NLE Psychiatric Disorders — Mood Disorders: Depression and Bipolar DisorderRevision Notes

Exam Tips

• NLE scenarios will describe a client with 'depressed mood or loss of interest for more than 2 weeks with poor grooming and suicidal thoughts' — recognize MDD immediately.
• The FIRST nursing action in any depressive disorder scenario is ALWAYS safety assessment (suicidal ideation).
• When asked what to AVOID in caring for a depressed client: avoid false reassurance, avoid leaving the client alone if at high risk.
• If the scenario mentions the client suddenly seems calm and cheerful after weeks of deep depression, recognize this as a DANGER SIGN — may indicate the decision to attempt suicide has been made.
• Remember RA 11036 (Mental Health Act) as the Philippine legal framework for all psychiatric care.

Key Points

• MDD is defined as a depressed mood OR loss of interest/pleasure (anhedonia) lasting at LEAST 2 WEEKS, plus associated symptoms.
• Use the mnemonic SIG E CAPS: Sleep disturbance, Interest loss (anhedonia), Guilt/worthlessness, Energy loss, Concentration difficulty, Appetite/weight change, Psychomotor agitation or retardation, Suicidal ideation.
• At least 5 of the SIG E CAPS symptoms must be present, and one must be either depressed mood or anhedonia.
• MDD can include psychotic features (mood-congruent delusions of guilt, worthlessness, or nihilism) in severe cases.
• SAFETY IS THE ABSOLUTE FIRST PRIORITY — always assess for suicidal ideation before any other nursing intervention.
• Avoid false reassurance and overly cheerful approach — this invalidates the client's feelings and damages therapeutic rapport.
• Use short, frequent contacts; a silent, accepting presence is more therapeutic than forced conversation.
• Meet BASIC PHYSICAL NEEDS first (Maslow): nutrition, hydration, elimination, sleep, hygiene — the client lacks energy for self-care.
• Structure daily activities with simple, achievable goals to gradually restore a sense of accomplishment and self-worth.
• CRITICAL DANGER PERIOD: Suicide risk INCREASES in early treatment as energy returns BEFORE mood lifts — the client now has the energy to act on suicidal plans.
• Common clinical findings: poor grooming, social withdrawal, slowed speech (monotone), psychomotor retardation, constipation, somatic complaints.

Definitions

Section Title

Major Depressive Disorder (MDD)

Common Mistakes

• Thinking that asking about suicide will 'plant the idea' — it does NOT; asking opens the door and communicates genuine concern.
• Using cheerful, dismissive statements like 'Just be happy!' or 'Count your blessings!' — these are non-therapeutic and invalidate the client.
• Forgetting that the highest danger period is EARLY in antidepressant treatment (energy returns before mood lifts), not during the deepest depression.
• Confusing anhedonia with sadness — a client can be anhedonic without appearing overtly sad.
• Neglecting physiologic needs (nutrition, hydration, sleep) in favor of psychosocial interventions — both must be addressed, with safety and physiology first (Maslow).

Exam Tips

• NLE will ask 'What is the priority nursing action?' for a suicidal client — the answer is ALWAYS safety: assess the plan and implement precautions.
• If asked about the BEST room assignment for a suicidal client: room nearest the nurses' station, with no ligature points, windows secured.
• Remember: previous suicide attempt is the STRONGEST predictor of future attempt — always prioritize this in risk assessment.
• One-to-one observation means the nurse stays WITH the client at all times — not just 'checking every 15 minutes.'
• RA 11036 allows involuntary admission when there is imminent risk of harm to self or others — this is a testable legal point.

