Table Of Content

xiii ➤ ➤ ➤ ➤ ➤ Contents ➤Unit 1 Current Theories and Practice 1 Foundations of Psychiatric- Mental Health Nursing 00 Mental Health and Mental Illness 00 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 00 Historical Perspectives of the Treatment of Mental Illness 00 Mental Illness in the 21st Century 00 Psychiatric Nursing Practice 00 Self-Awareness Issues 00 2 Neurobiologic Theories and Psychopharmacology 00 The Nervous System and How It Works 00 Brain Imaging Techniques 00 Neurobiologic Causes of Mental Illness 00 The Nurse’s Role in Research and Education 00 Psychopharmacology 00 Cultural Considerations 00 Self-Awareness Issues 00 3 Psychosocial Theories and Therapy 00 Psychosocial Theories 00 Cultural Considerations 00 Treatment Modalities 00 The Nurse and Psychosocial Interventions 00 Self-Awareness Issues 00 4 Treatment Settings and Therapeutic Programs 00 Treatment Settings 00 Psychiatric Rehabilitation Programs 00 Special Populations of Clients With Mental Illness 00 Interdisciplinary Team 00 Psychosocial Nursing in Public Health and Home Care 00 Self-Awareness Issues 00 ➤Unit 2 Building the Nurse–Client Relationship 5 Therapeutic Relationships 00 Components of a Therapeutic Relationship 00 Types of Relationships 00 Establishing the Therapeutic Relationship 00 Avoiding Behaviors That Diminish the Therapeutic Relationship 00 Roles of the Nurse in a Therapeutic Relationship 00 Self-Awareness Issues 00 6 Therapeutic Communication 00 What Is Therapeutic Communication? 00 Verbal Communication Skills 00 Nonverbal Communication Skills 00 Understanding the Meaning of Communication 00 Understanding Context 00 Understanding Spirituality 00 Cultural Considerations 00 The Therapeutic Communication Session 00 Community-Based Care 00 Self-Awareness Issues 00 7 Client’s Response to Illness 00 Individual Factors 00 Interpersonal Factors 00 Cultural Factors 00 Self-Awareness Issues 00 8 Assessment 00 Factors Influencing Assessment 00 How to Conduct the Interview 00 Content of the Assessment 00 Data Analysis 00 Self-Awareness Issues 00 ➤Unit 3 Current Social and Emotional Concerns 9 Legal and Ethical Issues 00 Legal Considerations 00 Ethical Issues 00 Self-Awareness Issues 00 10 Anger, Hostility, and Aggression 00 Onset and Clinical Course 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Treatment 00 Application of the Nursing Process 00 Community-Based Care 00 Self-Awareness Issues 00 11 Abuse and Violence 00 Clinical Picture of Abuse and Violence 00 Characteristics of Violent Families 00 Cultural Considerations 00 Spouse or Partner Abuse 00 Child Abuse 00 Elder Abuse 00 Rape and Sexual Assault 00 Community Violence 00 Psychiatric Disorders Related to Abuse and Violence 00 Application of the Nursing Process 00 Self-Awareness Issues 00 12 Grief and Loss 00 Types of Losses 00 The Grieving Process 00 Dimensions of Grieving 00 Cultural Considerations 00 Disenfranchised Grief 00 Complicated Grieving 00 Application of the Nursing Process 00 Self-Awareness Issues 00 ➤Unit 4 Nursing Practice for Psychiatric Disorders 13 Anxiety and Anxiety Disorders 00 Anxiety as a Response to Stress 00 Incidence 00 Onset and Clinical Course 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Treatment 00 Community-based Care 00 Mental Health Promotion 00 Panic Disorder 00 Application of the Nursing Process: Panic Disorder 00 Phobias 00 Obsessive-Compulsive Disorder 00 Application of the Nursing Process: Obsessive-Compulsive Disorder 00 Generalized Anxiety Disorder 00 Posttraumatic Stress Disorder 00 Acute Stress Disorder 00 Self-Awareness Issues 00 14 Schizophrenia 00 Clinical Course 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Treatment 00 Application of the Nursing Process 00 Community-Based Care 00 Mental Health Promotion 00 Self-Awareness Issues 00 15 Mood Disorders and Suicide 00 Categories of Mood Disorders 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Major Depressive Disorder 00 Application of the Nursing Process: Depression 00 Bipolar Disorder 00 Application of the Nursing Process: Bipolar Disorder 00 Suicide 00 Community-Based Care 00 Mental Health Promotion 00 Self-Awareness Issues 00 16 Personality Disorders 00 Categories of Personality Disorders 00 Onset and Clinical Course 00 Etiology 00 Cultural Considerations 00 Treatment 00 Paranoid Personality Disorder 00 Schizoid Personality Disorder 00 Schizotypal Personality Disorder 00 Antisocial Personality Disorder 00 Application of the Nursing Process: Antisocial Personality Disorder 00 Borderline Personality Disorder 00 Application of the Nursing Process: Borderline Personality Disorder 00 Histrionic Personality Disorder 00 Narcissistic Personality Disorder 00 Avoidant Personality Disorder 00 Dependent Personality Disorder 00 Obsessive-Compulsive Personality Disorder 00 Depressive Personality Disorder 00 Passive-Aggressive Personality Disorder 00 xiv Contents Community-Based Care 00 Mental Health Promotion 00 Self-Awareness Issues 00 17 Substance Abuse 00 Types of Substance Abuse 00 Onset and Clinical Course 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Types of Substances and Treatment 00 Treatment and Prognosis 00 Application of the Nursing Process 00 Community-Based Care 00 Mental Health Promotion 00 Substance Abuse in Health Professionals 00 Self-Awareness Issues 00 18 Eating Disorders 00 Overview of Eating Disorders 00 Etiology 00 Cultural Considerations 00 Treatment 00 Application of the Nursing Process 00 Community-Based Care 00 Mental Health Promotion 00 Self-Awareness Issues 00 19 Somatoform Disorders 00 Overview of Somatoform Disorders 00 Onset and Clinical Course 00 Related Disorders 00 Etiology 00 Cultural Considerations 00 Treatment 00 Application of the Nursing Process 00 Community-Based Care 00 Mental Health Promotion 00 Self-Awareness Issues 00 20 Child and Adolescent Disorders 00 Autistic Disorder 00 Rett’s Disorder 00 Childhood Disintegrative Disorder 00 Asperger’s Disorder 00 Attention Deficit Hyperactivity Disorder 00 Application of the Nursing Process: ADHD 00 Conduct Disorder 00 Application of the Nursing Process: Conduct Disorder 00 Community-Based Care 00 mental health promotion 00 Oppositional Defiant Disorder 00 Pica 00 Rumination Disorder 00 Feeding Disorder 00 Tourette’s Disorder 00 Chronic Motor or Tic Disorder 00 Separation Anxiety Disorder 00 Selective Mutism 00 Reactive Attachment Disorder 00 Stereotypic Movement Disorder 00 Self-Awareness Issues 00 21 Cognitive Disorders 00 Delirium 00 Application of the Nursing Process: Delirium 00 Community-Based Care 00 Dementia 00 Application of the Nursing Process: Dementia 00 Community-Based Care 00 mental health promotion 00 Role of the Caregiver 00 Related Disorders 00 Self-Awareness Issues 00 Contents xv ix ➤ ➤ ➤ ➤ ➤ The second edition of Psychiatric Mental Health Nurs- ing continues to have students as the primary focus. It presents sound nursing theory, therapeutic modalities, and clinical applications across the treatment continuum. Chapters are short, to the point, and easy to read and understand. They highlight and empha- size important material to facilitate student learning. This text uses the nursing process framework and emphasizes assessment, therapeutic communication, neurobiologic theory, and pharmacology throughout. Interventions focus on all aspects of client care, including communication, client and family teaching, and community resources, and their practical application in various clinical settings. Organization of the Text Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses current issues in psychiatric nursing, as well as the many treatment settings in which nurses encounter clients. It discusses neurobiologic theories and psychopharmacology and psychosocial theories and therapy thoroughly as a basis for understanding mental illness and its treatment. Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practice of mental health nursing. Chapters on therapeutic relationships and therapeutic communication pre- pare students to begin working with clients both in mental health settings and in all other areas of nursing practice. The chapter on the client’s response to illness provides a framework for understanding the individual client. An entire chapter is devoted to assessment, emphasizing its importance in nursing. Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental health settings, including legal and ethical issues; anger, aggression, and hostility; abuse and violence; and grief and loss. Nurses in all practice settings find themselves confronted with issues related to these topics. Additionally, many legal and ethical concerns are interwoven with issues of violence and loss. Unit 4: Nursing Practice for Psychiatric Dis- orders covers all the major categories identified in the DSM-IV-TR. Each chapter provides current informa- tion on etiology, onset and clinical course, treatment, and nursing care. New Features in the Second Edition • A new chapter on Legal and Ethical Issues addresses some current dilemmas in psychiatric nursing today. • Sections on Mental Health Promotion in Units 3 & 4 include the latest research. • Additional NCLEX-style multiple-choice questions are found in the Chapter Study Guide sections. • Updates in pharmacology include new drugs currently being tested and FDA Black Box Warnings for psychotropic medications. • Additional artwork illustrates key terms and concepts. Pedagogical Features Psychiatric Mental Health Nursing incorporates several pedagogical features designed to facilitate student learning: • Learning Objectives to focus the student’s reading and study • Key Terms that identify new terms used in the chapter. Each term is identified in bold and defined in the text. • Application of the nursing process using the assessment framework presented in Chapter 8, so students can compare and contrast the various disorders more easily • Critical thinking questions to stimulate students’ thinking about current dilemmas and issues in mental health • Key points that summarize chapter content to reinforce important concepts • Chapter Study Guides that provide workbook- style questions for students to test their knowledge and understanding of each chapter Preface Special Features • Clinical vignettes are provided for each major disorder discussed in the text to “paint a picture” for better understanding. • Drug alerts highlight essential points about psychotropic drugs. • Cultural considerations are emphasized in a separate section of each chapter in response to increasing diversity. • Therapeutic dialogues give specific examples of nurse–client interaction to promote therapeutic communication skills. • Internet resources with URLs are located at the end of each chapter to further enhance study. • Client and family education checklists are highlighted to strengthen students’ roles as educators. • Symptoms and interventions are highlighted for all chapters in Units 3 and 4. • Sample nursing care plans are provided for all chapters in Units 3 and 4. • Self-awareness feature at the end of each chapter encourages students to reflect upon themselves, their emotions, and their attitudes as a way to foster both personal and professional development. To the Faculty The following ancillary materials have been pre- pared to help you plan class and clinical learning activities, and evaluate students’ learning: • Instructor’s Resource Manual will include a variety of instructional support features for each chapter, including chapter summa- ries, lecture outlines, and teaching–learning strategies that involve classroom, clinical, and self-awareness activities. In addition, guide- lines are provided for leading class discussion relating to Critical Thinking Questions included in the textbook. Transparency masters provide summary lists of symptoms, interventions, and Client and Patient Teaching checklists for each of the 12 disorder chapters. • CD-ROM, included in the Instructor’s Resource Manual, contains: • Testbank containing 350 NCLEX-style test- ing items • Lecture outlines for each chapter • Powerpoint slide presentation To the Student This textbook has been written for you. Above all, it is designed to be “student-friendly.” Chapters are easy to read and understand, and pertinent infor- mation about caring for clients is presented in a practical, hands-on approach. Mental health nursing is an exciting and challenging field, and hope- fully that attitude comes through in this text. The knowledge and skills you develop while studying mental health nursing will promote your growth as a nurse and improve the care you provide to clients in all settings. In addition to the text itself, we are including a free CD-ROM in the back of the book. This CD contains an interactive Case Study on Anxiety, helpful additional NCLEX review questions, view guides to accompany films depicting common psychiatric disorders, and printable psychotropic drug monographs. Also, for more psychiatric-related materials to enhance your learning, be sure to visit http://connection.lww.com Sheila L. Videbeck, PhD, RN x PREFACE vii ➤ ➤ ➤ ➤ ➤ Chapter 12 Charlotte M. Spade, MS, RN, CS Associate Professor of Nursing Community College of Denver Denver, Colorado Contributor v ➤ ➤ ➤ ➤ ➤ Reviewers Linda Barratt, RN, BA, MA Instructor British Columbia Institute of Technology Burnaby, British Columbia, Canada Carolyn R. Pierce Buckelew, BSN, MA, APN, RNCS, NCC, ChP Nursing Instructor CE Gregory School of Nursing Raritan Bay Medical Center Perth Amboy, New Jersey Lucindra Campbell, MSN, APNP Assistant Professor of Nursing Houston Baptist University Houston, Texas Pattie Garrett Clark, RN, MSN Associate Professor and Nursing Outreach Coordinator Abraham Baldwin College Tifton, Georgia Carol Cornwell, PhD, MS, RN, CS Assistant Professor of Nursing and Director, Center for Nursing Scholarship Georgia Southern University School of Nursing Statesboro, Georgia Lesly Curtis, RN, BS, MS, MA Assistant Professor of Clinical Nursing Director, Entry to Practice Program Columbia University school of Nursing New York, New York Pamela Farley, RN, PhD Professor and Chairperson Berea College Berea, Kentucky Suzette Farmer, RN, MS Assistant Professor, Assistant Program Director Utah Valley State College Orem, Utah Cynthia Foust, PhD, RN Associate Professor Division of Nursing Southwestern Oklahoma State University Weatherford, Oklahoma Judith A. Gardner, MSN, RN, CNS Full-Time Nursing Faculty and Consultant Stark State College Canton, Ohio Alice Grady, MSN, RN, FNP Assistant Professor Nursing Department Tennessee Wesleyan College, Fort Sanders Knoxville, Tennessee Mary Ann Helms, MSN, MRE, RN Assistant Professor Tennessee State University School of Nursing Nashville, Tennessee Barbara A. Jones, DNSc, RN Associate Professor School of Nursing Gwynedd-Mercy College Gwynedd Valley, Pennsylvania Nancy G. McAfee, MSN, RN Program Director, Upward Mobility Program Lamar State College—Orange Orange, Texas Elaine Mordoch, RN, BN, MN Lecturer, Faculty of Nursing University of Manitoba Winnipeg, Manitoba, Canada Susan R. Seager, RN, MSN, EdD Associate Professor, Nursing Tennessee State University School of Nursing Nashville, Tennessee Margaret R. Swisher, RN, MSN Assistant Professor of Nursing Montgomery County Community College Blue Bell, Pennsylvania Charlotte D. Taylor RN, MSN Associate Professor of Nursing University of Arkansas–Monticello Monticello, Arkansas Arlene Wandel Zawadzki, MS, RN, CS, HNC Part-time Instructor Niagara County Community College Sanborn, New York vi REVIEWERS Unit 1➤ Current Theories and Practice 2 1 Learning Objectives After reading this chapter, the student should be able to 1. Describe characteristics of mental health and mental illness. 