(Test Bank) Psychiatric Mental Health Nursing

Videbeck, 1

Nursing

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1st Edition

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xiii➤➤➤➤➤ Contents ➤Unit 1 Current Theories and Practice 1 Foundations of Psychiatric- Mental Health Nursing 00 Mental Health and Mental Illness 00 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 00 Historical Perspectives of the Treatment of Mental Illness 00Mental Illness in the 21st Century 00Psychiatric Nursing Practice 00Self-Awareness Issues 00 2 Neurobiologic Theories and Psychopharmacology 00 The Nervous System and How It Works 00Brain Imaging Techniques 00Neurobiologic Causes of Mental Illness 00The Nurse’s Role in Research and Education 00Psychopharmacology 00Cultural Considerations 00Self-Awareness Issues 00 3 Psychosocial Theories and Therapy 00 Psychosocial Theories 00Cultural Considerations 00Treatment Modalities 00The Nurse and Psychosocial Interventions 00Self-Awareness Issues 00 4 Treatment Settings and Therapeutic Programs 00 Treatment Settings 00Psychiatric Rehabilitation Programs 00Special Populations of Clients With Mental Illness 00Interdisciplinary Team 00Psychosocial Nursing in Public Health and Home Care 00Self-Awareness Issues 00➤Unit 2 Building the Nurse–Client Relationship 5 Therapeutic Relationships 00 Components of a Therapeutic Relationship 00 Types of Relationships 00Establishing the Therapeutic Relationship 00Avoiding Behaviors That Diminish the Therapeutic Relationship 00 Roles of the Nurse in a Therapeutic Relationship 00Self-Awareness Issues 00 6 Therapeutic Communication 00 What Is Therapeutic Communication? 00Verbal Communication Skills 00Nonverbal Communication Skills 00Understanding the Meaning of Communication 00Understanding Context 00Understanding Spirituality 00Cultural Considerations 00The Therapeutic Communication Session 00Community-Based Care 00Self-Awareness Issues 00 7 Client’s Response to Illness 00 Individual Factors 00Interpersonal Factors 00Cultural Factors 00Self-Awareness Issues 00 8 Assessment 00 Factors Influencing Assessment 00How to Conduct the Interview 00Content of the Assessment 00Data Analysis 00Self-Awareness Issues 00➤Unit 3 Current Social and Emotional Concerns 9 Legal and Ethical Issues 00 Legal Considerations 00 Ethical Issues 00Self-Awareness Issues 00 10 Anger, Hostility, and Aggression 00 Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Self-Awareness Issues 00 11 Abuse and Violence 00 Clinical Picture of Abuse and Violence 00Characteristics of Violent Families 00Cultural Considerations 00Spouse or Partner Abuse 00Child Abuse 00Elder Abuse 00Rape and Sexual Assault 00Community Violence 00Psychiatric Disorders Related to Abuse and Violence 00Application of the Nursing Process 00Self-Awareness Issues 00 12 Grief and Loss 00 Types of Losses 00The Grieving Process 00Dimensions of Grieving 00Cultural Considerations 00Disenfranchised Grief 00Complicated Grieving 00Application of the Nursing Process 00Self-Awareness Issues 00 ➤Unit 4 Nursing Practice for Psychiatric Disorders 13 Anxiety and Anxiety Disorders 00 Anxiety as a Response to Stress 00Incidence 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Community-based Care 00 Mental Health Promotion 00Panic Disorder 00Application of the Nursing Process: Panic Disorder 00Phobias 00Obsessive-Compulsive Disorder 00Application of the Nursing Process: Obsessive-Compulsive Disorder 00 Generalized Anxiety Disorder 00Posttraumatic Stress Disorder 00Acute Stress Disorder 00Self-Awareness Issues 00 14 Schizophrenia 00 Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00 15 Mood Disorders and Suicide 00 Categories of Mood Disorders 00Related Disorders 00Etiology 00Cultural Considerations 00Major Depressive Disorder 00Application of the Nursing Process: Depression 00Bipolar Disorder 00Application of the Nursing Process: Bipolar Disorder 00Suicide 00Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00 16 Personality Disorders 00 Categories of Personality Disorders 00Onset and Clinical Course 00Etiology 00Cultural Considerations 00Treatment 00Paranoid Personality Disorder 00Schizoid Personality Disorder 00Schizotypal Personality Disorder 00Antisocial Personality Disorder 00Application of the Nursing Process: Antisocial Personality Disorder 00 Borderline Personality Disorder 00Application of the Nursing Process: Borderline Personality Disorder 00 Histrionic Personality Disorder 00Narcissistic Personality Disorder 00Avoidant Personality Disorder 00Dependent Personality Disorder 00Obsessive-Compulsive Personality Disorder 00Depressive Personality Disorder 00Passive-Aggressive Personality Disorder 00xiv ContentsCommunity-Based Care 00 