The term serious mental illness (SMI) refers to a group of psychiatric conditions, most of which tend to be biological in origin, that can significantly affect one’s level of functioning and quality of life, especially when untreated. Leaders in mental health and illness use two terms—serious and severe—interchangeably, with one word often defining the other. US organizations, including the National Institute of Mental Health (NIMH, 2021), the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020), and the National Alliance on Mental Illness (NAMI, n.d.), use the term serious mental illness, abbreviated as SMI. The World Health Organization (WHO, 2018) refers to the same group of illnesses as severe mental disorders.
SMIs include disorders that can be part of a group, such as mood disorders, personality disorders, psychotic disorders, as well as the different subtypes of schizophrenia. In 2017, almost 11.4 million adults (about 4.6% of all adults) in the United States lived with an SMI (NIMH, 2021). Fig. 32.1 illustrates the prevalence of SMI based on demographic characteristics.
SMIs can be lifelong disorders that oftentimes have an early onset during the late teenage years. Many patients can experience successful recovery and function at high levels with minimal to no symptoms of their disorder. Other times, the chronicity of the disorder can create cycles of recovery and decompensation in which the symptoms wax and wane. The degree to which individuals experience residual symptoms can depend on a variety of things, such as the type of illness, access to treatment, and coexisting medical or substance use disorders.
SMIs can be devastating and difficult to manage. Individuals with SMI are more likely to be victims of crime, have coexisting medical illnesses that are typically undertreated, and have shorter life expectancies. Individuals with SMIs are also more likely to experience homelessness, incarceration, be unemployed or underemployed, live in poverty, and have little to no advocacy for their needs.
Day-to-day functioning is impacted for people with SMIs. Activities of daily living (ADLs), functioning at work or school, maintaining relationships, and interacting socially may be a struggle. Other impairments are related to leisure activities, health maintenance, being safe in the community, and managing finances. They can experience difficulty exercising sound judgment, controlling impulses, concentrating, and coping with everyday stressors. Unfortunately, with all of these struggles, the path to recovery can be an uphill battle.
FIG. 32.1 Prevalence of serious mental illness in the United States.
National Institute of Mental Health. [2018]. Serious mental illness among US adults. Retrieved from http://www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among-us-adults.shtml.
Reduced access to healthcare services significantly impacts one’s ability to achieve and maintain a state of recovery from SMIs. Homelessness decreases quality of life and consistency of care coordination, while limited resources minimize the potential for successful engagement in treatment. Often, individuals with SMIs feel that they live in a world different than everyone else around them, making them feel alienated within their own communities.
Social stigma and lack of awareness by the general public creates a negative image against those with SMIs, which unfortunately contributes to the healthcare disparity seen within this population.
In this chapter, the primary term we will use for people with SMI is clients, which is a term commonly used in outpatient treatment settings. The term client refers to people who seek services and actively participate in their treatment and path to recovery and wellness. Other terms used to refer to individuals with SMI are people with mental health conditions and people with serious mental health conditions. In the context of a caregiver relationship, particularly outpatient clients who become hospitalized, they are usually referred to as patients.
Serious Mental Illness Across the Lifespan
SMI can affect individuals of any age, demographic, or background. Treatment for SMIs has changed drastically over the past several decades, transitioning from an institutionalization method of treatment, to more outpatient, community-based services and promoting independence. Typically, older adults are more accustomed to the institutionalization form of treatment with extended hospitalizations. Younger adults still may experience hospitalizations; however, this tends to be shorter in length, with more of an emphasis on receiving treatment within the community.
Older Adults
Older adults with SMIs have likely received their care within state mental hospitals. Typically, these individuals lived within the hospital and were cared for by a variety of staff members. Even though the overall percentage of the population who suffered from SMIs was minimal, they posed an incredible burden on the community and social policy in regard to placement and demand for care. Oftentimes, treatment was strictly regimented and quality of care was suboptimal. Human rights were not a top priority, and therefore, many violations of basic rights occurred. These patients generally had little input into the course of their treatment.
This institutional inpatient care model was widely accepted, as many families struggled to care for and provide consistent housing for individuals with SMIs. As a result, older adults may have become institutionalized or adapted to life in institutions where decisions were often made for them with disregard for any of their own input. Transitioning to independence in the community has been difficult after years of institutionalization.
Years of poor health maintenance, inadequate diet and housing, and substance use takes a toll on older adults physically. In addition, older adults tend to require more care for medication-induced medical conditions such as diabetes or metabolic syndrome (refer to Chapter 12). Due to their complex medical and psychiatric needs, older adults tend to live in assisted living or nursing home facilities where they are cared for, rather than being in the community with support and resources designed to assist them in maintaining their level of independent functioning.
Younger Adults
People without a history of institutionalization can sometimes have less of an issue with passivity and dependency. Instead, most experience hospitalizations that are typically shorter in length, followed by being referred to care on an outpatient basis. Unfortunately, these hospital stays can stabilize the illness but may fail to overcome not recognizing the need for treatment. This lack of recognition leads to poor treatment adherence, which contributes to a cycle of treatment, brief recovery, nonadherence, and relapse. Intermittent treatment puts young adults with SMI at particular risk for additional problems. These problems include increased frequency of relapse and hospitalizations, arrest and incarceration, homelessness, substance use, unemployment, and poorer long-term prognosis.
Development of Serious Mental Illness
SMI has much in common with chronic physical illness: the original problem increasingly overwhelms and erodes the ability to cope, which results in new problems. For example, in chronic congestive heart failure, the lungs and kidneys deteriorate due to cardiac insufficiency. Similarly, a person with schizophrenia may experience paranoia and a loss of social skills, causing interactions to become more anxiety provoking. The person begins to withdraw and experiences avoidance by others. This results in increased isolation and lack of support when support is most needed. As a result, coping abilities and functioning continue to deteriorate.
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, was the forefront of psychiatric care. Staff directed the treatment and focused on helping patients to function in their daily roles. The goal was to stabilize the disability, with little focus on the idea of recovery.
Advocacy movements in mental health produced sweeping change. First, individuals with SMI began to refer to themselves as clients to emphasize the choices they have regarding their care and course of treatment. This movement challenged the rehabilitation model as being paternalistic and focused on living with disability rather than on improving quality of life and achieving recovery. The recovery model, which has its roots in the substance use community, developed as a result.
