Foundations of Psychiatric-Mental Health Nursing PDF

M e n ta l H e a l t h a n d M e n ta l I l l n e s s Margaret Jordan Halter @ V i s it th e Evolve we b s ite fo r a p retest...

M e n ta l H e a l t h a n d M e n ta l I l l n e s s Margaret Jordan Halter @ V i s it th e Evolve we b s ite fo r a p retest o n t h e c o ntent i n t h i s c h a pter: http :/ I evo lve. e l s e vi e r. c o m !V a rc a ro l i s 1. Describe the continuum o f mental health and mental 7. Identify how the Diagnostic and Statistical Manual, illness. Fifth Edition (DSM-5) is used for diagnosing psychiatric 2. Explore the role of resilience in the prevention of and conditions. recovery from mental illness and consider resilience in 8. Describe the specialty of psychiatric-mental health response to stress. nursing. 3. Identify how culture influences the view of mental 9. Compare and contrast a DSM-5 medical diagnosis with a illnesses and behaviors associated with them. nursing diagnosis. 4. Discuss the nature/nurture origins of psychiatric 1 0. Discuss future challenges and opportunities for mental disorders. healthcare in the United States. 5. Summarize the social influences of mental healthcare in 1 1. Describe direct and indirect advocacy opportunities for the United States. psychiatric-mental health nurses. 6. Explain how epidemiological studies can improve medical and nursing care. O UT LINE Mental Health and Mental Illness, 2 Epidemiology of Mental Disorders, 10 Mental Health Continuum, 3 Classification o f Mental Disorders, 1 1 Risk and Protective Factors, 4 The DSM-5, 1 1 Individual Attributes and Behaviors, 4 The ICD-1 0-CM, 1 1 Social and Economic Circumstances, 5 Psychiatric-Mental Health Nursing, 11 Environmental Factors, 5 What Is Psychiatric-Mental Health Nursing? 1 1 Perceptions of Mental Health and Mental Illness, 6 Classification of Nursing Diagnoses, Outcomes, and Mental Illness Versus Physical Illness, 6 Interventions, 1 2 Nature Versus Nurture, 6 DSM-5 a n d NANDA-I-Approved Nursing Diagnoses, 12 Social Influences on Mental Healthcare, 6 Nursing Outcomes Classification (NOC), 12 Consumer Movement and Mental Health Recovery, 6 Nursing Interventions Classification (NIC), 12 Decade of the Brain, 7 Levels of Psychiatric-Mental Health Clinical Nursing Surgeon General's Report on Mental Health, 7 Practice, 1 2 Human Genome Project, 7 Basic Level, 1 3 President's New Freedom Commission on Mental Advanced Practice, 1 3 Health, 8 Future Issues for Psychiatric-Mental Health Nurses, 13 Institute ofMedicine, 8 Educational Challenges, 1 3 Brain Research through Advancing Innovative An Aging Population, 14 Neurotechnologies (BRAIN) Initiative, 9 Cultural Diversity, 14 Research Domain Criteria (RDoC) Initiative, 9 Science, Technology, and Electronic Healthcare, 14 Legislation and Mental Health Funding, 9 Advocacy and Legislative Involvement, 14 Mental Health Parity, 9 Patient Protection and Affordable Care Act of 2 0 1 0 , 9 1 2 U N IT 1 Fo u n d a t i o n s i n T h e o ry basic level registered nurse incidence psychiatric-mental health registered clinical epidemiology mental health nurse (PMH-RN) psychiatric-mental health advanced comorbid condition mental health continuum practice registered nurse cultural competence mental illness (PMH-APRN) Diagnostic and Statistical Manual of Nursing Interventions Classification Mental Disorders, Fifth Edition (NIC) psychiatric-mental health nursing (DSM-5) Nursing Outcomes Classification recovery diathesis-stress model (NOC) resilience electronic healthcare phenomena of concern stigma epidemiology prevalence If you are a fan of vintage films, you may have witnessed a scene communication skills, learning, emotional growth, resilience, similar to this: A doctor, wearing a lab coat, carrying a clip­ and self-esteem. Some of the attributes of mentally healthy peo­ board, and displaying an expression of deep concern, enters a ple are shown in Fig. 1. 1. hospital waiting room. He approaches an obviously distraught Society's definition o f mental illness evolves over time. It i s a gentleman seated there. The doctor says, ''I'm afraid your wife definition shaped by the prevailing culture and societal values, has suffered a nervous breakdown:' and it reflects changes in cultural norms, social expectations, From that point on in the film, the woman's condition is only political climates, and even reimbursement criteria by third­ vaguely hinted at. The husband dutifully drives through the asy­ party payers. lum gates and enters the stately building. Sounds of sobbing or In the past, the term mental illness was applied to behaviors shrieking patients are heard. Patients are rocking on the floor or considered "strange" and "different" -behaviors that occurred shuffling down the hall. infrequently and deviated from an established norm. Such cri­ As he nears his wife's room, the staff regard him with sad teria are inadequate because they suggest that mental health expressions and keep a polite distance. He may find his wife is based on conformity. Applying that definition to noncon­ lying in her bed motionless, standing by the window and formists and independent thinkers such as Abraham Lincoln, staring vacantly into the distance, or sitting among other Mahatma Gandhi, and Florence Nightingale might result in a non-interacting patients in the hospital's garden. The viewer judgment of mental illness. Although the sacrifices of a Mother can only speculate about the true nature of the woman's Teresa or the dedication of Martin Luther King Jr. are uncom­ illness. mon, virtually none of us would consider these much-admired behaviors to be signs of mental illness. Mental illness refers to all psychiatric disorders that have M ENTAL HEALTH AND M ENTAL ILLNESS definable diagnoses. These disorders are manifested in sig­ We have come a long way in acknowledging and addressing nificant dysfunctions that may be related to developmental, mental illness since the days of nervous breakdowns. In your biological, or psychological disturbances in mental function­ psychiatric-mental health nursing course, you will learn about ing. The ability to think may be impaired-as in Alzheimer's psychiatric disorders, associated nursing care, and treatments. disease. Emotions may be affected-as in major depression. As a foundation for this learning, we will begin by exploring Behavioral alterations may be apparent-as in schizophre­ what it means to be mentally healthy. nia. Or the patient may display some combination of the First, overall health is not possible without good men­ three alterations. tal health. The World Health Organization (WHO, 2014) Mental illness is such a common problem that most of us describes health as "a state of complete physical, mental, know someone with a disorder. You may even have one yourself. and social well-being and not merely the absence of disease According to the US Department Health and Human Services or infirmity:' There is a strong relationship between physical (HHS), in 2 0 1 4: health and mental health: Poor physical health can lead to One in five American adults experienced a mental health mental distress and disorders, and poor mental health can lead issue. to physical problems. One in ten young people experienced a period of major What does it mean to be mentally healthy? The WHO, again, depression. provides us with a useful definition. Mental health is a state of One in twenty-five Americans lived with a serious mental well-being in which each individual is able to realize his or her illness such as schizophrenia, bipolar disorder, or major own potential, cope with the normal stresses of life, work pro­ depression. ductively, and make a contribution to the community. Mental Suicide was the l Oth leading cause of death in the United health provides people with the capacity for rational thinking, States.  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 3 Rational thinking Meaningful relationships Effective coping Effective commun ication Resiliency Learn ing and Self-control productivity Positive self-concept Self-awareness Developmentally Self-care on task Happiness and joy Spiritual satisfaction FIG. 1. 