CE Article: An EMS Guide to Depression and Bipolar Disorder

Objectives

• Discuss the anatomy and physiology of depression and bipolar disorders
• Review assessment of symptoms associated with mood disorders
• Discuss treatment options for these patients

Your partner groans after you are dispatched for a 25-year-old female who feels depressed. As you walk to the truck, he asks why someone who is depressed needs an ambulance and what you are supposed to do for them. You think about a podcast you just listened to about how many EMS providers believe that “psych calls” are an abuse of the EMS system. You wonder if those findings would be different if more EMS providers understood how common mood disorders are, how biological changes affect mood and the impact of therapeutic communication by EMS can have.

Introduction

Depression and bipolar disorder are categorized as mood disorders and are frequently associated with calls for EMS. People with depression experience profound sadness, guilt and loss of interest in activities, while people with bipolar disorder experience those symptoms along with periods of high energy, euphoria and irritability. Paramedics may be called for a primary complaint involving a mood disorder, or it may be a co-morbid factor in another medical condition. Mood disorders may also present with physical symptoms that may be difficult to differentiate from a medical problem.

A thorough understanding of depression and bipolar disorder is necessary for paramedics to differentiate medical from psychiatric causes of presenting symptoms, to use therapeutic communication techniques for crisis mitigation and to determine whether a patient is competent to decide on their care. Some EMS services have gone further by implementing programs to improve crisis intervention, refer certain patients directly to mental health facilities instead of emergency departments, and conduct home visits to prevent the need for future 9-1-1 calls.

Anatomy and Physiology

Control of mood is believed to take place in a circuit within the cerebrum. Comprising most of the brain mass, the cerebrum is responsible for judgment, decision-making, and executing functioning. It contains six distinct regions: the cerebral cortex, corpus callosum, basal ganglia, hippocampus and amygdala.

The prefrontal cortex is located within the frontal lobe and is responsible for mood, attention and immune functioning. The hippocampus helps regulate emotions and memory, and is one of the few areas that produce new neurons. The amygdala is also involved with the formation and recall of memories, and the expression of negative emotions.¹ The hippocampus and amygdala are part of the limbic system, which processes emotional information, sets the level of arousal and is involved in motivation. The limbic system can be described as the connection between the “thinking brain” and the “feeling and reacting brain.”²

The functions of each of these regions in the brain are controlled by approximately 100 billion neurons, and neurotransmitters are responsible for communication between them. An electrical impulse is first received at a neuron’s dendrite, which is an antenna-like extension. The impulse then travels down the axon and into the nerve ending, where the neuron is stimulated to release the neurotransmitter into the synapse, which is a tiny space between neurons. The neurotransmitter may then move across the synaptic space and stimulate the dendrites of another neuron by attaching to specialized receptor sites, be reabsorbed through a process known as reuptake, or be broken down by enzymes in the synapse. Neurotransmitters may stimulate a neuron to “fire,” and trigger an electrical impulse, or they may transmit an inhibitory message that stops impulses. Serotonin and norepinephrine are the neurotransmitters most strongly linked to mood, but dopamine and gamma-aminobutyric acid (GABA) receptors are as well.^1,3

Hormones also play a role in mood. During times of stress, the adrenal glands release cortisol into the blood stream, which increases blood sugar, suppresses the immune system and aids the metabolism of fat and protein. High cortisol levels are useful in short-term “fight or flight” situations, however, over time they are associated with depression and anxiety.¹ Estrogen and progesterone are naturally occurring hormones that also affect mood. During pregnancy, levels of both hormones increase up to 50 times above normal, with a sudden drop below normal immediately after pregnancy.¹ Between 80%–85% of women experience mood changes during the first four weeks after pregnancy. These symptoms of postpartum depression (PPD) are often called the “baby blues.” Between 10%–30% of mothers continue to experience them in the following weeks.^1,4 PPD is different than post-partum blues. Postpartum blues are normal and mild. PPD, which is more severe, is not normal. It is a form of clinical depression that typically occurs within four weeks after birth. It may last up to a year.^1,4

Pathophysiology

Depression has been linked to low levels of the neurotransmitters norepinephrine and serotonin. One theory is that the neurotransmitter reuptake mechanism may be too active, and these neurotransmitters are removed from the synapse before they can stimulate another neuron.¹ Another theory states that these symptoms are caused by disruptions in the circuit between the prefrontal cortex, hippocampus, and amygdala, which are lined with serotonin receptors. Scans show lower levels of activity in these areas for people with depression.^1,3 Yet another theory involves glutamatergic dysregulation.⁴