The recovery model is supported by the National Alliance on Mental Illness (NAMI), the leading mental health consumer support and advocacy organization in the United States. Many other mental health organizations also support the recovery model.
The recovery model:
• Is patient/client-centered.
• Is hopeful and empowering.
• Emphasizes the person and the future rather than the illness and the present.
• Involves an active partnership between patient and care providers.
• Focuses on strengths and abilities rather than dysfunction and disability.
• Encourages independence and self-determination.
• Focuses on achieving goals of the patient’s choosing (not the staff’s).
• Emphasizes staff working collaboratively with clients, building on strengths to help consumers achieve the highest possible quality of life.
• Aims for increasingly productive and meaningful lives for those with SMI.
Issues Confronting Individuals With Serious Mental Illness
Establishing a Meaningful Life
Finding meaning in life and establishing goals can be difficult for people living with SMI, particularly if they also experience poor self-esteem. Patients struggle with the possibility that they may never be the person they once expected to be. It is helpful to find ways to reset goals so that meaning can be found in new directions, such as helping others, volunteering, or even successfully managing their illness. This reset is important to achieve a satisfactory quality of life and to avoid despair.
If a person cannot work or attend school, there is a significant amount of free time to fill. This free time can result in boredom and stagnation. Options for constructive use of leisure time are limited if a person does not have transportation or lacks financial means. Helping the patient discover affordable options to structure free time and bring pleasure to life is important to recovery and wellness. Helpful options include renting books/movies from the local library, volunteering, and going for walks to nearby parks. Joining a clubhouse or day program can counter social withdrawal, increase social skills, and build support systems.
Comorbid Conditions
Physical Disorders
People with SMI are at greater risk of co-occurring physical illnesses, such as hypertension, obesity, cardiovascular disease, and diabetes. The risk of premature death is more than three times greater than the general population and, on average, patients with SMI have a shortened lifespan of 10 to 20 years (John et al., 2018). Contributing factors include poor understanding of medical conditions, medication nonadherence, missed appointments and follow-up, and limited financial and community resources.
A mental illness can distract healthcare staff from the patient’s presenting medical needs. Persons with SMI may feel or be told that they are unwelcome in clinic waiting rooms because of their behaviors, appearance, or hygiene. Also, expressing health concerns in an eccentric or unclear manner can skew the quality of care received.
One patient with schizophrenia was experiencing priapism—a medically dangerous extended period of erection—as a medication side effect. Due to psychotic thinking, he interpreted the pain to the staff as “demons sticking needles in my [penis].” The resident did not assess for priapism partly because of the bizarre description, his assumption that the patient’s distress was due to his mental illness, and possibly his own discomfort working with this population.
There is strong support for integrating mental and physical healthcare in a single setting to enhance access, improve coordination, and facilitate staff understanding and communication. One example is for mental health centers partnering with primary care providers so that their clients can receive both forms of care in a single coordinated delivery setting.
Suicide
Suicide occurs 12 times more frequently in people with SMI. For example, half of those with schizophrenia attempt suicide, and one in 10 succeeds. Consider a successful premed student who develops SMI, then 3 years later finds herself unemployed and living in a group home. There is a significant disconnect between her former life path and her current situation. The loss of what might have been can lead to acute or chronic grief that, along with the chronicity of the illness and its demands and impact on daily life, can contribute to despair, depression, and risk of suicide. Helping the patient find meaning and strong support systems can help prevent suicidal thoughts and attempts.
Substance Use
Nearly 30% of adults diagnosed with a mental illness also abuse drugs and/or alcohol (HelpGuide, 2019). Substance use in this population can largely involve alcohol, marijuana, and illegal drugs such as methamphetamines and cocaine. It can be a maladaptive response to boredom or a form of self-medication, countering the dysphoria, anxiety, or other symptoms caused by illness or its treatment. Substance use significantly increases the risk of relapse and impairs judgment and impulse control.
While cigarette smoking has declined among the general population over the past decade, there has been little change among people with SMI. For example, those with mental illnesses account for 40% of cigarettes sold in the United States, even though they represent a small portion of the overall population (Lipari & Van Horn, 2017). The prevailing belief that nicotine is a form of self-medication that improves cognitive ability has not been supported by research. Nicotine can, however, reduce the effectiveness of certain psychotropic medications. In fact, nicotine raises blood pressure and heart rate, therefore physiologically causing anxiety, contrary to the belief that nicotine helps reduce anxiety as reported by individuals with SMIs.
Social Problems
Stigma
Stigma is the perception that an individual is flawed. The perception is covertly or overtly linked to some personal defect in the person being stigmatized. A lack of understanding and incorrect beliefs about mental illness result in stigma about SMI. For example, some may believe that people with SMI are violent when in fact violence is rare. Nonetheless, the result of this stigmatizing belief is fear and avoidance of people with SMI, particularly those who have psychotic disorders. Stigma can cause shame, anger, and isolation in individuals and can lead to discrimination in healthcare, housing, and employment.
It is often hard to grasp that individuals can recover from mental illness. This is mostly due to stereotypical images of mental illness and limited corrective contact with people with SMIs. Initiatives such as NAMI’s StigmaFree program seeks to improve understanding and acceptance through public education and campaigning for the reduction and elimination of stigma (NAMI, 2019a).
Isolation and Loneliness
Social isolation and loneliness are concerns with SMIs. Stigma, poor self-image, passivity, impaired hygiene, and similar factors reduce social interaction and interfere with relationships. Romantic relationships may be difficult to maintain and some may never experience a romantic relationship. Clubhouse programs and support groups can be an alternative way for individuals with SMI to meet others that not only share a similar lifestyle but can also empathize with their struggles and recovery process. As a result, a network of friendship can be built and even a romantic relationship can develop as well, while developing social skills and comfort.
Victimization
Stereotypes suggest that people with SMI are more likely to be violent than people without mental illness, but the reverse is actually true. People with mental illness are more likely to be victims of violence than perpetrators (Ghiasi et al., 2019). Sexual assault or coerced sexual activity also occurs in this vulnerable population. Impaired judgment, impaired interpersonal skills, impaired emotional recognition, poor self-esteem, dependency, and appearing more vulnerable to criminals may contribute to victimization. Drug use and poor living conditions in high-crime neighborhoods increase the risk of victimization and can worsen psychiatric conditions.
