All the mental health settings that were previously described may provide treatment for alcohol and substance use disorders, although specialized treatment centers exist apart from the mental healthcare system. More than 22 million individuals aged 12 or older needed treatment in 2013 for illicit drug or alcohol use problems. Only 2.5 million received specialized care (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). This treatment is typically outpatient and includes counseling, education, medication management, and 12-step programs. Because alcohol detoxification and other substance withdrawal can be life threatening, inpatient care may be required for medical management.
Obtaining sufficient sleep, meditating, eating right, exercising, abstaining from smoking, and limiting the use of alcohol are healthy responses to a variety of illnesses such as diabetes and hypertension. As with other medical conditions, lifestyle choices and self-help responses can have a profound influence on the quality of life and the course, progression, and outcome of psychiatric disorders. If we accept the notion that psychiatric disorders are usually a combination of
biochemical interactions, genetics, and environment, then it stands to reason that, by providing a healthy living situation, we are likely to fare better. If, for example, a person has a family history of anxiety and has demonstrated symptoms of anxiety, then a good first step (or an adjunct to
psychiatric treatment) could be to learn yoga and balance the amounts of life’s obligations with relaxation.
A voluntary network of self-help groups operates outside the formal mental healthcare system to provide education, contacts, and support. Since the introduction of Alcoholics Anonymous in the early 20th century, self-help groups have multiplied and have proven to be effective in the treatment and support of psychiatric problems. Groups specific to anxiety, depression, loss, caretakers’ issues, bipolar disorder, PTSD, and almost every other psychiatric issue are widely available in most communities.
Consumers, people who use mental health services, and their family members have successfully united to shape the delivery of mental healthcare. Nonprofit organizations such as the National Alliance on Mental Illness (NAMI) encourage self-help and promote the concept of recovery, or the self-management of mental illness. These grassroots groups also confront social stigma, influence policies, and support the rights of people experiencing mental illness.
Key Points to Remember
• Entry into the mental health system can be a bewildering process due to people’s reluctance to share their own experiences, cognitive changes from the disorders themselves, and confusion over physical versus mental symptoms.
• Treatment options should be based on the least restrictive environment, that is, the setting that provides the necessary care while allowing the greatest personal freedom.
• Psychiatric care settings evolved during the 20th century from mass institutionalization to a variety of outpatient and inpatient settings.
• A continuum of care model helps differentiate between levels of acuity within treatment settings.
• Primary care providers have an increasingly important role in identifying and treating mental disorders. This treatment choice may feel familiar and reduce stigma. Time limitations may impact a complete mental assessment and training limitations may make some providers uncomfortable.
• Specialty care providers possess an educational and experiential background in psychiatric and mental health.
• Patient-centered medical homes with multiple services and an array of providers are becoming increasingly popular as a way to integrate mental and other physical care.
• Community mental health centers provide a wide range of mental health services for individuals who lack funding for care.
• Registered nurses and social workers provide psychiatric home care for individuals who are homebound.
• Assertive community treatment (ACT) is an intensive case management for people who are unable or unwilling to participate in traditional treatment. ACT teams are composed of a variety of professionals who provide 24-hour, 7-days-a-week support.
• Intensive outpatient and partial hospitalization programs are available as a step down from inpatient care or as a step up from other less restrictive treatment settings.
• Emergency psychiatric care and crisis stabilization is available in emergency rooms and from emergency teams.
• Primary, secondary, and tertiary prevention are aimed at reducing the effects of mental illness by preventing its occurrence, preventing its progression, or by restoring functional ability.
• Inpatient settings include crisis stabilization units, general hospital and private hospital acute care, and a state-funded acute care system.
• Inpatient psychiatric-mental health nursing requires strong skills in management, communication, and collaboration.
• Basic level inpatient nursing interventions include admission, providing a safe environment, psychiatric and physical assessments, milieu management, documentation, medication administration, and preparation for discharge to the community.
Critical Thinking
1. You are a nurse working at a local community mental health center. During an assessment of a 45-year-old single, male patient, he reports that he has not been sleeping and that his thoughts seem to be “all tangled up.” Although he does not admit directly to being suicidal, he remarks, “I hope that this helps today because I don’t know how much longer I can go on like this.”
He is disheveled and has been sleeping in homeless shelters. He has little contact with his family and becomes agitated when you suggest that it might be helpful to contact them. He reports a recent hospitalization at the local veterans’ hospital and previous treatment at a dual-diagnosis facility, yet he denies substance use. When asked about his physical condition, he says that he has tested positive for hepatitis C and is “supposed to take” multiple medications that he cannot name.
a. List your concerns about this patient in order of priority.
b. Which of these concerns must be addressed before he leaves the clinic today?
c. Do you feel there is an immediate need to consult with any other members of the multidisciplinary team today about this patient?
d. Keeping in mind the concept of patient-centered care, how will you develop trust with the patient to increase his involvement with the treatment plan?
