Mental Health and Psychiatric Nursing: Study Guides

Mental health work feels unfamiliar to many nurses because the tools are interpersonal, not procedural, and the outcomes are harder to measure than a wound or a lab value. This is an overview of how we define mental health and illness, how treatment evolved, where the field stands now, and what the psychiatric nurse actually does.

Mental Health and Mental Illness

Neither term has a precise universal definition, because culture shapes a society's beliefs and values, which in turn shape how it defines health and illness.

Mental Health

There is no single universal definition, but behavior gives clues. Mental health is generally a state of emotional, psychological, and social wellness shown by satisfying relationships, effective coping, a positive self-concept, and emotional stability. The factors that influence it fall into three groups. Individual factors include biological makeup, autonomy and independence, self-esteem, capacity for growth, vitality, the ability to find meaning, emotional resilience, a sense of belonging, reality orientation, and stress management. Interpersonal factors include effective communication, the ability to help others, intimacy, and a balance of separateness and connectedness. Social and cultural factors include a sense of community, access to adequate resources, intolerance of violence, support for diversity, mastery of the environment, and a positive but realistic view of one's world.

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 is associated with present distress or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom." General diagnostic criteria include dissatisfaction with one's characteristics, abilities, and accomplishments; ineffective or unsatisfying relationships; dissatisfaction with one's place in the world; ineffective coping with life events; and a lack of personal growth. The contributing factors again split three ways. Individual factors include biological makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of uncertainty, a sense of disharmony, and loss of meaning. Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control. Social and cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination.

Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) is a taxonomy published by the APA. It describes all mental disorders and sets specific diagnostic criteria for each, built on clinical experience and research. It serves three purposes: to provide standardized nomenclature for all mental health professionals, to present the defining characteristics that differentiate diagnoses, and to help identify underlying causes. Its multiaxial system assesses the person across several axes so the practitioner can capture every relevant factor:

• Axis I identifies all major psychiatric disorders except mental retardation and personality disorders.
• Axis II reports mental retardation and personality disorders, plus prominent maladaptive personality features and defense mechanisms.
• Axis III reports current medical conditions relevant to understanding or managing the mental disorder.
• Axis IV reports psychosocial and environmental problems that may affect diagnosis, treatment, and prognosis.
• Axis V is the Global Assessment of Functioning, rating overall psychological functioning on a scale of 0 to 100 to reflect the person's current level of functioning.

Historical Perspectives on the Treatment of Mental Illness

Ancient Times

Ancient peoples read sickness as the displeasure of the gods, a punishment for sin, so those with mental disorders were seen as either divine or demonic depending on their behavior. Aristotle later tried to tie mental disorders to physical ones, theorizing that the amounts of blood, water, and yellow and black bile controlled the emotions. These four humors corresponded to happiness, calmness, anger, and sadness, and imbalance was thought to cause mental disorders, so treatment aimed at restoring balance through bloodletting, starving, and purging. In early Christian times disease was again blamed on demons, the mentally ill were seen as possessed, and priests performed exorcisms to rid them of evil spirits. During the Renaissance, England distinguished the mentally ill from criminals; those considered harmless wandered the countryside or lived in rural communities, while the more dangerous were jailed, chained, and starved. In 1547 the Hospital of St. Mary of Bethlehem was declared a hospital for the insane, the first of its kind, and by 1775 visitors were charged a fee to view and ridicule the inmates, who were treated as less than human.

Period of Enlightenment and the Creation of Mental Institutions

A more enlightened period began in the 1790s. Phillipe Pinel in France and William Tukes in England formed the concept of the asylum as a safe refuge, a haven offering protection at institutions where people had been whipped, beaten, or starved simply for being mentally ill (Gollaher, 1995). In the United States, Dorothea Dix (1802-1887) launched a crusade to reform care after visiting Tukes' institution in England, and was instrumental in opening 32 state hospitals that offered asylum to the suffering.

Sigmund Freud and the Treatment of Mental Disorders

The scientific study and treatment of mental disorders began with Sigmund Freud (1856-1939) and contemporaries such as Emil Kraeplin (1856-1926) and Eugene Bleuler (1857-1939). Freud challenged society to view human beings objectively and studied the mind, its disorders, and their treatment as no one had before. Kraeplin began classifying mental disorders by their symptoms, and Bleuler coined the term schizophrenia.

Development of Psychopharmacology

Treatment leapt forward around 1950 with the development of psychotropic drugs. Chlorpromazine (Thorazine), an antipsychotic, and lithium, an antimanic agent, were the first. Over the following 10 years came monoamine oxidase inhibitor antidepressants, the antipsychotic haloperidol (Haldol), tricyclic antidepressants, and the antianxiety benzodiazepines.

Mental Illness in the 21st Century

The National Institute of Mental Health (NIMH) estimates that more than 26% of Americans aged 18 and older have a diagnosable mental disorder, roughly 57.7 million persons each year (2006). Mental illness or serious emotional disturbance impairs daily activities for an estimated 10 million adults and 4 million children and adolescents, and mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age. Homelessness compounds the problem: the National Resource and Training Center on Homelessness and Mental Illness (2006) estimated that one-third of adult homeless persons have a serious mental illness and more than half also have substance abuse problems. In 1993 the federal government created and funded Access to Community Care and Effective Services and Support (ACCESS) to address the needs of people with mental illness who were homeless.

Psychiatric Nursing Practice

In 1873 Linda Richards graduated from the New England Hospital for Women and Children in Boston, then went on to improve psychiatric nursing care and organize educational programs in state mental hospitals in Illinois. Called the first American psychiatric nurse, she held that "the mentally sick should be at least as well cared for as the physically sick" (Doona, 1984). The first training of nurses to work with the mentally ill came in 1882 at McLean Hospital in Belmont, Massachusetts, where care was primarily custodial and focused on nutrition, hygiene, and activity.

The role expanded as somatic therapies developed. Insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive therapy (1937) pushed nurses to use their medical-surgical skills more extensively. The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey, was published in 1920, and in 1913 John Hopkins became the first school of nursing to include a psychiatric nursing course. In 1973 the division of psychiatric and mental health practice of the American Nurses Association (ANA) developed standards of care, revised in 1982, 1994, and 2000. These standards are authoritative statements describing the responsibilities for which nurses are accountable.

Self-awareness is central to the work: know yourself so your own values, attitudes, and beliefs are not projected onto the client and do not interfere with care. Self-awareness does not require changing your values and beliefs unless you choose to.