Serious mental illness

CHAPTER 31


Serious mental illness


Edward A. Herzog



Objectives



1. Discuss the effects of serious mental illness on daily functioning, interpersonal relationships, and quality of life.


2. Describe three common problems associated with serious mental illness.


3. Discuss five evidence-based practices for the care of the person with serious mental illness.


4. Explain the role of the nurse in the care of the person with serious mental illness.


5. Develop a nursing care plan for a person with serious mental illness.


6. Discuss the causes of treatment nonadherence, and plan interventions to promote treatment adherence.




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Categorizing mental illness according to levels of severity has tremendous implications for setting mental health policy, establishing insurance reimbursement standards, and facilitating access to appropriate care. In the United States, each state determines how to classify mental illness for the purpose of insurance coverage. The definitions used by the states generally fall into one of three categories. “Broad-based mental illness” refers to any commonly accepted mental health diagnosis whereas “serious mental illness” and “biologically based mental illness” refer only to a limited number of brain-based disorders that have a significant impact on functioning.


The federal government’s classifications of “severe and persistent mental illness (SPMI)” and “serious mental illness (SMI)” apply to those who are most deeply affected by psychiatric disorders. Disorders that fall into this category include severe forms of depression, panic disorder, and obsessive-compulsive disorder, as well as schizophrenia, schizoaffective disorder, and bipolar disorder. SPMI affects almost 3% of all adults (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012), and overall, one third of the disabled are disabled due to a mental illness (Anderson et al., 2011).


This chapter focuses on the broader classification of serious mental illness (SMI), which includes disorders in the SPMI group and affects more than 5% to 7% of the U.S. population (SAMHSA, 2012). Persons with SMI usually have difficulties in multiple areas, including activities of daily living (ADLs) (e.g., cooking, hygiene), relationships, social interaction, task completion, communication, leisure activities, remaining safe in the community, finances and budgeting, health maintenance, vocational and academic activities, coping with poverty, stigma, unemployment, and inadequate housing.


SMIs are chronic or recurrent. Some patients experience remissions interrupted by exacerbations of varying lengths; the remissions may be essentially symptom-free, but in most cases involve some degree of residual symptoms. For others, the illness follows a chronic and sometimes deteriorating course during which symptoms wax and wane but never remit.


People with serious mental illness are at risk for multiple physical, emotional, and social problems: they are more likely to be victims of crime, be medically ill, have undertreated or untreated physical illnesses, die prematurely, be homeless, be incarcerated, be unemployed or underemployed, engage in binge substance abuse, live in poverty, and report lower quality of life than persons without such illnesses.


Persons with SMI experience difficulties in a wide range of functions—from preparing meals to coping with everyday stressors. These impairments, along with related factors such as poverty, stigma, unemployment, and inadequate housing, can significantly impact quality of life and can cause persons with SMI to live in a “parallel universe” separate from “normals” (the name some use to describe people who do not have mental illnesses) (Fitch, 2007). Stigma, symptoms, or socially inappropriate behavior caused by SMIs can cause others to reject the patient and refuse friendship, housing, or employment.




Serious mental illness across the lifespan


SMI occurs in persons of any gender, age, culture, or location; however, the population currently living with SMIs can be separated into two groups who have had different experiences with the mental health system: (1) those old enough to have experienced long-term institutionalization (common before approximately 1975), and (2) those young enough to have been hospitalized only for acute care during exacerbations of their disorders.



Older adults


Before deinstitutionalization, the mass shift of patients with SMIs out of state hospitals and into the community that began in the 1960s and continued through the 1970s, many people lived long term in state psychiatric hospitals (refer to Chapter 4). Medical paternalism, in which the health care provider made all decisions for patients with SMIs, was pervasive at that time. Thus, patients became institutionalized. As a result, they became dependent on the services and structure of institutions and unable to function independently outside such institutions. It was difficult to distinguish whether behaviors such as regression were the result of the illness or institutionalization.



