MENTAL HEALTH CHAPTERS 1,2,3,4,6,7

Mental health◦ Ability to “cope with and adjust to the recurrent

stresses of living in an acceptable way”◦ Mentally healthy people successfully carry out

activities of daily living, adapt to change, solve problems, set goals, and enjoy life.

◦ Mentally healthy people cope well.◦ Mental health is influenced by three factors:

Inherited characteristics Childhood nurturing Life circumstances

Mental Illness is a disturbance in ones ability to cope effectively

CHAPTER 1

Early civilizations believed that mental illness was caused by wrath or evil spirits and by possessions.

Treatments were geared to removal of the evil spirit.◦ Examples- trephining(drilling holes in skull to

release evil spirits), Incantations, charms, sacrifice.

Mentally ill people were allowed to remain in societies as long as their behaviors were not violent. ◦ Violent members were banished.

Chapter 1Primitive Societies

The Greeks took many of their medical beliefs from other societies. Felt that mental illness can be explained through observation.

Hippocrates◦ Believed that nature was a strong healing force◦ Viewed mental illness as an imbalance of humors (air, fire, water, and

earth), overabundance or lack of one or more humors caused illness. This was known as humoral therapy- which lasted for centuries.

Plato◦ Recognized life as a dynamic balance maintained by the soul

Rational soul (head) Irrational soul (heart and abdomen)

◦ Believed that mental illness resulted when the rational soul was not able to control the irrational soul

By about 300 AD, epidemics had killed thousands, and the sick turned to churches for sanctuary.

Hospitals then were built to accommodate sufferers.

Chapter 1Greece and Rome

The Dark Ages◦ Priests were the caregivers for the sick.◦ Early Christians believed that disease was punishment for sins,

possession by the devil, and witchcraft.◦ To cure mental illness, many priests performed exorcisms and religious

ceremonies to drive out evil from affected individuals. Dark Ages

◦ Church doctrine stated that if people were insane, an outside force was causing the disorder.

◦ Church scholars even suggested that witches might be the source of human distress.

◦ Large institutions were established, and mentally ill individuals were herded into “lunatic asylums

Strong Arabic influence was felt in Europe.◦ Arabs had an extensive knowledge of drugs and awareness of the relationship

between emotions and disease. ◦ Universities were established- study medicine, surgery and care of the sick.

Chapter 1Middle Ages

Women were thought to be carriers of the devil because they stirred men’s passions.

Witch hunting was officially launched in 1487 with publication of the book The Witches’ Hammer. Due to this book receiving support from the Pope, many people were women, as well as children, and the mentally ill were burned at the stake

Few safe havens were available for individuals with mental illness during these troubled times.

Superstitions, Witches, and Hunters

The first English institution for mentally ill people was founded in 1247 by the Sheriff of London.

By 1330, Bethlehem Royal Hospital (or Bedlam) was a lunatic asylum. - Became infamous for its abuse to patients

Violently ill patients were chained to walls in small cells and often provided “entertainment” for the public

The First Mental Institutions

The Renaissance began in Italy around 1400. Mental illness was at last being recognized without

bias. By the mid-1500s, behaviors were accurately

recorded for personalities associated with melancholia (depression), mania, and psychopathology.

Despite advances in knowledge, the treatment of mentally troubled people remained inhumane.

Mental problems now were thought to be caused by some sort of brain disorder.

Sexual fantasies were still considered to be God’s punishment.

The Renaissance

It was during the seventeenth century that conditions for mentally ill individuals were at their worst.

People were still uncomfortable so they again moved to witch hunting as a way of protecting themselves from the unexplainable

Physicians and theorists were making observations and speculations about insanity.

Patients were bled, starved, beaten, and purged into submission.

Seventeenth Century

Psychiatry developed as a separate branch of medicine- later part of the 18th century

Inhumane treatment and vicious practices were openly questioned.

1792, Philippe Pinel liberated patients from their chains and advocated acceptance of the mentally ill as human beings in need of medical and nursing care.

In America, the Philadelphia Almshouse was erected. It accepted sick, infirm, prisoners, orphans and insane patients

The care and treatment of people with mental illness remained harsh in the United States as it was in Europe. ◦ Care for the mentally ill did not begin to improve until the

arrival of Alice Fisher, a Florence Nightingale-trained nurse.

Eighteenth Century

Dr. Benjamin Rush became a crusader for the insane.◦ His book titled Diseases of the Mind was the first psychiatric

text written in the United States. He advocated clean conditions and kindness

Mildly mentally affected people commonly were sold at slave auctions, while the more violent remained in asylums.

