Mood Disorders: Depression and Bipolar Disorder - Cheat Sheet
Your last-minute revision companion for mood disorders: the highest-priority psychiatric topic on the NLE. Master suicide assessment, antidepressants, lithium toxicity, and mania management in 30 minutes.
Major Depressive Disorder (MDD) — Definition & Assessment
Important facts
- SIG E CAPS mnemonic: Sleep (insomnia/hypersomnia), Interest (anhedonia), Guilt (worthlessness, excessive guilt), Energy (fatigue), Concentration (poor focus), Appetite (significant change), Psychomotor (agitation or retardation), Suicide (recurrent thoughts of death/suicide)
- Duration requirement: ≥2 weeks of symptoms
- Depressive episode may include psychotic features (mood-congruent delusions or hallucinations)
- Depression with atypical features: hypersomnia, hyperphagia, mood reactivity, rejection sensitivity
- Always assess for suicidal ideation — this is the HIGHEST priority in MDD
- Poor grooming, social withdrawal, constipation, and somatic complaints are common presentations
- Recurrent episodes are typical; single episode MDD is less common
Key definitions
Major Depressive Disorder
Example
Patient reports sad mood for 3 weeks with insomnia, fatigue, guilt, poor concentration, and worthlessness.
Depressed mood or anhedonia (loss of interest/pleasure) ≥2 weeks PLUS ≥5 additional symptoms from SIG E CAPS; causes functional impairment.
Anhedonia
Example
Previously enjoyed gardening but now has no desire to do it.
Complete loss of interest or pleasure in activities; cardinal feature of depression.
Diagrams to know
- SIG E CAPS symptom checklist for rapid assessment
- Depression severity scale (mild, moderate, severe, with psychotic features)
Suicide Risk Assessment & Safety — HIGHEST PRIORITY
Important facts
- NEVER ask 'Are you suicidal?' — ASK DIRECTLY: 'Are you thinking of killing yourself?' Asking does NOT plant the idea.
- Assess for the TRIAD: (1) Plan, (2) Method, (3) Means (access). If specific, lethal, and accessible = HIGH RISK.
- WARNING SIGNS: giving away prized possessions, making a will, saying goodbye, sudden calm/mood lift after deep depression (DANGER PERIOD), previous attempts, hopelessness.
- STRONGEST PREDICTOR of future suicide: previous suicide attempt.
- Risk factors: male sex, older age (especially >65), social isolation, chronic illness, substance use, access to lethal means.
- CRITICAL TIMING: Suicide risk INCREASES in EARLY TREATMENT when ENERGY RETURNS before mood improves — patient now has energy to act on plan.
- Sudden calm/lift in mood after severe depression may signal decision has been made — this is a DANGER PERIOD.
- Do NOT promise to keep suicidal disclosures secret; always report to treatment team and document.
- Under RA 11036 (Mental Health Act): involuntary treatment permitted for imminent risk of harm with appropriate safeguards and documentation.
- One-to-one continuous observation for HIGH RISK: client must remain in sight, including bathroom use.
Key definitions
Suicide Risk Assessment
Example
Client discloses wanting to die; assess if they have a plan (yes—jump from building), method (accessible), and means (lives on 5th floor).
Systematic evaluation of suicidal ideation, intent, plan, means, and access; guides level of observation and intervention.
High-Risk Suicide
Example
Client has written suicide note, owns loaded firearm, and recent psychiatric discharge.
Specific, lethal, available plan + intent + recent attempt history + hopelessness + access to means = HIGHEST RISK.
Diagrams to know
- Suicide risk stratification: low, moderate, high, imminent
- Precaution escalation based on risk level
Nursing Interventions for MDD & Suicide Prevention
Important facts
- PRIORITY #1: Safety — direct assessment for suicidal thoughts and plan; implement precautions based on risk level.
- Spend TIME with the client — silence communicates acceptance; do NOT use false reassurance or artificial cheerfulness (invalidates feelings).
- Meet BASIC PHYSIOLOGIC NEEDS (Maslow): nutrition, hydration, elimination, sleep, hygiene — depressed client lacks motivation.
- Structure day with SIMPLE, ACHIEVABLE activities to build sense of accomplishment and purpose.
- WATCH CLOSELY during early treatment: as energy RETURNS, suicide risk INCREASES before mood improves — provide closer observation.
- Provide SAFE ENVIRONMENT: remove or secure potential means — sharps, belts, cords, glass, excess medications, window access.
- Implement observation level based on risk: LOW (checkins every 30 min), MODERATE (continuous visual contact), HIGH (one-to-one continuous, never alone).
- Encourage expressing feelings and hopelessness without contradiction; validate emotion.
- Promote sleep, nutrition, and grooming; gently assist with self-care.
- Avoid engaging in argument about reasons to live; focus on coping and symptom management.
Key definitions
Therapeutic Presence
Example
Sitting silently with suicidal client for 10 minutes, twice per shift, without false reassurance.
Intentional, non-judgmental attention to client; short, frequent contacts that convey acceptance and worth.
Diagrams to know
- Observation levels by suicide risk category
- Depression-to-recovery timeline with danger periods marked
Bipolar Disorder — Bipolar I vs Bipolar II
Important facts
- BIPOLAR I = at least ONE MANIC EPISODE (full-blown mania); may or may not have depressive episodes.
- BIPOLAR II = NEVER has full mania; defined by hypomanic episodes + depressive episodes; hypomania does not cause marked impairment.
- Mood episode duration: MANIA ≥7 days; HYPOMANIA ≥4 days; DEPRESSION ≥2 weeks.
- Manic/hypomanic core features: ELEVATED mood (not always happiness—often irritable), DECREASED NEED FOR SLEEP (feeling rested after 3 hours), GRANDIOSITY, PRESSURED SPEECH, FLIGHT OF IDEAS, DISTRACTIBILITY.
- During mania: increased goal-directed activity, excessive involvement in high-risk activities (spending sprees, hypersexuality, substance abuse, risky investments).
- Manic client becomes EXHAUSTED and DEHYDRATED because they do not stop to eat, drink, or rest.