Economic Challenges
Unemployment and Poverty
Work and career tend to be a significant part of our personal identity. Lower levels of cognitive functioning, psychotic symptoms, and disorganized thinking can interfere with one’s ability to work and maintain employment. More than 60% of people with SMI are unemployed, and disability benefits generally do not provide adequate income for personal and living expenses (Sherman et al., 2017). Finding an employer open to hiring a person with SMI can be difficult, and antidiscrimination laws do not guarantee a job. Some mental health treatment facilities offer employment-based programs. Fig. 32.2 illustrates employment services offered in mental health treatment facilities.
Medications for psychiatric symptoms can be quite costly. Copays or Medicaid spend-downs (the monthly need to exhaust personal funds to continue Medicaid eligibility) are obstacles to treatment and obtaining prescription medication. Even with insurance, individuals may find that upfront costs are too high, there are limits to mental health coverage, or that coverage does not include any mental healthcare.
Providing mental healthcare coverage equal to that for physical healthcare, or insurance parity, was required under the Affordable Care Act of 2010. Yet many insurers still treat mental illness differently, for instance, requiring preauthorization for care when preauthorization is not required for comparable physical healthcare. Obtaining preauthorization can be a lengthy and time-consuming process, at times with no success. Short-term, limited-duration insurance coverage, enacted in 2017, is not required to comply with the Federal Parity Law.
FIG. 32.2 Employment services in mental health facilities.
Hudock, W. J., Lynch, S. E., Sherman, L. J., & Teich, J. (2017). Availability of supported employment in specialty mental health treatment facilities and facility characteristics: 2014. Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/report_3071/ShortReport-3071.html.
Housing Instability
People with SMI often have limited funds and housing options. Affordable housing may require living far from resources such as stores, healthcare, and support people or living in unsafe neighborhoods. For an adult who expects autonomy, living with parents can be challenging and may result in conflict. Nonadherence with treatment, impaired self-care, and household disruption often result in individuals being asked or being told to leave the shared housing.
For people with SMI who have attained housing apart from family members, an episode of erratic or threatening behavior may lead to eviction. Eviction leads to a negative reputation among landlords, which may close doors to future housing. If police are involved, they may not recognize symptoms of mental illness, leading to arrest. Imagine a client who is experiencing hallucinations in public. She becomes disruptive and is arrested, instead of the police de-escalating the situation accordingly. This arrest can potentially leave the woman ineligible for housing subsidies or public housing. Even with a subsidy, waiting lists might be several years long. Even then, the cost of living has risen substantially in many areas, making housing unaffordable even with subsidies. Finding and maintaining housing can be challenging. Clients can also lose housing due to extended hospitalization.
Fortunately, options such as “no reject, no eject” housing are becoming common. These are group homes that hold the client’s room even if hospitalized for extended periods of time. Some states have been granted waivers to allow the use of Medicaid-based funding for housing-related services (Abrams, 2019). This is a tremendous offering, since adequate housing is a social determinant of health.
Caregiver Burden
Caregivers, particularly family members, are challenged to cope with the persistent needs of individuals with SMI and may find themselves unable to shoulder the burden. They report that navigating the mental health system is challenging and stressful. Due to stigma or isolation, caregivers often carry this burden with little support, emotionally and financially.
Ensuring that caregivers are connected with resources and connecting the patient with services that will increase independence, such as vocational and housing support, are essential nursing interventions (NAMI, 2019b). Caregivers also age, become ill, and require care themselves, which often poses a difficult adjustment when a caregiver can no longer provide care or housing. Planning for the transition from family caregivers to other caregivers or independence before a crisis occurs and planning for financial support such as living trusts can preserve stability and help avoid relapse.
Treatment Issues
Anosognosia
Anosognosia (uh-no-sog-NOH-zee-uh), the inability to recognize one’s illness due to illness itself, affects most people with SMI. In SMI, the illness affects the one organ needed to have insight and make good decisions: the brain. As a result, it can take months or years for a person with SMI to recognize, acknowledge, and accept a mental illness. Anosognosia may seem like the person is in denial. While this can happen, anosognosia is much more likely in SMI. Lack of awareness of one’s mental illness is a significant obstacle to treatment. Table 12.3 in Chapter 12 includes interventions for anosognosia.
Nonadherence
Nonadherence to treatment can quadruple the likelihood of relapse. Anosognosia, medication side effects, medication costs, lack of trust in providers, poor access to care, and the stigma of mental illness also cause nonadherence. Factors that promote adherence, such as establishing a trusting therapeutic relationship, can be overlooked. Healthcare providers often respond primarily with medication education and pointing out the consequences of nonadherence, but patients faced with repetitive medication groups and exhortations to take medications may become more resistant rather than insightful. Box 32.1 describes nursing interventions that promote adherence.
Medication Side Effects
Psychotropic medications can produce a range of distressing side effects, from involuntary movements to increased risk of diabetes. Some side effects (e.g., dystonias) are treatable. Others may be temporary and diminish over time, or the individual can compensate for these through behavioral changes. For example, many psychotropic medications can cause drowsiness. If appropriate, clients can take these medications in the evening, usually before bedtime, to avoid daytime drowsiness. Addressing side effects is essential to promote adherence and maximize quality of life. Chapter 3 provides a detailed discussion of drugs used in the treatment of SMI, as do chapters on specific disorders.
BOX 32.1 Interventions to Improve Adherence to Treatment
• Encourage careful selections of medications that are most likely to be effective, well tolerated, and acceptable to the patient.
• Actively help the patient to manage side effects to avert/minimize distress that could cause nonadherence.
• 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., living in the community without rehospitalization), connecting them to treatment adherence.
• Assign consistently committed caregivers 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 people with anosognosia.
• Minimize obstacles to treatment by aiding 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. Peer support specialists could be especially helpful here.
• Provide culturally sensitive care. Not attending to cultural beliefs and practices (e.g., mistrust of healthcare and authority figures or valuing self-sufficiency or privacy above healthcare) can result in rejection of treatment.