2. Imagine that you were asked for your opinion with regard to your patient’s ability to make everyday decisions independently. What sort of things would you consider as you weighed safety versus autonomy and personal rights?
3. If nurses function as equal members of the multidisciplinary mental health team, what differentiates the nurse from the other members of the team?
Chapter Review
Questions
1. A patient needs supportive care for the maintenance treatment of bipolar disorder. The new nurse demonstrates an understanding of the services provided by the various members of the patient’s mental healthcare team when he makes which statement:
a. “Your social worker will help you learn to budget your money effectively.”
b. “Your counselor asked me to remind you of the group session on critical thinking at 2:00 today.”
c. “The mental health technician on staff today will administer the medication that you require.”
d. “Remember to ask the occupational therapist about sources of financial help that you are qualified for.”
2. A patient has been voluntarily admitted to a mental health facility after an unsuccessful attempt to harm himself. Which statement demonstrates a need to better educate the patient on his patient’s rights?
a. “I understand why I was restrained when I was out of control.”
b. “You can’t tell my boss about the suicide attempt without my permission.”
c. “I have a right to know what all of you are planning to do to me.”
d. “I can hurt myself if I want too. It’s none of your business.”
3. Which intervention demonstrates an attempt by nursing staff to meet the goals identified by the Joint Commission as National Patient Safety Goals? Select all that apply.
a. Identifying patients using both name and date of birth before drawing blood.
b. Sitting with the patient diagnosed with an eating disorder during meals.
c. Administering the Beck Scale on each patient at the time of admission.
d. Performing a medication history assessment on each new patient.
e. Using appropriate hand washing technique at all times.
4. The mental health team is determining treatment options for a male patient who is experiencing psychotic symptoms. Which question(s) should the team answer to determine whether a community outpatient or inpatient setting is most appropriate? Select all that apply.
a. “Is the patient expressing suicidal thoughts?”
b. “Does the patient have intact judgment and insight into his situation?”
c. “Does the patient have experiences with either community or inpatient mental healthcare facilities?”
d. “Does the patient require a therapeutic environment to support the management of psychotic symptoms?”
e. “Does the patient require the regular involvement of their family/significant other in planning and executing the plan of care?”
5. The nurse frequently includes daily sessions involving relaxation techniques. Which assessment data would most indicate a need for this intervention to be included in the initial plan of care for a patient?
a. Family history of anxiety and symptoms of anxiety b. Significant other has a chronic health issue
c. Hopes to retire in 6 months d. Recently adopted infant twins
6. A newly divorced 36-year-old mother of three has difficulty sleeping. When she shares this information to her gynecologist, she suggests which of the following services as appropriate for
a. Assertive community treatment b. Patients-centered medical home c. Psychiatric home care
d. Primary care provider
7. A Gulf War veteran has been homeless since being discharged from military service. He is now diagnosed with schizophrenia. The nurse practitioner recognizes that assertive community treatment (ACT) is a good option for this patient since ACT provides:
a. Psychiatric home care
b. Care for hard-to-engage, seriously ill patients c. Outpatient community mental health center care d. A comprehensive emergency service model
8. An adolescent female is readmitted for inpatient care after a suicide attempt. What is the most important nursing intervention to accomplish upon admission?
a. Allowing the patient to return to her previous room so that she will feel safe b. Orienting the patient to the unit and introduce her to patients and staff c. Building trust through therapeutic communication
d. Checking the patient’s belongings for dangerous items
9. Emma is a 40-year-old married female who has found it increasingly difficult to leave her home due to agoraphobia. Emma’s family is appropriately concerned and suggests that she seek psychiatric care. After investigating her options, Emma decides to try:
a. Telepsychiatry
b. Assertive community treatment c. Psychiatric home care
d. Outpatient psychiatric care
10. Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and
recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
a. Intermittent supervision is available in inpatient settings.
b. He requires stabilization of multiple symptoms.
c. He has nutritional and self-care needs.
d. Medication adherence will be mandated.
e. He is in imminent danger of harming himself.
Answers
1. b; 2. d; 3. a, c, d, e; 4. a, b, d, e; 5. a; 6. d; 7. b; 8. d; 9. a; 10. b, c, e Visit the Evolve website for a posttest on the content in this chapter:
http://evolve.elsevier.com/Varcarolis
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