Point of care: Be a detective, not a judge

Michael C. LaFerney | 01/19/2017

Not everything we call depression is depression.

Image of nurse in clinical setting

Jane, a nurse on the unit, suggests to Tracy, the psychiatric clinical nurse specialist, that she see Bob R. because “he is depressed.” When Tracy finds Bob, she observes he is engaged in activities with other residents. After the activity is over, she tells him, “I’d like to ask you about some symptoms of depression.”

Michael LaFerney“OK,” Bob replies, “but I’m not depressed.” He denies having any issues with appetite, sleep, fatigue, or loss of interest in activities. He denies any suicidal thought, concentration issues, and feelings of guilt or lack of self-esteem. Tracy, perplexed, asks Jane why she said Bob was depressed, and Jane responds, “He looked sad the other day when he was telling me about how he misses his family.”

Jane characterizes her statement as a diagnosis, but it isn’t a valid diagnosis. Rather, it is an expression, a common reaction of caregivers to behaviors they observe once or twice in patients in long-term care settings—observations that lead to unnecessary psychiatric consults and costs. Do we arrive at these conclusions to help our patients, or is it because we lack knowledge about what clinical depression really is?

Defining depression
Sadness can be a symptom of depression, but sadness doesn’t always warrant a diagnosis of depression. There are several types of depression, but a diagnosis of clinical depression requires the presence of several symptoms, and they must be present for a set period of time. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), also known as the DSM-5, is the guide we use in psychiatry to determine what constitutes a mental disorder. For example, a diagnosis of major depression requires 1) that the person feel depressed for a minimum of two weeks and 2) that five symptoms be present. Diagnosis of another type of depression known as persistent depressive disorder, also called dysthymia, requires that the person have symptoms more days than not over a two-year period and that the symptoms are not due to another disorder—for example, bipolar disorder (DSM-5, 2013).

We use a host of lab tests, X-rays, and scans to diagnose medical issues but often quickly diagnose mental health issues based on limited observations. Despite the fact that there are tools, such as Beck’s depression inventory and the Hamilton scale, that can be used if one suspects that a patient is depressed, they are rarely used.

Sometimes, physical symptoms are misdiagnosed as psychological ones. We may label a person “anxious” who is distressed by shortness of breath. We may conclude that a person who constantly uses the call bell has a “personality problem/disorder)” rather than identifying the medical issue that is prompting him or her to call frequently.

It’s a fundamental error—attributing a behavior to a personality trait rather than to the situation that causes it. Patients who yell out might be labeled “psychotic” because we assume they are responding to some internal stimulus, but patients can have a bad day just like the rest of us. Being irritable while interacting with a nurse doesn’t warrant a psychiatric evaluation. A particular behavior five days in row, on the other hand, may require investigation.

Diagnosis in psychiatry can be difficult, but patients deserve a thorough evaluation. We do not want to label a person with a disorder that can be stigmatizing; it must be justified. Just asking for a psychiatric evaluation almost ensures a mental health diagnosis. I remember evaluating a patient very extensively who was recovering from a stroke. Unable to find any mental health issue or abnormal behavior, I submitted as a diagnosis “NO mental disorder.” My paperwork was returned to me, rejected as non-billable. Finding him “normal” wasn’t acceptable. Not paying for evaluations when a mental disorder is not found ensures that a psychiatric disorder will be diagnosed because clinicians expect payment for their work!

How nurses can help
How can nurses aid mental health practitioners in diagnosing a patient’s condition? First, do not make a premature diagnosis and influence the diagnostician by stating the patient is depressed, is psychotic, or has personality problems. The best way is for nurses to accurately describe the behavior and symptoms they observe and record statements the patient makes that may indicate a mental health issue. Using behavioral charting is very helpful. As a psychiatric clinical nurse specialist, I often get a psych consult request that consists of one word—that’s not enough information to indicate why I need to see a patient.

The word behaviors without additional description is not helpful. Behaviors can mean almost anything. Be specific. Describing what is happening and when it is happening can be very important in arriving at the correct diagnosis. For example, “The patient is pulling out his hair” is specific and may lead, after ruling out medical issues and other symptoms, to a diagnosis of trichotillomania.

Timing of behaviors is important. A patient who is aggressive only during hands-on care will require a different treatment plan than someone whose aggression is impulsive and presents at any time of the day. A patient who yells only after his wife’s visit ends will have a different diagnosis than someone who yells in response to voices.

Nurses should familiarize themselves with the DSM-5. It also comes in a pocket edition for quick reference. Educate yourself on the symptoms of mental health disorders common on your unit. If you think a patient has a mental health issue, look it up in the DSM-5 and determine if symptoms relevant to this disorder are present. If they are, help the diagnostician make a more accurate diagnosis by relaying that information. It will be appreciated! Nurses can also become familiar with various short-assessment tools for use with patients. Most are self-reporting and can be easily scored.

Knowing symptoms and behaviors is also helpful in determining whether psychiatric medication is working. Sometimes, staff members will notice changes before a patient does. A patient may report still feeling depressed, but the nurse may notice that he or she is eating better, is up more and sleeping less, and has resumed interest in normal activities. Sharing that information with the patient may reassure the patient that he or she is getting better.

This can only occur, however, if a nurse is aware of the many symptoms that can contribute to an accurate diagnosis and doesn’t unconsciously and prematurely offer a diagnosis based on limited information.

Michael C. LaFerney, PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.

American Psychiatric Association. (2013, May 27). Diagnostic and statistical manual of mental disorders (5th Ed.) Arlington, VA: Author. 


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