• When other interventions have not been successful, use medication monitoring and 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 of limited benefit. For people on oral medications, fast-dissolving or liquid forms are the best options for ensuring their ingestion.
• 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 evaluates services provided to those with SMI and finds most states lacking adequate services to reach the majority of those with SMIs. There were several barriers to individuals finding a psychiatric provider or therapist. NAMI cited the following top three barriers (2017):
• Not accepting new patients
• Not accepting insurance plans
• Not close enough to work or home
Although standards of care exist for most SMIs, the level and quality of care can vary between different providers and treatment centers. An essential goal for providers is to continually update programs and practices (NAMI, 2017).
Residual Symptoms
Residual symptoms are symptoms that do not improve completely with consistent treatment. For example, a client being treated for schizophrenia may have strange beliefs, social withdrawal, or low energy even after psychosis has disappeared. These residual symptoms may occur even with consistent treatment and taking medication as prescribed. This can be frustrating, and clients may feel that these symptoms mean that treatments are not effective. This leads to helplessness and despair, and the patient may discontinue treatment as a result, worsening the illness.
Since residual symptoms tend to occur in older patients, comorbid physical symptoms may be responsible and should be explored (Khan et al., 2017). Once they have been ruled out, novel pharmacological treatment options should be considered for addressing symptoms such as lack of energy or social interest. Psychosocial interventions such as individual therapy and group therapy may improve mood. Addressing social isolation by expanding social outlets and physical inactivity by increasing regular exercise will result in a reduction of residual symptoms.
Relapse, Chronicity, and Loss
The majority of patients with an SMI face the possibility of relapse even when adhering to treatment, which may contribute to hopelessness and helplessness. Living with an SMI paradoxically requires more effort and emotional resources from people less able to cope with such demands. Each relapse can cause loss of relationships, employment, and housing, adding that much more loss to the patient’s life and making discharge planning significantly more complicated. For many clients, each relapse can be more severe in regard to the level of decompensation, and longer hospitalization stays.
Serious Mental Illness Resources
Our understanding of mental illness in general and SMI specifically has increased dramatically since the days of institutionalization. Research and educational support are available through governmental and grassroots organizations. Documentaries are also excellent sources of information for both healthcare providers and consumers. Box 32.2 highlights organizations and documentaries that address issues related to SMI.
Comprehensive Community Treatment
Ideally, the community-based mental healthcare system provides comprehensive, coordinated, and cost-effective care for the client with mental illness. However, services—particularly for SMI—are fragmented and inefficient, with blurring of responsibility among agencies, programs, and levels of government. Many clients “fall through the cracks,” and those who receive treatment have difficulty achieving financial independence because of limited job opportunities and the fear of losing health insurance in the workplace. Now, many can opt into the Medicaid Buy-In program, which is a state Medicaid benefit group that allows individuals coverage who would otherwise be ineligible due to their earnings (Centers for Medicare and Medicaid Services, 2018).
The goal of community psychiatric treatment is to improve the client’s ability to function independently and achieve a satisfying quality of life. Community mental health centers, 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 due to funding cutbacks, and clients may have difficulty finding the services they need amid the maze of agencies and services.
Community Services and Programs
The public healthcare system provides most care to those with SMIs. This system uses tax support to provide services even to those who are indigent and without adequate (or any) health insurance. Community mental health centers typically provide psychiatric or medical-somatic services and prescribe and monitor medications. Psychiatrists, advanced practice psychiatric-mental health registered nurses, and sometimes physician assistants provide these services along with support from registered nurses, therapists, counselors, and mental health workers.
Case management helps patients with day-to-day needs, treatment coordination, and access to services. Paraprofessional staff (people trained to assist professionals) usually provide this care. They work in the patient’s home, school, and vocational settings and coordinate overall care, facilitating access to services while providing basic education, guidance, and support. Case managers may 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.
BOX 32.2 Resources
Organizational Resources
Mental Health America is a nonprofit organization of advocates, consumers, and significant others who work to strengthen mental health services and educate the nation about mental health issues. Its website provides resources pertaining to recovery, wellness, and severe/serious mental illness.
The National Alliance on Mental Illness (NAMI) is a support and advocacy organization for people with SMI and those who care about them. It has national, state, and local chapters and provides a wealth of educational materials and services. NAMI provides a variety of support groups and educational programs, including:
Family-to-Family is a free eight-session class for families and friends of people with mental illness. Taught by NAMI-trained family members, it helps participants understand mental illness, increase coping skills, and become advocates for their loved ones.
Peer-to-Peer is a free eight-session educational program for adults with SMI who want to understand their illness and move toward recovery. It is taught by trained peers who themselves are recovering from SMI.
The National Institute of Mental Health (NIMH) is an offshoot of the National Institutes of Health and is the main national research organization for mental illness. Its website contains information about research findings, proposals, and grants, as well as a variety of educational resources on mental illness.
The Substance Abuse and Mental Health Services Administration (SAMHSA) seeks to reduce the impact of substance misuse and mental illness and works to move research findings into practice. Its website offers much useful information, including a mental health services locator to help consumers find local services.
Video Resources
Bedlam (2020). Examines the mental health crisis through intimate stories of people in emergency departments, jails, and homeless camps. Getting well cannot happen in a cell. Explores the reality of replacing mental healthcare with detention.
Definition of Insanity (2020). Follows a team public servants of working through the courts to steer people with mental illness with court cases on a path from incarceration to recovery.
Frontline: The New Asylums (2005). Details the societal factors that led to the incarceration of hundreds of thousands of people with severe mental illness in American jails and prisons. The video chronicles the financial and human consequences of this unintended and disastrous policy.
Frontline: The Released (2009). This companion video to The New Asylums follows inmates with mental illness as they are released to the community. The inadequacies and strengths of the community mental health system become apparent as the inmates struggle to establish a life outside of institutions.
Kings Park: Stories from an American Mental Institution (2011). Follows a group of former patients as they visit the now-closed state hospital where they spent months or years of their lives. Interviews chronicle the lives and experiences of those deinstitutionalized from the state hospital system, sometimes only to experience still sadder fates.
