KNOWN RISK FACTORS FOR PREVALENT MENTAL ILLNESS AND NURSING INTERVENTIONS FOR PREVENTION
Kathleen L. Patusky
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define the term risk factor
2. Explain how risk factors may be grouped or categorized
3. Describe the significance of protective factors
4. Identify the major risk factors associated with schizophrenia, affective disorders, substance-related disorders, anxiety disorders, and personality disorders
5. Describe interventions appropriate for primary and secondary prevention
6. Integrate the interpersonal process with primary, secondary, and tertiary prevention activities
Why does a patient develop a mental disorder? What makes one person more susceptible to developing mental illness than another? The answers to these questions are important to psychiatric-mental health nurses (PMHNs) because they provide the foundation for implementing preventive strategies.
Some individuals have RISK FACTORS that increase their chances of developing mental illness. Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected at random from the general population, will develop a disorder (U.S. Department of Health and Human Services [DHHS], 1999, p. 1). Thus, a risk factor might predispose an individual to develop a mental illness. However, risk factors do not guarantee that a mental illness will occur. Knowledge about risk factors is important to PMHNs as they develop interventions focused on preventing mental illness or its negative sequelae. Quality and safety education for nurses (QSEN) recognizes that nurses need to assess for risk factors continually as a means of promoting quality of care outcomes, consistent with the competency of safety and quality improvement (Hook & Dunagan, 2013).
This chapter provides an overview of risk factors and how they are categorized. It also describes the impact of protective factors on the development of a mental illness. The chapter addresses the important risk factors associated with major classifications of psychiatric-mental health disorders and describes preventive strategies to reduce the impact of risk factors for developing a psychiatric-mental health disorder.
Risk factors are characteristics, variables, or hazards that increase the probability that an individual will develop a disorder.
THE NATURE OF RISK FACTORS
The underlying cause(s) of mental illness continues to be elusive. However, extensive research into the biology of mental illness has led to the belief that there is a disruption in neurotransmission in the brain. Links among specific neurotransmitters such as serotonin, dopamine, and norepinephrine and the development of psychiatric disorders such as depression and schizophrenia have been postulated, leading to the development of drug therapy to control the disorders. Unfortunately, biology alone is not enough to explain the development of mental illness. Currently, scientists believe that mental illness is due to a combination of influences, not just the person’s biological makeup.
One major influence impacting mental health and the development of mental illness is a risk factor. As defined earlier, risk factors are those variables that might predispose an individual to develop a mental illness. A single risk factor is rarely enough to initiate a mental disorder. However, its presence makes the patient vulnerable to the effects of additional risk factors. As risk factors accumulate, the likelihood of a disorder increases. The existence of multiple risk factors is common to many psychiatric-mental health disorders.
Categories of Risk Factors
Risk factors can be categorized or classified in different ways. One method divides risk factors as individual, family, or community risk factors (Table 8-1). Another way of categorizing risk factors is within biological and psychosocial categories, or intrapersonal and environmental categories. A third approach delineates risk factors into more specific categories, such as genetic, biological, psychological, social, and environmental factors. For example, biological factors may include head injury, poor nutrition, and exposure to toxins or viruses. Social factors may include parental mental illness or criminality, economic hardship, abuse, neglect, exposure to violence, or death of a family member or close friend.
Many psychiatric disorders share risk factors that can be differentiated as biological/genetic or personal/social/environmental. Questions raised include:
Do individuals develop a mental illness because they inherit it?
Is it built into their physiology?
Or is mental illness cultivated as a learned phenomenon, an interaction among the person, family members and significant others, and the community?
The current perspective is that both genetics and environment play a role. For example, the person might have a genetic predisposition toward schizophrenia, but does not experience life traumas that activate the tendency. Therefore, schizophrenia will not emerge. On the other hand, a person might have a low genetic propensity for depression, but experiences major traumas, loss of loved ones, and financial instability within a short time span. Thus, a depressive episode may result. An understanding of the convergence of possible risk factors is important when evaluating patients for psychiatric-mental health disorders.
Some risk factors can be changed while others cannot. In addition, some risk factors are more responsive to treatment than others are. Age and gender, for example, are risk factors for many disorders that cannot be changed. Another risk factor, stress, may prompt the initial onset of a disorder and can be addressed so that stress levels are reduced.
