, to systematically gauge risk factors.
(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:
Risk for Self-Directed Violence (Risk for Suicide) – always a top consideration if the patient has suicidal thoughts, previous attempts, or feels hopeless【48†L386-L394】【48†L391-L399】. This is priority #1 because of the immediate threat to life.
Hopelessness – characterized by expressions of despair and negative belief that nothing will improve. Depressed patients may say things like “What’s the point? It will never get better.”
Ineffective Coping – patient may have difficulty mobilizing energy to deal with problems or may use maladaptive coping (e.g. alcohol use, social withdrawal).
Chronic Low Self-Esteem – feelings of worthlessness, guilt, and self-blame are common; patient verbalizes “I’m a failure” or excessively apologizes.
Social Isolation (or “Impaired Social Interaction”) – due to loss of interest and energy, depressed individunurseslabs.comnurseslabs.comnds and activities.
Disturbed Sleep Pattern – insomnia (difficulty falling or staying asleep) or hypersomnia causing daytime dysfunction.
Imbalanced Nutrition: Less than Body Requirements – if significant appetite and weight loss have occurred, or Self-Care Deficit (if patient is neglecting personal hygiene, grooming, eating).
Fatigue – persistent tiredness can be both a symptom and a problem that limits the person’s ability to function or participate in therapy.
Decisional Conflict or Impaired Concentration – difficulty in making even minor decisions due to impaired concentration.
For Mania/Hypomania (Bipolar):
Risk for Injury – manic patients are at risk of accidental injury (e.g., falls, crashes from reckless driving) or physical exhaustion due to overactivity and lack of rest【52†L285-L293】【52†L287-L295】. They may also be at risk for self-injurious behavior due to poor judgment (e.g. spending sprees leading to financial ruin isn’t direct injury, but could result in harm).
Risk for Other-Directed Violence – if the patient is extremely irritable, paranoid, or unable to control impulses, they may become aggressive orblogs.bcm.edublogs.bcm.eduothers.
Sleep Deprivation – a more severe form of “disturbed sleep pattern” where the lack of sleep is leading to impairment (after several days of no sleep, patients can become delirious). “Insomnia” or “disturbed sleep” is often usnursetogether.comt’s truly at the level of jeopardizing health (then “Sleep Deprivation”).
Impaired Mood Regulation – though not a NANDA diagnosis per se, we conceptualize the patient as having an inability to modulate mood.
Disturbed Thought Processes – blogs.bcm.edublogs.bcm.eduthoughts or flight of ideas in mania. They may have an inflated self-image (delusion of grandeur) or be disorganized in conversation.
Impaired Social Interaction – intrusive, hyperactive behaviors can alienate others; manic patients often violate social norms (e.g., inappropriate familiarity or provocative behavior).
Deficient Fluid Volume / Imbalanced Nutrition – if the patient is too active to sit and eat or drink, they could be dehydrated or losing weight.
Nonadherence (to medication) – common in bipolar due to denial of illness or because patients miss the “highs” of mania.
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 envircssrs.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 foundanurseslabs.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:
Ensure Safety from Suicide: If the patient has suicidal ideation (especially with intent or plan), implement precautions immediately. This includes close observation (potentially 1:1 supervision for high-risk patients), removing anynurseslabs.comnurseslabs.comfor self-harm (sharp objects, belts, shoelaces, medications)【48†L391-L399】【48†L393-L401】, and developing a safety plan (identifying triggers, coping strategies, and emergency contacts). Rationale: The patient’s safety is the top priority; removing means and providing supervision prevents impulsive suicide attempts【48†L386-L394】【48†L391-L399】. Engaging the patient in creating a safety plan can also instill hope by focusing on reasons to live and ways to cope when suicidal urges emerge.
Establish Trust and Therapeutic Alliance: Use therapeutic communication techniques to build rapport. Display empathy (“I can see how much pain you’re in”), listen actively, and be nonjudgmental. Encourage the patient to express feelings. Rationale: A trusting nnurseslabs.comnurseslabs.comlps the patient feel understood and not alone, which can reduce feelings of isolation and hopelessness【48†L399-L407】【48†L401-L404】. Simply talking about feelings can be relieving and is the first step in psychotherapy. Patients who feel safe with the nurse are more likely to be honest about suicidal thoughts or difficulties.
Promote Activity and Routine: Encourage the patient to participate in simple activities and establish a daily routine (even small tasks like getting out of bed, getting dressed, and attending group therapy). This may require significanurseslabs.comnurseslabs.comet’s take a short walk in the hallway together” or assistance with initiating grooming. Rationale: Depression often causes inertia; structured actinurseslabs.compsychomotor retardation* and reinforces the patient’s sense of capability【48†L396-L404】【48†L403-L410】. Behavioral activation – gradually increasing activity levels – is an evidence-based strategy that can improve mood by re-engaging reward pathways. Accomplishing small tasks can also give a sense of achievement.
Assist with Activities of Daily Living (ADLs) as Needed: If the patient is severely depressed (e.g., not bathing, staying in pajamas all day), break tasks into small, manageable steps and gently encourage self-care. For instance, “Would you like help picking out some clothes? Let’s try to take a shower this morning.” Provide direct assistance if the patient cannot perform ADLs. Rationale: Basic self-care is often neglected in depression due to low energy and motivation. Assisting with ADLs ensures the patient’s physical health (nutrition, hygiene) is maintained【48†L395-L403】【48†L396-L404】. Supporting ADLs also communicates to the patient that they are worth care and that improvement is possible. Over time, as energy returns, the patient should be encouraged to do more for themselves to rebuild autonomy and self-esteem.
Use of Therapeutic Activities: Engage the patient in occupational or recreational therapy appropriate to their energy level – for example, art, music, or low-impact exercise groups. Initially, passive activities (like listening to music or simple crafts) may be tolerable. Rationale: Structured therapeutic ablogs.bcm.edublogs.bcm.eduon from negative thoughts, a sense of accomplishmentnurseslabs.comnurseslabs.comon. Exercise, even mild (like a short walk), has antidepressant effects by releasing endorphins and can improve sleep and appetite. Socialization in group activities (even just sitting with others) can counteract isolation.
Cognitive Interventions: Help the patient identify and challenge negative thoughts if appropriate (this is a principle of cognitive-behavioral therapy). For example, if a patient says “I’m useless; I can’t do anything right,” the nurse might respond, “I hear that you feel like a failure. Let’s look at that – you got up and came to breakfast today, which was hard but you did it. Maybe there are things you can do.” Reinforce any positive qualities or efforts the patient demonstrates, and perhaps have them list small positive aspects about themselves when they are able【48†L405-L413】【48†L408-L416】. Rationale: Reframing cognitive distortionsblogs.bcm.edublogs.bcm.edurvasive negative bias in depression【48†L405-L413】. By helping patients see evidence against their negative beliefs (even something as simple as “you managed to shower today – that shows effort and strength”), the nurse aids in rebuilding the patient’s self-esteem and hope.
Encourage Expression of Feelings: Provide time to listen actively each day. Use open-ended questions (“What are you feeling right now?”) and minimal prompts (“Go on, I’m listening”). Validate the patient’s feelings (“That sounds very difficult. I’m sorry you’re going through this.”). Avoid cliché reassurance (don’t say “cheer up” or “it could be worse”). Rationale: Ventilating feelings in a supportive environment can relieve internal pressure. It also helps the nurse gauge the patient’s thought content (despair level, any harmful ideation) and shows the patient that someone cares and is not frightened by their emotions.
Monitor and Promote Adequate Nutrition and Hydration: Assess the patient’s food and fluid intake. If appetite is poor, offer small, high-protein, high-calorie snacks frequently, and favorite foods if possible. Consider my.clevelandclinic.orgmy.clevelandclinic.org* (shakes, etc.) if intake is very low. If the patient is too apathetic to eat, the nurse may need to sit with them at mealtimes and provide encouragement or assistance (cutting food, gently prompting). Rationale: Malnutrition and dehydration can quickly worsen fatigue and cognitive problems, creating a vicious cycle with depression【48†L414-L418】【48†L416-L420】. Regular nutrition helps energy levels and is essential for recovery. The act of eating regularly also gives structure to the day.
Promote Sleep Hygiene: Help the patient establish a regular sleep routine – going to bed and waking up at consistent times. Limit daytime napping (which can worsen nighttime insomnia). Encourage a relaxation routine in the evenimy.clevelandclinic.orgple, warm shower, caffeine-free tea, or listening to calm music. Ensure the environment at night is quiet and comfortable (reduce noise, dim lights). If the patient is lying awake ruminating, nursing measures like a brief back rub or reassurance might help. If prescribed, administer sleep medications (e.g., trazodone or a benzodiazepine) and monitor effectiveness. Rationale: Quality sleep is crucial for mood regulation and healing. Depression often disrupts sleep architecture (with problems like early-morning awakening or non-restful sleep), so these measures, along with medications, improve sleep continuity【52†L271-L279】【52†L275-L280】. Better sleep can in turn improve daytime mood and energy.
Medication Administration and Education: Administer antidepressant medications as ordered and monitor for effects and side effects. Common antidepressant classes include SSRIs, SNRIs, bupropion, mirtazapine, tricyclics, MAOIs (see Pharmacologic Treatments below for details). It is important to educate the patient (and family) that antidepressants typically take 2–4 weeks to start improving symptoms and up to 8–12 weeks for full effect【24†L25-L33】【24†L29-L37】. Emphasize continuing the medication even if they don’t feel better right away. Also review potential side effects (e.g., nausea, dry mouth, sexual side effects with SSRIs) and the importance of not abruptly stopping the medication. If the patient has low energy and is at risk for overdose, the hospital or family may manage the medication supply (to prevent hoarding pills for a suicide attempt). Rationale: Proper administration ensures therapeutic blood levels are reached. Education empowers the patient, setting realistic expectations and improving adherence. Monitoring and addressing side effects can prevent early discontinuation. Black Box Warning: Antidepressants may transiently increase suicide risk in young adults by boosting energy before mood improves – nurses must closely watch for any worsening agitation or emergent suicidal thinking, especially in the first few weeks【26†L702-L710】【26†L704-L709】.
