15.2 Mood Disorders, Psychosis & Crisis Intervention
Key Takeaways
- Major Depressive Disorder and Bipolar Disorder require rigorous assessment of suicidal risk, mood fluctuations, and somatic complications, with strict monitoring of therapeutic lithium levels (0.6–1.2 mmol/L).
- Schizophrenia and psychotic spectrum disorders demand differentiation between positive symptoms (hallucinations, delusions) and negative symptoms (anhedonia, avolition), paired with vigilant monitoring for antipsychotic adverse effects.
- Clozapine therapy mandates mandatory Absolute Neutrophil Count (ANC) surveillance to detect life-threatening agranulocytosis before dispensing medication in Singapore psychiatric units.
- Acute psychiatric crisis intervention relies on structured ISBAR communication, immediate environmental de-escalation, and protocolized suicide observation tiers (continuous 1:1 vs 15-minute line-of-sight).
15.2 Mood Disorders, Psychosis & Crisis Intervention
The management of mood spectrum conditions, psychotic disorders, and acute psychiatric crises represents a major domain within clinical nursing. Registered Nurses in Singapore must master disease psychopathology, psychopharmacological surveillance, somatic treatments, and rapid crisis intervention protocols. Safe practice demands adherence to Ministry of Health (MOH) clinical practice guidelines, hospital medication safety standards, and strict suicide prevention protocols.
Mood Disorders: Clinical Spectrum & Management
Mood disorders encompass major depressive disorder (MDD) and bipolar spectrum disorders, characterized by severe disruptions in emotional regulation, cognitive functioning, and physical well-being.
Major Depressive Disorder (MDD)
MDD is diagnosed when an individual experiences a depressed mood or anhedonia alongside at least four additional criteria for two weeks: weight changes, insomnia/hypersomnia, psychomotor changes, fatigue, feelings of worthlessness, diminished concentration, and suicidal ideation.
- Nursing Priorities: Assessing suicide risk using C-SSRS, monitoring nutritional intake, promoting sleep hygiene, maintaining structured activity schedules, and monitoring antidepressant response. Antidepressants (SSRIs such as Sertraline, Escitalopram) require 2 to 4 weeks for therapeutic onset; nurses must maintain heightened suicide vigilance as physical energy improves before mood lifts.
- Serotonin Syndrome: A potentially fatal reaction from excessive serotonergic activity. Symptoms include mental status changes (agitation, confusion), neuromuscular hyperactivity (hyperreflexia, clonus, tremors, rigidity), and autonomic instability (hyperthermia, tachycardia, diaphoresis). Treatment requires immediate cessation of serotonergic agents and supportive cooling.
Bipolar Spectrum Disorders
Bipolar I disorder involves at least one manic episode, whereas Bipolar II is characterized by hypomanic episodes and major depressive episodes.
- Mania Clinical Features: Grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, and high-risk impulsive behaviors.
- Nursing Priorities: Ensuring physical safety, maintaining hydration and caloric intake via high-density finger foods, reducing environmental stimuli, establishing clear limits on behavior, and administering mood stabilizers.
Psychotic Spectrum Disorders & Schizophrenia
Schizophrenia is a neurodevelopmental disorder characterized by disruptions in thought, perception, and behavior categorized into positive, negative, and cognitive domains:
- Positive Symptoms: Auditory hallucinations, persecutory or grandiose delusions, thought broadcasting/insertion, catatonia, and disorganized speech.
- Negative Symptoms: Affective flattening, alogia, avolition, anhedonia, and social withdrawal. Negative symptoms are resistant to typical antipsychotics and cause long-term disability.
Therapeutic Communication in Psychosis
- Managing Delusions: Do not validate or debate the delusion. Acknowledge feelings without agreeing with the false belief (e.g., "I understand you feel frightened, but I do not see anyone monitoring you; you are safe here in the ward").
- Managing Hallucinations: Directly inquire about command hallucinations (e.g., "Are the voices telling you to hurt yourself?"). Validate feelings, present reality, and redirect focus toward structured activities.
Psychopharmacology Safeguards & Nursing Responsibilities
Psychotropic medications require vigilant monitoring for therapeutic response, dosing accuracy, and severe adverse drug reactions.
