Chapter Ten: Mental Health

Specific Mental Illness Disorders

This section provides an overview of select common mental illness disorders that you may encounter as a nurse. The list is not exhaustive. The National Alliance on Mental Illness provides information on additional disorders, including overviews, possible treatments, and examples of how to support yourself and others with mental illnesses.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event (NIH, 2019).

It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened, even when they are not in danger (NIH, 2019).

While most traumatized people experience short-term symptoms, the majority do not develop ongoing (chronic) PTSD. Events that may later lead to PTSD can be violent or nonviolent. For example, experiences like the sudden, unexpected death of a loved one can cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, whereas others have symptoms that last much longer. In some people, the condition becomes chronic (NIH, 2019).

Long Description for Figure 10.2

Flashbacks, irritable, frustrated, angry, trouble with memory and attention, fatigue, poor self-care, feeling anxious, trouble sleeping, insomnia, and feeling depressed. Evidence-based treatments for P T S D: Many proven P T S D treatments are available such as prolonged exposure therapy; cognitive processing therapy; eye movement desensitization and reprocessing; stress inoculation training; treatment with specific medications effective in P T S D.

To be diagnosed with PTSD, an adult must have all the following for at least 1 month:

• At least one reexperiencing symptom
• At least one avoidance symptom
• At least two arousal and reactivity symptoms
• At least two cognition and mood symptoms

Reexperiencing symptoms include:

• Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Bad dreams
• Frightening thoughts

Reexperiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s thoughts and feelings. Words, objects, or situations that are reminders of the traumatic event can also trigger reexperiencing symptoms.

Avoidance symptoms include:

• Staying away from places, events, or objects that are reminders of the traumatic experience
• Avoiding thoughts or feelings related to the traumatic event

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change their routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include:

• Being easily startled
• Feeling tense or on edge
• Having difficulty sleeping
• Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind the person of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms include:

• Trouble remembering key features of the traumatic event
• Negative thoughts about oneself or the world
• Distorted feelings like guilt or blame
• Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic event but are not the result of injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.

It is natural to have some of these symptoms for a few weeks after a dangerous event. When the symptoms last more than a month, seriously affect one’s ability to function, and are not attributable to substance use, medical illness, or anything except the event itself, they might be indicators of PTSD. Some people with PTSD do not show any symptoms for weeks or months. Often, PTSD is accompanied by depression, substance abuse, or one or more of the other anxiety disorders (NIH, 2019).

Depression

Depression is more than just feeling down or having a bad day. When a sad mood lasts for a long time and interferes with everyday functioning, the likely cause is depression. Depression can become a serious health condition that affects all aspects of daily life. Symptoms of depression include:

• Feeling sad or anxious often or all the time
• Not wanting to do activities that used to be fun
• Feeling irritable, easily frustrated, or restless
• Having trouble falling asleep or staying asleep
• Waking up too early or sleeping too much
• Eating more or less than usual or having no appetite
• Experiencing aches, pains, headaches, or stomach problems that do not improve with treatment
• Having trouble concentrating, remembering details, or making decisions
• Feeling tired, even after sleeping well
• Feeling guilty, worthless, or helpless
• Thinking about suicide or self-harm

The exact cause of depression is unknown. It may be caused by a combination of genetic, biological, environmental, and psychological factors. Everyone is different, but the following factors may increase a person’s chances of becoming depressed:

• Having blood relatives who have had depression
• Experiencing traumatic or stressful events, such as physical or sexual abuse, the death of a loved one, or financial problems
• Going through a major life change, even if it was planned
• Having a medical diagnosis, such as cancer, stroke, or chronic pain
• Taking certain medications
• Using alcohol or drugs

In general, about one out of every six adults will have depression at some time in their life. Depression affects about 16 million American adults every year. Anyone can get depressed, and depression can happen at any age and in any type of person.

Many people who experience depression also have other mental health conditions. Anxiety disorders often go hand in hand with depression. People who have anxiety disorders struggle with intense and uncontrollable feelings of anxiety, fear, worry, and/or panic. These feelings can interfere with daily activities and may last for a long time (CDC, 2022).

