INTRODUCTION TO MENTAL HEALTH AND FOUNDATIONS OF MENTAL HEALTH & MENTAL ILLNESS

The World Health Organization

• defines health as a state of complete physical, mental, and social wellness, not merely absence of disease or infirmity.

• This definition emphasizes health as a positive state of well-being, not just absence of disease.

Mental Health

is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.

Autonomy and Independence

• The person can look within for guiding values and rules by which to live.

• He or she considers the opinions and wishes of others but does not allow them to dictate decisions and behavior.

The person who is autonomous and independent can work interdependently or cooperative with others without losing his or her autonomy.

Maximization of one's potential

• The person is oriented toward growth and self-actualization.

He or she is not content with status quo and continually strives to grow as a person.

Tolerance of life's uncertainties

The person can face the challenges of day-to-day living with hope and a positive outlook despite not knowing what lies ahead.

Self-esteem

The person has a realistic awareness of his or her abilities and limitations.

Mastery of the environment

The person can deal with and influence the environment in a capable, competent, and creative manner

Reality Orientation

The person can distinguish the real world from a dream, fact from fantasy, and act accordingly.

Stress Management

• The person can tolerate life stresses, appropriately handle anxiety or grief, and experience failure without devastation.

He or she uses support from family and friends to cope with crises, knowing that the stress will not last forever.

Individual Factors, Interpersonal Factors, and Sociocultural Factors

FACTORS INFLUENCING A PERSON'S MENTAL HEALTH

Individual Factors

include a person's biological makeup, sense of harmony in life, emotional resilience or hardiness, spirituality, and positive identity (Seaward, 1997)

Interpersonal Factors

include effective communication, ability to help others, intimacy, and a balance of separateness and connection.

Sociocultural Factors

include a sense of community, access to adequate resources, intolerance of violence, and support of diversity among people.

Mental Illness

The American Psychiatric Association (APA, 2000) defines it as a "clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, disability, pain, loss of freedom"

Individual Factors, Interpersonal Factors, and Sociocultural Factors

FACTORS INFLUENCING A PERSON'S MENTAL ILLNESS CAN BE VIEWED

Individual Factors

include a person's biological makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in one's life (Seaward, 1997)

Interpersonal Factors

include effective communication, excessive dependency or withdrawal from relationships, and loss of emotional control.

Sociocultural Factors

include lack of sources, violence, homelessness, poverty, and discrimination such as racism, classism, ageism, and sexism.

The Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-IV-TR)

now in its fourth edition, is a taxonomy published by the APA. Describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research.

To provide a standardized nomenclature and language for all mental health professionals

The DSM-IV-TR Purpose (1)

To present defining characteristics or symptoms that differentiate specific diagnoses.

The DSM-IV-TR Purpose (2)

To assist in identifying the underlying causes of disorders

The DSM-IV-TR Purpose (3)

Multi-Axial Classification System

involves assessment on several axes, or domains of information, allows the practitioner to identify all the factor that relate to a person’s condition:

Axis I

• is for identifying all major psychiatric disorders except mental retardation and personality disorders.

Examples include depression, schizophrenia, anxiety, and substance-related disorders.

Axis II

is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.

Axis III

is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person.

Axis IV

• is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders.

• Included are problems with primary support group, social environments, education, occupation, housing, economics, access to health care, and legal system.

Axis V

presents a Global Assessment of Functioning (GAF), which rates the person’s overall psychological functioning on a scale of 0 to 100.

Ancient Times

• People during this era believed that any sickness indicated displeasure of gods and in fact was punishment for sins and wrongdoing.

• Those with mental disorders were viewed as being either divine or demonic depending on their behavior

Later Aristotle (9382-322 BC)

• Aristotle attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions.

• These four substances or humors, corresponded with happiness, calmness, anger, and sadness.

In Early Christian Times (1-1000 AD)

• primitive beliefs an superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed.

• When the priests failed in exorcisms, they used more severe measures such as incarceration in dungeons, flogging, starving, and other brutal treatments.

The Renaissance (1300-1600)

• people with mental illness were distinguished from criminals in England

• Those considered harmless were allowed to wander the countryside or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984).

Continuation of Renaissance

• The Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind.