The cause of bipolar disorder is less understood. It has a strong genetic component. This is demonstrated through identical twins, who have a 40% chance of developing bipolar disorder when one twin is diagnosed, compared to 5%–10% of first-degree relatives and 1%–2.5% of the general population.¹ One theory is that although depression is still caused by low levels of serotonin and norepinephrine, the manic episodes are caused by spikes in norepinephrine. Another theory is that irregularities in impulse transmission within neurons cause them to fire either too rapidly, which results in mania, or too slowly, which results in depression.¹ If misdiagnosed as depression, some prescribed medications may trigger a manic episode by increasing levels of serotonin and norepinephrine.⁶

Although a genetic predisposition may be important in providing the biological component of mood disorders, environmental factors can exacerbate or induce the onset of symptoms. Risk factors such as trauma, stress or intense conflict within families can increase the likelihood of development of a mental health disorder where genetic factors are already present.^3,6 Changes in exposure to light and sleep patterns can affect serotonin and cortisol levels, and they may lead to depression. One form of depression is seasonal affective disorder, which causes a change in symptoms from season to season depending on climate and light exposure.

Signs and Symptoms

Mood changes are normal responses to life events and usually do not impair daily functioning. It is expected for one to feel sad after the death of a loved one, or to feel energetic after an accomplishment. A diagnosis of a mood disorder depends on the length and severity of symptoms and how much they interfere with daily activities.

Depression is characterized by feelings of sadness, lack of energy, low self- worth, guilt or loss of interest in activities. It may present with crying spells, a flat affect or angry outbursts. Some people who are depressed may lose their appetite or experience insomnia, while others may overeat or sleep excessively. Physical pain—including headaches, indigestion, dizzy spells, or generalized pain—is also common.^1,3

Extreme cases of depression may have psychotic symptoms, which are a loss of contact with reality. These include delusions, which are ideas without a foundation, or hallucinations, which are the auditory, tactile or visual perception of things that are not actually present.

Another symptom of depression is catatonia, which presents as an inability to move, purposeless motor activity, involuntary repetition of words or phrases, or posturing.^1,3 Catatonia can be difficult, if not impossible, to differentiate from a neurologic condition in the emergency setting.

Bipolar disorder is characterized by fluctuations between periods of depression and manic episodes. Symptoms of the manic phase include feelings of euphoria, high energy and powerful emotions. There may be an inflated self-esteem or grandiosity, and the euphoria is often out of proportion with life events. During an episode, a patient with bipolar disorder who is experiencing a manic episode may report having racing thoughts and a decreased need for sleep.^1,6 Also common is tangential thinking, or rapid speech patterns about several unrelated topics.⁴ A patient experiencing a manic episode may also engage in reckless behavior or direct anger at people perceived as getting in the way of their ambitions. Delusions and hallucinations may occur in extreme forms of mania as well.^1,6

With bipolar disorder, the episodes of depression tend to occur more frequently and last longer than manic ones. Some people experience rapid cycling, which is defined as four or more mood cycles in a year.^1,6 Even with rapid cycling, the transition occurs over days—not minutes or hours. Patients who present in one state are unlikely to transition to the other during the course of care with a paramedic. However, people with bipolar disorder may also have “mixed states” in which they have manic symptoms while feeling depressed.^1,6 These mixed states account for 40% of inpatient admissions for bipolar disorder.¹

Diagnostic Criteria

The American Psychiatric Association publishes a classification of mental disorders in the Diagnostic and Statistical Manual. Its fifth edition was published in 2013, and is referred to as the DSM-V. Diagnoses are based on an objective list of symptoms after evaluation by a mental health professional.

The DSM-V defines a major depressive disorder as five or more symptoms during a two-week period that cause significant distress or impairment. The following are those symptoms:

• Daily depressed mood most of the day;
• Daily diminished interest or pleasure in almost all activities for most of the day;
• Significant weight loss or weight gain or daily increase or decrease in appetite;
• Daily insomnia or hypersomnia;
• Daily psychomotor agitation or retardation;
• Daily fatigue;
• Daily feelings of worthlessness or hopelessness;
• Recurrent thoughts of death or suicide;
• A suicide attempt or plan for death by suicide; and
• No history of a manic or hypomanic episode.¹

Note: Visit the American Association of Suicidology's Recommendations of Reporting on Suicide for more on the discussion of preferred terminology regarding suicide, including the following terms used in this article: "death by suicide" and "suicide completion."