Minds on the Edge: Facing Mental Illness (2011). Features a discussion of issues facing individuals with severe mental illness. Using hypothetical situations and featuring mental health professionals, advocates, policy makers, and consumers, looks at the problems in the mental health system and offers insights into ways that this population could be helped more effectively.
Right to Fail (2019). A series that explores the struggles and complex debate behind independent living for people with severe mental illness. It chronicles the potential for people to succeed on their own terms with the right support, and also the right to fail.
The Soloist (2009). Based on a true story, this film chronicles the life of a man whose promising musical career was interrupted by schizophrenia. It accurately portrays severe mental illness and many of the issues experienced by consumers and those who attempt to help them.
Day programs provide structure and therapeutic activities to patients who attend the program one or more days a week. Services often include education regarding social skills, ADLs, and prevocational skills (the fundamentals needed before one can be successfully employed [e.g., interviewing, dressing for work]). Day programs also provide social contact and peer support. Staff monitor the patient’s status so that they can detect and address concerns quickly. A variety of staff, and sometimes clients themselves, provide day program services. Peer support specialists (i.e., other clients who are in recovery) may provide some of the services.
Individual and group 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). Psychotherapy approaches for SMI include (1) family therapy (helping family members function more effectively by 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 skills [e.g., conflict resolution]), and (3) support groups (providing support related to daily challenges of living with chronic illness).
The following services may be provided by community mental health centers or through other public and private agencies:
Crisis intervention services focus on helping patients regain their ability to cope when facing overwhelming stress, such as psychological trauma or relapse. Impaired cognition and problem-solving increase the risk of crisis in people 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 in less-restrictive settings and avoid more-disruptive inpatient care.
Crisis intervention emphasizes finding new support or calling on existing resources for additional support. Crisis services range from staff on call who provide direct support 24 hours a day by phone or in person, to support lines (or “warm” lines, for lower levels of distress) or hotlines (for crises and high levels of distress) providing phone-based screening, support, crisis intervention, and referral services. Crisis residential or stabilization programs in some communities typically provide a stay of several days to 2 weeks when 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. Individuals 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. An additional emergency service is a mobile crisis team. It is composed of mental health professionals who go to residences, jails, or even street corners. In some communities, law-enforcement officers are responsible for initiating involuntary emergency psychiatric evaluations. Local probate courts can also order such evaluations upon petition by family members or other interested parties.
Housing services help people progress toward independent living and to maintain stability and avoid homelessness. Settings include supervised or unsupervised group homes and independent community housing. Board-and-care homes provide room, board, and limited supervision by laypeople in their homes. Programming may target special populations such as individuals with a forensic history. This group includes criminal offenders who may have been found not guilty by reason of insanity who no longer require inpatient care, but require special or intensive monitoring and programming in the community.
Partial hospitalization programs (PHPs), often affiliated with inpatient programs, typically provide most of the services available to inpatients but on an outpatient basis. Patients usually attend PHPs Monday through Friday for most of the day. Inpatients may be stepped down to PHP programs from inpatient units for further stabilization before being released to other community services. Outpatients may use PHP services to control symptoms in order to avoid inpatient care. Intensive outpatient programs (IOPs) are similar but tend to be less lengthy.
Community outreach programs often focus on homeless individuals or people who do not seek care on their own. Professional or paraprofessional teams work in the community to engage people with mental illness who need services and to provide patient advocacy. Often, these patients can be difficult to reach and connect with; therefore, continuous outreach is needed before even minimal contact is made. Multiservice centers collaborate with outreach programs to supply hot meals, laundry, and shower facilities. They can also provide clothing, social activities, and transportation to and from services. For SMI people who are homeless or living in drop-in shelters, these centers provide access to phones and a mailing address, usually essential when seeking work or benefits.
Substance Use Treatment
A variety of services exist for those who have a dual diagnosis of SMI and alcohol-related or drug-related problems. Substance disorder clinics provide therapeutic and rehabilitative services and medication-assisted treatments such as detoxification or methadone. They also provide psychosocial interventions and psychotherapy. Help for families is also available. Most clinicians endorse integrated treatment that is delivered by a single provider rather than split between a mental health agency and a drug/alcohol agency. Refer to Chapter 22 for a detailed discussion of treatment settings for patients with substance use disorders.
Vignette
Christopher, who has a history of SMI, is causing a disturbance in the public library. He is arrested when he refuses a police officer’s order to leave. Charged with disorderly conduct, he is subsequently found to be “guilty but insane” and conditionally released to mandatory psychiatric treatment. At a local clinic, he receives a long-acting intramuscular antipsychotic medication due to his history of nonadherence. He also joins a day program and is assigned to 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 Christopher wants to work, he is referred to Goodwill Industries, where he receives job training and coaching, leading to a job unloading trucks. The stable housing and the requirements of his conditional release lead to consistent treatment and prevent nonadherence. He remains stable and employed for the next 5 years.
Evidence-Based Treatment Approaches
Assertive Community Treatment
Assertive community treatment (ACT) involves consumers working with a multidisciplinary team that provides a comprehensive array of services. This team approach eliminates the need for multiple departments or agencies to provide services. Research supports this model for improving the quality of life and reducing inpatient admissions, incarceration, and homelessness among people with SMI (Mueser, 2019). At least one member of the team is available 24 hours a day for crisis care, though this may not be available depending on resources. The emphasis is on treating patients within their own environment. Although ACT programs cost more to operate, proponents believe those costs are offset by reduced care costs elsewhere.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) has been effective in helping individuals with SMI reduce and cope with symptoms such as delusions and impaired social functioning (Provincial System Support Program, 2017). The cognitive component of CBT focuses on patterns of thinking and “self-talk” (i.e., what one says to oneself internally). It identifies distorted thinking and negative self-talk and guides patients to substitute more effective ways of thinking. The behavioral component of CBT uses natural consequences and positive reinforcers (rewards) to shape the person’s behavior in a more positive or adaptive manner. Refer to Chapter 2 for a more detailed discussion of CBT.
