Establish the Patient’s Decision-Making Capacity and Paramedic

A mood disorder can be characterized by an “overall depressed mood, an elevated mood leading to mania, and hypomania and will “vary in intensity and severity.” Christina Gregory, PhD. Defines these characteristics as feelings of negativity, cognitive, mood, sleep, behavioral, whole body, weight effects, feelings of apathy, general discontent, loss of interest in things that use to be pleasurable, mood swings, overall sadness, thoughts of suicide, problems sleeping, feel excessively irritable, socially isolated and restless, often affects weight, whether by losing weight or feel overly hungry and put on excess weight. Mania presents as a high level of energy and seeming to be in an extremely good mood. A person will have feelings of euphoria with symptoms such as rapid or excessive talking, sleeping much less than normal, being easily distracted, making poor decisions and acting impulsively with these symptoms lasting for three days or more. 

17% of the U. S. population suffers from depression over the course of their lifetime. Bi-Polar disorder has a much lower impact at only 1%. The population most at risk are “children, teens, or adults who have a parent with a mood disorder.” Many feel sad or depressed but major life events can expose or worsen these feelings of sadness or depression. Women have almost twice the risk of developing depression than men.

A diagnosis for a mood disorder is obtained by having a “complete medical history and psychiatric evaluation” done by a psychiatrist or another mental health provider. There is no prevention but seeking treatment after an early diagnosis can lessen the “severity of symptoms, enhance a person's normal growth and development and improve their quality of life of people with mood disorders.” Mood disorders include Bi-polar disorder, major depression, mood disorders related to health conditions, dysthymia and mood disorder induced by substances.

As a Paramedic it is important to understand and recognize the signs and symptoms of mood disorders. Differentiating this from a physical cause of symptoms will lead to a safer and more successful outcome. Age needs to be taken into consideration as children have unique and special features that separate them from older patients.4 Such as “psychomotor retardation is rare among depressive children” and are more likely to have “auditory hallucinations and somatic issues are seen more in prepubertal children.”4 Children are unable to express their feelings, making a mood disorder diagnosis much more difficult.

The patient and law enforcement also play a key role in the initial dispatch. If there is any suspected threat of violence during the 911 call, law enforcement should be dispatched with EMS.4 Some actions paramedic should be aware of are increasing agitation, loud speech, threats toharm oneself or someone else, clenched fist, pacing, and/or threatening gestures.4 While a screaming or raised voice about the situation may be acceptable, anger directed toward EMS providers should be handled by law enforcement.

If a patient is extremely agitated, the use of physical restraints or chemical restraints may be necessary. Common chemical sedation medications are Benzodiazepines and Antipsychotics such as Valium, Ativan, Versed and are administered either intranasally, intramuscularly, or intravenously. Sedatives used in hospital settings are more commonly Clonazepam, Olanapine, Risperidone and antipsychotics such as Haldol, Droperidol, or Geodan.

Medication used for mood disorders are called mood stabilizers. Lithium being the most common early treatment. Carbamazepine, Valproate and Lamotigen are anticonvulsants that are also used in the treatment of mood disorders. These work on the “impulse transition within the neuron.” Atypical Antipsychotics such as Olanzapine, Quetiapine and Aripiprazde work on dopamine and serotonin receptors. Medications for mood disorders are typically taken daily with the initial few months are to relieve symptoms and possibly make depression go away.

Medication is then taken for an additional four to nine months or longer to prevent re-lapse.While there is no physical dependence to these medications, they can have a host of side effects. These include nausea, temporary sleep problems and restlessness. It is not uncommon to try multiple medications before finding one that works. A serious side effect is teens consider suicide and attempt to take their own lives more often when taking SSRI’s or SSNRI’s.

Medication is a good start, but therapy is as important. There is doctorate level therapist such as psychologist and master level therapist such as clinical social workers and professional counselors. None of which can prescribe medication but will work in tandem with a psychiatrist. Therapy has few physiological side-effects and can be effective for patients who haven't responded to medications. Therapy does take longer than drug therapy ad it is not usually effective without the use of medication in people with bi-polar or severe depression. 

Long term treatment also depends on the financial resources of the patient. Will health insurance pay for treatment, is there even health insurance? Are there resources for help close to where the patient lives? It is vital to have services available and those services attainable to ensure long term success. While vitals and blood work will be monitored to make sure the patient is physically metabolizing the medications, it is important that the patient work on their own treatment. Diet, exercise, and maintaining a healthy lifestyle as well as not having unrealistic expectations or an unwillingness to respond to therapy is required.

The first few moments on scene will determine how smoothly the call will go. Some helpful tips are to remember not to invade the patient's personal space and to get down to their eye level, as well as maintaining a calm and nonjudgmental facial expression. To improve crisis intervention and free up wait times in emergency rooms, some EMS services have implemented programs for paramedics to have an Assessment Plan in place. Mobile health paramedics help reduce 911 usage among enrolled patients by 86%.7 They are in contact with primary care and mental health providers and help patients with resources, compliance and maintain their treatment plan,

Paramedics will be able to help patients become successful or remain compliant by being better trained in mood disorders, Statements such as “I’m here to help you as much as I can”, “I’m here to listen.” Ask questions such as “I am sure this is hard to talk about, but please tell me...” It is important to remember paramedics are not therapist and cannot prevent mental health calls. They can help with the severity of symptoms, the quality of care they receive, and help ensure the safety of both the community and EMS.