According to the The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), criteria for Major Depressive Disorder includes the patient experiencing five or more of the following symptoms for a the same 2-week period and represent a change from previous functioning:

• Continual depressed mood
• Markedly diminished interest or pleasure in all, or almost all, activities.
• Significant weight loss when not dieting or weight gain or decrease or increase in appetite
• Insomnia or hypersomnia
• Psychomotor agitation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
• Diminished ability to think or concentrate, or indecisiveness,
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and are not attributable to the physiological effects of a substance or another medical condition.

According to the DSM-5, the types of depressive disorders include the following:

• Major Depressive Disorder: Five or more symptoms are present during the same 2-week period and represent a change from previous functioning and at least one of the symptoms is depressed mood or loss of interest or pleasure.
• Specifiers may be attached to the diagnosis such as:
  • With anxious distress (tense and/or restless)
  • With mixed features (manic symptoms)
  • With psychotic features (delusions and/or hallucinations)
  • With peripartum onset (includes perinatal and postpartum depression)
  • With a seasonal pattern (includes seasonal affective disorder)
• Persistent Depressive Disorder (Dysthymia): Depressed mood for most of the day for at least 2 years.
• Premenstrual Dysphoric Disorder: In the majority of menstrual cycles, at least five symptoms are present in the week before the onset of menses, start to improve after the onset of menses, and become minimal or absent in the week postmenses.
• Substance/Medication-Induced Depressive Disorder: A persistent disturbance in mood that develops during or soon after substance intoxication or during withdrawal from a substance.
• Depressive Disorder Due to Another Medical Condition: A persistent period of depressed mood that is the direct consequence of another medical condition. (Open RN, 2022b)

Bipolar Disorder

Schizophrenia

Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem as if they have lost touch with reality, which can be distressing for them and their family and friends. The symptoms of schizophrenia can make it difficult to participate in usual, everyday activities, but effective treatments are available. Many people who receive treatment can engage in school or work, achieve independence, and enjoy personal relationships (NIH, 2023).

It is important to recognize the symptoms of schizophrenia, with the intervention being critical to stabilization. People with schizophrenia are usually diagnosed between the ages of 16 and 30, after the first episode of psychosis. The condition is rare in children under age 16. Starting treatment as soon as possible following the first episode of psychosis is an important step toward recovery. However, research shows that gradual changes in thinking, mood, and social functioning often appear before the first episode of psychosis (NIH, 2023).

Schizophrenia symptoms can differ from person to person, but they generally fall into three main categories: psychotic, negative, and cognitive.

Psychotic symptoms include changes in the way a person thinks, acts, and experiences the world. People with psychotic symptoms may lose a shared sense of reality with others and experience the world in a distorted way. For some people, these symptoms come and go. For others, the symptoms become stable over time. Psychotic symptoms include:

• Hallucinations: When a person sees, hears, smells, tastes, or feels things that are not there. Hearing voices is common for people with schizophrenia. People who hear voices may hear them for a long time before family or friends notice a problem.
• Delusions: When a person has strong beliefs that are not true and may seem irrational to others. For example, individuals experiencing delusions may believe that people on the radio and television are sending special messages that require a certain response, or they may believe that they are in danger or that others are trying to hurt them.
• Thought disorder: When a person has ways of thinking that are unusual or illogical. People with thought disorders may have trouble organizing their thoughts and speech. Sometimes a person will stop talking in the middle of a thought, jump from topic to topic, or create words that have no meaning.
• Movement disorder: When a person exhibits abnormal body movements. People with a movement disorder may repeat certain motions over and over.

Negative symptoms include loss of motivation, loss of interest or enjoyment in daily activities, withdrawal from social life, difficulty showing emotions, and difficulty functioning normally.

Negative symptoms include:

• Having trouble planning and sticking with activities, such as grocery shopping
• Having trouble anticipating and feeling pleasure in everyday life
• Talking in a dull voice and showing limited facial expression
• Avoiding social interaction or interacting in socially awkward ways
• Having very low energy and spending a lot of time in passive activities. In extreme cases, a person might stop moving or talking for a while, which is a rare condition called catatonia.