INDIVIDUAL RISK FACTORS
FAMILY RISK FACTORS
COMMUNITY RISK FACTORS
• Neurological deficits; traumatic brain injury (Mayo Clinic, 2015)
• Physical illness, chronic medical conditions (DHHS, 1999; Mayo Clinic, 2015)
• Below-average intelligence (DHHS, 1999)
• Psychoactive drug use (Mayo Clinic, 2015)
• Childhood abuse or neglect
• Lack of friendships or healthy relationships
• Combat (Mayo Clinic, 2015)
• Biological relatives with a mental disorder (Mayo Clinic, 2015)
• Maternal experiences during pregnancy; for example, exposure to viruses or toxins, drug or alcohol use (Mayo Clinic, 2015)
• Marital discord
• Social disadvantage
• Overcrowding or large family size
• Father/mother’s criminality
• Father/mother’s mental disorder
• Foster care (DHHS, 1999)
• High crime rate/violence
• Inadequate schools
• Inadequate housing
• Poor access to health care
Risk factors can be identified before the emergence of a psychiatric-mental health disorder. Risk factors also can change in response to a new developmental stage or a new stressor. For example, starting college at age 45 years may raise the issue of stresses related to self-image, family responsibilities, or financial resources. In addition, risk factors may develop as a consequence of a psychiatric-mental health disorder, thus increasing the person’s susceptibility for further difficulties or future problems.
Risk factors may be classified in different ways. Possible categories include: individual, family, and community; biological and psychosocial; intrapersonal and environmental; or genetic, biological, psychological, social, and environmental. Many psychiatric disorders share risk factors that can be differentiated as biological and/or genetic or personal/social/environmental.
The risk factors for each individual are unique. What is a risk factor for one person may not be a risk factor for another. Thus, the one person may have protective factors to mitigate the effects of risk factors.
PROTECTIVE FACTORS are characteristics, variables, or traits that guard against or buffer the effect of risk factors. They promote adaptation, thereby improving the individual’s response to a risk factor. Protective factors may actually reduce the probability that a person will develop a psychiatric-mental health disorder or may decrease the severity of a problem.
Protective factors may be classified as internal or external. Examples of internal protective factors include: good health, high stress tolerance, positive coping skills, average or better intelligence, flexibility, and a positive outlook on life. Examples of external protective factors include: supportive and positive family, social and community relationships, adequate economic resources, and recreational activities.
Individuals possess characteristics, variables, or traits that guard against or buffer the effect of risk factors. These are known as protective factors.
Generally, people feel more secure and better able to cope with life situations when their health is good; they have a sense of control over what is happening around them; and they have a sense of connectedness to others, including family and community members. Knowing that others are available and willing to provide social support is also protective. Spiritual beliefs and a sense of meaning and purpose in life help individuals during difficult times. Economic resources can provide security to individuals, especially older adults.
RESILIENCE is a personal trait of individuals that serves as a protective mechanism. Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress (American Psychological Association [ApA], 2015). People are not born with resilience. It is something that is learned over time and involves behaviors, thoughts, and actions. Resilient people have a sense that they are able to cope with chronic stress or recover from trauma through skills such as communication skills, problem-solving skills, and positive coping styles. Skills that help an individual cope with life’s problems can strengthen resilience and foster a belief in the self and in one’s ability to cope.
The influence of resilience has been cited in multiple research studies. Resilience has been shown to protect against suicidal ideation (Min, Lee, & Chae, 2015), posttraumatic stress disorder (PTSD; Wisco et al., 2014), and the negative long-term effects of child abuse and neglect (Schulz et al., 2014), to name just a few areas of influence. In response to such findings, interventions that would promote resilience have been growing. In one systematic review of studies on resilience-promoting programs, six of seven randomized control trials showed that such programs were effective (Macedo et al., 2014). The ability to increase resilience in individuals can serve a mitigating function against risk factors.
Resilience is a protective function that is learned over time.
The Stress-Vulnerability-Coping Model
An individual’s risk and protective factors determine how well he or she will cope with stressors. If risk factors are high and protective factors are low, the individual will have more difficulty coping and an increased chance of developing a psychiatric-mental health disorder. The STRESS-VULNERABILITY-COPING MODEL of mental illness presents one way of understanding how risk factors are involved with the development of psychiatric-mental health disorders (Mental Illness Fellowship Victoria [MIFV], 2008).
