Mood Disorders (Depression & Bipolar)

Definitions

• Mood refers to a person’s feelings, state of mind, or experience with emotions.
• Mood problems refer to difficulty managing or controlling one’s moods or emotions. Two significant mood problems are depression and mania.
• Depression involves feelings of sadness, guilt, hopelessness, or constant fatigue. Warning signs can include withdrawal from others or loss of interest in activities the person would usually enjoy.
• Dysthymia is often described as a chronic, though less severe, form of depression.
• Mania is often described as extreme feelings of excitement, irritability, and racing thoughts. Warning signs can include patterns of impulsivity and a decreased need for sleep.
• Hypomania is often described as a persistent, though less severe, form of mania.
• Mood disorder refers to several disorders characterized by mood problems. These disorders include:
  • Major Depressive Disorder, which involves multiple symptoms of depression, more often than not, for at least two weeks.
  • Postpartum Depression, which is a type of depression a woman can get in the first year after having a baby or, in some cases, after weaning a nursing child.
  • Pervasive Depressive Disorder, which refers to symptoms of dysthymia, more often than not, for at least one year.
  • Seasonal Affective Disorder Syndrome (SADS), which refers to mood problems that occur during certain times of the year (such as during the dark of winter).
  • Bipolar Disorder, which refers to moods alternating between depression and mania, or depression and hypomania, at least once.
  • Cyclothymic Disorder, which refers to a mood alternating between dysthymia and hypomania.

A client who displays some or all of the following signs and symptoms may have a depression disorder:

• Difficulty concentrating, remembering details, and making decisions.
• Fatigue and decreased energy.
• Feeling guilty, worthless, or helpless.
• Feeling hopeless or pessimistic.
• Sleep trouble, including getting too much or too little sleep.
• Irritability and restlessness.
• Loss of interest in former hobbies or favorite activities, including sex.
• Changes in appetite, including eating too much or too little.
• Discomfort, such as headaches or cramps, that doesn't improve with treatment.
• Persistent feelings of anxiousness or emptiness.
• Thoughts of suicide or attempting suicide.

If the client's symptoms of depression are causing problems with relationships, work, school, or family, the client should be referred for a mental health assessment. If the client's issues are or may be co-occuring with a medical condition, see Chapter E-1: Introduction to Overlapping Issues

• Mood problems are common among people who need behavioral health treatment and can be managed in a number of ways, including:
  • Counseling from behavioral health professionals like you, a clinician, or social worker.
  • Support from family, friends, teachers, Elders, and/or spiritual leaders.
  • Traditional medicine or medicine prescribed by a medical provider.
  • Exercise, healthy eating habits, and other self-care.
  • Spiritual practices, like prayer or meditation.
• Mood problems can seriously impact a person’s life and behavior at home, at school, at work, and in the community. They can also impact health and can prevent self-care, leading to health problems. The problems are not always as obvious as substance abuse or psychosis, but can be serious and deserve close attention. In addition, certain health problems can also increase the risk of depression.
  • If you suspect the client's presenting problems are related to substance use, see Chapter D-2: Substance Use and Abuse.
  • For more information on the relationship between mental and physical health, see Chapter E-2: Co-occurring Disorders.
• Medication can be an effective way to treat mood disorders, especially in combination with therapy. Some people with mood problems do not take medication because they are not aware of the option or because they choose not to.
  • For clients or parents of minor clients who do not know about medications, consider making a referral to a medical provider. Help the client or caregiver create and stick to a routine for taking the medication.
  • Because the benefits of medication can be reinforced through non-medical treatments, help clients to address and manage their mood problems during sessions even if they are using medication.
  • For clients who are not using medication, provide them with information about other treatment options. Work with the client and/or caregiver to develop healthy tools for managing moods.
  • Some medications for mood problems have been linked to an increase in depression, mania, or suicidal thoughts and behaviors. For clients with caregivers or involved family members, you can also teach their family to watch for these changes.
• Sometimes, clients' family members, caregivers, and other loved ones do not take their mood problems seriously, thinking they will “just get over it” or that their problems are not real conditions. However, depression is more than sadness or unhappiness and mania is more than excitement or being happy. These are serious problems that involve the body, mind, mood, and thoughts. Help the client to address unhelpful attitudes of family and friends.
• Having depression or another mood problem is similar to having a medical condition like diabetes or high blood pressure. These conditions require treatment and can be treated successfully.
• People who experience mood problems may have difficulty talking about their feelings. Instead, they might act out or withdraw from others.
• Mood problems may increase the risk of self-harm or of thoughts of suicide.
  • See Chapter D-6: Suicidal Thoughts and Plans.
  • See Chapter D-7: Self-Harm and Self-Injury.
• Medical issues and medications can cause mood problems or make them worse because of the way mental and physical issues can overlap with each other. Clients experiencing mood problems should always have a medical evaluation to rule out this possibility.
• Mood problems may happen at the same time as, or in response to, other problems, such as:
  • Trauma.
  • Developmental issues.
  • Substance use.
  • Environment.
  • Separation from loved ones.
  • Family problems.
  • Major life changes.
• Family members, and especially parents and caregivers, of people with mood problems may need extra support and education on how to help their loved ones.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history, including past diagnoses, therapy, hospitalizations, out-of-home placements or any current medications.