Mental Health Promotion 00Self-Awareness Issues 00 17 Substance Abuse 00 Types of Substance Abuse 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Types of Substances and Treatment 00Treatment and Prognosis 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00Substance Abuse in Health Professionals 00Self-Awareness Issues 00 18 Eating Disorders 00 Overview of Eating Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00 19 Somatoform Disorders 00 Overview of Somatoform Disorders 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00 Mental Health Promotion 00Self-Awareness Issues 00 20 Child and Adolescent Disorders 00 Autistic Disorder 00 Rett’s Disorder 00Childhood Disintegrative Disorder 00Asperger’s Disorder 00Attention Deficit Hyperactivity Disorder 00Application of the Nursing Process: ADHD 00Conduct Disorder 00Application of the Nursing Process: Conduct Disorder 00Community-Based Care 00mental health promotion 00Oppositional Defiant Disorder 00Pica 00Rumination Disorder 00Feeding Disorder 00Tourette’s Disorder 00Chronic Motor or Tic Disorder 00Separation Anxiety Disorder 00Selective Mutism 00Reactive Attachment Disorder 00Stereotypic Movement Disorder 00Self-Awareness Issues 00 21 Cognitive Disorders 00 Delirium 00Application of the Nursing Process: Delirium 00Community-Based Care 00Dementia 00Application of the Nursing Process: Dementia 00Community-Based Care 00mental health promotion 00Role of the Caregiver 00Related Disorders 00Self-Awareness Issues 00Contents xvix➤➤➤➤➤ The second edition of Psychiatric Mental Health Nurs- ingcontinues to have students as the primary focus. It presents sound nursing theory, therapeutic modal-ities, and clinical applications across the treatmentcontinuum. Chapters are short, to the point, and easyto read and understand. They highlight and empha-size important material to facilitate student learning. This text uses the nursing process framework and emphasizes assessment, therapeutic communication,neurobiologic theory, and pharmacology throughout.Interventions focus on all aspects of client care, in-cluding communication, client and family teaching,and community resources, and their practical appli-cation in various clinical settings. Organization of the Text Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses currentissues in psychiatric nursing, as well as the manytreatment settings in which nurses encounter clients.It discusses neurobiologic theories and psychophar-macology and psychosocial theories and therapythoroughly as a basis for understanding mental illnessand its treatment. Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practiceof mental health nursing. Chapters on therapeuticrelationships and therapeutic communication pre-pare students to begin working with clients both inmental health settings and in all other areas of nurs-ing practice. The chapter on the client’s response toillness provides a framework for understanding theindividual client. An entire chapter is devoted to as-sessment, emphasizing its importance in nursing. Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental healthsettings, including legal and ethical issues; anger,aggression, and hostility; abuse and violence; andgrief and loss. Nurses in all practice settings findthemselves confronted with issues related to thesetopics. Additionally, many legal and ethical concernsare interwoven with issues of violence and loss.Unit 4: Nursing Practice for Psychiatric Dis- orders covers all the major categories identified in the DSM-IV-TR. Each chapter provides current informa-tion on etiology, onset and clinical course, treatment,and nursing care. New Features in the Second Edition • A new chapter on Legal and Ethical Issues ad- dresses some current dilemmas in psychiatricnursing today. • Sections on Mental Health Promotion in Units 3 & 4 include the latest research. • Additional NCLEX-style multiple-choice ques- tions are found in the Chapter Study Guidesections. • Updates in pharmacology include new drugs currently being tested and FDA Black BoxWarnings for psychotropic medications. • Additional artwork illustrates key terms and concepts. Pedagogical Features Psychiatric Mental Health Nursing incorporates several pedagogical features designed to facilitatestudent learning: • Learning Objectives to focus the student’s read- ing and study • Key Terms that identify new terms used in the chapter. Each term is identified in boldand defined in the text. • Application of the nursing process using the as- sessment framework presented in Chapter 8,so students can compare and contrast the var-ious disorders more easily • Critical thinking questions to stimulate stu- dents’ thinking about current dilemmas andissues in