Carrie is passing medications for the morning pill line in a large medium security state prison. One of the women shuffles to the window looking tired and ill. Carrie asks the her “How are you doing?” as she prepares her prescribed medication and the patient says she hasn’t eaten or slept since she got here 3 weeks ago because the others on the unit are so noisy and the food is terrible. Carrie knows that both of those things are true, but she is concerned about how ill this patient is looking and schedules her for Mental Health Clinic later that afternoon. After completing pill line, Carrie lets the mental health nurse know that she is concerned about this patient’s mental state and thinks she should be evaluated for a medical or mental health condition that might be causing her symptoms.

Being incarcerated is depressing in and of itself, but Carrie is wise to have this patient evaluated for something more. There are medical conditions that can lead to lack of appetite and insomnia that need to be ruled out. In addition, this patient might have a mood disorder.

Mood disorders are alterations in emotions that are expressed as depression, mania or both. They interfere with a person’s life, troubling him or her with severe long-term sadness, agitation, or elation. The accompanying guilt, anger, self-doubt leads to altered life activities and relationships. The primary mood disorders are bipolar disorder and major depressive disorder.

Few correctional nurses are surprised to find so many incarcerated patients struggling with depression. This mental health diagnosis is common in the general patient population, but even more so in the inmate population.   According to a 2017 Bureau of Justice report, 24 % of those in prison and 31% of incarcerated individuals in jails reported symptoms of major depression.  Like depression, bipolar disorder is common among the incarcerated patient population, with that same report indicating that more than half of the incarcerated individuals interviewed reported symptoms of mania in the last year. Thus, if you work behind bars, it is likely that you will deal frequently with patients showing symptoms of or being in active treatment for a mood disorder.

Rule Out Medical Conditions First

A constant theme in addressing mental health disorders is the importance of ruling out a medical cause for the symptoms presenting. One study of admissions to a VA psychiatric unit found that about 3% of those admitted were incorrectly diagnosed as having symptoms of mental illness when they were actually suffering from a medical condition. The top misdiagnosed medical condition in this study was hyperglycemia/ diabetes, however many other medical conditions can cause depression-like symptoms, including hypothyroidism, liver disease, and anemia. This study also found that those patients misdiagnosed had incomplete medical histories. It is especially easy to jump right to a mental illness cause (of the symptoms seen) if the patient already has a past history of psychiatric care, but that would be a significant error. Correctional nurses can assist with the accurate diagnosis of a condition by obtaining a full medical history and conducting an appropriate physical assessment, and then accurately and thoroughly documenting their findings. and consulting with a provider. 

KEEP THE PATIENT SAFE: Consider Potential for Self-Harm

Another constant theme in addressing mental health disorders is the importance of considering  the likelihood of patient self-harm. Suicidal ideations should be considered each time a mood disorder is being evaluated. In fact, depression in implicated in more suicides behind bars than any other mental health condition.

Is it Depression or Bipolar?

If your patient presents with depressive symptoms, they could also be indicative of the down side of a bipolar disorder. With this condition, the patient has excessive mood swings between periods of high activity, racing thoughts, and poor impulse control (mania) and periods of intense feelings of loss and hopelessness (depression). It is important, then, to ask a potentially depressed patient if they have also experienced times of manic activity in the past. Other characteristics of bipolar disorder include of the following:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Racing thoughts
• Attention easily drawn to unimportant or irrelevant external stimuli
• Excessive activity such as unrestrained buying sprees, gambling, or foolish investments

Anticipate Treatment Options

Effective treatment for mood disorders combines medication and therapy to reduce symptoms and develop responses to the condition that will return the patient to a normal level of function. Here is a helpful guide about various mental health medications from the National Institute of Mental Health (NIMH).

Medication

Antidepressants are likely to be prescribed for depression, while mood stabilizers are initiated for those with a bipolar condition.

Anti-Depressants: The most common anti-depressant medication categories are tricyclics (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).  Each has a specific side effect profile, but here are common side effects for all classes:

• Slow start:  Most anti-depressants have a slow start up for symptom relief – up to 4 weeks. Counsel patients to persevere through the side effects for depression relief. If there is no response in a month, a medication change may be warranted.
• Dry mouth:  Make sure the patient has access to liquids.
• Sedation:  If sedation is an issue, consider moving the medication to the last dose of the day. SSRIs and SNRIs can cause insomnia. If this occurs, consider moving the medication to the morning dose.
• Nausea:  Try to provide medication near meal time if this is an issue.
• Discontinuation syndrome:  The abrupt discontinuation of most anti-depressants can lead to dizziness, lethargy, headache, and nausea. Therefore, there should be adequate bridging of anti-depressants at intake. Patients newly prescribed these medications need patient education about the importance of therapy continuation.

Mood Stabilizers: Lithium is an often-used mood stabilizing medication for bipolar disorder, although other medications prescribed include atypical antipsychotics such as Olanzapine (Zyprexa), Aripiprazole (Abilify), and Risperidone (Risperdal).  Lithium toxicity is a serious concern for these patients, and lithium levels should be closely monitored through blood work. The medication should be held prior to the draw and the provider should be contacted immediately for levels of above 1.2 mEq/L , although some individuals have exhibited toxicity symptoms at a level of 1.2 mEq/L. Symptoms of toxicity may include:

• Blurred vision
• Headache
• Hand tremors
• Nausea and vomiting
• Severe diarrhea
• Ataxia
• Mental confusion

Elevated Lithium levels can lead to seizures, coma, and cardiovascular collapse. Thus, the monitoring of lithium levels is vital for patient safety.

Therapy

Group and cognitive therapy can be helpful for patients with a mood disorder.  Group therapy can provide a supportive environment to gain perspective on the condition while cognitive therapy can help a patient control the thought distortions and expectations that potentiate disordered moods.

The patient Carrie was concerned about did have an elevated blood glucose and lab results indicated that she was a new onset Type II Diabetic. She was evaluated for suicide potential and obtained a low score on the screening. A mood disorder was ruled out by the psychiatrist when he evaluated the patient at the monthly clinic. She was recommended for enrollment in a patient diabetes support group that was being piloted in the facility.

How do you address mood disorders like depression and bipolar disorder in your setting? Share your thoughts in the comments section of this post.