The DSM-V uses the following diagnosis of bipolar disorder in its definition of a manic episode:

• A period of at least one-week of abnormally and persistently elevated, expansive, or irritable mood, and persistently increased activity or energy, for most of the day, nearly every day, causing significant problems
• Presence of at least one of the following symptoms: inflated self-esteem or grandiosity; increased talkativeness, or pressure to keep talking; decreased need for sleep; flight of ideas or racing thoughts; distractibility; increase in goal-directed activity or psychomotor agitation; and excessive involvement in activities that have a high potential for painful consequences, such as overspending, overeating , or promiscuity.¹

The DSM-V contains two types of bipolar disorder. Bipolar I disorder includes a history of a manic episode and symptoms of major depression. Bipolar II disorder also has a history of major depression, but with hypomanic episodes. Hypomania includes the same symptoms as mania, but the distinction is that they are less severe and do not cause significant impairment to daily function.^1,6 Cyclothymic disorder, another diagnosis in the DSM-V, is one in which a person experiences numerous hypomanic symptoms and mild depressive symptoms.¹

On the way to the call you think about the stories you read on the Code Green Campaign’s website from EMS providers who live and work with mood disorders. You wonder if their partners knew how much some of those people were suffering sometimes and if it would change their attitude towards patients with those conditions.

Epidemiology

Major depression is the leading cause of disability in people between ages 15 and 44 in the U.S., and by 2020 is estimated to be the second leading cause of disability in the world.^1,5 As many as two thirds of people with depression do not realize they have it, and nearly 20% of patients with untreated depression ultimately complete suicide.³

Approximately 8% of adults in the U.S. suffer from severe depression in a given year. About 5% suffer a less severe form, and around 19% of adults experience at least one episode of major depression in their life. It is twice as common among women, with 26% of women having at least one episode in their lives, compared with 12% of men.^1,3 People of any age may suffer from depression. The mean age of onset is 32, and it is most common among people in their 40s.^1,5

Depression is also prevalent among people with other medical problems and is associated with a higher mortality rate than non-depressed patients.³ It is experienced by 50% of stroke patients, 30% of cancer patients, 20% of heart attack victims, and 18% of people with diabetes.¹ Depressed patients are also less likely to adhere to treatment regimens for their chronic illnesses. One meta-analysis of studies examining chronic illnesses and depression found that patients with depression were 1.76 times more likely to be non-compliant with their prescribed medication usage.⁷ Another meta-analysis of diabetic patients found a correlation between depression and non-adherence to treatment plans.⁸ Noncompliance with chronic illness management contributes to frequent and preventable EMS and emergency department usage, as well as high healthcare costs.⁹

EMS practitioners are not immune from depression. In 2009, the National Registry of EMTs included an optional, validated survey to assess symptoms of depression, anxiety, and stress for reregistering EMTs and paramedics. It found that 6.8% of reregistering EMS practitioners was depressed. Rates were higher among paramedics than EMTs, and among all practitioners who worked for a county or private EMS service, who worked for services with a moderate call volume, and who had more than 16 years of experience. This was the first study of its kind to address these issues in the U.S. and is an area for further research.¹⁰

For bipolar disorder, 4.7% of people suffer from some form of it during their lifetime.⁵ The prevalence among adults of Bipolar I at any given time is 1%, 1.1% for Bipolar II, and 2.4–4.7% for cyclothymic disorder.⁵ It can be diagnosed at any age after childhood and is most commonly diagnosed in late teens to early adulthood. Bipolar is diagnosed equally among men and women even though women experience more depression.^1,5 The lifetime risk of a completed suicide attempt for patients with bipolar disorder is 17%.⁵ According to the National Mental Health Association, 80% of people with bipolar disorder may be misdiagnosed or not diagnosed at all.¹

You arrive on scene at a well kept suburban residence. Law enforcement has been dispatched, but they are not on scene yet. You are greeted outside of the residence by a man who states that he called 9-1-1. He reports that he is the patient’s co-worker and that they are also dating. He explains that the patient is being treated for depression, has not been feeling well over the past week and that he came to check on her when she did not show up at work. He reported that the patient stated that she could not get out of bed this morning, that she is still in bed now, and that she does not want any help. He is concerned that she may want to harm herself, however, and called 9-1-1 because he did not know what else to do. He states that there are no weapons in the residence, and that no one has been drinking any alcohol or using drugs.

Assessment

The following are the goals of a paramedic assessment for mood disorders:

• Identify safety threats;
• Establish a rapport;
• Rule out medical causes of symptoms;
• Determine whether the patient has any suicidal or homicidal thoughts, and
• Establish the patient’s decision-making capacity.

The safety assessment begins with the initial dispatch—for EMS providers, bystanders and the patient. Law enforcement should be sent along with EMS if any threat of violence is detected during the 9-1-1 call, and should enter the scene before EMS. Even if law enforcement is present, remember that safe situations can escalate into dangerous ones. Although few people with a mood disorder become violent, EMS providers need to be aware of the following few red flag behaviors:

• Increasing agitation;
• Loud speech;
• Threats to harm oneself or someone else;
• Clenched fists;
• Pacing, and
• Threatening gestures.¹¹

One consideration, however, is whether the patient’s anger is concerning their situation or directed at caregivers. Yelling about a situation may be acceptable, because anger is a normal response to potentially negative financial or social consequences associated with hospitalization. A patient with this form of anger may respond to verbal de-escalation. On the other hand, anger or threatening statements directed toward caregivers should be taken seriously and are best managed by law enforcement.¹²

When possible, keep bystanders or family members a safe distance from an agitated patient, and position yourself between the patient and an escape route. Unless retreat is necessary, stay with the patient and attempt to assess them in the room in which they are found. Allowing them to go into a kitchen or bedroom is an opportunity for them to obtain a weapon.

