COMMUNITY AND PUBLIC HEALTH NURSING

PRACTICUM

Risk, Decision-Making and Community Mental Health

Risk is an extremely powerful concept and used carefully can have positive and liberating effects for support of people experiencing mental health problems. However, used without care and sensitivity risk can be repressive and disempowering. Mental health nurses are expected to assess and manage risk, and the ways in which they do this have a major impact on the users of their services. I will start my discussion of risk with a consideration of the different ways in which risk can be defined and used. I will then consider the factors which shape the day-to-day management of risk. I will end the chapter with a broader consideration of the underlying social processes that shape the definition and management of risk in contemporary society.

DEFINING RISK

While risk appears to have entered the English language during the seventeenth century, its use and meaning have changed over time. Initially risk was associated with probability, especially with gambling and games of chance whose study created a specialist branch of mathematics, statistics (Douglas 1990). In modern society interest in risk is more generalised and links to desire to use knowledge gained from the past to predict and manage the future (Giddens 1990), and to allocate responsibility and blame when this process fails (Douglas 1986). In the twentieth century research generated new forms of technical expertise in risk, which have been applied across a bewildering range of areas of policy and practice (Lupton 1999).

The possibility that a given course of action will not achieve its desired and intended outcome but instead some undesired and undesirable situation will develop. (adapted from Alaszewski and Manthorpe 1991). While it is possible to provide a broad definition of risk, it is important to recognize that such a definition may not command wide support, even within expert or professional circles. In the medical and health care literature the dominant approach is in terms of the ‘risk of’ specified adverse health events assessed in terms of mortality and morbidity. This involves the identification of factors associated with such events within populations – ‘risk factors’ or personal characteristics that make individuals ‘at risk’ (see, for example, the BMA’s influential guide, British Medical Association 1990). However, it is also possible to identify another approach: ‘risk in’ health care, in which the emphasis is on the social processes which shape and influence health outcomes. These processes include ‘risk communication’, ‘risk perception’ and ‘risk management’, and it is these aspects of risk which form the basis of my discussion.

While some commentators have argued that such variations seriously limit the utility of risk as a concept (see, for example, Dowie 1999), an alternative approach is to acknowledge such variations and examine the range of meanings that people find in risk issues. These meanings are linked both to the symbolic associations of risk and the variety of perspectives which individuals and groups use in making sense of risk (Petts et al. 2001). While social scientists initially tended to uncritically accept ‘common-sense’ definitions of risk as anxietyprovoking danger, there is increasing awareness that risk is not only a contested concept, but in practice the experience of risk offers many attractions to individuals: it can provide opportunities for excitement, challenge and personal fulfilment (Lupton 1999).

RISK IN COMMUNITY NURSING

In a study funded by the English National Board for Nursing Midwifery and Health Visiting (Alaszewski et al. 1998, 2000) we examined the ways in which community nurses supported vulnerable adults (including older people, people with mental health needs and people with learning disabilities) in the community and assessed and managed risk. We started by examining the ways in which nurses, users and carers conceptualised risk. Risk appeared to be a concept that most nurses in our study (72) took for granted rather than considered to be problematic. When asked to define risk most nurses did not have a ready response, they needed to pause to consider it and indeed some were initially reluctant to provide a definition. When they did articulate their reply, the majority (59, 82 per cent) saw risk in terms of hazard and harm, especially the negative consequences of decisions or actions. For example, a nurse managing a mental health team defined risk in the following way:

Right, I think risk is multi-faceted . . . being a manager . . . I have to be aware of risk to clients in terms of self-harm and harm to others and that in this team doesn’t focus on people who are depressed and may have suicidal tendencies or to people who are psychotic and may be at risk of self-harm . . . we also deal with people with dementia and being aware of the risks they carry . . . they may forget to eat and they are at risk of dehydration and malnutrition, loss of awareness about safety issues so that they might walk in front of a bus . . .

Nurses using this approach tended to see it as self-evident or ‘common sense’. However, other nurses recognised that risk was a contested concept and that there were different ways of approaching it. For example, a lecturer on the mental health branch of a pre-registration course made the following response when asked to define risk:

That’s the 50 million dollar question. What may be a risk for me may not be for another person – it very much depends on your point of view of what risk is. The definition causes me problems. The other thing I have a problem with is who has the right to define it because that will affect what you do about it.