Vignette
Christopher has done well in a group home and decides to move to his own apartment. Over the next 2 months, his mental status remains stable. However, his nurse, who weighs him monthly, notices that he has lost 12 pounds. Christopher denies any change in his eating habits, and he doesn’t follow up with the primary care provider to whom he’s been referred. During the next 6 weeks, he loses another 10 pounds. Christopher’s work supervisor noticed that Christopher is talking out loud to himself, is more isolated, and today, smelled of alcohol. The supervisor dismisses him for the day and requires him to get treatment before returning to work. At his appointment, the psychiatrist, nurse, and nurse-therapist discuss these changes and recommend that Christopher go into the PHP for support and medication reevaluation. Although he denies that he has a problem, Christopher reluctantly agrees.
Cognitive Enhancement Therapy
Cognitive enhancement therapy (CET) is based on the principle of neuroplasticity—that healthier areas of the brain can assume neurological functions for the compromised areas of the brain. CET is a lengthy process of structured computer-based drills and group exercises (e.g., 60 or more) that incrementally challenge and strengthen functions such as focusing attention and processing and recalling information. It can also help with interpreting social and emotional information, such as judging a person’s mood from expression or tone of voice. Research has shown that CET leads to sustained improvement in cognition and improves social and vocational functioning (Wojtalik et al., 2017).
Family Support and Partnerships
Families and significant others can face significant stresses related to the mental illness of a loved one, and both may suffer from insufficiencies in empathy and understanding. Sound family support is one of the strongest predictors of recovery. When treatment providers work as empathic partners with patients and significant others, this enhances treatment and reduces conflict. NAMI’s Family-to-Family program focuses on understanding SMI, coping skills, and the recovery process (NAMI, 2019b). NAMI meetings and support groups are specific to various SMIs. For example, the Depression and Bipolar Support Alliance serves as an excellent source of support and practical guidance for primary consumers (patients) and secondary consumers (their significant others).
Social Skills Training
Social skills training is an evidence-based practice that focuses on teaching a wide variety of social and ADL skills, largely with the focus of making progress in small increments. People with SMI often have social deficits that cause functional impairment. For example, a person may not realize that standing too close to others can cause discomfort for others, which can lead to negative outcomes such as rejection or a poor job evaluation. Care providers break down complex interpersonal skills, such as resolving a conflict, into more manageable subcomponents. They then teach them how to manage the problem step by step. They also use role-playing and group interaction to practice skills.
Vignette
Christopher is admitted to the PHP. He attends groups on medication, living with SMI, substance use, and symptom management. The clinicians notice odd behavior. Christopher will only eat or drink out of unopened containers and seems guarded. He discloses that he has not taken any medication since he moved out of his group home. The psychiatrist changes his prescription to a quick-dissolving oral and a long-acting injectable medication. He begins to eat normally and gains 4 pounds in 2 weeks.
He is discharged from the PHP a month later. He again attends the day program at the community mental health center. There, he is provided with structure, supportive group therapy, socialization, case management, and medication management. His case manager finds him a room in a family care home with a supportive caregiver. Over the next 3 months, Christopher gradually returns to his baseline functioning. He returns to work 2 days a week and also attends the day program 2 days a week.
Vocational Rehabilitation and Related Services
Clients with SMI who are employed experience improved socialization, confidence, organizational abilities, income, and quality of life. Vocational services, or vocational rehabilitation, typically include training skills to enhance employment and financial support for attaining employment. Day programs may use a clubhouse model in which clients run the programming for peers. Client-run businesses, such as a coffee shop or housekeeping service, teach all members to perform a job in the business as well as different aspects of running a business. Such programs have led to the supported employment model, which has been shown to be more effective in helping individuals with SMI achieve employment (McKay et al., 2018). Elements of this approach include:
1. Financial incentives to employers to employ people with SMI
2. Rapid placement in a competitive job preferred by the patient
3. Continuing individualized support on the job
4. Integration of mental health and employment services
Evidence-Based Practice
What Is the Link Between Antipsychotic Medication and Diabetes?
Problem
Individuals with SMI are at a higher risk for developing diabetes. This risk is associated with the use of antipsychotic medications.
Purpose of This Study
The purpose of this study was to review recent studies that link diabetes with antipsychotic medication and to identify methods for decreasing this risk.
Methods
Publications including literature reviews, meta-analyses, and randomized controlled trials from the last 5 years were reviewed.
Key Findings
• Second-generation antipsychotic medications, which are more widely used and effective than first-generation antipsychotics, increased the risk of developing diabetes, especially in adolescents and young adults.
• Clozapine and olanzapine use are associated with a higher risk of developing diabetes compared with other antipsychotic medications.
• Antipsychotics directly affect insulin sensitivity and secretion.
Implications for Nursing Practice
Antipsychotic medications are highly effective. However, understanding the risk of diabetes and strategies to prevent diabetes is crucial for nurses who advocate for and educate patients. Early screening and lifestyle changes are effective ways to prevent and manage diabetes, especially when initiated at the start of antipsychotic therapy.
Holt, R. (2019). Association between antipsychotic medication use and diabetes. Current Diabetes Reports, 19(10), 96.
Other Treatment Approaches
Court-Involved Intervention
Psychiatric advance directives are legal documents that allow an individual whose disorder is in remission to direct how to manage treatment if judgment becomes impaired during a relapse. For example, a client can agree to accept hospitalization or medications, should a relapse occur. This proactive plan helps the consumer maintain control over treatment and avoid the need for involuntary admission and court involvement. These directives do vary by state, so it is important to understand how laws by state mandate this.
Guardianship involves the appointment of a person (guardian) to make decisions for the consumer during times when judgment is impaired or is disabled with anosognosia. Guardians may be family members, significant others, or attorneys. They are typically appointed during a court process addressing the issue of whether or not a patient is competent to provide for personal needs and make appropriate decisions regarding psychiatric care.
Individuals who have been appointed a guardian typically may not enter into contracts or authorize their own treatment. All of those actions require the guardian’s approval. In some cases, the guardian’s authority is limited to the person’s finances, as when a client 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 client’s funds to meet such needs. An alternative is the use of a payee, often a volunteer or staff member at a community agency or center, whom the consumer agrees to allow to manage the finances, usually via a contract. Payees can be very beneficial for clients, as they can work together to create a budget and ensure the client is learning about managing the finances.