mental health • Key points that summarize chapter content to reinforce important concepts • Chapter Study Guides that provide workbook- style questions for students to test their knowl-edge and understanding of each chapterPrefaceSpecial Features • Clinical vignettes are provided for each major disorder discussed in the text to “paint a pic-ture” for better understanding. • Drug alerts highlight essential points about psychotropic drugs. • Cultural considerations are emphasized in a separate section of each chapter in response toincreasing diversity. • Therapeutic dialogues give specific examples of nurse–client interaction to promote thera-peutic communication skills. • Internet resources with URLs are located at the end of each chapter to further enhance study. • Client and family education checklists are highlighted to strengthen students’ roles aseducators. • Symptoms and interventions are highlighted for all chapters in Units 3 and 4. • Sample nursing care plans are provided for all chapters in Units 3 and 4. • Self-awareness feature at the end of each chap- ter encourages students to reflect upon them-selves, their emotions, and their attitudes as away to foster both personal and professionaldevelopment. To the Faculty The following ancillary materials have been pre-pared to help you plan class and clinical learningactivities, and evaluate students’ learning: • Instructor’s Resource Manual will include a variety of instructional support features for each chapter, including chapter summa-ries, lecture outlines, and teaching–learningstrategies that involve classroom, clinical, and self-awareness activities. In addition, guide-lines are provided for leading class discussionrelating to Critical Thinking Questions in-cluded in the textbook. Transparency mastersprovide summary lists of symptoms, interven-tions, and Client and Patient Teaching check-lists for each of the 12 disorder chapters. • CD-ROM, included in the Instructor’s Resource Manual, contains: ••Testbank containing 350 NCLEX-style test- ing items ••Lecture outlines for each chapter ••Powerpoint slide presentation To the Student This textbook has been written for you. Above all, it is designed to be “student-friendly.” Chapters areeasy to read and understand, and pertinent infor-mation about caring for clients is presented in apractical, hands-on approach. Mental health nurs-ing is an exciting and challenging field, and hope-fully that attitude comes through in this text. Theknowledge and skills you develop while studyingmental health nursing will promote your growth asa nurse and improve the care you provide to clientsin all settings. In addition to the text itself, we are including a free CD-ROM in the back of the book. This CD contains aninteractive Case Study on Anxiety, helpful additionalNCLEX review questions, view guides to accompanyfilms depicting common psychiatric disorders, andprintable psychotropic drug monographs. Also, formore psychiatric-related materials to enhance yourlearning, be sure to visit http://connection.lww.com Sheila L. Videbeck, PhD, RNx PREFACEvii➤➤➤➤➤ Chapter 12 Charlotte M. Spade, MS, RN, CS Associate Professor of Nursing Community College of DenverDenver, ColoradoContributorv➤➤➤➤➤ Reviewers Linda Barratt, RN, BA, MA Instructor British Columbia Institute of TechnologyBurnaby, British Columbia, Canada Carolyn R. Pierce Buckelew, BSN, MA, APN, RNCS, NCC, ChP Nursing Instructor CE Gregory School of NursingRaritan Bay Medical CenterPerth Amboy, New Jersey Lucindra Campbell, MSN, APNP Assistant Professor of NursingHouston Baptist UniversityHouston, Texas Pattie Garrett Clark, RN, MSN Associate Professor and Nursing Outreach CoordinatorAbraham Baldwin CollegeTifton, Georgia Carol Cornwell, PhD, MS, RN, CS Assistant Professor of Nursing and Director, Center for Nursing Scholarship Georgia Southern University School of NursingStatesboro, Georgia Lesly Curtis, RN, BS, MS, MA Assistant Professor of Clinical NursingDirector, Entry to Practice ProgramColumbia University school of NursingNew York, New York Pamela Farley, RN, PhD Professor and ChairpersonBerea CollegeBerea, KentuckySuzette Farmer, RN, MS Assistant Professor, Assistant Program DirectorUtah Valley State CollegeOrem, Utah Cynthia Foust, PhD, RN Associate ProfessorDivision of NursingSouthwestern Oklahoma State UniversityWeatherford, Oklahoma Judith A. Gardner, MSN, RN, CNS Full-Time Nursing Faculty and ConsultantStark State CollegeCanton, Ohio Alice Grady, MSN, RN, FNP Assistant ProfessorNursing DepartmentTennessee Wesleyan College, Fort SandersKnoxville, Tennessee Mary Ann Helms, MSN, MRE, RN Assistant ProfessorTennessee State UniversitySchool of NursingNashville, Tennessee Barbara A. Jones, DNSc, RN