Some nurses (22, 31 per cent) used their awareness of the contested nature of risk to argue for a more positive approach in which risk-taking was seen as a potentially liberating experience and an essential part of human growth and development. For example, one learning disability nurse contrasted the ‘official’ approach to risk with a more positive approach:

What I understand by risk and what the health authority understands is two different things. To me risk is a way of clients gaining knowledge, being able to develop, learn new things . . . often staff as well – the staff taking risks they actually learn things by that and learn what the clients can do from risks. The health authority thinks of risk as . . . protecting their backs.

Nurses using this approach tended to emphasize both the ‘normality’ of risk-taking and its benefits in terms of personal learning benefits and development and as a source of pleasure. For example, a learning disability student described risk in the following way:

[It] depends on your point of view and style of life and philosophy. I might see going to the casino and gambling as a risk but someone else might not. A result of circumstances involving an activity. There is a risk in everything and it is what is ‘acceptable’. Taking a gamble – the idea of being bad being more fun than being good. It’s an aspect of life which most people enjoy – a bit of fear, getting the adrenalin going can be a good thing.

RISK AND DECISION-MAKING

Mental health nurses need to decide how they respond to these pressures to minimize harm and ensure safety in their everyday practice. This tension is particularly evident in the decision-making process. As Narayan and Corcoran-Perry observe, ‘Decision-making tasks of interest in professional domains are characterized by complexity, ambiguity, and uncertainty’ (1997, p. 354). Despite the centrality of decision-making and risk to professional practice, in our study we could find little evidence that nurses were systematically prepared for this aspect of practice (Alaszewski et al. 1998, pp. 58–82). Nurses had to acquire appropriate skills through trial and error in practice.

The complexity of task and skills required was evident when we analysed the decisions which nurses had to make in their everyday practice: it was clear both that they were complex and that they required developed skills. I have selected one example that illustrates this complexity. It involves an experienced community mental health nurse who decided to support his client, a single mother with young children, when she wanted to come off her medication. The nurse summarised the key components of the decision and made explicit reference to risk assessment in his justification of his decision:

I feel that I have a good knowledge of the client and a very good relationship with [her] . . . the decision really was to reduce her medication, and not to stop, and I think that if she had been irresponsible she would have said I’m not taking any again, she wasn’t saying that she was saying she wanted to reduce . . . so I felt that was an appropriate risk.

In making the decision, the nurse had to identify and balance a number of factors, including the client’s aims and intentions, the possible consequences, especially harm to her children, and the actions and reactions of other professionals involved with the client. While nurses and other professionals are being encouraged to ground their decisions in evidence, most of the key factors were unique to the circumstances of the decision, such as the client’s intentions and the response of other professionals. Thus the nurse had to draw on his personal experience and use his professional judgement to assess the risks and make the decision. He described this process in the following way:

I suppose the potential outcome, negative one, is that she may have another psychotic episode which she has only ever had one in her life, which is good, but we could have another one where she would have become suspicious, perhaps neglected herself, there was two young children at home who you could argue maybe were potentially at risk. I think I balanced that up because when she was mentally ill before . . . she had actually taken the children to the casualty department, wanting them to be looked at because she felt they had been poisoned . . . I felt that there was less risk this time because I was visiting in addition to social services, in addition to consultant psychiatrist’s appointments, where before she has a breakdown with nobody so she could have floundered for far longer where this time there was support and screening.

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.

PREVENTING MENTAL DISORDERS

With the burden of disease imposed by mental disorders, both nationally and worldwide, there is a growing urgency felt in the field of public health to put more effort into prevention. There is currently much more scientific information available on the treatment of mental illness than on how to prevent it. To enhance preventive intervention efforts, more clarity on the causes of mental illness, better information on whom to target, and more accurate measures for evaluating program effectiveness are needed. Yet there is still much that can be done.