1 S o m e attri b utes of m e nta l h e a l t h. M ENTAL HEALTH CONTINU U M experience mild to moderate discomfort and distress. Mild You may wonder if there is some middle ground between impairment in functioning such as insomnia, lack of concen­ mental health and mental illness. After all, it is a rare person tration, or loss of appetite may be felt. If the distress increases who does not have doubts as to his or her sanity at one time or or persists, individuals might seek professional help. Problems another. The answer is that there is definitely a middle ground. in this category tend to be temporary, but individuals with mild In fact, mental health and mental illness can be conceptualized depression, generalized anxiety disorder, and attention-deficit as points along a mental health continuum (Fig. 1.2). disorder may fit into this group. On one end of the continuum is mental health. Well-being The most severely affected individuals fall into the men­ describes the general condition of people in this category. tal illness portion of the continuum. At this point, individ­ Well-being is characterized by adequate to high-level func­ uals experience altered thinking, mood, and behavior. It tioning. While individuals at this end of the continuum may may include relatively common disorders such as depression experience stress and discomfort resulting from problems of and anxiety, as well as major disorders such as schizophre­ everyday life, they experience no serious impairments in daily nia. The distinguishing factor in mental illness is typically functioning. chronic or long-term impairments that range from moderate For example, you may spend a day or two in a gray cloud to disabling. of self-doubt and recrimination over a failed exam, a sleepless All of us fall somewhere on the mental health-mental illness night filled with worry about trivial concerns, or months of continuum and shift gradually or suddenly. Many people will genuine sadness and mourning after the death of a loved one. never move into the mental illness stage. On the other hand, During those low times, you are fully or vaguely aware that you many people who do reach a more severe level of impairment are not functioning well. However, time, exercise, a balanced can experience recovery that ranges from a glimmer of hope to diet, rest, interaction with others, and mental reframing may leading a satisfying life. alleviate these problems or concerns. People who have experienced mental illness can testify to the At the opposite end of the continuum is mental illness. existence of changes in functioning. The following comments of Individuals may have emotional problems or concerns and a 40-year-old woman illustrate the continuum between illness 4 U N IT 1 Fo u n d a t i o n s i n T h e o ry Mental Health - Mental I l l ness Conti n u u m Occasional stress to m i l d d i stress Mild to moderate d i stress N o i m pairment M i l d or tem porary i m pairment FIG. 1. 2 M e nta l h e a lth-m e n ta l we l l-be i n g co nti n u u m. ( F ro m U n ivers ity of M i c h i g a n , " U n d e rsta n d i n g U. ". Wha t is mental health ? Retrieved from http s : //h r. u m i c h. e d u/be n efits-we l l n ess/h e a lth/ m h ea lthy/m e nta l-e m ot i o n a l-we l l-be i n g/u n d e rsta n d i n g- m e nta l-e motiona l-hea lth/m e n ta l-e m oti o n a l ­ h e a lth-c l a s s e s-tra i n i n g -eve nts/o n I i n e -t u t o r i a 1-s u pe rvi s o rs/secti o n - 1 -w h a t -yo u-n e e d - k n ow-a b o u t­ m e nta 1-hea lth-pro b l e m s-s u bsta n ce-m i s u se). and health as her condition ranged from deep depression to mania to well-being (recovery) : I ndividual attributes and Depression It was horror and hell. I was at the bottom of the behaviors deepest and darkest pit there ever was. I was worthless and unforgivable. I was as good as-no, worse than-dead. Mania I was incredibly alive. I could sense andfeel every­ thing. I was sure I could do anything, accom­ Mental health plish any task, and create whatever I wanted if and well-being only other people wouldn't get in my way. Well-being I am much calmer. I realize now that, when I was Social and (Recovery) manic, it was a pressure-cooker feeling. When Environmental economic factors I am happy now, or loving, it is more peaceful circumstances and real. I have to admit that I sometimes miss the intensity-the sense of power and creativ­ ity-of those manic times. I never miss anything about the depressed times, but of course the FIG. 1.3 Contri b u t i n g factors to m e nta l h e a l t h a n d w e l l-be i n g. power and the creativity never bore fruit. Now F ro m World H e a lth O rga n izati o n. (2 0 1 2 ). Risks to mental health : I do get things done, some of the time, like most An o vervie w of vuln erabilities and risk factors. Retri eved from people. And people treat me much better now. I ht t p : //www. w h o. i n t/m e n ta l _ h e a l t h/m h g a p/ri s ks_to_m e n t a I_ guess I must seem more real to them. I certainly hea lth_E N_2 7 _08_ 1 2. pdf seem more real to me (Altrocchi, 1 980). of managing thoughts and feelings and navigating the everyday pressures of life. The ability to respond to social cues and par­ RIS K AND PROTECTIVE FACTORS ticipate in social activities influences our view of ourselves and Many factors can affect the severity and progression of a mental how others view us. illness, as well as the mental health of a person who does not Biological and genetic factors can also influence mental have a mental illness. Individual characteristics and attributes health. Prenatal exposure to alcohol and oxygen deprivation at influence mental health and well-being (WHO, 2012). Socio­ birth are two examples of biological factors. Genetic factors are economic circumstances and the environment also influence huge predictors of mental health and are implicated in nearly mental health (Fig. 1.3). every psychiatric disorder. What makes some people adapt to tragedy, loss, trauma, and I n d ivid u a l Attr i b utes a n d Behaviors severe stress better than others? The answer may be the individual Individual attributes refer to characteristics that are both inborn attribute of resilience. Resilience is the ability and capacity for peo­ and learned that make us who we are. We all have unique ways ple to secure the resources they need to support their well-being. It  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 5 promoting confidence and coping skills or for instilling anxiety and feelings of inadequacy. Use the fol lowing sca l e to rate each item l isted below: The social environment extends to schools and peer groups. 1 = Not true of me Again, this environment has the ability to affect mental health 2 = Sometimes true 3 = Moderately true positively and negatively. For example, socioeconomic status 4 = Usua lly true dictates the sort of resources available to support mental health 5 = Very true and reduce concerns over basic needs such as food, clothing, 1. Even if I plan ahead for a d iscussion with my spouse. my boss. or my and shelter. Educational advancement is a tremendous sup­ c h i l d , I sti l l fi nd myself acting emotio na l ly. porter of mental health by providing opportunities for a satisfy­ 2. I am unable to harness positive emotions to h e l p me focus on a task. ing career, security, and economic benefits. 3. I can contro l the way I fee l when adversity stri kes. 4. I get carried away by my fee l i ngs. Envi ronmenta l Fa ctors 5. I a m good at id entifyi ng what I a m thinking and how it affects my mood. The overall environment that affects mental health relates to the 6. If someone does someth ing that u psets me, I a m a b l e to wait until a n political climate and cultural considerations. Access and lack a ppropriate time w h e n I have ca lmed down to d i scuss i t of access to basic needs and commodities such as healthcare, 7. My emotions affect my a b i l ity t o focus on w h a t I n e e d to g e t done a t h o m e , sch ool, or work. water, safety services, and a strong highway system have a pro­ 8. When I discuss a hot topic with a colleague o r fa m i l y member, I am a b l e found effect on community mental health. Social and economic to k e e p my emotions i n check. policies, which are formed at the global, national, state, and local government levels, also impact mental health. For example, in Add Yo u r Score o n the Add Yo u r Score o n the the United States, laws have been gradually shifting toward bet­ Following Ite ms: Following Ite ms: ter reimbursement for mental health services. This shift makes 3 it easier to access and improve mental healthcare. 