“Once insane always insane” was no longer the rule as people were being helped.

Dorothea Dix surveyed asylums, jails, and almshouses. Because of her voice, care of the mentally ill greatly improved.

By the late 1800s, a two-class system of psychiatric care had emerged: “private care” for the wealthy and “publicly provided care” for the remainder of society.

Nineteenth Century United States

Clifford Beers wrote A Mind That Found Itself. ◦ A student from Yale who attempted suicide. He

spent three years as a patient in a mental institution and spoke of the beatings, isolation, and confinement of the mentally ill person.

◦ The social consciousness of a nation had finally been awakened.

Committee for Mental Hygiene was formed in 1909.◦ Focused on removing the stigma of mental illness◦ Under Beers guidance, the movement grew nation

wide.

Twentieth Century

Sigmund Freud ◦ Introduced the term psychoanalysis to the world ◦ Felt that forces within and outside the personality were

responsible for mental illness ◦ His theories dealt with the theme of repressed

sexual energies. ◦ He succeeded explaining human behavior in

psychological terms ◦ Presented the first comprehensive theory of

mental illness based on observation

Psychoanalysis

During World War I, men were drafted into service as rapidly as they could be processed.◦ Many were considered too “mentally deficient” to fight.

Plans were created to devise methods for early identification of problems, removal of mentally troubled personnel from combat duty, and early treatment close to the fighting front. War sparked a renewed interest in mental hygiene.◦ Drugs such as amphetamines were introduced. ◦ Insulin therapy was used for schizophrenia.◦ Electroconvulsive therapy (ECT) helped to improve severe

depression. ◦ Lobotomy helped eliminate violent behaviors.

In 1937, Congress passed the Hill-Burton Act.◦ Funded the construction of psychiatric units throughout the

United States

Influences of War

In 1946, Congress passed the National Mental Health Act. Provided funding for programs in research, training of mental health professionals, and expansion of facilities.

In 1949, the National Institute of Mental Health was organized.

As a result of the Korean War of the 1950s and the Vietnam War of the 1960s and 1970s, posttraumatic stress disorders became recognized among soldiers fighting wars.

Influences of War

Psychotherapeutic drugs are chemicals that affect the mind.

John Cade discovered that lithium carbonate could be used to control mood swings in bipolar (manic-depressive) illness.

Chlorpromazine (Thorazine) was introduced in 1956 and proved useful in controlling many behaviors observed in schizophrenia and other psychoses.

Psychotherapeutic Drugs

The federal government began the movement called deinstitutionalization. ◦ From 560,000 in 1955, the number of

institutionalized patients dropped to fewer than 120,000 people by 1994.

It was believed that people with mental disorders could live within their communities and work with their therapists on an outpatient

Functioning Outside of the Institution

The Community Mental Health Centers Act (1963)◦ Congress passed amendments to the Community Mental

Health Centers Act in 1975. The Medicare/Medicaid Bill of 1965- led to the release of

institutionalized patients into the community The President’s Commission on Mental Health (1978)-

Assess the mental health needs of the community Mental Health Systems Act (1980) Omnibus Budget Reconciliation Act of 1981 Omnibus Budget Reconciliation Act of 1987 National Alliance for Mental Illness (NAMI) (2006)

◦ Conducted the “first comprehensive survey and grading of state adult mental healthcare systems conducted in more than 15

Congressional Actions

Chapter 2Current Mental Health Care Systems

Inpatient care◦ Inpatient psychiatric admissions are based on

need. ◦ Clients must be able to pay for services and

cooperate with care providers; their level and severity of illness are also factors.

◦ Inpatient care provides clients with safe, stable, and therapeutic surroundings 24 hours a day.

◦ Clients may be committed to psychiatric care by way of the criminal justice system.

Care Settings

Outpatient care◦ Provides services to people with mental

problems in their home environment◦ Clients are able to remain within their

communities and associate with the real world. People who are unable to function in the

community setting experience recidivism.◦ Behavior pattern with relapse of a symptom,

disease, or behavior

Care Settings

The community support systems (CSS) model views clients holistically.

The goal is to create a support system that fosters individual growth and movement toward independence. ◦ Coordinated social, medical, and psychiatric

services assist this model in being successful.

Community Support Systems Model

The case management system

◦ A holistic system of interventions, designed to support the transition of mentally ill clients into the community Psychosocial rehabilitation Consultation Resource linkage (referral) Advocacy Therapy Crisis intervention

◦ Clients are involved with assessment, planning, and evaluation of their care.