Models for Preventing Mental Disorders

Some models have proved useful in approaching prevention of mental disorders. Two are examined here: the Public Health Model and the Mental Health Intervention Spectrum Model.

The Public Health Model

Early efforts to prevent illness used the Public Health Model of prevention, which was originally designed to control infectious diseases. This model includes three levels of prevention:

primary prevention keeps a health problem from occurring, secondary prevention seeks to detect a health problem at its earliest stage and keep it from getting worse, and tertiary prevention aims to reduce the disability associated with the health problem. Applying the Public Health Model to the mentally ill population, Gerald Caplan (1964), in his classic work using this model, proposed population intervention at three prevention levels:

• Primary prevention activities with a population would decrease the number of new cases (incidence) of a mental disorder or reduce the rate of their development.

• Secondary prevention activities would lower the number of existing cases of a mental disorder, thereby reducing its rate (prevalence). Examples of these activities are screening, early case finding, and early treatment.

• Tertiary prevention activities would decrease the severity of a mental disorder and its associated disabilities through rehabilitation. An example is a program of intensive case management and social skills training for schiziphrenics.

Mental health prevention efforts in the United States have used this model for many years in addressing the range of prevention levels. However, its application in terms of funding and support has been strongest in the area of secondary prevention.

The Mental Health Intervention Spectrum Model

In recent years, research has enhanced the understanding of risk factors and their association with health outcomes in relation to mental disorders. As a result, in 1994 the Institute of Medicine’s Committee on Prevention of Mental Disorders developed a comprehensive model called the Mental Health Intervention Spectrum Model (MHISM) (Institute of Medicine, 1994).

The MHISM model presents a range of interventions for mental illness that includes prevention, treatment, and maintenance. The prevention aspects of the model are most relevant to the discussion here. The prevention section of the MHISM model lists three types of interventions: universal, selective, and indicated. Universal preventive interventions target a whole population group or the general public who are not identified as being at risk for a specific mental disorder. This approach is useful for planning large-scale preventive interventions, such as a comprehensive program of prenatal services that could promote healthy brain development with a subsequent reduction in the incidence of schizophrenia.

The second type, selective preventive interventions, targets selected at-risk groups or individuals within a population. These are individuals or groups who have been identified as having a much higher risk of developing a mental disorder. An example of a selective preventive intervention is a support group and bereavement counseling for elderly persons who have lost a spouse, to prevent the onset of or lessen the degree of depression.

The third type, indicated preventive intervention, targets high-risk individuals who show signs of a beginning mental disorder or who have other evidence of a predisposition for a mental disorder. An example is parenting training and support for young mothers who were abused as children, especially if they show early signs of repeating that abuse with their own children.

Both the Public Health Model and the MHISM provide useful perspectives for designing preventive interventions and continue to be used today.

Preventive Interventions

Prevention is a fundamental role of the community health nurse working with mentally ill clients or with communities attempting to respond to the problems of mental disorders.

Primary Prevention

With primary prevention, the goal is to both anticipate potential threats and prevent the actual development of a mental disorder. Combining the Public Health Model with “universal” preventive intervention from the MHISM, an intervention for a population or group can be designed by following these steps:

• Select a mental disorder, one that epidemiologic data have shown to be a significant problem for intervention (eg, adolescent alcoholism).

• Identify the target population for intervention (eg, all adolescents in a given community).

• Determine causes and risk factors that contribute to the disorder from research data in the literature. For example, identify factors that appear to contribute to teenagers’ wanting to use and abuse alcohol (eg, peer pressure, risktakingbehaviors, escape).

• Design, implement, and evaluate an intervention. Conduct an educational program in the schools that addresses the contribution of risk factors to the development of adolescent alcoholism.

Other examples of primary prevention include support groups for children of divorced parents or spouses considering divorce, safe-housing projects, programs to prevent substance abuse, suicide prevention programs, and parenting classes. Informing parents of developmental milestones, age-related behaviors, and stress-reducing strategies can significantly reduce the risk of abuse. Other opportunities for primary prevention include supportive care for teenage mothers, well-baby classes, and stress-management classes.

