Week 1: Foundations of Psychiatric–Mental Health Nursing

Mental Health and Mental Illness

  • Definitions

    • Mental health and mental illness are difficult to define precisely.

    • Healthy Individuals:

      • Can carry out societal roles and exhibit appropriate behavior.

    • Ill Individuals:

      • Fail to fulfill roles or exhibit inappropriate behavior.

      • Cultural values and beliefs strongly influence definitions of health and illness.

      • Different societies may have varying views on acceptable behavior.

Mental Health

World Health Organization Definition

  • Health is a state of complete physical, mental, and social well-being.

  • Emphasizes health as a positive state of well-being, not just the 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.

Factors Influencing Mental Health

  • Individual Factors:

    • Biological makeup.

    • Autonomy.

    • Self-esteem.

    • Emotional resilience.

  • Interpersonal Factors:

    • Effective communication.

    • Intimacy.

    • Balance of separateness and connectedness.

  • Social Determinants:

    • Sense of community.

    • Access to resources.

    • Support of diversity.

    • Social inclusion.

Mental Illness

Definition

  • Includes disorders affecting mood, behavior, and thinking (e.g., depression, schizophrenia, anxiety disorders).

  • Causes significant distress or impaired functioning.

Indicators of Mental Illness

  • Dissatisfaction with self and relationships.

  • Ineffective coping and overwhelming daily life.

  • Feelings of hopelessness.

Factors Contributing to Mental Illness

  • Individual Factors:

    • Biological makeup.

    • Unrealistic worries.

    • Inability to distinguish reality from fantasy.

  • Interpersonal Factors:

    • Ineffective communication.

    • Excessive dependency.

    • Inadequate social support.

  • Social Determinants:

    • Lack of resources.

    • Violence.

    • Homelessness.

    • Poverty.

    • Discrimination (e.g., stigma, racism).

Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)

Overview

  • Published by the American Psychiatric Association

  • Fifth Edition, Text Revision (DSM-5-TR), most recent revision released in 2022.

  • Purpose of DSM-5-TR:

    • Describes all mental disorders.

    • Outlines specific diagnostic criteria based on clinical experience and research.

    • Used by mental health clinicians in the United States and some other countries.

    • International Classification of Diseases, 11th edition (ICD-11) is widely used globally.

    • Some countries have their own taxonomies, some based on DSM-5-TR.

Purposes of DSM-5-TR

  • Standardized nomenclature and language for all mental health professionals.

  • Defining characteristics or symptoms to differentiate specific diagnoses.

  • Identifying Underlying Causes of Disorders:

    • Classification system helps identify all factors related to a person's condition, including:

    • Major psychiatric disorders (e.g., depression, schizophrenia, anxiety, substance-related disorders).

    • Relevant medical conditions.

    • Psychosocial and environmental problems.

DSM-5-TR as a Resource for Student Nurses

  • Understanding Reasons for Admission:

    • Helpful for understanding the reason for a client's admission.

  • Building Knowledge:

    • Aids in building knowledge about the nature of psychiatric illnesses.

  • Not Used for Diagnosing:

    • Student nurses do not use DSM-5-TR to diagnose clients.

Historical Perspectives on Mental Illness

Ancient Times

  • Beliefs about Mental Illness:

    • Sickness seen as displeasure of the gods.

    • Mental disorders viewed as divine or demonic.

    • Individuals viewed differently:

    • Divine individuals were worshipped.

    • Demonic individuals were ostracized and punished.

  • Aristotle's Theory (382 to 322 BC):

    • Related mental disorders to physical disorders, suggesting emotions were controlled by bodily fluids (blood, water, yellow and black bile).

    • Treatment aimed at restoring balance through bloodletting, starving, and purging.

  • Early Christian Times (1 to 1000 AD):

    • Diseases blamed on demons.

    • Treatment involved exorcisms and brutal measures like incarceration, flogging, and starving.

  • Renaissance Period in England (1300 to 1600):

    • Distinction between harmless and dangerous individuals with mental illness:

    • Harmless individuals were allowed to wander.

    • Dangerous individuals were imprisoned, chained, and starved.

    • Hospital of St. Mary of Bethlehem (1547):

    • First hospital for the insane, where visitors were charged a fee to view and ridicule inmates.

Period of Enlightenment and Creation of Mental Institutions

  • Enlightenment in the 1790s:

    • Philippe Pinel and William Tuke promoted the concept of asylum as a safe refuge offering protection.

    • Moral treatment of people with mental illnesses was advocated.

  • Dorothea Dix's Crusade in the United States (1802 to 1887):

    • Focused on reforming treatment of mental illness.

    • Resulted in the opening of 32 state hospitals.

    • Advocated for adequate shelter, nutritious food, and warm clothing.

  • Challenges:

    • Short-lived period of enlightenment due to accusations of abuse in state hospitals.

    • Patients isolated in rural locations; negative connotation of "insane asylum" resulted.

