MOOD DISORDERS AND SUICIDE

Mood disorders, also known as affective disorders, are characterized by pervasive disturbances in
emotional regulation that affect a person’s capacity to function. These conditions are among the most
prevalent psychiatric diagnoses and are strongly associated with suicide risk. The two primary mood
disorders are Major Depressive Disorder (MDD) and Bipolar Disorder, each presenting with distinct
patterns of emotional dysregulation. Although treatable, they often impose long-term effects on
relationships, employment, and self-perception.
MAJOR DEPRESSIVE DISORDER (MDD)
MDD is defined by a depressed mood or loss of interest in nearly all activities for at least two
consecutive weeks. It is not simply sadness but a profound disruption in mood and function.
Core Symptoms:
• Anhedonia (loss of pleasure)
• Fatigue or anergia
• Psychomotor retardation or agitation
• Changes in appetite or weight
• Sleep disturbances (insomnia or hypersomnia)
• Impaired concentration and decision-making
• Feelings of worthlessness or excessive guilt
• Suicidal ideation or thoughts of death
Approximately 20% of clients may exhibit psychotic features, leading to psychotic depression, which
includes hallucinations or delusions.
Etiologic Factors:
• Biological: Genetic predisposition, neurotransmitter imbalances (serotonin, norepinephrine)
• Psychosocial: Stress, trauma, loss
• Environmental: Isolation, unemployment
Treatment:
• First-line pharmacotherapy: SSRIs (e.g., fluoxetine), due to a more favorable side effect profile
• Other medications: TCAs (e.g., amitriptyline) and MAOIs (e.g., phenelzine) – less preferred due to
side effects and dietary restrictions
• ECT: Especially effective in elderly patients or treatment-resistant cases
BIPOLAR DISORDER
This disorder involves mood swings between mania, depression, and euthymia (normal mood). It affects
men and women equally and tends to emerge in late adolescence or early adulthood.
Types:
Manic Hypomanic Major Depressive
Type Overall Severity
Episodes Episodes Episodes
Present; lasts ≥1
Most severe; marked
week, may require Common, but not
Bipolar I Not required, functional impairment
hospitalization or required for
Disorder though may occur and hospitalization
cause significant diagnosis
likely
impairment
Required; lasts ≥4 Required; often
Absent; full manic
Bipolar II days, less severe, more prolonged Moderate to severe;
episodes do not
Disorder no hospitalization and severe than risk of suicide is high
occur
needed in Bipolar I

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 Manic Hypomanic Major Depressive
Type Overall Severity
Episodes Episodes Episodes
Present; multiple Present but does
Mild to moderate;
Cyclothymic Absent; manic episodes over ≥2 not meet full
chronic but less
Disorder criteria never met years (≥1 in criteria for major
functionally impairing
children) depression
Mixed state:
Bipolar
concurrent High risk of suicide;
Disorder,
symptoms of mania May be present Present complex and unstable
Mixed
and depression mood state
Features
nearly every day
Bipolar ≥4 mood episodes
Variable; more difficult
Disorder, (mania/hypomania/ Present in some Present in some
to treat, poorer
Rapid depression) within episodes episodes
prognosis
Cycling 12 months

Manic Episode Symptoms:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Pressured speech and flight of ideas
• Distractibility and psychomotor agitation
• Risky behaviors (spending sprees, promiscuity)
Mania may progress to psychosis, delusions, or hallucinations, requiring hospitalization.
Treatment:
• Lithium carbonate: Gold standard, with narrow therapeutic range (0.6–1.2 mEq/L)
o Requires regular serum monitoring to avoid toxicity
o Salt and fluid balance must be maintained
• Anticonvulsants: Valproate, carbamazepine, lamotrigine
• Antipsychotics: Often used in acute mania
SUICIDE
Suicide is the intentional act of ending one’s life and is closely linked to mood disorders, especially
depression and bipolar disorder.
Risk Factors:
• Demographic:
o Male, White, adolescent, elderly
o Divorced, widowed, unemployed