VIGNETTE


During her adolescence and young adulthood, Marian was a resident at a facility that cared for people with SMI. On discharge, she moves to a community home, where she spends long periods sitting in front of the living room window. Marian does not ask to go out into the garden she watches for so many hours. Indeed, she rarely asks for anything, including snacks or recreational activities, instead waiting for others to approach her or provide for her. Her caregivers work for several months to help her to recognize and articulate or act on her needs. There is a major celebration the day she walks into the kitchen and makes a sandwich of her own volition. Some of the dependency caused by institutionalization is being positively altered.




Younger adults


People young enough never to have been institutionalized usually do not have problems of passivity and dependency; however, a series of short-term hospitalizations has given them limited experience with treatment and has contributed to a cycle of treatment, brief recovery, and relapse. Intermittent treatment can increase denial and puts young adults with SMI at particular risk for additional problems, including increased frequency of relapse, legal difficulties, homelessness, substance abuse, and unemployment.



VIGNETTE


After graduating from high school, Christopher enlists in the army and serves for 5 years. He settles on the West Coast and takes a job in the post office. In his first psychotic break, Christopher becomes paranoid and threatening at work and is hospitalized briefly. After discharge, Christopher refuses aftercare and will not take medication. He quits his job and moves to another city. For the next 15 years, Christopher works intermittently, is homeless off and on, and drinks heavily whenever he has money. His only treatment is when he is involuntarily hospitalized when his behavior is threatening to others. He consistently resists aftercare recommendations, showing no insight into his illness. One day Christopher simply disappears.





Rehabilitation versus recovery: Two models of care


For many years, the concept of rehabilitation, which focused on managing patients’ deficits and helping them learn to live with their illnesses, dominated psychiatric care. Staff directed the treatment and focused on helping patients to function in their daily roles. Advocates and patients with SMI (many of whom prefer to call themselves “consumers” to emphasize the choices they have, or seek to have, over their treatment) have increasingly sought a different treatment approach. This consumer movement has criticized the rehabilitation model as being paternalistic and focused on living with disability rather than on quality of life and eventual cure.


The recovery model developed out of the consumer movement. It is supported by the National Alliance on Mental Illness (NAMI), perhaps the leading mental health consumer-advocacy organization, and the President’s New Freedom Commission on Mental Health (2003) stresses it in its recommendations for the future of mental health care. The recovery model:



A patient in recovery stated, “Slowly I accepted my illness but wanted to live a full life in spite of it. I was desperate to succeed in the real world, and I entered college. There I expanded my social ties, so I wouldn’t have to be forced into the identity of schizophrenia. My teachers gave me courage and respect” (Group for the Advancement of Psychiatry [GAP], 2000, p. 22).



Issues confronting those with serious mental illness


Establishing a meaningful life


Finding meaning in life and establishing goals can be difficult for persons living with SMI, particularly if they also experience poor self-esteem or apathy. Patients may struggle with the possibility that they may never be the person they once expected to be. Finding a way to “reset” one’s goals so that meaning can be found in new ways (e.g., helping others, volunteering, or simply surmounting a significant illness) is important to achieving a satisfactory quality of life and in avoiding despair.


If a person cannot work or attend school, there is a significant amount of free time to be filled. Unstructured free time and resulting boredom can be a significant problem. Options for constructive use of leisure time can be very limited if a person doesn’t have transportation, lacks money for movies or other pastimes, doesn’t live near parks or libraries, is afraid to go outside, or doesn’t have enough confidence to join peers in social activities. Such issues can reduce access to potential support resources and can sometimes lead to maladaptive coping via substance abuse or petty theft.



Comorbid conditions



Physical disorders

Persons with SMI are at greater risk from co-occurring physical illnesses, particularly hypertension, obesity, cardiovascular disease, and diabetes. The risk of premature death is over three times greater than the general population, and on average, patients with SMI die more than 25 years prematurely (Daumit et al., 2010). Contributing factors include failing to provide for their own health needs (e.g., forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma.


