Partnering With Patients

Chana Engel researches bipolar and other mood disorders in children and adolescents at the Intramural Program of the National Institute of Mental Health.  The first NP to work in the bipolar spectrum disorder section, she serves as a research co-investigator, recruiting and screening patients, evaluating their symptoms, and providing clinical care for inpatients. She previously worked as an instructor at Columbia Nursing teaching Entry to Practice nursing students during their clinical rotation on an inpatient psychiatric unit. In addition, Engel served as a staff nurse in the inpatient psychiatric unit at Payne Whitney Psychiatric clinic, and as a clinical research coordinator for drug and longitudinal hemorrhagic stroke trials in the neurology department at Massachusetts General Hospital. Engel received the Distinguished Alumni Award for nursing practice at the 2015 Alumni Reunion. 

Q: The teenage brain is a work in progress -- the frontal lobe, which controls decision making and risk aversion isn’t fully formed yet. How do you accommodate treatment for adolescents with this in mind?

Knowing that the brain is growing in adolescents is critical because their symptoms may change over time as different areas of the brain, including the frontal lobe, continue to  develop.

Teenagers with mood disorders often feel that their emotions are out of their control. Being ostracized by their peers for their emotional outbursts can be devastating, when they so want to fit in with their peers.  Some strategies that may appear simple can help. These include prescribing an extended release medication that they can take once a day instead of immediate release medications multiple times a day, so they don’t have to leave class to get medication from the school nurse. Another is teaching them to recognize physical changes in their bodies like nausea or feeling warm that may be the first signs they are becoming irritable or anxious.

During my group therapy clinical rotation  at Columbia Nursing, one exercise taught younger children to color in an outline of a body to show where they felt emotions. For example, a child might draw lines coming from their head to indicate a headache when they felt upset. This could prompt them to remember the drawing the next time their head hurt, and ask their teacher if they could be excused to go calm down.

Q: What clinical applications for bipolar spectrum disorders treatment have resulted from your research?

Our group does research with children who have pediatric bipolar disorder and those who have chronic, severe irritability. We have a treatment study that is currently underway for those children with chronic, severe irritability, and I work on longitudinal studies examining what happens to these children over time.   I don’t have “Aha!” moments discovering one perfect intervention, but I have had several insights.

For example, some parents better understand their children’s behavior when they have another relative with a mood disorder. But often, families are baffled by their children’s actions and feel frustrated because they don’t know how to help them. They often feel isolated, and criticized by their own families and others in their communities. These disorders don’t show obvious cues for what is going on as one sees with many physical disabilities or treatments for other childhood illnesses, for example, a child receiving chemotherapy whose hair has fallen out. When a child throws a tantrum in the grocery store, a stranger might tell the parent to exercise more discipline with them. But that person doesn’t understand that the child has an illness that is not that easy to  control.

Q: When is it appropriate to prescribe drugs versus counseling to control adolescent behavior?

We have learned from studies of depression and anxiety disorders that a combination of therapy and drugs works best in most cases. Children cannot get better simply by “trying harder” to not feel their emotions. We see mood and anxiety disorders as brain-based illnesses where medication and the right kind of psychotherapies can offer significant benefits. Often, medication alone isn’t enough. Psychological therapy for younger children, as well as individual, group, and family psychotherapy can benefit older children. Parents given good information and “coached” by their providers on how to work with their children also helps.

Q: Suicide ranks as the 10th leading cause of death in the US.  How can psychiatric NPs and other providers prevent suicide in the inpatient and outpatient settings?

Sometimes lay people avoid asking if someone feels suicidal because they worry that by asking about suicide, it will put the idea in someone’s mind. Well-trained providers in all disciplines who are unafraid to ask if someone feels suicidal are crucial.

Suicidal people often feel ashamed. Empathy is key. As a staff nurse, I would express to our patients that we wouldn’t judge them for having these thoughts, and would support them regardless of what brought them into the hospital.

Meeting patients “where they are” is critical, and it’s something that many nurses excel at. If a provider comes in and says “I’m going to fix this,” to a new patient, it takes control away from the patient. There will be a greater chance of success if providers form a partnership with their patients. I learned how to be upfront with patients as a psychiatric-mental health nurse practitioner student at Columbia Nursing. We were taught to tell patients what to expect when starting a new medication or treatment, provide a timeline of the side effects they may experience, and to ask what side effects were “deal breakers” for them. Especially in adult patients, this could include side effects such as sedation, which could interfere with their ability to safely drive, or metabolic effects including weight gain. Clearly delivering information to patients and partnering with them makes them more likely to stick with treatment, and to feel comfortable telling you if they are having side effects or considering stopping their treatment.

Q: You majored in neuroscience and worked on clinical drug trials to treat stroke patients at your first job. Why did you decide to pursue nursing?

I knew I wanted to work in health care after I finished my first bachelor’s degree in neuroscience, but I wasn’t sure which field. I worked with several remarkable physicians and nurse practitioners during my first job in clinical research. They cared for patients and their families where they might later return home, move to a rehabilitation facility, or in many cases make the choice to provide palliative care. Their job was especially challenging. These patients often struggled with communicating and understanding health care providers.  Newly paralyzed patients were suddenly dependent on others, and families were confronted with making choices they did not expect days before. Those NPs showed so much knowledge and compassion to the most vulnerable patients, and I was inspired to pursue nursing by their example.