- Judgment is SEVERELY IMPAIRED during mania — client cannot recognize consequences (financial, legal, sexual, reputational).
- Bipolar I has higher suicide risk than MDD; suicide often occurs during depressive episodes following mania.
- Rapid cycling: ≥4 mood episodes/year; associated with worse prognosis and treatment resistance.
Key definitions
Bipolar I Disorder
Example
Patient experiences 2-week episode of expansive mood, grandiosity, pressured speech, decreased sleep need, increased spending, racing thoughts.
At least ONE manic episode (abnormally elevated/irritable mood ≥1 week, markedly impaired function or hospitalization required); history of major depressive episodes.
Bipolar II Disorder
Example
Patient has 5-day episode of elevated mood and increased productivity (not hospitalization-level), followed by 2-week depressive episode with suicidal ideation.
At least ONE hypomanic episode (milder elevation, 4+ days, no marked impairment or hospitalization) PLUS at least one major depressive episode; NEVER a full manic episode.
Mania
Example
Patient sleeps 2 hours/night, talks rapidly, spends $10,000 in one day, engages in multiple sexual encounters, starts 5 business projects simultaneously.
Abnormally elevated, expansive, or irritable mood ≥1 week with grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, goal-directed activity, high-risk behavior; causes marked impairment or requires hospitalization.
Hypomania
Example
Patient is more talkative and productive at work for 5 days, needs only 6 hours sleep, but functions normally and causes no significant disruption.
Milder version of mania lasting ≥4 days; elevated/irritable mood with increased activity, grandiosity, decreased sleep need; NO marked impairment or hospitalization required.
Diagrams to know
- Mood spectrum: depression → baseline → hypomania → mania
- Bipolar I vs Bipolar II diagnostic criteria comparison
Nursing Interventions for Mania
Important facts
- REDUCE ENVIRONMENTAL STIMULATION: quiet, calm setting with few people; manic client is hyperaware and overstimulated.
- PROVIDE FIRM, CONSISTENT LIMITS on manipulative, intrusive, or boundary-violating behavior in matter-of-fact, non-punitive tone.
- MEET PHYSIOLOGIC NEEDS (Maslow priority): client forgets to eat, drink, sleep because of high activity; offer HIGH-CALORIE FINGER FOODS and fluids that can be consumed on-the-go (sandwiches, milkshakes, juice).
- CHANNEL ENERGY into safe, non-competitive, simple activities; avoid activities requiring sustained concentration or competition (which triggers irritability).
- MONITOR for exhaustion and dehydration; may require IV fluids if severe.
- PROTECT from consequences of poor judgment: manage finances, prevent inappropriate sexual behavior, limit Internet/phone access if risky.
- Do NOT engage in debate or power struggles; use clear directives and redirection.
- Avoid overstimulating activities: large groups, competitive games, music, television.
- Sleep deprivation fuels mania — establish rest periods even if client refuses.
- Monitor for aggression or psychosis; manic clients with psychotic features (grandiose delusions) may become hostile if challenged.
Key definitions
Environmental De-escalation
Example
Move patient from noisy dayroom to quiet room; limit visitors; dim lights; reduce stimuli.
Reducing stimulation, noise, people, and competing demands to calm manic client and prevent escalation to aggression or psychosis.
Diagrams to know
- Escalation pathway in mania and de-escalation interventions
- Manic client care flow: observation → limit-setting → need met → energy channeled
Antidepressants — SSRIs (First-Line)
Common values
Value
2–4 weeks
Symbol
t_onset
Quantity
SSRI therapeutic onset
Value
24–72 hours (active metabolite up to 9 days)
Symbol
t_1/2
Quantity
Fluoxetine half-life (allows longer washout)
Value
5 weeks (due to long half-life)
Symbol
t_washout
Quantity
MAOI washout after fluoxetine
Important facts
- SSRI ONSET: 2–4 weeks for therapeutic effect (not immediate); counsel client to continue despite early lack of response.
- FIRST-LINE for MDD: safest, best tolerated, fewer drug interactions than TCAs or MAOIs.
- Early side effects (first 1–2 weeks): nausea, insomnia, sexual dysfunction, headache, agitation; usually subside.
- CRITICAL: During first 2–4 weeks, watch for INCREASED SUICIDAL IDEATION in young adults (FDA black box warning); energy returns before mood improves.
- NEVER combine SSRI + MAOI directly: causes SEROTONIN SYNDROME (hyperthermic crisis); allow WASHOUT PERIOD: 2 weeks between SSRI/MAOI, 5 WEEKS after fluoxetine (long half-life).
- Do NOT stop abruptly: causes SSRI discontinuation syndrome (flu-like symptoms, dizziness, paresthesia, brain zaps); taper gradually.
- Drug interactions: SSRIs inhibit cytochrome P450 enzymes; caution with drugs metabolized by CYP2D6 or CYP3A4 (certain antiarrhythmics, antipsychotics).
- Sexual dysfunction: occurs in 20–40% of patients; may warrant switch to different agent or addition of cyproheptadine.
- Hyponatremia (SIADH): especially in elderly; monitor sodium, symptoms of hyponatremia (confusion, weakness, lethargy, seizures).
- Pregnancy/breastfeeding: generally considered safe; inform client of minimal fetal risk but risk of untreated depression.
Key definitions
Selective Serotonin Reuptake Inhibitors (SSRIs)
Example
Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), citalopram (Celexa).
Block reuptake of serotonin at presynaptic neuron; increase serotonin availability; first-line antidepressants due to safety, tolerability, and efficacy.
Diagrams to know
- SSRI mechanism of action (serotonin reuptake blockade)
- SSRI timeline: onset 2-4 weeks with danger period for suicidal ideation
Antidepressants — Tricyclic Antidepressants (TCAs)
Common values
Value
2–4 weeks
Symbol
t_onset
Quantity
TCA therapeutic onset
Value
Highly cardiotoxic at doses >1000 mg
Symbol
LD50
Quantity
Overdose lethal dose (variable)
Important facts
- Onset: 2–4 weeks (same as SSRIs).
- HIGHEST RISK: CARDIOTOXICITY in overdose — dysrhythmias (QT prolongation, conduction delays) are LEADING CAUSE OF DEATH in TCA overdose.
