Major Depressive Disorder (MDD) is a mental health disorder characterized by at least two weeks of persistently sad mood or loss of interest in activities (anhedonia), causing significant impairment in daily life functioning, accompanied by five or more symptoms including :
Depressed mood most of the time
Loss of interest or pleasure in activities
Feelings of worthlessness or excessive guilt
Lack of energy
Insomnia or hypersomnia
Inability to concentrate or indecisiveness
Decrease or increase in appetite
Psychomotor retardation or agitation
As per the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria, MDD is a subclassification under depressive disorders, which also include Disruptive Mood Dysregulation Disorder, Persistent Depressive Disorder (Dysthymia), Premenstrual Dysphoric Disorder, Substance/Medication-Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition, Other Specified Depressive Disorder and Unspecified Depressive Disorder.
Nursing diagnoses address responses to illness or disease. Nurses may identify that the following nursing diagnoses, in addition to others not mentioned, apply to the needs of people with MDD:
Impaired Mood Regulation
Disturbed Sleep Pattern
Risk for Suicide
MDD is considered to be caused due to a combination of biological, genetic, and psychosocial factors. According to cognitive theory, depression results from specific cognitive distortions in persons susceptible to depression. The learned helplessness theory of depression connects depressive phenomena to the experience of uncontrollable life events.
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MDD has been found to have the highest lifetime prevalence of any psychiatric disorder. The lifetime prevalence rate for MDD is 5 to 17 percent, with almost double in women than in men. The mean age of onset for MDD is about 40 years. Risk factors can be categorized into three broad groups: internal, external, and adverse life events.  Later in life, risk factors for depression include social isolation, death of a spouse, comorbidities, uncontrolled pain, insomnia, and cognitive and functional impairments .
It is important first to rule out any medical etiologies for depression. A general medical history, family medical and psychiatric history, substance use history, medication history, and social history should be evaluated, and a complete physical examination should be performed. A mental status examination is very helpful in recognizing a patient with Major Depressive Disorder.
Laboratory studies, including complete blood count with differential, comprehensive metabolic panel, lipid panel, TSH, Vitamin D and toxicology screening, are done to rule out other causes of depression, such as hypothyroidism, alcoholism, vitamin D deficiency etc. Nearly 30% of people with substance abuse problems have major or clinical depression. Other tests may sometimes include:
CT scan or MRI of the brain to rule out serious illnesses such as a brain tumors or dementia
Electroencephalogram (EEG) to record the electrical activity of the brain, such as in epilepsy
In most medical office settings, the Patient Health Questionnaire-9 (PHQ9), a self-report instrument, is commonly used to detect Major Depressive Disorder. In hospital settings, there are different scales, such as Hamilton Rating Scale for Depression (HAM-D), used to detect depression in patients. PHQ-9 is a 9-item self-administered diagnostic screening and severity tool based on current diagnostic criteria for major depression. HAM-D is a multiple-choice questionnaire that may be used to rate the severity of a patient’s depression. One of the other popular scales used in Beck Depression Inventory (BDI) is a 21-question multiple-choice self-report that measures the severity of depression symptoms and feelings.
Medications such as:
Selective serotonin reuptake inhibitors (SSRIs) such as citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone
Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, venlafaxine, desvenlafaxine, and levomilnacipran
Atypical antidepressants antidepressants such as bupropion, mirtazapine, nefazodone, trazodone and vortioxetine
Tricyclic antidepressants antidepressants such as imipramine, nortriptyline, amitriptyline, doxepin, trimipramine, desipramine, and protriptyline
Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine, phenelzine, isocarboxazid, and selegiline
Other medications, such as mood stabilizers or antipsychotics, may be added to an antidepressant to enhance antidepressant effects.
Psychotherapy can be used alone or with other treatments.
Brain stimulation, such as electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS), is also used for patients with treatment-resistant depression who have failed to improve with several antidepressant medications.