Family Involvement and Psychoeducation: With patient consent, involve family members or significant others in care. They can provide collateral history and support. Educate family (and patient) about the nature of depression – it is a medical illness, not a personal failing, and it tends to be recurrent. Teach them the signs of worsening depression or suicidal ideation to watch for at home. Encourage family to be patient and to not dismiss the person’s feelings with “just cheer up” messages (educate about stigma and the need for support). Provide resources such as NAMI (National Alliance on Mental Illness) family support groups. Rationale: Family understanding can create a more supportive home environment and facilitate treatment adherence【48†L430-L439】【48†L435-L442】. Psychoeducation has been shown to reduce relapse rates. It also helps counteract stigma; many cultures and families have misconceptions about depression (e.g., seeing it as weakness) which, if corrected【38†L84-L92】【38†L85-L93】, will encourage the patient to continue treatment and feel supported.
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:
Maintaimy.clevelandclinic.orgmy.clevelandclinic.orgal for Injury: Create a safe environment by removing any dangerous objects from the vicinity (sharp items, belts, shoelaces if self-hncbi.nlm.nih.govncbi.nlm.nih.govn)【52ncbi.nlm.nih.govncbi.nlm.nih.govecause manic patients are often hyperactive and easily distracted, ensure the surroundings are as hazard-free as possible (for example, keep corridors clear of equipment to prevent tripping during pacing). Supervise the patientncbi.nlm.nih.govcially if behavior is erratic – assign staff to observe at all times if needed. If the patient shows sncbi.nlm.nih.govting aggression or inability to control impulses (shouting, threatening, physical restlessness), set limits in a firm, calm manner: “You ancbi.nlm.nih.govd right now, but you cannot hit or threaten people. If you cannot control your behavior, we will help you to stay safe.” Keep instructions short and simple. In extreme cases, use of seclusion or restraints might be considered as a last resort if other de-escalation ncbi.nlm.nih.govpataafp.orgaafp.org【56†L37-L46】, but the goal is to avoid this by early intervention. Rationale: Manic individuals often lack insight and impulse control, so external structure and limit-setting are necessary to protect them and otheraafp.orgaafp.org】. Clear, concise communication helps cut through their distractibility. Limitsaafp.orgaafp.orgboundaries that the patient cannot set for themselves during mania.
Decrease Environmental Stimulation: Place the manic patient in a quiet part of the unit, away from loud noise or a lot of activity, if possible. A private room with minimal decor may be ideal, but ensure they are safe (remncbi.nlm.nih.govncbi.nlm.nih.govey might climb on, etc.). Keep lighting soft and noise low. Limit the number of people interacting with the patient at one time – too many voices can be overwhelming. Redirect the patient gently if they become overly stimulated (e.g., “Let’s step away from the dayroom now and go to a cssrs.columbia.educssrs.columbia.eduRationale: Mania is often exacerbated by excessive stimuli; patients are already overstimulated internally, so a calm external environment helps to reduce sensory overload and agitation【52†L336-L344】【52†L338-L342】. This can greenspacehealth.comlation of manic symptoms (for example, a quiet space can help decrease pressure of speech or racing thoughts somewcssrs.columbia.eduse Calm, Simple Communication:** When speaking with a manic patient, use a calm, matter-of-fact tone. Keep sncbi.nlm.nih.govncbi.nlm.nih.gov“Please sit down. Here is a sandwich.”* – rather than long explanationncbi.nlm.nih.govncbi.nlm.nih.gov to follow. Reorient the patient gently if they jump topics: “Right now, we my.clevelandclinic.orgmy.clevelandclinic.orgour medication.” Avoid arguing or getting into power struggles. If the patient is delusional (e.g., says “I am the chosenaafp.orgaafp.org challenge the delusion (that may provoke anger); instead, respond with neutral honesty: *“I understancssrs.columbia.educssrs.columbia.eduon’t see it that way, but I want to help you because you seem very excited and anxious.”uptodate.come: Short, focused communication is easier for the over-stimulated mamentalhealth.commentalhealth.comL327】【52†L325-L333】. A calm demeanor can also have a modeling effect, helping to tone down thblogs.bcm.edublogs.bcm.eduing one topic at a time helps contain flight of ideas. Acknowledgpsychdb.compsychdb.com without reinforcing delusions maintains trust and avoncbi.nlm.nih.govncbi.nlm.nih.govsupporting false beliefs.
Provide Structure to ncbi.nlm.nih.govncbi.nlm.nih.govn manic episodes often start many tasks but finish few. The nurse cancbi.nlm.nih.govncbi.nlm.nih.govivities for the patient. For instance, schedule frequent rest periods – manic patnurseslabs.comnurseslabs.comg unless prompted, so the nurse might say, “Let’s sit and have nursetogether.comnursetogether.com for the last 30 minutes”【49†L29-L37】【49†L30-L34】. Promote rest by ennursetogether.comnursetogether.comet time” periodically even if the patient says they are not tired. Givenurseslabs.comnurseslabs.comnel energy in constructive ways: **folding towels, drawing, walking with stafnurseslabs.comnurseslabs.com or competitive games (which could increase frustration or aggression). Rationale: Strncbi.nlm.nih.govncbi.nlm.nih.govnd a manic patient and prevent complete exhaustion【26†L665-L673】【26†Lmedicalnewstoday.commedicalnewstoday.comt can prevent physical collapse (since mania may drive them to neanurseslabs.comnurseslabs.compurposeful tasks like walking or sorting papers give an outlet for excessive energy while minimizing pnurseslabs.comnurseslabs.comation. Physical exercise can also help discharge energy – e.g.,ncbi.nlm.nih.govenjoy it and can focus, use an exercise bike or take them to a low-stimulus area for exercise; this can reducpmc.ncbi.nlm.nih.govmy.clevelandclinic.org sleep later【52†L344-L351】【52†L346-L349】.
Nutrition and Hydration Support: A manic patient mancbi.nlm.nih.govacted to sit and eat a full meal. Offer high-calorie, portable foods (finger foods) that they can eat on the go – for ncbi.nlm.nih.goviches, granola bars, cheese sticks, fruit – and fluids they can drink from a cup with a lid (to avoid spillnurseslabs.comnurseslabs.comand the food to them while they’re moving: “Here, take a bite of this”. Remind them to drink fluids regularly, as dehydration can occur. Monitor their weight and physical stanurseslabs.comnurseslabs.com ensure the patient gets nutrition without having to settle at a table, which they may refuse to do【26†L665-L673】【26†L677-L680】. High-energy output requires more calories; providing easy nutrition prevents dangerous weight loss or electrolyte imbalances. This intervention also addresses their poor concentration – they might not focus long enough for a tray meal, but they’ll eat a sandwich while walking and talking. Adequate hydration is important since manic patients may forget to drink and risk dehydration.
Sleep Promotion: Establish a bedtime routine inaafp.orgaafp.orgonment. Prior to sleep, reduce stimuli even further – dim lights, quiet voice. Avoid caffeine or heavy meals in the eveniaafp.orgaafp.orgo active at night, it might be necessary to limit visitors or phone access in late hours to reducncbi.nlm.nih.govncbi.nlm.nih.govcations (e.g., a prescribed benzodiazepine or antipsychotncbi.nlm.nih.govhould be given as ordered to help with sleep – inform the patient in simple terms: “This medicine will help slow your mind so you can rest.” Aim for at least 4–6 hours of sleep permedicalnewstoday.comL87】【51†L81-L88】 as a starting goal, since total sleep deprivation can precipitate worsening mania or even delirium. Rationale: Sleep deprivation can escalate mania; restoring some sleep is often the first step to recovery【26†L673-L680】【26†L675-L680】. The interventions above create an environment conducive to sleep. Medication may be crucial because the patient’s brain may not “turn off” on its own – a sedative or antipsychotic can slow racing thoughts enough for sleep to occur【52†L260-L268】【52†L262-L270】.
Set Limits on Dangerous or Inappropriate Behavior: Manic individuals may have poor boundaries – they might intrude on others’ space, make inappropriate sexual comments, or spend money recklessly. It’s important for the nurse to politely but firmly redirect such behaviors. For example, if a patient is sexually inappropriate, respond, “That language is not acceptable here. Let’s focus on something else.” If they are trying to coerce other patients into rule-breaking, staff must intervene. Consistent limit-setting among the care team is vital, so the patient doesn’t receive mixed messages. Rationale: Clear behavioral limits provide external control that the patient lacks during mania【26†L681-L688】【26†L678-L686】. It also protects the rights and safety of others on the unit. Consistency helps the patient learn what behaviors are expected and that the staff will enforce rules uniformly, which can actually help them feel more secure.
Medication Administration and Monitoring: Administer ordered medications for mania which typically include mood stabilizers and/or antipsychotics. In acute mania, injectable antipsychotics or benzodiazepines might be used for rapid calming. For example, haloperidol or olanzapine might be given if the patient is extremely agitated or psychotic, and lorazepam might be given for sedation. Ensure the patient actually swallows oral medications (they might cheek pills). If the patient refuses medication (common if they don’t think they’re ill), the team might need to implement a short-term medication over objection (depending on legal status) if they are a danger. Monitor medication effects: e.g., watch lithium levels if the patient is on lithium – blood draws are needed about 5 days after starting or dose changes to ensure a therapeutic (0.6–1.2 mEq/L) but not toxic level【26†L673-L680】【26†L675-L680】. For divalproex (valproate), check liver function tests and CBC. For antipsychotics, monitor for extrapyramidal symptoms or metabolic side effects. Rationale: Medications are usually essential to bring mania under control【24†L25-L33】【24†L26-L34】. Lithium is considered a first-line agent that not only treats mania but has anti-suicidal properties【26†L673-L680】【26†L675-L683】. However, lithium’s narrow therapeutic index means the nurse must be vigilant for toxicity signs (tremor, ataxia, vomiting)【50†L399-L408】【50†L401-L409】. Fast-acting medications like antipsychotics can rapidly decrease manic symptoms and prevent harm【24†L53-L61】【24†L55-L63】. Monitoring adherence is tricky in mania; thus the possibility of cheeking or refusal is high – sometimes a long-acting injectable may be considered if adherence is poor. The nurse’s role is to educate the patient (as much as they can process) on why the med is given: “This will help slow your mind and protect you,” and to ensure it’s taken.