- Because of overdose danger in suicidal clients, DISPENSE LIMITED QUANTITIES (e.g., 1-week supply at a time); monitor for hoarding.
- ANTICHOLINERGIC SIDE EFFECTS (prominent): dry mouth, blurred vision, constipation, urinary retention, orthostatic hypotension, tachycardia, confusion.
- GI effects: weight gain, constipation (monitor for fecal impaction).
- Sedation: therapeutic for insomnia; give larger dose at bedtime.
- Orthostatic hypotension: major concern in elderly and medically ill; assess for dizziness, falls; educate on position changes.
- NEVER combine with MAOI: risk of serotonin syndrome.
- Drug interactions: TCAs potentiated by CNS depressants, anticholinergics; caution with sympathomimetics (hypertension risk).
- EKG baseline before starting; monitor if high doses or concurrent cardiac disease.
- Therapeutic drug levels exist for some TCAs (e.g., nortriptyline); monitoring may guide dosing.
Key definitions
Tricyclic Antidepressants (TCAs)
Example
Amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor), clomipramine (Anafranil).
Block reuptake of norepinephrine and serotonin; effective but DANGEROUS in overdose and CARDIOTOXIC; use with extreme caution in suicidal clients.
Diagrams to know
- TCA mechanism (norepinephrine + serotonin reuptake blockade)
- Anticholinergic side effects spectrum
Antidepressants — Monoamine Oxidase Inhibitors (MAOIs)
Common values
Value
>180 mmHg systolic (typically 180–230+)
Symbol
BP_crisis
Quantity
Hypertensive crisis blood pressure
Value
2 weeks (most); 5 weeks (fluoxetine)
Symbol
t_washout
Quantity
SSRI/TCA washout before MAOI
Important facts
- MAOI ONSET: 2–4 weeks (same delay as other antidepressants).
- Reserved for TREATMENT-RESISTANT depression: when SSRIs and other agents fail.
- CRITICAL: TYRAMINE-FREE DIET IS ESSENTIAL — tyramine + MAOI → HYPERTENSIVE CRISIS (can be FATAL).
- TYRAMINE-RICH FOODS TO AVOID: aged cheeses (cheddar, blue, brie, mozzarella aged >few days), cured/smoked/aged meats (salami, pepperoni, sausage, bacon, ham, anchovies, caviar), fermented soy products (soy sauce, tofu, miso), sauerkraut, fermented/aged foods, TAP OR DRAFT BEER (bottled OK in moderation), RED WINE especially Chianti, overripe/spoiled foods, yeast extracts.
- SAFE FOODS: fresh meats, fish, poultry; fresh fruits/vegetables; milk, yogurt, fresh cheese (ricotta, cream cheese); whole grain breads; pasta; rice.
- OTC COLD/COUGH/DECONGESTANT MEDICATIONS: AVOID (contain sympathomimetics — phenylephrine, pseudoephedrine, phenylpropanolamine).
- NEVER combine MAOI + SSRI/TCA/other serotonergic agent without WASHOUT: 2 weeks for most SSRIs, 5 weeks for fluoxetine; risk of SEROTONIN SYNDROME.
- Teach client to RECOGNIZE HYPERTENSIVE CRISIS SIGNS: severe occipital headache, palpitations, neck stiffness, sweating, chest pain, shortness of breath; SEEK EMERGENCY CARE IMMEDIATELY.
- If hypertensive crisis occurs: STOP MAOI, emergency medical evaluation; may require phentolamine (alpha blocker) or nifedipine to lower BP.
- Sexual dysfunction and weight gain common.
- Hepatotoxicity risk: monitor LFTs; contraindicated in liver disease.
Key definitions
Monoamine Oxidase Inhibitors (MAOIs)
Example
Phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), selegiline (Emsam at low doses).
Irreversibly inhibit MAO enzyme; block breakdown of serotonin, norepinephrine, dopamine; reserved for treatment-resistant depression due to serious dietary and drug interactions.
Hypertensive Crisis
Example
Patient on phenelzine eats aged cheddar cheese; develops severe occipital headache, palpitations, neck stiffness, BP 210/120 → requires emergency care.
Severe, acute elevation in blood pressure (often >180 mmHg systolic) caused by combining MAOI with tyramine-rich food/drink; can cause stroke, MI, or death.
Diagrams to know
- MAOI mechanism (MAO inhibition, monoamine accumulation)
- Tyramine interaction pathway: tyramine + MAOI → sympathomimetic surge → hypertensive crisis
- Foods to avoid with MAOI (visual chart)
Serotonin Syndrome — Critical Emergency
Common values
Value
24–72 hours
Symbol
t_onset
Quantity
Typical onset after drug interaction
Value
12 mg
Symbol
D_load
Quantity
Cyproheptadine loading dose
Value
2 mg every 6 hours
Symbol
D_maint
Quantity
Cyproheptadine maintenance
Important facts
- CAUSE: combining serotonergic drugs (SSRI + MAOI most common; also SSRI + tramadol, SSRI + triptan for migraine, SSRI + St. John's wort, SSRI + DXM in cough syrup).
- ONSET: typically within 24–72 hours of dose increase or starting new serotonergic agent.
- TRIAD OF SYMPTOMS:
- 1. MENTAL STATUS CHANGES: agitation, anxiety, confusion, disorientation, hallucinations, coma.
- 2. AUTONOMIC INSTABILITY: hyperthermia (fever often >38.5°C), tachycardia, tachypnea, hypertension or hypotension, diaphoresis (profuse sweating), flushing.
- 3. NEUROMUSCULAR ABNORMALITIES: tremor, hyperreflexia, muscle rigidity, clonus (spontaneous or inducible), myoclonus, ataxia, nystagmus, seizures.
- SEVERITY can range from MILD (mild tremor, agitation) to LIFE-THREATENING (severe hyperthermia, seizures, rhabdomyolysis, DIC, coma, death).
- Diagnosis: clinical; no specific lab test.