Nurses often initially interview patients in both inpatient and outpatient settings and ask them questions about their medical history and medication history. Many facilities must screen patients for self-harm or intent to harm others. Patients or their families may share with nurses that they are feeling down or depressed. Nurses can further notify the healthcare team to assess the patient’s mental health. The nurses can also provide support and education on MDD. If a patient expresses suicidal ideations, the nurse should stay with the patient and notify a healthcare provider. The patient should not be left alone.
When To Seek Help
People with MDD should seek help anytime they have thoughts of hurting themselves or others if they are considering stopping their treatments, if side effects become unmanageable, or if their symptoms are worsening.
Coordination of Care
An interdisciplinary approach is essential for the effective and successful treatment of MDD. Primary care physicians, psychiatrists, nurses, therapists, social workers, and case managers form an integral part of these collaborated services. In most cases, primary care is the first setting where individuals with MDD present mostly with somatic complaints. Depression screening in primary care settings is very imperative. Regular screening of the patients using depression rating scales such as PHQ-9 can be very helpful in the early diagnosis and intervention, thus improving the overall outcome of MDD. Suicide screening at each psychiatric visit can help lower suicide incidence. Since patients with MDD are at increased risk of suicide, close monitoring and follow-up by mental health workers become necessary to ensure safety and compliance with mental health treatment. The involvement of families can further add to a better outcome of overall mental health treatment. Meta-analyses of randomized trials have shown that depression outcomes are superior when using collaborative care compared to usual care.
Health Teaching and Health Promotion
Patient education profoundly impacts the overall outcome of major depressive disorder. Since MDD is one of the most common psychiatric disorders causing disability worldwide and people in different parts of the world are hesitant to discuss and seek treatment for depression due to the stigma associated with mental illness, educating patients is very crucial for their better understanding of the mental illness and better compliance with the mental health treatment. Family education also plays an important role in the successful treatment of MDD. Psychoeducation plays a significant role in improving patient compliance and medication adherence. Recent evidence also supports that lifestyle modification, including moderate exercises, can help to improve mild-to-moderate depression. 
Nurses can also provide education about the side effects and expected treatment response when patients are prescribed antidepressant antidepressant medications. Important points of education include:
Initially, it takes 2 – 4 weeks to see improvement in symptoms; do not discontinue the medication unless you have talked to your provider
Notify the provider or go to the hospital immediately for suicidal thoughts
Side effects may include tiredness, sexual dysfunction, weight gain, dry mouth, nausea, and more
Do not stop taking antidepressant antidepressants abruptly for any reason. Discuss with the provider; tapering off medication may be required to avoid withdrawal symptoms.
Most mental health disorders are characterized by mood swings such as depression and elation. This chapter looks at disorders in which mood changes are the dominant condition and are disabling. Changes in mood are more intense and persistent in people with mood disorders, and they can interfere with work and home life. A variety of disturbances in behavior, cognition, communication, and physical functioning are also associated. When working with the client, an effective nurse will consider all of these factors.
As with all aspects of mental health nursing, the key to working effectively with someone suffering from a mood disorder is a collaborative relationship marked by openness and respect, in which the nurse is viewed as a partner in the client’s recovery.
The coexistence of two or more disorders is referred to as comorbidity. A mood disorder, for example, is rarely a single illness. Mood disorders are frequently associated with other conditions such as personality disorders, eating disorders, anxiety disorders, and, in particular, substance abuse disorders (Hussein Rassool 2006). Similarly, clients with schizophrenia frequently experience mood swings. It is unclear why these conditions coexist. Is one disorder the result of another, or do they both share the same original disruptive mechanism? Is it more common for people suffering from depression to drink excessively in an attempt to self-medicate, or are clients suffering from severe mental illnesses more’sensitive’ to small amounts of alcohol or drugs (Hall & Queener 2007; Khantzian 1997; Mueser, Bennet, & Kushner 1995)? Several theories have been proposed, but there is little agreement. Furthermore, clients with mental health disorders are more likely to be exposed to health risk factors, have poorer physical health, and die from a variety of causes, including suicide (Australian Institute of Health and Welfare (AIHW) 2006).
