Understanding Mental Health and Illness

• Mental health is universal

State of Well-Being

• Involves realizing potential, coping with stress, working productively, and contributing to the community
• Provides capacity for rational thinking, communication, learning, emotional growth, resilience, and self-esteem

Mental Illness

• Mental illness does not affect everyone
• Mental illness evolves over time
• 1 in 20 people in the United States experience serious mental illness
• Psychiatric disorders are defined by significant dysfunctions that may relate to developmental, biological, or psychological disturbances
• About 50% of homeless people also have substance use disorders and mental illness

DSM-5 List of Disorders

• Includes neurodevelopmental, schizophrenia spectrum, bipolar, depressive, and anxiety disorders
• Also includes obsessive-compulsive, trauma, stressor-related, dissociative, and somatic symptom disorders
• Covers feeding, eating, elimination, sleep-wake, sexual dysfunction, disruptive, and impulse control disorders
• Features substance-related, addictive, neurocognitive, personality, and paraphilic disorders

Mental Status Examination #1

Level of Consciousness

• Alert: Fully responsive
• Lethargic: Drowsy but able to respond and falls asleep easily
• Stuporous: Requires strong stimuli to respond and may not respond verbally
• Comatose: Unconscious and unresponsive to stimuli
  • Decorticate rigidity involves internal rotation of joints and legs
  • Decerebrate rigidity involves neck and elbow extension with flexion

Mental Status Examination #2

Physical Appearance

• Hygiene considerations include grooming, showering, and teeth brushing
• Nutritional status includes eating and drinking habits
• Clothing choice can be indicative of depression (same outfit daily) or mania (colorful or disoriented outfits)
• Physical signs like using drugs, homelessness, stress, smoking, scars, burns, and wounds
• Self-harm is not the same as suicide, physical pain is a coping mechanism

Mental Status Examination #3

Behavior

• Voluntary movement is consciously controlled by the brain
  • Signals are sent from the brain to muscles through the spinal cord and nerves for actions like waving or walking
• Involuntary movement is automatic without conscious thought
  • Examples include heartbeat, reflexes, tremors, tics, and psychomotor agitation or retardation

Eye Contact

• Good eye contact indicates confidence, self-esteem, and trustworthiness
• Poor eye contact suggests untruthfulness or disengagement

Mood and Affect

• Mood describes the client's feeling
  • Examples: happy, frustrated, labile (quickly changing), angry, sad
• Affect is the expression of mood
  • Flat affect shows no expression
  • Expansive affect expresses exaggerated emotion
  • Incongruent affect does not match the mood, and blunted affect reduces emotional expression

Mental Status Examination #4

Cognitive and Intellectual Abilities

• Includes assessing level of consciousness (ALOC), recent and remote memory, insight, calculation, abstraction, judgment, and speech patterns

Mini-Mental State Examination (MMSE)

• Scoring ranges from 24-30 (no impairment) to 0-17 (severe impairment)

Considerations Across the Lifespan

Children and Adolescents

• Assessment factors include temperament, social and environmental factors, cultural and religious concerns, and developmental level
• Mentally healthy children view the world as safe
• Children can experience the same mental health conditions as adults
• Diagnosing is difficult, and there is risk for delayed or inadequate interventions
• HEADSSS Assessment: Home, Education, Activities, Drugs, Sexuality, Suicide, Safety

Older Adults

• Assessment includes functional ability, economic and social status, and environmental factors like stairways

Legal and Ethical Guidelines

Client's Rights

• Include being treated with dignity, involvement in treatment planning, and the right to refuse treatment
• Patients can also request to leave if voluntary
• They can be protected from self-harm, have legal counsel, communicate privately, and give informed consent
• Confidentiality is maintained, visitors can be chosen or refused, and patients can refuse to participate in research

Treatment

• The least restrictive environment is prioritized
• The right to send/receive mail, keep belongings unless unsafe(shoelaces and belts), lodge complaints, and participate in religious worship

Ethics

• Ethical issues are philosophical ideas about right and wrong
• Nurses face dilemmas often, concerning beneficence (doing good), autonomy (client's decisions), justice (fair treatment), fidelity (loyalty), veracity (honesty), and nonmaleficence (doing no harm)
• Bioethics determine best course of action when ethical conflicts happen

Health Insurance Portability and Accountability Act (HIPAA)

• Confidentiality is maintained, even after death
• Ensures confidentiality in professional communications and requires continuity of care within the treatment plan

Exceptions

• Tarasoff Ruling: duty to warn if client threatens harm to a third party
• Abuse reporting, even with suspicions and court-mandated situations

Admission to Inpatient Care

• Aims for rapid stabilization and community return
• Psychiatric problems align with the DSM-5
• If outpatient and partial hospitalization are unavailable, inpatient admission follows, with voluntary and involuntary options