• By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates who were seen as animals, less than human (McMillan, 1997).

Period of Enlightenment and Creation of Mental Institutions

In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995).

Sigmund Freud, Emil Kraepelin, and Eugene Bleuler

The period of scientific study and treatment of mental disorders began with

Sigmund Freud

challenged society to view human beings objectively

Emil Kraepelin

began classifying mental disorders according to their symptoms

Eugene Bleuler

coined the term “schizophrenia”.

Development of Psychopharmacology

• A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs (drugs used to treat mental illness).

• For the first time, drugs actually reduced agitation, psychotic thinking, and depression.

Move toward community mental health

The movement toward treating those with mental illness ion less restrictive environments gained momentum in 1963 with the enactment of the Community Mental Health Centers Act.

Deinstitutionalization

a deliberate shift from institutional care in state hospitals to community facilities, began.

Mental Illness in the 21st Century

• The Department of Health and Human Services (2002) estimates that 56 million Americans have a diagnosable mental illness.

• Mental illnesses or serious emotional disturbances impair daily activities for an estimated 10 million adults and 4 million children and adolescents.

Major Depression, Bipolar Disorder, Schizophrenia and Obsessive-Compulsive Disorder

• Four of the ten leading causes of disability in the US and other developed countries are mental disorders

• Yet, only one in four adults and one in five children and adolescents in need of mental health services get the care they need.

Negative and Positive

Some believe that deinstitutionalization has had _____ as well as _____ effects (Torrey, 1997).

Deinstitutionalization

• reduced the number of public hospital beds by 80%, the number of admissions to those beds correspondingly increased by 90% (Appleby & Desai, 1993).

• led to severe and persistent mental illnesses have shorter hospital stays, they are admitted to hospitals more frequently.

• Shorter hospital stays further complicate frequent, repeated hospital admissions. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized.

Decompensation and Rehospitalization.

• People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. The result frequently is _ and _

Dual

Many people have a ___ problem of both severe mental illness and substance abuse.

Dual Problem

exacerbates symptoms of mental illness, again making rehospitalization more likely.

Substance abuse issues

cannot be dealt with in the 3 to 5 days typical for admissions in the current managed care environment.

4 to 8, 1000

__ to __ percent of clients seen in psychiatric emergency rooms are armed (Ries, 1997), and people with severe and persistent metal illness who are not receiving adequate care commit about __ homicides per year (Torrey, 1997).

Homelessness

• a major problem in the US today. The Department of Health and Human Services (2002) estimates that 750,000 people live and sleep in the streets.

• Estimates of the prevalence of mental illness among them are: one-third of adult homeless persons have a serious mental illness and more than one-half also have substance abuse problems (DHHS, 2002).

Homelessness

worsens psychiatric problems for many people with mental illness who end up on the streets, which contributes to a vicious cycle.

Cause of homelessness

• This clearly stemmed from the lack of adequate community resources.

• Money saved by states when state hospitals were closed has not been transferred to community programs and support.

Inpatient psychiatric treatment

• still accounts for most of the spending of mental health in US, so community mental health has never been given the financial base it needs to be effective.

• Mental health services provided in the community must be individualized, available, and culturally relevant to be effective (Lamb & Bachrach, 2001).

Funded Access to Community Care and Effective Services and Support (ACCESS)

• Improve access to comprehensive services across a continuum of care;

• Reduce duplication and cost of services;

• Improve the efficiency of services.

Objectives for the future

• Unfortunately, only one in four affected adults and one in five children and adolescents recieve treatment (DHHS, 2002).

• Statistics like these underlie the Healthy People 2010 objectives for mental health proposed by the US Department of Health and Human Services

• These objectives, originally developed as Healthy People 2000, were revised in January 2000 to increase the number of people who are identified, diagnosed, treated, and helped to live healthier lives.

• It also strives to decrease rates of suicide and homelessness, to increase employment among those with serious mental illness, and to provide more services for both juveniles and adults who are incarcerated and have mental health problems.

Community-based care

• By 1990, only 1,300 programs provided various types of psychosocial rehabilitation services.

• People with severe and persistent mental illness were either ignored or underserved by the CMHCs (International Association of Psychosocial Rehabilitazion Services, 1990).