Associate ProfessorSchool of NursingGwynedd-Mercy CollegeGwynedd Valley, Pennsylvania Nancy G. McAfee, MSN, RN Program Director, Upward Mobility ProgramLamar State College—OrangeOrange, TexasElaine Mordoch, RN, BN, MN Lecturer, Faculty of Nursing University of ManitobaWinnipeg, Manitoba, Canada Susan R. Seager, RN, MSN, EdD Associate Professor, NursingTennessee State University School of NursingNashville, Tennessee Margaret R. Swisher, RN, MSN Assistant Professor of NursingMontgomery County Community CollegeBlue Bell, PennsylvaniaCharlotte D. Taylor RN, MSN Associate Professor of NursingUniversity of Arkansas–MonticelloMonticello, Arkansas Arlene Wandel Zawadzki, MS, RN, CS, HNC Part-time InstructorNiagara County Community CollegeSanborn, New Yorkvi R EVIEWERSUnit 1➤ Current Theories and Practice21 Learning Objectives After reading this chapter, the student should be able to 1.Describe characteristics of mental health and mentalillness. 2.Discuss the purpose and use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 3.Identify important histori- cal landmarks in psychi-atric care. 4.Discuss current trends in the treatment of peoplewith mental illness. 5.Discuss the American Nurses Association stan-dards of practice for psychiatric-mental health nursing. 6.Describe common student concerns about psychiatricnursing.Key Terms asylum case managementdeinstitutionalizationDiagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) managed caremanaged care organizationsFoundations of Psychiatric-Mental Health Nursing➤➤➤➤➤ mental disorder mental healthphenomena of concernpsychotropic drugsrevolving doorself-awarenessstandards of careutilization review firmsAs you begin the study of psychiatric-mental health nursing, you may be excited, uncertain, and even alittle anxious. The field of mental health often seemsa little unfamiliar or mysterious, making it hard toimagine “What is this experience going to be like?” or“What does a nurse do in this area?” This chapter ad-dresses these and other questions by providing anoverview of the history of mental illness, advances intreatment, current issues in mental health, and therole of the psychiatric nurse. MENTAL HEALTH AND MENTAL ILLNESS Mental health and mental illness are difficult to de- fine precisely. People who can carry out their roles insociety and whose behavior is appropriate and adap-tive are viewed as healthy. Conversely those who failto fulfill roles and carry out responsibilities or whosebehavior is inappropriate are viewed as ill. The cul-ture of any society strongly influences its values andbeliefs, and this in turn affects how that society de-fines health and illness. What one society may viewas acceptable and appropriate, another society maysee as maladaptive or inappropriate. Mental Health The World Health Organization (WHO) defineshealth as a state of complete physical, mental, andsocial wellness, not merely the absence of disease orinfirmity. This definition emphasizes health as a pos-itive state of well-being, not just absence of disease.People in a state of emotional, physical, and socialwell-being fulfill life responsibilities, function effec-tively in daily life, and are satisfied with their inter-personal relationships and themselves. No single, universal definition of mental health exists. Generally a person’s behavior can provide cluesto his or her mental health. Because each person canhave a different view or interpretation of behavior(depending on his or her values and beliefs), the de-termination of mental health may be difficult. In mostcases, mental health is a state of emotional, psycho- logical, and social wellness evidenced by satisfyinginterpersonal relationships, effective behavior andcoping, positive self-concept, and emotional stabil-ity. Mental health has many components, and a widevariety of factors influence it (Mohr, 2003): •Autonomy and independence: The person can look within for guiding values and rulesby which to live. He or she considers theopinions and wishes of others but does not allow them to dictate decisions and behavior. The person who is autonomousand independent can work interdependentlyor cooperatively with others without losing his or her autonomy. •Maximization of one’s potential: The person is oriented toward growth and self-actualization.He or she is not content with the status quoand continually strives to grow as a person. •Tolerance of life’s uncertainties: The person can face the challenges of day-to-day livingwith hope and a positive outlook despite notknowing what lies ahead. •Self-esteem: The person has a realistic aware- ness of his or her abilities and limitations. •Mastery of the environment: The person can deal with and