The stress-vulnerability-coping model identifies risk factors according to three categories: biological, personal, and environmental. Biological risk factors include a family history of mental illness, brain abnormalities, neurodevelopmental problems, and diseases of a medical nature. Personal risk factors include poor social skills, poor coping skills, and communication difficulties. Environmental risk factors include substance abuse, work or school problems, rejection by other people, stressful relationships, poor social support, and the occurrence of major life events (MIFV, 2008).
This model also identifies protective factors for psychiatric-mental health disorders. These include good physical health, no family history of mental illness, good coping and communication skills, good levels of social support, medication, and talk therapy when indicated. Although the stress-vulnerability-coping model was originally developed to explain the development of schizophrenia, it is now used to understand other psychiatric disorders as well (MIFV, 2008).
According to the stress-vulnerability-coping model, mental illness arises from the interplay of the three dominant factors, that is, stress, vulnerability, and coping. Good coping skills protect the individual from developing a mental illness even when they are in high-stress situations and vulnerable. This vulnerability increases as the number and intensity of risk factors increase.
RISK FACTORS FOR MAJOR PSYCHIATRIC-MENTAL HEALTH DISORDERS
The probability that an individual will develop a psychiatric-mental health disorder is dependent on that person’s risk and protective factors. Although these factors are unique to the individual, some of these factors, such as genetics, often are seen as playing a role in the development of several different psychiatric-mental health disorders. The risk factors for the major classes of psychiatric-mental health disorders are addressed.
Disorders of Attention
Before the Diagnostic and Statistical Manual (5th ed.; DSM–5; American Psychiatric Association [APA], 2013), disorders of attention were categorized as disorders of infancy, childhood, or adolescence. In actuality, attentional disorders may begin during the first part of life, but often continue into adulthood. The mental illnesses under this category include attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).
Genetics/biology and temperament are two important intrapersonal risk factors for the development of psychiatric-mental health disorders that may begin at infancy and progress to adolescence and adulthood (Box 8-1). Genetics refers to the complex makeup of genes and DNA that will contribute to the biology of the child’s brain. Biology also includes any birth traumas, exposure to infections or toxins while in utero, or other insults that affect brain structures or chemistry.
BOX 8-1: RISK FACTORS FOR DISORDERS OF ATTENTION
• Genes/DNA and brain development
• Birth traumas/premature birth
• Intrauterine exposure to drugs
• Exposure to infections, toxins (such as lead poisoning), or other insults affecting brain structures or chemistry
• Blood relatives with ADHD or another mental disorder (Mayo Clinic, 2015)
TEMPERAMENT has been viewed as a precursor to personality. Researchers have suggested that temperament is “hard-wired” into each child at birth, not learned. Temperament represents innate aspects of personality that determine how a child tends to respond to the world. It is the distinctive behavior involved with activity and adaptation.
Several studies have been done to describe temperament. A classic landmark study by Thomas, Chess, and Birch (1968) identified three patterns of temperament:
Easy or flexible: Positive mood and approach to new situations, low emotional intensity, and regular eating and sleeping patterns. Children are generally calm, happy, and not easily upset.
Difficult, active, or feisty: Negative mood and response to new situations, high emotional intensity, irregular sleeping, and eating patterns. Children are often fussy, fearful of new people or situations, easily upset by noise or commotion, and intense in their reactions.
Slow-to-warm-up or cautious: Negative but mild emotional response to new situations that are intense and initially slow in adapting but eventually become positive. Children are inactive and fussy, tend to withdraw or react negatively to new situations but become more positive with continued exposure.
Another study described children as challenging (fitting a typology of high maintenance, cautious, and slow-to-warm-up) or easy (industrious, social, and eager to try; McClowery, 2002). Neither challenging nor easy temperaments are necessarily risk factors on their own. The issue is one of “goodness of fit” (Thomas et al., 1968). For example, if an infant is fussy and cranky, he or she will likely be fine if the mother is easy going and not overly disturbed by the infant’s agitation. However, if the mother is anxious and stressed, both she and the infant are likely to irritate each other further. As children age, temperament is assimilated into personality and the issue of goodness of fit can continue to determine the quality of a child’s social relationships (Maziade et al., 1985; Thomas & Chess, 1984; Werner & Smith, 1992).
Genetics/biology and temperament are two important intrapersonal risk factors for the development of attentional psychiatric- mental health disorders.