Secondary Prevention

Secondary prevention efforts attempt to reduce the prevalence of mental disorders in the community or the severity of disorders in affected individuals. Health screening for mental illness is an important secondary prevention strategy to detect illness in its earliest stages. National Anxiety Screening Day, National Depression Screening Day, and similar programs are community-based examples and should be promoted in local media, clinics, libraries, schools, churches, welfare offices, and even on bulletin boards in supermarkets.

Also, the community health nurse provides secondary prevention through monitoring of medication use. It is essential that the nurse be familiar with medications that clients are taking, particularly drug interactions and contraindications. This is particularly true for elderly clients, who may be taking medications for physical conditions as well. The nurse may be the primary person to identify breakthrough symptoms, noncompliance, or failure of clients or family members to fill prescriptions. As discussed later, the nurse’s advocacy role can enable the client or family to negotiate systems that may be interfering with medication compliance.

Secondary prevention efforts also include case-finding and referral for primary or follow-up care. This means alertness and vigilance to find people in the community who show early signs of developing problems. Examples are a support program for family caregivers of patients with Alzheimer disease and an educational and support program for parents of autistic children. Facilitation of a self-help group, depending on its precise nature and goals, can also be an effective secondary prevention measure.

Mental Disorders

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 Addiction

Although often previously associated with physiological tolerance and withdrawal effects, the term “addiction” has achieved a broader definition (e.g., see www.dsm5.org; accessed on February 22, 2010; also Brewer & Potenza, 2008; Griffiths, 2005a; Marks, 1990; Orford, 2001; Schneider & Irons, 2001). Among many researchers and clinicians, “addiction” has come to refer to a disorder in which an individual becomes intensely preoccupied with a behavior that at first provides a desired or appetitive effect. The appetitive effect generally is equated with changes in firing in the mesolimbic dopaminergic system, but there are numerous brain neurotransmission and hormonal systems involved, including mu opioid, serotonin, norepinephrine, anandamide, and the hypothalamic-pituitary-axis (HPA), among others; associated with subjective reports of arousal, pleasure, or fantasy (Brewer & Potenza, 2008; Johansson, Grant, Kim, Odlaug, & Gotestam, 2009; Schneider & Irons, 2001; Volkow & Wise, 2005). The addictive behavior occurs with several pattern variations (e.g., bingeing or sustained preoccupation), but always repeatedly, involving a great deal of time thinking about and engaging in the behavior, which operates beyond the need to remove intense anxiety common in compulsive disorders (Brewer & Potenza, 2008; Marks, 1990).

An addiction disorder also involves loss of ability to choose freely whether to stop or continue the behavior (loss of control) and leads to experience of behavior-related adverse consequences (Schneider & Irons, 2001). In other words, the person becomes unable to reliably predict when the behavior will occur, how long it will go on, when it will stop, or what other behaviors may become associated with the addictive behavior. As a consequence, other activities are given up or, if continued, are no longer experienced as being as enjoyable as they once were. Further negative consequences of the addictive behavior may include interference with performance of life roles (e.g., job, social activities, or hobbies), impairment of social relationships, criminal activity and legal problems, involvement in dangerous situations, physical injury and impairment, financial loss, or emotional trauma.

Although many drug and nondrug addictions do not appear to produce obvious physical dependence (i.e., physiological-based tolerance and withdrawal effects), they do create a subjective need for increased involvement in the behavior to achieve satiation and abrupt termination of the behavior often leads to symptoms such as depression, intense anxiety, hopelessness, helplessness, and irritability (e.g., see Allegre, Souville, Therme, & Griffiths, 2006; Hausenblas & Down, 2002, regarding exercise dependence). The addictive behavior may seem to the addict “as if” it is the best solution to resolve these negative symptoms (Sussman & Unger, 2004). Regardless of level of physical dependence, relapse rates across various addictions appear to be relatively high (e.g., over 70% for a 1-year period; Brandon, Vidrine, & Litvin, 2007; Hodgins & e-Guebaly, 2004; Miller, Walters, & Bennett, 2001; Schneider & Irons, 2001). The likelihood of these consequences is depicted for 11 potentially addictive behaviors in Table 1 (i.e., cigarettes, alcohol, illicit drugs, binge eating, gambling, Internet, love, sex, exercise, work, and shopping).