Voluntary Admission

• Clients may leave against medical advice (AMA)
• Before AMA release, evaluation for involuntary hold occurs

Involuntary Admission

• In California, a 5150 hold mandates a 72-hour evaluation when there is danger to self or others, or grave disability

Seclusion and Restraints

• Used as a last resort
• Can be chemical (neuroleptic) or physical, is not for convenience or punishment
• Time limits are specified for adults (4 hours), ages 9-17 (2 hours), and ages 8 and younger (1 hour), renewable once
• Assessments for circulation, food, water, hygiene, and vital signs

Required Actions

• Documentation every 15-30 minutes and a written physician's order required
• Release happens when the client is no longer an imminent threat

Tort Laws

• Torts address wrongful acts or injuries against a person or their property

Intentional Torts

• Include false imprisonment (holding someone against their will)
• Assault (verbal threat)
• Battery (physical harm)

Unintentional Torts

• Negligence: failure to provide adequate care and must prove duty, breach, harm, and damages
• Malpractice is professional negligence

Advance Directives

Durable Power of Attorney

• Is legally binding
• Agents are designated to make healthcare decisions if the person can't

Living Wills

• The document is prepared while mentally sound
• The preferences for care if the client is incompetent, are designated

Milieu Therapy

• This environment supports, is safe, and smoothly therapeutic
• It is also called a therapeutic community
• Aims to minimize stress and maximize benefits
• Goals include learning coping skills, efficient interaction, and relationship-building
• Nurses structure the environment (community meetings)

Boundaries of the Therapeutic Relationship

• Boundaries maintain the nurse-client relationship safely
• Blurred boundaries occur when the nurse's needs are prioritized

Transference and Countertransference

• Transference is related to feelings developed for the healthcare team member
• Countertransference occurs when characteristics in one's past is displaced

Activities Within the Therapeutic Milieu

Community Meetings

• These meetings enhance the emotional climate, improve communication, create self-worth, and discuss unit concerns

Individual and Group Therapy

• In individual therapy sessions, mental health providers address specific concerns
• In group therapy, clients address familiar mental health issues

Psychoeducation and Recreation

• Psychoeducation is dependent on the client’s level of functioning
• Recreational activities, like games and outings, are also important

Settings for Mental Health Care

Acute Care

• Intensive treatment and supervision in locked units to stabilize clients and return them to the community
• The interprofessional team develops client-centered plans

Community Care

• Includes schools, clinics, PHP, substance facilities, counseling centers, home healthcare, and forensic settings

History of Mental Health Care in the USA

• Before the mid-20th century, care was centered mainly in acute facilities
• Acts in '46, '55, and '63 aimed to deinstitutionalize due to poor conditions
• In the 1970s, case management began to meet client needs
• Managed behavioral healthcare organizations (MBHOs) coordinated care
• This is to provide acute care facilities, and it is to develop the community

Levels of Prevention

Primary Prevention

• Aims to promote health and prevent mental health problems

Secondary Prevention

• Focuses on early detection through screening

Tertiary Prevention

• Works for rehabilitation, halting disease progression, and minimizing fallout

Community-Based Mental Health Problems

Partial Hospitalization Programs (PHP)

• Provides intense short-term treatment and requires detoxification, stress management, medical supervision, substance abuse counseling, plus relapse prevention

Assertive Community Treatment (ACT)

• Case management is nontraditional and treatment by an interprofessional team is also provided

Community Mental Health Centers

• Offer educational groups, medication programs, and individuals with family counselling

Rehabilitation and Homecare

• Programs and residential services can provide them

Classical Psychoanalysis

• Focuses on free association, dream analysis, and resolving conflict
• The personality structures are Id, Ego, and Superego

Psychotherapy

• Therapist-client interaction helps develop trust for problem exploration
• Psychodynamic therapy focuses on the present state instead of early life

Interpersonal (IPT)

• Specific problems can be solved to improve relationships

Cognitive Therapy

• Focuses on thoughts that influence emotions

Cognitive Reframing

• It also helps in changing distortions and to develop supportive ideas

Behavioral Therapy

• It teaches clients to also reduce anxiety and includes
  • Modeling -Operant Conditioning -Systematic Desensitization -Aversion Therapy

Cognitive-Behavioral Therapy

• Focuses on behaviors and thoughts and accepts clients

Other Techniques

• Therapy includes thought stopping, flooding therapy and validation therapy and CBT focuses client changes

Humanistic Theory

• Humanistic theory involves Maslows hierarchy of needs

Biological Model

• A bio model to create memories and uses medication

Developmental Theory

• Ericksons and Piaget's theories for social and cognitive states