Nutrition/Hydration as above and PRN medical care: Continue to monitor physical health: check vital signs (mania can sometimes trigger arrhythmias or dehydration), ensure bowel habits (some manic patients forget to use the bathroom regularly or can become constipated from not sitting still long enough). Provide PRN care like a cool cloth if they’re overly warm from constant movement, or a soothing shower if tolerated.
Attention to Elimination: Encourage the patient to use the restroom regularly. In severe mania, someone might be so distracted that they ignore bladder cues. This can lead to incontinence episodes or UTIs. The nurse can simply remind, “Let’s take a bathroom break.” Also, check if the patient is having any diarrhea or vomiting if on lithium, as this can affect lithium levels (lithium toxicity risk rises with dehydration)【25†L19-L27】【25†L25-L28】.
Engage Family or Trusted Individuals (if possible): Involve family members to help monitor the patient’s behavior and to provide collateral information on baseline functioning. Often family can tell when an episode is brewing. Teach family not to take the patient’s comments or anger personally during the episode (patients may say hurtful or outlandish things in mania). Also discuss the importance of setting boundaries at home (e.g., limiting access to car or credit cards during future episodes for safety). Rationale: Families can be invaluable in supporting medication adherence and watching for early signs of relapse【48†L430-L438】【48†L435-L443】. They also need support and education, since dealing with a loved one’s mania can be frightening or frustrating.
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:
Selective Serotonin Reuptake Inhibitors (SSRIs): (e.g., fluoxetine, sertraline, citalopram, escitalopram, paroxetine). SSRIs work by increasing serotonin levels in the synapse. They are considered first-line for MDD due to relatively favorable side effect profiles. Common side effects: gastrointestinal upset (nausea, diarrhea), headache, insomnia or somnolence, sexual dysfunction (decreased libido or difficulty orgasm). Nurses should monitor for improved sleep, appetite, energy as early signs of response, but also watch for increased agitation or suicidal ideation in initial weeks (especially in adolescents/young adults)【26†L702-L709】【26†L704-L709】. Patient education: do not abruptly stop SSRIs (to avoid discontinuation syndrome of flu-like symptoms and insomnia); no need for addiction fear – they are not habit-forming. Remind that it may take a few weeks to feel better. SSRIs also have low cardiotoxicity in overdose (safer for suicidal patients than older antidepressants).
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): (e.g., venlafaxine, duloxetine, desvenlafaxine). These boost both serotonin and norepinephrine. They can be effective especially if fatigue or chronic pain coexists (duloxetine is also indicated for neuropathic pain). Side effects overlap with SSRIs; venlafaxine can raise blood pressure at higher doses (monitor BP). SNRIs can precipitate sweating and anxiety initially due to noradrenergic activity. They also carry a suicide warning. Venlafaxine is noted to have a somewhat higher risk of causing a switch to mania in bipolar patients compared to SSRIs【26†L702-L709】【26†L704-L709】 – hence avoid in bipolar unless on mood stabilizer.
Atypical Antidepressants: This group includes bupropion, mirtazapine, and others like trazodone (used more for sleep at low doses). Bupropion increases dopamine/norepinephrine and is energizing (useful for low energy, excessive sleep, and for smoking cessation). It does not cause sexual side effects, which is a big advantage for some patients. But avoid in those with seizure risk or eating disorders (lowers seizure threshold). Mirtazapine increases serotonin/norepi in a different way and is sedating with appetite increase (often leads to weight gain) – good for depressed patients with insomnia and weight loss. Trazodone is a weak antidepressant but a popular sleep aid (watch for side effect of priapism in males, though rare). Nurses administering these should tailor education: e.g., bupropion dose not to be doubled if missed (due to seizure risk), mirtazapine best taken at night.
Tricyclic Antidepressants (TCAs): (e.g., amitriptyline, nortriptyline, imipramine). Older class, very effective but with more side effects (anticholinergic effects like dry mouth, constipation, blurry vision, urinary retention; orthostatic hypotension; sedation; weight gain). They also can be cardiotoxic in overdose (risk of fatal arrhythmias), so generally not first-line if suicide risk is high【24†L23-L31】. Nurses need to monitor blood pressure, EKG in older patients or high doses, and watch for anticholinergic side effects (provide sugar-free gum for dry mouth, stool softeners for constipation, precautions for dizziness). Patient teaching: avoid alcohol (increases sedative effect), be careful changing positions (orthostasis). TCAs are lethal in overdose (only a week’s supply can be dangerous), so dispensing small quantities or having family manage the pills might be necessary.
Monoamine Oxidase Inhibitors (MAOIs): (e.g., phenelzine, tranylcypromine, selegiline patch). These are seldom used except in treatment-resistant cases due to dietary restrictions. MAOIs block an enzyme that breaks down monoamines, but also inactivate tyramine (from foods). Patients must avoid high-tyramine foods (aged cheeses, cured meats, fermented products, wine, etc.) to prevent a hypertensive crisis【26†L702-L709】【26†L705-L709】. Nurses must provide a detailed diet list and alert about drug interactions (e.g., decongestants can also cause dangerous BP rise with MAOIs). Common side effects: hypotension, insomnia, sexual dysfunction, weight gain. Because of the intense management, MAOIs are usually last resort, but they can be very effective for atypical depression. In hospital, ensure dietary compliance; have anti-hypertensive (like IV phentolamine or nifedipine) on hand in case of hypertensive emergency (BP, headache, flushing). When switching an MAOI to another antidepressant, a 2-week washout is needed to avoid serotonin syndrome.
Newer Treatments: In recent years, treatments like esketamine (Spravato) nasal spray (a form of ketamine approved for treatment-resistant depression) and brexanolone (for postpartum depression) have emerged. Esketamine, given in clinics under supervision, can rapidly reduce depression within hours by modulating glutamate (NMDA receptors)【11†L163-L171】. Nurses involved in esketamine administration monitor for dissociation, blood pressure changes, and ensure the patient has safe transport home (due to possible sedation). Brexanolone is an IV infusion of a neurosteroid (allopregnanolone) for severe postpartum depression; it requires 60-hour monitored infusion. These specialized therapies are for specific cases and require nurses to monitor vitals and mental status closely during administration.
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.
Lithium: The classic mood stabilizer for Bipolar I. Lithium treats acute mania and helps prevent recurrence of both manic and depressive episodes. It has proven anti-suicidal effects, significantly reducing suicide risk in bipolar patients【26†L673-L681】【26†L675-L682】. Therapeutic blood level is ~0.6–1.2 mEq/L; levels >1.5 can cause toxicity【50†L399-L407】【50†L399-L407】. Nursing considerations: Monitor lithium levels regularly (every 5 days when starting or adjusting dose, then every 1–3 months during maintenance)【25†L49-L57】【25†L55-L63】. Ensure patient consumes consistent salt and fluid intake – dehydration or low sodium (e.g., from heavy sweating, diuretic use, or illness with vomiting/diarrhea) can raise lithium levels and precipitate toxicity【25†L73-L80】【25†L75-L79】. Watch for signs of toxicity: early signs include diarrhea, vomiting, drowsiness, tremor, muscle weakness, lack of coordination【50†L399-L408】【50†L401-L409】. Late signs: coarse tremor, confusion, severe polyuria, ataxia, even seizures or coma【57†L445-L454】【57†L447-L455】 – this is a medical emergency. Common side effects at therapeutic levels: fine hand tremor, mild nausea (take with food to reduce), increased thirst and urination (polyuria/polydipsia due to mild nephrogenic diabetes insipidus), weight gain, and long-term, potential effects on thyroid (hypothyroidism) and kidneys【50†L419-L427】【50†L419-L427】. So nurses should monitor thyroid function (TSH) and renal labs (BUN, creatinine) every 6-12 months【50†L417-L423】【50†L419-L427】. Patient teaching: stay hydrated (2-3 L of water a day, more if sweating), don’t drastically change salt intake, get levels checked, and do not stop lithium suddenly. Also, avoid NSAIDs if possible (they can increase lithium levels). Lithium is not recommended in pregnancy (risk of birth defects). Despite the hassle of monitoring, lithium is the gold-standard for classic euphoric mania and maintenance【26†L671-L680】【26†L673-L680】, and many patients respond very well to it.
Anticonvulsants (Anti-Seizure Medications) used as Mood Stabilizers: Several antiepileptic drugs have mood-stabilizing properties:
Valproate (Divalproex Sodium/Valproic Acid): Very effective for acute mania, especially rapid-cycling or mixed episodes【26†L681-L688】【26†L684-L690】. It works faster than lithium in many cases (can titrate to high dose in a few days)【26†L670-L678】【26†L671-L678】. Typical blood level target for mania is 50–125 µg/mL (monitor valproate levels, LFTs, CBC). Side effects: sedation, tremor, weight gain, potential liver toxicity (black box: hepatic failure), pancreatitis, thrombocytopenia, hair loss. Not for use in pregnancy (high risk of birth defects). Nursing: check liver enzymes and platelet counts periodically, watch for signs of liver issues (abdominal pain, jaundice) or bleeding. Educate patient about avoiding alcohol (both are liver-metabolized) and not to discontinue abruptly. Often a first-line for mania, can be combined with antipsychotics. Fast titration advantage: one can load valproate to therapeutic level within a couple of days, so it’s often used in acute inpatient settings for quick control【25†L55-L63】【25†L55-L63】.
Carbamazepine: Useful for mania, especially in patients who don’t respond to lithium or have mixed features. Also indicated for trigeminal neuralgia (so helpful if comorbid pain issues). Requires monitoring of levels and can cause aplastic anemia or agranulocytosis (rarely), so CBC must be monitored. Also can cause liver enzyme elevation. It has many drug interactions (induces liver enzymes). Not a first-line mood stabilizer but an option for refractory cases or certain subtypes. Side effects: dizziness, drowsiness, nausea, risk of serious rash (Stevens-Johnson syndrome, especially in certain Asian populations with HLA-B*1502 allele – genetic testing recommended in those patients). Nurse should monitor WBC and ANC (absolute neutrophil count) for any drop.
