Affective Disorders (Mood Disorders): Comprehensive Nursing Notes
Affective or mood disorders are conditions in which persistent depression, elevated/irritable mood, or alternating mood episodes cause significant distress or impaired functioning. Major groups are depressive disorders and bipolar disorders. Every assessment must include suicide risk, psychosis, mania history, substances, physical causes and reproductive status.
Classification
| Disorder/episode | Core picture | Important distinction |
|---|---|---|
| Major depressive episode | Persistent low mood and/or loss of interest plus cognitive, physical and functional symptoms | Ask about previous mania/hypomania before antidepressant treatment. |
| Manic episode | Elevated, expansive or irritable mood with increased energy, reduced sleep, pressured speech, grandiosity, distractibility, risky activity; severe impairment/psychosis may occur | Usually bipolar I; hospitalization may be required. |
| Hypomanic episode | Similar but less severe, observable change without marked impairment or psychosis | With major depression supports bipolar II. |
| Mixed features | Depressive and manic symptoms together | High agitation and suicide risk. |
| Persistent depressive disorder/cyclothymic disorder | Chronic subthreshold depressive or fluctuating mood symptoms | Longitudinal history is essential. |
Aetiology and risk factors
Mood disorders arise from interaction among genetic vulnerability, neurotransmitter and circadian regulation, endocrine/medical illness, temperament, trauma, loss, chronic stress and social adversity. Postpartum state, medicines (such as corticosteroids), thyroid disease, anaemia, HIV/CNS disease, epilepsy and alcohol/substance use may cause or worsen mood symptoms.
Assessment
- History: onset, duration, severity, previous episodes, sleep, appetite, energy, concentration, psychomotor change, guilt, function, seasonal/postpartum pattern and family history.
- Screen for mania: periods of unusually high/irritable mood, little need for sleep, increased talk/activity, grandiosity, overspending or sexual/risk behaviour.
- Suicide assessment: thoughts, intent, plan, means, rehearsal, past attempts, substance use, protective factors and ability to accept help. Do not rely on a “no-suicide contract.”
- Mental-state and physical examination: psychosis, catatonia, cognition, intoxication, neurological/endocrine signs and medicine adverse effects.
- Investigations: guided by presentation—glucose, FBC, renal/liver/electrolytes, thyroid tests, pregnancy test, ECG and toxicology; mood-stabilizer-specific baseline tests.
Urgent admission/referral: imminent suicide risk, severe self-neglect, dehydration/refusal of food, psychotic depression, mania with danger/exhaustion, catatonia, delirium, severe postpartum symptoms or inability of family/community care to maintain safety.
Management principles
Depression
- Mild presentations: psychoeducation, problem-solving/psychological therapy, activity scheduling, sleep and social support; monitor risk.
- Moderate–severe: structured psychotherapy plus antidepressant when indicated, with close early monitoring for activation, adverse effects and suicide risk.
- Psychotic depression, catatonia, severe suicidality or life-threatening refusal of intake requires specialist care; electroconvulsive therapy may be lifesaving when clinically indicated and consent/legal requirements are followed.
Mania/bipolar disorder
- Low-stimulation environment, restore sleep, hydration and nutrition, remove hazards, set clear consistent limits and use de-escalation.
- Prescribed antipsychotic and/or mood stabilizer according to severity, previous response, comorbidity, pregnancy potential and monitoring capacity.
- Do not use antidepressant monotherapy in bipolar disorder; review antidepressants if mania emerges.
Medicine table
| Class | Indications/action | Contraindications/interactions | Adverse effects and monitoring |
|---|---|---|---|
| SSRIs (e.g., fluoxetine, sertraline) | Depressive and anxiety disorders; increase serotonergic transmission. | Do not combine with MAOIs; caution other serotonergic drugs, bleeding-risk drugs and bipolar activation. | Nausea, insomnia, sexual dysfunction, hyponatraemia, serotonin toxicity; monitor mood/suicide risk early. |
| Tricyclics (e.g., amitriptyline) | Depression where appropriate; also some pain syndromes. | Dangerous in overdose; caution cardiac disease, glaucoma, urinary retention; additive sedation/anticholinergic effects. | Hypotension, arrhythmia, sedation, constipation, dry mouth; ECG/risk assessment where indicated. |
| Lithium | Acute/maintenance bipolar disorder and suicide-risk reduction in selected patients. | Avoid/caution renal disease, dehydration, pregnancy; toxicity increased by NSAIDs, ACE inhibitors and thiazides. | Tremor, thirst/polyuria, thyroid/renal effects; monitor serum level, renal/thyroid function, hydration. Vomiting, coarse tremor, ataxia or confusion suggests toxicity. |
| Valproate | Mania and maintenance in selected patients. | Major fetal risk; avoid in pregnancy and women/girls able to become pregnant unless strict specialist conditions apply; contraindicated significant liver disease. | Weight gain, tremor, GI effects, thrombocytopenia, hepatotoxicity; pregnancy prevention, LFT/FBC monitoring. |
| Antipsychotics | Acute mania, psychosis and selected bipolar maintenance. | Agent-specific QT, metabolic, neurological and prolactin risks; sedative interactions. | Monitor EPS, NMS, weight/BMI, waist, BP, glucose and lipids. |
Nursing management
| Nursing diagnosis | Interventions and rationale |
|---|---|
| Risk for suicide | Direct repeated assessment, remove means, observation matched to risk, collaborative safety plan, prompt treatment and careful handover; risk changes rapidly. |
| Imbalanced nutrition | Record intake/weight, offer small frequent high-calorie foods during mania or supported meals in depression, fluids and dietitian/medical review. |
| Sleep-pattern disturbance | Reduce evening stimulation, structured routine, monitor hours slept, administer prescribed medicine and evaluate response. |
| Disturbed thought processes | Short calm communication, do not argue with grandiose/guilty delusions, reality orientation and psychosis-risk assessment. |
| Self-care deficit/social withdrawal | Grade activities, assist without fostering dependence, acknowledge small gains, involve occupational and family supports. |
| Caregiver strain | Education, crisis contacts, relapse signs, respite/support and shared plan with patient consent. |
Special populations
- Pregnancy/postpartum: urgent specialist risk–benefit review; postpartum psychosis is an emergency threatening parent and infant.
- Children/adolescents: irritability may predominate; involve caregivers while protecting confidentiality and safeguarding.
- Older adults: search for medical illness, medicines, delirium and dementia; start medicines cautiously.
Relapse prevention and health education
- Regular sleep/wake schedule, medicine adherence, avoid alcohol/drugs, physical activity and ongoing physical-health monitoring.
- Written warning signs: sleep reduction, rising activity/spending/talkativeness, withdrawal, hopelessness or missed medicines.
- Provide crisis contacts and scheduled follow-up soon after discharge; involve chosen family/support persons.
Revision questions
- Differentiate mania and hypomania.
- Why must every depressed patient be screened for previous mania?
- Outline lithium toxicity prevention and monitoring.
- Write a nursing care plan for acute mania or severe depression.
References
- WHO. mhGAP Guideline, 2023.
- WHO. mhGAP Intervention Guide, Version 2.0.
- Uganda Ministry of Health. Uganda Clinical Guidelines, 2023.