These symptoms are sometimes mistaken for symptoms of depression or other mental illnesses.

Cognitive symptoms include problems in attention, concentration, and memory. These symptoms can make it hard to follow a conversation, learn new things, or remember appointments. A person’s level of cognitive functioning is one of the best predictors of their day-to-day functioning. Cognitive functioning is evaluated using specific tests. Cognitive symptoms include:

• Having trouble processing information to make decisions
• Having trouble using information immediately after learning it
• Having trouble focusing or paying attention (NIH, 2023)

According to the DSM-5, schizophrenia is diagnosed when two (or more) of the following characteristics are present for a significant portion of time during a 1-month period (or less if successfully treated). At least one symptom is delusions, hallucinations, or disorganized speech:

• Delusions
• Hallucinations
• Disorganized speech (i.e., frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior; catatonia is a state of unresponsiveness
• Negative symptoms (i.e., diminished emotional expression or avolition.) Avolition refers to reduced motivation or goal-directed behavior. (First & Compton, 2022b)

Most people with schizophrenia are not violent. Overall, people with schizophrenia are more likely than those without the illness to be harmed by others. For people with schizophrenia, the risk of self-harm and violence to others is greatest when the illness is untreated. It is important to help people who are showing symptoms to get treatment as quickly as possible (NIH, 2023).

Suicide and Self-Harm

Suicide is a major public health concern. In 2019, suicide was the 10th leading cause of death overall in the United States, claiming the lives of over 47,500 people. Suicide is complicated and tragic, but it is often preventable. Knowing the warning signs for suicide and how to get help can help save lives (NIH, 2021).

Suicide is when people harm themselves intending to end their life and they die as a result. A suicide attempt is when people harm themselves with the goal of ending their life, but they do not die. Avoid using expressions such as “committing suicide,” “successful suicide,” or “failed suicide” when referring to suicide and suicide attempts, as these expressions often carry negative meanings.

Warning signs that someone may be at immediate risk for attempting suicide include:

• Talking about wanting to die or wanting to kill themself
• Talking about feeling empty or hopeless or having no reason to live
• Talking about feeling trapped or feeling that there are no solutions
• Feeling unbearable emotional or physical pain
• Talking about being a burden to others
• Withdrawing from family and friends
• Giving away important possessions
• Saying goodbye to friends and family
• Putting affairs in order, such as making a will
• Taking great risks that could lead to death, such as driving extremely fast
• Talking or thinking about death often

Other serious warning signs that someone may be at risk for attempting suicide include:

• Displaying extreme mood swings, suddenly changing from very sad to very calm or happy
• Planning or looking for ways to kill themself, such as searching for lethal methods online, stockpiling pills, or buying a gun
• Talking about feeling great guilt or shame
• Using alcohol or drugs more often
• Acting anxious or agitated
• Changing eating or sleeping habits
• Showing rage or talking about seeking revenge

It is important to note that suicide is not a normal response to stress. Suicidal thoughts or actions are a sign of extreme distress and should not be ignored. If these warning signs apply to you or someone you know, get help as soon as possible, particularly if the behavior is new or has increased recently (NIH, 2021; Schreiber & Culpepper, 2021).

Factors That Influence Mental Health

There is no single cause for mental health issues. Several factors that result from interactions between the mind, body, and environment contribute to the development of a condition.

The various and complex factors that influence our mental health and well-being are often defined as either risk factors or protective factors. Risk factors adversely affect a person’s mental health, whereas protective factors strengthen a person’s mental health and work to improve a person’s ability to cope with difficult circumstances. All areas of life influence risk and protective factors—psychological, social, environmental, cultural, and situational.

Similar life events can have very different impacts on different individuals, depending on what else is happening in their lives at that time, their resiliency, and their ability to learn from life’s challenges. Over the lifespan, a person may move through different points, from optimal mental health and well-being to being unwell and through to recovery.