The important principle for nurses is that we care for our clients holistically, in many aspects of their lives, rather than treating them as a single, abstract disorder.
Mood disorder epidemiology
Australians seek mental health care from a variety of public and private health-care providers. General practitioners, as well as community and hospital-based mental health services, are among them.
• Community-based services—According to recent AIHW 2006 statistics, clients with a primary diagnosis of either mood disorder (24%) or schizophrenia (49%) accounted for the greatest number of contacts with government-operated community mental health services in 2003/04. Following mood disorders and schizophrenia, clients with neurotic, stress-related, or somatoform disorders accounted for nearly 10% of all service contacts.
• Hospital-based services—the majority of public and private mental health hospitalizations last at least one night. Mood disorders accounted for 32% (22,170 public, 11,870 private) of all overnight private and public mental health hospital admissions in 2003/04 (106,100 total: 83,200 public, 22,900 private). Schizophrenia accounted for 31% (30,450 public, 2400 private) (AIHW 2006). 13% of admissions were for neurotic, stress-related, or somatoform disorders (9780 public, 3820 private).
Mood disorders account for a sizable portion of Australia’s mental health disease burden. According to recent statistics, mental health disease accounted for 13% of Australia’s disease burden in 2003. (Begg et al 2007). Mental health issues were also linked to higher exposure to health risk factors, poorer physical health, and higher rates of death from a variety of causes, including suicide (Begg et al 2007).
Depressive symptoms can range from mild, such as “feeling blue,” to very severe, with extreme sadness and dejection and an inability to enjoy activities. If the depressive symptoms are all-encompassing and debilitating in most aspects of the client’s life, the illness is classified as major depressive disorder. If the client describes ‘feeling blue’ for an extended period of time and exhibits mild depression symptoms, their illness may be classified as dysthymia.
The most important distinguishing factors are the number of symptoms, severity of symptoms, and duration of symptoms. It is also important to recognize that, depending on life events, temporary sadness and grief are a normal part of human functioning and should not be viewed as disease states.
Mild depressive disorder
Mild depression outnumbers major depression. It can be interpreted as an exaggeration of everyday unhappiness. The client may complain of “the blues,” but does not exhibit the characteristics of major depression. Tearfulness, anxiety, low mood, lack of energy and interest, irritability, and sleep disturbance are all symptoms of mild depression.
The sleep disturbance in mild depression is not the early morning waking of major depressive disorder, but rather difficulty falling asleep and frequent waking throughout the night, with sleep finally coming at the end of the night.
Somatic symptoms (physical symptoms that have a psychological rather than a physiological basis) are not prominent in mild depression, and delusions and hallucinations do not occur.
Major depressive disorder
Low mood, lack of energy, loss of pleasure or interest in activities (called anhedonia), negative thinking, disturbed sleep, difficulty concentrating, and recurring thoughts of death and suicide are the seven main characteristics of major depression. It is a disorder that is frequently found in day clinics and on wards but goes unnoticed when the client presents with a variety of physical ailments. It is critical that the illness is recognized, as depression is one of the leading causes of self-harm and suicide, and it can have a significant impact not only on the client but also on their family and friends (Gelder, Mayou & Geddes 2005a).
A number of characteristics distinguish major depressive disorder from milder forms of depression. These include changes in appearance and behavior, as well as thinking, mood, perception, and neurovegetative symptoms, which are detailed below. Some, but not all, of these symptoms may be displayed by clients.
Personality and behavior
Psychomotor retardation is a slowing of mental and physical activity that is a symptom of major depression. Surprisingly, and in contrast, agitation and a sense of restlessness are also symptoms of major depressive disorder. This is referred to as agitated depression. The client frequently finds it difficult to sit still for an extended period of time and may pace around the room.
Mood The client is typically depressed and anguished. The client expresses hopelessness and powerlessness in their situation. They also describe a distinct quality to their low mood that differs from ordinary sadness.
