Nursing Care for Severe Mental Illness
Serious Mental Illness
Serious mental illness (SMI) is a term used to define those disorders that persist over time and result in extensive functional impairment in daily living skills and abilities that involve social interaction, interpersonal relations, and work skills (Johnson, 1997).
These disorders include but are not limited to schizophrenia, schizoaffective disorder, recurrent major depression, and bipolar disorder (Lyon, 2001). It has been estimated that about 2.8% of the adult population in the United States experience one of these disorders in a 1-year period (National Institutes of Mental Health (NIMH), 1994).
Many of these disorders are considered lifelong
and involve some level of disability, rendering the individual vulnerable to
poor health outcomes and decreased quality of life. Symptoms of severe mental
illness are manifested in cognitive dysfunction, social skills deficits,
disruption in emotional and behavioral responses, impaired communication, and
self-care deficits.
Cognitive Impairment
Cognitive impairment in individuals with chronic mental illness includes impairment in conceptualization, information processing, attention, executive functioning, and memory. The more severe impairments involve the ability to solve problem and process complex information. Insight and judgment are severely limited.
This is manifested as the inability to recognize the existence of illness and need for treatment, self-knowledge deficits, and poor decision-making abilities. Cognitive impairments are associated with poor functional outcomes and variances in adaptive functioning.
Individuals with serious mental illness have difficulty making decisions, as the ability to process and respond to information is often impaired. Often individuals with serious mental illness are unable to meet their basic needs for food, shelter, and money, resulting in increased risk-taking behaviors. It is not an uncommon practice to barter sexual favors for these items and engage in unsafe sexual practices.
Carey, Carey, Weinhardt, and Gordon (1997) measured the behaviors associated
with risk of transmission of HIV in a population of 60 adults with serious
mental illness. The findings indicated that 48% of men and 37% of women engaged
in at least one high-risk behavior.
Social Skill Deficit in Mental Illness
Social skills deficits result in self-concept changes, decreased stress response, and underassessment of personal resources. Social skills deficits include deficits in conversational capacity and impairments in processing interpersonal stimuli, such as eye contact or assertiveness. Individuals with SMI may look eccentric or disheveled, have poor hygiene and bizarre dress.
Other behaviors such as aggression, psychomotor retardation, and regression are often present and misinterpreted by others. Results are decreased financial status secondary to inability to gain employment, stigma, social isolation, financial disparities, and homelessness. Coping skills deficits result in self concept changes, decreased stress response, and underassessment of personal resources.
Many individuals with SMI have suffered the loss of family support and relationships. As the symptoms of SMI progress, an individual becomes increasingly isolated.
According to Borge, Martinsen, Ruud, Wante, and Frilis (1999), the degree of loneliness, meaningful leisure time activities, and satisfaction with living environment were identified as the most important factors influencing perceived quality of life in a population of clients with SMI .
As social support and factors related to
perceived quality of life wane, the individual becomes increasingly susceptible
to negative health outcomes.
History of Psychiatric Illness and Health Care
Examining historical trends in psychiatric care reveals a shift from institutionalization to community-based care for individuals with serious mental illness. In the 1960s, deinstitutionalization became a national objective as deplorable conditions in state facilities were recognized, yet few communities were prepared to care for individuals with serious mental illness.
Nonetheless, inpatient populations began to decline as patients were discharged into the community. Often the communities were ill prepared to care for the large number of individuals with serious mental illness, resulting in increased homelessness and increased numbers of incarcerated individuals with serious mental illness.
Fortunately, community programs have emerged providing a range of treatment and rehabilitation services, including case management and residential services. In addition, many advocacy groups have emerged such as the National Alliance for the Mentally Ill. These groups advocate for the rights of those with serious mental illness on both the local, state, and national level.
Although there have been advances in understanding and treating serious mental illness and the development of more efficacious medications and community based treatment services, the likelihood of nurses encountering clients with untreated serious mental illness in a variety of health care and community settings is high.
Nurses must be in a position to assess, intervene,
and evaluate individuals with serious mental illness in order to provide
holistic nursing care.
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