Examples of risk factors include:

• Genetic predisposition
• Unhoused condition and/or unemployment
• Alcohol and other drug use
• Discrimination and racial injustice
• Family conflict or family disorganization
• Stressful life events

Examples of protective factors include:

• Personal attributes, including the ability to cope with stress, face adversity, and employ problem-solving skills
• Physical health and healthy behaviors
• Physical activity levels
• Social support and inclusion
• Strong cultural identity and pride

Achieving and maintaining good mental health requires building protective factors, minimizing risk factors, and breaking down barriers to seeking help.

Mental health is not as simple as being well or unwell. It can be viewed as a continuum, where individual optimal mental health is at one end, represented by feeling and functioning well. On the other end of the spectrum are mental health issues, which are characterized by changes in thoughts, feelings, or behaviors that affect an individual’s ability to carry out their everyday activities (Government of Western Australia Mental Health Commission, n.d.).

The Stigma of Mental Health

Words can hurt. Many derogatory words and phrases are used about mental illness. However, these words maintain the stereotyped image and do not reflect the reality of mental illness. Try not to use these words. It is more appropriate to refer to “a person who has a mental illness” when speaking about someone than saying, “Mentally ill people are nuts, crazy.” How often have we heard comments like this or seen portrayals in movies, television shows, or books? We may even be guilty of making comments like them ourselves. Is there any truth behind these portrayals, or is that negative view based on our ignorance and fear?

Stigmas are negative stereotypes about groups of people. Common stigmas about mentally ill people include:

• Individuals who have a mental illness are dangerous.
• Individuals who have a mental illness are irresponsible and cannot make life decisions for themselves.
• People with a mental illness are childlike and must be cared for by parents or guardians.
• People who have a mental illness should just get over it.

Each of those preconceptions about people who have a mental illness is based on false information. Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different chronic disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body.

Stigmas against individuals who have a mental illness lead to injustices, including discriminatory decisions regarding housing, employment, and education. Overcoming the stigmas commonly associated with mental illness is yet another challenge that people with a mental illness must face. Indeed, many people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself. The public’s stigmatizing attitudes toward mental illness lead many persons with mental illness to feelings of shame and guilt, loss of self-esteem, social dependence, and a sense of isolation and hopelessness. One of the worst consequences of stigma is that people who are struggling with a mental illness may be reluctant to seek treatment that would, in most cases, significantly relieve their symptoms.

Providing accurate information is one way to reduce stigmas about mental illness. Advocacy groups protest stereotypes imposed on those who are mentally ill. They demand that the media stop presenting inaccurate views of mental illness and that the public stop believing these negative views. A powerful way of countering stereotypes about mental illness occurs when members of the public meet people who are effectively managing a serious mental illness: holding jobs, providing for themselves, and living as good neighbors in a community. Interaction with people who have mental illnesses challenges a person’s assumptions and changes a person’s attitudes about mental illness (NIH, 2007).

The Nurse’s Role in Mental Health Care

The World Health Organization (WHO) recommends an “optimal mix of services pyramid,” in which mental health care services that cost the least and are the most frequently needed (e.g., self-care and informal community care) form the base of the pyramid and more expensive services needed by a smaller fraction of the mentally ill population (e.g., long-term inpatient care facilities) are at the top of the pyramid. To develop this mix of services, the WHO recommends that countries do the following:

• Limit the number of mental hospitals
• Build community mental health services
• Develop mental health services in general hospitals
• Integrate mental health services into primary health care
• Build informal community mental health services
• Promote self-care (Unite for Sight, 2021)

Advancement and development of healthier communities will continue to require attention to the support of mental health services and a focus on the underserved and vulnerable populations. Some of these strategies will depend on several factors:

• Sufficient planning and investment for mental health care
• Sufficient workforce to provide mental health services
• Consistency of mental health care inputs and processes with best practice and human rights protection
• Improved outcomes for people with mental disorders (Unite for Sight, 2021)

To improve both local and global access to mental health care, the investment in mental health care services must be closely considered, culturally sensitive in its design, informed by extensive research, and afforded adequate funding.

