Anxiety and Mood Disorders
Anxiety and mood disorders are the most common psychiatric conditions you will encounter — not only on the psych unit, but on every med-surg floor, in the ED, in obstetrics, and in the clinic. The patient recovering from a heart attack who cannot sleep for dread, the postpartum mother who feels nothing for her baby, the manic client who has not slept in three days and is booking flights he cannot afford: these are your patients too. Recognizing these disorders, keeping the patient safe (suicide risk is the single highest-stakes assessment in mental health nursing), and using therapeutic communication skillfully are core nursing competencies. This page teaches you to understand the illness, not just memorize drug names.
Learning Objectives
- Differentiate normal stress from pathological anxiety and describe the major anxiety disorders (GAD, panic disorder, phobias, OCD, PTSD).
- Distinguish major depressive disorder (MDD), persistent depressive disorder, and bipolar disorder (types I and II).
- Perform a focused mental status and suicide-risk assessment and prioritize safety interventions.
- Apply therapeutic communication and evidence-based nursing interventions for anxious, depressed, and manic clients.
- Explain the actions, adverse effects, and key teaching points for SSRIs, SNRIs, benzodiazepines, lithium, and mood stabilizers.
- Recognize psychiatric emergencies: serotonin syndrome, lithium toxicity, and acute suicidal crisis.
Quick Answer
Anxiety disorders involve excessive, persistent fear or worry that impairs function; mood disorders involve a sustained disturbance of emotional state — depression (low), mania (elevated), or a swing between them (bipolar). Nursing priorities are always safety first (assess suicide and self-harm risk directly), then a therapeutic, nonjudgmental relationship, structure and routine, and support of medication adherence. First-line drugs for both anxiety and depression are SSRIs, which take 2 to 6 weeks to work; benzodiazepines relieve acute anxiety but carry dependence and sedation risk. Lithium is the classic mood stabilizer for bipolar disorder and requires blood-level monitoring because its therapeutic and toxic ranges nearly overlap. The most dangerous period is often when a severely depressed client begins to improve and regains the energy to act on suicidal thoughts.
Where It Came From
For most of history, melancholia (deep sadness) and mania (frenzied excitement) were described but not connected. Hippocrates (around 400 BCE) attributed melancholia to an excess of "black bile," giving us the word itself — a humoral theory that, though wrong, was an early attempt to see mood as a bodily, treatable condition rather than moral failing or demonic possession.
The modern understanding was shaped by a real clinical need: to predict who would recover, who would relapse, and how to treat them. In the late 1800s the German psychiatrist Emil Kraepelin studied the long-term course of thousands of patients and drew a distinction that still organizes psychiatry — separating "manic-depressive insanity" (episodic, with recovery between episodes — what we now call bipolar and recurrent mood disorders) from "dementia praecox" (progressive deterioration — later renamed schizophrenia). This was classification driven by prognosis, not theory.
The need for a shared language so clinicians, researchers, and insurers could agree on what a diagnosis meant produced the DSM (Diagnostic and Statistical Manual, first edition 1952; the current DSM-5-TR, 2022) and the WHO's ICD. A landmark change came in DSM-III (1980), which added explicit, checklist-style criteria to make diagnosis reliable, and formally separated "bipolar disorder" from "unipolar" major depression — a split that matters enormously for nursing, because giving an antidepressant alone to a bipolar client can trigger mania. On the treatment side, the accidental discoveries of lithium's calming effect (John Cade, Australia, 1949) and of the first antidepressants in the 1950s transformed these from lifelong custodial conditions into manageable illnesses. Nightingale-era nursing had emphasized environment, rest, and observation — principles that survive in today's milieu therapy and the nurse's role as the constant, watchful presence on the unit.
Understanding Anxiety Disorders
Anxiety becomes a disorder when it is out of proportion to the threat, persists beyond the trigger, and impairs functioning. Physiologically it is the fight-or-flight response misfiring — sympathetic activation driving tachycardia, sweating, tremor, chest tightness, and a sense of dread. Neurochemically, dysregulation of GABA (the brain's main inhibitory, "calming" transmitter) and serotonin is central, which is why SSRIs and GABA-enhancing benzodiazepines both help.
