NLE Psychiatric Disorders — Mood Disorders: Depression and Bipolar DisorderDetailed Explanation

Major Depressive Disorder (MDD): Assessment and Nursing Management

Major Depressive Disorder (MDD) is a serious mood disorder characterized by a persistently depressed mood or markedly diminished interest and pleasure in nearly all activities (called anhedonia) that lasts for at least TWO WEEKS and represents a change from the person's baseline functioning. To meet the diagnostic criteria, the client must also have at least four to five additional symptoms from the following list — a useful way to remember these is the mnemonic SIG E CAPS: Sleep disturbance (insomnia or hypersomnia), Interest loss (anhedonia), Guilt or feelings of worthlessness, Energy loss or fatigue, Concentration difficulty, Appetite or weight change, Psychomotor changes (agitation or retardation), and Suicidal ideation or recurrent thoughts of death. In clinical assessment, the nurse observes for a flat or blunted affect, monotone and slowed speech, psychomotor retardation (moving and thinking slowly), social withdrawal, poor personal grooming and hygiene, constipation, and somatic complaints such as headaches or vague body pains. In severe cases, MDD may include psychotic features such as mood-congruent delusions (e.g., believing they are being punished for imagined sins). Nursing Management uses the nursing process framework. The PRIORITY nursing diagnosis is Risk for Suicide (NANDA) or Risk for Self-Directed Violence, because the safety of the client always comes first — this is consistent with Maslow's hierarchy, where physiological and safety needs precede all others. Secondary diagnoses include Hopelessness, Social Isolation, Imbalanced Nutrition: Less than Body Requirements, Self-Care Deficit, and Disturbed Sleep Pattern. Key nursing interventions: (1) SAFETY FIRST — always assess for suicidal ideation before anything else; (2) Therapeutic use of self — spend short, frequent, non-demanding time with the client; a calm, accepting presence communicates that the client has worth and is not alone; (3) Avoid false reassurance — do not say 'Wag ka magalala, okay ka naman' or 'Cheer up!' because this invalidates the client's real suffering; (4) Meet basic physiologic needs — the client may not have enough energy to eat, drink, move, or bathe; the nurse must assist and monitor; (5) Structure the day with simple, achievable tasks to restore a sense of accomplishment and purpose; (6) CRITICAL DANGER PERIOD — when a depressed client's energy begins to return (early in treatment, usually within the first 1–2 weeks of antidepressant therapy), the risk of acting on suicidal thoughts actually INCREASES. The mood may not yet have lifted, but the client now has enough energy to act. This is a frequently tested NLE concept.

Suicide Risk Assessment and Precautions

Suicide assessment is the SINGLE HIGHEST PRIORITY skill in psychiatric nursing. On the NLE, any question involving a client with suicidal statements, behaviors, or risk factors will almost always have the correct answer centered on SAFETY. Understanding how to assess risk and institute precautions is non-negotiable. Direct Assessment: The nurse MUST ask directly — 'Are you thinking of killing yourself?' or 'Are you having thoughts of ending your life?' Asking does not plant the idea; it opens a therapeutic channel. Then assess the PLAN (does the client have a specific method?), METHOD (is the method lethal? — firearms, hanging, jumping from height are more lethal than wrist cutting), and MEANS (does the client have ACCESS to the method? — is there a gun at home? a stockpile of pills?). Warning Signs to recognize: (1) Giving away prized possessions (e.g., giving rosary, jewelry, cellphone to loved ones); (2) Making a will or saying final goodbyes; (3) A SUDDEN CALM or improvement in mood after a period of deep depression — this may signal that the client has made a decision to act; (4) Expressions of hopelessness ('Wala na akong pag-asa'), burden ('Mas maayos pa kung wala ako'), or being a burden to others; (5) Previous suicide attempts — this is the STRONGEST PREDICTOR of future attempts. Risk Factors: Prior attempts (strongest predictor), male sex (men use more lethal means), older age, social isolation, chronic illness, substance use disorder, access to lethal means (especially firearms), family history, and recent significant loss. Priority Precautions: (1) Provide a SAFE ENVIRONMENT — remove or secure all potential means of self-harm: sharps (razors, scissors, needles), belts, cords, shoelaces, glass objects, medications, and restrict access to windows and unmonitored areas; (2) Institute appropriate level of OBSERVATION — for high risk, this means ONE-TO-ONE CONTINUOUS OBSERVATION (the nurse or assigned staff stays with the client at ALL TIMES, including during bathroom use, meals, and sleep); (3) Establish a THERAPEUTIC RELATIONSHIP — the client must feel safe to talk; (4) DO NOT promise confidentiality about suicidal disclosures — the nurse has a legal and ethical obligation to report to protect the client; (5) Document all assessments and interventions. Under RA 11036 (Mental Health Act), involuntary admission or treatment may be applied when there is IMMINENT RISK OF HARM to self or others, provided proper documentation and safeguards are in place. This is an important Philippine legal reference for the NLE.