• Clinical:
o Depression, bipolar disorder, schizophrenia
o Substance use, borderline personality disorder
o Chronic medical illnesses (e.g., cancer, HIV)

• Environmental:
o Isolation, recent losses, lack of support, access to lethal means

Suicide rates are especially high among men aged 45–65 and adults >65, who account for 25% of
suicides despite being only 10% of the population.
Behavioral Warning Signs:
• Giving away possessions
• Sudden calmness after depression
• Making final arrangements or saying goodbye
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 • Direct or indirect statements (e.g., “I won’t be a problem much longer”)
Nursing Care and Suicide Prevention
Suicide Assessment:
• Ask directly about suicidal thoughts and plans
• Lethality assessment: Inquire about method, timing, access, intent
• Contracting: Use no-suicide contracts when appropriate
• Close supervision: Remove harmful objects, maintain safe environment

Psychosocial Nursing Care:

• Build trust; use therapeutic communication
• Educate patient and family about illness and treatment adherence
• Monitor for early signs of relapse
• Encourage participation in therapy and support networks
Best Practices:
• Incorporate Zero Suicide Model in care settings
• Strengthen protective factors: family support, peer connection, access to care
Key Takeaways:
• Mood disorders are major contributors to disability and suicide globally
• Depression is underdiagnosed, often masked by somatic complaints
• Bipolar disorder often presents initially as depression, delaying diagnosis
• Lithium toxicity can be fatal—signs include diarrhea, vomiting, muscle weakness
• Suicide is preventable with early detection, treatment, and safety planning

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 ANXIETY AND ANXIETY DISORDERS
Anxiety is a universal human experience and a natural response to stress. While it serves as a necessary
alert system in dangerous or unfamiliar situations, anxiety becomes pathological when it is persistent,
excessive, and interferes with daily functioning.
I. Nature of Anxiety
Definition:
• Anxiety: A vague, subjective feeling of uneasiness, apprehension, or dread that arises from an
unknown or non-specific threat.
• Fear: A response to a specific and identifiable danger.
Characteristics:
• Involves behavioral, emotional, cognitive, and physiological responses.
• Can be adaptive (motivating problem-solving or self-improvement) or maladaptive (resulting in
avoidance, distress, or functional impairment).
II. Levels of Anxiety (Peplau’s Framework)
Level Features Implications
Heightened perception, alertness, increased Helpful in learning and decision-
Mild
motivation making
Moderate Narrowed focus, selective inattention, tension Learning possible but limited
Greatly reduced perception, focus only on detail, Learning and communication are
Severe
somatic symptoms (e.g., palpitations, GI upset) significantly impaired
Sense of doom, inability to function, may include Medical emergency; no learning or
Panic
hallucinations/delusions rational thought possible
III. Etiology of Anxiety Disorders
Biological Factors
• Genetics: Moderate heritability in panic disorder, phobias, and social anxiety; family links in GAD
and OCD.
• Neurochemistry:
o ↓ GABA → less inhibition of neuronal excitability.
▪ GABA's Role: GABA is the primary inhibitory neurotransmitter in the central
nervous system. Its primary function is to reduce neuronal excitability by causing
hyperpolarization (making the neuron more negatively charged) and decreasing
the release of other neurotransmitters.
▪ Inhibition of Excitability:
▪ When GABA binds to its receptors on a neuron, it opens chloride channels,
allowing chloride ions to flow into the cell. This influx of negatively charged
ions makes the neuron more negatively charged (hyperpolarization) and
less likely to fire.
▪ Impact of Reduced GABA:
▪ If GABA levels are reduced (o ↓ GABA), the inhibitory effect on neuronal
excitability is weakened. This can lead to:
▪ Increased neuronal firing: Neurons become more easily activated.
▪ Reduced neuronal inhibition: Other excitatory neurotransmitters can have
a greater effect.
▪ Potential for seizures or other neurological disorders: In some cases, a lack
of GABA inhibition can contribute to conditions like epilepsy or anxiety.
o ↑ Norepinephrine → increased arousal and fear.
o ↓ Serotonin → mood instability, especially in GAD, OCD, panic disorder.