The severity of the mood varies according to the time of day. The client will get up early. Mornings are usually the worst, with pessimistic thoughts about the day ahead and a focus on past perceived failures. The person’s mood improves throughout the day.
The client is frequently agitated and anxious. They may withdraw socially and emotionally from other people. There is a significant decrease in enjoyment or interest in previously enjoyed activities (Gelder et al 2005a).
Thinking and speaking
A depressed person becomes more egocentric. They are preoccupied with themselves and fail to recognize that others may have needs as well. All of their thoughts are bleak and negative.
The individual regards themselves as inept, unlovable, and a failure. They will also regard the world as inept and unlovable. Others will perceive you as uncaring and unhelpful. Depressed people’s thinking becomes catastrophic, and their emotional state is crippled by excessive guilt.
Concentration and memory problems are common symptoms of major depression. The individual may have difficulty reading or concentrating on a problem. The cognitive difficulties involved in making a simple decision immobilize them. Negative self-absorption, low energy, and a lack of interest in others dominate their outlook. They almost never strike up a conversation. When asked a question, they will take a long time to respond before giving a brief and perfunctory response.
The depressed person’s thinking spectrum also narrows. The individual is preoccupied with negative thoughts and ideas to the exclusion of all else. These thoughts and ideas become fixed and repetitive, and rumination eventually interferes with normal thought processes.
Reflecting on the past, present, and future
When a person thinks about the present, he or she will see the negative side of everything that happens. They will believe that others regard them as a failure, and if something good happens to them, they will attribute it to a lucky chance that will never happen again.
When reflecting on the past, the person will become consumed with inappropriate guilt, often over trivial matters. They may believe they have disappointed someone and contributed to their misfortune. The depressed person may not have thought about these issues in years, but in the midst of their depression, these thoughts will flood back and overwhelm them.
Their outlook on the future will be unrelentingly pessimistic. They anticipate disaster at work, failure in their relationships with family and friends, and an unavoidable deterioration in their physical health. This preoccupation with a bleak future and a sense of doom frequently leads to suicidal ideation and should be treated with caution (Gelder et al 2005a).
Delusions and hallucinations may accompany major depressive disorders. People with moderate depressive disorders may experience inappropriate guilt, whereas people with severe depressive disorders will experience guilt delusions. These are known as psychotic symptoms, and when combined with depression, the condition is known as psychotic depression.
The same themes that manifest as inappropriate emotions in moderate depression manifest as psychotic symptoms in major depression, such as feelings of worthlessness, failure, or incompetence. When hallucinations occur, they usually take the form of negative, derisory voices repeating nihilistic themes such as ‘You’re a failure, you’re incompetent, you’re evil,’ and so on.
Sleep disturbances, particularly difficulties falling asleep and waking up early in the morning, are common symptoms of depression. Clients suffering from depression will also wake up feeling tired.
Fatigue, loss of appetite, decreased sexual interest, and poor hygiene are all common symptoms of major depression. Weight loss is a good indicator of a possible depressive disorder. A subset of the population, often from non-Western backgrounds, will not describe themselves as depressed. These depressed people will instead describe a variety of pain conditions or other physical symptoms. This is known as somatisation, and it should be taken seriously.
Box 16.1 Major depressive episode classification
Major depressive disorder is defined as the presence of at least five of the nine symptoms listed below:
• Depressed mood most of the day, nearly every day • Significantly reduced interest or pleasure in all, or nearly all, activities most of the day, nearly every day • Significant weight loss when not dieting or weight gain • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day • Fatigue or loss of energy nearly every day • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Reprinted with permission from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision (copyright 2000).
16.1 Critical thinking challenge
Why do you believe people are so hesitant to admit they are depressed and in need of help?
What would be your initial reaction if you were diagnosed with depression, started weekly therapy, and were prescribed antidepressants?