- Management: IMMEDIATE STOP of offending drug(s); SUPPORTIVE CARE (cooling measures, hydration, cardiac monitoring); give CYPROHEPTADINE (serotonin antagonist), 12 mg load then 2 mg q6h PO or per NG tube.
- Monitor for complications: rhabdomyolysis (dark urine, elevated CK), acute kidney injury, coagulopathy, seizures.
- Prognosis: most resolve within 24 hours of stopping drug; mild cases may resolve with supportive care alone.
- PREVENTION: adequate washout period between serotonergic drugs; educate patient and provider about drug interactions.
Key definitions
Serotonin Syndrome
Example
Patient on SSRI started on MAOI without washout; develops agitation, confusion, hyperthermia (39.5°C), tachycardia, hyperreflexia, clonus, tremor within 24 hours.
Life-threatening condition from excess serotonergic activity; triad: mental status changes, autonomic instability, neuromuscular abnormalities; managed by stopping offending drug(s) and supportive care.
Diagrams to know
- Serotonin syndrome symptom triad and severity scale
- Decision tree: suspect serotonin syndrome → stop drug → supportive care + cyproheptadine
Lithium Carbonate — Mood Stabilizer (HIGHEST YIELD TOPIC)
Formulas
Therapeutic serum lithium level = 0.6–1.2 mEq/L (maintenance); up to 1.5 mEq/L for acute mania (under close monitoring)
Meaning
Therapeutic range for steady-state mood stabilization; levels above 1.5 mEq/L approach toxicity.
Watch out
DRAW SAMPLE 12 HOURS AFTER THE LAST DOSE (trough level, not peak) — this is THE most common student error. Levels drawn at peak will be falsely elevated and mislead dosing decisions.
When to use
Determine if patient's lithium level is in therapeutic range; guide dosing adjustments.
Lithium toxicity begins above 1.5 mEq/L; SEVERE toxicity >2.0 mEq/L; LIFE-THREATENING >2.5–3.0 mEq/L
Meaning
Toxic threshold is close to therapeutic range (narrow therapeutic index); toxicity is dose-dependent and severity-escalated.
Watch out
Do NOT assume mild GI symptoms are unrelated to lithium — even nausea/diarrhea can be early toxicity; check level immediately. Severe toxicity can progress rapidly to seizures and coma.
When to use
Recognize toxicity symptoms and correlate with serum level; guide emergency intervention.
Common values
Value
0.6–1.2 mEq/L
Symbol
L_therapeutic
Quantity
Therapeutic lithium level (maintenance)
Value
Up to 1.5 mEq/L (under close monitoring)
Symbol
L_acute
Quantity
Acute mania lithium level
Value
>1.5 mEq/L (mild begins); >2.0 mEq/L (severe); >2.5–3.0 mEq/L (life-threatening)
Symbol
L_toxic
Quantity
Toxicity threshold
Value
12 hours after last dose
Symbol
t_trough
Quantity
Lithium level draw timing (trough)
Value
1–3 weeks
Symbol
t_onset
Quantity
Onset of mood stabilization
Value
2–3 liters
Symbol
V_fluid
Quantity
Recommended daily fluid intake
Important facts
- THERAPEUTIC SERUM LEVEL: 0.6–1.2 mEq/L (maintenance); acute mania may use upper end (~1.5 mEq/L) under close supervision.
- TOXICITY THRESHOLD: levels ≥1.5 mEq/L; SEVERE toxicity >2.0 mEq/L; LIFE-THREATENING >2.5–3.0 mEq/L.
- MUST DRAW LEVEL 12 HOURS AFTER LAST DOSE (trough) — NOT at peak; peak is 2–4 hours post-dose.
- EARLY/MILD TOXICITY (1.5–2.0 mEq/L): nausea, vomiting, diarrhea, fine hand tremor, muscle weakness, thirst (polyuria), drowsiness, slurred speech.
- MODERATE-SEVERE TOXICITY (>2.0 mEq/L): coarse tremor, ataxia, confusion, muscle twitching, hyperreflexia, nystagmus, seizures, progression to coma, cardiovascular collapse.
- MECHANISM OF SODIUM-LITHIUM RELATIONSHIP: Lithium is transported via sodium channels and reabsorbed in renal proximal tubule like sodium. Low sodium diet, dehydration, sweating, vomiting, diarrhea, diuretics → sodium loss → kidneys reabsorb more lithium → serum lithium RISES.
- CRITICAL TEACHING: Maintain CONSISTENT, NORMAL sodium intake; avoid sudden dietary salt changes and crash diets. Maintain ADEQUATE HYDRATION (2–3 liters/day). Be cautious in hot weather and heavy exercise (fluid/sodium loss from perspiration).
- NSAIDs and THIAZIDE DIURETICS RAISE lithium levels; ACE inhibitors and loop diuretics may also increase levels. Monitor closely if these drugs added.
- Onset of mood-stabilizing effect: 1–3 weeks; acute mania often treated with adjunctive antipsychotic or benzodiazepine in interim.
- Baseline tests: serum creatinine (renal function), TSH, EKG if high risk. Periodic monitoring (renal/thyroid function) because lithium can cause hypothyroidism and affects kidneys with chronic use.
- Do NOT stop abruptly: risk of rebound mania or rapid cycling; taper gradually over 1–2 weeks.
- Take with food to reduce GI upset.
- If toxicity suspected: STOP lithium immediately; check serum level stat; IV hydration and support; severe toxicity may require HEMODIALYSIS to remove lithium.
- Pregnancy: teratogenic (associated with Ebstein's anomaly, cardiac defects); requires careful risk/benefit discussion.
- Polyuria and polydipsia (thirst) are common side effects; educate patient this is expected and not a sign of toxicity (unless accompanied by tremor, confusion).
Key definitions
Narrow Therapeutic Index
Example
Lithium level 1.0 = therapeutic; 1.6 = toxic. A small dosing error or medication interaction causes significant toxicity risk.
Therapeutic dose and toxic dose are very close; small increases in dose or serum level cause toxicity; requires regular monitoring.
Lithium-Sodium Relationship
Example
Patient on low-salt diet or loses sodium via diarrhea → lithium reabsorption increases → serum level rises even without dose change.