Sigmund Freud and Treatment of Mental Disorders

  • Scientific Study and Treatment:

    • Initiated with Sigmund Freud (1856 to 1939).

  • Contributions by Others:

    • Emil Kraepelin and Eugen Bleuler also made significant contributions.

  • Freud's Contributions:

    • Provided an objective view of human beings and their mental disorders along with treatments.

  • Kraepelin's Contributions:

    • Proposed classification of mental disorders according to symptoms.

  • Bleuler's Contributions:

    • Coined the term schizophrenia.

Recent Trends and Changes in Mental Health

Development of Psychopharmacology

  • Introduction of psychotropic drugs in the 1950s.

    • First drugs included Chlorpromazine (Thorazine) and lithium.

    • Development of monoamine oxidase inhibitor (MAOI) antidepressants followed.

    • Other significant introductions included haloperidol (Haldol), tricyclic antidepressants, and benzodiazepines.

  • Impact of Psychotropic Drugs:

    • Reduction in agitation, psychotic thinking, and depression.

    • Resulted in shorter hospital stays and improved patient outcomes, allowing patients to return home.

    • Decreased noise, chaos, and violence in hospitals.

Move Toward Community Mental Health

  • Community Mental Health Centers Construction Act (1963):

    • Marked the shift from institutional care to community facilities.

    • Emphasis on deinstitutionalization and development of community-based services such as:

    • Emergency care.

    • Inpatient care.

    • Outpatient services.

    • Partial hospitalization, screening services, and education.

  • Federal Legislation for Income Support:

    • Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) aimed to ensure financial independence for people with severe mental illness.

  • Changes in Commitment Laws (early 1970s):

    • Made it more difficult to commit individuals for mental health treatment against their will.

    • Resulted in decreased state hospital populations and reduced state spending.

Mental Illness in the 21st Century

  • Prevalence of Mental Illness:

    • 57.8 million adults in the United States reported having a mental illness in 2021, with only 26.5 million receiving treatment within the past year.

    • Nearly 11 million children and adolescents were diagnosed with mental disorders.

    • The economic burden of mental disorders exceeds that caused by all types of cancer.

    • Leading cause of disability for individuals aged 15 to 44 years in the United States and Canada.

    • Only one in four adults and one in five children/adolescents requiring mental health services received care.

Revolving Door Effect and Shorter Unplanned Hospital Stays

  • Revovling Door Effect:

    • Shorter unplanned hospital stays complicate frequent and repeated admissions, where patients improve but do not become stabilized, leading to discharge without necessary coping skills.

  • Dual Diagnosis:

    • Individuals with severe mental illness and substance misuse experience exacerbated symptoms and increased likelihood of rehospitalization.

  • Homelessness Statistics:

    • Over half a million individuals experience homelessness on any given night, with one-third exhibiting severe mental illness or chronic substance use disorder.

Objectives for the Future

  • Untreated Populations:

    • Many, including the homeless, incarcerated, and those with dual diagnoses, go untreated.

  • Healthy People 2030 Objectives:

    • Focus on prevention, screening, assessment, and treatment of mental disorders.

    • Aim to improve health and quality of life for those affected by mental and behavioral disorders.

Community-Based Care: Challenges and Realities

Community Mental Health Centers

  • Timeline Failure:

    • Planned community mental health centers to be built by 1980 never materialized, resulting in only 1,300 programs by 1990 (instead of the planned 2,000).

    • Many individuals needing services had unmet needs, where half of those with severe mental illness received no treatment in the previous year.

    • Individuals with minor or mild cases are more likely to receive treatment compared to those with severe and persistent mental illness.

Consequences of Nontreatment

  • Outcomes of untreated mental illness include:

    • Preventable disability.

    • Poorer quality of life.

    • Deterioration of personal relationships.

    • Worsening of untreated disorders leading to:

    • Physical health problems.

    • Homelessness.

    • Arrest and incarceration.

    • Victimization.

    • Suicidality.

    • Familial violence and danger to others.

  • Community Support Services:

    • Services focus on rehabilitation, vocational needs, education, socialization, symptom management, and medication adherence.

Cost Containment and Managed Care

Concept of Managed Care

  • Aims to balance quality of care and cost.

  • Care is based on need rather than request.

  • Case Management:

    • Coordinates all types of care needed by the client.

    • Aims to decrease fragmented care while providing support in the least restrictive environment.

  • **Challenges:

    • High costs of psychiatric care due to the long-term nature of disorders.

    • Mental health care is often separated from physical health care in insurance coverage, leading to issues in comprehensive care.

Medicare and Medicaid

  • Medicare:

    • Cover individuals aged 65 and older, those with permanent kidney failure, and individuals with certain disabilities.

  • Medicaid:

    • Covers low-income individuals and families, with variations depending on the state.

  • Mental Health Parity:

    • Mental Health Parity Act (1996):

    • Eliminated annual and lifetime dollar limits for mental health care for companies with more than 50 employees.