The first few moments of a patient encounter often determine how smoothly the call will go, and it is essential to establish a rapport with the patient. Form a general impression about the patient’s appearance, general health, cleanliness, and living conditions. If possible, position yourself at the patient’s eye level at a 45º angle, without encroaching on their personal space. Your facial expression should convey that you are calm and non-judgmental.⁴

Once you have established scene safety and a rapport with the patient, proceed with the same primary assessment that you would for any medical complaint. Check for airway patency, the effectiveness and work of breathing, and circulation by the presence and rate of a radial pulse, and skin condition. Keep in mind that people with behavioral emergencies often have undiagnosed active medical problems.

If no problems are detected in the primary survey, proceed with a mental status exam (MSE). This is a standard approach used by mental health professionals to objectively assess a patient’s state of mind. It also serves as an organized method for paramedics to detect a medical cause of the patient’s symptoms. Patients with depression and bipolar disorder may present with an altered level of consciousness that may be caused by a problem other than their mood disorder, such as a seizure, cerebrovascular accident (CVA), overdose, hypoglycemia, and sepsis.⁵

Law enforcement arrives a short time later, and you enter the residence with the patient’s boyfriend. No safety threats are found as you scan the residence, and you have planned an egress route from the patient’s bedroom if the situation escalates. The patient is lying in bed, and appears upset that paramedics and police were called. She states that she does not want any help and all she wants is to be left alone to sleep. You kneel down to eye level with the patient, introduce yourself and your partner, and ask her name. You explain that you were called because someone cared about her andyou are only here to help. You ask if she would mind if you asked her some questions and check her vital signs.

After ruling out a medical cause of the symptoms, the MSE provides objective information for caregivers to determine the most appropriate plan of action and to document justification of that action. This includes determining whether the patient has the mental capacity to consent to care or refuse to be transported to the hospital. Objective MSE findings should be discussed with online medical control and law enforcement to help make this decision.

Components of the MSE include assessing the level of consciousness, orientation, activity, speech, thought, memory, affect and mood, and perception. It can be remembered using the mnemonic COASTMAP, which stands for consciousness, orientation, activity, speech, thought, memory, affect/mood, and perception.⁵ Use open-ended questions while performing this exam, such as asking patients how they feel or why they think they feel bad. To assess consciousness, determine whether the patient is alert, confused, requires tactile stimulation for arousal, or is unresponsive to pain. Note the patient’s ability to concentrate during your assessment. Observe whether they are easily distracted or can focus on a conversation. For orientation, ask the year, month, and current location. Look not only for accuracy, but also how long it takes to answer.⁵

Activity is an examination of the patient’s behavior. Are they able to do what you ask, such as sit still in a chair? Do they pace around the room, or are they sitting still without moving at all? For speech, note the rate, volume, and articulation. Is it fast or slow, loud or soft, garbled or slurred? To assess thought, listen to content of the patient speech. Does it make sense in the context of the situation, or is there a flight of ideas or delusion? To assess memory, tell the patient your name when you first introduce yourself, ask if they remember it later. Asking when and what they last ate is also useful to detect a medical cause of their mentation. Like orientation, observe accuracy and how long it takes the patient to answer.⁵

Affect and mood are objecting findings about the patient’s body language. Note their posture and facial expressions, as well as statements they make. Do they appear euphoric or sad, and would it be considered appropriate for the situation? Assessing perception is intended to determine whether the patient is hallucinating. This is evident when the patient makes statements that do not match reality, or broadcasts their thoughts.⁵ Ask the patient if they hear or see things that others cannot hear or see. Patients having hallucinations may also stare at a focused spot in the distance, mutter under their breath, or scratch their limbs.

A mental status exam reveals that she is oriented to person, place, and time, focuses on the person speaking to her, and answers questions clearly. She sits up in bed when you ask her, but appears sad, and says she has not eaten anything for two days. She also says that she stopped taking her medication a week earlier because it made her nauseous, and that she did not feel that it was working anyway. The patient denies feeling like she wants to harm herself or anyone else. She also states that she does not want to go to the hospital because she is afraid of missing more work. You tell her that you understand she does not feel like going to the hospital, but there are people there who can help her feel better, and that people who care about her would worry if she does not go. After about 30 minutes, with some encouragement from her boyfriend, she agrees to go to the hospital. You ask if she would like to go on the stretcher or to walk to the ambulance, and she chooses to walk.

Your partner starts driving while you repeat vital signs, and her boyfriend follows behind. When you finish taking her blood pressure, you ask again if she has ever thought about hurting herself. She then acknowledges that she has hoped that she would not wake up after falling asleep, and wondered if she had enough medication in her pill bottles to do that. She then says that she did not want her boyfriend to know that, and hoped that does not mean she has to be admitted to the hospital. You explain that you don’t know whether she will be admitted or not, but that you do have to report that to the ED staff when you arrive.

A suicide assessment is especially important when called for people with a mood disorder. Remember that asking a patient about suicide will not put thoughts in their head about it.^4,11 Instead, it gives the patient an opening to talk about it, and is something paramedics should be comfortable speaking with patients about.

When possible, a suicide assessment is best done with bystanders outside of hearing distance, conducted either in a separate room or in the ambulance. In addition, open-ended questions should initially be used. Ask about the onset of their symptoms, and if anything changed today. If the patient did not mentioned suicide during another part of the MSE, directly ask them about it. One script to use as a guide is “Some people in your situation feel like hurting themselves. Do you feel like that now?”¹¹ Patients may deny suicidal intent, but also say they felt that way earlier that day or another recent time. This is also important to continue to explore in order to accurately assess safety. If patients do express a current desire to hurt themselves, use close-ended questions to determine whether they have a plan in mind and the means to carry out that plan.

The following generally indicate a more serious threat:

• Detail: The more detailed the suicide plan is, such as describing how they would use a weapon or the dosage of a medication they would take;
• Means: By having the means to carry out the plan, such as possessing a weapon or large quantity of medication, and
• Destructiveness: The more lethal the method is, such as using a firearm compared to taking pills.

The patient goes on to describe how how she has had problems with depression since high school, but that it has never been this bad before. She sees a therapist and has tried three different medications with a psychiatrist, but she feels hopeless that her symptoms will never get better. You nod your head as she speaks, and say that you are sorry she feels so badly. You offer to answer any questions she has about her care, and if there is anything you can do to help her feel better.

Treatment

When EMS is called for symptoms of a mood disorder, treatment should focus on maintaining patient safety, therapeutic communication, and relaying information to the receiving facility. Remember that to the patient, a mental health crisis is a true emergency that they have little control over, and they deserve respect and compassion from the people who arrive to care for them. In some cases, physical or chemical restraint may be required for agitation, or if it is determined that patients must be transported against their will. Long-term treatment is managed by mental health professionals, including psychiatrists, psychologists, social workers, and counselors, through medications and therapy. Many communities have mobile crisis teams that visit mental health clients and can involuntarily commit them to a mental health facility if deemed necessary.

For paramedics, much of the therapeutic benefit for depressed and manic patients is with communication. Speak clearly and slowly, and avoid sounding sarcastic or judgmental.¹² Allowing the patient to talk allows them to process what is bothering them and you to reassess their mental state. Use eye contact, nod occasionally, and paraphrase back what the patient tells you. This shows them that you are listening empathetically. Some patients may not feel like speaking, and paramedics should not feel the need to fill silence during transport.

When verbal de-escalation or negotiation is necessary, one technique is to use “but” statements. Start by paraphrasing something that the patient told you, then say “but,” and direct them back to the goal of the contact. An example is “I understand that you are depressed and just want to stay home, but your family is very worried about you, and want you to get help at the hospital.”¹¹

Agitated patients who do not respond to verbal de-escalation and who require physical restraint may benefit from chemical sedation. Common sedatives administered by paramedics include benzodiazepines and antipsychotics. Benzodiazepines, which include diazepam (Valium), lorazepam (Ativan), and midazolam (Versed), work by stimulating GABA receptors to produce neuronal inhibition. These may be administered intranasally, intramuscularly, or intravenously. Respiratory depression and hypotension are two side effects that must be monitored after administration. Ketamine is also administered by paramedics in some countries.¹³

Some agents more commonly administered in the hospital setting are clonazepam, olanapine, and risperidone. Antipsychotics include haloperidol (Haldol), droperidol, and ziprasidone (Geodon). These cause sedation by inhibiting dopamine receptors. One rare, but potential side effect of these medications is that they may lengthen the QT interval and cause a ventricular dysrhythmia. Therefore, the patient should be placed on the cardiac monitor and have a 12-lead ECG obtained as soon as practical, and be monitored through the duration of contact.

One of the more difficult situations paramedics face is when a patient with a behavioral condition refuses to go to the hospital. Unless a patient is unable to make decisions believed to be in their own best interest, they have the right to refuse care. If, based on objective assessment findings, the patient is believed to be in imminent danger to themselves or others, it is best to get early involvement of law enforcement, online medical control, and/or mobile crisis counseling teams. They can determine whether an emergency petition is necessary, which would allow the patient to be taken against their will for a psychiatric evaluation.¹¹

It is important to accurately communicate findings to the staff at the receiving facility, both verbally and on the patient care report. The patient may share information in the ambulance that they may not repeat, either out of fear of a hospital admission or as a result of poor rapport with the staff. Documentation of a mental status exam should be objective, and include quotations of questions and answers. The hospital may use that information to determine whether the patient requires admission.¹¹

Establishing trust and providing therapeutic communication is an important skill for paramedics to use with psychiatric patients. However, paramedics are not therapists. Attempting to provide therapy is outside their scope of practice and should be done by mental health professionals.¹¹ Active listening is helpful, but providing advice about managing their symptoms can cause harm.

For long-term care, a patient might seek treatment from one of several different clinicians. A psychiatrist is a medical doctor who has also had specialized training in mental health disorders and the neurophysiology of the brain. Psychiatrists typically see individuals for medication evaluation and management and do not do therapy. Appointments are of a shorter variety and focus on finding the appropriate psychotropic medication to treat the symptoms of the disorder. Since there is no permanent cure for mental illness, physicians must focus on finding the best medication with the least number of side effects to help the patient effectively live with their disease. In addition to medication management, psychiatrists are also concerned with a patient’s physical concerns, such as diet, exercise, and maintaining a healthy lifestyle. They may monitor vital signs or order blood work to ensure their patients are physically metabolizing medications as expected.

Antidepressants aim to block the reuptake process in the synapses, enabling norepinephrine or serotonin to stay in synapse longer and bind to a postsynaptic neuron. The most common medications used today are the selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), and escitalopram (Lexapro). These medications are popular because they have fewer side effects than other medications and make overdose difficult.^1,2 Velafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta) selectively block the reuptake of serotonin and norepinephrine. Wellbutrin (buproprion) acts on serotonin, norepinephrine, and dopamine receptors.³

Older medications include the monamine oxidase inhibitors (MAOIs), which inhibit the enzyme that breaks down norepinephrine. These medications include phenelzine (Nardil) and tranylcypromine (Parnate). They are less commonly prescribed because of risk of high blood pressure, and they come with dietary restrictions. Tricyclic antidepressants also block the neurotransmitter reuptake process but have a higher risk of overdoses than other medications^.1

A non-pharmacologic treatment for depression is light therapy. Exposure to bright light at certain periods of the day is believed to suppress the release of melatonin, which can help both seasonal affective disorder and non-seasonal depression.¹⁴

Treatment of bipolar disorder includes a class of medications known as mood stabilizers. The most common mood stabilizer and first-line treatment is lithium. Other mood stabilizing medications are anticonvulsants, which are the same medications used for seizures. These include carbamazepine (Tegretol), valproate (Depakote), and lamotigen (Lamictal). The exact mechanism of action of these medications is unclear. One theory is that they work on impulse transition within the neuron by stimulating neuroprotective protein, and may also affect the sodium/potassium ion transmission within the neuron.^1,5,15

Another class of medications used to treat bipolar disorder are atypical antipsychotics. These were initially developed as a newer class of medications to treat schizophrenia, and include olanzapine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify). These medications work on certain dopamine and serotonin receptors.¹

Patients may see a psychiatrist alone or in conjunction with a therapist for more involved treatment regarding their mood disorder. Often, patients will seek out therapy at the recommendation of their psychiatrist, or may search independently for a therapist. Therapists can come from a variety of backgrounds and education levels, and are typically divided into two primary groups: a doctorate level therapist and a master’s level therapist. Doctorate level therapists are psychologists, who hold a PhD or a PsyD in clinical psychology. There are a number of master’s level therapists with different educational approaches, including clinical social workers, professional counselors of mental health, and pastoral counselors. Typical suffixes for master’s degree therapists may be “LCSW” for licensed clinical social workers, “LPCMH” for licensed professional counselor of mental health or “MA” for Master of Arts. These clinicians do not prescribe medications, but often communicate with a patient’s psychiatrist to coordinate treatment goals.

In addition to long-term care, mobile crisis units are available in many communities for life-threatening mental health incidents. In cases of someone feeling suicidal or homicidal, mobile crisis units are dispatched either by an individual, police department, or paramedics to assess a patient for safety. Units are comprised of trained mental health workers who are familiar with treatment options in their area and how to assess a patient’s safety. In certain cases, mental health workers may seem less intimidating to a patient than police officers or EMS providers, and they can work in conjunction with officers to determine the next treatment option. Depending on services available in a given area, workers may recommend involuntary inpatient treatment, voluntary inpatient treatment, or follow up with such outpatient providers as a therapist, psychiatrist, or partial hospitalization programs.