Lamotrigine: More effective for bipolar depression and maintenance than acute mania (it’s not useful in acute mania due to need for slow titration). It’s often given to prevent depressive episodes in Bipolar I or as the main drug in Bipolar II (which is dominated by depression). Biggest concern: Stevens-Johnson Syndrome (SJS), a life-threatening skin rash. To mitigate this, lamotrigine must be titrated very slowly (over 6-8 weeks) to the target dose. If patient stops taking it for more than a few days, they have to start titration from the beginning. Side effects: generally well tolerated except rash risk; some get headache or diplopia. Nursing: educate about any rash – any rash or mucous membrane sore -> hold med and see prescriber immediately to rule out SJS. Otherwise, monitor mood as lamotrigine often helps bipolar patients have fewer depressive swings.
Other anticonvulsants (like oxcarbazepine, topiramate) are sometimes used off-label or adjunctively, but evidence is strongest for the above three.
Atypical Antipsychotics: Many second-generation antipsychotics (SGAs) are FDA-approved for bipolar mania or bipolar depression. Examples: Olanzapine, Risperidone, Quetiapine, Ziprasidone, Aripiprazole, Asenapine, Cariprazine, Lurasidone. In acute mania, SGAs can rapidly reduce symptoms (sometimes used with lithium or valproate for synergy)【24†L53-L61】【24†L55-L63】. Quetiapine, Lurasidone, and Cariprazine are approved for bipolar depression【24†L57-L65】【24†L59-L67】. Symbyax (the combination of olanzapine and fluoxetine) is another option for bipolar depression. These drugs modulate dopamine and serotonin. Nursing considerations: Monitor for metabolic side effects (weight gain, blood sugar, cholesterol) – especially olanzapine and quetiapine have high risk【26†L696-L703】【26†L698-L700】. Periodically check weight, glucose, and lipids. Also observe for extrapyramidal symptoms (less common in SGAs but can happen: tremors, rigidity, restlessness akathisia). Sedation is common with some (quetiapine, olanzapine) – sometimes a benefit at bedtime. Ensure patient knows not to drive until they see how it affects them (due to sedation). For risperidone, watch for any signs of prolactin elevation (e.g., breast changes). Antipsychotics can be given IM for acute mania if needed (e.g., IM ziprasidone or IM olanzapine). They often act faster than lithium/valproate alone, so guidelines often recommend an SGA plus a traditional mood stabilizer for severe mania【24†L53-L61】【24†L55-L63】.
Key point: antipsychotics treat mania and some are effective for bipolar depression (notably quetiapine, lurasidone). Quetiapine in particular is effective across bipolar depression and mania and is often used for maintenance too【26†L711-L718】【26†L713-L718】. Lurasidone is weight-neutral and good for bipolar depressive episodes in pregnancy category B (often chosen for bipolar depression in pregnant patients due to better safety).
Many bipolar patients will remain on an antipsychotic long-term as part of their regimen. The nurse should encourage adherence and manage side effects: e.g., if weight gain is an issue, involve dietitian or exercise programs, check prolactin if sexual side effects emerge with risperidone, etc.
Benzodiazepines: While not true “mood stabilizers,” benzos like lorazepam or clonazepam are often used short-term for acute mania to help with anxiety, agitation, and sleep【52†L260-L268】【52†L262-L270】. E.g., giving lorazepam at bedtime to a manic patient to aid sleep, or IM lorazepam for acute calming. These are adjuncts and not for long-term use due to dependence risk. Nurses must monitor for oversedation, respiratory depression (especially if combined with other sedatives), and educate that it’s short-term (to prevent patient expecting it indefinitely). Avoid in patients with substance abuse history if possible.
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.
Psychotherapy: Evidence-based psychotherapies significantly help in depression and bipolar disorder, often in conjunction with medications.
Cognitive Behavioral Therapy (CBT): Focuses on identifying and modifying distorted thought patterns and behaviors that contribute to depression. For example, a patient learns to challenge the automatic thought “I am worthless” with more balanced thinking. CBT also encourages scheduling pleasant activities and problem-solving. It can reduce relapse by teaching patients skills to handle stress and negative thoughts. Nurses can support CBT principles in daily interactions by reinforcing positive self-statements or pointing out cognitive distortions gently (as described in interventions for depression above).
Interpersonal Therapy (IPT): Focuses on improving interpersonal relationships and social functioning, based on the idea that relationship problems (loss, role disputes, role transitions, social deficits) can trigger or perpetuate depression. IPT helps patients communicate feelings, deal with grief, or adapt to life changes (like postpartum role). Nursing role may involve helping patient practice communication skills or role-playing difficult conversations, and encouraging social engagement as therapy homework【48†L380-L388】【48†L380-L387】.
Behavioral Therapies: Including behavioral activation (scheduling activities that increase positive reinforcement), and in bipolar, social rhythm therapy (maintaining daily routines to support circadian rhythms)【50†L449-L457】【50†L449-L457】.
Family-Focused Therapy: Particularly in bipolar disorder, involving family members to improve communication, reduce “expressed emotion” (critical or hostile attitudes that can trigger relapse), and solve problems collaboratively【50†L449-L457】【50†L451-L454】. Psychoeducation about the illness is a big component. Nurses can initiate family psychoeducation sessions or support groups.
Dialectical Behavior Therapy (DBT): Useful if comorbid personality disorder or self-harm behaviors exist. It combines CBT techniques with mindfulness and emotional regulation skills.
Group Therapy: Both support groups (peer-led, like Depression and Bipolar Support Alliance) and therapy groups led by professionals can provide valuable sharing of experiences and coping strategies. Group sessions give patients a sense of not being alone and provide hope by seeing others’ recovery. Nurses may facilitate inpatient psychoeducational groups on medication management, coping skills, etc.
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.
Electroconvulsive Therapy (ECT): ECT is a highly effective treatment for severe depression, treatment-resistant depression, acute suicidality, or depression with psychotic features. It’s also used in bipolar disorder for severe mania or catatonia that doesn’t respond to medication【50†L457-L460】【54†L1-L4】. ECT involves passing a brief electrical current through the brain to induce a controlled seizure, under general anesthesia and muscle relaxation. It’s typically done 2-3 times a week for 6-12 treatments. Nursing role pre-ECT: obtain informed consent, ensure NPO status (since anesthesia will be used), remove dentures or any loose objects, and check vitals. Post-ECT nursing care: monitor airway and breathing until the patient is fully awake, check vital signs, reorient the patient (post-ictal confusion is common), and assure that temporary memory loss or headache can occur. Provide reassurance – some patients wake up disoriented or with short-term memory gaps (often clears over hours to days). ECT has stigma, so nurses educate that it is safe (modern ECT is performed with anesthesia, so there’s no convulsing like in old movies) and often lifesaving, with a high success rate in lifting severe depression. Memory side effects mostly affect the time around the treatments (some can have retrograde amnesia for events weeks before ECT). ECT is particularly beneficial for patients who cannot wait weeks for an antidepressant to work due to suicide risk or those who cannot tolerate medications【26†L694-L699】【26†L696-L700】.
Repetitive Transcranial Magnetic Stimulation (rTMS): A newer option for depression, rTMS uses magnetic pulses (applied via a coil on the scalp) to stimulate specific brain areas (usually left prefrontal cortex). It’s done outpatient daily for several weeks. Nurses in a psych clinic may assist with rTMS sessions, ensuring the patient has no metal in head (no metallic implants), positioning the magnet, and observing for scalp discomfort or headache (common side effects). rTMS does not require anesthesia and has no cognitive side effects, unlike ECT. It’s not as immediately potent as ECT but is a good option for moderate depression or for those who want to avoid ECT or medications.
Ketamine Infusions: As mentioned, intravenous ketamine (or intranasal esketamine) given in specialized clinics can rapidly reduce depressive symptoms in treatment-resistant cases. Nurses monitor blood pressure (ketamine can transiently raise it) and dissociative effects (patients might feel strange, like out-of-body, temporarily). The patient is observed for ~2 hours after dose. Ketamine’s effect is rapid (often within 24 hours) but can be temporary; it’s usually given in a series of infusions.
Light Therapy (Phototherapy): For Seasonal Affective Disorder (SAD) (winter depression), bright light therapy (10,000 lux fluorescent light box, 30 minutes each morning) is very effective. Nurses teach patients how to use a light box – sit at a slight angle about 2 feet away, with eyes open but not looking directly into the light, usually early morning daily during fall/winter. Monitor for any irritability or hypomania as a side effect (rarely, light therapy can trigger a manic switch in bipolar patients). Also ensure they understand it’s a specific therapeutic light box (not just a household lamp). This treatment works by influencing melatonin and circadian rhythms.
Exercise and Lifestyle: Regular aerobic exercise has antidepressant effects comparable to medications in mild depression【50†L442-L450】【50†L449-L457】. It also helps in bipolar by improving cardiovascular health (important since many bipolar meds cause weight gain). Nurses can help patients set small exercise goals (even short walks) and educate on how exercise releases endorphins, reduces stress. Diet can also play a role (e.g., omega-3 fatty acids from fish oil have some mood-stabilizing evidence). Encouraging a balanced diet, limited alcohol/caffeine (caffeine can worsen anxiety/insomnia and trigger mania in some bipolar patients), and smoking cessation (nicotine can interfere with psychiatric meds metabolism) are all part of holistic care.
Sleep Hygiene and Routine (IPSRT): Emphasize maintaining a regular sleep-wake schedule, even on weekends, for bipolar patients to prevent episodes【50†L449-L457】【50†L451-L457】. Teach avoiding shift work or frequent time zone changes if possible, as these can precipitate mania. Good sleep hygiene includes a cool, dark, quiet bedroom; using bed only for sleep or relaxing (no work or bright screens in bed); and avoiding vigorous exercise or heavy meals right before bedtime.
Support Groups and Psychoeducation: Encourage patients and families to attend groups like Depression and Bipolar Support Alliance (DBSA) or National Alliance on Mental Illness (NAMI) programs. These provide psychoeducation, reduce isolation, and let people share coping strategies. Psychoeducation topics for patients include: understanding the illness, early warning signs of relapse (e.g., reduced need for sleep might herald mania; withdrawing might herald depression – list personal signs), importance of adhering to treatment, and strategies for handling stress and medication side effects【48†L430-L438】【48†L432-L439】.