Key Points

• Suicide is the HIGHEST-PRIORITY safety concern in psychiatric nursing — always addressed first.
• ASK DIRECTLY: 'Are you thinking of killing yourself?' — direct questioning does NOT increase suicide risk; it establishes trust and opens communication.
• Assess the PLAN, METHOD, and MEANS: Does the client have a specific, lethal, and accessible plan? Higher specificity = higher risk.
• Warning signs to monitor: giving away prized possessions, making a will, saying goodbye, sudden calm after deep depression (decision made), hopelessness.
• Strongest predictor of future suicide: a PREVIOUS ATTEMPT — always ask about past attempts.
• Additional risk factors: male sex, older age, social isolation, chronic illness, substance use, access to lethal means, history of trauma.
• PROVIDE A SAFE ENVIRONMENT: Remove or secure sharps, belts, cords, glass, medications, and restrict access to windows and exits.
• Institute ONE-TO-ONE CONTINUOUS OBSERVATION for high-risk clients — the client must be within sight at ALL times, including during bathroom use.
• Do NOT promise to keep suicidal disclosures secret — this is a safety violation and a breach of professional duty.
• Establish a therapeutic relationship: allow the client to express feelings without judgment.
• Under RA 11036, involuntary treatment for imminent risk of self-harm is permitted with proper documentation and safeguards.

Definitions

Section Title

Suicide Risk Assessment and Priority Precautions

Common Mistakes

• Believing that asking about suicide will 'suggest the idea' to the client — this is a myth; direct questioning is therapeutic and safe.
• Promising confidentiality regarding suicidal disclosures — this must NEVER be promised; safety overrides confidentiality.
• Assuming a calm client is no longer at risk — sudden calmness in a previously severely depressed client is a RED FLAG.
• Thinking only inpatient clients need suicide precautions — community nurses under RA 11036 also have duties to assess and refer.
• Underestimating risk in clients who 'only have passive ideation' — passive ideation still requires assessment and documentation.

Exam Tips

• NLE question tip: If the scenario says a client 'has never had a full manic episode but has had hypomanic and depressive episodes' — this is BIPOLAR II.
• For manic client nutrition: the answer is HIGH-CALORIE FINGER FOODS (sandwiches, fruit, energy bars) and portable fluids — not sitting for full meals.
• When asked about the environment for a manic client: QUIET, LOW-STIMULATION, with few people and minimal distractions.
• Firm limits are set in a MATTER-OF-FACT, NON-PUNITIVE way — not as punishment, but as consistent boundaries for safety.
• Remember that lithium (discussed in pharmacology) is used to TREAT and PREVENT manic episodes.

Key Points

• Bipolar disorder is characterized by alternating mood episodes: depression and mania (or hypomania).
• BIPOLAR I: At least ONE full manic episode (elevated/irritable mood lasting ≥1 week, OR requiring hospitalization). Depressive episodes are common but not required for diagnosis.
• BIPOLAR II: At least ONE hypomanic episode PLUS at least ONE major depressive episode. NEVER a full manic episode — if full mania occurs, it becomes Bipolar I.
• MANIA features (mnemonic DIG FAST): Distractibility, Irresponsibility/impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep decreased, Talkativeness/pressured speech.
• HYPOMANIA is a milder, shorter (≥4 days) mood elevation that does NOT cause marked functional impairment and does NOT require hospitalization.
• Manic clients are at serious PHYSIOLOGIC RISK: exhaustion, dehydration, malnutrition — they do not stop to eat, drink, or sleep.
• PRIORITY INTERVENTIONS FOR MANIA: Reduce environmental stimulation (calm, quiet setting), ensure physical safety, meet physiologic needs.
• Offer HIGH-CALORIE FINGER FOODS and fluids that can be consumed 'on the go' — the manic client will not sit for a full meal.
• Set FIRM, CONSISTENT, NON-PUNITIVE limits on manipulative or intrusive behavior — matter-of-fact tone, no arguing.
• Channel energy into SAFE, NON-COMPETITIVE activities; avoid activities requiring concentration, competition, or group interaction that could escalate.
• Protect the client from consequences of POOR JUDGMENT: impulsive spending, sexual indiscretions, legal problems — the nurse acts as a protective advocate.
• Suicide risk is ALSO present in bipolar disorder, especially during mixed episodes and depressive phases — always assess.