Some law enforcement and EMS agencies have adopted mental health crisis intervention training. The National Alliance on Mental Illness (NAMI) Crisis Intervention Team program is a 40-hour course that includes identifying specific mental illnesses, learning de-escalation techniques, and getting clinical time with mobile crisis units. It was originally developed for law enforcement to better respond to people in mental health crisis and reduce incarceration rates, and has been used by EMS services to better manage these situations.¹⁶

After reporting what the patient told you to the ED staff, wishing her well, and documenting her statements in your PCR, your partner tells you he does not understand why and ambulance had to be tied up for that patient. You reply that the patient felt comfortable telling you things that she did not feel comfortable telling anyone else, and that the patient’s outcome may have been much different had you not been called. You also state that people call 911 when they don’t know what to do, that pain from mental illness is a real as pain from other medical conditions, and it was in the patient’s best interest to be evaluated in the emergency department.

You go on to explain that behavioral emergencies may be an area for paramedics to specialize. With some additional education and clinical rotations, perhaps paramedics could medically screen patients with psychiatric complaints and direct them to resources that are more appropriate to care for them than an emergency department.

Tips and Tricks

EMS practitioners at all levels receive less training in managing psychological complaints than other medical problems, such as cardiac and respiratory problems. Many EMS practitioners may feel uncomfortable caring for patients with symptoms of mood disorders. Additional educational resources are available, such as local chapters of National Alliance of Mental Illness.

Give patients as many choices as possible, but do not offer one that is not available. If it has been determined that the patient has to go to the hospital for a safety reason, do not ask if they would like to go. However, if there is a choice of hospitals available, ask them which they would prefer to go to. The same principle applies to making promises. Do not make a promise that cannot be kept, such as promising the patient they will not be admitted while encouraging them to be transported. Promises like taking good care of the patient, keeping them safe, and helping them feel comfortable can be kept and should be delivered.

Some helpful comments might include stating why you are with them.

• “I’m here to help you as much as I can.”
• “I’m here to listen.”
• “I’m here to see how we can help you feel better.”

Other tips on how to communicate with a patient with a suspected mood disorder include never telling a patient that you know how they feel; even practitioners who may have experienced symptoms of a mood disorder do not know exactly how another person feels at any given time. Also, do not tell a patient that you can keep their information confidential from other responders because you will likely need to consult with law enforcement, mobile crisis, or a receiving facility. During an assessment, asking questions preceded by a statement that can soften some of the direct questions about their safety, such as: “I am sure this is very hard to talk about, but please tell me. …”

Additionally, telling a patient “everything will be OK,” is counterproductive because you do not know this to be true. If you feel the need to reassure someone in distress, one of the following statements would be better:

• “I will do everything in my power to help you.”
• “Please let me know if I can answer any questions for you.”

Community Paramedics

Some EMS services have adopted additional crisis intervention training to manage patients with psychiatric conditions. These include advanced practice paramedics who direct patients to mental health facilities, and community paramedics who visit patients with mental illnesses to prevent readmission.

Advanced practice paramedics (APP) with Wake County (North Carolina) EMS developed a program to direct patients with a psychiatric complaint directly to a mental healthcare facility instead of an emergency department. Their APP academy included advanced clinical decision-making, pharmacology review, epidemiology of mental health and substance abuse, and the NAMI CIT course. Wake County APPs are automatically dispatched along with an ambulance to all incidents for mental health or substance abuse complaints. Using a screening checklist to rule out a medical cause of psychiatric symptoms, patients who are not agitated or combative can be directed to one of their partner mental health facilities. The patient can be transported to the facility by EMS or law enforcement, and the APP delivers a face-to-face report with staff members at the receiving facility.¹⁷

Wake County (North Carolina) APPs successfully diverted 940 mental health or substance abuse patients between July 2010 and December 2013.³ This significantly increased the amount of appropriate care psychiatric patients received and reduced emergency department (ED) wait times for patients with other complaints. The average ED stay for a mental health patient is 14 hours before they are admitted to state mental health facility or referred to their primary psychiatric provider. In contrast, the average initial evaluation and treatment of patients with chest pain is three hours. Therefore, more than four chest pain patients could be seen in the room occupied by one mental health patient.¹⁸

Another program that provides advanced ALS care is the St. Paul, Minn.-based Allina Health community paramedic (CP) program. In this hospital-based program, plain-clothed CPs conduct home visits to people recently discharged from a psychiatric facility. Approximately 25% of mental health patients discharged from Allina Health return within one month, mostly due to barriers to follow-up care. Sixteen plain-clothed paramedics provide this service in unmarked Ford Escapes to reduce the stigma associated with frequent ambulance and police responses for people in a mental health crisis who pose no safety threat. Allina CPs assess patient compliance with treatment plans and transport patients to appointments—all with the goal of preventing a future 9-1-1 call or hospital admission for a crisis. Because of a shortage of beds at mental health facilities in the region, the CP program saves ambulances unit hours that can be used for other medical problems.¹⁸

In Fort Worth, TX, Medstar Mobile Healthcare’s community paramedic program identified depression and its related substance abuse as one cause of frequent 9-1-1 calls for a small number of patients for exacerbations of chronic conditions. These psychosocial problems cannot be adequately managed in the emergency department, and patients are often admitted or observed only because of concerns about the patient’s ability to care for themselves. Patients who become enrolled in Medstar’s mobile health paramedic program receive an initial 1.5–2 hour assessment from a mobile health paramedic, which includes examining access and need for mental health services.