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:
Symptom Expression: In some cultures, depression is expressed more through physical (somatic) symptoms than emotional complaints【43†L253-L261】【43†L255-L263】. For instance, many patients from East Asian backgrounds may emphasize somatic complaints like headaches, dizziness, fatigue, or “internal heat” rather than saying "I feel sad" due to cultural norms that discourage open discussion of emotions. Research has shown Chinese depressed patients often present with somatic discomfort or feelings of body pain/pressure【43†L253-L261】【43†L255-L263】. Similarly, Japanese patients might focus on abdominal pain or neck pain when depressed【43†L255-L263】【43†L257-L265】. In such cases, nurses should carefully assess for depression even if the patient initially only reports physical issues – using gentle inquiry about mood and utilizing tools (translated PHQ-9 questionnaires, etc.). Conversely, some Western patients might openly report depressed mood. Cultural idioms of distress also vary – e.g., in some Middle Eastern or Mediterranean cultures, a person might describe depression as a “heavy heart” or feeling hot/cold internally. The nurse should learn common cultural expressions to better interpret patient complaints.
Stigma and Acceptance: Different cultures have varying levels of stigma around mental illness. In certain cultures, admitting to depression or seeing a psychiatrist is highly stigmatized, seen as a personal weakness or something that brings shame to the family【35†L57-L65】【35†L59-L67】. For example, some cultures might interpret depression as a spiritual or moral failing rather than a medical condition. Dr. Asim Shah notes that some communities view depression as a “produced state of mind by wealthy people” – implying if you have real problems (poverty, etc.) you don’t get depression【38†L82-L90】【38†L84-L92】. This stigma can prevent people from seeking help. Nurses should approach such patients with extra sensitivity, framing depression in acceptable terms (e.g., emphasizing physical symptoms or stress-related terms). It may help to say “many people have this reaction to stress, and it is treatable” rather than labeling it outright as depression if the patient is resistant to that label.
Cultural Beliefs about Causes and Remedies: Some cultures attribute mood problems to different causes – for instance, imbalance of “yin and yang,” disrupted energy flow, evil eye, or spiritual possession. Patients might prefer traditional healers or religious counsel over medical treatment【43†L278-L287】【43†L280-L288】. Nurses should respectfully inquire about any alternative treatments the patient is using (herbs, acupuncture, rituals) to ensure safety and integrate this into care if possible. For example, if a patient believes in Ayurveda or Traditional Chinese Medicine concepts, collaborating with those practices (as long as not harmful) can build trust. Folk remedies or dietary practices should be discussed (e.g., St. John’s Wort for depression is popular in some areas – nurse should caution about interactions, like with SSRIs). Use interpreters for patients with limited English proficiency to avoid miscommunication about symptoms or instructions.
Help-Seeking Patterns: In many non-Western societies, people first seek help from family or community and spiritual leaders rather than mental health professionals【43†L290-L299】【43†L292-L300】. A patient from a tight-knit ethnic community might worry about confidentiality or being seen at a mental health clinic. Nurses can provide reassurance about confidentiality and perhaps offer information about community mental health resources that are more private or integrated into primary care. In some cultures, the concept of seeing a therapist to talk about personal issues is foreign; psychoeducation is needed to explain how therapy works and its benefits, possibly framing it as “stress management training” or similar if that’s more acceptable.
Familial and Gender Roles: Culture also dictates family structure and support. In cultures with extended family households, a depressed individual might have more built-in support (or sometimes more family conflict). Some cultures expect family to “take care of their own,” possibly leading to reluctance to involve outsiders or hospitalization. Gender roles may influence whether a person expresses distress – e.g., men in many cultures are discouraged from crying or admitting sadness, so depressed men might present as angry or engage in substance abuse instead (an attempt to cope that masks depression). Nurses should not assume emotional openness; they might need to find culturally appropriate ways to discuss feelings (perhaps using third-person examples, or normalizing by saying “many people in your situation feel overwhelmed”).
Cultural Concepts of Depression: Not all languages even have a word for “depression” as a clinical entity【39†L168-L176】【39†L170-L176】. The nurse might need to describe it in terms that resonate culturally. For example, in some African cultures, what we call depression might be described as “thinking too much” syndrome. In some Southeast Asian groups, it might be described as a physical “pressure” or heartache. Recognizing these expressions helps in assessment. Some cultures permit open emotional expression (Mediterranean, Hispanic cultures might be more expressive) whereas others value stoicism (Asian or Northern European cultures). The nurse should gauge the patient’s cultural style and adapt communication – e.g., a very stoic patient might prefer a focus on somatic relief and problem-solving rather than probing feelings immediately.
Religious Considerations: A patient’s faith can be a source of support or conflict. Some may find solace in prayer and community (which is good to encourage as part of coping), while others might feel guilt (“God is punishing me”) contributing to depression. A spiritually sensitive approach, possibly involving a chaplain if the patient desires, can be beneficial. For many, depression treatment can go hand-in-hand with spiritual support rather than be seen as either/or.
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:
Children and Adolescents: Mood disorders can present differently in youth. Depression in children may manifest more as irritability, boredom, or physical complaints (stomach aches, etc.) rather than verbal reports of sadness【23†L855-L861】. Kids might withdraw from play or have new academic problems. Teenagers might become markedly irritable, sulk, or get into trouble (e.g., truancy, substance use) instead of seeming “sad.” The DSM-5 criteria account for this by allowing “irritable mood” as a symptom equivalent to depressed mood for children/adolescents. Youth are also more likely to have concurrent anxiety and behavior disorders. When assessing children, nurses often must gather information from caregivers and teachers (children may lack insight or vocabulary). Tools like the PHQ-A (Adolescent PHQ-9) or Children’s Depression Inventory (CDI) can be helpful. Treatment for depressed youth often emphasizes therapy (CBT, play therapy, family therapy) first, with careful use of SSRIs if needed (only a few, like fluoxetine and escitalopram, are approved for teens). Nurses must monitor closely for suicidal thoughts when youth are on antidepressants due to the FDA black box warning – adolescents are a high-risk group for suicide. Family involvement is crucial: improving family communication and reducing conflict (sometimes via family therapy) can significantly help a depressed teen.
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.
Older Adults: Depression in older adults is common but often under-recognized because it can present as memory problems or somatic complaints. Sometimes it is misdiagnosed as dementia – coined “pseudodementia,” where cognitive impairment is actually due to depression. A distinguishing feature is that depressed older adults will often emphasize what they cannot remember and have variable effort/engagement on cognitive testing, whereas those with true dementia might confabulate or be unaware of their deficits. Nurses working with seniors should screen for depression when patients report unexplained aches, fatigue, or if they have lost interest in once-enjoyed hobbies. Also, late-life depression can be precipitated by losses (friends, spouse, independence) and co-existing medical illnesses (stroke, heart disease)【45†L153-L160】【45†L155-L160】. Risk of suicide is high in elderly men in particular – white men over 85 have the highest suicide rate of any demographic group. They tend to use lethal means (firearms) and often have fewer warning signs. Therefore, any expression of hopelessness or wanting to “not be a burden” in an elderly patient should be taken seriously and assessed for suicidal intent.
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.
Peripartum and Postpartum Depression: Women have unique risks such as postpartum depression (PPD) which occurs in ~10-20% of new mothers, typically within 4-6 weeks after delivery but up to a year postpartum. PPD is more than the “baby blues” – it involves persistent low mood, tearfulness, anxiety about the baby’s health, feelings of inadequacy as a mother, and often guilt or even scary thoughts (like fear they might accidentally or impulsively harm the ... harm the baby, which greatly distresses them). Postpartum psychosis, a rare but severe condition (approx. 0.1–0.2% of births), is a psychiatric emergency where the mother experiences delusions (often related to the baby) and mood swings shortly after childbirth. Nurses must educate new mothers and their families about the “red flags” of PPD versus normal baby blues. Baby blues (experienced by ~50-80% of women) are transient mood swings, tearfulness, and anxiety peaking around day 4-5 postpartum and resolving within 2 weeks; in contrast, PPD is more intense and lasting, requiring intervention【64†L25-L33】【64†L27-L33】. Risk factors for PPD include a history of depression or bipolar disorder, inadequate support, and stressful life events. Nursing care for PPD involves screening (using tools like the Edinburgh Postnatal Depression Scale), providing support with infant care (to not overwhelm the mother), encouraging rest (sleep deprivation can worsen depression), and possibly facilitating counseling. Treatments include psychotherapy and possibly antidepressants (SSRIs that are safe in breastfeeding, such as sertraline). Cultural note: Some cultures have strong postpartum support traditions (extended family assisting the mother for 40 days, etc.), which can protect against PPD, whereas in nuclear-family settings some women may feel isolated. Nurses should assess the mother’s support system. In cases of postpartum psychosis or severe PPD with suicidal or infanticidal risk, hospitalization and ECT are considered. It’s important for nurses to convey no blame to the mother – PPD is a medical condition, not a sign of failure as a mom. Emphasize that with treatment, she will get better and can bond with her baby.
Gender Considerations: Gender can influence the prevalence, presentation, and management of mood disorders:
Women: As noted, women have roughly twice the prevalence of unipolar depression as men【13†L190-L198】. Hormonal factors like menstrual cycle changes (e.g., in severe cases, Premenstrual Dysphoric Disorder), pregnancy, postpartum, and menopause transitions can trigger mood symptoms. Nurses should assess for perimenstrual mood worsening or postpartum timing. Women are more likely to report typical depressive symptoms such as sadness, guilt, and worthlessness openly. They also are more likely to seek help for mental health issues (which partly contributes to higher reported rates). Postpartum mood disorders are unique to women; perimenopausal depression is also a phenomenon when estrogen fluctuations occur in mid-life. In bipolar disorder, women more often have rapid cycling and Bipolar II (more depressive episodes and hypomania)【5†L155-L163】【5†L199-L207】. They may also experience mood exacerbations related to hormonal shifts (e.g., postpartum mania or depression, or mood worsening premenstrually in bipolar). Certain medications like valproate are teratogenic, so for women of childbearing age, family planning and contraceptive counseling are key nursing considerations.