2. Discuss the purpose and use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 3. Identify important historical landmarks in psychiatric care. 4. Discuss current trends in the treatment of people with mental illness. 5. Discuss the American Nurses Association standards of practice for psychiatric-mental health nursing. 6. Describe common student concerns about psychiatric nursing. Key Terms asylum case management deinstitutionalization Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) managed care managed care organizations Foundations of Psychiatric- Mental Health Nursing ➤ ➤ ➤ ➤ ➤ mental disorder mental health phenomena of concern psychotropic drugs revolving door self-awareness standards of care utilization review firms As you begin the study of psychiatric-mental health nursing, you may be excited, uncertain, and even a little anxious. The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine “What is this experience going to be like?” or “What does a nurse do in this area?” This chapter addresses these and other questions by providing an overview of the history of mental illness, advances in treatment, current issues in mental health, and the role of the psychiatric nurse. MENTAL HEALTH AND MENTAL ILLNESS Mental health and mental illness are difficult to de- fine precisely. People who can carry out their roles in society and whose behavior is appropriate and adap- tive are viewed as healthy. Conversely those who fail to fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The cul- ture of any society strongly influences its values and beliefs, and this in turn affects how that society defines health and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive or inappropriate. Mental Health The World Health Organization (WHO) defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. This definition emphasizes health as a positive state of well-being, not just absence of disease. People in a state of emotional, physical, and social well-being fulfill life responsibilities, function effec- tively in daily life, and are satisfied with their interpersonal relationships and themselves. No single, universal definition of mental health exists. Generally a person’s behavior can provide clues to his or her mental health. Because each person can have a different view or interpretation of behavior (depending on his or her values and beliefs), the de- termination of mental health may be difficult. In most cases, 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 stabil- ity. Mental health has many components, and a wide variety of factors influence it (Mohr, 2003): • Autonomy and independence: The person can look within for guiding values and rules by which to live. He or she considers the opinions and wishes of others but does not allow them to dictate decisions and behavior. The person who is autonomous and independent can work interdependently or cooperatively with others without losing his or her autonomy. • Maximization of one’s potential: The person is oriented toward growth and self-actualization. He or she is not content with the status quo and continually strives to grow as a person. • Tolerance of life’s uncertainties: The person can face the challenges of day-to-day living with hope and a positive outlook despite not knowing what lies ahead. • Self-esteem: The person has a realistic awareness of his or her abilities and limitations. • Mastery of the environment: The person can deal with and influence the environment in a capable, competent, and creative manner. • Reality orientation: The person can distin- guish the real world from a dream, fact from fantasy, and act accordingly. • Stress management: The person can tolerate life stresses, appropriately handle anxiety or grief, and experience failure without devas- tation. He or she uses support from family and friends to cope with crises, knowing that the stress will not last forever. These factors constantly interact; thus, a person’s mental health is a dynamic or ever-changing state. Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social/cultural. Individual factors include a person’s biologic makeup, sense of harmony in life, vitality, ability to find meaning in life, emotional resilience or hardiness, spirituality, and positive identity (Seaward, 1997). Interpersonal factors include effective communication, ability to help others, intimacy, and a balance of separateness and connection. Social/ cultural factors include a sense of community, access to adequate resources, intolerance of violence, and support of diversity among people. Individual, interpersonal, and social/cultural factors are discussed in Chapter 7. Mental Illness The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (p. xxxi). General criteria to diagnose mental disorders include dissatisfaction with one’s characteristics, abilities, and accomplishments; ineffective or nonsatisfying relationships; dissatisfaction with one’s place in the world; ineffective coping 1 FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING 3 with life events; and lack of personal growth. In addition, the person’s behavior must not be culturally expected or sanctioned, nor does deviant behavior necessarily indicate a mental disorder (APA, 2000). Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/ cultural categories. Individual factors include biologic makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in one’s life (Seaward, 1997). Interpersonal factors include ineffective communication, excessive dependency or withdrawal from relationships, and loss of emotional control. Social and cultural factors include lack of resources, violence, homelessness, poverty, and discrim- ination such as racism, classism, ageism, and sexism. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR) The Diagnostic and Statistical Manual of Men- tal Disorders-Text Revision (DSM-IV-TR), now in its fourth edition, is a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. All mental health clinicians who diagnose psychiatric disorders use the DSM-IV-TR. The DSM-IV-TR has three purposes: • To provide a standardized nomenclature and language for all mental health professionals • To present defining characteristics or symptoms that differentiate specific diagnoses • To assist in identifying the underlying causes of disorders A multi-axial classification system that involves assessment on several axes, or domains of informa- tion, allows the practitioner to identify all the factors that relate to a person’s condition: • Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders. Examples include depression, schizophrenia, anxiety, and substance-related disorders. • Axis II is for reporting mental retardation and personality disorders as well as promi- nent maladaptive personality features and defense mechanisms. • Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person. • Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and legal system. • Axis V presents a Global Assessment of Functioning (GAF), which rates the person’s overall psychological functioning on a scale of 0 to 100. This represents the clinician’s assessment of the person’s current level of functioning; the clinician also may give a score for prior functioning (for instance, high- est GAF in past year or GAF 6 months ago). All clients admitted to a hospital for psychiatric treatment will have a multi-axis diagnosis from the DSM-IV-TR. Although student nurses do not use the DSM-IV-TR to diagnose clients, they will find it a helpful resource to understand the rea- son for the admission and to begin building knowledge about the nature of psychiatric illnesses. HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL ILLNESS Ancient Times People of ancient times believed that any sickness indicated displeasure of the gods and in fact was pun- ishment for sins and wrongdoing. Those with mental 4 Unit 1 CURRENT THEORIES AND PRACTICE Demons disorders were viewed as being either divine or demonic depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake. Later Aristotle (382–322 BC) at- tempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These four substances, or humors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to cause mental disorders, so treatment aimed at restoring balance through bloodletting, starving, and purging. Such “treatments” persisted well into the 19th century (Baly, 1982). In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exor- cisms to rid evil spirits. When that failed, they used more severe measures such as incarceration in dun- geons, flogging, starving, and other brutal treatments. During the Renaissance (1300–1600), people with mental illness were distinguished from criminals in England. Those considered harmless were allowed to wander the countryside or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547, the Hospital of St. Mary of Bethlehem was of- ficially declared a hospital for the insane, the first of its kind. By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridicul- ing the inmates, who were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the United States), the mentally ill were considered evil or possessed and were punished. Witch hunts were conducted, and offenders were burned at the stake. Period of Enlightenment and Creation of Mental Institutions In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven of- fering protection at institutions where people had been whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995). With this movement began the moral treatment of the mentally ill. In the United States, Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit to Tukes’ institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffering. Dix believed that society was obligated to those who were mentally ill and promoted adequate shelter, nutritious food, and warm clothing (Gollaher, 1995). The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural location of hospitals was viewed as isolating patients from family and their homes, and the phrase “insane asylum” took on a negative connotation. Sigmund Freud and Treatment of Mental Disorders The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856–1939) and others such as Emil Kraepelin (1856–1926) and Eugene Bleuler (1857–1939). With these men, the study of psychiatry and the diagnosis and treatment of mental illnesses started in earnest. Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had before. Many other theorists built on Freud’s pi- oneering work (see Chap. 3). Kraepelin began classi- fying mental disorders according to their symptoms, and Bleuler coined the term “schizophrenia.” Development of Psychopharmacology A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs (drugs used to treat mental illness). Chlor- promazine (Thorazine), an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed. Over the following 10 years, mono- amine oxidase inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents called benzodiazepines were introduced. For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Hos- pital stays were shortened, and many people were well enough to go home. The level of noise, chaos, and violence greatly diminished in the hospital setting (Trudeau, 1993). Move Toward Community Mental Health The movement toward treating those with mental illness in less restrictive environments gained momen- tum in 1963 with the enactment of the Community Mental Health Centers Act. Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began. Community mental health centers served smaller geographic catch- ment (service) areas that provided less restrictive 1 FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING 5 treatment located closer to the person’s home, family, and friends. These centers provided emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education. Therefore, deinsitutionalization had three components: release of individuals from state institutions, diversion from hospitalization, and development of alternative community services (Lamb & Bachrach, 2001). In addition to deinstitutionalization, federal leg- islation was passed to provide an income for disabled persons: Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). This allowed people with severe and persistent mental illnesses to be more independent financially and not have to rely on family for money. States were able to spend less money on care of the mentally ill than they had in state hospitals, because these programs were fed- erally funded. Also commitment laws changed in the early 1970s, making it more difficult to commit people for mental health treatment against their will. This further decreased the state hospital populations and, consequently, the money that states spent on them (Torrey, 1997). MENTAL ILLNESS IN THE 21ST CENTURY The Department of Health and Human Services (2002) estimates that 56 million Americans have a diagnos- able mental illness. Furthermore, mental illnesses or serious emotional disturbances impair daily activities for an estimated 10 million adults and 4 million children and adolescents. For example, attention deficit/ hyperactivity disorder affects 3% to 5% of school-age children. More than 10 million children younger than 7 years grow up in homes where at least one parent suffers from significant mental illness or substance abuse, which hinders the readiness of these children to start school. The economic burden of mental illness in the United States, including both health care costs and lost productivity, exceeds $170 billion (Department of Health and Human Services [DHHS], 2002). Four of the ten leading causes of disability in the United States and other developed countries are mental disorders: major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder (NIMH, 2002). Yet only one in four adults and one in five children and adolescents in need of mental health services get the care they need. Some believe that deinstitutionalization has had negative as well as positive effects (Torrey, 1997). Although deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those beds correspondingly increased by 90% (Appleby & Desai, 1993). Such findings have led to the term revolving door effect. While people with severe and persistent mental illnesses have shorter hospital stays, they are admitted to hospitals more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general hospital psychiatric units. In some cities, emergency department visits for acutely disturbed persons have increased by 400% to 500%. Shorter hospital stays further complicate fre- quent, repeated hospital admissions. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus they are discharged into the community without being able to cope with community living. The re- sult frequently is decompensation and rehospitalization. In addition, many people have a “dual” problem of both severe mental illness and substance abuse. Use of alcohol and drugs exacerbates symptoms of mental illness, again making rehospitalization more likely. Substance abuse issues cannot be dealt with in the 3 to 5 days typical for admissions in the current managed care environment. Many providers believe today’s clients to be more aggressive than those in the past. Four to eight percent of clients seen in psychiatric emergency rooms are armed (Ries, 1997), and people with severe and persistent mental illness who are not receiving adequate care commit about 1,000 homicides per year (Torrey, 1997). Ten to fifteen percent of those in state prisons have severe and persistent mental illness (Lamb & Weinberger, 1998). Homelessness is a major problem in the United States today. The Department of Health and Human Services (2002) estimates that 750,000 people live and sleep in the streets. Estimates of the prevalence 6 Unit 1 CURRENT THEORIES AND PRACTICE Revolving door of mental illness among the homeless population are that one-third of adult homeless persons have a serious mental illness and more than one-half also have substance abuse problems (DHHS, 2002). Those who are homeless and mentally ill are found in parks, air- port and bus terminals, alleys and stairwells, jails, and other public places. Some use shelters, halfway houses, or board-and-care rooms; others rent cheap hotel rooms when they can afford it (Haugland et al., 1997). Homelessness worsens psychiatric problems for many people with mental illness who end up on the streets, which contributes to a vicious cycle. Many problems of the homeless mentally ill, as well as those who pass through the revolving door of psychiatric care, stem from the lack of adequate community resources. Money saved by states when state hospitals were closed has not been transferred to community programs and support. Inpatient psychiatric treatment still accounts for most of the spend- ing for mental health in the United States, so community mental health has never been given the financial base it needs to be effective. In addition, mental health services provided in the community must be individualized, available, and culturally relevant to be effective (Lamb & Bachrach, 2001). Only 15% of people with mental illness appear to be get- ting minimally adequate treatment, which is a pre- scription for medication and four or more visits with a psychiatrist or eight visits with any kind of mental health specialist (Wang, 2002). In 1993, the federal government created and funded Access to Community Care and Effective Ser- vices and Support (ACCESS) to begin to address the needs of people with mental illness who were homeless either all or part of the time. The goals of ACCESS were to improve access to comprehensive services across a continuum of care, reduce dupli- cation and cost of services, and improve the efficiency of services (Randolph et al., 1997). Programs such as these provide services to people who otherwise would not receive them. Objectives for the Future Unfortunately only one in four affected adults and one in five children and adolescents receive treatment (DHHS, 2002). Statistics like these underlie the Healthy People 2010 objectives for mental health proposed by the U.S. Department of Health and Human Services (Box 1-1). These objectives, originally 1 FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING 7 Box 1-1 ➤ HEALTHY PEOPLE 2010 MENTAL HEALTH OBJECTIVES • Reduce suicides to no more than 6 per 100,000 people • Reduce the incidence of injurious suicide attempts by 1% in 12 months for adolescents ages 14–17 • Reduce the proportion of homeless adults who have serious mental illness to 19% • Increase the proportion of persons with serious mental illnesses who are employed to 51% • Reduce the relapse rate for persons with eating disorders including anorexia nervosa and bulimia nervosa • Increase the number of persons seen in primary health care who receive mental health treatment screening and assessment • Increase the proportion of children with mental health problems who receive treatment • Increase the proportion of juvenile justice facilities that screen new admissions for mental health problems • Increase the proportion of adults with mental disorders who receive treatment by 17% • Adults 18–54 with serious mental illness to 55% • Adults 18 and older with recognized depression to 50% • Adults 18 and older with schizophrenia to 75% • Adults 18 and older with anxiety disorders to 50% • Increase the population of persons with concurrent substance abuse problems and mental disorders who receive treatment for both disorders • Increase the proportion of local governments with community-based jail diversion programs for adults with serious mental illness • Increase the number of states that track consumers’ satisfaction with the mental health services they receive to 30 states • Increase the number of states with an operational mental health plan that addresses cultural competence • Increase the number of states with an operational mental health plan that addresses mental health crisis inter- vention, ongoing screening, and treatment services for elderly persons U.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: DHHS.