influence the environment in acapable, competent, and creative manner. •Reality orientation: The person can distin- guish the real world from a dream, fact fromfantasy, and act accordingly. •Stress management: The person can tolerate life stresses, appropriately handle anxiety orgrief, and experience failure without devas-tation. He or she uses support from familyand friends to cope with crises, knowing thatthe stress will not last forever. These factors constantly interact; thus, a person’s mental health is a dynamic or ever-changing state. Factors influencing a person’s mental health can be categorized as individual, interpersonal, and so-cial/cultural. Individual factors include a person’s biologic makeup, sense of harmony in life, vitality,ability to find meaning in life, emotional resilience or hardiness, spirituality, and positive identity (Seaward, 1997). Interpersonal factors include effec- tive communication, ability to help others, intimacy, and a balance of separateness and connection. Social/ cultural factors include a sense of community, access to adequate resources, intolerance of violence, andsupport of diversity among people. Individual, inter-personal, and social/cultural factors are discussed inChapter 7. Mental Illness The American Psychiatric Association (APA, 2000)defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern thatoccurs in an individual and that is associated withpresent distress (e.g., a painful symptom) or disabil-ity (i.e., impairment in one or more important areasof functioning) or with a significantly increased riskof suffering death, pain, disability, or an importantloss of freedom” (p. xxxi). General criteria to diagnosemental disorders include dissatisfaction with one’scharacteristics, abilities, and accomplishments; in-effective or nonsatisfying relationships; dissatisfac-tion with one’s place in the world; ineffective coping1FOUNDATIONS OF PSYCHIATRIC -MENTAL HEALTH NURSING 3with life events; and lack of personal growth. In ad- dition, the person’s behavior must not be culturallyexpected or sanctioned, nor does deviant behaviornecessarily indicate a mental disorder (APA, 2000). Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/cultural categories. Individual factors include bio- logic makeup, anxiety, worries and fears, a sense ofdisharmony in life, and a loss of meaning in one’s life(Seaward, 1997). Interpersonal factors include in- effective communication, excessive dependency orwithdrawal from relationships, and loss of emotionalcontrol. Social and cultural factors include lack of re- sources, violence, homelessness, poverty, and discrim-ination such as racism, classism, ageism, and sexism. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS(DSM-IV-TR) The Diagnostic and Statistical Manual of Men- tal Disorders-Text Revision (DSM-IV-TR), now in its fourth edition, is a taxonomy published by the APA. The DSM-IV-TR describes all mental dis- orders, outlining specific diagnostic criteria for eachbased on clinical experience and research. All mentalhealth clinicians who diagnose psychiatric disordersuse the DSM-IV-TR.The DSM-IV-TR has three purposes: •To provide a standardized nomenclature and language for all mental health professionals •To present defining characteristics or symp- toms that differentiate specific diagnoses •To assist in identifying the underlying causes of disorders A multi-axial classification system that involves assessment on several axes, or domains of informa-tion, allows the practitioner to identify all the factorsthat relate to a person’s condition: •Axis I is for identifying all major psychiatric disorders except mental retardation andpersonality disorders. Examples include depression, schizophrenia, anxiety, and substance-related disorders. •Axis II is for reporting mental retardation and personality disorders as well as promi-nent maladaptive personality features anddefense mechanisms. •Axis III is for reporting current medical conditions that are potentially relevant tounderstanding or managing the person’smental disorder as well as medical condi-tions that might contribute to understandingthe person. •Axis IV is for reporting psychosocial and environmental problems that may affect thediagnosis, treatment, and prognosis of men-tal disorders. Included are problems withprimary support group, social environment,education, occupation, housing, economics,access to health care, and legal system. •Axis V presents a Global Assessment of Functioning (GAF), which rates the person’soverall psychological functioning on a scaleof 0 to 100. This represents the clinician’s assessment of the person’s current level offunctioning; the clinician also may give ascore for prior