Kidneys handle lithium like sodium; LOW sodium intake, dehydration, or urinary sodium loss → kidneys reabsorb more lithium → serum lithium RISES → toxicity risk.
Diagrams to know
- Lithium toxicity severity scale with symptoms and serum levels
- Sodium-lithium reabsorption mechanism in kidney
- Lithium monitoring timeline and level interpretation chart
Reactions or equations
Low sodium (diet, dehydration, GI loss) → Decreased urinary sodium → Kidneys reabsorb lithium like sodium → Serum lithium RISES → Toxicity
Note
This is THE MOST CRITICAL concept for lithium safety. Students must understand and teach this relationship.
Conditions
Any condition causing sodium depletion (diuretics, diarrhea, vomiting, sweating, low-salt diet) increases lithium reabsorption.
Other Mood Stabilizers & Antipsychotics for Mania
Important facts
- VALPROIC ACID (DIVALPROEX): effective for acute mania and maintenance; monitor liver function (LFTs) and platelet count (thrombocytopenia risk); risk of pancreatitis (monitor amylase); TERATOGENIC (avoid in pregnancy, especially 1st trimester).
- CARBAMAZEPINE: effective for acute mania, especially with aggression; monitor for agranulocytosis (low WBC) and Stevens-Johnson syndrome (serious rash); AUTOINDUCES its own metabolism (increases clearance over time), requiring dose adjustments; many drug interactions.
- LAMOTRIGINE: used for bipolar depression (less for mania); SERIOUS RISK of Stevens-Johnson syndrome and toxic epidermal necrolysis, especially if rapid titration; MUST TITRATE SLOWLY; associated with rash in 10% of patients.
- ATYPICAL ANTIPSYCHOTICS (quetiapine, olanzapine, aripiprazole, risperidone): effective for acute mania and maintenance; FDA-approved for bipolar mania; often used adjunctively with mood stabilizer; monitor for weight gain, metabolic syndrome, tardive dyskinesia.
- Benzodiazepines (lorazepam, clonazepam) used for acute agitation/mania while waiting for mood stabilizer effect (lithium takes 1–3 weeks); short-term bridge therapy.
Key definitions
Anticonvulsant Mood Stabilizers
Example
Valproic acid (Depakote) for acute mania; carbamazepine (Tegretol) for mania with aggression; lamotrigine for bipolar depression.
Antiepileptic drugs (valproate, carbamazepine, lamotrigine) used for mania, especially if lithium fails or contraindicated; lower suicide risk than some alternatives.
Diagrams to know
- Comparison of mood stabilizer classes and clinical use
- Timeline: acute mania management with benzodiazepine bridge + mood stabilizer initiation
Electroconvulsive Therapy (ECT) — Rapid-Acting Treatment
Common values
Value
Typically 2–3 times per week for 2–4 weeks (8–12 treatments)
Symbol
freq_ECT
Quantity
ECT treatment frequency
Value
3–5 treatments (days to 1–2 weeks)
Symbol
t_response
Quantity
Time to symptom improvement
Value
20–60 seconds
Symbol
t_seizure
Quantity
Seizure duration
Value
70–80%
Symbol
efficacy
Quantity
Success rate for severe depression
Important facts
- INDICATIONS: severe depression (especially with psychotic features or high suicide risk), treatment-resistant depression (failed 2–3 antidepressant trials), depression during pregnancy (safer than prolonged pharmacotherapy), catatonia, mania (less common).
- RAPID EFFECT: symptom improvement often within 3–5 treatments (days to 1–2 weeks), versus weeks to months for medication.
- MECHANISM: brief electrical current induces controlled generalized seizure under anesthesia; exact mechanism unclear but likely involves monoamine, GABA, and HPA axis changes.
- PROCEDURE: NPO (fasting) typically after midnight; general anesthesia (propofol or methohexital); MUSCLE RELAXANT succinylcholine given to prevent physical convulsion injury; stimulating electrodes applied (bilateral or unilateral); seizure duration 20–60 seconds; patient wakes within minutes.
- PRIOR PREPARATION: obtain INFORMED CONSENT (critical — some patients hesitant due to stigma/misconceptions); ensure NPO; remove dentures, jewelry, hairpins, contact lenses; have patient void; take baseline vital signs; place IV; give anticholinergic (atropine) to reduce salivation/secretions.
- AFTER ECT: position patient on SIDE to maintain airway and prevent aspiration; monitor vital signs, SpO2, and respiratory status; reorient frequently (confusion is common); monitor for nausea.
- MOST COMMON SIDE EFFECT: transient CONFUSION and SHORT-TERM MEMORY LOSS, especially after first few treatments; usually resolves after series ends or shortly thereafter.
- REASSURANCE: confusion and memory loss are TEMPORARY and expected; brain imaging, cognition testing show no permanent damage; memory typically returns fully.
- Relative contraindications: recent MI, uncontrolled hypertension, pheochromocytoma, increased intracranial pressure (brain tumor, space-occupying lesion); can often be managed with precautions.
- Success rate: ~70–80% for severe depression; higher than medication for acute, severe, or psychotic depression.
- Maintenance ECT: some patients require periodic ECT treatments to prevent relapse; alternative if medications ineffective.
Key definitions
Electroconvulsive Therapy (ECT)
Example
Patient with severe depression, suicidal intent, and failed medication trials receives 8–12 bilateral ECT treatments over 2–4 weeks with significant symptom improvement.
Controlled induction of generalized seizure under general anesthesia using electrical current; effective rapid treatment for severe/treatment-resistant depression, depression with psychosis, or high-suicide-risk depression.
Diagrams to know
- ECT procedure timeline: pre-ECT preparation → anesthesia/seizure induction → post-ECT recovery
- ECT effectiveness compared to medications over time
RA 11036 (Mental Health Act) — Philippine Legal/Ethical Framework
Important facts
- RA 11036 mandates HUMANE TREATMENT and protects HUMAN RIGHTS of persons with mental health conditions.
- INVOLUNTARY ADMISSION/TREATMENT: permitted for imminent risk of self-harm (suicide) or harm to others, with documented evaluation by licensed mental health professional, informed consent process, and family notification.