Diagnostic overshadowing results when a mental illness distracts medical staff from the patient’s real medical needs (Chadwick et al., 2010). For example, expressing health concerns in an eccentric or unclear manner can influence the quality of care received. One patient with schizophrenia experienced a priapism—a medically dangerous extended period of penile erection—as a medication side effect. Due to his psychosis, he described the resulting paresthesias to emergency department staff as “demons sticking needles in my [penis].” The ED resident did not assess for priapism partly because of the bizarre description and partly due to avoidance of this person. A response to this weighty problem has been a movement toward integrating mental and physical health care in a single setting to enhance access, improve coordination, and facilitate staff understanding and communication. While there are many models for this integration, one example is for mental health centers to partner with primary care providers so that their consumers can receive both forms of care in a single, coordinated delivery setting.




Substance abuse

Comorbid substance abuse occurs in 60% of those with SMI (Kerfoot et al., 2011). It may be a form of self-medication, countering the dysphoria or other symptoms caused by illness or its treatment (e.g., the sedation caused by one’s medications), or a maladaptive response to boredom. Nicotine use has always been higher in the population of those with SMI and is not declining as it has been in the general population. Substance abuse contributes to comorbid physical health problems, reduced quality of life, incarceration, relapse, and reduced effectiveness of medications.



Social problems



Stigma

Stigma is the propensity to view and respond to others negatively based on a belief that they possess undesirable traits. Stigma about SMI stems from a lack of understanding and causes others to make assumptions about persons with SMI. For example, many people believe that SMI persons are violent, when in fact violence by SMI persons is unusual; nonetheless, the result of this stigmatizing belief is fear and avoidance of SMI persons. Stigma interferes with access to quality health care and related services, results in discrimination and isolation, and can cause shame and anger. The President’s New Freedom Commission on Mental Health (2003) targeted stigma reduction as a focus for the next 25 years.


According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2008), only 25% of young adults believe that one can recover from mental illness; this belief is perpetuated by stereotypical images of mental illness in U.S. culture and limited corrective contact with persons with SMIs. Initiatives such as SAMHSA’s “What a Difference a Friend Makes” program (2008) and NAMI’s “Stigmabusters” campaign (2008) seek to improve understanding and acceptance through public education and reduction of stigma. As one patient explained, “We need to grieve the loss of normal lives, normal families, and normal places in society …. we are placed at the very lowest rung on the ladder of society. We are believed by many to be axe-murdering fiends—all of us, even though statistics do not bear this notion out” (GAP, 2000, p. 9).




Victimization

Stereotypes would have us believe that people with SMI are more likely to be violent than people who do not have mental illness, but the reverse is actually true: mentally ill people are more likely to be victims of violence than perpetrators (Hughes et al., 2012)). Sexual assault or coerced sexual activity also occurs in this vulnerable population. Impaired judgment, impaired interpersonal skills (e.g., unknowingly acting in ways that might provoke others, such as standing too close or not recognizing irritation in another’s facial expression), passivity, poor self-esteem, dependency, living in high-crime neighborhoods, and appearing more vulnerable to criminals may contribute to this problem. Drug abuse and transient living conditions increase the risk of victimization and resulting worsening of one’s mental health (Whitley, 2011).



Economic challenges



Unemployment and poverty

Most persons derive at least part of their identity and sense of value from the work they do. Many persons with SMI would like to work, but symptoms such as cognitive slowing or disorganization interfere with obtaining or succeeding at work. Eighty-five percent of persons with SMI are unemployed, and disability entitlements received by 50% of those with SMIs do not provide much income. Finding an employer open to hiring a person with SMI can be difficult, and antidiscrimination laws do not guarantee a job.


Newer antipsychotic medications can be extremely expensive (over $1000/month). Co-pays or Medicaid “spend-downs” (the monthly need to exhaust one’s funds to reestablish Medicaid eligibility) are obstacles to treatment. Persons with insurance may find that their share of costs is prohibitively high or that their insurance provider limits mental health care coverage or does not cover it at all. Providing mental health care coverage equal to that for physical health care, or parity, has been legislated in many states (and somewhat at the national level), but “loopholes” reduce mental health care coverage for many. Changes in national health care policy may reduce these obstacles to needed physical and mental health care.