5 2 Predominant cultural beliefs, attitudes, and practices influence 6 4 mental health. There is no standard measure for mental health, 8 7 partly because it is culturally defined. One approach to differen­ Pos itive tota l = Negative tota l = __ Pos itive tota l m i n u s negative tota l = __ tiating mental health from mental illness is to consider what a particular culture regards as acceptable or unacceptable. In this A score higher than 1 3 is rated as a bove average in emotio na l regu lation. view, those with mental illness are those who violate social norms A score between 6 a nd 13 is inconcl usive. and thus threaten (or make anxious) those observing them. For A score l ower than 6 is rated as below average i n emotio na l reg u lation. If yo u r emotional reg u lation is below average, you may need to master some example, traditional Japanese culture may consider suicide to be ca l m i n g s ki l ls. Here a re a few tips: an act of honor, and Middle Eastern "suicide bombers" are con­ When a nxi ety strikes, you r breath ing may become sha l l ow and q u ick. You sidered holy warriors or martyrs. Contrast these viewpoints with can h e l p control the anxiety by contro l l i n g yo u r breath ing. I n h a l e sl owly Western culture where people who attempt or complete suicides through your nose, breath ing deeply from your bel ly, not your chest are nearly always considered mentally ill. Stress wi l l make your body tight and stiff. Aga in, you can counter the Throughout history, people have interpreted health or sick­ effects of stress on the body and bra i n if you relax your muscl es. ness according to their own current views. A striking example Try positive imagery; create a n image that is re laxing such as visual izing of how cultural change influences the interpretation of mental yourself on a secluded beach. illness is an old definition of hysteria. According to Websters Resil ience is with i n your reach. Dictionary (Porter, 1 9 1 3), hysteria was: F r o m R e i v i c h , K. , & S hatte, A. (2002 ). The resilience factor: 7 essen tial skills A nervous affection... in women, in which the emotional for overcoming life 's obstacles. New York, N Y : B roadway Books. Any t h i rd pa rty use of t h i s materia l , outside of t h i s p u b l icatio n , is p r o h i b i t e d. I nter­ and reflex excitability is exaggerated, and the will power ested p a rties m u st a p p l y d i rectly to R a n d o m H o u s e , I n c. for p e r m i s s i o n. correspondingly diminished, so that the patient loses control over the emotions, becomes the victim of imaginary sensa­ tions, and often falls into paroxysm or fits. is a quality found in some children of poverty and abuse who seek out trusted adults. These adults provide them with the psychologi­ Treatment for this condition, thought to be the result of sex­ cal and physical resources that allow them to excel. ual deprivation, often involved sexual activity. Thankfully, this Being resilient does not mean being unaffected by stressors. diagnosis fell into disuse as women's rights improved, the fam­ People who are resilient are effective at regulating their emo­ ily atmosphere became less restrictive, and societal tolerance of tions and not falling victim to negative, self-defeating thoughts. sexual practices increased. You can get an idea of how good you are at regulating your emo­ Cultures differ not only in their views regarding men­ tions by taking the Resilience Factor Test in Box 1. 1. tal illness but also the types of behavior categorized as mental illness. Culture-bound syndromes seem to occur S o c i a l a n d Economic C i rc umsta nces in specific sociocultural contexts, and people in those cul­ Your immediate social surroundings impact personal attributes. tures easily recognized them. For example, one syndrome The earliest social group, the family, has tremendous effects on recognized in parts of Southeast Asia is running amok, in developing and vulnerable humans. The family sets the stage in which a person (usually a male) runs around engaging in 6 U N IT 1 Fo u n d a t i o n s i n T h e o ry almost indiscriminate violent behavior. In the United States, explained the ongm of mental illness as faulty psychologi­ anorexia nervosa is recognized as a disorder characterized by cal processes that could be corrected by increasing personal voluntary starvation. The disorder is well known in Europe, insight and understanding. For example, a patient experiencing North America, and Australia but unheard of in many other depression and apathy could be assisted to explore feelings from parts of the world. childhood when overly protective parents strictly discouraged attempts at independence. Percepti ons of M e nta l H e a lth a n d M e nta l I l l n ess This psychological focus was challenged in 1 952 when M e nta l I l l n ess Versus Phys i c a l I l l n ess chlorpromazine (Thorazine) was found to have a calming People often make a distinction between mental illnesses and effect on agitated, out-of-control patients. Imagine what this physical illnesses. This is a peculiar distinction. Mental refers discovery must have been like for clinicians. Out of despera­ to the brain, the most complex part of the body, responsible for tion they had resorted to every biological treatment imaginable the higher thought processes that set us apart from all other including wet wraps, insulin shock therapy, and psychosur­ creatures. Surely the workings of the brain-the synaptic con­ gery (in which holes were drilled in the head of a patient and nections, the areas of functioning, the spinal innervations and probes inserted into the brain) as attempts to change behavior. connections-are physical. The scientific community began to believe that if psychiatric One problem with this distinction is that it implies that problems respond to medications that alter neurochemistry, psychiatric disorders are "all in the head." Most damaging is then a disruption of intercellular components must already be the belief that these disorders are under personal control and present. indistinguishable from a choice to engage in bad behavior. A diathesis-stress model-in which diathesis represents These beliefs support the stigma to which people with mental biological predisposition and stress represents environmental illness are often subjected. Stigma, the belief that the overall stress or trauma-is the most accepted explanation for mental person is flawed, is characterized by social shunning, disgrace, illness. This nature-plus-nurture argument asserts that most and shame. psychiatric disorders result from a combination of genetic vul­ Perhaps the difference between mental and physical ill­ nerability and negative environmental stressors. One person ness lies in the tradition of explaining the unexplainable may develop major depression largely as the result of an inher­ through superstition. Consider that the frightening convul­ ited and biological vulnerability that alters brain chemistry. sions of epilepsy were once explained as demon possession or Another person with little vulnerability may develop depres­ a curse. Unfortunate individuals with epilepsy were subjected sion as a result of a stressful environment that causes changes to horrible treatment including shunning, imprisonment, and in brain chemistry. exorcisms. Today, people recognize that seizures are part of a disorder and not under personal control. How do we know? S o c i a l I nfluences on M e nta l H e a lth care Because we can see epilepsy on brain scans as areas of overactiv­ C o n s u m e r M ovement a n d M e nta l H e a lth Recovery ity and excitability. Over 1 00 years ago, tremendous energy was directed toward There are no specific biological tests to diagnose most psy­ improving equality in the United States. Black men were given chiatric disorders-no cranium culture for depression and no the right to vote in 1 870 as were women, finally, in 1 920. Treat­ magnetic resonance imaging (MRI) for obsessive-compulsive ing people fairly and challenging labels became a focus of the disorder (OCD). However, researchers are convinced that the American culture. root of most mental disorders lies in intercellular abnormalities. With regard to treatment of people with mental illness, We can now see clear signs of altered brain function in several decades of institutionalization had created significant political mental disorders including schizophrenia, OCD, stress disor­ and