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Psychological Theories
• Freud: Anxiety results from conflict between the id, ego, and superego; managed unconsciously
through defense mechanisms.
• Sullivan: Anxiety originates from early interpersonal experiences, especially poor caregiver
responses.
• Peplau: Integrated interpersonal and physiological dimensions in nursing care; emphasized
therapeutic communication based on anxiety level.
Behavioral Theory
• Anxiety is learned through conditioning (e.g., phobias); can be unlearned through exposure and
new behavior patterns.
IV. Classification of Anxiety Disorders
1. Generalized Anxiety Disorder (GAD)
• Chronic, excessive worry most days for ≥6 months.
• Symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep
disturbance.
2. Panic Disorder
• Recurrent, unexpected panic attacks with somatic symptoms (chest pain, dizziness, shortness of
breath, fear of dying).
• May lead to agoraphobia.
3. Phobias: Phobias are intense, irrational fears of specific objects, activities, or situations that lead to
avoidance behavior and significant distress.
• Agoraphobia
o Definition: Fear of being in situations where escape might be difficult or help unavailable
in case of a panic attack.
o Examples: Fear of open spaces, crowded places, public transport, or being outside alone.
o Key Feature: Often leads to avoidance of leaving home.
• Specific Phobia
o Definition: Persistent, irrational fear of a particular object or situation that poses little or
no actual danger.
o Examples: Fear of heights (acrophobia), animals (zoophobia), flying (aerophobia),
injections (trypanophobia).
o Key Feature: Person experiences immediate anxiety when exposed to the
object/situation.
• Social Anxiety Disorder (Social Phobia)
o Definition: Intense fear of being judged, embarrassed, or negatively evaluated in social or
performance situations.
o Examples: Fear of public speaking, meeting new people, eating in public.
o Key Feature: Avoidance of social settings; may severely impact work, school, or

4. Separation Anxiety Disorder

• Developmentally inappropriate fear of being separated from attachment figures.
5. Selective Mutism
• Failure to speak in social situations despite the ability to speak.
6. Substance/Medication-Induced and Medical Condition Anxiety
• Anxiety caused directly by drug use or medical illness (e.g., endocrine disorders, CHF, COPD).
V. Defense Mechanisms in Anxiety
• Used unconsciously to reduce anxiety and maintain ego control.
• Common examples:

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 o Repression
o Displacement
o Projection
o Avoidance (can become maladaptive if overly relied on).
VI. Cultural Considerations
• Cultural context influences how anxiety is experienced and expressed:
o Koro (Asia): Fear of genital retraction and death.
o Susto (Latin America): Fear-induced spiritual loss leading to somatic complaints.

VII. Treatment Approaches

Pharmacologic
• Benzodiazepines (e.g., lorazepam, alprazolam): Fast-acting, short-term use only due to risk of
dependence.
• Buspirone: Non-sedating, long-term use.
• SSRIs and SNRIs: First-line agents for GAD, panic disorder, and social phobia.
• Beta-blockers (Propranolol): For performance anxiety and tremors.

Psychotherapeutic
• Cognitive Behavioral Therapy (CBT):
o Positive reframing
o Decatastrophizing
o Thought-stopping
o Relaxation training (e.g., deep breathing, guided imagery)

Nursing Interventions
• Remain calm and stay with the client during panic attacks.
• Use short, clear statements; avoid complex choices.
• Reduce environmental stimuli.
• Teach and reinforce relaxation techniques.
• Encourage social support and structured routines.
VIII. Nursing Process Considerations
Assessment
• Restlessness, irritability, tension, fidgeting, narrowed attention, inability to concentrate.
Diagnosis
• Anxiety r/t perceived threat AEB physiological, cognitive, or behavioral symptoms.
Planning & Outcomes
• Client will:
o Verbalize reduced anxiety.
o Demonstrate use of relaxation techniques.
o Engage in activities of daily living and social roles.