Antipsychotic Agents
- First-Generation (Typical) Antipsychotics (e.g., Haloperidol): Primary D2 antagonists effective for positive symptoms carrying high risks of Extrapyramidal Side Effects (EPS):
- Acute Dystonia: Severe spasms of tongue, neck (torticollis), or eyes (oculogyric crisis). Emergency care: IM/IV Benztropine.
- Akathisia: Subjective motor restlessness and pacing.
- Pseudoparkinsonism: Bradykinesia, rigidity, shuffling gait, tremor.
- Tardive Dyskinesia (TD): Involuntary choreoathetoid movements of facial muscles from long-term treatment.
- Second-Generation (Atypical) Antipsychotics (e.g., Risperidone, Olanzapine, Clozapine): Serotonin-dopamine antagonists with lower EPS risk but significant metabolic side effects (weight gain, dyslipidemia, diabetes).
- Clozapine Protocol in Singapore: Clozapine is indicated for treatment-resistant schizophrenia. It carries a risk of life-threatening Agranulocytosis (severe neutropenia).
- Mandatory ANC Monitoring: Absolute Neutrophil Count (ANC) must be verified prior to initiation and before dispensing. In Singapore practice, ANC is monitored weekly for 18 weeks, biweekly up to 1 year, and monthly thereafter. Clozapine MUST be withheld if ANC drops below $1.5 \times 10^9/\text{L}$. Patients presenting with fever or sore throat require immediate full blood count (FBC) testing.
- Neuroleptic Malignant Syndrome (NMS): A life-threatening emergency associated with antipsychotics. Clinical tetrad: Hyperthermia ($>38.5^\circ\text{C}$), "Lead-pipe" muscle rigidity, Autonomic instability, and Altered mental status. Emergency actions: Hold antipsychotics, notify doctor immediately, initiate cooling, administer IV fluids, and arrange ICU transfer.
Mood Stabilizers: Lithium Carbonate
Lithium is a primary mood stabilizer for Bipolar Disorder with a narrow therapeutic index:
- Therapeutic Range: 0.6 to 1.2 mmol/L for maintenance therapy.
- Lithium Toxicity Levels:
- Mild-Moderate (1.5 - 2.0 mmol/L): Coarse hand tremors, persistent GI upset, muscle weakness, ataxia, confusion.
- Severe ($>2.0\text{ mmol/L}$): Seizures, oliguria/renal failure, coma, cardiovascular collapse.
- Nursing Actions: Ensure adequate fluid ($2-3\text{ L/day}$) and sodium intake (hyponatremia increases lithium reabsorption, causing toxicity). Monitor renal and thyroid function regularly.
Electroconvulsive Therapy (ECT) Nursing Management
Electroconvulsive therapy (ECT) induces a brief generalized seizure via electrical current under general anesthesia for severe depression, catatonia, or mania.
| ECT Phase | Essential Nursing Interventions |
|---|---|
| Pre-ECT | Verify consent, maintain NPO status 6-8 hours, ensure voiding, remove dentures/jewelry, administer Atropine. |
| Intra-ECT | Maintain airway, assist with Methohexital/Propofol and Succinylcholine, place bite block, monitor seizure duration. |
| Post-ECT | Position in recovery position, maintain airway, monitor vitals every 15 mins, reorient patient due to memory loss. |
Psychiatric Crisis & Suicide Management Tiers
Nurses implement protocolized observation levels based on C-SSRS risk stratification:
- Tier 1 (Continuous 1:1 Direct Observation): Patient is within arm's reach of a nurse 24/7. Required for acute high-risk active suicidal intent.
- Tier 2 (Intermittent Checks): Visual observation every 15 minutes at random intervals for moderate suicidal risk.
- Tier 3 (General Ward Surveillance): Standard observation every 30 to 60 minutes for low-risk stabilization patients.
A Registered Nurse is caring for a patient diagnosed with treatment-resistant schizophrenia who has been prescribed Clozapine. Which laboratory parameter must the nurse verify prior to dispensing and administering the scheduled dosage?
A patient receiving Haloperidol develops severe muscle rigidity, a body temperature of 39.8°C, diaphoresis, autonomic instability, and altered mental status. Which life-threatening emergency should the nurse immediately suspect?
What is the targeted therapeutic serum concentration range for a patient receiving long-term Lithium Carbonate maintenance therapy for Bipolar Disorder?