Men: Men have a lower diagnosed rate of depression, but this may be partly due to underreporting. Men with depression are more likely to present with irritability, anger, or risk-taking behaviors (like increased alcohol/drug use, reckless driving) instead of saying “I’m depressed.” They also have a higher propensity to complete suicide – men die by suicide at rates 3-4 times higher than women, often using more lethal means【35†L57-L65】【35†L59-L67】. Thus, even though women attempt suicide more, men’s attempts are more often fatal, making suicide assessment in depressed males extremely critical. Culturally, men might feel stigma in admitting emotional vulnerability, so nurses might approach the topic indirectly, for instance by asking about stress, sleep, or irritability. In bipolar disorder, males have an equal prevalence to females and might have more classic Bipolar I presentations. One gender-related aspect: males with bipolar may have onset a bit earlier on average (late teens) and are at risk for co-occurring substance misuse.
LGBTQ+ individuals: Although not strictly a “gender” category, it’s relevant to mention that individuals who are LGBTQ+ have higher rates of depression and suicidality compared to the general population, often due to stigma, discrimination, and minority stress. Nurses should provide an open, affirmative environment, as shame or lack of understanding from healthcare providers can be a barrier to care. Simply using a patient’s preferred pronouns and acknowledging their partner or identity can build trust. Screening for mood disorders in this population is important, and resources like LGBTQ+-friendly therapists or support groups can be very helpful.
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:
Risk for Self-Directed Violence related to hopelessness and suicidal ideation.
Hopelessness related to divorce, loss of support, and depressive illness as evidenced by patient stating “It will never get better, I can’t go on”.
Imbalanced Nutrition: Less than Body Requirements related to decreased appetite and depression, as evidenced by 15 lb weight loss in 2 months.
(Additional: Disturbed Sleep Pattern, Self-Care Deficit (hygiene), etc., could also be pertinent. Here we’ll focus on the top three.)
Goals (Outcomes):
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.)
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.
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.)
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:
Suicide Precautions: Place A.B. on suicide precautions level 1, meaning continuous observation or safety checks every 15 minutes per unit protocol. Keep her in a room near the nurse’s station for easier monitoring. Remove any potentially dangerous objects from her room (belts, razors, glass items). Establish a no-suicide contract or safety plan: have A.B. agree verbally or in writing that “If I feel like harming myself, I will seek out staff.” Rationale: Given her suicidal ideation, stringent monitoring is critical to ensure she does not act on any impulses【48†L386-L394】【48†L391-L399】. Many suicides in hospitals occur by sudden impulse, so removing means (e.g., no access to sharps or ligature points) and frequent checks reduce opportunity【48†L391-L399】【48†L393-L401】. A safety plan empowers the patient to alert staff and identifies coping strategies to use in crisis, fostering a sense of control and collaboration in maintaining safety. (Research shows directly asking about suicidal thoughts does not “plant” ideas and is essential for prevention, so the nurse will continue to assess suicidality daily.)
Therapeutic Relationship & Hope Instillation: Spend scheduled 1:1 time with A.B. at least twice each shift to engage in supportive conversation. During these times, use active listening and convey empathy: “I hear how overwhelming things feel right now.” Avoid facile reassurance, but do express realistic hope: for example, share that depression is treatable and that many people do recover【38†L84-L92】【38†L85-L93】. Introduce the idea that her feeling of hopelessness is a symptom of depression (not an objective truth), which can lift as treatment progresses. Encourage her to identify one small positive or a reason to keep living, such as her child’s need for her (if appropriate, as sometimes mentioning children can either instill hope or guilt – gauge her reaction). Rationale: A trusting nurse-patient relationship is the foundation for all other interventions【48†L399-L407】【48†L401-L408】. It provides A.B. a safe space to express feelings. By framing hope as something that can return (even if she can’t feel it now), the nurse challenges her cognitive distortion that her situation is hopeless. Consistent presence and empathy can counteract her sense of isolation and worthlessness. Even sitting quietly as she cries shows her she’s not alone in her pain.
Promote Nutrition: Consult with a dietitian to get nutrient-dense, small-portions meals for A.B. since large meals overwhelm her. Provide frequent small snacks – for example, offer a half sandwich or a milkshake mid-morning and mid-afternoon, and a nutrition supplement drink in the evening. Make the eating environment relaxed, maybe have her eat with one staff member or a supportive peer to encourage intake. Monitor weight bi-weekly and document food intake percentage each meal. If she’s not finishing meals, ask about her favorite foods and try to have those available to entice appetite. Rationale: Depression often blunts appetite, so smaller, favorite foods can improve intake【48†L414-L418】【48†L416-L420】. Nutritional status is crucial for recovery; weight monitoring will objectively tell us if interventions are working. Involving A.B. in choices gives her some control back (important when she feels helpless) and increases the likelihood she’ll eat. Encouraging socialization at meals can gently combat her isolation, and eating with someone can sometimes increase food consumed (due to social cues or prompting).
Sleep Enhancement: Establish a nighttime routine for A.B. Encourage her to take a warm shower before bed, provide a decaffeinated herbal tea, and practice a brief relaxation exercise (the nurse can guide her through a 5-minute breathing or mindfulness meditation in the evening). Ensure the milieu is quiet at night (cluster evening care to minimize disturbances). If prescribed, administer trazodone 50 mg at bedtime for sleep and monitor effect. Rationale: Improving sleep will likely boost her mood and daytime energy. Insomnia fuels a vicious cycle in depression of fatigue and negative thinking. Non-pharmacologic measures plus medication can help restore her circadian rhythm. Trazodone is a sedating antidepressant often used in low dose for sleep in depressed patients – it will help her sleep without strong hangover effects (and low risk for dependency). The nurse will ask each morning how she slept to track progress. Within a few days of better sleep, patients often show slight improvement in concentration and outlook.
Activity Scheduling (Behavioral Activation): Even though she has low energy, encourage simple, achievable activities each day. For example, accompany A.B. on a short 5-minute walk in the hallway in the morning, and encourage her to sit by the window or in the dayroom for at least 30 minutes a day. Involve her in a low-effort recreational therapy session, such as drawing or listening to music in a group. As she gains energy (perhaps after about a week on medication), help her set a daily small goal (e.g., “Today I will take a shower and get dressed in day clothes”). Rationale: Behavioral activation is a key evidence-based intervention – doing even small activities can slightly elevate mood via increasing dopamine and providing a sense of accomplishment【48†L395-L403】【48†L396-L404】. Walking with the nurse also gives an opportunity for therapeutic dialogue or quiet companionship. Goal-setting gives her structure and can counteract the inertia of depression. When she meets a goal, the nurse should recognize and praise it (“You attended group today – that’s a great step forward!”), which reinforces progress and chips away at her negative self-view.
Cognitive Support: When A.B. expresses hopeless or self-critical statements (“My life is over; I’m a bad mother”), respond with empathetic listening first, then gently challenge cognitive distortions. For instance: “I know you feel like a bad mother. Depression makes us think the worst about ourselves. But you arranged for your child’s care and you’re getting help – those are responsible, caring actions.” Encourage her to journal one small “achievement” or positive thing each day, even if it’s as simple as “talked with my sister on the phone.” Rationale: This intervention borrows from CBT techniques, helping A.B. to begin reframing her thoughts【48†L405-L413】【48†L408-L416】. It’s important not to invalidate her feelings, but to plant seeds of doubt about the absolute truth of her negative thoughts. Over time, as depression lifts, she may start to internalize these more balanced perspectives. Journaling positives primes her to look for them, countering the depressive bias of only seeing the negative. It also creates a record she can read later to remind herself that not everything is bleak.
Medication Management and Teaching: A.B. was started on sertraline 50 mg daily by the psychiatrist on admission (SSRI antidepressant). The nurse reinforces teaching: explains the purpose (“to help your brain chemistry rebalance and improve your mood, sleep, appetite”) and emphasizes the importance of taking it daily as prescribed. Inform her about common side effects like nausea or headache in the first week, and that these often pass. Importantly, educate that it may take 2–4 weeks to feel a significant improvement【8†L121-L129】【9†L1-L4】, so she shouldn’t be discouraged if it’s not instant. Also caution her to talk to staff if she experiences any increase in anxiety or thoughts of self-harm (occasionally, energy improves slightly before mood, which can affect suicide risk in early treatment). Rationale: Knowledge is power – understanding how the medication works can improve adherence. Many patients lose hope if a pill doesn’t work in a few days; setting proper expectations prevents premature discontinuation. Sertraline’s side effects and delayed onset have been explained, so she knows what to expect. The nurse will monitor her daily for side effects and therapeutic effects, and communicate with the team. By the time of discharge, assuming sertraline is tolerated, the dose might be optimized (perhaps to 100 mg) for outpatient continuation. Also, since she’s a mother, discuss with her and the provider about breastfeeding status (if relevant – sertraline is one of the safer SSRIs in breastfeeding, but ensure pediatrician is aware). For now, her sister is caring for the baby, so likely she’s not breastfeeding, but it’s a consideration in postpartum depression cases.
Family/Social Support Involvement: With A.B.’s consent, involve her sister in care discussions before discharge. Arrange a family meeting with A.B., her sister, and the social worker to plan supports after discharge – e.g., her sister may continue helping with childcare for a period. Provide education to the sister about A.B.’s condition: “Depression is an illness, and critical comments or pushing her to ‘snap out of it’ could worsen her guilt. Instead, encourage her small steps and reassure her of your support.” Supply information on outpatient therapy and possibly support groups (NAMI or local depression support). Ensure a follow-up appointment with a therapist and psychiatrist is arranged within a week of discharge (continuity is crucial). Rationale: Engaging her sister turns her into an ally in recovery rather than someone who might inadvertently stigmatize or stress A.B.【48†L430-L438】【48†L436-L440】. Family education can reduce conflict and misunderstanding at home. Given A.B. is a single mom now, her sister’s ongoing help will be a protective factor – planning for it and expressing gratitude to the sister also helps the sister feel valued in the team. The warm hand-off to outpatient care reduces the chance of relapse or feeling abandoned after discharge. We want to ensure A.B. isn’t going home to the exact environment that precipitated her crisis without new tools or supports in place.
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:
Risk for Injury related to hyperactivity, impaired judgment, and lack of sleep, as evidenced by nearly no rest and physical exhaustion (risk of collapse) and spending sprees (financial harm).
Risk for Other-Directed Violence related to irritability, poor impulse control, and intrusive behavior, as evidenced by yelling at boss and sexually inappropriate comment on unit.
Disturbed Thought Processes related to biochemical imbalances of acute mania, as evidenced by grandiose delusions and flight of ideas.