• Community support services programs were developed to meet the needs of persons with mental illness outside the walls of institution.

• These programs focus on rehabilitation, vocational needs, education, and socialization, as well as management of symptoms and medication.

Community-based care

• Unfortunately, the community-based system did not accurately anticipate the extent of the needs of people with severe and persistent mental illness.

• Many clients do not have the skills needed to live independently in the community, and teaching these skills is often time-consuming and labor-intensive, requiring a one-to-one staff-client ratio.

• Despite the flaws in the system, community-based programs have positive aspects that make them preferable for treating many people with mental illness.

• People in institutions often lose motivation and hope as well as functional daily living skills. Therefore, treatment in the community is a trend that will continue

Cost Containment and Managed Care

• Managed care is a concept designed to purposely control the balance between the quality of care provided and the cost of that care.

• It began in early 1970s in the form of health maintenance organization (HMOs).

• People received care based on need rather than on request.

• In 1990s, a new form of managed care called utilization review firms or managed care organizations were developed to control the expenditure of insurance funds by requiring providers to seek approval before the delivery of care.

Case management or Management of care

• a case-by-case basis, represented an effort to provide necessary services while containing cost.

• This approch is designed to decreased fragmented care from a variety of sources, eliminate unneeded overlap of services, provide care in the least restrictive environment, and decrease costs for the insurers.

• In reality, expenditures are often reduced by withholding services deemed unnecessary of substituting less expensive care such as hospital admission.

Psychiatric Care

• costly because of the long-term nature of the disorders.

• A single hospital stay can cost $20,000 to $30,000, and there are fewer objective measures of health or illness.

Mental Healthcare

• separated from physical health care in terms of insurance coverage

• When private insurance limits are met, public funds through the state are used to provide care.

Privately owned

• Mental health care is managed through __________ behavioral health care firms that often provide the services as well as manage their cost

• As a result, many persons with mental illness do not seek care and in fact avoid treatment. These persons are often homeless or in jail.

To provide effective treatment to all who need it and To find the resources to pay for this care

Two of the greatest challenges for the future are

Covers people 65 years and older with permanent kidney failure, or with certain disabilities and is jointly funded by the federal and state governments and covers low-income individuals and families.

The Health Care Finance Administration (HCFA) administers two insurance programs

Not all

Unfortunately, ___ people who are disabled apply for disability benefits, and ___ people who apply are approved. Thus, many people with severe and persistent mental illness have no benefits at all.

Spending caps and substance abuse treatment

• Another funding issue in mental health involves _ by insurers for mental illness and _

• Some policies place an annual dollar limitation for treatment, while others limit the number of days that will be covered annually or in the insured person’s lifetime (of the policy).

Cultural Considerations

Nurses must be prepared to care for this culturally diverse, and that includes being aware of cultural differences and infuence mental health and the treatment of mental illness.

Psychiatric Nursing Practice

Richards is called the First American psychiatric Nurse; she believed that “the mentally sick should be at least as well cared for as the physically sick” (Doona, 1984

1882

• The first training of nurses to work with persons with mental illness was in —- at Mclean Hospital in Waverly, Mass.

• The care was primarily custodial and focused on nutrition, hygiene, and activity. Nurses adapted medical-surgical principles to the care of clients with psychiatric disorders and treated them with tolerance and kindness.

insulin shock therapy, psychosurgery and electroconvulsive therapy

Treatments such as _ required nurses to use their medical-surgical skills further.

Hildegard Peplau and June Mellow

Two early nursing theorists shaped psychiatric nursing practice

Hildegard Peplau

• Published Interpersonal Relations in Nursing and Interpersonal Techniques: The Crux of Psychiatric Nursing.

• Describes the therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety.

June Mellow

• Published Nursing Therapy described her approach of focusing on the client’s psychosocial needs and strengths.

• Contends that the nurse as therapist is particularly suited to working with those with severe mental illness in the context of daily activities, focusing on the here-and-now to meet each person’s psychosocial needs (1986).

Standards of Care

• In 1973, the division of psychiatric and mental health practice of the American Nurses Association developed standards of care, which it revised in 1982, 1994, and 2000.

• authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable.