COMMUNITY AND PUBLIC HEALTH NURSING
PRACTICUM
Types of mental disorders. Symptoms and nursing care.
In the past century, research and public health innovations in Ukraine and worldwide contributed to significant improvements in health and treatment of disease. Once-dreaded diseases, such as cancer and human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS), are increasingly survivable and even curable. The average people’s lifespan has almost doubled, and the physical health of individuals overall has never been better. However, the picture has been different for mental health, which has remained a low national priority, and for mental illness, which has been mostly feared and misunderstood.
Community Mental Health Today
As is evident from this historical view, the understanding of mental illness and mental health has come a long way, yet many challenges remain. The treatment of mental illness remains controversial. Whereas some see mental illness as primarily a physiologic disorder and advocate pharmacologic therapy, others see it as a crisis of meaning, development, or cognition that requires primarily “talk therapy” with a skilled psychotherapist, and still others view mental illness as a spiritual crisis requiring spiritual guidance, meditation, prayer, and a supportive community. All of these views have been prominent in different societies at different historical periods, and all still have some validity today.
Traditionally, mental health services have focused primarily on treatment of the mentally ill. However, in an era of greater enlightenment, the significance of prevention and health promotion are influencing community mental health workers to start expanding the range of services. Today, community mental health is a field of practice that seeks to address the needs of the mentally ill, prevent mental illness, and promote the mental health of the community. With a new national commitment for mental health, advances in research, and improved treatment modalities, the future for promotion of mental health and treatment of mental disorders looks promising.
The Obstacle of Stigma
Despite increased attention to the challenges faced by the mentally ill, the Surgeon General’s report emphasizes that “a formidable obstacle to future progress” remains, and “that obstacle is stigma” (SAMHSA, 1999, p. 5). Stigma is an unjustified mark of shame and discredit attached to mental illness. It is the result of myths and misunderstandings that have been perpetuated down through the ages as illnesses of the mind remained a mystery and a threat. Stigma toward mental illness is largely attributable to ignorance and misconceptions. Until recently, society lacked knowledge about the mind, how it works, why mental illness occurs, and how to successfully recover from it. In addition, most people have experienced some form of mental health problem that is similar to the symptoms of mental illness and assume that anyone can get over it. They greatly underestimate the difficulty of dealing with a painful, disabling SMI. Stigma is also attributable to fear—fear that is spawned by ignorance. Consequently, it is easy to label these illness behaviors as shameful and to shun and discredit those who are the victims. Persistence of stigma and fear is a destructive force that prevents this client population from receiving the health services it needs.
Nevertheless, as discussed earlier, the tide is turning. The White House Conference on Mental Health in 1999 promoted a national anti-stigma campaign, and mental health has become a higher priority nationally, as evidenced in Healthy People 2010 and in the Surgeon General’s 2001 supplemental report calling national attention to ethnic and racial disparities in mental health care (SAMHSA, 2001). Finally, the Global Burden of Disease study (WHO, 1999) showed that mental illness is surprisingly significant in its contribution to the world’s burden of disease. As these efforts spawew information, expanded research, and more effective policies and programs, there will be increasing opportunities, particularly for community mental health nurses, to educate the public and start eradicating the obstacle of stigma.
EPIDEMIOLOGY OF MENTAL DISORDERS
Epidemiologic information about mental illness, which describes its occurrence and distribution in the community, provides a road map that guides community mental health nursing practice. Such information helps the nurse determine what, where, and for whom services are needed. However, in the past, it was not easy to epidemiologically measure the incidence and prevalence of mental illness in the community.
Because mental illness has not been a reportable condition by law, only those individuals who were housed in mental hospitals or asylums could be accurately counted. An even larger number of persons, either receiving treatment through mental health centers and private practices or untreated and living in the community, were unknown to public health policy makers and program planners. Then, in 1952, the American Psychiatric Association first published its Diagnostic and Statistical Manual: Mental Disorders (DSM-I), in order to provide an official manual of mental disorders with a focus on clinical utility. The DSM became a source of diagnostic information for clinical practice, research, and education, in addition to providing a language for communicating about mental illness with other service providers and policy makers.
For epidemiologic purposes, the DSM made it possible to more consistently define mental disorders and to estimate their occurrence in the community. The latest version of this manual, DSM-IV-TR, updates the 1994 publication of DSMIV (American Psychiatric Association, 2000). With publication of DSM-V not expected until approximately 2006, the Text Revision was designed as an intermediary source to bridge the gap between major DSM publications. DSM-IVTR reviews the following axis 1 clinical disorders:
• Disorders usually first diagnosed in infancy, childhood, or adolescence
• Delirium, dementia, and amnestic and other cognitive disorders
• Mental disorders due to a general medical condition
• Substance-related disorders
• Schizophrenia and other psychotic disorders
• Mood disorders
• Anxiety disorders
• Somatoform disorders
• Factitious disorders
• Dissociative disorders
• Sexual and gender identity disorders
• Eating disorders
• Sleep disorders
• Impulse-control disorders not elsewhere classified
• Adjustment disorders
• Other conditions that may be a focus of clinical attention
Incidence and Prevalence of Mental Disorders
Every year, one out of five Americans, or more than 51 million people, experience a diagnosable mental disorder. Of this group, more than 6.5 million, including 4 million children and adolescents, are disabled by an SMI (SAMHSA, 1999). More than 19 million Americans older than 18 years of age will suffer from a depressive illness at some time during their lives, and many of these individuals will be incapacitated for significant lengths of time by their illness. Over two thirds of suicides in the United States each year are caused by major depression, which is also the leading cause of disability. More than 2 million Americans 18 years of age and older, about 1% of the population, suffer from bipolar disorder, and an almost equal number of adults suffer from schizophrenia. Indeed, almost all people who kill themselves have a diagnosable mental disorder (NIMH, 2001).
Studies focusing on the prevalence of mental illness are limited and sometimes inconclusive; however, the poor, the poorly educated, and the unemployed typically experience higher rates of mental illness than the general population. A large portion of the mentally ill population, many of whom are homeless, remain untreated in the community. The poor, disproportionately representative of racial and ethnic minorities, are even more vulnerable due to lack of access to care and questionable quality of the care that is received (SAMHSA, 2001).
Age influences the patterns of mental illness in the community. Each year about one of every five children and adolescents has the signs and symptoms of a DSM-IV disorder. The most commonly occurring conditions among American children ages 9 to 17 years are anxiety disorders, disruptive disorders, mood disorders, and substance use disorders. Attention-deficit/hyperactivity disorder (ADHD) affects approximately 4% of U. S. school-age children, with boys two to three times more likely to be affected than girls.
Autism, a developmental disorder, has a prevalence among children of 1 to 2 per 1000 people and is four times more common in boys than in girls (NIMH, 2001) (see Chapter 28). For American adults, the most prevalent mental disorders are anxiety disorders, followed by mood disorders, especially major depression and bipolar disorder. Anxiety, depression, and schizophrenia present special problems for this age group—anxiety and depression because they contribute to such high rates of suicide, and schizophrenia because it is so persistently disabling. For the growing number of older adults, there is increased incidence of Alzheimer disease, major depression, substance abuse, anxiety, and other disabling mental disorders. Particular problems arise with dementia, which causes significant dependency and results in costly long-term care; with depression, which contributes to the high suicide rates among men in this age group; and with the disabling effects of schizophrenia (SAMHSA, 1999).
Gender differences also arise in the prevalence of certain mental disorders. Anxiety disorders and mood disorders, including major depression, occur twice as frequently in women as in men. Women of color, women on welfare, poor women, and uneducated women are more likely to experience depression than women in the general population. The three main types of eating disorders (anorexia, bulimia nervosa, and binge eating) also affect more women than men (NIMH, 2001). Women attempt suicide more frequently than men, but completed suicides are more common among men.
Analysis of national suicide data from 1991 to 1996 suggested that White and African-American widowed men younger than 50 years of age were at particular risk to commit suicide, compared with the general population of married men, and young African-American men were most at risk (Luoma & Pearson, 2002). Vital statistics data from 2000 indicated that White men older than 85 years of age had the highest suicide rate for any group in the United States (Minino et al., 2002).
Adding to the heavy toll that mental illness exacts is the financial burden it creates. Costs associated with treatment of mental disorders, poor productivity, lost work time, and disability payments are astronomical. The direct and indirect costs of mental illness and addictive disorders in the United States. are greater than $400 billion annually (USDHHS, 2000a). Furthermore, the cost to society when treatment is not provided for these illnesses has been estimated to be three to seven times the cost of direct treatment. Certainly, these facts have policy implications and suggest the need for greater preventive and mental health promoting efforts.
Schizophrenia
Schizophrenia (/ˌskɪtsɵˈfrɛniə/ or /ˌskɪtsɵˈfriːniə/) is a mental disorder characterized by a breakdown in thinking and poor emotional responses. Common symptoms include delusions, such as paranoia; hearing voices or noises that are not there; disorganized thinking; a lack of emotion and a lack of motivation. Schizophrenia causes significant social and work problems. Symptoms begin typically in young adulthood and about 0.3–0.7% of people are affected during their lifetime. Diagnosis is based on observed behavior and the person’s reported experiences.
Genetics, early environment, psychological and social processes appear to be important contributory factors. Some recreational and prescription drugs appear to cause or worsen symptoms. The many possible combinations of symptoms have triggered debate about whether the diagnosis represents a single disorder or a number of separate syndromes. Despite the origin of the term from the Greek roots skhizein (“to split”) and phrēn (“mind”), schizophrenia does not imply a “split personality”, or “multiple personality disorder”—a condition with which it is often confused in public perception. Rather, the term means a “splitting of mental functions”, reflecting the presentation of the illness.
The mainstay of treatment is antipsychotic medication, which primarily suppresses dopamine receptor activity. Therapy, job training and social rehabilitation are also important in treatment. In more serious cases—where there is risk to self or others—involuntary hospitalization may be necessary, although hospital stays are now shorter and less frequent than they once were.
The disorder is thought to mainly affect the ability to think, but it also usually contributes to chronic problems with behavior and emotion. People with schizophrenia are likely to have additional conditions, including major depression and anxiety disorders; the lifetime occurrence of substance use disorder is almost 50%. Social problems, such as long-term unemployment, poverty, and homelessness are common. The average life expectancy of people with the disorder is 12 to 15 years less than those without. This is the result of increased physical health problems and a higher suicide rate (about 5%).
Symptoms
Self-portrait of a person with schizophrenia, representing that individual’s perception of the distorted experience of reality in the disorder
Individuals with schizophrenia may experience hallucinations (most reported are hearing voices), delusions (often bizarre or persecutory in nature), and disorganized thinking and speech. The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to speech that is not understandable known as word salad in severe cases. Social withdrawal, sloppiness of dress and hygiene, and loss of motivation and judgment are all common in schizophrenia. There is often an observable pattern of emotional difficulty, for example lack of responsiveness. Impairment in social cognition is associated with schizophrenia, as are symptoms of paranoia; social isolation commonly occurs. Difficulties in working and long-term memory, attention, executive functioning, and speed of processing also commonly occur. In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation, all signs of catatonia. About 30% to 50% of people with schizophrenia do not have insight; in other words, they do not accept their condition or its treatment. Treatment may have some effect on insight. People with schizophrenia often find facial emotion perception to be difficult.
Positive and negative
Schizophrenia is often described in terms of positive and negative (or deficit) symptoms. Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. They can include delusions, disordered thoughts and speech, and tactile, auditory, visual, olfactory and gustatory hallucinations, typically regarded as manifestations of psychosis. Hallucinations are also typically related to the content of the delusional theme. Positive symptoms generally respond well to medication.
Negative symptoms are deficits of normal emotional responses or of other thought processes, and respond less well to medication. They commonly include flat expressions or little emotion, poverty of speech, inability to experience pleasure, lack of desire to form relationships, and lack of motivation. Negative symptoms appear to contribute more to poor quality of life, functional ability, and the burden on others than do positive symptoms. People with greater negative symptoms often have a history of poor adjustment before the onset of illness, and response to medication is often limited.
Onset
Late adolescence and early adulthood are peak periods for the onset of schizophrenia, critical years in a young adult’s social and vocational development. In 40% of men and 23% of women diagnosed with schizophrenia, the condition manifested itself before the age of 19. To minimize the developmental disruption associated with schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms. Those who go on to develop schizophrenia may experience transient or self-limiting psychotic symptoms and the non-specific symptoms of social withdrawal, irritability, dysphoria, and clumsiness during the prodromal phase.
Diagnosis
Schizophrenia is diagnosed based on criteria in either the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), or the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10). These criteria use the self-reported experiences of the person and reported abnormalities in behavior, followed by a clinical assessment by a mental health professional. Symptoms associated with schizophrenia occur along a continuum in the population and must reach a certain severity before a diagnosis is made. As of 2013 there is no objective test.
Mood disorders
Mood disorder is a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR) classification system where a disturbance in the person’s mood is hypothesized to be the main underlying feature.The classification is known as mood (affective) disorders in ICD 10.
English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.
Two groups of mood disorders are broadly recognized; the division is based on whether a manic or hypomanic episode has ever been present. Thus, there are depressive disorders, of which the best-known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and characterized by intermittent episodes of mania or hypomania, usually interlaced with depressive episodes. However, there are also psychiatric syndromes featuring less severe depression known as dysthymic disorder (similar to but milder than MDD) and cyclothymic disorder (similar to but milder than BD). Mood disorders may also be substance-induced or occur in response to a medical condition.
Classification
Depressive disorders
Major depressive disorder (MDD), commonly called major depression, unipolar depression, or clinical depression, wherein a person has one or more major depressive episodes. After a single episode, Major Depressive Disorder (single episode) would be diagnosed. After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent). Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at the bottom “pole” and does not climb to the higher, manic “pole” as in bipolar disorder.
Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide. Seeking help and treatment from a health professional dramatically reduces the individual’s risk for suicide. Studies have demonstrated that asking if a depressed friend or family member has thought of committing suicide is an effective way of identifying those at risk, and it does not “plant” the idea or increase an individual’s risk for suicide in any way.[6] Epidemiological studies carried out in Europe suggest that, at this moment, roughly 8.5 percent of the world’s population are suffering from a depressive disorder. No age group seems to be exempt from depression, and studies have found that depression appears in infants as young as 6 months old who have been separated from their mothers.
Depressive disorder is frequent in primary care and general hospital practice but is often undetected. Unrecognized depressive disorder may slow recovery and worsen prognosis in physical illness, therefore it is important that all doctors be able to recognize the condition, treat the less severe cases, and identify those requiring specialist care.
Diagnosticians recognize several subtypes or course specifiers: Atypical depression (AD) is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (“comfort eating”), excessive sleep or somnolence (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. Difficulties in measuring this subtype have led to questions of its validity and prevalence.
Melancholic depression is characterized by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
Psychotic major depression (PMD), or simply psychotic depression, is the term for a major depressive episode, in particular of melancholic nature, wherein the patient experiences psychotic symptoms such as delusions or, less commonly, hallucinations. These are most commonly mood-congruent (content coincident with depressive themes).
Catatonic depression is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporose, and either is immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms can also occur in schizophrenia or a manic episode, or can be due to neuroleptic malignant syndrome.
Postpartum depression (PPD) is listed as a course specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which affects 10–15% of women, typically sets in within three months of labor, and lasts as long as three months. It is quite common for women to experience a short-term feeling of tiredness and sadness in the first few weeks after giving birth; however, postpartum depression is different because it can cause significant hardship and impaired functioning at home, work, or school as well as, possibly, difficulty in relationships with family members, spouses, or friends, or even problems bonding with the newborn. In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications. Women with personal or family histories of mood disorders are at particularly high risk of developing postpartum depression.
Seasonal affective disorder (SAD), also known as “winter depression” or “winter blues”, is a specifier. Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times over a two-year period or longer. It is commonly hypothesised that people who live at higher latitudes tend to have less sunlight exposure in the winter and therefore experience higher rates of SAD, but the epidemiological support for this proposition is not strong (and latitude is not the only determinant of the amount of sunlight reaching the eyes in winter). SAD is also more prevalent in people who are younger and typically affects more females than males.
Dysthymia is a condition related to unipolar depression, where the same physical and cognitive problems are evident, but they are not as severe and tend to last longer (usually at least 2 years). The treatment of dysthymia is largely the same as for major depression, including antidepressant medications and psychotherapy.
Double depression can be defined as a fairly depressed mood (dysthymia) that lasts for at least two years and is punctuated by periods of major depression.
Depressive Disorder Not Otherwise Specified (DD-NOS) is designated by the code 311 for depressive disorders that are impairing but do not fit any of the officially specified diagnoses. According to the DSM-IV, DD-NOS encompasses “any depressive disorder that does not meet the criteria for a specific disorder.” It includes the research diagnoses of recurrent brief depression, and minor depressive disorder listed below.
Depressive personality disorder (DPD) is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features. Originally included in the DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study.
Recurrent brief depression (RBD), distinguished from major depressive disorder primarily by differences in duration. People with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2–3 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa, and both illnesses have similar risks.
Minor depressive disorder, or simply minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.
Bipolar disorders
Bipolar disorder (BD), an unstable emotional condition characterized by cycles of abnormal, persistent high mood (mania) and low mood (depression), which was formerly known as “manic depression” (and in some cases rapid cycling, mixed states, and psychotic symptoms).
Subtypes include:
Bipolar I is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes. A depressive episode is not required for the diagnosis of Bipolar I Disorder, but depressive episodes are usually part of the course of the illness.
Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes.
Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
Bipolar Disorder Not Otherwise Specified (BD-NOS), sometimes called “sub-threshold” bipolar, indicates that the patient suffers from some symptoms in the bipolar spectrum (e.g., manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.
It is estimated that roughly 1% of the adult population suffers from bipolar I, a further 1% suffers from bipolar II or cyclothymia, and somewhere between 2% and 5% percent suffer from “sub-threshold” forms of bipolar disorder. Furthermore the possibility of getting bipolar disorder when one parent is diagnosed with it is 15-30%. Risk when both parents have it is 50-75%. Also, while with bipolar siblings the risk is 15-25%, with identical twins it is about 70%.
A minority of people with bipolar disorder have high creativity, artistry or a particular gifted talent. Before the mania phase becomes too extreme, its energy, ambition, enthusiasm and grandiosity often bring people with this type of mood disorder life’s masterpieces.
Substance-induced mood disorders
A mood disorder can be classified as substance-induced if its etiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Also, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such as amphetamine, methamphetamine, and cocaine can cause manic, hypomanic, mixed, and depressive episodes.
Alcohol-induced mood disorders
High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression. But recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. Participants studied were also assessed during stressful events in their lives and measured on a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviant peers, unemployment, and their partner’s substance use and criminal offending. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression that is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence
Risk Factors Influencing the Mentally Ill Population
As a community health nurse concerned about the mentally ill, you have examined some of the epidemiologic information about this population. What are some of the causative factors contributing to the at-risk status of the mentally ill?
Using a vulnerability model, it is helpful to consider four categories of factors that influence the at-risk status of this population: biological, psychological, sociocultural, and environmental factors.
Biologic Factors
Certain biologic factors can place people at increased risk for mental illness. Neurobiologic and genetic mechanisms play a significant role, usually in combination with other factors. An example is autism, which has a familial pattern and is often associated with mental retardation (American Psychiatric Association, 2000). Although no single gene has been found to cause a specific mental disorder, variations in multiple genes can disrupt healthy brain function and, under certain environmental conditions, lead to mental illness. Age is another factor. Many mental illnesses appear to have their origins in early childhood, or even in the way the brain develops prenatally, but lie dormant until adulthood.
Biologic risk factors in children for development of a mental disorder include the following (SAMHSA, 1999):
• Prenatal damage from exposure to alcohol, illegal drugs, or tobacco
• Low birth weight
• Inherited predisposition to mental disorder
• Physical problems (such as abnormalities of the central nervous system [CNS] that affect behavior, thinking, or feeling and are caused by infection, injury, poor nutrition, or environmental toxins)
• Intellectual disabilities such as retardation
Some individuals may acquire mental impairment as a result of traumatic brain injuries or illnesses that cause tissue damage or anoxia. Birth defects and injuries sustained at birth also contribute to risk.
Psychological Factors
Psychological factors also influence the vulnerability of this population. Stress connected with employment, financial worries, family problems, death of a loved one, and other life events can contribute to mental illness if the in dividuals affected have not developed healthy coping patterns.
Neglect and abuse during childhood place individuals at greater risk for various mental disorders, and dysfunctional family life can predispose to conduct disorders and antisocial personality disorders. Low self-esteem also seems to accompany poor mental functioning. Alcohol and drug abuse can lead to chemical dependence, physiologic damage, and mental impairment; also, a family history of mental and addictive disorders is a risk factor for children (SAMHSA, 1999).
Sociocultural Factors
Economic hardship affects the mental health of many individuals. Anxiety over such things as inadequate income and housing, increasing debt, or unemployment can create emotional stress with which some people cannot cope.
Multigenerational poverty continues to place individuals at greater risk for mental disorders. Data on racial and ethnic distribution among the mentally ill are limited and inconclusive. A higher proportion of minorities appear among the impoverished mentally ill in the community. However, mental health problems and mental disorders exist in families of all social classes and cultural backgrounds; no one is immune. What is clear is that minority group members who need mental health care are “less likely to receive needed care” and “when they receive care, it is more likely to be poor in quality” (SAMHSA, 2001, p. 3). Inadequate mental health services in the community, lack of adequate community support systems, and little emphasis on prevention are major sociocultural factors increasing vulnerability to mental illness. Overall, research is demonstrating that most mental disorders are caused by some combination of genetic, biologic, and psychosocial influences (SAMHSA, 1999) (see Research: Bridge to Practice).
Environmental Factors
Geographic environmental factors play a lesser role in affecting vulnerability to mental illness. Nonetheless, climate and geography can cause severe stresses if there are threats of frequent hurricanes, tornadoes, floods, or earthquakes. Some individuals are affected by absence of natural sunlight during long, grey winters. They experience a type of depression called seasonal affective disorder (SAD), which is far more common iorthern regions. Additionally, many conditions in urban areas are anxietyproducing, including transportation problems, excessive noise, crowded streets, inadequate sanitation, high crime rates, and impersonal services.
Lead poisoning continues to be a serious public health problem contributing to mental impairment. Children are especially vulnerable to lead poisoning, whose sources include peeling paint in older homes and workplaces, exhaust fumes, drinking water channeled through lead pipes, the glaze on ceramic mugs or bowls that have not been properly fired, various home remedies, foreign-made candy, and crystal glassware whose lead has leached after repeated dishwasher use or extended contact with acidic beverages. The risk of lead poisoning is not confined to children living in poverty. With the growing popularity of home improvement and renovation, individuals who are unaware of the risks or choose not to have professional guidance in lead paint abatement may inadvertently place their children at risk for lead poisoning. Although poverty is strongly associated with lead poisoning in children, other risk factors must also be considered.
INTERVENTIONS FOR COMMUNITY MENTAL HEALTH
Epidemiologic data and information about risk factors help to guide the community mental health nurse in planning forcommunity mental health services. Such services, to be truly comprehensive, should encompass the entire range of prevention levels—primary, secondary, and tertiary. The majority of community mental health services in the past have focused their efforts on addressing the needs of the mentally ill. Although this population must continue to be a priority, it is now becoming clear that community mental health efforts must also focus to a much greater degree on preventing mental illness and promoting mental health. These latter two emphases hold the key to a healthier future for the nation and the world.
Serving the Mentally Ill Population
In order to design appropriate services for the mentally ill population, it is important for the community health nurse to build on knowledge of epidemiologic data, risk factors, and other information, then work in concert with other health team members for planning and implementing services. To begin with, it is important to know the needs of people with mental disorders. Needs of the Mentally Ill As the needs of this population are assessed, various healthrelated problems will be found. The nature of these problems, and the degree to which they are preventable, vary with the type and severity of the mental disorder, whether the affected individuals are receiving and complying with needed treatment, and the degree of independence with which they can function in the community. Although the mentally ill population is disparate in terms of its wide range of diagnoses and conditions, there are nonetheless many problems shared by members of this group. Furthermore, interventions designed to address specific needs for an individual or a group can often provide wide-reaching benefits to the whole population. The problems of this group, like those of other vulnerable populations, can be divided into three categories: physical, psychological, and social.
Physical Problems
The physical problems of the mentally ill are numerous. Because many people in this population take medications for a prolonged period, a major problem for them is dealing with serious medication side effects. Prolonged tranquilizer use, for example, can cause tardive dyskinesia, an irreversible condition in which damage to the cerebral cortex caused by the drug leads to tremors and loss of motor control. Clients taking psychotropic drugs tend to have increased problems with constipation and regular elimination. They frequently have sleep disturbances that lead to sleep deprivation and make them vulnerable to other physical health problems. Poor compliance in taking prescribed medications is an additional problem for this population. Many forget to take their medications or do not value their importance; others lose track in moving from one group home or living situation to the next. Psychotropic medications can affect clients’ vision, making it difficult to read or even to decipher medication label instructions. The medications usually are needed to enable mentally ill individuals to function and live independently; if treatment protocols are not followed consistently, many will be at risk for exacerbation of symptoms.
Poor nutrition is another serious concern within the mentally ill population, particularly for those living on their own. Eating disorders and poor eating habits are prevalent in this group and include undernutrition due to lack of access to consistent food sources. Because of their impaired function or limited finances or both, many mentally ill clients are unable to shop, prepare food for themselves, or make appropriate food choices. A high-fat, highcarbohydrate, “junk food” diet leads to obesity for many in this population, as well as promoting greater risk for coronary artery disease, diabetes, and dental problems. The mentally ill population, particularly the men, are also vulnerable to liver disease, heart disease, and cancer because of their high rate of dependency on alcohol, drugs, and cigarette smoking.
As a population, the mentally ill are vulnerable to a number of communicable diseases, including sexually transmitted diseases, HIV/AIDS, and tuberculosis. Depending on their extent of mental dysfunction, these clients, particularly those with SMIs, also face problems associated with limited motor coordination and self-care ability, including personal hygiene.
Psychological Problems
The psychological problems of the mentally ill vary depending on the type and severity of the disorder. The stresses of coping with daily living, compounded by the complexities of city life or the isolation resulting from rural living, may create responses such as confusion, depression, frustration, and anger. Psychological isolation, loneliness, and poor self-esteem are interrelated problems for most people with mental disorders. People with these conditions are often unable to establish supportive relationships and feel the stigma that society places on mental illness. In addition, few have adequate, if any, family or friendship supports. Chemical dependency and other forms of addiction are a serious concern for many of the mentally ill. Lacking adequate coping skills to deal with daily life and seeking relief or escape from the stresses they feel, people with mental disorders frequently turn to alcohol, drugs, cigarette smoking, and gambling, singly or in combination. Dependence on these habits leads to additional physical, emotional, social, and financial problems.
Social Problems
Stigma, discussed earlier, poses a major problem for the mentally ill. Fear and misunderstanding of mental disorders by the larger society lead to disrespect, mistreatment, lack of acceptance, and social isolation, which in turn reduce this population’s already limited resources. Without needed support from family, friends, and community, the mentally ill are further handicapped and even more vulnerable.
System inadequacies cause another set of problems for the mentally ill. Income for these individuals is limited, and finding and sustaining employment is difficult given their disabilities. If they have worked, they are eligible in the United States for Social Security Disability income; if they have never worked, they can receive supplemental income under the Social Security Act. However, in both cases only a subsistence level of living is provided. Many clients have unstable housing, which creates mobility with additional problems.
A further problem is limited finances for treatment or health care benefits. The Mental Health Parity Act of 1996 limits mental health coverage compared with non–mental health conditions. It has resulted in increased numbers of the poor going without their prescribed psychotropic medications and psychotherapy because they do not have the means to pay for them. It has also resulted in several high-visibility crimes committed by individuals with SPMIs who were without treatment at the time of the crime. Services for the mentally ill are often fragmented and inadequate; improved services and collaboration among providers who serve this population are needed.
Service Interventions for the Mentally Ill Population
The needs of the mentally ill are addressed primarily through either biomedical or psychotherapeutic approaches. Often a combination of both is found to be effective.
Biomedical Approaches
Biomedical therapy for persons with mental disorders involves the use of medications or electroshock therapy.
Pharmacotherapy
Historically, the treatment of the mentally ill consisted of isolation, restraint, ice packs, insulin shock therapy, electroconvulsive therapy, brain surgery, and minimal drug use. The most common drugs in use were paraldehyde, chloral hydrate, and barbiturates. In the early 1950s, the first tranquilizer, thorazine, was prescribed, ushering in a new wave of pharmacologic treatment for mental illness.
Psychotropic medications not only have resulted in relief of symptoms but also have significantly improved the quality of life for millions of clients worldwide. Many clients previously held in long-term psychiatric facilities are now treated in community mental health centers or group homes or access outpatient facilities from their homes. The successful addition of medications to the treatment regimen of mental illness has promoted the position that mental illness is often biologically based or responsive to biologic treatment.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT), also called shock therapy, uses electrically induced seizures primarily to treat severe depression. It has proved to be a safe and effective therapy and is often used for clients whose disease has not responded to drug therapies, for the elderly, and for highly suicidal clients, when there is no time to wait for the onset of the effects of antidepressants (Kalb, Ellinger, & Reulbach, 2003; Skye, 2001).
Psychotherapy
Psychotherapy is the treatment of mental or emotional disorders through psychologically based interventions. These interventions may be used alone, in combination with pharmacotherapies, or with complementary therapies such as yoga, relaxation exercises, or visualization. It is not uncommon for many of the therapy groups or modalities used in conjuction with professional psychotherapy to be facilitated by allied health personnel or lay individuals. The community mental health nurse, as case manager, may often participate in these activities or provide overall supervision of the activities and personnel, ensuring that the overall therapeutic needs of the clients are being met and that the activities are both safe and effective.
Common Psychotherapeutic Strategies
Additional psychotherapeutic strategies that may be provided based on individual needs, include the following:
• Art therapy—used as a means for expression through drawings, sculpture, or music. It is particularly effective with children and with clients whose verbal skills are limited.
• Behavior therapy—aims to reduce or eliminate certain behaviors through concentrated, specific guidelines. Smoking cessation and weight-loss groups are examples of behavior-modification approaches.
• Client-centered therapy—focuses on enabling clients to identify and actualize their own internal resources to work through their concerns.
• Cognitive behavioral therapy—focuses on clients’ beliefs and actions and on reducing these beliefs and actions into more positive moods.
• Insight-oriented therapy—assists clients to improve their functioning through insight into themselves and their situation.
• Interpersonal therapy—focuses on clients’ ability to gain insight into their psychological distress in relation to disturbed interpersonal relationships.
• Group therapy—makes use of the interactions among several clients who share an interest in a common issue, such as anxiety, panic, depression, or eating disorders. Therapy groups may also be used for survivors of sexual assault, sexual abuse, or domestic violence, as well as many other topics.
Psychotherapy, sometimes called “talk therapy,” uses one or more of these strategies. It is offered in a variety of settings and is available either individually or on a group basis. Private psychotherapy services can be accessed through referral or word-of-mouth for clients who are financially able to pay. Managed care organizations often restrict the number of therapy visits, posing a challenge to both clients and therapists. Clients with limited funds may access individual and group therapies through mental health clinics or community agencies. In addition to these therapies, there are community resources that enhance primary treatment.
References
Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.
Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.
The ICD-10 Classification of Mental and Behavioural Disorders. World Health Organisation. 1993.
Ayuso-Mateos, J.L. et al. , 2001.Depressive Disorders in Europe: Prevalence figures from the ODIN study. British Journal of Psychiatry, 179, pp. 308-316
Hitchcock, J.E., Schubert, P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action / Delmar.
American Psychological Association. (1994) Publication Manual of the American Psychological Association (4th ed.). Washington, DC: Author.
http://www.health.gov/healthypeople/.
www.health.state.mn.us/divs/chs/phn/definitions.pdf
http://www.nursingworld.org, The official website of the American Nurses’ Association. http://www.apha.org, This is the home page of the American Public Health Association (APHA). http://www.communityhlth.org, The Association for Community Health Improvement.
http://www.florence-nightingale.co.uk