Mobile health paramedics develop a plan to get patients identified resources, assess compliance with an agreed-on treatment plan, and stay in contact with primary care and mental health providers. From July 2009 to November 2013, 9-1-1 usage among enrollees dropped 86% after graduation from the program. This translated to an estimated average of more than $23,000 saved per enrollee in ambulance and ED charges, and an estimated 14,000 ED bed hours freed.⁹

Conclusion

Depression and bipolar disorder are classified as mood disorders, which have biological causes that may be exacerbated by environmental changes. Together, they are a frequent reason for calls to EMS, both as a mental health crisis and as a contributing factor in medical complaints. EMS care focuses on assessing safety, determining the patient’s decision-making capacity, and providing therapeutic communication. A thorough understanding of mood disorders is needed to effectively perform these tasks and to direct patients to the most appropriate facility.

References

1. Comer RJ. Abnormal psychology. 8th ed. New York: Worth; 2014. p. 223–283.

2. Swenson R. Review of clinical and functional neuroscience; 2006. Dartmouth Medical School. Available from: https://www.dartmouth.edu/~rswenson/NeuroSci/chapter_9.html.

3. Halverson JL, Bhalla RN, Moraille-Bhalla P, Andrew LB. Depression. Mediscape, c1994–2014, [updated 2014 Aug 11]. Available from: emedicine.medscape.com/article/286759-overview.

4. Frye MA, et al. Increased Anterior Cingulate/Medial Prefrontal Cortical Glutamate and Creatine in Bipolar Depression. Neuropsychopharmacology, 2007 Dec;32(12):2490–9.

5. Stratford C. Behavioral emergencies. In: Pollak AN, Elling B, Smith M, editors. Nancy Caroline’s Emergency Care in the Streets. 7th ed. Sudbury: Jones & Bartlett. p. 1369–97.

6. Soref S, McInnes LA. Bipolar Affective Disorder. Medscape, c1994-2014, [updated 2014 Aug 18]. Available from: https://emedicine.medscape.com/article/286342-overview.

7. Grenard JL, et al. Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. Journal of General Internal Medicine, 2011;26(10):1175–82.

8. Gonzalez JS, et al. Depression and diabetes treatment nonadherence a meta-analysis. Diabetes Care, 2008;31(12):2398–2403.

9. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. Trained paramedics provide ongoing support to frequent 911 callers, reducing use of ambulance and emergency department services. Innovations exchange. 2014 January 29.

10. Bentley MA, MacCrawford J, Wilkins JR, Fernandez AR, Studnek JR. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care, 2013;17:330–338.

11. Polk DA, Mitchell JT. Prehospital Behavioral Emergencies and Crisis Response. Sudbury, MA: Jones & Bartlett, 2009.

12. Teitsort K. Verbal Skills. In: EMS Safety: Taking Safety to the Streets Course Manual. National Association of Emergency Medical Technicians, 2011. p. 109–110.

13. Scheppke K, Braghiroli J, Shalaby M, Chait R. Prehospital use of IM Ketamine for sedation of violent and agitated patients. Western Journal of Emergency Medicine; 15(7):736–741.

14. Golden R, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry, 2005; 162:656–662.

15. Frye MA. Bipolar Disorder — A Focus on Depression. N Engl J Med, 2011;364:51–9.

16. National Alliance on Mental Illness. Crisis intervention teams. Available from https://www.nami.org/template.cfm?section=CIT2.

17. Guillaume G, Linder GE, Lyons M, McDougall L, Nayman BD. Taking substance abuse and mental health out of the emergency department. EMS World; January 6, 2014.

18. Serres C. For mental health patients, an unmarked ride to psychiatric care. Star-Tribune, July 16, 2014. 

Bob Sullivan, MS, NRP, teaches with the paramedic program at Delaware Technical Community College in Dover, DE. He has previously worked in municipal, private, and volunteer EMS services, and can be contacted via his blog at EMSPatientPerspective.com.

Shauna Sullivan, LCSW, LLC, is a licensed clinical social worker with more than 10 years experience in the field. An alumna of Bryn Mawr College and the University of Delaware, she has experience in outpatient, intensive outpatient, and inpatient facilities for those challenged by mental illness. Presently, she operates her own private practice in Wilmington, DEC=, where she sees individuals and families for outpatient treatment.