functioning (for instance, high-est GAF in past year or GAF 6 months ago). All clients admitted to a hospital for psychi- atric treatment will have a multi-axis diagnosisfrom the DSM-IV-TR. Although student nurses do not use the DSM-IV-TR to diagnose clients, they will find it a helpful resource to understand the rea-son for the admission and to begin building knowl-edge about the nature of psychiatric illnesses. HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL ILLNESS Ancient Times People of ancient times believed that any sickness indicated displeasure of the gods and in fact was pun-ishment for sins and wrongdoing. Those with mental4 Unit 1 CURRENT THEORIES AND PRACTICE Demons disorders were viewed as being either divine or de- monic depending on their behavior. Individuals seenas divine were worshipped and adored; those seen asdemonic were ostracized, punished, and sometimesburned at the stake. Later Aristotle (382–322 BC) at- tempted to relate mental disorders to physical dis-orders and developed his theory that the amountsof blood, water, and yellow and black bile in the bodycontrolled the emotions. These four substances, orhumors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humorswere believed to cause mental disorders, so treatmentaimed at restoring balance through bloodletting, starv-ing,and purging. Such “treatments” persisted well into the 19th century (Baly, 1982). In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseaseswere again blamed on demons, and the mentally illwere viewed as possessed. Priests performed exor-cisms to rid evil spirits. When that failed, they usedmore severe measures such as incarceration in dun-geons, flogging, starving, and other brutal treatments. During the Renaissance (1300–1600), people with mental illness were distinguished from criminals inEngland. Those considered harmless were allowed towander the countryside or live in rural communities,but the more “dangerous lunatics” were thrown inprison, chained, and starved (Rosenblatt, 1984). In1547, the Hospital of St. Mary of Bethlehem was of-ficially declared a hospital for the insane, the first ofits kind. By 1775, visitors at the institution werecharged a fee for the privilege of viewing and ridicul-ing the inmates, who were seen as animals, less thanhuman (McMillan, 1997). During this same period inthe colonies (later the United States), the mentallyill were considered evil or possessed and were pun-ished. Witch hunts were conducted, and offenderswere burned at the stake. Period of Enlightenment and Creation of Mental Institutions In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel inFrance and William Tukes in England formulatedthe concept of asylum as a safe refuge or haven of- fering protection at institutions where people hadbeen whipped, beaten, and starved just because theywere mentally ill (Gollaher, 1995). With this move-ment began the moral treatment of the mentally ill.In the United States, Dorothea Dix (1802–1887) begana crusade to reform the treatment of mental illnessafter a visit to Tukes’ institution in England. Shewas instrumental in opening 32 state hospitals thatoffered asylum to the suffering. Dix believed that so-ciety was obligated to those who were mentally illand promoted adequate shelter, nutritious food, and warm clothing (Gollaher, 1995). The period of enlightenment was short-lived. Within 100 years after establishment of the first asy-lum, state hospitals were in trouble. Attendants wereaccused of abusing the residents, the rural location ofhospitals was viewed as isolating patients from fam-ily and their homes, and the phrase “insane asylum”took on a negative connotation. Sigmund Freud and Treatment of Mental Disorders The period of scientific study and treatment of men- tal disorders began with Sigmund Freud (1856–1939)and others such as Emil Kraepelin (1856–1926) andEugene Bleuler (1857–1939). With these men, thestudy of psychiatry and the diagnosis and treatment ofmental illnesses started in earnest. Freud challengedsociety to view human beings objectively. He studiedthe mind, its disorders, and their treatment as no onehad before. Many other theorists built on Freud’s pi-oneering work (see Chap. 3). Kraepelin began classi-fying mental disorders according to their symptoms,and Bleuler coined the term “schizophrenia.” Development of Psychopharmacology A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs (drugs used to treat mental illness). Chlor- promazine (Thorazine), an antipsychotic drug, andlithium, an antimanic agent, were the first drugs to be developed. Over the following 10 years, mono-amine oxidase inhibitor antidepressants; haloperidol(Haldol), an antipsychotic; tricyclic antidepressants;and