social concerns. Groups of people with mental illnesses­ ders, and depression. frequently called mental health consumers-began to advocate for their rights and fought against discrimination and forced N atu re Versus N u rture treatment. For centuries, people believed that extremely unusual behav­ In 1 979 people with mental illnesses and their families iors resulted from supernatural (usually evil) forces. In the formed a nationwide advocacy group, the National Alliance on late 1 800s, the mental health pendulum swung briefly to a Mental Illness (NAMI). In the 1 980s, individuals in the con­ biological focus with the "germ theory of diseases:' Germ sumer movement organized by NAMI began to resist the tra­ theory explained mental illness in the same way other ill­ ditional arrangement of mental healthcare providers dictating nesses were being described-that is, a specific agent in treatment without the input of the patient. This paternalistic the environment caused them. This theory was abandoned relationship was demoralizing, and it also implied that patients rather quickly because clinicians and researchers could not were not competent to make their own decisions. Consumers identify causative factors for mental illnesses. There was no demanded increased involvement in decisions concerning their "mania germ" that could be viewed under a microscope and treatment. subsequently treated. The consumer movement also promoted the concept of Although biological treatments for mental illness contin­ recovery, a new and an old idea. On one hand, it represents ued to be explored, psychological theories dominated and a concept that has been around a long time: that some peo­ focused on the science of the mind and behavior. These theories ple-even those with the most serious illnesses such as  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 7 schizophrenia-recover. One recovery was depicted in the movie Jeffs i nvolvement in the recovery support group changed his view of h i mself, A Beautiful Mind. In this film, a brilliant mathematician, John and he began to take the lead ro l e in h i s own care. According to Jeff, " N obody Nash, seems to have emerged from a continuous cycle of devas­ knows your body better than you do, and some, maybe some menta l hea lth tating psychotic relapses to a state of stabilization and recovery providers o r doctors, think, ' H ey, I am the professiona l, and you're the person (Howard, 200 1 ). seeing m e. I know what's best for you.' But technical ly, it isn't true. They only A newer conceptualization o f recovery evolved into a con­ provide you with the too l s to get better. They can't crawl inside you and see sumer-focused process. According to the Substance Abuse how you are.'' and Mental Health Services Administration (SAMHSA, 2012), Jeff asked for and received newer, m o re effective med ications. He moved recovery is "a process of change through which individuals into his own apartment and retu rned to community col lege and focused on improve their health and wellness, live a self-directed life, and information technology. Jeff now attends recovery support groups reg u l a rly and has ta ken up bicyc l i n g. H e has h i s high an d l ow days but mainta ins goals, strive to reach their full potential:' The focus is on the consumer hope, an d a purpose for h i s l ife. and what he or she can do. A real-life example of recovery follows: Adapted from S u bsta n c e Abuse and M e ntal H ea lth Ad m i n istratio n. (2 0 1 2 ). SAMHSA's working definition o f recovery updated. R etrieved from http:!/blog.samhsa. gov/20 1 2/03/23/defi ntion-of-recovery-u pdated/#. VpO i n p M rL B I. V I G N ETTE : Jeff began hearing voices when he was 1 9 a n d was diag­ nosed with schizophrenia the same yea r. H e d ropped out of col lege, l o st h i s part-time j o b at a factory, a n d b e g a n c o l l ecting Social Secu rity D i s a b i l ity D e c a d e of the B ra i n I n c o m e. For 20 years, Jeff was told what m e d ication to ta ke, where to l ive, I n 1 990 President George H.W. Bush designated the last decade and what to d o. of the 1 900s as the Decade of the Brain. The overriding goal of A t the community hea lth center where he received services, he m e t a fe l low this designation was to make legislators and the public aware patient, Linda, who was involved with a recovery support group. She gave h i m a pamphlet w i t h a l ist of the 10 guiding p r i n c i p l e s of recovery: of the advances that had been made in neuroscience and brain 1. Recovery emerges from hope: Recovery provides the essenti a l moti­ research. This US initiative stimulated a worldwide growth of vati ng message of a better future: That people can and do overcome the scientific research. Advances and progress made during the barriers and obstacles that confront them. Hope is the cata lyst of the Decade of the Brain include: recovery process. Understanding the genetic basis of embryonic and fetal neu­ 2. Recovery is person driven: Self-determ ination and self-d i rection a re ral development the foundations for recovery. Consumers lead, contro l , exerc ise choice Mapping genes involved in neurological illnesses including over, a n d determine their own path of recovery. 3. Recovery occurs through many pathways: I n d ivid uals a re unique mutations associated with Parkinson's disease, Alzheimer's with d i stinct needs, strengths, preferences, goals, culture, an d back­ disease, and epilepsy ground (including past tra u m a ) that affect their pathways to recovery. Discovering that the brain uses a relatively small number of Recovery is nonlinear a n d may involve setbacks. Absti nence from the use neurotransmitters but has a vast assortment of neurotrans­ of a lcohol, nonprescribed med ications, and tobacco is essenti a l. A sup­ mitter receptors portive environment is essenti a l , espec i a l ly for c h i l dren. Uncovering the role of cytokines (proteins involved in the 4. Recovery is hol istic: Recovery encompasses a n individ u a l 's whole l ife immune response) in such disorders as depression including m i n d , body, spirit, a nd commun ity. 5. Recovery is supported by peers and a l l i es: M utual support an d a i d Refining neuroimaging techniques g r o u p s p l a y a n inva l ua b l e r o l e in recovery. Peers im prove soci al learning, Bringing together computer modeling and laboratory provide experiential knowledge and ski l ls, a n d a sense of belonging. H e l p­ research, which resulted in the new discipline of computa­ ing others h e l ps one's self. tional neuroscience. 6. Recovery is supported through relationships and social networks: The presence and i nvolvement of people who believe i n the persona l 's Surgeon G e n e ra l's R e p o rt o n M e nta l H e a lth a b i l ity to recover; who offer hope, support, and encouragem ent; and who The first Surgeon General's report on the topic of mental health suggest strategies and resou rces for change are important. 7. Recovery is culturally based and influenced: Cu lture and cu ltural was published in 1 999 (HHS). This landmark document was background a re keys in determining a person's journey and unique pathway based on an extensive review of the scientific literature in con­ to recovery. Services should be cu ltura l ly grounded, attuned, sensitive, con­ sultation with mental health providers and consumers. The gruent, and competent, as well as personal ized to meet unique needs. two most important messages from this report were that ( 1 ) 8. Recovery is supported by addressi ng trauma: Tra uma ( e.g., physi­ mental health i s fundamental to overall health, and (2) there cal o r sexua l abuse, domestic violence, wa r, disaster) is associated with are effective treatments. The report is reader-friendly and a substance use and menta l hea lth problems. Services and supports should good introduction to mental health and illness. You can review be trauma-i nformed to foster safety a nd trust, a s well as promote choice, em powerment, a n d c o l l a borati on. the report at http:/ /www.surgeongeneral.gov/library/mental­ 9. Recovery i nvolves ind ividual, fam i ly, and community strengths health/home.html. and responsi b i l ity: I n d ividuals, fa m i l ies, and comm u n ities have strengths and resou rces that serve as a foundation for recovery. H u m a n G e n o m e Project 1 0. Recovery is based on respect: Commun ity, systems, an