Housing instability

Many persons with SMIs have limited funds, which equates to limited options for housing. Affordable housing may require living far from needed resources (e.g., stores, health care, and support persons) or in unsafe neighborhoods. Living with family can produce conflict about patient behavior (e.g., nonadherence, impaired self-care) that can lead to estrangement and disrupt housing with family.


An episode of inappropriate behavior could lead to eviction and a negative reputation among landlords, closing doors to future housing. Symptoms can cause behavior that leads to police arrest. One person asked a store clerk if he could pay him later for soda and, thinking concretely, mistook the clerk’s sarcastic “Oh, sure” as genuine approval, only to leave with the soda and find himself charged with theft an hour later; this arrest could leave him ineligible for housing subsidies, public housing, and other entitlements. Even with a subsidy, waiting lists might be several years long. Finding and keeping good housing can be very challenging.




Treatment issues



Nonadherence

At any point in time, nearly half of all persons with mental illness are not receiving treatment or are nonadherent to treatment; this can double the likelihood of relapse (Arango & Amador, 2010). Most health care providers address this problem with medication education, but patients faced with repetitive medication groups and exhortations to take medications often become more resistant rather than insightful. Other obstacles, such as side effects, drug costs, interruptions in treatment, and rotating treatment providers, increase the risk of nonadherence and threaten stability and prognosis. Box 31-1 describes nursing interventions that promote adherence.



BOX 31-1      INTERVENTIONS TO IMPROVE ADHERENCE TO TREATMENT




• Select medications that are most likely to be effective, well tolerated, and acceptable to the patient.


• Actively manage side effects to avert/minimize distress that could cause nonadherence.


• Carefully monitor medication decreases or changes to control side effects and maximize therapeutic effects.


• Simplify treatment regimens to make them more acceptable and understandable to the patient (e.g., once-a-day dosing instead of twice).


• Tie treatment adherence to achieving the patient’s goals (not staff’s or society’s) to increase motivation. Reinforce improvements (e.g., such as living in the community without rehospitalization), connecting them to treatment adherence.


• Assign consistent, committed caregivers who are skilled at building trusting, therapeutic relationships and who will be able to work with the patient for extended periods of time.


• To improve patient insight and motivation, educate the patient and family about SMI and the role of treatment in recovery; however, education alone will not lead to adherence, particularly for persons with anosognosia (as described on this page).


• Minimize obstacles to treatment by providing assistance with treatment costs and access.


• Involve the patient and family in support groups with members who have greater insight and firsthand experience with illness and treatment—people whose viewpoints the patient may be more likely to appreciate and accept.


• Provide culturally sensitive care. Not attending to cultural beliefs and practices (e.g., mistrust of health care and authority figures, or valuing self-sufficiency or privacy above health care) can result in rejection of treatment.


• When other interventions have not been successful, use medication monitoring, long-acting forms of medication (depot injections or sustained-release forms) to increase the likelihood that needed medication will be in the patient’s system. Note: mouth checks may not find pills hidden in the patient’s mouth (engaging the patient in conversation for several minutes after he takes the pills is also helpful).


• Never reject, blame, or shame the patient when nonadherence occurs. Instead, label it as simply an issue for continuing focus, and accept that achieving adherence often requires numerous tries. Remind yourself that nonadherence is common and often is due to anosognosia from the illness itself.





Treatment inadequacy

NAMI regularly evaluates services provided to those with SMI and finds most states lacking. The most recent such rating (in 2009) gave below-average ratings to 27 states, and the highest grade, a “B”, to only 6 states; problems cited included fragmented and inadequately funded services, inadequate housing, and excessive institutionalization instead of treating persons in less restrictive settings (NAMI, 2010). Research has also suggested that racial, economic, and other nonmedical factors (e.g., uninsured persons being hospitalized less and blacks being more likely to be given antipsychotic medications) affect treatment decisions (Rost et al., 2011). Although standards of care now exist for most SMIs, they are not always followed; consumers must be informed and diligent in ensuring that they are receiving the most effective treatment, and agencies and staff must be diligent in updating their programs and practice.