The biopsychosocial causation model
What factors contribute to depression? As with many diseases in mental health, researchers have concentrated on three major areas of influence: biological, psychosocial, and sociocultural factors. Each of these areas has been thoroughly researched to determine how they contribute to this mood disorder. To accurately assess what causes depression, we must recognize that no single factor is likely to be entirely responsible. The illness is caused by a combination of factors interacting. The biopsychosocial model of causation refers to this combination of factors.
Factors of genetic origin
Sullivan, Neale, and Kendler (2000) examined a number of twin studies (over 21,000 twins in total) and discovered that an identical twin was roughly twice as likely as a non-identical twin to suffer from major depression. According to Sullivan et al. (2000), genetic factors account for 31-42% of the risk of developing major depression.
Interaction between genes and the environment
Much effort has gone into determining the specific genes involved in depression. There has been limited success thus far, but several approaches have shown promise. One of these is the gene-environment interaction concept. Researchers discovered that while some people had a genetic predisposition to depression (in the serotonin transporter gene), if they had also experienced stressful life events in the previous five years or had been severely maltreated as children, they were far more likely to develop depression than those who only had the gene or had stressful life events/maltreatment as children (Caspi et al 2003; Moffitt, Caspi & Rutter 2005). This implies that looking for genes associated with depression would be more fruitful if the gene-environment interaction was also investigated.
The idea that depression is caused by a complex interaction between neurotransmitters and other brain systems emerged in the 1960s and has gained traction since then. It should be emphasized that depression is more than just a lack of serotonin or other neurotransmitters (monoamines) in the brain. The’monoamine hypothesis’ was proposed in 1965, but by the 1980s, researchers had concluded that it was overly simplistic. A number of studies, for example, have found that people with severe depression have higher levels of neurotransmitters like noradrenaline and only a small proportion have lower levels of serotonin (Thase, Jindal & Howland 2002). Researchers have recently proposed that the causes of depression are more complex and likely depend on an interaction between neurotransmitters and disturbances in the body’s hormonal, neurophysiological, and biological systems (Southwick, Vythilingam & Charney 2005). Although this is a more accurate description, explaining it as a single mechanism or process is difficult.
Circadian rhythms and hormone systems
It has been proposed that hormonal systems, specifically the hypothalamic-pituitary-adrenal axis, are to blame (HPA)
A depressed young man, according to Nurse
Branko had been the primary provider for his family since his father died when he was fifteen. He lived in an inner-city suburb with his mother and two younger sisters and worked as a storeman at a nearby supermarket.
Branko’s mother had been depressed for as long as he could remember. Antidepressants and counseling from their local priest appeared to help his mother, but Branko spent most of his time working, paying bills, cooking meals, and getting his sisters ready for school each day. His job at the supermarket allowed him to pick up his sisters from school and then return to work in the evening after his family had settled.
The 14-year-old eldest daughter had called the local health center, concerned that her mother had become ‘unwell’ again. She requested that a nurse come to their home to see her. That’s where I stepped in.
I was surprised to find Branko still in his dressing gown when I arrived at their house the next day. He informed me that his mother had been bedridden for the past two weeks and had been eating poorly. He was concerned about her. I spoke with his mother, conducted an assessment, and then spent the next half hour arranging her admission to an acute mental healthcare ward.
I sat down with Branko while we waited for the ambulance. He appeared to be very flat. His voice was flat and unanimated. When I asked him why he wasn’t at work, he replied vaguely that he wasn’t feeling well. We sat in silence for a while because it was clear he didn’t want to talk. The ambulance arrived, and before I left, I made a plan to see him again a week later.
I had known Branko for a few years in the context of providing care for his mother. I suspected he was stressed, but hoped he was doing well. I’d never seen him so flat before, and I could tell he was in pain. My first priority was to pay him regular visits in order to establish a therapeutic relationship. This was partly in preparation for his mother’s discharge from the hospital, but it was also because I wanted to engage with him and build trust between us. I hoped he would open up and express his feelings. This happened gradually. When I visited, we would spend a lot of time sitting quietly together. I tried to be as genuine and honest with him as possible at all times. As a result, he gradually began to open up to me.