d societa l The Human Genome Proj ect was a 1 3 -year proj ect that lasted acceptance and a ppreciation of consumers-i ncluding protecting their from 1 990-2003 and was completed on the 5 0th anniver­ rights and e l i m i nating d iscri m i nation a nd stigma-are cruc ial in achieving sary of the discovery of the DNA double helix. The proj ect recovery. has strengthened biological and genetic explanations for 8 U N IT 1 Fo u n d a t i o n s i n T h e o ry psychiatric conditions. The goals of the proj ect (US Depart­ Medicine (IOM). It highlighted effective treatments for mental ment of Energy, 2008) were to do the following: illness and addressed the huge gap between the best care and Identify the approximately 20,000 to 25,000 genes in human the worst. It focused on such issues as the problem of coerced DNA. (forced) treatment, a system that treats mental health issues Determine the sequences of the 3 billion chemical base pairs separately from physical health problems, and lack of quality that make up human DNA. control. The report encouraged healthcare workers to focus on Store this information in databases. safe, effective, patient-centered, timely, efficient, and equitable Improve tools for data analysis. care. Address the ethical, legal, and social issues that may arise Another important and related publication issued by the from the proj ect. Institute of Medicine in 20 1 1 is The Future of Nursing: Focus Researchers are continuing to make progress in understand­ on Education. This report contends that the old way of training ing genetic underpinnings of diseases and disorders. You will nurses is not adequate for the 2 1 st century's complex require­ be learning about these advances in the clinical chapters that ments. It calls for highly educated nurses who are prepared to follow. care for an aging and diverse population with an increasing incidence of chronic disease. They recommended that nurses Pres i d e nt's New Fre e d o m Commission on M e nta l H e a lth be trained in leadership, health policy, system improvement, The President's New Freedom Commission on Mental research, and teamwork. Health chaired by Michael Hogan released its recommenda­ aua/ity and safety education for nurses. Recommendations tions for mental healthcare in America in 2003. This was the from both documents were addressed by a group called Quality first commission since First Lady Rosalyn Carter's (wife of and Safety Education for Nurses (QSEN; pronounced Q-sen) President Jimmy Carter) in 1 978. The report stated that the and were funded by the Robert Wood Johnson Foundation. system of delivering mental healthcare in America was in a They have developed a structure to support the education of shambles. It called for a streamlined system with less frag­ future nurses who possess the knowledge, skills, and attitudes mentation in the delivery of care. The commission advocated to continuously improve the safety and quality of healthcare. for early diagnosis and treatment, adoption of principles of Consider this tragic story: recovery, and increased assistance in helping people find Betsy Lehman was a health reporter for the Boston housing and work. Box 1.2 describes the goals necessary for Globe who was married to a cancer researcher. When she such a transformation of mental healthcare in the United herself was diagnosed with cancer she was prescribed an States. incorrect, extremely high dose of an anticancer drug. Ms. Lehman sensed something was wrong and appealed to the I n stitute of M e d i c i n e healthcare providers who did not respond to her concerns. The Improving the Quality of Health Care for Mental a n d Sub­ The day before she died, she begged others to help because stance- Use Conditions: Quality Chasm Series was released in the professionals were not listening (Robert Wood Johnson 2005 by the Health and Medicine Division (HMD) of the Foundation, 20 1 1 ). National Academies of Medicine, formerly the Institute of How could her death have been prevented? Consider the key areas of care promoted by QSEN and how they could have pre­ vented Ms. Lehman's death: 1. Patient-centered care: Care should be given in an atmo­ sphere of respect and responsiveness, and the patient's val­ ues, preferences, and needs should guide care. Goa1 1 2. Teamwork and collaboration: Nurses and interprofessional Americans understand that menta l hea lth is essenti a l to overa l l hea lth. teams need to maintain open communication, respect, and Goal 2 shared decision making. Menta l hea lthcare is consumer- and fa m i ly-d riven. 3. Evidence-based practice: Optimal healthcare is the result of Goal 3 integrating the best current evidence while considering the Disparities in menta l hea lth services are e l i m inated. patient/family values and preferences. Goal 4 4. Quality improvement: Nurses should be involved in mon­ Early menta l hea lth screening, assessment, and referra l to services a re com­ itoring the outcomes of the care that they give. They should mon practice. also be care designers and test changes that will result in Goa1 5 quality improvement. Exce l l ent menta l hea lthcare is d e l ivered, and research is acce lerated. 5. Safety: The care provided should not add further injury (e.g., Goal 6 Technology is used to access menta l hea lthcare and informatio n. nosocomial infections). Harm to patients and providers are minimized through both system effectiveness and individual Data f r o m U S Department of H ea lth a n d H u m a n S e rvices, Pre s i d e n t ' s N e w performance. Freedom C o m m i s s i o n o n M e ntal H ea l t h. ( 2 003 ). Achieving the promise: Transforming m e n tal health care in America. U S D H H S P u b l ication N o. 6. Informatics: Information and technology are used to com­ S M A-03-383 2. Retrieved from http ://www. m e n ta l h ea lt h co m m issio n. municate, manage knowledge, mitigate error, and support gov/reports/fi n a I report/f u l l report -02. htm decision making.  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 9 B ra i n Research thro u g h Adva n c i n g I n n ovative In response to this problem, advocates fought for parity. This N e u rote c h n o l o g i es ( B RAI N ) I n itiative term means equivalence or equal treatment. The Mental Health In 20 1 3 President Barack Obama announced that $300 million Parity Act was passed in 1 996. This legislation required insurers in public and private funding would be devoted to the Brain that provide mental health coverage to offer annual and lifetime Research through Advancing Innovative Neurotechnologies benefits at the same level provided for medical/surgical cover­ (BRAIN) Initiative. This money would be used to develop inno­ age. Unfortunately, by the year 2000, the Government Account­ vative techniques and technologies to unravel the mystery of ing Office found that although 86% of health plans complied how the brain functions. The goal is to uncover news ways to with the 1 996 law, 87% of those plans actually imposed new prevent, treat, and cure psychiatric disorders, epilepsy, and trau­ limits on mental health coverage. matic brain injury. The Wellstone-Domenici Parity Act was enacted in 2008 According to the National Institutes of Health (20 16) more than for group health plans with more than 50 employees. The law $70 million is going to over 1 70 researchers working at 60 different required that any plan providing mental health coverage must institutions. These researchers are examining such topics as: do so in a manner that is functionally equivalent or on par Developing computer programs that may help researchers with coverage of other health conditions. This parity pertains detect and diagnose autism and Alzheimer's disease from to deductibles, co-payments, coinsurance, and out -of-pocket brain scans expenses, as well as treatment limitations (e.g., frequency of Building a cap that uses ultrasound waves to precisely stimu­ treatment and number/frequency of visits). late brain cells Creating a "neural dust" system made of tiny electric sensors Patient Protecti on a n d Afford a b l e Care Act of 201 0 for wirelessly recording brain activity Parity laws were a good first step in providing more equitable Improving current rehabilitation technologies for helping coverage for mental healthcare. However, parity laws do not the lives of stroke patients require health plans to cover psychiatric care. Furthermore, the