Peplau described levels of anxiety, a framework nurses use to match intervention to severity:
- Mild — heightened alertness; learning is enhanced. Normal and useful.
- Moderate — narrowed perceptual field; can still be redirected. Selective inattention.
- Severe — greatly reduced perception; focuses on scattered details; needs firm direction.
- Panic — loss of rational thought, possible loss of control, feeling of impending doom. Safety is the priority; the client cannot learn or problem-solve.
Key anxiety disorders: Generalized anxiety disorder (GAD) — uncontrollable worry most days for 6+ months. Panic disorder — recurrent, abrupt panic attacks with fear of the next one. Phobias — specific, social, or agoraphobia. Obsessive-compulsive disorder (OCD) — intrusive obsessions relieved temporarily by compulsive rituals. Post-traumatic stress disorder (PTSD) — re-experiencing, avoidance, hyperarousal after trauma.
Mnemonic for a panic attack — "STUDENTS FEAR the 3 C's" is one option; simpler is to remember the four "cardinal" clinical features: palpitations, dyspnea, dizziness, and depersonalization/fear of dying. During panic, stay with the client, use short simple sentences, a calm low voice, and guide slow breathing.
Nursing considerations for the anxious client
- Do not flood a severe/panic-level client with choices or explanations — they cannot process them.
- Remain calm; anxiety is contagious, and so is composure.
- Teach anxiety-reduction skills (deep breathing, grounding, progressive muscle relaxation) when the client is at a mild-to-moderate level and can learn.
- Cognitive behavioral therapy (CBT) and, for phobias/PTSD, gradual exposure are first-line psychotherapies.
Understanding Depression and Bipolar Disorder
Major depressive disorder requires 2+ weeks of depressed mood or anhedonia plus additional symptoms. Use the classic screening mnemonic SIG E CAPS:
- Sleep changes (insomnia or hypersomnia)
- Interest loss (anhedonia)
- Guilt/worthlessness
- Energy loss/fatigue
- Concentration difficulty
- Appetite/weight change
- Psychomotor agitation or retardation
- Suicidal ideation
Note that in older adults depression may present as memory complaints ("pseudodementia") and in men or adolescents as irritability rather than sadness. Postpartum depression is a critical variant to screen for.
Bipolar disorder is defined by episodes of elevated mood. Bipolar I requires at least one full manic episode (a distinct period of elevated/irritable mood plus increased energy for 1+ week, or any duration if hospitalization is needed). Bipolar II involves hypomania (milder, no marked functional impairment or psychosis) plus major depressive episodes. Mania mnemonic DIG FAST: Distractibility, Indiscretion (risk-taking), Grandiosity, Flight of ideas, Activity increase, Sleep decrease (little need), Talkativeness (pressured speech).
The nursing takeaway that saves lives on the exam and the unit: a client presenting with depression may actually have undiagnosed bipolar disorder, and an antidepressant alone can precipitate a manic switch. Always screen for a history of manic/hypomanic episodes.
Case vignette
A 42-year-old woman is admitted after three sleepless nights spent redecorating her house at 3 a.m., spending $8,000 on furniture, and speaking so rapidly her family cannot interrupt. She is euphoric, then abruptly irritable. Nursing priorities: reduce environmental stimulation (quiet, low-lit area), set firm consistent limits without arguing, provide high-calorie finger foods she can eat while pacing (she will not sit for a meal), protect her from exhaustion and from consequential decisions, and monitor for the safety of self and others. This is acute mania — a psychiatric emergency of exhaustion and poor judgment.
Suicide Risk: The Nurse's Non-Negotiable Assessment
Suicide risk assessment is the highest priority in mood disorder nursing. Ask directly — asking about suicide does NOT plant the idea; it is protective and opens the door. Assess ideation, plan, means, and intent (a specific plan with available lethal means is high risk). Use the acronym SAD PERSONS or your facility's tool.