Bipolar Disorder: Types, Assessment of Mania, and Nursing Management

Bipolar Disorder is a chronic mood disorder characterized by episodes of extreme mood elevation (mania or hypomania) and episodes of depression. It is important to understand the TWO main types: BIPOLAR I DISORDER: Requires at least ONE FULL MANIC EPISODE. The manic episode is a distinct period of abnormally elevated, expansive, or irritable mood lasting at least ONE WEEK (or any duration if hospitalization is required). Psychotic features may be present. A history of depression is common but NOT required for the Bipolar I diagnosis. BIPOLAR II DISORDER: Defined by at least one HYPOMANIC episode PLUS at least one MAJOR DEPRESSIVE episode. IMPORTANT: A person with Bipolar II has NEVER had a FULL manic episode. Hypomania is a milder, shorter elevation of mood (at least 4 days) that does NOT cause marked functional impairment, does NOT require hospitalization, and does NOT include psychotic features. Key Distinction for NLE: Bipolar I = full mania (may need hospitalization, may have psychosis); Bipolar II = hypomania + depression (never full mania). Assessment of Mania (DIG FAST mnemonic): Distractibility, Irresponsibility and reckless behavior, Grandiosity (inflated self-esteem), Flight of ideas, Activity increased (goal-directed), Sleep decreased (need for sleep decreases WITHOUT fatigue), Talkativeness/pressured speech. Clinical Picture of Mania: The manic client is a clinical management challenge. They have severely impaired judgment and insight, believing their grandiose plans are brilliant. They do not recognize they are ill. They are hyperactive, speak rapidly and loudly (pressured speech), jump from topic to topic (flight of ideas), may be sexually disinhibited, may go on spending sprees, and can become IRRITABLE and even agitated or aggressive when their plans are thwarted. They do NOT stop to eat, drink, or rest, putting them at SERIOUS RISK of exhaustion, dehydration, and nutritional deficits — these are the physiologic priority concerns. Nursing Management of the Manic Client: (1) REDUCE ENVIRONMENTAL STIMULATION — place the client in a quiet, low-stimulus room; avoid loud areas, many people, or chaotic environments, as these worsen agitation and escalate manic behavior; (2) ENSURE PHYSIOLOGIC SAFETY — this is the TOP priority: the manic client does not eat or drink because they are too busy; offer HIGH-CALORIE FINGER FOODS (sandwiches, fruits, nuts, energy bars) that they can eat while moving, and provide fluids frequently; monitor for dehydration, exhaustion, and weight loss; (3) SET FIRM, CONSISTENT LIMITS on manipulative, intrusive, or dangerous behavior in a MATTER-OF-FACT, NON-PUNITIVE way — the entire team must be consistent; inconsistency allows manipulation; (4) PROTECT from consequences of poor judgment — notify family if the client is attempting to make large financial decisions, sign contracts, or engage in risky sexual behavior; restrict access to phone, wallet, or internet if clinically indicated; (5) CHANNEL ENERGY into safe, non-competitive activities — avoid activities that require sustained concentration or competition, as these may increase frustration and agitation; (6) DO NOT argue, debate, or try to use logic to convince the manic client their grandiose ideas are wrong — this escalates agitation; instead, use calm, direct, brief communication. Bipolar Disorder and Suicide: Clients with bipolar disorder have a very HIGH lifetime risk of suicide — particularly during DEPRESSIVE episodes. The assessment and precautions for the depressive phase are the same as in MDD.

Antidepressants: SSRIs, TCAs, and MAOIs

Antidepressant pharmacology is one of the most heavily tested areas on the NLE. You must know the mechanism, onset of action, key side effects, nursing considerations, and critical drug and food interactions for each class. SSRIs (Selective Serotonin Reuptake Inhibitors): The FIRST-LINE treatment for MDD due to their favorable safety profile and tolerability. Common SSRIs: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), citalopram (Celexa). Mechanism: block the reuptake of serotonin in the synaptic cleft, increasing serotonin availability. Onset: 2–4 WEEKS for full therapeutic effect — a critical teaching point for adherence. Side effects: nausea, headache, insomnia, sexual dysfunction, and weight changes. Important: teach the client that the drug must be taken consistently and not stopped abruptly (discontinuation syndrome: dizziness, 'brain zaps,' flu-like symptoms). CRITICAL: Do NOT combine SSRIs with MAOIs — this causes SEROTONIN SYNDROME (life-threatening). A washout period of at least 2 weeks is required when switching between SSRIs and MAOIs (and UP TO 5 WEEKS after stopping fluoxetine, due to its long half-life, before starting an MAOI). TCAs (Tricyclic Antidepressants): Common TCAs: amitriptyline, imipramine, nortriptyline, clomipramine. Mechanism: block reuptake of both serotonin AND norepinephrine. Effective but limited by their dangerous side effect profile, especially in overdose. Onset: 2–4 weeks. Side effects — ANTICHOLINERGIC EFFECTS (think 'dry, blind, constipated, retained, fallen'): Dry mouth, Blurred vision, Constipation, Urinary retention, and Orthostatic hypotension (falls risk). MOST CRITICAL: TCAs are CARDIOTOXIC IN OVERDOSE — they cause fatal dysrhythmias. This makes TCAs EXTREMELY DANGEROUS in a suicidal client who might hoard pills. NURSING ACTION: DISPENSE LIMITED QUANTITIES, monitor the client carefully, and be alert for pill hoarding. Also do NOT combine with MAOIs. MAOIs (Monoamine Oxidase Inhibitors): Common MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), selegiline (Emsam — patch form). Mechanism: inhibit the enzyme monoamine oxidase, which normally breaks down serotonin, norepinephrine, and dopamine — resulting in increased levels of these neurotransmitters. Effective for treatment-resistant depression but reserved due to SERIOUS interactions. Onset: 2–4 weeks. TYRAMINE-RESTRICTED DIET (CRITICAL NLE CONTENT): Normally, monoamine oxidase in the gut breaks down tyramine (an amino acid in aged, fermented, and preserved foods). When MAO is inhibited, tyramine from food is absorbed into the bloodstream, causing a MASSIVE release of norepinephrine → HYPERTENSIVE CRISIS (sudden, severe rise in blood pressure, severe occipital headache, stiff neck, palpitations, diaphoresis, nausea — can be FATAL if untreated). Foods HIGH in tyramine to AVOID (memorize these): • Aged cheeses (kesong puti/fresh cheese is okay; aged cheddar, brie, camembert, blue cheese — AVOID) • Cured, smoked, or aged meats and sausages (longganisa, tocino if cured and aged, salami, pepperoni) • Fermented soy products: soy sauce (toyo), miso, tofu (some preparations) • Sauerkraut and other fermented vegetables • Tap and draft beer, red wine (especially Chianti and Burgundy), AND homemade wines • Overripe or spoiled fruits and vegetables • Yeast extracts (Marmite, Vegemite) • Broad beans (fava beans) Also AVOID: Over-the-counter cold, cough, and decongestant medications containing sympathomimetics (pseudoephedrine, phenylephrine) — they can also precipitate hypertensive crisis. SEROTONIN SYNDROME (CRITICAL EMERGENCY): Caused by EXCESS SEROTONERGIC ACTIVITY — most commonly from combining an SSRI with an MAOI, but also with SSRI + tramadol, SSRI + triptans, or SSRI + St. John's Wort. TRIAD of manifestations: 1. Mental status changes: agitation, confusion, anxiety 2. Autonomic instability: hyperthermia (high fever), tachycardia, diaphoresis, labile blood pressure 3. Neuromuscular abnormalities: tremor, hyperreflexia, myoclonus, CLONUS, muscle rigidity Management: STOP the offending drug(s) IMMEDIATELY, supportive care (cooling, IV fluids, cardiac monitoring), and give a serotonin antagonist — CYPROHEPTADINE. This is a life-threatening emergency.