Branko described how he had lost his appetite and felt constant fatigue. He was also irritable much of the time with the long hours at work and burdens at home. He recognised his irritability and hated himself for it. He didn’t like being irritable with his family. He’d had a girlfriend for a couple of months the year before, but there was little time in his life to devote to another relationship and it soon ended. He then found himself lacking energy and more irritable than before. At times during our interactions Branko was angry with himself. At other times he turned his anger on me. I realised he wasn’t targeting me personally and that it was a symptom of his illness. He would always apologise after the anger had passed and we would be relaxed with each other again.
All the time I was with him I expressed hope to him that his spirits would lift. I focused on what a good, caring son and brother he was. He regularly visited his mother in hospital. I also praised him on how his sisters were turning out with his help. They were well respected at the school and getting good marks in their studies.
Finally his mother did return from hospital. This seemed to be a turning point for him. Branko had missed his mother keenly. She was brighter and able to help more around the house and with the two girls. Branko himself seemed to be coping better and was taking less time off from work. He agreed to trial some antidepressant medication. He had also mentioned during my last visit that he was thinking of getting in touch with his ex-girlfriend to see if she wanted to spend some time with him.
On my final visit a couple of weeks later it was obvious that he was better. He’d recently gained a promotion at work and his girlfriend was coming around that night for dinner with his family. He thanked me for my efforts over the past couple of months and spoke in positive terms about his future. I was glad.
axis and the cortisol and thyroid hormones, are implicated in depression (Marangell et al 1997; Thase et al 2002). (Marangell et al 1997; Thase et al 2002). Also implicated are low levels of brain activity in key regions of the brain (Davidson et al 2002), the qualities of REM sleep, and disturbances in circadian rhythms (24-hour body cycles) (Thase et al 2002). (Thase et al 2002).
It has been argued that psychosocial factors play as strong a part in the development of depression as biological factors. However, it is likely that it is the impact of stressful life events on the biochemical hormonal and circadian systems that causes depression (Hammen 2005; Howland & Thase 1999). (Hammen 2005; Howland & Thase 1999).
It has long been established that women are more than twice as likely to develop depression as men (Nolan-Hoeksema 2002). (Nolan-Hoeksema 2002). The theories that have been proposed to explain this range from biological (hormonal and genetic factors) to social and psychological (Helgeson 2002; Nolan-Hoeksema 2002). (Helgeson 2002; Nolan-Hoeksema 2002).
One approach suggests that depression is largely a consequence of women’s roles in society. These researchers argue that women regularly experience a lack of control over negative life events and that this contributes to the development of depression. These events include poverty, discrimination in the workplace, unemployment, imbalance of power in relationships with men, high rates of abuse (sexual and physical) and overload in role expectation (e.g. wife, work, children) (Ben Hamida, Mineka & Bailey 1998; Heim, Graham & Miller 2000; Nolan-Hoeksema 2002). (Ben Hamida, Mineka & Bailey 1998; Heim, Graham & Miller 2000; Nolan-Hoeksema 2002). Again, it is likely that these life events affect hormonal and neurophysiological systems to produce depression.
Table 16.1 Nursing interventions for clients with depression
Be genuine and honest with patients. Accept them for who they are (both negative and positive aspects) (both negative and positive aspects).
• Depressed people have chronically low self-esteem.
• Genuine acceptance by others is a first step to recovery.
Treat anger and negative thinking as symptoms of the illness, not as personally targeted at the nurse.
• Depressed people are often negative and angry.
• By identifying that negativity and anger are aspects of the illness, the nurse can encourage the client to move on from these issues to express more appropriate emotions.
Never reinforce hallucinations, delusions or irrational beliefs.
• It is not appropriate to agree with the client’s perceptual abnormalities. Equally, arguing that they do not exist serves little purpose.
• The nurse should state their perception of the situation.
• The nurse should state that there is a discrepancy between what is perceived by the client and what is perceived by the nurse. \s• The nurse should then steer the conversation to discussing real people and real events.