Consumer-Run Programs
As previously discussed with vocational rehabilitation, client-run programs may be informal clubhouses, which can offer socialization, recreation, group classes, as well as types of services. They may also be competitive businesses, such as snack bars or janitorial services, which provide needed services and client employment while encouraging independence and building vocational skills. In Cincinnati, Ohio, for example, clients working with a food service professional run a restaurant open to the public, while both learning skills and developing experience in the food-service industry. Community mental health centers typically have client-run programming as part of day programs that are very successful and meaningful for clients and staff alike.
Peer Support
Peer support involves receiving support from one’s peers. This can be from untrained peers in a peer support group or by specially trained and sometimes certified peer support specialists. NAMI and other programs offer training that enables consumers to assist peers effectively in their recovery process. Peer support specialists may work in hospitals or day programs to encourage and help their peers, and act as an advocate for clients. They draw on firsthand experience with SMI to enhance their effectiveness. People with SMI are often more open to accepting support from people who have experienced what they are going through, which can improve coping skills.
Technology
Technology can reduce healthcare-associated costs, and improve treatment access and client outcomes. Electronic records available in multiple locations can assist in assessments or promote continuity of care anywhere in the community. Those who cannot afford electronic access often have, or can be provided with, a cell phone, allowing for improved monitoring and faster response if, for example, a patient misses an appointment. Smartphone applications can help clients manage stress, prevent weight gain through exercise or dietary means, and remember scheduled treatments or appointments. Text reminders can promote treatment adherence by tracking medications or appointments. Medication dispensers that track when medications are taken are also helpful. Personnel in remote locations are now able to speak with clients by telephone or internet-based video when patients cannot otherwise access distant services or specialists. Telemedicine is becoming more widespread in an attempt to reach more clients and deliver care to a bigger population of individuals suffering with SMIs.
Exercise
Exercise holds benefits for people with SMI, including improved coping with symptoms, reduced anxiety and depression, and enhanced self-esteem. Exercise helps with weight control, which is essential for people with weight-related comorbidities such as diabetes and hypertension. Exercise is a cost-effective intervention that can be done almost anywhere. While SMI symptoms such as avolition are obstacles to exercise, motivational and group interventions can improve exercise participation (Wang et al., 2018). Many community recreational centers provide discounted passes or memberships for individuals with SMIs, creating more incentive for them to participate in an active lifestyle. Day centers and clubhouses can also offer exercise classes, such as yoga and outdoor hiking groups.
Nursing Care of Patients With Serious Mental Illness
Nurses encounter patients with SMI in a variety of medical and psychiatric settings. All roles and techniques used by psychiatric-mental health nurses in inpatient psychiatric settings also apply in the community and other outpatient healthcare settings.
Assessment Strategies
Important aspects of assessment include:
• Intentional risk to self or others: Suicidality or homicidality
• Unintentional risk: Inadequate nutrition, clothing inadequate for the weather, neglect of medical needs, or carelessness while driving, smoking, or cooking
• Depression or hopelessness
• Anxiety
• Signs of impending relapse: Decreased sleep, increased impulsivity or paranoia, diminished reality testing, increased delusional thinking, or command hallucinations
• Physical health problems that can cause psychiatric symptoms and be mistaken for mental illness or relapse (e.g., brain tumors or drug toxicity)
• Comorbid illnesses: To ensure that the patient provides appropriate self-care and receives adequate healthcare
• Treatment nonadherence: Signs such as worsening of symptoms, unused medications, missed appointments, illicit drug use, or reluctance to discuss these issues
Table 32.1 lists selected signs and symptoms of problems associated with SMI, potential nursing diagnoses that apply to the patient with SMI, and examples of specific nursing outcomes.
Intervention Strategies
Box 32.3 outlines relevant nursing interventions for the management of SMI. Basic nursing interventions for patients with SMI are listed in the following text. Additional interventions are in Table 12.3 in Chapter 12 and in other chapters covering individual mental illnesses.
• Involve the patient in goal setting and treatment planning. This increases treatment adherence and improves treatment outcomes.
• Emphasize quality of life rather than simply focusing on symptoms, as this conveys an interest in the person rather than the illness and promotes recovery.
• Maintain sustained therapeutic relationships; trust in providers is key to overcoming anosognosia and achieving treatment adherence. People with SMI often require extended periods to form these connections.
• Focus on coping with current issues rather than past difficulties.
• Encourage reality testing to enable clients to recognize and counter hallucinations and delusional thinking. For instance, if a person experiences frightening hallucinations while in public, the person can learn to scan the room and determine if others seem frightened. If not, the client can learn techniques about how to cope with hallucinations to prevent a possible negative event occurring in public.
• Enable clients to recognize and respond to stigma. Stigma predisposes SMI people to isolation and social discomfort. The resulting isolation contributes to loneliness and reduces access to support, thus creating a repetitive cycle of isolation and disengagement of treatment.
• Promote social skills and provide opportunities for socialization, especially with positive role models, such as other clients who are further along in recovery.
• Involve clients in support groups such as NAMI that expose members to those who can truly empathize. Such groups provide support, socialization opportunities, and practical suggestions for issues and problems facing clients and significant others. Peer support specialists are another excellent resource for this purpose.
• Educate clients about their illness and recovery. Understanding the illness enhances coping, treatment adherence, and quality of life.
• Care for the whole person. SMI patients have more physical illness; poorer hygiene and health practices; less access to effective medical treatment; and increased risk for victimization, STDs, and undesired pregnancies. They also have more premature mortality than the general population. Avoiding obesity through exercise and good nutritional practices can reduce the risk of comorbidities such as metabolic syndrome. Sound physical health conserves energy and resources for use in coping with SMI. Case management plays a significant role in assisting clients to connect with medical care providers.