Mood Stabilizers: Lithium Therapy

Lithium carbonate is the CLASSIC mood stabilizer and remains a FIRST-LINE agent for Bipolar Disorder — both for treating acute mania and for long-term maintenance to prevent recurrence of manic and depressive episodes. It has a NARROW THERAPEUTIC INDEX, meaning the difference between a therapeutic dose and a toxic dose is very small. This makes lithium monitoring one of the most critical pharmacology topics on the NLE. THERAPEUTIC AND TOXIC LEVELS (memorize precisely): • THERAPEUTIC serum level: 0.6–1.2 mEq/L (maintenance) • Acute mania may be managed toward the upper range (up to ~1.5 mEq/L) under very close monitoring • TOXICITY begins at levels ABOVE 1.5 mEq/L • SEVERE/DANGEROUS toxicity: ABOVE 2.0 mEq/L • CRITICAL/LIFE-THREATENING: 2.5–3.0+ mEq/L (cardiovascular collapse, coma, death) SIGNS OF LITHIUM TOXICITY BY LEVEL: • Early/Mild (1.5–2.0 mEq/L): Nausea, vomiting, diarrhea; FINE hand tremor; muscle weakness; excessive thirst (polydipsia); increased urination (polyuria); drowsiness; slurred speech • Moderate to Severe (>2.0 mEq/L): COARSE tremor (not fine); ataxia (unsteady gait); confusion; muscle twitching; hyperreflexia; nystagmus; progression to SEIZURES and coma • Above 2.5–3.0 mEq/L: Cardiovascular collapse and DEATH SODIUM-LITHIUM RELATIONSHIP (CRITICAL NLE CONCEPT): Lithium is handled by the kidneys in the SAME WAY as sodium. When the body's sodium is LOW, the kidneys 'think' lithium is sodium and REABSORB MORE LITHIUM → serum lithium level RISES → TOXICITY RISK. Causes of dangerous sodium/fluid loss that can trigger lithium toxicity: • Low-sodium (low-salt) diet or crash diet • Dehydration from vomiting, diarrhea, fever, or heavy sweating • Hot weather or heavy exercise • Thiazide diuretics (e.g., hydrochlorothiazide) — frequently tested! • NSAIDs (ibuprofen, mefenamic acid/Ponstan) — block prostaglandins that normally promote lithium excretion → lithium level rises TEACHING POINTS: Maintain a CONSISTENT, NORMAL sodium intake (do not suddenly restrict salt). Drink ADEQUATE FLUIDS — about 2–3 liters per day. Be careful in hot weather, during illness with vomiting/diarrhea, and during exercise. AVOID NSAIDs and be cautious with diuretics. NURSING CONSIDERATIONS for Lithium: 1. MONITOR SERUM LITHIUM LEVELS REGULARLY — draw the blood sample 12 HOURS AFTER THE LAST DOSE (trough level) for accurate measurement 2. Baseline and periodic RENAL FUNCTION TESTS (BUN, creatinine) — lithium is excreted by the kidneys and can cause nephrogenic diabetes insipidus (polyuria/polydipsia) with long-term use 3. Baseline and periodic THYROID FUNCTION TESTS — lithium can cause HYPOTHYROIDISM (goiter, fatigue, weight gain, cold intolerance) — a frequently tested long-term effect 4. Take lithium WITH FOOD to reduce GI upset 5. Do NOT stop abruptly — risk of rebound mania 6. ONSET of mood-stabilizing effect is 1–3 WEEKS — during acute mania, an ANTIPSYCHOTIC or BENZODIAZEPINE may be used CONCURRENTLY until lithium takes effect 7. Treatment of severe toxicity: hemodialysis may be required to remove lithium Other Mood Stabilizers: • VALPROIC ACID/DIVALPROEX (Depakote): monitor liver function tests (LFTs) and platelet count; risk of PANCREATITIS; TERATOGENIC (causes neural tube defects — absolutely contraindicated in pregnancy without careful risk-benefit analysis) • CARBAMAZEPINE (Tegretol): monitor for AGRANULOCYTOSIS (CBC regularly) and serious RASH (Stevens-Johnson syndrome); autoinduces its own metabolism (drug levels may drop over time) • LAMOTRIGINE (Lamictal): risk of serious rash, including STEVENS-JOHNSON SYNDROME — must be titrated VERY SLOWLY (low and slow); particularly effective for bipolar depression

