The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine what the experience will be like or what nurses do in this area. This is an overview of the history of mental illness, advances in treatment, current issues in mental health, and the role of the psychiatric nurse.
Mental Health and Mental Illness
Mental health and mental illness are difficult to define precisely. The culture of any society strongly influences its beliefs and values, and this in turn affects how that society defines health and illness.
No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his or her mental health.
- In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
- Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social/cultural.
- Individual, or personal, factors include a person’s biologic make up, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities.
- Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness.
- Social/cultural, or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of one’s world.
The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
- General criteria to diagnose mental disorders include dissatisfaction with one’s characteristics, abilities, and accomplishments; ineffective or unsatisfying relationships; dissatisfaction with one’s place in the world; ineffective coping with life events; and lack of personal growth.
- Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/cultural categories.
- Individual factors include biologic make up, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of meaning in one’s life.
- Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control.
- Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination.
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) is a taxonomy published by the APA.
- The DSM-IV-TR describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research.
- The DSM-IV-TR has three purposes:
- To provide a standardized nomenclature and language for all mental health professionals.
- To present defining characteristics or symptoms that differentiate specific diagnoses.
- To assist in identifying the underlying causes of disorders.
- The multiaxial classification system that involves assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a person’s condition.
- Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders.
- Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.
- Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person.
- Axis IV for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders.
- Axis V presents a Global Assessment of Functioning, which rates the person’s overall psychological functioning on a scale of 0 to 100; this represents the clinician’s assessment of the person’s current level of functioning.
Historical Perspectives of the Treatment of Mental Illness
- People of ancient times believed that any sickness indicated displeasure of the gods and in fact was punishment for sins and wrongdoing.
- Those with mental disorders were viewed as either divine or demonic, depending on their behavior.
- Later, Aristotle attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions.
- These four substances, or humors, corresponded with happiness, calmness, anger, and sadness; imbalances of the four humors were believed to cause mental disorders, so treatment was aimed at restoring balance through bloodletting, starving, and purging.
- In early Christian times, all diseases were again blamed on demons, and the mentally ill were viewed as possessed; priests perform exorcism to to rid evil spirits.
- During the Renaissance, people with mental illness were distinguished from criminals in England; those considered harmless were allowed to wander the countryside and or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved.
- In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind; by 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the intimates, who were seen as animals, less than human.
Period of Enlightenment and Creation of Mental Institutions
- In the 1790s, a period of enlightenment concerning persons with mental illness began.
- Phillipe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, or starved just because they were mentally ill (Gollaher, 1995).
- In the United States, Dorothea Dix (1802-1887) began a crusade to reform the treatment of mental illness after a visit to Tukes’ institution in England; she was instrumental in opening 32 state hospitals that offered asylum to the suffering.
Sigmund Freud and Treatment of Mental Disorders
- The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856-1939) and others, such as Emil Kraeplin (1856-1926) and Eugene Bleuler (1857-1939).
- With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest.
- Freud challenged society to view human beings objectively; he studied the mind, its disorders, and their treatment as no one had before.
- Kraeplin began classifying 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, or drugs used to treat mental illness.
- Chlorpromazine (Thorazine) an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed.
- Over the following 10 years, monoamine oxidase inhibitor antidepressants, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents, called benzodiazepines, were introduced.
Mental Illness in the 21st Century
The National Institute of Mental Health (NIMH) estimates that more than 26% of Americans aged 18 years and older have a diagnosable mental disorder- approximately 57.7 million persons each year (2006).
- Furthermore, mental illness or serious emotional disturbances impair daily activities for an estimated 10 million adults and 4 million children and adolescents.
- Mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age.
- Homelessness is a major problem in the United States today; the National Resource and Training Center on Homelessness and Mental Illness (2006) estimates that one-third of adult homeless persons have a serious mental illness and that more than one half also have substance abuse problems.
- In 1993, the federal government created and funded Access to Community Care and Effective Services and Support (ACCESS) to begin to address the needs of people with mental illness who were homeless either all or part of the time.
Psychiatric Nursing Practice
- In 1873, Linda Richards graduated from the New England Hospital for Women and Children in Boston; she went on to improve nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois.
- Richards is called the first American psychiatric nurse; she believed that “the mentally sick should be at least as well cared for as the physically sick” (Doona, 1984).
- The first training of nurses to work with persons with mental illness was in 1882 at McLean Hospital in Belmont, Massachusetts.
- The care was primarily custodial and focused on nutrition, hygiene, and activity.
- The role of psychiatric nurses expanded as somatic therapies for the treatment of mental disorders were developed.
- Treatments such as insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive therapy (1937) required nurses to use their medical-surgical skills more extensively.
- The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey was published in 1920; in 1913, John Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum.
- In 1973, the division of psychiatric and mental health practice of the American Nurses Association (ANA) developed standards of care, which it revised in 1982, 1994, and 2000.
- Standards of care are authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable.
- The goal of self-awareness is to know oneself so that ones’ values, attitudes, and beliefs are not projected to the client, interfering with nursing care; self-awareness does not mean having to change one’s values and beliefs unless one desires to do so.
Sources and references for this study guide for mental health and psychiatric nursing, including interesting studies for your further reading:
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. [Link]
- Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
- Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]