Evaluation
• Monitor for reduction in somatic and behavioral symptoms.
• Reinforce use of independent coping strategies.
IX. Key Takeaways
• Anxiety becomes a disorder when it impairs functioning and persists beyond a reasonable time.
• Panic disorder is the most acute and distressing form, while GAD is the most common chronic
form.
• Integrated treatment (medications + therapy) is most effective.
• Nurses play a pivotal role in recognizing symptoms, ensuring safety, and providing therapeutic
communication.
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 I. MOOD DISORDERS AND SUICIDE (Drill Questions)

1. What are the hallmark symptoms of Major Depressive Disorder (MDD), and how is it
differentiated from normal sadness?
o MDD involves a depressed mood or loss of interest in most activities for at least two
weeks. Core symptoms include anhedonia, fatigue, appetite and sleep disturbances,
impaired concentration, psychomotor changes, feelings of worthlessness or guilt, and
suicidal ideation. It is more pervasive and functionally impairing than normal sadness.
2. Discuss the role of neurotransmitters in the etiology of MDD. Which ones are primarily involved
and how?
o Imbalances in serotonin and norepinephrine are implicated. Low levels of these
neurotransmitters affect mood regulation and emotional response.
3. Compare the different types of bipolar disorder (I, II, cyclothymic, mixed features, rapid cycling)
based on their defining mood episodes and severity.
o Bipolar I: Manic episodes ≥1 week, often severe, may need hospitalization. Depression
may occur.
o Bipolar II: Hypomania (≥4 days, not requiring hospitalization) and major depression.
o Cyclothymic: ≥2 years of hypomanic and depressive symptoms not meeting full criteria.
o Mixed Features: Simultaneous mania and depression; high suicide risk.
o Rapid Cycling: ≥4 mood episodes in 12 months; more difficult to treat.
4. What are the core symptoms of a manic episode, and how can these escalate into a psychiatric
emergency?
o Grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility,
risky behaviors. Manic episodes can lead to psychosis, requiring hospitalization.
5. Why is lithium carbonate considered the gold standard in bipolar disorder treatment, and what
precautions should nurses take regarding its administration?
o Lithium stabilizes mood but has a narrow therapeutic range (0.6–1.2 mEq/L). Nurses must
monitor serum levels, ensure adequate salt and fluid intake, and watch for toxicity signs
(e.g., vomiting, muscle weakness).
6. Identify at least three behavioral warning signs of suicide and explain how each might signal risk.
o Giving away possessions (planning end of life), sudden calmness after depression (may
indicate decision to die), making final arrangements (indicates planning).
7. What factors make suicide particularly prevalent among certain age groups and demographics?
o High rates in men aged 45–65 and >65, especially among white, divorced, widowed, or
unemployed individuals. Chronic illnesses and psychiatric conditions also increase risk.
8. Describe the key nursing interventions for suicide prevention, including assessment tools and
psychosocial strategies.
o Ask directly about suicidal thoughts, assess lethality, remove harmful objects, ensure
close supervision, use therapeutic communication, involve family support, and promote
adherence to treatment.