The risk factors in Box 8–1 are particularly relevant to ADHD. The ASD risks include male gender, family history of ASD, preterm delivery (before 26 weeks), older parental age, and certain medical disorders (including fragile X syndrome, tuberous sclerosis, Tourette and Rett syndromes; Mayo Clinic, 2015).
In addition to genetics/biology and temperament, other general risk factors during childhood may lead to a variety of psychiatric-mental health problems. These include the individual factors of neurophysiological deficits such as attention-deficit disorders (ADD), hyperactivity and autism, difficult temperament, chronic physical illness, and below-average intelligence. In addition, children are especially sensitive to family issues such as severe marital discord, social disadvantage, overcrowding or large family size, paternal criminality, maternal mental disorder, and admission into foster care. Community factors such as living in an area with a high rate of crime and inadequate schools also can have a major effect (DHHS, 1999).
Moreover, some individual risk factors can lead to a state of vulnerability in which other risk factors can have a greater effect. For example, although low birth weight is a general risk factor for multiple physical and mental outcomes, when combined with a high-risk environment, it often results in poorer outcomes (McGauhey, Starfield, Alexander, & Ensminger, 1991). In another example, foster placement instability and family chaos have been associated with suboptimal development of the prefrontal cortex, leading to poor executive function, which results in greater risk of ADHD, other behavioral disorders, and substance abuse (Fisher, Mannering, Van Scoyoc, & Graham, 2013).
Experts have concluded that genetic and environmental risk factors interact in the development of schizophrenia (Box 8-2). Studies have shown that the correlation of schizophrenia between identical twins is less than 50%, supporting the claim that genetics alone is insufficient as a cause. However, the high correlation supports a strong genetic component. This strong relationship decreases gradually among relatives of the patient with schizophrenia. Moreover, second-degree relatives are several times more likely to develop schizophrenia than someone in the general population, while third-degree relatives are twice as likely to develop schizophrenia. Although a specific causal gene has not been identified, several possibilities are being explored. Experts believe that there are at least as many as 12 gene variations that can result in symptoms (Schizophrenia.com, 2015).
BOX 8-2: RISK FACTORS FOR SCHIZOPHRENIA
Gestational and birth complications
• Maternal malnutrition
• Rh incompatibility
• Exposure to viruses, toxins (especially first and second trimesters)
Birth during late winter or early spring
Major life changes
Lower socioeconomic status (poverty)
Stress/exposure to traumatic events
Substance abuse, especially psychoactive drugs during teenage and young adulthood years
Inflammation or autoimmune diseases
Father is older age
From Benros et al. (2011); Heins et al. (2011); Mayo Clinic (2015); and Orlovska et al. (2014).
A long history of research has considered gestational and birth complications as biological risk factors for schizophrenia. Closely associated with these complications are maternal malnutrition and Rh incompatibility. In addition, a late winter or early spring birth (particularly during the months of February and March) has been identified as a risk factor due to maternal exposure to influenza or viral infections, especially during the second trimester (Mayo Clinic, 2015; Schizophrenia.com, 2015). When fetal distress has been combined with developmental delay, a fivefold increase in the risk of schizophrenia has been identified (Arehart-Treichel, 2011).
The stress-vulnerability-coping model, described earlier in this chapter, was developed initially to explain schizophrenia. This model included poverty as a risk factor, although some researchers view poverty as a result of illness rather than part of the cause. Meltzer and Fatemi (2008) concluded that patients with schizophrenia are at high risk for poverty because they face difficulties with unemployment, homelessness, inadequate housing, poor health, and poor access to health care—labeled the “downward drift” in socioeconomic status. Especially tragic is the fact that first episodes often occur during late adolescence or the early 80s. Major life changes, another risk factor, are relevant at this time as individuals leave home for the first time, go to college, start a first job, or marry. Additional risk factors include substance abuse and stressors of everyday life.
Researchers have attempted to identify risk factors that would predict psychosis in young adults before a full-blown episode, permitting earlier interventions (Cannon et al., 2008). The factors identified were accurate in predicting psychosis 35% of the time. This number rose to 65% to 80% if specific combinations of risk factors were found in study participants. These combinations included: (a) decline in social functioning, as well as an increase in withdrawal and inactivity; (b) family history of psychosis with recent deterioration of function (e.g., drop in grades, withdrawal from school activities); (c) increase in unusual thoughts; and (d) increase in suspiciousness or paranoia and past or current drug abuse.