Definitions

Section Title

Bipolar Disorder: Types and Nursing Management

Common Mistakes

• Confusing Bipolar I and Bipolar II: Bipolar II does NOT mean 'less serious'; it means hypomania (not full mania) + major depression.
• Thinking mania is always euphoric — it can present as IRRITABLE rather than elevated mood, especially in Filipino cultural contexts.
• Offering structured, competitive group activities to a manic client — this INCREASES stimulation and escalates behavior.
• Arguing with a manic client about their grandiose beliefs — this escalates agitation; set limits calmly and redirect.
• Forgetting the physiologic needs of the manic client — dehydration and exhaustion are real medical emergencies.

Exam Tips

• Memorize tyramine-rich foods: aged cheese (kesong matanda), cured meats (tocino, longganisa analogy), soy sauce, red wine, draft beer — these Filipino food analogies help memory.
• Serotonin syndrome = HYPERTHERMIA + hyperreflexia + altered mental status. Neuroleptic malignant syndrome (NMS) = hyperthermia + RIGIDITY + bradyreflexia — know the difference.
• NLE question: 'A client on phenelzine (MAOI) eats aged cheese. What do you expect?' → Hypertensive crisis.
• NLE question: 'A client on fluoxetine is switched to phenelzine. How long should you wait?' → 5 WEEKS (fluoxetine washout).
• TCA overdose treatment includes cardiac monitoring and sodium bicarbonate for dysrhythmias — know the emergency management.

Key Points

• ALL antidepressants take 2–4 WEEKS for full therapeutic effect — this is a universal teaching point for all antidepressant classes.
• SSRIs ARE FIRST-LINE: fluoxetine, sertraline, paroxetine, escitalopram, citalopram — safest profile, most commonly prescribed.
• SSRIs work by blocking reuptake of serotonin, increasing serotonin availability in the synapse.
• Teach: Do NOT stop SSRIs abruptly (discontinuation syndrome); continue even when feeling better.
• NEVER combine an SSRI with an MAOI — risk of LIFE-THREATENING serotonin syndrome.
• TCAs (amitriptyline, imipramine, nortriptyline, clomipramine): effective but DANGEROUS IN OVERDOSE — cardiotoxic (dysrhythmias are the main cause of death in TCA overdose).
• TCAs have significant ANTICHOLINERGIC EFFECTS: dry mouth, blurred vision, constipation, urinary retention, orthostatic hypotension.
• Because suicidal clients could hoard TCA pills, DISPENSE LIMITED QUANTITIES and monitor pill counts.
• MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline): reserved for TREATMENT-RESISTANT depression due to serious dietary and drug interactions.
• MAOIs require a TYRAMINE-RESTRICTED DIET — failure to follow causes HYPERTENSIVE CRISIS (severe occipital headache, palpitations, stiff neck, dangerously elevated BP — can be FATAL).
• TYRAMINE-RICH FOODS TO AVOID: aged cheeses, cured/smoked/aged meats and sausages, fermented soy products (soy sauce, miso, tofu), sauerkraut, tap/draft beer, red wine (especially Chianti), yeast extracts, overripe or spoiled foods.
• Also avoid OTC cold/cough/decongestant preparations with sympathomimetics (pseudoephedrine) while on MAOIs.
• WASHOUT PERIOD between MAOI and SSRI (or vice versa): at least 2 WEEKS for most agents; 5 WEEKS for fluoxetine (due to long half-life of fluoxetine and its active metabolite).
• SEROTONIN SYNDROME: excess serotonergic activity, usually from combining serotonergic drugs (SSRI + MAOI, SSRI + tramadol, SSRI + triptans, SSRI + St. John's wort).
• Serotonin syndrome triad: MENTAL STATUS CHANGES (agitation, confusion) + AUTONOMIC INSTABILITY (hyperthermia, tachycardia, diaphoresis) + NEUROMUSCULAR ABNORMALITIES (tremor, hyperreflexia, myoclonus, clonus, rigidity).
• Management of serotonin syndrome: STOP the offending drug(s) IMMEDIATELY, supportive care (cooling, hydration, cardiac monitoring), serotonin antagonist CYPROHEPTADINE as needed — can be life-threatening.

Definitions

Section Title

Pharmacology: Antidepressants (SSRIs, TCAs, MAOIs)

Common Mistakes

• Forgetting the 2–4 week onset for ALL antidepressants — clients often stop medication early thinking it 'does not work.'
• Not knowing the washout period: 2 weeks for most SSRIs to MAOIs; 5 WEEKS for fluoxetine to MAOI (fluoxetine has a very long half-life).
• Mixing up which condition is caused by tyramine (hypertensive crisis) vs. which is caused by drug-drug serotonergic interaction (serotonin syndrome).
• Thinking serotonin syndrome only occurs with SSRI + MAOI — it can also occur with tramadol, triptans, St. John's wort, or dextromethorphan combined with SSRIs.
• Not restricting TCA quantities in suicidal clients — this is a critical safety oversight since TCAs are fatal in overdose.

Formulas

Exam Tips

• MEMORIZE THE NUMBERS: Therapeutic = 0.6–1.2 mEq/L; Toxicity starts = >1.5 mEq/L; Severe = >2.0 mEq/L.
• NLE classic question: 'Which food should the nurse teach the client on lithium to maintain consistent intake of?' → SODIUM (salt). Consistent salt and 2–3 L fluid/day.
• NLE toxicity question: 'Client on lithium develops coarse tremor, ataxia, and confusion. Lithium level is 2.3 mEq/L. What is the priority?' → WITHHOLD lithium, notify physician, prepare for hemodialysis.
• Remember: Ibuprofen (NSAID) + lithium = TOXICITY RISK. This is a common medication interaction tested on NLE.
• For lamotrigine: 'Titrate SLOWLY to avoid rash' is the key teaching point. Any rash = stop and reassess.

Key Points

• LITHIUM CARBONATE is the classic, gold-standard mood stabilizer for bipolar disorder (mania prevention and treatment, and maintenance).
• Lithium has a NARROW THERAPEUTIC INDEX — blood levels must be monitored regularly to prevent toxicity.
• THERAPEUTIC SERUM LEVEL: 0.6–1.2 mEq/L (maintenance). Acute mania may be managed toward the upper end (~1.5 mEq/L) under close monitoring.
• TOXICITY BEGINS ABOVE 1.5 mEq/L. SEVERE/DANGEROUS: ABOVE 2.0 mEq/L. POTENTIALLY FATAL: 2.5–3.0 mEq/L.
• Draw lithium levels 12 HOURS AFTER THE LAST DOSE (trough level) for accurate measurement.
• SIGNS OF LITHIUM TOXICITY by severity: Early (1.5–2.0): N/V/D, FINE hand tremor, muscle weakness, thirst, polyuria, drowsiness, slurred speech. Moderate-Severe (>2.0): COARSE tremor, ataxia, confusion, muscle twitching, hyperreflexia, nystagmus, seizures. Severe (>2.5): cardiovascular collapse, coma, death.
• CRITICAL TEACHING — LITHIUM FOLLOWS SODIUM: Kidneys handle lithium like sodium. LOW SODIUM → kidneys reabsorb MORE lithium → LITHIUM RISES → TOXICITY.
• Causes of low sodium/dehydration that raise lithium: low-salt diet, crash dieting, excessive sweating (hot weather, exercise), vomiting, diarrhea, diuretics.
• Teach: Maintain CONSISTENT NORMAL SODIUM INTAKE and drink 2–3 LITERS OF FLUID PER DAY.
• DRUGS THAT RAISE LITHIUM LEVELS (increasing toxicity risk): NSAIDs (ibuprofen, mefenamic acid) and THIAZIDE DIURETICS — teach clients to avoid or use with caution.
• Lithium requires 1–3 WEEKS for mood-stabilizing effect to begin — use antipsychotics or benzodiazepines for acute mania in the interim.
• Take lithium WITH FOOD to reduce GI upset. Do NOT stop abruptly.
• Baseline and periodic monitoring: RENAL FUNCTION TESTS (lithium can impair kidneys) and THYROID FUNCTION TESTS (lithium can cause hypothyroidism).
• Treatment of severe lithium toxicity: HEMODIALYSIS to remove lithium rapidly.
• OTHER MOOD STABILIZERS: Valproic acid/divalproex (monitor LFTs and platelets; risk of pancreatitis; TERATOGENIC — category D/X), Carbamazepine (monitor for agranulocytosis and rash; auto-induces its own metabolism), Lamotrigine (risk of serious rash/Stevens-Johnson Syndrome — must titrate SLOWLY).
• ATYPICAL ANTIPSYCHOTICS (olanzapine, quetiapine, risperidone) are also used for acute mania and bipolar maintenance.

Definitions

Section Title

Pharmacology: Lithium and Other Mood Stabilizers

Common Mistakes

• Drawing lithium levels at the wrong time — must be drawn 12 HOURS AFTER the last dose (trough), not just before the next dose or at random times.
• Forgetting that LOW sodium raises lithium — students often think the relationship is the opposite. Remember: SODIUM LOW = LITHIUM HIGH = TOXICITY.
• Thinking that a fine tremor from lithium means toxicity — a fine hand tremor is an EXPECTED early side effect, not necessarily toxicity. COARSE tremor + ataxia + confusion = toxicity.
• Not teaching clients about NSAIDs and thiazide diuretics raising lithium levels — mefenamic acid (common OTC painkiller in the Philippines) is an NSAID that can precipitate lithium toxicity.
• Forgetting that valproic acid is teratogenic — must always ask about pregnancy status before prescribing.

Exam Tips

• NLE ECT sequence: Consent → NPO → Void → Remove dentures/jewelry → Baseline VS → Anesthetic + Succinylcholine → ECT → Side-lying position → Reorient.
• Post-ECT FIRST action: Position on the SIDE and monitor airway and breathing.
• Expected side effect: Memory loss (short-term) and confusion — REASSURE the client and family.
• Succinylcholine = MUSCLE RELAXANT used in ECT. Know this drug name.
• ECT is indicated for RAPID response needs (high suicide risk, severe depression with psychosis) when medications take too long.

Key Points

• ECT is an effective treatment for SEVERE or TREATMENT-RESISTANT depression, depression with PSYCHOTIC features, HIGH SUICIDE RISK requiring RAPID response, and some cases of ACUTE MANIA.
• ECT works by inducing a controlled generalized seizure using a brief electrical current, administered under GENERAL ANESTHESIA with a MUSCLE RELAXANT.
• Typical course: 6–12 treatments, given 3 times per week.
• PRE-ECT NURSING CARE: Obtain INFORMED CONSENT (a legal and ethical requirement under RA 9173 and RA 11036), ensure NPO status (typically nothing after midnight), remove dentures, jewelry, and hairpins, instruct client to void, take BASELINE VITAL SIGNS.
• Pre-ECT medications: Short-acting GENERAL ANESTHETIC (e.g., methohexital), MUSCLE RELAXANT — succinylcholine (to prevent injury during seizure), ATROPINE may be given to reduce secretions and prevent bradycardia.
• DURING ECT: A controlled grand mal seizure lasts 30–60 seconds. Oxygen is given. Vital signs and EEG/ECG are monitored.
• POST-ECT NURSING CARE: Position client on the SIDE (lateral position) to maintain airway and prevent aspiration. Monitor vital signs and respiratory status closely.
• Reorient the client frequently — confusion and disorientation are expected after ECT.
• Most common side effects: TRANSIENT CONFUSION and SHORT-TERM MEMORY LOSS (anterograde and retrograde amnesia) — these usually RESOLVE over weeks.
• REASSURE the client and family that memory loss is temporary and expected.
• Headache and muscle aches may also occur post-ECT.
• ECT does NOT cause permanent brain damage — reassurance is important.

Definitions

Section Title

Electroconvulsive Therapy (ECT)

Common Mistakes

• Forgetting that INFORMED CONSENT must be obtained BEFORE ECT — legally required under RA 9173 (Nursing Act) and RA 11036 (Mental Health Act).
• Thinking the client should be positioned SUPINE post-ECT — correct position is LATERAL (side-lying) to maintain airway and prevent aspiration.
• Confusing succinylcholine's role — it is a MUSCLE RELAXANT, not an anesthetic. It prevents physical injury but does NOT cause anesthesia.
• Not reassuring clients about memory loss — failure to prepare the client can cause significant anxiety and loss of therapeutic trust.
• Forgetting to check NPO status pre-ECT — aspiration is a serious risk under general anesthesia.

Exam Tips

• When NLE asks about the legal basis for involuntary admission of a suicidal client in the Philippines: RA 11036.
• Nursing diagnosis priority: Risk for Suicide > Hopelessness > Self-Care Deficit — always apply Maslow's hierarchy (safety first).
• When asked about client rights in psychiatric settings: RA 11036 protects rights to humane treatment, informed consent, and confidentiality.
• Remember: Nurses operate under RA 9173 (their own scope of practice) while delivering care guided by RA 11036 (client mental health rights).
• Community mental health referral is part of holistic discharge planning — NLE may test appropriate community resources and follow-up care.

Key Points

• Republic Act No. 11036 (Philippine Mental Health Act) is the governing law for mental health care in the Philippines, mandating HUMANE TREATMENT and protecting the RIGHTS of persons with mental health conditions.
• RA 11036 covers rights to: voluntary and involuntary treatment with safeguards, informed consent, confidentiality, freedom from abuse and neglect, and access to mental health services.
• Involuntary admission is permitted under RA 11036 ONLY when there is IMMINENT RISK of harm to self or others, and requires proper documentation.
• Republic Act No. 9173 (Philippine Nursing Act of 2002) defines nursing practice and standards, requiring nurses to practice within their scope and maintain professional accountability.
• NCM (Nursing Care Management) approach applies: ASSESS → DIAGNOSE → PLAN → IMPLEMENT → EVALUATE, with safety as the priority at all times.
• NANDA nursing diagnoses commonly applied in mood disorders: Risk for Suicide (highest priority), Hopelessness, Ineffective Coping, Self-Care Deficit, Imbalanced Nutrition: Less Than Body Requirements, Disturbed Sleep Pattern, Social Isolation.
• For MANIC clients: Additional diagnoses include Risk for Injury, Imbalanced Nutrition: Less Than Body Requirements (due to inadequate intake during mania), Impaired Social Interaction, Disturbed Thought Processes.
• PATIENT TEACHING priorities: Emphasize the CHRONIC, RECURRENT nature of mood disorders and importance of CONTINUED medication even when feeling well.
• Antidepressant teaching: Delayed onset (2–4 weeks), do not stop abruptly, early increase in suicide risk as energy returns, when to seek emergency help.
• Lithium teaching: Consistent salt and fluid intake (2–3 L/day), signs of toxicity, regular blood monitoring, avoid NSAIDs and thiazides.
• MAOI teaching: Tyramine-restricted diet (aged cheese, cured meats, soy sauce, red wine, draft beer), signs of hypertensive crisis, when to seek emergency care.
• Connect clients and families to COMMUNITY MENTAL HEALTH SERVICES and support groups — RA 11036 mandates community-based mental health programs.
• Family education is critical — teach family members to recognize warning signs of relapse and suicidal ideation.

Definitions

Section Title

Philippine Legal Framework and Patient Teaching

Common Mistakes

• Citing RA 9173 when asked about mental health patient rights — the correct law is RA 11036 (Mental Health Act) for rights of mental health patients; RA 9173 governs nursing practice.
• Prioritizing psychosocial nursing diagnoses over 'Risk for Suicide' — safety (suicide risk) is ALWAYS the highest priority using Maslow's hierarchy.
• Not including family in patient teaching — mood disorders are chronic and recurrent; family education is essential for relapse prevention.
• Forgetting to connect clients to community mental health resources — RA 11036 mandates community-based services, and discharge planning must include these resources.