- RESTRAINT/SECLUSION: permitted only as last resort for imminent safety risk, with documented justification, regular monitoring, and time limits; NOT for discipline or convenience.
- ANTI-DISCRIMINATION: protects persons with mental health conditions from discrimination in employment, education, housing, and healthcare.
- CONFIDENTIALITY: patient records protected; disclosure permitted only with informed consent or legal order.
- RIGHT TO TREATMENT, REHABILITATION, AND RECOVERY: RA 11036 emphasizes reintegration and community mental health services, not prolonged institutionalization.
- ROLE OF NURSE: advocate for patient rights, ensure informed consent, document all involuntary actions with justification, monitor for abuse or violation of rights, connect patient to community mental health services upon discharge.
Key definitions
Mental Health Act (RA 11036)
Example
Patient with suicidal ideation can be involuntarily admitted for imminent risk of harm with proper documentation, evaluation, and family notification as per RA 11036.
Philippine law mandating humane, rights-respecting treatment of persons with mental health conditions; protects involuntary admission rights, involuntary treatment safeguards, and anti-discrimination provisions.
Diagrams to know
- RA 11036 involuntary admission flowchart: indication → evaluation → consent/notification → documentation
Patient & Family Teaching — Key Messages
Important facts
- ANTIDEPRESSANT TEACHING: Takes 2–4 weeks for full effect; do not stop abruptly (risk of discontinuation syndrome); watch for increased suicidal thoughts early in treatment; call provider if worsening thoughts, severe side effects.
- LITHIUM TEACHING: Maintain CONSISTENT, normal salt intake and ADEQUATE fluids (2–3 liters/day); be cautious in hot weather and with exercise (dehydration raises lithium level); report signs of toxicity (nausea, tremor, confusion, slurred speech); regular blood tests required; never stop abruptly.
- MAOI TEACHING: Avoid ALL aged cheeses, cured/smoked meats, fermented soy products, draft beer, red wine, yeast extracts; avoid OTC cold/decongestant medicines; report severe headache, chest pain, palpitations (hypertensive crisis signs) to ER immediately.
- SUICIDE WARNING SIGNS: Increase in risky behavior, giving away possessions, talking about being burden, sudden calm after depression, increased substance use, withdrawing from support; encourage patient to call crisis line, talk to trusted person, or go to ER.
- MANIA/BIPOLAR EDUCATION: Importance of mood stabilizer adherence even when feeling well; early signs of relapse (decreased sleep, increased spending, risky behavior); risk of suicide during depressive phase; regular follow-up appointments and blood monitoring essential.
- ECT TEACHING: Confusion and memory loss after ECT are temporary and expected; most recover full memory; ECT is safe, effective option for severe depression; does not affect intelligence or personality.
- RECOVERY EXPECTATION: Mood disorders are chronic, recurrent; recovery is possible with medication, therapy, and lifestyle; relapse prevention involves continued treatment, sleep/stress management, and recognizing early warning signs.
Must remember
SUICIDE IS THE HIGHEST PRIORITY in mood disorders. ASK DIRECTLY: 'Are you thinking of killing yourself?' Assess for PLAN, METHOD, MEANS. Implement safety: remove hazards, one-to-one observation for high risk, never promise confidentiality on suicidal disclosure. Risk INCREASES when ENERGY RETURNS early in treatment.
MDD diagnostic criteria: Depressed mood OR anhedonia ≥2 weeks PLUS ≥5 additional symptoms from SIG E CAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide). Can include psychotic features.
Bipolar I = at least ONE MANIC EPISODE (≥7 days, severe, hospitalization often needed). Bipolar II = NEVER full mania; defined by hypomanic episodes (4+ days, no marked impairment) + major depression. Key difference: Bipolar II never has full mania.
LITHIUM THERAPEUTIC LEVEL: 0.6–1.2 mEq/L (maintenance). TOXICITY: >1.5 mEq/L (early); >2.0 mEq/L (severe); >2.5–3.0 mEq/L (life-threatening). DRAW LEVEL 12 HOURS AFTER LAST DOSE. Lithium follows sodium: low sodium/dehydration → lithium rises → toxicity. Teach consistent salt intake + 2–3 L fluid/day.
LITHIUM TOXICITY SIGNS (escalating): Early (1.5–2.0 mEq/L): nausea, vomiting, diarrhea, fine tremor, thirst, polyuria, drowsiness. Severe (>2.0 mEq/L): coarse tremor, ataxia, confusion, muscle twitching, hyperreflexia, nystagmus, seizures, coma. If suspected, STOP lithium, check level stat, support care, consider hemodialysis.
SSRI + MAOI = SEROTONIN SYNDROME (hyperthermic emergency). Manifestations: mental status changes (agitation, confusion), autonomic instability (hyperthermia, tachycardia, diaphoresis), neuromuscular (tremor, hyperreflexia, clonus). Management: STOP drug(s), supportive care, CYPROHEPTADINE (12 mg load, 2 mg q6h). Washout: 2 weeks (most SSRIs), 5 weeks (fluoxetine).
MAOI DIETARY RESTRICTION: Avoid aged cheeses, cured/smoked/aged meats, fermented soy (soy sauce, tofu, miso), sauerkraut, draft beer, red wine, yeast extracts. Tyramine + MAOI = HYPERTENSIVE CRISIS (severe headache, neck stiffness, BP >180 mmHg, stroke/MI risk) → EMERGENCY. Also avoid OTC cold/decongestant meds (sympathomimetics).
Antidepressants (SSRI, TCA, MAOI) take 2–4 WEEKS for full effect. NEVER stop abruptly (discontinuation syndrome). Watch for EARLY SUICIDAL IDEATION in first weeks as energy returns. Teach adherence, explain delay, monitor closely.
Manic client nursing care: REDUCE environmental stimulation (quiet, calm, few people). Meet basic needs (high-calorie finger foods, fluids on-the-go, prevent exhaustion/dehydration). Set FIRM LIMITS on intrusive/manipulative behavior. Channel energy into safe, non-competitive activities. PROTECT from consequences of poor judgment (financial, sexual, legal).