Risk factors for schizophrenia include the interaction between genetics and environment. In addition, gestational and birth complications are associated biological risk factors.
Affective or mood disorders include major depression and bipolar disorder. Decades of research support the heritability of unipolar (major depression) and bipolar disorders. An increased risk for bipolar disorder among first-degree relatives with bipolar disorder has been shown to range from 3% to 8%. The risk of depression among first-degree relatives with depression may be two to three times that of the general population. In identical twin studies, findings support the conclusions that genetics play a greater role in bipolar disorders than in major depression, that there is a genetic overlap between bipolar and depressive disorders, and that environmental influences play a significant role in mood disorders (Kelsoe, 2009). With genetics serving as a risk factor for both depression and bipolar disorder, new findings indicate a genetic “hotspot” that identifies risk for both disorders (McMahon et al., 2010). The search for additional genetic risk factors for depression or bipolar disorder continues. Table 8-2 identifies the risk factors associated with mood disorders.
Gender is an additional risk factor for developing affective disorders. Bipolar I disorder occurs equally in men and women, whereas bipolar II disorder is more common in women. Bipolar I may be expressed differently in women, with higher rates of depression, mixed mania, and suicidal behavior; later onset of illness; and comorbidities with eating, anxiety, and metabolic disorders. Men showed earlier onset of illness; higher rates of mania; and comorbidities with alcoholism and other forms of substance abuse (Azorin et al., 2013). A study examining gender differences in depression severity and depressive subtypes acknowledged that, while women had higher lifetime rates of depression, they did not necessarily score higher than men on measures of severity if their depression was of the unipolar type. If women’s depression was of the bipolar subtype, however, their measures of severity were significantly higher than those of the men (Parker, Fletcher, Paterson, Anderson, & Hong, 2014).
Attention deficit hyperactivity disorder (ADHD)
History of depressive episodes
Biological: Abnormal mood regulation circuitry
Few social supports
Physiological factors also serve to increase the risk of mood disorders. Very low birth weight (less than 1,500 g) is more likely to experience depression as adults than are infants of normal birth weight (greater than 2,499 g; Westrupp, Northam, Doyle, Callanan, & Anderson, 2011). Brain imaging has revealed a biological risk factor of abnormal mood regulation circuitry in the brain. This abnormality is present even when the patient with depression feels well. It reasserts itself during relapse when levels of certain neurotransmitters drop (Hasler et al., 2008). Given the cyclical nature of depression, this risk factor offers an explanation for both the initiation and the relapses of major depressive disorders. The potentially cyclical nature of depression indicates that a history of past episodes is a risk factor. Life stressors also are known to play a role in the emergence of depression. Substance use, particularly central nervous system (CNS) depressants, can result in depression. Individuals with few social supports, especially the elderly or those with a medical illness, are at high risk for depression. At the same time, one study noted that 20% of patients with major depression later developed either mania or hypomania, and another study identified the use of antidepressants as a risk factor for bipolar I in certain genotypes (Boschloo et al., 2014; Frye et al., 2015).
Family conditions are an important area of discovery with bipolar disorder. The risk of bipolar disorder has been shown to be higher among children of fathers older than 50 years and younger than 20 to 24 years of age. No association was found with maternal age (Chudal et al., 2014). Children having a parent or a sibling with bipolar disorder are four to six times more likely to develop the disorder than the average person. However, most children with a family history of bipolar disorder do not develop the illness (Nurnberger & Foroud, 2000). Studies have shown that certain traits, including a history of hospitalizations, comorbid obsessive-compulsive disorder, age at first manic episode, and number and frequency of manic episodes, are present in families with a bipolar member (Potash et al., 2007). These traits serve as risk factors for the child’s development of bipolar disorders.
Family circumstances are also implicated in major depression. The nature of familial influences, involving complex relationships that can affect all systems of an individual, particularly highlight how multifaceted risk factors can become. Post (1992) described the biological phenomenon of kindling, in which stress changes neurotransmission mechanisms, a first episode of depression or mania occurs, and electrophysiological sensitivity to future stress results in subsequent depressive or manic states. This translates into the effects that childhood adversity has on the emergence of mood disorders (Oldehinkel & Ormel, 2015).