Resources for persons with serious mental illness


Comprehensive community treatment


Ideally, the community-based mental health care system provides comprehensive, coordinated, and cost-effective care for the consumer with mental illness; however, in 2003, the President’s New Freedom Commission on Mental Health concluded that services—particularly for those with serious mental illness—were fragmented and inefficient, with blurring of responsibility among agencies, programs, and levels of government. Many consumers “fall through the cracks,” and those who received treatment had difficulty achieving financial independence because of limited job opportunities and the fear of losing health insurance in the workplace (becoming employed and having an income may cause ineligibility for public health care coverage) (President’s New Freedom Commission on Mental Health, 2003).


The overall goal of community psychiatric treatment is to improve the consumer’s ability to function independently and achieve a satisfying quality of life. State hospitals and psychiatric units in general hospitals provide inpatient care. Community mental health centers (CMHCs), private providers (psychiatrists, psychologists, counselors, social workers, and advanced practice registered nurses [APRNs]), and other private, public, and governmental agencies provide outpatient care. Community services vary with local needs and resources; rural communities or those with limited finances may provide only mandated services (and limited access to them) whereas other communities may have a broad array of accessible services. Needed services may be unavailable or have long waiting lists, and consumers may have difficulty finding the services they need amid the maze of agencies and services.



Community services and programs

Psychiatric or medical-somatic services center on prescribing medications and related biological aspects of treatment (e.g., monitoring physical health status). Psychiatrists, advanced practice registered nurses, and sometimes physician assistants provide services, along with support from basic-level nurses.


Case management is usually provided by paraprofessional staff (people trained to assist professionals), who help patients with day-to-day needs, treatment coordination, and access to services. They work in their patient’s home, school, and vocational settings and coordinate the patient’s overall care, brokering and facilitating access to services while providing psychosocial education, guidance, and support. Case managers may also provide medication monitoring, observing and facilitating the patient’s use of medications to promote adherence. One evidence-based model of case management for patients with SMIs is assertive community treatment (ACT), discussed later in this chapter.


Day programs provide structure and offer therapeutic activities to patients who come to the program 1 or more days per week. Social skills training, discussed later in this chapter, focuses on socialization, activities of daily living (ADLs), and prevocational training (the fundamentals needed before one can be successfully employed [e.g., interviewing, dressing for work, and interacting professionally with co-workers]). Day programs also provide social contact and peer support and allow staff to monitor the patient’s status so that concerns can be detected and addressed quickly. A variety of staff, and sometimes consumers themselves, provide day program services.


Crisis intervention services focus on helping patients regain their ability to cope when facing overwhelming situations, such as psychological trauma or relapse. Impaired cognition and problem solving increase the risk of crisis in persons with SMI. Stressors, such as changes in routines at home or work, physical or financial problems, victimization, or anniversaries of traumatic events, may overwhelm coping and result in crises. A person with SMI and limited coping abilities may respond to a small stressor first by seeking hospitalization; crisis intervention seeks to help that person manage the stressor and avert a crisis and inpatient care.


Crisis intervention includes four steps: (1) clarify the reality of the situation; (2) build on the patient’s strengths and support system; (3) identify realistic, step-by-step goals; and (4) promote problem solving. Direct interventions, such as finding new resources or calling on existing resources for additional support, are emphasized. Services range from staff on call to provide direct support 24 hours a day by phone or in person to support lines (“warm” lines) or hotlines providing phone-based screening, support, crisis intervention, and referral services. Crisis residential or stabilization programs in some communities help persons who are in crisis and/or facing impending relapse, typically providing a stay of several days to 2 weeks during which acuity is too great to remain in a community residence but not high enough to require hospitalization.


Emergency psychiatric services provide emergency assessments, crisis intervention, and sometimes emergency medications or adjustments. Persons with SMI may be unable to recognize that their illness is worsening or that they are becoming unsafe; therefore, most communities provide a 24-hour emergency psychiatric evaluation program that can initiate emergency inpatient admissions on an involuntary basis via a mobile crisis team (wherein mental health professionals respond to patient residences, jails, or even street corners) and/or specially trained personnel in a crisis center or emergency department setting. In some communities, law-enforcement officers are responsible for initiating involuntary psychiatric evaluations. Local probate courts can also order such evaluations upon petition by family members or other interested parties.