People are intended to thrive in their communities. It is where they should not only live but also prosper. Many mental health services are delivered within the community, and many are managed by community health nurses. The health care delivery system intends to help create and sustain physically and mentally healthy communities. In addition, it is responsible for identifying and caring for individuals who experience a mental health disorder and for supporting these individuals to return to a successful and productive life within their community. Community health nurses work in many mental health settings and assume many responsibilities for the mental health of individuals and the communities they live in. Nurses are often part of an interprofessional team that focuses on prevention, care management, restoration, or recovery.

As noted by Barnett et al. (2018), it is clear that significant differences exist globally as well as domestically between individuals who need mental health care and those who receive it. In low- and middle-income countries, over 75% of individuals who would benefit from care do not receive it (WHO, 2008, 2010). In the United States, ethnic and racial minorities are less likely to receive mental health treatment than are non-Hispanic White individuals (Alegria et al., 2010; Coker et al., 2009; Wells et al., 2001). In both examples, when treatment is available for underserved populations, it is often neither evidence-based nor high quality (Alegria et al., 2010; Dua et al., 2011). Creating evidence-based treatments in vulnerable communities has been a major focus of international and domestic policies (Barry & Huskamp, 2011; Becker & Kleinman, 2013; WHO, 2010). The WHO started the Mental Health Gap Action Programme to scale up evidence-based treatments for individuals with mental health, neurological, and substance use disorders in low- and middle-income countries (Dua et al., 2011; WHO, 2010). Domestically, the Patient Protection and Affordable Care Act emphasizes the provision of evidence-based care (Barry & Huskamp, 2011). It is concerning that even with these efforts to find innovative solutions, a public health model of workforce development is needed to address existing mental health disparities. This workforce will need to comprise physicians, nurses, social workers, community workers, and other health care professionals trained to identify and care for patients with mental health disorders.

Even when services are available, a wide range of factors affect whether individuals access or seek care, including structural barriers (e.g., lack of transportation), low mental health literacy, mental health stigma, and negative perceptions of mental health care providers (Alegria et al., 2010; Chow et al., 2003; Kilbourne et al., 2006; Nadeem et al., 2007). Nurses play an essential role in considering assessing and planning services for patients who face these challenges.

Treatment Settings

Community mental health nurses practice in a range of behavioral health care settings (Kudless & White, 2007). These include:

• Community mental health centers
• Detoxification centers
• Group homes for individuals with mental disorders and serious mental illnesses
• Residential substance abuse treatment programs

In these settings, community mental health nurses have many roles:

• Making nursing diagnoses of the medical and emotional status of patients
• Recommending treatment options
• Consulting with psychiatrists and other behavioral health staff in designing appropriate treatment plans for clients
• Administering and documenting reactions to psychotropic drugs and other medications
• Participating in group or one-to-one therapy sessions individually or with other health professionals
• Providing nursing services to individuals diagnosed with mental illness, alcoholism or substance abuse, and mental disorders or developmental disabilities, as well as providing nursing services to their caretakers or families
• Making referrals to primary care providers (Kennedy et al., 1997)

Public health nurses can work with agencies to take two important steps:

1. Incorporate mental health promotion into chronic disease prevention efforts and conduct surveillance and research to improve the evidence base about mental health in the United States
2. Collaborate with stakeholders to develop comprehensive mental health plans to enhance coordination of care (CDC, 2005)

Practice Application

➔ Setting the Scene

Stop the Stigma: Why It’s Important to Talk About Mental Health (Heather Sarkis)

Watch this video by scanning the QR code or visiting https://youtu.be/gy1iH_Gxn0Q

➔ Think About It

Drawing from Ms. Sarkis’s TEDTalk, consider:

1. Did you find any facts she shared surprising?
2. Why do you think mental health is so stigmatized into today’s society? What is the impact of such stigmatization?
3. How have you encountered mental illness in your life? How did it influence your experience with others?
4. What is one thing you can do to help reduce or eliminate stigma related to mental illness?
5. As a nurse:
   1. What can you do to help your patients avoid being treated as if “it’s all in their heads”?
   2. How can you incorporate acceptance and treatment of mental health into your practice, especially if this is not your area of focus?

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