- Institute suicide precautions per protocol: remove means (belts, cords, sharps), close/constant observation, and a no-suicide/safety plan.
- Watch the "improvement" window: a severely depressed, psychomotor-retarded client is at heightened risk as energy returns before mood fully lifts — they now have the drive to act.
- A sudden calm, giving away possessions, or "putting affairs in order" can signal a decision has been made. Escalate immediately.
- Contracts for safety are not a substitute for observation and clinical judgment.
Psychopharmacology Essentials
- SSRIs (sertraline, fluoxetine, escitalopram) — first-line for both depression and anxiety. Teach: full effect takes 4 to 6 weeks; do not stop abruptly (discontinuation syndrome); watch for increased suicidal ideation in the first weeks, especially in those under 25 (black-box warning).
- SNRIs (venlafaxine, duloxetine) — similar profile; can raise blood pressure.
- Serotonin syndrome — a medical emergency from serotonin excess (often SSRI plus another serotonergic drug, e.g., an MAOI, triptan, or St. John's wort). Signs: hyperthermia, agitation, tremor, muscle rigidity/clonus, autonomic instability. Stop the drug and get help.
- Benzodiazepines (lorazepam, alprazolam) — fast relief of acute anxiety; risk of sedation, falls, dependence, and dangerous CNS depression with alcohol. For short-term use.
- Lithium — gold-standard mood stabilizer. Narrow therapeutic index: maintenance level to mEq/L; toxicity above mEq/L. Teach consistent salt and fluid intake (dehydration and low sodium raise lithium levels), regular blood monitoring, and early toxicity signs: coarse tremor, GI upset, confusion, ataxia, slurred speech. Not used in pregnancy without careful risk assessment.
- Anticonvulsant mood stabilizers (valproate, lamotrigine, carbamazepine) — valproate needs liver and platelet monitoring; lamotrigine carries a risk of Stevens-Johnson syndrome (report any rash).
All medication management requires a provider's order; nurses administer, monitor, teach, and report — and use professional judgment to hold and question unsafe orders.
Real-World Applications
Anxiety and mood screening belong far beyond psychiatry. Nurses routinely use the PHQ-9 for depression and GAD-7 for anxiety in primary care, and screen every postpartum patient for depression before discharge. On med-surg units, untreated anxiety worsens pain perception and delays recovery; recognizing a panic attack prevents an unnecessary cardiac workup — or, just as important, prevents dismissing a real MI as "just anxiety." In the ED, every overdose and self-harm presentation demands a suicide risk assessment. Understanding lithium and salt balance lets you catch toxicity in a bipolar patient admitted for gastroenteritis, where fluid loss can push levels into the toxic range.
Common Mistakes
- "Don't ask about suicide — you might give them the idea." This is false and dangerous. Direct, compassionate questioning reduces risk and is the standard of care. Correction: ask openly about ideation, plan, means, and intent.
- Treating apparent depression with an antidepressant without screening for bipolar disorder. An SSRI given to an undiagnosed bipolar client can trigger a manic switch. Correction: always ask about past manic/hypomanic episodes before assuming unipolar depression.
- Telling an anxious or depressed client to "just relax" or "look on the bright side," or offering false reassurance ("everything will be fine"). This is non-therapeutic, minimizes their experience, and shuts down communication. Correction: use open-ended statements, reflection, and silence; acknowledge feelings ("This sounds really hard").
- Assuming a client who suddenly seems better is out of danger. Improving energy in depression can precede a suicide attempt. Correction: maintain precautions and heightened observation during early recovery.
- Overlooking lithium toxicity in a dehydrated patient. Low sodium and fluid loss concentrate lithium. Correction: teach steady hydration/salt intake and monitor levels, especially during illness, diuretic use, or heat.