Studying how the brain reads and speaks parity laws only applied to large insurers. The Patient Protec­ tion and Affordable Care of 2 0 1 0 (ACA) improves coverage for Rese a rc h Doma i n Criteria ( R D o C ) I n itiative most Americans who are uninsured through a combination of In other specialty areas, symptom-based classification has been expanded Medicaid eligibility (for the very poor), creation of replaced by more scientific understanding of the problem. For Health Insurance Exchanges in the states (to serve as a broker example, physicians do not make a cardiac diagnosis depend­ to help uninsured consumers choose among various plans), and ing on the type of chest pain a person is having but rather on the so-called "insurance mandate;' a requirement that people diagnosing the specific problem such as myocarditis. Psychiatry without coverage obtain it. The ACA improves mental health­ continues to rely heavily on symptoms in the absence of obj ec­ care coverage in several ways (Norris, 2 0 1 6 ) : tive and measurable data. Eliminates medical underwriting i n the individual and small In 20 1 3 the National Institute of Mental Health (NIMH) group markets, so medical history no longer results in enroll­ announced that it would no longer fund DSM diagnosis-based ment denials for preexisting conditions or higher premiums. studies. Instead it would put all of its time, effort, and money Requires all individual and small group health plans to cover into something called the Research Domain Criteria (RDoC) 10 essential health benefits with no annual or lifetime dollar Initiative. This promising initiative challenges researchers to limits. Mental health and addiction treatment are among the seek causes for mental disorders at the molecular level. NIMH essential benefits. hopes to transform the current diagnostic procedure by using Makes health insurance with mental health benefits available genetics, imaging, and fresh information to create a new classi­ for many individuals who previously had been uninsured. fication system. Significant numbers of these (mostly low-income) persons had untreated mental health problems. LEGISLATION AND M ENTAL HEALTH FU NDING Provides for prescription coverage for all new individual and small group health plans, including medications to treat M e nta l H e a lth Parity behavioral health problems. Imagine insurance companies singling out a group of disorders Requires all non-grandfathered health plans-including large such as digestive diseases for reduced reimbursement. Imagine group plans-to cover a range of preventive care at no cost to people with colon cancer being assigned higher co-pays than the patient. other cancers. Imagine limiting the number of treatments for Allows young adults to remain on their parents' health plans which patients could be reimbursed for Crohn's disease over a until age 26. This is important to mental health since most lifetime. People would be outraged by such discrimination. Yet psychiatric disorders emerge in adolescence or early 20s. this is exactly what has happened with psychiatric disorders. Although the ACA has dramatically improved mental health- Too often, insurance companies: care coverage, there are still problems. Problems include finding Did not cover mental healthcare at all a mental health professional for care within certain plans and Identified yearly or lifetime limits on mental health coverage limited coverage for some brand-name drugs, especially anti­ Limited hospital days or outpatient treatment sessions psychotics. Also, health insurance companies may be more Assigned higher co-payments or deductibles than twice as likely to deny authorization for mental health care 10 U N IT 1 Fo u n d a t i o n s i n T h e o ry compared with authorization for general medical care (NAMI, for major depression in New York City schools between 2000 20 1 5). Hopefully, these deficiencies will be addressed as the and 2 0 1 0. ACA continues to be evaluated and evolves. A disease with a short duration such a s the common cold tends to have a high incidence (many new cases in a given year) and a low prevalence (not many people suffering from a cold at EPIDEM IOLOGY OF M ENTAL DISORDERS any given time). Conversely, a chronic disease such as diabetes Epidemiology, as it applies to psychiatric-mental health, is will have a low incidence because the person will be dropped the quantitative study of the distribution of mental disorders from the list of new cases after the first year (or whatever time in human populations. Understanding this distribution helps increment is being used). identify high-risk groups and risk factors associated with illness Lifetime risk data, or the risk that one will develop a disease onset, duration, and recurrence. in the course of a lifetime, will be higher than both incidence According to SAMHSA (20 14), nearly 44 million adults in the and prevalence. According to Kessler, Berglund, and colleagues United States experienced a diagnosable mental illness in 2013. In (2005), 46.4% of all Americans will meet the criteria for a psy­ fact, neuropsychiatric disorders are the leading category of disease chiatric disorder in their lifetimes. Table 1. 1 shows the preva­ with twice the disability as the next category, cardiovascular dis­ lence of some psychiatric disorders in the United States. eases. More than a third of this disability is caused by depression. Originally, epidemiology meant the study of epidemics. Individuals may have more than one mental disorder or Clinical epidemiology is a broad field that examines health and another medical disorder. The simultaneous existence of two or illness at the population level. Studies use traditional epidemi­ more disorders is known as a comorbid condition. For exam­ ological methods and are conducted in groups usually defined ple, schizophrenia is frequently comorbid with diabetes. by the illness or symptoms or by the diagnostic procedures or Two different but related words used in epidemiology are treatments given for the illness or symptoms. Clinical epidemi­ incidence and prevalence. Incidence conveys information about ology includes the following: the risk of contracting a disease. It refers to the number of new Studies of the natural history-what happens if there is no cases of mental disorders in a healthy population within a given treatment and the problem is left to run its course-of an illness period of time, usually annually. An example of incidence is the Studies of diagnostic screening tests number of Atlanta adolescents who were diagnosed with major Observational and experimental studies of interventions depression between 2000 and 200 1. used to treat people with the illness or symptoms Prevalence describes the total number of cases, new and Analysis of epidemiological studies can reveal the frequency existing, in a given population during a specific period of with which psychological symptoms appear together with phys­ time, regardless of when they became ill. An example of prev­ ical illness. For example, epidemiological studies demonstrate alence is the number of adolescents who screened positive that depression is a significant risk factor for death in people Preva lence 12 M onth % Over Receiving Disorder 12 M o nths ( % ) Treatment C o m m e nts Schizophrenia 1.1 45.8 Affects men and women equa l ly Major depressive disorder 6.7 5 1.7 Leading cause of disability in U n ited States and esta b l ished economies worldwide Nearly twice as many women (6.5%) as men (3.3%) suffer from major depressive disorder every year Bipolar d isorder 2.6 48.8 Affects men and women equa l ly General ized anxiety disorder 3.1 43.2 Can begin across l ife cycle; risk is highest between chi ldhood and middle age Pa nic d i sorder 2.7 59. 1 Typica l ly deve l o ps i n ado l escence o r early adu lthood About one i n three people with panic disorder deve lop agoraphobia Obsessive-compulsive disorder No data Fi rst sym ptoms begin i n chi ldhood o r ado l escence Posttra umatic stress disorder 3.5 49.9 Can deve lop at any time ( PTS D ) About 30% of Vietna m vetera ns experienced PTSD after the war; percent- age high among fi rst responders to Sept 1 1 , 2001 , US terrorist attacks S o c i a l phobia 6.8 40. 