ECT (electroconvulsive therapy): Indicated for severe/treatment-resistant depression, depression with psychosis, high-suicide-risk depression. RAPID effect (3–5 treatments → symptom improvement). Transient confusion & short-term memory loss expected (temporary). Requires informed consent, NPO, muscle relaxant (succinylcholine), positioning on side post-ECT, frequent reorientation.
Last minute tips
LITHIUM LEVEL TIMING: Students mistake peak for trough. ALWAYS draw at 12 hours post-dose for accurate therapeutic/toxic assessment. Peak levels falsely elevate and will mislead dosing. Write this on your hand if needed.
BIPOLAR I vs II: The ONE key difference is the PRESENCE OF FULL MANIA. If client has ever had a full manic episode (≥7 days, severe impairment, hospitalization often needed) = Bipolar I. If ONLY hypomanic episodes (4+ days, no marked impairment, no hospitalization) = Bipolar II. No full mania ever in Bipolar II.
SEROTONIN SYNDROME is a CLINICAL DIAGNOSIS (no lab test). If you see the TRIAD (mental status change + autonomic instability + neuromuscular signs) in a patient on serotonergic drugs (SSRI, MAOI, tramadol, triptan, St. John's wort), think serotonin syndrome immediately. Stop the drug and give supportive care + cyproheptadine.
ECT SIDE EFFECTS: Confusion and memory loss after ECT are TEMPORARY and EXPECTED — many students mistakenly think they're signs of damage. Reassure patient. Memory returns fully in days to weeks. This is a testable concept on NLE; know it solidly.
SUICIDE ASSESSMENT: Asking about suicidal thoughts does NOT plant the idea — it opens the door to honesty and shows you care. ALWAYS ask directly. Assess the TRIAD (plan/method/means). A specific, lethal, available plan = HIGH RISK. Prior attempts = STRONGEST PREDICTOR. One-to-one observation for high risk; never leave alone; never promise confidentiality.
Comparison tables
MDD vs Bipolar I vs Bipolar II — Diagnostic Comparison
| Feature | Major Depressive Disorder | Bipolar I | Bipolar II |
|---|---|---|---|
| Core mood episodes | Depressive only (≥2 weeks) | Manic (≥1 week) + depressive | Hypomanic (≥4 days) + depressive (≥2 weeks) |
| Manic episode required? | No | YES (at least one) | No — hypomania only |
| Hypomanic episode required? | No | Not required (may occur) | YES (at least one) |
| Severity/impairment | Depressive: can be mild to severe | Manic: SEVERE; often requires hospitalization | Hypomanic: NO marked impairment; does NOT require hospitalization |
| Work/school functioning during mania/hypomania | Impaired by depression | Severely impaired (manic client unable to sustain focus or judgment) | May appear productive/energized but eventually impaired |
| Suicide risk | HIGH (especially during depressive episodes) | HIGHEST (often during depressive phase or mixed states) | HIGH (during depressive episodes) |
| First-line treatment | SSRI or other antidepressant | Mood stabilizer (lithium) ± antipsychotic; antidepressants used cautiously (risk of switching to mania) | Mood stabilizer + antidepressant carefully monitored |
| Onset age | Can occur at any age; often 20–40 years | Often earlier (late adolescence to 20s) | Often later (20–30s+) |
Antidepressant Classes — Key Comparison for NLE
| Class | Examples | Onset | Mechanism | Advantages | Major Disadvantages | Critical Caution |
|---|---|---|---|---|---|---|
| SSRIs | Fluoxetine, sertraline, paroxetine, escitalopram, citalopram | 2–4 weeks | Block serotonin reuptake | FIRST-LINE; safe, well-tolerated, fewer interactions, good efficacy | Sexual dysfunction (20–40%), hyponatremia (elderly), delayed onset | DO NOT combine with MAOI without washout (2 wks, 5 wks for fluoxetine); watch for early suicidal ideation |
| TCAs | Amitriptyline, imipramine, nortriptyline, clomipramine | 2–4 weeks | Block NE + 5-HT reuptake; anticholinergic activity | Effective; anticholinergic side effects useful for anxiety/sleep | CARDIOTOXIC in overdose (dysrhythmias); anticholinergic effects (dry mouth, constipation, orthostatic hypotension); weight gain; sedation | DANGEROUS in suicidal patients (dispense limited quantity); do NOT combine with MAOI; avoid in cardiac disease |
| MAOIs | Phenelzine, tranylcypromine, isocarboxazid, selegiline | 2–4 weeks | Irreversibly inhibit MAO; block monoamine breakdown | Effective for treatment-resistant depression | SERIOUS dietary restrictions (tyramine-free); serious drug interactions; hypertensive crisis risk; hepatotoxicity risk | TYRAMINE-FREE DIET ESSENTIAL (aged cheese, cured meats, fermented foods, draft beer, red wine); NEVER combine with SSRI/TCA/serotonergic drugs without washout (2–5 wks); educate patient on hypertensive crisis signs |
Lithium Toxicity — Signs by Severity & Serum Level
| Serum Level (mEq/L) | Severity Category | Characteristic Signs & Symptoms |
|---|---|---|
| 0.6–1.2 | THERAPEUTIC | No toxicity; therapeutic effect expected |
| 1.5–2.0 | EARLY/MILD TOXICITY | Nausea, vomiting, diarrhea, fine hand tremor, muscle weakness, thirst/polyuria, drowsiness, slurred speech, poor concentration |
| >2.0 | MODERATE-SEVERE TOXICITY | Coarse tremor, ataxia, confusion, muscle twitching, hyperreflexia, nystagmus, weakness, coarse speech, agitation |
| >2.5–3.0 | SEVERE/LIFE-THREATENING TOXICITY | Seizures, coma, cardiovascular collapse, arrhythmias, acute kidney injury, rhabdomyolysis, death |
Serotonin Syndrome — Causes, Manifestations, Management (NLE GOLD STANDARD)
| Aspect | Key Information |
|---|---|
| MOST COMMON CAUSE | SSRI + MAOI (most dangerous combination); also SSRI + tramadol, SSRI + triptan, SSRI + DXM, SSRI + St. John's wort |
| ONSET | 24–72 hours after starting new serotonergic drug or dose increase |