Comparison and Connections
| Feature | Anxiety Disorders | Major Depression (unipolar) | Bipolar Disorder |
|---|---|---|---|
| Core disturbance | Excessive fear/worry | Persistent low mood/anhedonia | Mood episodes: mania and depression |
| Key transmitters | GABA, serotonin | Serotonin, norepinephrine, dopamine | Complex; dysregulation across systems |
| First-line meds | SSRIs; benzodiazepines (short-term) | SSRIs/SNRIs | Mood stabilizers (lithium, valproate, lamotrigine) |
| Antidepressant alone | Helpful | Helpful | Risky — may induce mania |
| Top nursing priority | Reduce anxiety; safety in panic | Suicide risk; hope | Safety, limit-setting, prevent exhaustion |
Depression and anxiety very frequently co-occur, and both share serotonin involvement — which is why one drug class treats both. Distinguish situational grief (a normal response to loss, mood reactive to circumstances) from major depression (pervasive, with worthlessness and impaired function). See also therapeutic communication and the therapeutic milieu in Fundamentals of Nursing and neurotransmitter pharmacology in Pharmacology for Nurses.
Practice Questions
Recall
Q: What is the maintenance therapeutic serum range for lithium? A: Approximately to mEq/L. Rationale: Levels above mEq/L indicate toxicity; lithium's narrow index mandates routine monitoring.
Understanding
Q: Why must a nurse screen for a history of mania before an antidepressant is started for depressive symptoms? A: Because the client may have bipolar disorder, and an antidepressant given without a mood stabilizer can precipitate a manic episode. Rationale: Unipolar and bipolar depression look similar but are treated differently.
Application
Q: A client experiencing a panic attack is pacing, hyperventilating, and cannot follow instructions. What is the nurse's best initial action? A: Stay with the client, remain calm, and use short, simple directions while guiding slow breathing. Rationale: In panic-level anxiety the client cannot process complex information; presence and safety come first, teaching comes later.
Analysis
Q: A severely depressed client who has been withdrawn and immobile for a week suddenly appears brighter, is more energetic, and gives a peer a treasured watch. What does the nurse conclude and do? A: This may signal increased suicide risk, not recovery — the client now has energy to act, and giving away possessions can indicate a decision to die. Maintain/heighten suicide precautions, notify the provider, and assess directly for a plan. Rationale: The early-improvement window is a classic high-risk period.
FAQ
How long do antidepressants take to work? Physical symptoms (sleep, appetite, energy) may improve in 1 to 2 weeks, but full mood improvement typically takes 4 to 6 weeks. Clients must not stop early because "it isn't working."
Are benzodiazepines a good long-term anxiety treatment? No. They work fast for acute anxiety but cause tolerance, dependence, sedation, and fall risk. SSRIs plus CBT are preferred for ongoing management.
Is it safe to ask a patient directly if they are thinking about suicide? Yes — it is essential and protective. It does not increase risk; it allows the patient to talk and lets you plan for safety.
Why does someone with bipolar disorder need to keep taking medication when they feel fine? Mood stabilizers prevent relapse of both mania and depression. Stopping during a "good" phase is a leading cause of recurrence and hospitalization.
What is the difference between feeling sad and clinical depression? Sadness is temporary and tied to a cause; depression is a pervasive 2+ week disturbance with anhedonia, worthlessness, changes in sleep/appetite/energy, and often suicidal thoughts, causing functional impairment.
Quick Revision
- Anxiety levels: mild (learning enhanced) → moderate → severe → panic (safety only).
- Depression screen: SIG E CAPS; mania screen: DIG FAST.
- Safety first: assess suicide ideation, plan, means, intent — ask directly.
- Highest-risk window: energy returning early in depression recovery.
- SSRIs: first-line, 4 to 6 weeks, taper (no abrupt stop), black-box suicidality warning under 25.
- Serotonin syndrome: hyperthermia, rigidity, clonus, autonomic instability — emergency.
- Lithium therapeutic to mEq/L; toxic above ; keep salt/fluids steady; watch tremor, ataxia, confusion.
- Never give an antidepressant alone to a bipolar client — risk of manic switch.
- Acute mania nursing: low stimulation, firm limits, finger foods, prevent exhaustion.