antianxiety agents called benzodiazepines wereintroduced. For the first time, drugs actually reducedagitation, psychotic thinking, and depression. Hos-pital stays were shortened, and many people werewell enough to go home. The level of noise, chaos, andviolence greatly diminished in the hospital setting(Trudeau, 1993). Move Toward Community Mental Health The movement toward treating those with mental ill- ness in less restrictive environments gained momen-tum in 1963 with the enactment of the CommunityMental Health Centers Act. Deinstitutionalization, a deliberate shift from institutional care in state hos-pitals to community facilities, began. Community men-tal health centers served smaller geographic catch-ment (service) areas that provided less restrictive1FOUNDATIONS OF PSYCHIATRIC -MENTAL HEALTH NURSING 5treatment located closer to the person’s home, family, and friends. These centers provided emergency care,inpatient care, outpatient services, partial hospital-ization, screening services, and education. Therefore,deinsitutionalization had three components: releaseof individuals from state institutions, diversion fromhospitalization, and development of alternative com-munity services (Lamb & Bachrach, 2001). In addition to deinstitutionalization, federal leg- islation was passed to provide an income for disabledpersons: Supplemental Security Income (SSI) andSocial Security Disability Income (SSDI). This allowedpeople with severe and persistent mental illnessesto be more independent financially and not have torely on family for money. States were able to spendless money on care of the mentally ill than they hadin state hospitals, because these programs were fed-erally funded. Also commitment laws changed in theearly 1970s, making it more difficult to commit peoplefor mental health treatment against their will. Thisfurther decreased the state hospital populations and,consequently, the money that states spent on them(Torrey, 1997). MENTAL ILLNESS IN THE 21ST CENTURY The Department of Health and Human Services (2002) estimates that 56 million Americans have a diagnos-able mental illness. Furthermore, mental illnesses orserious emotional disturbances impair daily activities for an estimated 10 million adults and 4 million chil-dren and adolescents. For example, attention deficit/hyperactivity disorder affects 3% to 5% of school-agechildren. More than 10 million children younger than7 years grow up in homes where at least one parentsuffers from significant mental illness or substanceabuse, which hinders the readiness of these chil-dren to start school. The economic burden of mentalillness in the United States, including both healthcare costs and lost productivity, exceeds $170 billion(Department of Health and Human Services [DHHS],2002). Four of the ten leading causes of disability in theUnited States and other developed countries are men-tal disorders: major depression, bipolar disorder, schiz-ophrenia, and obsessive-compulsive disorder (NIMH,2002). Yet only one in four adults and one in five chil-dren and adolescents in need of mental health ser-vices get the care they need. Some believe that deinstitutionalization has had negative as well as positive effects (Torrey, 1997).Although deinstitutionalization reduced the numberof public hospital beds by 80%, the number of admis-sions to those beds correspondingly increased by 90%(Appleby & Desai, 1993). Such findings have led tothe term revolving door effect. While people with severe and persistent mental illnesses have shorter hospital stays, they are admitted to hospitals morefrequently. The continuous flow of clients being ad-mitted and discharged quickly overwhelms generalhospital psychiatric units. In some cities, emergencydepartment visits for acutely disturbed persons haveincreased by 400% to 500%. Shorter hospital stays further complicate fre- quent, repeated hospital admissions. People withsevere and persistent mental illness may show signsof improvement in a few days but are not stabilized.Thus they are discharged into the community with-out being able to cope with community living. The re-sult frequently is decompensation and rehospitaliza-tion. In addition, many people have a “dual” problemof both severe mental illness and substance abuse.Use of alcohol and drugs exacerbates symptoms ofmental illness, again making rehospitalization morelikely. Substance abuse issues cannot be dealt within the 3 to 5 days typical for admissions in the cur-rent managed care environment. Many providers believe today’s clients to be more aggressive than those in the past. Four to eight per-cent of clients seen in psychiatric emergency roomsare armed (Ries, 1997), and people with severe