1 Typica l ly begins in c h i l d hood o r adol escence Agora phobia 0.08 45.8 Begins in young adu lthood Spec ific phobia 8.7 32.4 Begins in chi ldhood Any perso n a l ity disorder 9.1 N o data Antisoc i al personal ity d isorder m ore common i n men Alzheimer's d i sease 10 (65+) Rare, inherited forms can strike i n the 30s-40s 50 (85 yea rs+) Data from Kessler, R. C. , C h i u , W T , D e m l e r, 0. , & Walters, E. E. (2005). Preva l e nce, seve rity, and c o m o rbid ity of twe lve-m onth D S M - I V d i sorders i n t h e N a t i o n a l Comorbid ity S u rvey R e p l ication ( N CS-R ). Archives o f General Psychia try, 62(6), 6 1 7-2 7.  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 11 with cardiovascular disease and premature death in people with 13. Sexual Dysfunctions breast cancer. 14. Gender Dysphoria 1 5. Disruptive, Impulse Control, and Conduct Disorders C l assificati o n of M e nta l D isorders 16. Substance-Related and Addictive Disorders Nursing care, as opposed to medical care, is care based on 1 7. Neurocognitive Disorders responses to illness. Registered nurses do not diagnose, pre­ 18. Personality Disorders scribe, and treat major depression. They treat the problems 19. Paraphilic Disorders associated with depression such as insomnia or hopelessness. 20. Other Disorders Nurses provide effective care using the nursing process as a A common misconception is that a classification of mental guide to holistic care. Nurses, physicians, and other healthcare disorders classifies people, when the DSM actually classifies dis­ providers are part of an interprofessional team. When the team orders. For this reason, the DSM and this textbook avoid the use is well coordinated, it can provide optimal care for the biologi­ of labels such as "a schizophrenic" or "an alcoholic:' Viewing cal, psychological, social, and spiritual needs of patients. the person as a person and not an illness requires more accurate To carry out their diverse professional responsibilities, terms such as "an individual with schizophrenia" or "my patient educators, clinicians, and researchers need clear and accurate has major depression:' guidelines for identifying and categorizing mental illness. For clinicians in particular, such guidelines help in planning and The /CD- 10-CM evaluating their patients' treatment. In an increasingly global society, it is important to view the United At present, there are two major classification systems used in States' diagnosis and treatment of mental illness as part of a bigger the United States: the Diagnostic and Statistical Manual, Fifth picture. The international standard of disease classification is the Edition (DSM-5) and the International Classification ofDisease, International Classification of Diseases, Tenth Revision (ICD-1 0) Tenth Revision, Clinical Modification (ICD- 1 0-CM) (WHO, (WHO, 20 1 6). The United States has adapted this resource with a 2016). Both are important in terms of planning for patient care "clinical modification;' hence its title of ICD-1 0-CM. and determining reimbursement for services. However, the DSM-5 is the dominant method of categorizing and diagnosing PSYCHIATRIC- M ENTAL HEALTH NURSING mental illness in the United States and is the framework for din­ ical disorders in this textbook. In most clinical settings, nurses work with people going through a variety of crises. These crises may be based on physical, psy­ The DSM-5 chological, mental, and spiritual distress. Most of you have The Diagnostic and Statistical Manual (DSM) is a publication of already come across people going through difficult times in the American Psychiatric Association (APA). First published in their lives. While you may have handled these situations well, 1 952, the latest 20 1 3 edition describes criteria for 1 57 disorders. there may have been times when you wished you had additional The development of the DSM-5 was influenced by clinical field skills and knowledge. trials conducted by psychiatrists, psychiatric-mental health The psychiatric nursing rotation will greatly increase your advanced practice registered nurses, psychologists, licensed insight into the experiences of others with mental health alter­ clinical social workers, licensed counselors, and licensed mar­ ations. Exploring mental health and mental illness may even riage and family therapists. help you increase insight into yourself. You will learn essential The DSM identifies disorders based on specific criteria. It is used information about psychiatric disorders and, hopefully, have in inpatient, outpatient, partial hospitalization, consultation-li­ the opportunity to develop new skills for dealing with a vari­ aison, clinics, private practice, primary care, and community set­ ety of behaviors associated with them. The rest of this chapter tings. The DSM also serves as a tool for collecting epidemiological is devoted to psychiatric nursing-what psychiatric nurses do, statistics about the diagnosis of psychiatric disorders. their scope of practice, and the challenges and evolving roles for The following is a list of disorder categories in the DSM-5. the future healthcare environment. You may notice that the order of the list is similar to the way the chapters are organized in this textbook. What Is Psyc h i atri c - M e nta l Hea lth N u rs i n g ? 1. Neurodevelopmental Disorders Psychiatric-mental health nursing i s the nursing specialty that 2. Schizophrenia Spectrum Disorders is dedicated to promoting mental health through the assess­ 3. Bipolar and Related Disorders ment, diagnosis, and treatment of behavioral problems, mental 4. Depressive Disorders disorders, and comorbid conditions across the lifespan (Amer­ 5. Anxiety Disorders ican Nurses Association et al., 20 14). Psychiatric-mental health 6. Obsessive-Compulsive Disorders nurses work with people throughout their life span: children, 7. Trauma and Stressor-Related Disorders adolescents, adults, and the elderly. 8. Dissociative Disorders Psychiatric-mental health nurses assist people who are in 9. Somatic Symptom Disorders crisis or who are experiencing life problems, as well as those 10. Feeding and Eating Disorders with long-term mental illness. These nurses work with patients 1 1. Elimination Disorders with dual diagnoses (e.g., a mental disorder and a comorbid 12. Sleep-Wake Disorders substance disorder), homeless persons and families, forensic 12 U N IT 1 Fo u n d a t i o n s i n T h e o ry Kamitsuru, 20 14) provides standardized diagnoses, many of which are related to psychosocial/psychiatric nursing care. These diagnoses provide a common language to aid in the Phenomena of concern for psychiatric-menta l hea lth n u rses include: selection of nursing interventions and ultimately lead to out­ Promotion of opti m a l menta l and physica l hea lth and well-being come achievement. Prevention of menta l a n d behaviora l distress and i l l ness Promotion of socia l inclusion of menta l ly and behaviora l ly fra g i l e DSM-5 a n d NAN DA-1-A p p roved N u rs i n g D i a g noses individua l s Co-occurring menta l hea lth and substa nce use disorders Psychiatric-mental health nursing includes the diagnosis and Co-occurring menta l hea lth and physical disorders treatment of human responses to actual or potential mental Alterations in thinking, perceivi ng, commun icati ng, and functi oning related health problems. "A nursing diagnosis is a clinical judgment to psycholog ica l and physiological d istress concerning a human response to health conditions/life pro­ Psychological and physiological distress resu lting from physica l , interper­ cesses, or vulnerability for that response by an individual, fam­ sona l , a nd/or environment tra uma or neglect ily, group, or community" (Herdman & Kamitsuru, 20 14, p. 25). Psychogenesis and individua l vulnera b i l ity While the DSM-5 is used to diagnose a psychiatric disorder, Complex c l i n ica l presentations confounded by pove rty and poor, inconsis­ a well-defined nursing diagnosis provides the framework for tent, o r toxic environmenta l factors identifying appropriate nursing interventions for dealing with Alterations in se lf-concept re lated to loss of physical organs a nd/or l i m bs, the patient's reaction to the disorder. psychic trauma, d eve lopmenta l conflicts, or injury I n d ividua l , fa m i l y, or group isolation and d ifficu lty with interpersonal re la- Nursing Outcomes Classification (NOC) tions Se lf-harm a n d self-destructive behaviors including m utilation and suicide The Nursing Outcomes Classification (NOC) is a comprehen­ Violent