    • Parity laws vary by state, affecting access to necessary services.

Cultural Considerations

Increasing Diversity

  • A growing number of U.S. residents trace their ancestry to African, Asian, Arab, or Hispanic origins.

  • Nurses must be aware of cultural differences that impact mental health and treatment.

Changing Family Structures

  • A high divorce rate (approximately 50%) has led to an increase in single-parent and blended families.

  • A 20% increase in single-person households and same-sex partnerships has occurred, alongside the expansion of legal marriage and adoption rights for same-sex couples in all 50 states.

Future Trends

  • Continued increase in diversity within U.S. households will challenge nurses to provide sensitive and competent care tailored to various cultural backgrounds.

Psychiatric Nursing Practice

Historical Overview

  • Linda Richards:

    • First American Psychiatric Nurse, graduated in 1873 from New England Hospital for Women and Children.

  • Improved nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois.

Early Training and Care

  • First training program established in 1882 at McLean Hospital, Belmont, Massachusetts, which focused on nutrition, hygiene, and activity.

  • Adapted medical-surgical principles for psychiatric care.

Expansion of Psychiatric Nursing Role

  • Development of somatic therapies, including:

    • Insulin shock therapy (1935).

    • Psychosurgery (1936).

    • Electroconvulsive therapy (1937).

  • Increased use of medical-surgical skills in psychiatric nursing.

Key Publications and Courses

  • First Psychiatric Nursing Textbook:

    • Nursing Mental Diseases by Harriet Bailey (1920).

  • Johns Hopkins University:

    • Included a psychiatric nursing course in 1913.

  • In 1950, the National League for Nursing required psychiatric nursing experience as a part of training.

Influential Nursing Theorists in Psychiatric Nursing

Hildegard Peplau

  • Published Interpersonal Relations in Nursing (1952) and Interpersonal Techniques: The Crux of Psychiatric Nursing (1962).

  • Described phases and tasks of the therapeutic nurse–client relationship, emphasizing interpersonal dimensions in nursing practice.

June Mellow

  • Published Nursing Therapy (1968), focusing on clients' psychosocial needs and strengths.

  • Advocated for the nurse as a therapist for those with severe mental illness, emphasizing the importance of meeting psychosocial needs in daily activities.

Standards of Care in Psychiatric Nursing

American Nurses Association (ANA)

  • Develops and revises standards of care describing nurses' responsibilities used to determine safe and acceptable practices in legal issues.

American Psychiatric Nurses Association (APNA)

  • Has standards of practice and professional performance, outlining areas of practice and phenomena of concern including:

    • Promotion of optimal health.

    • Prevention of distress, illness, suicide, self-harm, bullying, and violence.

    • Addressing stigma, social determinants, bias, discrimination.

    • Community-based disasters, global pandemics, conflicts, and war.

Student Concerns in Psychiatric–Mental Health Nursing

Common Concerns

  • Student nurses often find psychiatric–mental health nursing different from previous nursing experiences.

  • Concerns are normal and usually subside after initial client contact.

  • Common Concerns Include:

    • Fear of saying the wrong thing.

    • Handling inappropriate behavior.

    • Personal safety.

Handling Fear of Saying the Wrong Thing

  • No single statement can significantly worsen a client's problems;

  • Key elements include listening carefully, showing interest, and demonstrating care.

  • Clarification is crucial if something seems out of place.

Working in Mental Health Settings

  • Mental health settings may involve fewer physical care tasks and diagnostic tests.

  • Students might feel insufficient for "just talking" but should appreciate relationship-building and trust as essential tasks.

Addressing Client Rejection

  • Common but not personal;

  • Clients in distress often welcome genuine listeners who show interest.

Establishing Trust and Rapport

  • Asking personal questions should follow establishing trust, as sincere inquiry is part of therapeutic communication.

Dealing with Inappropriate Behavior

  • It's important to ensure emotional responses do not lead to client feeling rejected.

  • Staff support can assist in managing challenging situations.

Managing Safety Concerns

  • Mentally ill individuals rarely harm others; they are more prone to self-harm.

  • Students should avoid physical restraint, ensuring safety in open areas.

Confidentiality Concerns

  • Essential in mental health settings; notify instructors if recognizing someone and reassure clients about confidentiality.

Drawing Parallels with Clients

  • Finding similarities can be shocking but is common; understanding that coping skills vary among individuals is essential.

Summary

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

  • Mental health and mental illness are influenced by a variety of individual factors.

  • Historically, mental illness was viewed often as demonic possession, sin, or weakness, with punitive responses; today it is understood as a medical issue with various symptoms.

  • The DSM-5-TR serves as a standard classification system for mental disorders, defining characteristics while identifying underlying causes of mental illness.

  • Students navigating psychiatric clinicals often experience various concerns and fears which can ease with interaction and experience.

  • Self-awareness is essential for psychiatric nursing, allowing practitioners to understand their values and beliefs, avoiding projection in client relationships.