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 II. ANXIETY AND ANXIETY DISORDERS (Drill Questions)
1. Differentiate between anxiety and fear and explain when anxiety becomes pathological.
o Anxiety is a vague apprehension without a clear threat; fear is a response to known
danger. Anxiety is pathological when it’s persistent, excessive, and interferes with
functioning.
2. According to Peplau’s framework, what are the four levels of anxiety, and how do these levels
affect an individual’s capacity to learn and function?
o Mild: Heightened awareness; learning enhanced.
o Moderate: Focus narrows; learning possible but reduced.
o Severe: Perception greatly reduced; learning impaired.
o Panic: Disorganized, irrational; learning impossible, may need emergency care.
3. Explain the biological and psychological factors implicated in the development of anxiety
disorders, including neurotransmitter involvement.
o Biological: ↓GABA, ↑norepinephrine, ↓serotonin; genetic predisposition.
o Psychological: Freud (conflict among id, ego, superego); Sullivan (interpersonal trauma);
Peplau (interpersonal nursing care model).
4. Enumerate and describe at least four specific anxiety disorders, including their diagnostic
features.
o GAD: Chronic worry ≥6 months.
o Panic Disorder: Recurrent panic attacks with physical symptoms.
o Phobias: Irrational fear of objects/situations (e.g., agoraphobia).
o Social Anxiety Disorder: Fear of negative evaluation in social situations.
5. What is the role of defense mechanisms in coping with anxiety, and when can these become
maladaptive?
o Defense mechanisms (e.g., repression, displacement, projection) reduce anxiety
unconsciously. They become maladaptive when they distort reality or impair functioning.
6. How do cultural syndromes like Koro and Susto reflect the sociocultural context of anxiety?
o Koro (Asia): Fear of genital retraction and death.
o Susto (Latin America): Anxiety after trauma, believed to cause spiritual loss with somatic
symptoms. These highlight the cultural expression of anxiety.
7. Compare the pharmacological and psychotherapeutic treatment approaches to anxiety, and
identify when each is most appropriate.
o Pharmacologic: Benzodiazepines (short-term relief), SSRIs/SNRIs (long-term), beta-
blockers (performance anxiety).
o Psychotherapy: CBT (reframing, thought-stopping), useful for long-term management and
skill-building.
8. What are the key nursing responsibilities during a panic attack and in the overall care plan of a
client with anxiety disorder?
o Stay with the client, remain calm, use short statements, reduce stimuli, teach relaxation
techniques, and encourage structured routines and support systems.

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QUIZ #1

Identification: Anxiety and Anxiety Disorders

1. _____ This is a vague feeling of uneasiness or dread without a known cause, often confused with
fear.
2. _____ According to Peplau, this level of anxiety is considered a medical emergency due to
disorganized behavior and possible hallucinations.
3. _____ This neurotransmitter is decreased in anxiety and is responsible for reducing neuronal
excitability in the brain.
4. _____ It is the most common chronic anxiety disorder characterized by excessive worry lasting
six months or more.
5. _____ This term refers to the irrational and intense fear of a specific object or situation that
causes avoidance behavior.
6. _____ A culturally bound syndrome in Latin America where spiritual fright causes anxiety and
physical symptoms.
7. _____ This therapeutic approach uses techniques like reframing, thought-stopping, and
relaxation to manage anxiety.
8. _____ The nurse’s priority action when a patient is experiencing a panic attack.
9. _____ A long-term, non-sedating anxiolytic medication used for managing generalized anxiety
disorder.
10. _____ A defense mechanism in which a person redirects emotions from the original source to a
safer substitute target.

Answer Key

1. Anxiety
2. Panic
3. GABA
4. Generalized Anxiety Disorder
5. Phobia
6. Susto
7. Cognitive Behavioral Therapy (CBT)
8. Stay with the client (or "Remain with the client")
9. Buspirone
10. Displacement

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QUIZ #2

Identification Test: Mood Disorders and Suicide

1. _________ is characterized by a depressed mood or loss of interest in almost all activities lasting
for at least two weeks.
2. The inability to feel pleasure in normally enjoyable activities, common in depression, is called
__________.
3. The gold standard medication for treating bipolar disorder is __________.
4. The neurotransmitters most associated with the pathophysiology of Major Depressive Disorder
are __________ and __________.
5. A type of bipolar disorder marked by hypomania and major depressive episodes, without full
manic episodes, is known as __________.
6. __________ is the mood disorder subtype involving four or more mood episodes within 12
months.
7. A sudden calmness after a period of severe depression can be a behavioral warning sign of
__________.
8. __________ disorder is characterized by mood swings between mania, depression, and periods
of normal mood.
9. Hallucinations or delusions occurring in the context of a depressive episode may indicate
__________ depression.
10. One high-risk demographic group for suicide includes __________ men over the age of
__________.

Answer Key

1. Major Depressive Disorder (MDD)

2. Anhedonia
3. Lithium carbonate
4. Serotonin and Norepinephrine
5. Bipolar II Disorder
6. Rapid Cycling Bipolar Disorder
7. Suicide
8. Bipolar Disorder
9. Psychotic
10. White; 65

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