Electroconvulsive Therapy (ECT): Nursing Care

Electroconvulsive Therapy (ECT) is a treatment procedure in which a brief, controlled electrical current is passed through the brain to induce a generalized seizure under general anesthesia. Despite its historical stigma, ECT is an EFFECTIVE, SAFE, and sometimes LIFE-SAVING treatment for specific indications. INDICATIONS for ECT: • Severe, treatment-resistant depression (MDD that has not responded to multiple antidepressant trials) • Depression with PSYCHOTIC FEATURES • Severe suicidal risk requiring RAPID RESPONSE (ECT works faster than antidepressants) • Certain cases of MANIA that are unresponsive to medications • Depression during pregnancy (when medications are contraindicated) HOW ECT WORKS: Under general anesthesia (typically thiopental or propofol), a muscle relaxant (SUCCINYLCHOLINE) is given to prevent physical convulsions and injury during the seizure. ATROPINE may be given prior to reduce oral secretions and prevent bradycardia. An electrical stimulus is delivered, inducing a brief (typically 25–60 seconds) generalized seizure detectable on EEG. A course of ECT is typically 6–12 sessions given 3 times per week. NURSING CARE — PRE-ECT (Before the Procedure): 1. INFORMED CONSENT — ensure the client (and family/legal guardian if applicable) has given voluntary, informed consent. This is a legal and ethical requirement under RA 9173 and RA 11036. Explain the procedure, risks, benefits, and alternatives. 2. NPO (Nothing by Mouth) — the client must be NPO from midnight or as ordered (typically 6–8 hours before) to prevent aspiration during anesthesia. 3. Pre-procedure preparation: Have the client VOID (empty bladder) before the procedure to prevent involuntary urination. Remove DENTURES, JEWELRY (rings, earrings, hairpins) to prevent injury and ensure safety. 4. Baseline vital signs — document before the procedure. 5. A SHORT-ACTING ANESTHETIC and a MUSCLE RELAXANT (succinylcholine) are given by the anesthesiologist. 6. ATROPINE may be given to reduce secretions and prevent bradycardia. 7. Oxygen and suction equipment must be at the bedside. NURSING CARE — POST-ECT (After the Procedure): 1. AIRWAY POSITIONING — position the client on the SIDE (lateral/recovery position) to maintain airway patency and PREVENT ASPIRATION. 2. Monitor VITAL SIGNS and RESPIRATORY STATUS until fully awake (oxygen saturation, respiratory rate, BP, HR). 3. REORIENT the client frequently and reassuringly — 'You are at the hospital, you just had your ECT treatment. You are safe.' 4. The most COMMON side effects are TRANSIENT CONFUSION and MEMORY LOSS (especially anterograde and retrograde short-term memory), which usually RESOLVE over time. REASSURE the client and family that this is expected and temporary. 5. Stay with the client until they are fully oriented and stable. NOTE: ECT does NOT change the personality or cause permanent brain damage. The memory effects are usually temporary and most clients improve significantly after a full course.

The statement 'Mas okay pa kung hindi na ako narito' is a WARNING SIGN of suicidal ideation. Suicide is the HIGHEST PRIORITY concern in psychiatric nursing (Maslow: safety before all else). Although nutritional needs and self-care are important, the immediate priority is to ASSESS SUICIDAL RISK. Asking directly ('Are you thinking of killing yourself?') is therapeutic, safe, and essential. Note also that this client is on sertraline for only 5 days — he is in the EARLY TREATMENT DANGER PERIOD when energy may improve before mood lifts, increasing the risk of acting on suicidal thoughts. Options A, B, and D are all appropriate interventions but are NOT the priority when there is an indication of suicidal ideation.

In acute mania, the client cannot sit still long enough to eat regular meals. Dehydration and nutritional deficit are the PRIORITY physiologic concerns, consistent with Maslow's hierarchy (physiologic needs = first level). The correct nursing intervention is to provide calorie-dense finger foods that can be consumed while the client is active ('on the go'). Forcing the client to sit for structured meals is likely to increase frustration and escalate behavior. Additionally, the nurse should reduce environmental stimulation (move to a quieter area), set firm and consistent limits on intrusive behavior in a non-punitive manner, and monitor vital signs, fluid intake and output, and weight.

This question applies the tyramine-restricted diet in a Filipino cultural and dietary context. Aged cheddar cheese is high in tyramine. Longganisa is a cured/aged meat product high in tyramine. Toyo (soy sauce) is a fermented soy product high in tyramine. Red wine contains significant tyramine. White rice, fresh (not overripe) banana, and fresh steamed chicken are LOW in tyramine and safe. The nurse must teach the client to avoid aged, fermented, cured, smoked, or overripe foods while on an MAOI to prevent hypertensive crisis — a potentially fatal complication.

Thiazide diuretics cause sodium and water loss. Because lithium is handled like sodium by the kidneys, sodium depletion causes the kidneys to REABSORB MORE LITHIUM, raising serum levels to toxic range. This is a classic drug interaction. The current symptoms — nausea, vomiting, diarrhea, fine tremor, thirst, and polyuria — are classic early signs of lithium toxicity at levels between 1.5 and 2.0 mEq/L. The NLE frequently tests this interaction, especially with the Philippine context of common antihypertensive use.

This tests the complete pre-ECT preparation checklist — a frequently tested area on the NLE. Additional considerations include: confirming that the anesthesiologist has reviewed the chart, ensuring IV access is established, and having oxygen, suction, and emergency resuscitation equipment at the bedside. The muscle relaxant succinylcholine will be administered by the anesthesiologist. Atropine may also be given to reduce secretions and prevent bradycardia. Each of these steps has a specific rationale: NPO prevents aspiration under anesthesia; voiding prevents accidents; removing metal prevents injury and burn from the electrical stimulus; consent protects legal and ethical rights.