| SYMPTOM TRIAD | (1) MENTAL STATUS: agitation, anxiety, confusion, hallucinations, coma. (2) AUTONOMIC: hyperthermia (>38.5°C), tachycardia, hypertension/hypotension, diaphoresis. (3) NEUROMUSCULAR: tremor, hyperreflexia, clonus (spontaneous or inducible), rigidity, myoclonus, ataxia, seizures |
| SEVERITY SPECTRUM | Mild (tremor, agitation) → Moderate (fever, hyperreflexia, clonus) → SEVERE (seizures, rhabdomyolysis, DIC, coma, death) |
| MANAGEMENT (CRITICAL) | STOP offending drug(s) IMMEDIATELY. Supportive care: cooling measures, IV fluids, cardiac monitoring. Give CYPROHEPTADINE (serotonin antagonist): 12 mg load, then 2 mg q6h PO/NG. Monitor for rhabdomyolysis (CK, myoglobinuria). |
| PROGNOSIS | Most recover within 24 hours of stopping drug; mild cases resolve with supportive care alone. Severe cases with complications (rhabdo, DIC, AKI) have higher mortality. |
| PREVENTION | WASHOUT PERIOD: 2 weeks between most SSRIs and MAOI; 5 WEEKS after fluoxetine (long half-life). Educate provider and patient about serotonergic drug interactions. |
Mood Stabilizers — Classes, Mechanisms, Monitoring
| Drug Class/Example | Mechanism | Indication | Onset | Key Monitoring | Major Side Effects / Cautions |
|---|---|---|---|---|---|
| LITHIUM (lithium carbonate) | Unclear; affects monoamine function, G-proteins, neuroprotection | Bipolar I mania & maintenance; some depression | 1–3 weeks | Serum level (12 hrs post-dose); renal/thyroid function baseline & periodic; EKG | Polyuria, polydipsia (common, expected), fine tremor, weight gain, hypothyroidism, renal effects, narrow therapeutic index (0.6–1.2 mEq/L therapeutic; >1.5 toxic) |
| VALPROIC ACID (Depakote) | Unclear; likely GABA enhancement, histone deacetylase inhibition | Acute mania, bipolar maintenance, especially with aggression | 2–3 days (faster than lithium) | LFTs (hepatotoxicity risk), platelet count (thrombocytopenia), ammonia, pancreatitis (amylase) | GI upset, tremor, weight gain, hair loss, hepatotoxicity, pancreatitis, thrombocytopenia, TERATOGENIC (avoid pregnancy, especially 1st trimester) |
| CARBAMAZEPINE (Tegretol) | Unclear; likely sodium channel blockade | Acute mania with aggression, bipolar maintenance | 1–2 weeks | CBC (agranulocytosis), rash (SJS/TEN), skin exam; autoinduces own metabolism | Ataxia, dizziness, diplopia, GI upset, agranulocytosis (rare but serious), Stevens-Johnson syndrome (serious rash, 1–6 weeks), autoinduces metabolism (clearance increases over time → dose adjustments needed), many drug interactions |
| LAMOTRIGINE (Lamictal) | Sodium channel blockade, glutamate inhibition | Bipolar depression (less for mania) | 2–4 weeks | Rash monitoring (especially first 6 wks), slow titration | Rash (10%, can progress to SJS/TEN if not caught), MUST TITRATE SLOWLY to reduce rash risk, diplopia, ataxia, headache |
| ATYPICAL ANTIPSYCHOTICS (quetiapine, olanzapine, aripiprazole, risperidone) | Dopamine & serotonin antagonism | Acute mania, bipolar maintenance | 1–3 days (faster than lithium) | Weight, glucose, lipids, prolactin (risperidone), movement disorder screening (tardive dyskinesia) | Weight gain, metabolic syndrome, tardive dyskinesia, sedation, orthostatic hypotension, QT prolongation (some agents) |
Diagrams
Mood Disorders Overview — Core Concepts
A hierarchical mind map showing the major categories of mood disorders, diagnostic criteria (SIG E CAPS), types of bipolar disorder, antidepressant classes, mood stabilizers, and nursing management priorities. This provides a bird's-eye view of all key concepts in the chapter.
Lithium Management Flowchart — Assessment, Dosing, Toxicity
A comprehensive flowchart for lithium assessment and management, showing the critical relationship between serum level ranges (therapeutic, early toxicity, severe toxicity), associated symptoms, and nursing actions. Includes the sodium-lithium interaction that causes toxicity. This is a high-yield visual for NLE.
Serotonin Syndrome Progression — Recognition & Response
A state diagram showing the progression from normal medication use through risk factors, early onset, and escalating severity of serotonin syndrome, with corresponding management actions at each stage. This helps students visualize the timeline and severity spectrum, making it easy to recognize and respond appropriately.
Suicide Risk Assessment & Safety Precautions — Decision Tree
A detailed flowchart for suicide assessment and risk stratification. Shows the progression from asking directly, assessing the plan-method-means triad, determining risk level (moderate vs high), and implementing appropriate safety precautions. Includes danger periods and documentation requirements. This is essential NLE content.
Lithium Toxicity Manifestations by System
A pie chart showing the distribution of lithium toxicity symptoms across physiological systems. This visual breakdown helps students understand that lithium toxicity is a multi-system emergency affecting neuromuscular, mental status, GI, autonomic, and renal function in roughly equal proportions.
Antidepressant Onset & Suicide Risk Timeline
A timeline showing the critical periods in antidepressant therapy when suicide risk is highest. The weeks 2–4 window (when energy returns before mood improves) is specifically highlighted as the danger period. This visual helps students understand why close observation is essential early in treatment.
Bipolar I vs Bipolar II — Diagnostic Differentiation
A flowchart that differentiates between Bipolar I, Bipolar II, and Major Depressive Disorder based on the presence or absence of full manic episodes. Shows the diagnostic decision tree with treatment implications for each. The key discriminator is the presence of a full manic episode (≥7 days, severe impairment, hospitalization) that defines Bipolar I.