Recognising and treating mood disorders

It is important for the primary care nurse to be able to distinguish mood fluctuations from dysfunctional moods, and to be aware of treatment options.

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Introduction

Mood disorders, also known as affective disorders, include major depression, bipolar disorder and dysthymia. These disorders can impact significantly on a person’s life including their ability to eat, sleep, work and build successful relationships, and may influence how a person thinks about themselves. 

Mood disorders are diagnosed through the use of standardised measures, subjective reporting and objective assessment of a person’s functioning across a number of life domains.

Sometimes it is clear from the patient’s presentation that a disturbance in mood exists but symptoms may be more subtle in the primary care setting, and require careful assessment. The patient’s mood might be one of euphoria and elation, with thoughts running through their head at speed, skipping from topic to topic as a spun stone skips over water. Or they might be deeply depressed, full of thoughts of guilt and painful emotions, with both speech and movement considerably slowed.

Alternatively all their emotions might be flattened, dampened, unresponsive or incongruous. 

It may be the primary care nurse who is in a position to note changes in a client’s mood or functioning, or the client may confide in the primary care nurse, sharing his or her distress.

Epidemiology

According to the Australian Bureau of Statistics (ABS), mood disorders affect 6.2% of people aged 16−85 years (7.1% of women and 5.3% of men). The rate is higher for those aged 16−44 years (7.6%) than it is for those aged 55−85 years (3.3%). 

The ABS data further noted that “59% of people with a mental illness also had a physical condition, compared with 48% of those without any mental disorder”. 

This link between physical and mental illness means general healthcare settings are an important screening area for such illnesses. The prevalence of comorbidities of depression with diseases such as diabetes, cancer and heart disease should alert the primary care nurse to the increased possibility of such a disorder and prompt routine assessments.

Diagnosis

It is important to note that fluctuations in mood are a normal occurrence. Everybody has emotional responses to stressful situations and will find themselves feeling particularly happy or sad from time to time. It is appropriate, too, to have longer periods of low mood at times of grief and loss.

What separates dysfunctional mood from normal fluctuations in emotional state is the intensity, duration and impact of the symptoms.

Things that you might notice first include: 

- changes in mood 

- changes in attention to dress and activities of daily living 

- reports of changes of increased energy 

- slowed down or pressured speech (where a lot of ideas are voiced rapidly) 

- sudden weight change 

- voicing of hopelessness in cases of depression, or grandiose ideas if manic 

- increased drug and alcohol usage or other high risk behaviours.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV – TR), provides a systemised classification system for identifying and diagnosing mental illness.

Other tools listed below (Table 1) are perhaps more appropriate for use by nurses and their clients in the primary care setting as part of the screening process. 

Pharmacotherapy and other biological treatment approaches

In general practice, a common approach to the treatment of mood disturbance is pharmacological. This includes the prescription of antidepressants, anxiolytics and, sometimes, mood stabilisers or neuroleptics. 

Noncompliance is commonly reported, and nurses need to be aware of common uncomfortable side-effects that contribute to this, and educate and support the patient to ameliorate these symptoms.

Although some individuals with moderate to severe depression respond well to antidepressant medication only, there is a high rate of relapse upon discontinuation (Stuhlmiller, 2009) and most people require an approach that also addresses cognitive and/or social deficits. Nurses are often in a position to be able to intervene at this level.

The nurse-patient relationship as a major intervention

The first step in engaging a patient in active participation in their own mental healthcare is the development of a therapeutic rapport. Because a patient often sees the nurse-patient relationship as a more ‘equal’ relationship, it allows for an open, trusting, non-judgemental forum for communication to take place.

Appointment times need to be structured to allow the patient to discuss their concerns at length. The nurse-client relationship is a privileged one where the pace and agenda are often set by the client. This can be a challenge for nurses who are used to a more task-orientated approach. 

The relationship should be characterised by openness, acceptance and a non-judgemental attitude. It requires the ability to sit with someone in their moments of pain and distress and not be overwhelmed. Instead, the nurse helps the patient to identify their strengths, look for exceptions in their world view and evidence of their ability to cope in past situations. The nurse as objective observer both notices change and looks for opportunities and readiness for making change and responding to symptoms as they present.