Sleep Deprivation related to manic hyperarousal, as evidenced by 2–3 hours sleep per night for past 2 weeks.
Nonadherence (Medication) related to denial of illness due to manic euphoria could be noted for long-term planning.
Goals (Outcomes):
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.
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).
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).
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.
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:
Ensure Safety and Limit-Setting: Begin constant observation for J.S. due to his hyperactivity and poor impulse control. Place him in a single room if possible to decrease stimuli and prevent conflicts with roommates (he’s already been inappropriate to another patient). When he makes aggressive or inappropriate statements, respond calmly and firmly: “J.S., those comments are not acceptable here. I need you to respect others’ space.” Use clear, simple limits: “You may not touch other people. If you cannot control this, we will have to help you with a time-out/seclusion.” All staff should convey consistent messages. If he starts to escalate (yelling, not redirectable), employ the team approach: several staff approach with a calm, firm demeanor to show a united, controlled front. Utilize PRN medication early (e.g., offer lorazepam or haloperidol as ordered) if he cannot be verbally de-escalated. Prepare a seclusion room as last resort if he becomes a danger and does not respond to meds or verbal directives【56†L37-L46】【56†L39-L46】. Rationale: Manic patients often push boundaries; consistent limit-setting and immediate non-punitive consequences help maintain safety【57†L398-L406】【57†L401-L409】. He needs external control because he lacks internal control presently. A single room with minimal stimuli reduces triggers for agitation (no roommate to potentially irritate or vice versa). Presenting a unified, calm approach prevents splitting staff or sending mixed signals. PRN medications can halt escalating agitation quickly (preventing the need for physical restraint). Staff should use seclusion/restraint only if absolutely necessary, and ensure it’s done safely and in line with legal/ethical guidelines – having this contingency known can actually prevent needing it (if the patient realizes boundaries are firm). By day 2, with medication on board, ideally his need for such intense monitoring will lessen.
Reduce Environmental Stimulation: Keep J.S.’s environment low-key. For instance, lead him to a quiet room when the unit is busy, or to the patio for some fresh air away from group activity (with supervision). Do not assign him to group therapy in the first couple of days when he’s unable to control his behavior – instead, provide one-on-one activities or simple tasks (like organizing magazines) to focus his energy. Limit visitors initially if they further stimulate him (e.g., a bunch of friends might hype him up more; perhaps just parents visiting and encourage short, calm visits). Rationale: Manic stimuli threshold is low – any extra noise or commotion can intensify his manic symptoms【52†L336-L344】【52†L338-L342】. A quieter environment will help him settle and reduce sensory overload. As he begins to respond to treatment, he can gradually rejoin group activities in a controlled manner (perhaps starting with a small occupational therapy group that has structure). Minimizing chaos around him helps prevent escalation and helps the medications/other interventions take effect more effectively.
Provide Outlet for Physical Energy: J.S.’s motor activity is excessive; channel this constructively. For example, arrange supervised exercise: take him to the gym to shoot basketball hoops (alone with staff) or do jumping jacks in a secluded area. Provide safe physical activities like walking laps with a staff member, or offer him a stress ball to squeeze. If agitation rises, sometimes engaging in a brief chore like wiping down tables or sweeping (nothing dangerous like accessing cleaning chemicals, but simple muscular work) can help burn off energy. Rationale: He has “endless” energy that needs release; if not given an outlet, it can worsen anxiety or turn into aggression【52†L344-L351】【52†L346-L349】. Exercise uses up some adrenaline and can have a calming after-effect (once heart rate slows post-exercise). It also can be framed positively (“Let’s go shoot some hoops to help that athlete in you”). This must be balanced with ensuring he doesn’t overexert to the point of collapse – hence supervised and time-limited sessions are key (e.g., 15 minutes of activity then encourage a rest break).
Promote Nutrition and Hydration: Finger foods are ideal. Provide high-calorie, portable snacks that J.S. can eat while moving: e.g., protein bars, sandwiches, pieces of fruit, cheese sticks. Offer a hand-held fluid frequently (bottle of water or sports drink) since he’s probably sweating and not thinking to drink【52†L338-L345】【52†L342-L347】. Don’t force sitting at dining table; instead, walk with him and hand him bites of a sandwich, saying “Here, have a bite, keep your energy up.” Consider a nutritional supplement shake if he won’t stop to eat a full meal. Monitor for signs of dehydration (check skin turgor, mucous membranes) especially with constant pacing. Rationale: In mania, patients often “forget” to eat or are too distractible to complete a meal, risking weight loss and dehydration【26†L675-L680】【26†L677-L680】. Finger foods allow him to eat on the go without having to focus for long. Frequent small snacks can cumulatively meet nutritional needs. Hydration is critical because mania-driven hyperactivity can lead to fluid loss. Also, hydration can help mitigate some side effects of medications (like lithium, if resumed – lithium can cause thirst and requires adequate fluid intake). Over the first few days, success is if he’s consuming enough to maintain weight and not getting medically compromised. Weighing him might not be feasible during peak mania (he may refuse), but the care team can use other markers like blood pressure, urinary output, etc., to ensure he’s hydrated and nourished.
Facilitate Sleep: Institute a sleep routine firmly. Despite his protests of not being tired, after evening medication the nurse should create an environment conducive to sleep: dim lights, low noise after 9-10pm, and discourage stimulating activities. At bedtime, offer PRN lorazepam (a sedative) in addition to his scheduled meds to help him relax. Perhaps use soft calming music or white noise in his room to drown internal stimuli. Avoid engaging him in conversation late at night – just offer a brief, calming presence then leave him to rest (manic patients will keep talking if someone is there to listen). If he can’t fall asleep within 30 minutes, guide him to do a quiet activity in low light (like reading a simple magazine) rather than pacing the halls (which wakes him further). Strictly limit caffeine – none after early afternoon. Rationale: Rest is a priority – even a few hours of sleep will help reset the brain and can significantly reduce manic symptoms intensity【26†L673-L680】【26†L675-L680】. In mania, the body and mind are in overdrive; sleep deprivation can cause physical collapse or tipping into psychosis. Benzodiazepines (like lorazepam) are often used short-term to induce sleep and reduce agitation until mood stabilizers take effect【52†L260-L268】【52†L262-L270】. The nurse monitors how much he sleeps each night; an increase from 2 to, say, 5 hours is a good sign that interventions are working. Early in hospitalization he might require nighttime sedation; as mania resolves, natural sleep should improve.
Medication Administration: The psychiatrist orders a regimen, for example: Lithium carbonate re-initiation (since he wasn’t taking it) at 300 mg TID, and Risperidone 2 mg BID to rapidly control manic symptoms. The nurse’s role:
Ensure J.S. actually swallows his meds – check for cheeking since he has poor insight and might try to avoid them. Possibly use a liquid or fast-dissolve formulation of risperidone if non-cooperative.
Educate him (in brief, matter-of-fact terms due to short attention) each time: “This medicine will help slow your mind down and help you think more clearly.” He may respond with denial, but persist gently.
Monitor vital signs and side effects: Lithium can cause tremors – check for any fine hand tremor. Also, because he’s moving a lot, ensure he’s drinking well to avoid lithium toxicity (remind him to drink water). For risperidone, watch for any muscle stiffness or excessive sedation.
Draw blood for a lithium level ~5 days after starting (and notify MD if level goes outside 0.6–1.2 mEq/L range). Also, baseline and periodic thyroid and kidney labs for lithium as ordered.
Use PRN lorazepam 1–2 mg PO/IM for breakthrough agitation as needed in first couple of days (according to protocol or MD order).
Engage J.S. in medication adherence discussions when he’s slightly calmer: find out why he stopped lithium (“I felt fine, didn’t need it”). Provide psychoeducation in small bites: “Bipolar is a lifelong condition – feeling fine was actually because the medicine was working. Stopping it made you sick again.” Use analogies he might relate to (e.g., compare to diabetes needing insulin).
Enlist his parents in medication education too – so they understand to help encourage him to stay adherent after discharge. Potentially arrange for long-acting injectable antipsychotic if adherence remains a concern (e.g., discuss with MD using a monthly injectable risperidone or aripiprazole). Rationale: Medication is key to stabilizing mania, but J.S.’s poor insight means we must be vigilant in administration【26†L669-L677】【26†L670-L678】. Checking for cheeking ensures he’s not spitting out pills. Lithium plus an antipsychotic is a common effective combo: lithium for long-term stabilization, risperidone for quick calming【24†L53-L61】【24†L55-L63】. Monitoring levels and side effects is crucial for safety (especially since dehydration can quickly raise lithium levels to toxic). Through consistent, simple explanations, we start the process of building his insight that meds are not optional. In mania, comprehensive teaching won’t be retained, but repetition and involvement of family helps. By discharge, goal is he agrees to continue meds (even if begrudgingly) and maybe allow parents to assist (like holding and dispensing medication for him at home short-term). If he utterly refuses oral meds even as he calms, the team might consider a court-ordered medication or depot injection approach. Fortunately, risperidone tends to calm patients within a couple of days, and with rest, his thinking may improve enough that he can reason about medications a bit.
Communication Techniques: When interacting with J.S., use short, simple sentences and a calm but firm tone. For example, instead of “I really think you should consider sitting down and talking because you need to eat and rest,” simply say “Sit down, please. Eat this sandwich.” Give one direction at a time. Avoid open-ended questions that might trigger flight of ideas; instead use closed requests: “Take these pills now.” Do not argue with any grandiose claims (don’t try to logically talk him out of believing he’ll record an album). Instead, redirect: if he says “I have a meeting with the record label,” respond with something like “Right now, let’s focus on writing down that idea later – at the moment, please drink this water.” Acknowledge any legitimate feelings behind delusions (“I can see you’re excited about your music – we’ll support you with that when you’re well.”) Rationale: Simplified communication helps penetrate his overloaded attention【26†L677-L684】【26†L678-L686】. Setting one task at a time increases likelihood of compliance. Avoiding power struggles is crucial – arguing about his delusions or plans can lead to anger; it’s more therapeutic to gently shift his attention to the here-and-now needs (food, meds, rest). By not outright confronting his false beliefs during the acute phase, we prevent unnecessary conflict; those can be addressed in therapy after stabilization. Praise any cooperation: “Thank you for taking the medication.” This positive reinforcement can encourage more compliance.