Multidisciplinary health care team◦ Professionals working within the mental health system have various

educational backgrounds.◦ The care team assists in providing quality client care and consists of

psychiatrists, social workers, psychologists, nurses, and others who share their professional expertise and develop therapeutic plans for clients.

Client and family◦ Clients contribute important information that may make the difference

between success or failure of therapeutic plans.

Community Mental Health Settings

Certain groups of people in every community are at high risk for developing mental health problems.◦ Homeless people ◦ Children, families, adolescents, and older adults◦ People who are HIV (human immunodeficiency

virus) positive◦ Clients who live in rural areas

High-Risk Client Populations

Economic issues◦ Funding has not kept pace with the need for

services.◦ Congress established the Health Care Financing

Administration in 1983. Social issues

◦ Mentally ill individuals are likely to be struggling with basic issues, such as poverty, homelessness, and substance abuse.

Factors That Affect Mental Health Care

Chapter 3 Ethical and Legal Issues

Attitudes are ideas that help shape our points of view.◦ Can also describe one’s outlook

Belief is a conviction that is intellectually accepted as true whether or not it is based in fact.

Value is something that is held dear or a feeling about the worth of an item, idea, or behavior.◦ Formed in childhood

Morals reflect one’s attitudes, beliefs, and values.◦ Not easily changed

Values and Morals

A right is described as a power, privilege, or existence to which one has a just claim.

Rights help to define social interactions because they contain the principle of justice; they equally and fairly apply to all citizens.

Rights also are associated with obligations.

Rights

The Patient’s Bill of Rights (1972)◦ All clients have the rights to respectful care,

privacy, confidentiality, continuity of care, and relevant information.

◦ Addresses clients’ rights to Examine their bills Refuse treatment Participate in research

The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities was adopted in 2003.◦ Statements of rights for the most vulnerable people

in society.

Patient’s Rights

Ethics is a set of rules or values that govern right behavior. Ethics reflect

◦ Values◦ Morals◦ Principles of right and wrong

The purpose of ethical behavior is to protect the rights of people. Ethical codes serve two purposes: ◦ Act as guidelines for standards of practice◦ Let the public know what behaviors can be expected from their health care

providers Ethical principles on which codes of ethics are based include the

following: Autonomy- Right of people to act for themselves and make choices Beneficence- To actively do good Nonmaleficence- Do No Harm Justice- all clients are treated equally Fidelity- Do what you say-keep your promises Veracity- duty to tell the truth

Ethics/Ethical Behaviors

Have been developed by◦ International Council of Nurses◦ American Nurses Association◦ National Federation of Licensed Practical Nurses◦ Canadian Nurses Association

Provide information to clients, be truthful, and support your clients, but consult your supervisor if any question of appropriateness arises.

Codes of Ethics

Ethical dilemmas exist when there is uncertainty or disagreement about the moral principles related to a course of action.

Ethical dilemmas arise when problems cannot easily be solved by decision making, logic, or use of scientific data.

Ethical Conflict

Laws are the controls by which a society governs itself.◦ Apply to every member of society◦ Created as a result of

Rules Regulations Morals Ethical principles

Laws and the Legal System

Public law◦ Focuses on the law between government and its

citizens◦ Protects the members of society◦ Also known as criminal law◦ Consists of misdemeanors and felonies

Private law◦ Focuses on the law between citizens and/or

institutions◦ Torts and contracts◦ Also known as civil law

Public vs. Private Law

Client-caregiver relationship◦ Caregiver and client enter into an implied contract

of acceptance of service. ◦ Care providers are legally responsible for their

professional obligations and behaviors.

Laws and Mental Healthcare

When a client initiates the request for mental health services, it is considered a voluntary admission.◦ Voluntarily admitted clients may legally discharge

themselves at any time. Involuntary admission is a process for

institutionalization initiated by someone other than the client. ◦ Involuntary psychiatric admissions provide a

protected, therapeutic environment.◦ Clients may stay for days to years.

Adult Psychiatric Admissions

Care providers in mental health are faced with balancing client rights and the need to protect society.

The most common crimes in health care settings include homicide, controlled substance violations, and theft.

Areas of Potential Liability

Both negligence and malpractice are rooted in the “reasonable and prudent person” theory.

Negligence ◦ Omission (or commission) of an act that a

reasonable and prudent person would (or would not) do

Malpractice ◦ Failure to exercise an accepted degree of

professional skill that results in injury, loss, or damage

Negligence and Malpractice

Mental health care providers help clients cope with their problems.

They provide dignified, humane treatment, which includes protection of rights as human beings, citizens, and clients.

