Carrie is passing medications for the morning pill line in a large medium security state prison. One of the inmates shuffles to the window looking tired and ill. She asks the inmate “How are you doing?” as she prepares his prescribed medication and he says he can’t eat or sleep since he got here 3 weeks ago because the others on the unit are so noisy and the food is terrible. Carrie knows both those things to be true but she is concerned about how ill this patient is looking and schedules him for Mental Health Clinic later that afternoon. After completing pill line she lets the mental health nurse know that she is concerned about this patient’s mental state and thinks he should be evaluated for a medical or mental health condition that might be causing his symptoms.
Being incarcerated is a downer 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 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 depression.
Few 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 with 20-30% reporting symptoms of major depression according to a Bureau of Justice report. Like depression, bipolar disorder is common among the inmate patient population with that same report indicating that more than half of interviewed inmates reported symptoms of mania in the last year. So, if you work behind bars, it is likely that you will frequently deal with patients showing symptoms of or being in active treatment for a mood disorder.
Rule Out Medical Conditions First
A constant theme in dealing with mental health disorders is to rule out a medical cause for the symptoms. One study of admissions to a VA psychiatric unit found that about 3% of admissions were incorrect diagnoses of symptoms as mental illness that was actually caused by a medical condition. The top misdiagnosed medical condition in this study was hyperglycemia/diabetes, however many other medical conditions can cause depression-like symptoms such as hypothyroidism, liver disease, and anemia. This study also found that these misdiagnoses had incomplete medical histories. It is especially easy to jump right to a mental illness diagnosis if the patient already has a past history of psychiatric care. Correctional nurses can assist with the accurate diagnosis of a condition by obtaining a full medical history along with thorough documentation of subjective and objective assessment findings.
Rule Out Self-Harm
Another constant theme in dealing with mental health disorders is to consider the likelihood of patient self-harm. Suicide ideations should be considered when 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 depression symptoms, it could also be 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 about past seasons of manic activity. For example, any 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 handy guide to 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.
Antidepressants.The most common anti-depressant medication categories are tricyclic (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Each have a specific side effect profile but here are common ones for all classes:
- Slow start: Most antidepressants 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 SRIs can cause insomnia. In this case, 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 antidepressants can lead to dizziness, lethargy, headache, and nausea. Therefore, there should be adequate bridging of antidepressants at intake and patients new to these medications need instruction on the importance of therapy continuation.
Mood Stabilizers. Lithium is still the most popular mood stabilizing medication for a bipolar disorder, although others in use include atypical antipsychotics such as Olanzapine (Zyprexa), Aripiprazole (Abilify), and Risperidone (Risperdal). Lithium toxicity is a real issue for these patients and can be difficult to manage in a jail or prison. Lithium levels should be closely monitored with at least weekly laboratory work. The medication should be held and the provider contacted for levels of 1.5 mEq/L or above. At these levels the following symptoms may be noted:
- Blurred vision
- Ringing ears
- Nausea and vomiting
- Severe diarrhea
- Mental confusion
Lithium levels of 3.5 can lead to seizures, coma, and cardiovascular collapse so monitoring lithium levels is vital for patient safety.
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 inmate Carrie was concerned about did have an elevated blood glucose and is being worked up for Type II Diabetes. He was evaluated for suicide potential and obtained a low score on the screening. A mood disorder was ruled out by the psychiatrist at his monthly clinic and he was entered into an inmate diabetes support group that was being piloted in the facility.
How do you deal with mood disorders like depression and bipolar disorder in your setting? Share your thoughts in the comments section of this post.
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