Occupational Therapy and Distraction: As his acute mania begins to subside (perhaps day 3 or 4 with meds on board), involve him in simple, structured activities that channel concentration. OT sessions like painting, clay modeling, or other hands-on tasks can occupy his mind in a safe way. Keep tasks short (15-20 min) initially. Also, encourage writing in a notebook – since he’s a musician, perhaps writing lyrics or ideas (this gives an outlet for racing thoughts). Rationale: This serves two purposes: it gives him a sense of productivity (matching his grandiose drive in a harmless way), and it gradually rebuilds his ability to focus. Creative yet structured tasks can be satisfying for manic patients once they are a bit calmer; it appeals to their need for engagement but in a controlled format supervised by therapists. It’s also a gauge for the nurse to see improvement if he can sit and do a task for longer over the days.
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:
Postpartum Depression (Situational Low Self-Esteem) – not a NANDA label per se, but Hopelessness or Situational low self-esteem related to new motherhood role strain, as evidenced by statements of inadequacy and guilt.
Impaired Parent-Infant Attachment related to maternal depression and exhaustion, as evidenced by mother’s report of feeling nothing toward baby and reduced affectionate interaction.
Fatigue (or Sleep Pattern Disturbance) related to depression and newborn care demands, as evidenced by insomnia and reports of exhaustion.
Nutrition, Imbalanced: Less than body requirements related to loss of appetite (mother) could also be considered if weight loss is notable.
Risk for Self-harm (since she has passive thoughts – keep an eye, though currently no active plan).
Goals (Outcomes):
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.
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.)
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.
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.
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:
Establish Trust and Normalize Feelings: The nurse provides a nonjudgmental space for E.M. to talk about her feelings of inadequacy and lack of joy. Validate that PPD is a real, common condition and that she is not a “bad mother” for feeling this way【38†L98-L107】【38†L100-L107】. For example: “Many new mothers feel overwhelmed and depressed; it doesn’t mean you don’t love your baby. Depression is treatable and you can bond with your baby as you start to feel better.” Share that up to 1 in 7 women experience PPD【64†L7-L15】, to reduce her shame. Encourage her to vent about the challenges (sleepless nights, etc.), and actively listen. Rationale: E.M. currently feels guilty and alone; hearing that others go through this and that she’s not “failing” can relieve self-blame【38†L84-L92】【38†L88-L96】. Building trust is key for her to be honest about any dark thoughts (like her fleeting wish to disappear). Normalizing and educating about PPD turns this from a character flaw into a medical issue that can be addressed, which often reduces guilt and instills hope.
Safety Surveillance: Although she’s at home, the nurse and E.M. create a suicide safety plan due to her passive suicidal ideation. This includes: recognizing when those thoughts occur, identifying coping strategies (e.g., call husband or friend, do a grounding exercise thinking of baby’s needs), and emergency steps (calling her nurse, OB, or crisis line if thoughts worsen). Involve the husband by educating him to watch for any warning signs (like talk of “family better without me”) and to secure any potential means (remove firearms if any, safely store medications). Schedule frequent contact: initially home visits 2-3 times a week or daily phone check-ins to ensure she’s safe and supported. Rationale: While she has no plan, PPD can worsen suddenly, especially if guilt becomes unbearable. A proactive safety plan and spousal support act as a net if her thoughts darken【31†L39-L47】【31†L41-L49】. The husband can help supervise and encourage her to rest and not act on any negative thoughts. Regular nurse contact provides accountability and a chance to reassess mood often. If she ever expresses intent or plan, immediate evaluation for possible inpatient care would be needed.
Encourage Rest and Practical Support: Assess the division of infant care. It appears E.M. is taking on most tasks alone. Work with her and her husband to arrange periodic breaks for her. For instance, instruct the husband (and willing family/friends) to take over baby care for a solid 4-5 hour stretch at night (perhaps giving a bottle of expressed breast milk) so E.M. can get an uninterrupted block of sleep【68†L278-L284】【68†L278-L283】. If she feels guilty accepting help, frame it as “sleep is medicine – by resting, you’re improving your ability to care for your baby.” Also suggest napping when the baby naps at least once a day (leave dishes, chores – prioritize mom’s rest). The nurse can help prioritize tasks or enlist a postpartum doula or volunteer if available to assist with household chores a few hours a week. Rationale: Sleep deprivation is both a contributor to and symptom of PPD. Even one longer sleep period can markedly improve mood and cognitive function in a depressed new mom【68†L278-L286】【68†L278-L283】. Many mothers feel they must do everything; giving “permission” to rest and assuring the husband’s involvement can improve her physical state and gradually her mood. Delegating non-essential tasks frees up time and energy for recovery and bonding.
Promote Mother-Baby Bonding with Guidance: Without pressuring E.M. to “feel” a certain way, gently encourage structured bonding activities. For example, suggest she try skin-to-skin contact with the baby for a few minutes after feeding – holding the diaper-clad baby on her chest. Guide her in observing the baby’s responses (does the baby calm to her voice? does he grasp her finger?). Teach her infant massage techniques (simple stroking of baby’s arms/legs) that she can do daily after bath time【68†L278-L286】【68†L280-L287】. These physical interactions can sometimes kindle affectionate feelings. Also, praise her for what she is already doing well: “You’re breastfeeding him and he’s gaining weight – that’s a wonderful effort you’re making for him.” Help her reframe her negative thoughts: if she says “I’m a terrible mother,” point out evidence to contrary: “I see a mom who, despite feeling awful, is still making sure her baby is cared for – that’s strength and love.” Rationale: Depressed mothers often have flat affect and worry they’re failing to bond, which further depresses them【68†L295-L303】【68†L295-L302】. Skin-to-skin and infant massage have been shown to improve bonding and maternal mood, likely by releasing oxytocin and endorphins in mom and baby【68†L278-L286】. It also helps the baby, making them more content, which could reassure mom. By focusing on concrete interactions (rather than expecting her to gush emotionally), we set achievable steps that can build attachment gradually. Positive reinforcement from the nurse helps counter her self-criticism and shows her she is doing many things right.
Reduce Isolation:
Connect E.M. with a postpartum depression support group (many areas have new mom support meetups or PPD-specific groups, even virtual ones). Encourage her to attend or at least talk to other mothers (perhaps a friend or relative who had PPD, if available).
Involve her husband more in emotional support: instruct them to have a daily check-in time when he’s home, where she can share her feelings without judgment. Perhaps have the nurse facilitate a session with both present to model supportive communication.
Encourage short, pleasant outings if she’s up for it – a walk in the park with baby in stroller and husband on weekend, or sitting on the porch for fresh air. Even a brief change of scenery can improve mood and remind her there’s a world beyond diapers and pumping.
If family can help, maybe her mother or sibling can come for a weekend to provide company and help (but ensure any family who comes is supportive and not critical; if her mother was helpful before, maybe invite her again). Rationale: New motherhood can be very isolating, especially once initial help leaves【38†L98-L107】【38†L100-L107】. Social support is a known protective factor in PPD【68†L278-L284】【68†L280-L283】. Hearing other moms in a group say “I felt the same” greatly reduces her shame and loneliness. Also, talking with peers who overcame PPD can inspire hope. The husband’s understanding is crucial – educating him to listen and not dismiss her fears is key (e.g., avoid him saying “you’re fine” which minimizes her feelings). Brief outings help combat cabin fever and provide mild exercise (also beneficial for mood). If she seems overwhelmed by visitors, we’ll adjust; but often family presence (if positive) can allow her to nap and feel cared for herself. The nurse essentially helps mobilize her support network.
Psychotherapy and Referral: Arrange for individual therapy (counseling) specializing in postpartum issues. Likely a combination of CBT (to handle guilt and negative thoughts) and interpersonal therapy (to adjust to role transition to motherhood) will be useful【38†L98-L107】【38†L98-L105】. If accessible, refer to a therapist or a PPD program – possibly her OB can coordinate or a community mental health center. If she’s hesitant to see a “shrink,” frame it as part of standard postpartum care for those having a tough adjustment. If accessing therapy in person is hard (due to baby), explore teletherapy options from home. Begin basic CBT work during nursing visits: for example, have her keep a thought journal where she writes automatic thoughts (“I’m failing”) and then the nurse can help her come up with alternative thoughts (“I’m doing my best; baby is safe and fed”). Also work on problem-solving – e.g., identify what baby cues stress her the most (perhaps the baby’s crying triggers her anxiety?), and come up with a plan (like putting baby safely in crib for a few minutes to compose herself is okay). Additionally, consider medication: Since she is breastfeeding and depression is moderate, first-line may be therapy and social interventions. However, if no improvement in a couple weeks or symptoms worsen, an SSRI like sertraline (which has minimal transmission in breast milk) could be started【64†L35-L38】【64†L35-L38】. The nurse should discuss this possibility with her OB or primary doctor in advance. Many women can take sertraline while breastfeeding with monitoring of the infant for any issues (usually none or mild GI upset at most). Rationale: Psychotherapy is very effective for PPD and has no risks to breastfeeding. It gives her coping skills, helps restructure negative thoughts, and addresses the life role change. By initiating a referral early, we shorten the duration of untreated depression. If E.M.’s symptoms do not start to lift with therapy and support within a few weeks, pharmacotherapy is indicated to avoid prolonged suffering. Sertraline is often the antidepressant of choice in breastfeeding due to its low infant exposure【64†L35-L38】. The nurse’s role is to provide information so E.M. can make an informed choice about meds; some mothers fear taking meds postpartum, but we balance that against the risks of untreated depression (which include poor bonding and potential developmental impact on baby if mom’s depression continues). The goal is to get mom well which ultimately benefits the baby most.
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
Bipolar I: At least one manic episode (7+ days, severe impairment ± psychosis). Usually episodes of depression too.
Bipolar II: At least one hypomanic episode (4+ days, no psychosis) and one major depressive episode. No full mania.
Cyclothymic Disorder: ≥2 years of chronic
fluctuating mild hypomanic and depressive symptoms that don’t meet full
criteria for episodes【5†L159-L167】【5†L161-L168】.
(Both BD I and II can have “mixed features” (simultaneous mania
& depression signs) or rapid cycling (≥4 episodes/year)
specifiers【19†L267-L275】【19†L269-L277】.)
【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 Management – 1) 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】.
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