Treatment Plan, including a history of the presenting problem and recommended course of treatment. Review the DSM-5 for criteria on mood-related disorders.

General concerns:

• Difficulty concentrating
• Has problems that he has not talked about with others
• Reports aches and pains without another medical explanation
• Difficulty sleeping or excessive need for sleep
• Difficulty relaxing
• Withdrawn from friends and family
• Has a family member who experiences mood problems

Emotions/mood:

• Often bored or feels generally “bored with life”
• Uncharacteristic changes in mood and behavior
• Frequently sad or tearful
• Often angry or irritable
• Loss of interest in things she used to enjoy
• Mood swings alternating between an elevated mood (mania or hypomania) and a depressed mood (depression or dysthymia)
• Has had suicidal thoughts, plans, or attempts

Changes in behavior:

• Sleeps too much or not enough
• Impulsive
• Engages in risky behaviors
• Restless or hyperactive
• Uses or abuses substances
• Has engaged in self-harm
• Significant weight gain or loss since the onset of symptoms

General concerns

• Have you experienced any recent stresses, losses, or major life changes?
• Is there anyone in your family who frequently feels sad or depressed?
• Do you ever feel like you don’t have a lot of energy or are you tired a lot?
• Are there times when you feel you have too much energy and no need for sleep?
• Do you have someone to talk to when you are having a hard time?

Emotions/mood

• How have you been feeling lately?
• How often do you feel sad?
  • Have you ever felt so sad that you had no hope for the future?
  • Have you ever had thoughts of suicide?
  • Have you ever attempted suicide?
• How often do you feel happy?
  • Do you ever feel so happy that your mind begins to race?
  • Do you ever have so much energy that you don’t know what to do?
• Do you ever feel grumpy or really irritable without knowing why?
• Have you ever felt so sad or angry that it was hard for you to do things?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

When working with a client who is experiencing an episode of depression, it can be helpful to have an understanding of their overall level of activity throughout the day. Behavioral Activation is a critical approach to treating depression. This approach helps the client to identify, schedule, and engage in activities that are known to bring out positive feelings. Although many clients who are depressed do not often feel like they have the energy to engage in these activities, once they start gaining momentum, their mood can begin to improve. Also, many people who experience depression have difficulty sleeping (both sleeping too much and/or too little) and can benefit from information on sleep hygiene to promote consistent, restful sleep. Along with Behavioral Activation, you may consider having clients identify and track their automatic negative thoughts or teaching them how to change negative thought processes.

When you are working with a client who has a diagnosis of bipolar disorder or is in the midst of a manic or hypo-manic episode, consult with your supervisor about how to support the client's treatment plan. Because bipolar disorder has a pattern of relapse and recurrence of symptoms over time, it is often a candidate for mood stabilizing medications. This treatment can be very effective in assisting clients; however, it is critical that clients follow and consistently adhere to their medication regimen. Refer clients who are not currently taking medications for this condition to a medical professional or psychiatrist. For clients who have already been prescribed medications for this condition, you can support them via medication management strategies that encourage them to continue taking the medications as they have been prescribed.

It is also very important for people who have bipolar disorder to manage their stress effectively. Stress can trigger manic or hypo-manic episodes. Work with the client to develop a schedule and routine that will reduce psycho-social stressors. Finally, if possible, including family members in sessions to provide education about bipolar disorder will help family members to understand the individual.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.