Group and individual psychotherapy includes counseling and therapy based on a variety of models, usually provided by independently licensed mental health professionals (e.g., licensed independent social workers or APRNs). Approaches appropriate for those with SMI include (1) family therapy (helping family members function more effectively and providing skills and knowledge necessary to support loved ones with mental illnesses), (2) psychoeducation groups (educating about mental health topics [e.g., psychotropic drugs] and building skills [e.g., conflict resolution]), and (3) support groups (providing support related to daily challenges of living with chronic illness). Three other approaches—cognitive therapy, cognitive-behavioral therapy (CBT), and supportive psychotherapy—are discussed later in this chapter.


Housing services include supervised or unsupervised group homes, “board-and-care” homes (wherein room, board, and limited supervision are provided by laypersons in their homes), independent community housing (apartments, houses), and programming for specialized populations, such as forensic patients (e.g., criminal offenders found “Not Guilty by Reason of Insanity,” who no longer require inpatient care but require special or intensive monitoring and programming in the community). Housing services are designed to help the patient progress toward independent living, maintain stability, and avoid homelessness.


Partial hospital programs (PHPs) provide services similar to those received during inpatient psychiatric care on an outpatient basis. Often affiliated with inpatient programs, they typically include most of the services available to inpatients. Patients may be “stepped down” to PHP programs from inpatient units to further stabilize acute psychiatric conditions before being fully released to community-based services. Intensive outpatient programs (IOPs) are similar but typically community based and focused on services for high-need persons.


Guardianship involves the appointment of a person (guardian) to make decisions for the consumer during times when judgment is impaired. Guardians may be significant others or attorneys and typically are appointed during a court process addressing the issue of whether or not a patient is competent to provide for his own needs. Those with a guardian typically may not enter into contracts, consent to sexual activity, or authorize their own treatment; those actions require the guardian’s approval. In some cases, the guardian’s authority may be limited to the person’s finances, as when a consumer is functional in most respects but unable to manage money, placing basic needs for food and shelter at risk; the guardian is responsible for using the consumer’s funds to meet such needs. An alternative is the use of a payee, often a volunteer or staff member, whom the consumer agrees to allow to manage his finances, usually via a contract.


Community outreach programs, often focused on homeless persons, send professional or paraprofessional teams into the community to engage persons with mental illness in needed services, to foster self-care, and to provide patient advocacy. Multiservice centers collaborate with outreach programs to supply hot meals, laundry and shower facilities, clothing, social activities, transportation to and from services, and access to a telephone and a mailing address (often essential when seeking work or benefits) for persons who are homeless or living in drop-in shelters.



VIGNETTE


After 3 years, Christopher returns home to his parents. A policeman tells him to leave a library where he is causing a disturbance, and he is arrested when he threatens the policeman. He is found “Guilty but Insane” on a charge of disorderly conduct and is released on the condition that he receive psychiatric treatment. He goes to a clinic and receives long-acting intramuscular antipsychotic medication due to his history of nonadherence. He also joins a day program and gets a case manager, who helps him apply for Supplemental Security Income. When his aging parents state that he can no longer live with them, he moves to a group home. Because he wants to work, he is referred to Goodwill Industries, where he gets job training and coaching, leading to a job unloading delivery trucks. He stays on that job for the next 5 years. When the requirements of his conditional release are completed, he continues in treatment and continues working nearly full time. Because he is stable, his medication is changed to an oral antipsychotic, and he continues to receive supervision in his group home.

Related posts:

  1. The nursing process and standards of care for psychiatric mental health nursing
  2. Somatic symptom disorders
  3. Sexual dysfunctions, gender dysphoria, and paraphilias
  4. Biological basis for understanding psychiatric disorders and treatments

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Feb 3, 2017 | Posted by in NURSING | Comments Off on Serious mental illness

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