Responsibility of the Care Provider

Chapter 4Sociocultural Issues

Culture is a total way of life. ◦ Shared system of values that provides a framework for

who we are Race describes a group of people who share

distinct physical characteristics.◦ Skin color, facial features

Ethnicity is associated with the customs, cultural habits, and socialization patterns of a particular group. ◦ Values, traditions, expectations, and customs are passed

from one generation to another.

The Nature of Culture

Spirituality and religion play important roles in the concept of culture.

Spirituality refers to belief in a power greater than any human being.

Religion relates to a defined, organized, and practiced system of worship.◦ Often mental health clients have religious components

to their illnesses. Culture is an abstract concept, composed of the

values, beliefs, roles, and norms of a group. ◦ Cultural values strongly influence thinking and actions.

A culture’s belief system develops over generations. ◦ Formed by feelings and convictions that are believed to

be true

The Nature of Culture

Beliefs about mental health have a strong impact on outcomes of treatment.

Values and beliefs help to define norms, which are a culture’s behavioral standards.◦ Norms are the established rules of conduct that define

which behaviors are encouraged, accepted, tolerated, and forbidden within a culture.

◦ A role is an expected pattern of behaviors associated with a certain position, status, or gender.

Stereotype is an oversimplified mental picture of a cultural group.◦ Stereotyping may take negative, positive, or traditional

forms. ◦ Prejudice (extreme negative stereotyping)

Health care providers need to know and understand their own racial, ethnic, religious, and social stereotypes.

Characteristics of Culture

Health care providers should practice cultural competence.◦ Transcultural nursing

All care providers must guard against the tendency to transfer their own cultural expectations onto clients or to make generalizations based on their own cultural attitudes

Cultural assessments allow us to learn how clients perceive and cope within their world. ◦ Communication

Verbal and nonverbal components

◦ Environmental control How the individual perceives he/she controls the environment

◦ Space, territory, and time Space comforts, control over space, concept of time

Cultural Assessment

Treating refugees◦ A refugee is a person who, because of war or

persecution, flees from his or her home or country and seeks refuge elsewhere.

◦ Stress-related problems are a factor. ◦ Obtain immigration history and a history of

arrival to the new country, time, and who or what was lost.

◦ Refugees tend to have a greater incidence of depression, anxiety, and stress disorder.

Culture and Mental Health Care

Chapter 6Complementary and Alternative Therapies

Allopathic medicine◦ Uses medical and surgical methods to treat

disease Complementary medicine

◦ Treatments that agree or “work with” allopathic therapies Massage

Alternative medicine◦ Treatments that are used instead of

conventional medicine Herbal therapy

Alternative and Complementary Therapies

Integrative medicine attempts to blend the most effective practices and treatments from both conventional and alternative treatment systems. ◦ Emphasis is on interrelationships among body,

mind, and spirit. ◦ Holistic care

We are no longer content to treat the illness. We are learning to treat the whole person.

Integrative Medicine

National Center for Complementary and Alternative Medicine◦ Dedicated to exploring complementary and

alternative healing practices in the context of rigorous science

◦ CAM therapies can be divided into two basic groups. Body-based CAM Energy-based CAM

NCCAM

Whole medical systems◦ Ayurveda

Focus is on the innate harmony of the body, mind, and spirit.

◦ Homeopathy Uses natural substances in micro-doses to relieve

symptoms◦ Naturopathy

Views disease as an alteration in the process by which the body heals itself

◦ Traditional Chinese medicine (TCM) Based on the view that the body is a delicate balance of

opposing forces: yin and yang

Body-Based CAM

Biologically-based practices attempt to improve the human condition through the use of substances extracted from nature.

Examples◦ Aromatherapy

Use of certain scented essential oils to promote health and well-being

◦ Dietary supplements “Dietary ingredient” supplement to the diet

◦ Herbal products Use of certain plants (herbs) to treat disease and alleviate

suffering

Biologically-Based Practices

Practices that focus on moving the body into an improved state of function through treatment

Examples◦ Chiropractic treatment

Relationship between body structure (the spine) and function is the subject of study for chiropractic care.

◦ Chelation Uses the chemical ethylenediaminetetraacetic acid (EDTA) and its ability

to bind with heavy metals

Examples◦ Eye movement desensitization

Uses controlled eye movements to help reprocess traumatic memories

◦ Massage Manipulation of muscles and connective tissue to relax the body and

enhance well-being

◦ Phototherapy Use of bright lights for the treatment of depression

Body-Based Practices

Practitioners believe in a vital, life-force energy that flows through the human body.

Energy medicine is divided into two parts.◦ Biofield therapies

Examples include acupuncture, biofeedback, Qi Gong, Reiki, therapeutic touch, and color therapy.