Better Access Scheme

Many patients with a mental illness may participate in a GP Mental Health Care Plan. This plan involves the GP assessing the patient, identifying needs, setting and agreeing management goals, identifying any action to be taken by the patient, selecting appropriate treatment options and arrangements for ongoing management of the patient, and documenting this in the plan. 

The nurse’s role in this instance is that of collaboration with the GP and client to set appropriate goals and plan appropriate intervention and treatment, advocate for the client as necessary, coordinate clinical services for the client, and ensure regular review of the plan and the movement toward the goals as set out within the plan.

It may at times be necessary for the nurse to discuss with the treating GP the necessity of referral of the client for additional support from more specialist services.

Such specialist service providers may include a credentialled mental health nurse, psychologist, psychiatrist or community-based mental health treatment for full psychiatric assessment, psychotherapy or supportive counselling. 

A client may also ask for information on alternative therapies or support groups.

Consider referral when:

- there is a marked deterioration in normal functioning in one or more life domains

- the mood disturbance is sustained beyond normal adjustment periods despite interventiona person requests specialist help

- the person is engaged in high-risk behaviours that are out of character

- alcohol and drug usage is sustained above cultural norms and/or is causing dysfunction or distress to the individual or family members

- you feel you’re working out of scope

- a person reports thoughts of suicide, self-harm or harm to others.

In times of acute crisis or risk, it is appropriate to make arrangements for the person to be assessed for hospitalisation. This can be done voluntarily by the client, or the nurse may have to utilise the Mental Health Act to enable an involuntary assessment if a client is considered at risk to themselves or others.

Self-awareness and self-care – for the nurse

It is imperative that the nurse remain aware of their own response to the patient – ensuring objectivity and a non-judgemental attitude. 

For example, some nurses find the frank discussion of suicide distressing because it conflicts with their own values or beliefs, or the disclosure of childhood sexual abuse confronting and stressful. 

It is a skill to remain calm and open to such discussions, and if a nurse finds that they are not able to continue the relationship in a non-judgemental or constructive way, or indeed if the nurse is ‘caring too much’, then the handing-over of care of that client to another nurse or professional is appropriate. 

However, it is common for negative or strong emotions to arise for a nurse when dealing with a patient whose symptoms are sustained, irrational, erratic or destructive. 

Most health professionals engaged in work with mentally ill clients seek peer support or clinical supervision for constructive debriefing, and it is highly recommended that they do so.

Dealing with these issues can be demanding, confronting and emotionally draining, and the associated stress can result in non-objective (even damaging) interventions or, at its extreme, in burnout. 

You should be alert to losing objectivity if you are: 

- thinking that you are the only person who understands the client

- spending time over and beyond what is reasonable

- spending time outside work hours with the client

- being rude or dismissive of a client’s symptoms

- feeling disgusted by what the client discloses

- feeling angry at the client.

Burnout occurs when a nurse experiences prolonged stress and after a period of overwork and over-engagement with work finds themselves no longer able to contribute positively to the work environment or to their patients. Symptoms include helplessness and hopelessness, loss of motivation, ideals and hope.

The purpose then of peer support, mentoring or clinical supervision is to reflect on the relationship and its effect on the nurse, brainstorming for constructive responses to the client, professional development of the nurse and ultimately the achievement of better outcomes for the client. 

The Australian College of Mental Health Nurses recommends super­vision take place away from the workplace environment with a supervisor of the nurse’s own choosing and with a clearly set-out contract detailing the supervision relationship and process. 

An overview of the main causes of bipolar:

- genetics

- brain chemistry

- environment

- medical illness

- pregnancy


An overview of the main causes of depression:

- genetics

- biochemical factors

- effects of illness

- ageing brain

- gender issues

- the role of stress and personality 

- postpartum period

This Update is by Madonna Cuskelly, RMHN (Credentialled), BA (Psychology), Grad Dip Soc Science (Counselling) and Workplace Assessor and Trainer.

The author has no disclosures. Any reference to products throughout this review does not constitute endorsement.