behavior including physical abuse, sexua l abuse, and bul lying sive source for standardized outcomes and definitions of these Low hea lth l iteracy rates contributing to treatment nonadherence outcomes (Moorhead et al., 2 0 1 3 ). A five-point Likert scale is used with all outcomes and indicators. A rating of 5 is always From A m e ric a n Psych iatric N u rses Assoc i a t i o n , I nternati o n a l Society of Psyc h iatric- M e n t a l H ea lth N u rses, & American N u rses Associati o n. (2 0 1 4). the best possible score and a rating of 1 is always the worst pos­ Psychiatric-m e n tal health nursing: Scope and s tandards o f practice (2nd sible scale. Words used in the scales include 1 = Extremely com­ ed. ). S i lver S p r i n g , M D N u rs e s B o o ks. o r g. promised to 5 = Not compromised and 1 =Never demonstrated to 5 = Consistently demonstrated. patients (i.e., people in jail), and individuals who have survived The 490 outcomes are listed in alphabetical order. Outcomes abusive situations. Psychiatric-mental health nurses work with are organized into seven domains: functional health, physiolog­ individuals, couples, families, and groups in every nursing set­ ical health, psychosocial health, health knowledge and behav­ ting. They work with patients in hospitals, in their homes, in ior, perceived health, family health, and community health. The halfway houses, in shelters, in clinics, in storefronts, on the psychosocial health domain includes four classes: psychologi­ street-virtually everywhere. cal well-being, psychosocial adaptation, self-control, and social The Psychiatric-Mental Health Nursing: Scope and Standards interaction. of Practice defines the specific activities of the psychiatric-men­ tal health nurse. This publication-jointly written in 2 0 1 4 by the Nursing Interventions Classification (NIC) American Nurses Association (ANA), the American Psychiatric The Nursing Interventions Classification (NIC) is another Nurses Association (APNA), and the International Society of book used to standardize, define, and measure nursing care. Psychiatric-Mental Health Nurses (ISPN)-defines the focus The NIC (Bulechek et al., 20 1 3 ) defines a nursing interven­ of psychiatric-mental health nursing as "promoting mental tion as "any treatment, based upon clinical judgment and health through the assessment, diagnosis, and treatment of knowledge, that a nurse performs to enhance patient/client human responses to mental health problems and psychiatric outcomes" (p. xv) including direct and indirect care through disorders" (p. 14). a series of nursing activities. There are seven domains: basic The psychiatric-mental health nurse uses the same nursing physiological, complex physiological, behavioral, safety, family, process you have already learned to assess and diagnose patients' health system, and community. Two domains relate specifically illnesses, identify outcomes, and plan, implement, and evaluate to psychiatric nursing: behavioral, including communication, nursing care. Box 1. 3 describes phenomena of concern-human coping, and education, and safety, covering crisis and risk experiences and responses-for psychiatric-mental health nurses. management. C l assificati o n of N u rs i n g D i a g n oses, O utcomes, Leve ls of Psyc h i atri c - M e nta l Hea lth C l i n ic a l and I nterventi ons N u rs i n g Practi ce To provide the most appropriate and scientifically sound Psychiatric-mental health nurses are registered nurses edu­ care, the psychiatric-mental health nurse uses standardized cated in nursing and licensed to practice in their individual classification systems developed by professional nursing states. Psychiatric nurses are qualified to practice at two levels, groups. The book Nursing Diagnoses: Definitions and Clas­ basic and advanced, depending on educational preparation. sification 201 5-201 7 of the North American Nursing Diag­ Table 1. 2 describes basic and advanced psychiatric nursing nosis Association International (NANDA-I ; Herdman & interventions.  CH APTE R 1 M e n ta l H e a l t h a n d M e n ta l I l l n e s s 13 Adva n c e d Pract i c e One of the first advanced practice nursing roles in the United States was the psychiatric clinical nurse specialist in the 1 950s. These expert nurses were originally trained to provide indi­ Basic Level vidual therapy and group therapy in state psychiatric hospitals I nterventio n Description and to provide training for other staff. Eventually they, along Coordination of ca re Coordinates implementation of the n u rsing care with psychiatric nurse practitioners who were introduced in the plan and docum ents coordination of care mid - 1 960s, gained diagnostic privileges, prescriptive authority, Hea lth teaching and hea lth Individual ized antici patory g u idance to prevent and the ability to provide psychotherapy. maintenance or reduce menta l i l l ness or enhance menta l Currently, the psychiatric-mental health advanced practice hea lth ( e. g. , commun ity screen ings, parenting registered nurse (PMH-APRN) is a licensed registered nurse cla sses, stress managem ent) M i l ieu thera py Provides. structures. and maintains a safe and with a Master of Science in Nursing (MSN) or Doctor of Nurs­ therapeutic environment in collaboration with ing Practice (DNP) in psychiatric nursing. This DNP is not to patients, fam ilies, and other hea lthcare clinicians be confused with a doctoral degree in nursing (PhD), which Pharmaco logica l , biolog­ Applies c urrent knowledge to assessing patient's is a research degree, whereas the DNP is a practice doctorate. ica l , and integrative response to med ication, provides med ication The PMH-APRN may function autonomously depending on therapies teaching, and commun icates observations to the state and is eligible for specialty privileges. Some advanced other mem bers of the hea lthcare team practice nurses continue their education to the PhD level. Unlike other specialty areas, there is no significant differ­ Adva nced Practice ence between a psychiatric nurse practitioner (NP) and a clin­ I nterventio n Description ical nurse specialist (CNS) as long as the CNS has achieved All o f the Above P l u s : prescriptive authority. Certification is required and is obtained Med ication prescription Prescription of psychotro pic med ications with through the American Nurses Credentialing Center. Only one and treatment appropriate use of diag nostic tests; hospita l adm itting privileges examination-the Psychiatric-Mental Health Nurse Practi­ Psychothera py I n d ivid u a l. couple. group, or fam i ly thera py using tioner-Board Certified (PMHNP-BC) -is currently available. evidence-based therapeutic fra meworks and Three other examinations have been discontinued: the n u rse-patient re lationship Adult Psychiatric-Mental Health Nurse Practitioner-Board Consu ltation Sharing of c l inical expertise with nurses or those Certified (PMHNP-BC) in other disciplines to enhance their treatment Adult Psychiatric-Mental Health Clinical Nurse Specialist­ of patients or address systems issues Board Certified (PMHCNS-BC) Data from American Psyc h iatric N u rses Associat i o n , I nternat i o n a l Child/ Adolescent Psychiatric-Mental Health Clinical Nurse Soci ety of Psyc h iatric-M ental H ea l t h N u rses, & American N u rses Asso­ Specialist-Board Certified (PMHCNS-BC) ciati o n. (2 0 1 4). Psychia tric-mental health nursing: Scope and standards While these examinations are no longer given, you will still of practice. S i lver S p r i n g , M D : N u rs e B o o k s. o r g. find many nurses who practice in these roles. Their credentials will continue to be renewed if professional development and B a s i c Leve l practice hour requirements are met. Basic level registered nurses are professionals who have com­ pleted a nursing program, passed the state licensure exam­ FUTURE ISS U ES FOR PSYCHIATRIC- M ENTAL ination, and are qualified to work in most any general or HEALTH NURS ES specialty area. The psychiatric-mental health registered nurse (PMH-RN) is a nursing graduate who possesses a diploma, Significant trends will affect the future of psychiatric nursing in an associate degree, or a baccalaureate degree and chooses to the United States. These trends include educational challenges, work in the specialty of psychiatric-mental health nursing. At an aging population, increasing cultural diversity, and expand­ the