◦ Electromagnetic field therapies The use of energy to treat illness Examples include magnetic therapy, repetitive

transcranial magnetic stimulation (TMS), pulsating electromagnetic therapy, and millimeter wave therapy.

Energy Medicine

Alternative approaches to mental illness emphasize the interactions of body, mind, and spirit.◦ Animal-assisted therapy◦ Culturally based healing◦ Diet and nutrition◦ Expressive therapies◦ Pastoral counseling◦ Self-help groups◦ Stress reduction and relaxation

CAM Mental Health Therapies

Chapter 7Psychotherapeutic Drug Therapy

Psychiatric medications act on the body’s nervous system primarily by altering the delicate chemical balances within that system.

Most interrupt the chemical messenger (neurotransmitter) pathways within the brain.

A primary responsibility of health care providers, especially nurses, is to differentiate therapeutic from unwanted effects.

How Psychotherapeutic Drug Therapy Works

Four classes of psychotherapeutic drugs:◦ Antianxiety agents◦ Antidepressants ◦ Antimanics◦ Antipsychotics

People who are receiving medications must be monitored routinely for effectiveness, side effects, and life-threatening adverse reactions.

Classifications of Psychotherapeutic Drugs

Antianxiety agents are drugs that reduce the psychic tension of stress. ◦ Anxiolytics or “minor tranquilizers”

Medications in the antianxiety group are divided by their chemical formulas into categories.

Benzodiazepines◦ Mainly used to decrease anxiety◦ Act by increasing gamma-aminobutyric acid

(GABA) activity, which results in decreased anxiety◦ Because long-term use of antianxiety drugs can

result in dependence, therapy for clients usually is limited to a few months.

Antianxiety Medications

Buspirone (BuSpar)◦ Belongs to the azaspirone drug class◦ Does not cause the sleepiness or muscle relaxation

associated with benzodiazepines◦ Therapeutic effects not seen for 3 to 6 weeks after

treatment initiation Pregabalin (Lyrica)

◦ Side effects are fewer than those of other antianxiety drugs so patients are more likely to comply with treatment.

Interactions◦ Central nervous system (CNS) depression when combined

with CNS depressants◦ Increased concentrations of the cardiac drug digoxin◦ Interfere with absorption into the bloodstream when taken

with antacids

Antianxiety Medications

Antidepressant medications act on the body by increasing certain neurotransmitter activities.

The physician’s first choice for the treatment of depression is often an antidepressant.

Antidepressants are divided into categories:◦ Tricyclic antidepressants◦ Monoamine oxidase inhibitors (MAOIs)◦ Selective serotonin reuptake inhibitors (SSRIs)◦ Atypical antidepressants◦ Selective serotonin/norepinephrine reuptake inhibitors (SSNRIs)

Antidepressant medications may be taken 1 to 4 weeks before symptom relief is noted.

Side effects include dry mouth, nose, and eyes, urinary retention, and hypertensive crisis.◦ These discomforts can be so bothersome that some people

refuse to take their medications regularly. MAOIs have many drug and food interactions

Antidepressant Medications

Lithium◦ Naturally occurring salt used to treat the manic

phase of bipolar depression◦ Well absorbed into the bloodstream and

excreted faster than sodium by the kidneys Important for clients to balance their salt intake, fluid

intake, and activity◦ Interacts with a variety of other drugs◦ Levels higher than 1.5 mEq/L are considered

toxic.◦ Clinical improvement commonly takes as long

as 3 weeks.

Antimanic Medications

Antipsychotics also are called major tranquilizers or neuroleptics.◦ Used to treat the symptoms of major mental disorders

(schizophrenia, acute mania, and organic mental illnesses) and resistant bipolar (manic-depressive), paranoid, and movement disorders

Interactions◦ Antacids

Hinder the absorption of antipsychotics into the bloodstream◦ Alcohol◦ Antianxiety medications◦ Antihistamines◦ Antidepressants◦ Barbiturates◦ Meperidine (Demerol) and morphine

Produce severe CNS depression when mixed with antipsychotics

Antipsychotic Medications

Noncompliance is an informed decision made by a client not to follow a prescribed treatment program.◦ The physician should be notified. ◦ Work with your clients to find and eliminate the

factors that lead to noncompliance

Noncompliance

Presenting clients with information about the benefits, risks, and side effects of specific treatments ◦ Enabling them to make voluntary and

knowledgeable decisions about their care Patient Self-Determination Act

◦ States that clients have the right to accept or refuse care and cannot be pushed, coerced, or talked into following a certain course

Informed Consent