Spend time with withdrawn clients, even if no words are spoken.
• Withdrawn people are still very aware of where they are and who they are with.
• Simply by spending time with withdrawn clients, nurses can help the clients emerge from their isolation by providing a non-threatening one-on-one relationship, practising assertive interactions and providing positive regard.
Make positive decisions for clients if they are unwilling to make decisions for themselves, e.g. it is time to get out of bed.
• Depressed people can have difficulties making even the simplest of decisions.
• By using problem-solving techniques—i.e. identifying options, the advantages and disadvantages of each option available, and exploring the consequences of taking these actions—the nurse can guide the client to appropriate decisions.
Express hope that they will get better. Focus on their strengths, however small these seem.
• By identifying their strengths and giving them hope and positive regard, we encourage them to regain a sense of self-worth.
Identify and involve clients in activities where they can enjoy success.
• It is important for clients to feel good about themselves. \s• By involving clients in activities that they can accomplish, they may begin to improve their sense of self-worth.
Mania is characterised by three main features: persistently elevated mood, which may be one of elation or irri tability; increased activity; and poor quality of judgment. The occurrence of manic episodes with a depressive disorder is called bipolar disorder. Mania is less common than depression. Again, it is important that the illness not go unrecognised because as the illness progresses, the client may become less and less inclined to accept treatment, and the consequences of the illness (increased activity, poor judgment) may become more serious.
Hypomania has similar symptoms to mania, with the following exceptions: there is no significant impairment in social or occupational function; there are no psychotic features; and there is generally no need for hospitalisation.
Although the name bipolar disorder suggests two categories of symptoms—depression and mania—it does not require a depressive episode for the diagnosis to be made. There are individuals suffering from bipolar disorder who have never had a depressive episode. In general, the disorder is characterised by a cycling between depression and normal mood and mania. This may occur over periods of time from days to weeks to months.
As with depression, the more severe form of mania is accompanied by delusions and hallucinations (Gelder et al 2005a) (Gelder et al 2005a).
Personality and behavior
The behaviour of a person with mania is characterised by four main factors: increased activity, impulsivity, disinhibition and inflated ideas. The increased activity, often for long periods, leads to physical exhaustion.
People with mania spend excessively and dramatically increase their intake of drugs and alcohol. They become sexually hyperactive and disinhibited. As a result, their behaviour is considered inappropriate by others. It is important to remember that such activities are often out of character for the person and may later cause embarrassment and problems at work and in their social circle.
In appearance the person may wear colourful clothing and too much make-up. When their condition is more severe they may be dishevelled and malodorous. They are often distractible, which leads to them initiating and then leaving unfinished a series of activities. As they become more manic, their behaviour becomes more disorganised and they have trouble completing even the simplest tasks (Gelder et al 2005a) (Gelder et al 2005a).
Mood \sThe person’s mood is elated. They may appear as euphoric, excessively optimistic and may display infectious gaiety. At other times they may be irritable and aggressive. They can be quite labile through the day but there is not the same clear pattern of change in outlook as is associated with depression.
Thinking and speaking
The person’s thoughts are unusually rapid, abundant and varied. Their speech reflects these rapid changes in thoughts and this is described as pressure of speech. As they become more activated, their speech may consist of puns, jokes, rhymes and irrelevancies. At the next level they exhibit looseness of associations between ideas, and the ability to concentrate diminishes. At its most severe, acute manic speech is indistinguishable from the speech of someone with acute schizophrenia.
Most manic clients have delusions—the person thinks their ideas are novel, their opinions profound and their work of outstanding genius. Their delusions often have a religious, persecutory or paranoid flavour. They believe that they are extremely wealthy or powerful and become irritable when their thoughts are challenged.
Hallucinations might occur with mania. Their content is congruent with the person’s fluctuations in mood. For example, the client will hear voices that have religious or persecutory content when they are in a negative mood and praise them excessively when their mood is positive.
When manic, clients have little time for sleep. They may wake very early, feeling energetic, become active