andpersistent mental illness who are not receiving ade-quate care commit about 1,000 homicides per year(Torrey, 1997). Ten to fifteen percent of those in stateprisons have severe and persistent mental illness(Lamb & Weinberger, 1998). Homelessness is a major problem in the United States today. The Department of Health and HumanServices (2002) estimates that 750,000 people liveand sleep in the streets. Estimates of the prevalence 6 Unit 1 CURRENT THEORIES AND PRACTICE Revolving doorof mental illness among the homeless population are that one-third of adult homeless persons have a seri-ous mental illness and more than one-half also havesubstance abuse problems (DHHS, 2002). Those whoare homeless and mentally ill are found in parks, air-port and bus terminals, alleys and stairwells, jails,and other public places. Some use shelters, halfwayhouses, or board-and-care rooms; others rent cheaphotel rooms when they can afford it (Haugland et al.,1997). Homelessness worsens psychiatric problemsfor many people with mental illness who end up onthe streets, which contributes to a vicious cycle. Many problems of the homeless mentally ill, as well as those who pass through the revolving door ofpsychiatric care, stem from the lack of adequate com-munity resources. Money saved by states when statehospitals were closed has not been transferred tocommunity programs and support. Inpatient psychi-atric treatment still accounts for most of the spend-ing for mental health in the United States, so com-munity mental health has never been given thefinancial base it needs to be effective. In addition,mental health services provided in the communitymust be individualized, available, and culturally rel-evant to be effective (Lamb & Bachrach, 2001). Only15% of people with mental illness appear to be get- ting minimally adequate treatment, which is a pre-scription for medication and four or more visits witha psychiatrist or eight visits with any kind of mentalhealth specialist (Wang, 2002). In 1993, the federal government created and funded Access to Community Care and Effective Ser-vices and Support (ACCESS) to begin to address the needs of people with mental illness who werehomeless either all or part of the time. The goals ofACCESS were to improve access to comprehensiveservices across a continuum of care, reduce dupli- cation and cost of services, and improve the efficiencyof services (Randolph et al., 1997). Programs such asthese provide services to people who otherwise wouldnot receive them. Objectives for the Future Unfortunately only one in four affected adults and one in five children and adolescents receive treat-ment (DHHS, 2002). Statistics like these underliethe Healthy People 2010 objectives for mental health proposed by the U.S. Department of Health andHuman Services (Box 1-1). These objectives, originally1FOUNDATIONS OF PSYCHIATRIC -MENTAL HEALTH NURSING 7 Box 1-1 ➤HEALTHY PEOPLE 2010 M ENTAL HEALTH OBJECTIVES •Reduce suicides to no more than 6 per 100,000 people •Reduce the incidence of injurious suicide attempts by 1% in 12 months for adolescents ages 14–17 •Reduce the proportion of homeless adults who have serious mental illness to 19% •Increase the proportion of persons with serious mental illnesses who are employed to 51% •Reduce the relapse rate for persons with eating disorders including anorexia nervosa and bulimia nervosa •Increase the number of persons seen in primary health care who receive mental health treatment screening and assessment •Increase the proportion of children with mental health problems who receive treatment •Increase the proportion of juvenile justice facilities that screen new admissions for mental health problems •Increase the proportion of adults with mental disorders who receive treatment by 17% •Adults 18–54 with serious mental illness to 55% •Adults 18 and older with recognized depression to 50% •Adults 18 and older with schizophrenia to 75% •Adults 18 and older with anxiety disorders to 50% •Increase the population of persons with concurrent substance abuse problems and mental disorders who receive treatment for both disorders •Increase the proportion of local governments with community-based jail diversion programs for adults with serious mental illness •Increase the number of states that track consumers’ satisfaction with the mental health services they receive to 30 states •Increase the number of states with an operational mental health plan that addresses cultural competence •Increase the number of states with an operational mental health plan that addresses mental health crisis inter- vention, ongoing screening, and treatment services for elderly persons U.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: DHHS.