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.

Addiction

Addiction is the continued repetition of a behavior despite adverse consequences, or a neurological impairment leading to such behaviors.

Addictions can include, but are not limited to, drug abuse, exercise addiction, food addiction, computer addiction and gambling. Classic hallmarks of addiction include impaired control over substances or behavior, preoccupation with substance or behavior, continued use despite consequences, and denial. Habits and patterns associated with addiction are typically characterized by immediate gratification (short-term reward), coupled with delayed deleterious effects (long-term costs).

Physiological dependence occurs when the body has to adjust to the substance by incorporating the substance into its 'normal' functioning. This state creates the conditions of tolerance and withdrawal. Tolerance is the process by which the body continually adapts to the substance and requires increasingly larger amounts to achieve the original effects. Withdrawal refers to physical and psychological symptoms experienced when reducing or discontinuing a substance that the body has become dependent on. Symptoms of withdrawal generally include but are not limited to anxiety, irritability, intense cravings for the substance, nausea, hallucinations, headaches, cold sweats, and tremors.

Substance dependence

Substance dependence can be diagnosed with physiological dependence, evidence of tolerance or withdrawal, or without physiological dependence. DSM-IV substance dependencies include:

303.90 Alcohol dependence

304.00 Opioid dependence

304.10 Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence)

304.20 Cocaine dependence

304.30 Cannabis dependence

304.40 Amphetamine dependence (or amphetamine-like)

304.50 Hallucinogen dependence

304.60 Inhalant dependence

304.80 Polysubstance dependence

304.90 Phencyclidine (or phencyclidine-like) dependence

304.90 Other (or unknown) substance dependence

305.10 Nicotine dependence

Withdrawal

Withdrawal is the body's reaction to abstaining from an addictive substance of which it has become dependent and tolerant. Without the substance, physiological functions that were dependent on the substance will react because of the body's tolerance and dependence of the substance. Chemical and hormonal imbalances may arise if the substance is not introduced. Physiological and psychological stress is to be expected if the substance is not re-introduced.

Recovery/Interventions

In addition to the traditional behavioral self-help groups and programs available for rehabilitation, there is a varied array of preventive and therapeutic approaches to combating addiction. For example, a common treatment option for opiate addiction is methadone maintenance. This process consists of administering the drug, a potent opiate with some potential for abuse, as a drink in a supervised clinical setting. In this way, the brain opiate levels increase slowly without producing the high but remain in the system long enough to deter addicts from injecting heroin.

Another form of drug therapy involves buprenorphine, a drug which seems to be even more promising than methadone. A partial agonist for certain opiate receptors, this treatment blocks the effects of opiates but produces only mild reactions itself. Moreover, this method of detoxification has little value in the drug market.

New research indicates that it may even be possible to develop antibodies which combat a particular drug's effect on the brain, rendering the pleasurable effects null. Recently, vaccines have been developed against cocaine, heroin, methamphetamine, and nicotine. These advances are already being tested in human clinical trials and show serious promise as a preventive and recovery measure for addicts or those prone to addiction.

Furthermore, another method of treatment for addiction that is being studied is deep brain stimulation. A serious procedure, DBS targets several brain regions including the nucleus accumbens, subthalamic nucleus, dorsal striatum, and medial prefrontal cortex among others.[9] Other studies have concurred and demonstrated that stimulation of the nucleus accumbens, an area that is apparently one of the most promising regions, allowed a seventy-year-old man to stop smoking without issue and attain a normal weight.

Behavioral addiction

The term addiction is also sometimes applied to compulsions that are not substance-related, such as compulsive shopping, sex addiction/compulsive sex, overeating, problem gambling, exercise/sport and computer addiction. Sometimes the compulsion is not to "do" something but to avoid or "do nothing" e.g. procrastination (compulsive task avoidance). In these kinds of common usages, the term addiction is used to describe a recurring compulsion by an individual to engage in some specific activity, despite harmful consequences, as deemed by the user themselves to their individual health, mental state, or social life. There may be biological and psychological factors contributing to these addictions.

References

Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.

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