TABLE 32.1
Signs and Symptoms, Nursing Diagnoses, and Outcomes for Serious Mental Illness
Signs and Symptoms Nursing Diagnoses Outcomes
Absence of eye contact, difficulty expressing thoughts, difficulty in comprehending usual communication pattern, inappropriate verbalization Impaired verbal communication Improved verbal communication: Exchanges messages accurately with others, uncompromised spoken language, accurately interprets messages received
Withdrawal, inappropriate interpersonal behavior, social discomfort, lack of belonging Impaired socialization Improved socialization: Engages others, appears relaxed, cooperates with others, uses assertive behaviors as appropriate, exhibits sensitivity to others
Absence of supportive significant other(s), preoccupation with own thoughts, shows behaviors unaccepted by dominant cultural group, withdrawn, reports feeling alone, feels different from others, feels rejected Social isolation Decreased social isolation: Interacts with others (e.g., family, friends, neighbors, mental health consumers), participates in community activities (e.g., church, volunteer work, clubs), participates in leisure activities with others
Failure to keep appointments, missing medication dosages, evidence of exacerbation of symptoms, failure to progress Nonadherence to [medication regime, treatment regime] Adherence to [medication regime, treatment regime]: Discusses prescribed treatment regimen with health professional, performs treatment regimen as prescribed, keeps appointments with health professionals, monitors own treatment response
Self-negating verbalization, lacks success in life events, hesitant to try new situations, indecisive behavior, lack of eye contract, nonassertive behavior Chronic low self-esteem Improved self-esteem: Describes feelings of self-worth, fulfills personally significant roles, maintains eye contact, accepts compliments from others
Apprehension about care receiver’s care if caregiver is unable to provide care, apprehension about possible institutionalization of care receiver, lack of time to meet personal needs, anger, stress, frustration, impatience, limited social life Caregiver stress Reduced caregiver stress: Caregiver receives adequate respite, social support, opportunities for leisure activities, supplemental services to assist with care; caregiver reports sense of control and certainty about future
International Council of Nursing Practice. (2019). ICNP browser. Retrieved from https://www.icn.ch/what-we-do/projects/ehealth/icnp-browser. ICNP® is owned and copyrighted by the International Council of Nurses (ICN). Reproduced with permission of the copyright holder.
BOX 32.3 Interventions for Serious Mental Illness
ADLs, Activities of daily living; NAMI, National Alliance on Mental Illness.
Self-Care Assistance: ADLs a
• Teach the appropriate and safe storage of medications.
• Assist with the use of public transportation (e.g., buses and bus schedules, taxis, city, or county transportation for disabled people).
• Assist in establishing safe methods and routines for cooking, cleaning, and shopping.
Family Support
• Encourage family to share concerns, feelings, and questions.
• Accept the family’s values in a nonjudgmental manner.
• Provide emotional support and connect to support resources such as NAMI and respite services.
• Promote congruence among patient, family, and staff expectations.
a Partial list.
From Bekhet, A. K., Zauszniewski, J. A., Matel-Anderson, J., Suresky, M. J., & Stonehouse, M. (2018). Evidence for psychiatric and mental health nursing interventions. Online Journal of Issues in Nursing, 23(2). Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No2-May-2018/Evidence-Psychiatric-Mental-Health-Interventions.html
• Involving individuals with co-occurring substance use disorders in Alcoholics Anonymous and Narcotics Anonymous (AA/NA) and other dual-diagnosis services. Substance use disorder rates are high in SMI populations. These disorders increase relapse, foster disengagement with treatment, and interfere with recovery. Achieving sobriety is most associated with AA and integrated treatment programs.
Evaluation
Evaluation is ongoing. Psychiatric nurses evaluate the degree to which the outcomes have been met. At this point in the nursing process, care may be re-prioritized based on the patient’s progress.
Current Issues Affecting Individuals With Serious Mental Illness
Outpatient Commitment
Involuntary inpatient care has long been used to treat those who are unable to recognize their illness (anosognosia) and the need for treatment. Outpatient commitment, which provides mandatory treatment in the community, is relatively new. Typically ordered by a court when a patient leaves a hospital or prison, it is for people who would otherwise be unlikely to continue treatment, resulting in their becoming a danger to self or society.
The practice of outpatient commitment is controversial. On the one hand, individuals who do not recognize having a mental illness are provided with healthcare and, potentially, a better quality of life. They are allowed maximum freedom and are able to live in the community and avoid institutionalization. On the other hand, this approach is paternalistic and at odds with the recovery model of mental healthcare. Research on the effectiveness of outpatient commitment has demonstrated results that both support and reject this approach. Clients may struggle with the inability to make their own decisions with participation in treatment, and the consequences can be severe should they not engage in treatment. They may feel forced into treatment, which may have little to no benefit on their recovery if it is not on their terms.
Criminal Offenses and Incarceration
People with SMIs may commit crimes due to desperation, impaired judgment, or impulsivity. Most often, they are nonviolent crimes such as petty theft or disorderly conduct. Police may also become involved with people who seem unable to care for themselves, have become a public nuisance, or cannot be persuaded to accept treatment but do not meet criteria for involuntary treatment (usually imminent danger to self or others). For example, a client with impaired judgment without shelter in cold weather may stay in a laundromat for warmth. The presence of unkempt persons talking to themselves and not using appropriate personal space will cause others to feel uncomfortable. If expelled, they are at risk of hypothermia. In such a case, the risk to self may not be “imminent,” and emergency hospitalization is not a legal option. Significant others or police may then seek their arrest simply for their own safety.
Most mental illness advocates believe that incarceration is harmful. Imprisonment can lead to victimization, despair, relapse due to stress or overstimulation, loss of housing or employment, and inadequate treatment. Criminal convictions may make consumers ineligible for most housing or employment, trapping them in a cycle of release and reincarceration.
Advocates support diversion from jail to clinical care. Many communities have adopted interventions to achieve diversion. Police are receiving education that helps them identify behaviors associated with mental illness, distinguish these behaviors from criminal intent, and connect people with services rather than jailing them. Special mental health courts are designed to intercept people whose crimes are secondary to mental illness. These courts employ specially trained officials with authority to order treatment in lieu of conviction, thereby avoiding the stigma and the consequences of conviction and incarceration.
Deinstitutionalization and Transinstitutionalization
Prior to the 1960s, people often lived long term in state psychiatric hospitals (refer to Chapter 4). The newer treatments available in the 1960s improved many patients’ conditions enough that they no longer needed to be institutionalized and could live instead in the community. Deinstitutionalization, the mass shift of patients from state hospitals into the community, began in the 1960s and has continued since. However, planned systems of community care needed by individuals with SMI did not always materialize, leaving them to fend for themselves without access to the services they needed. It was also common for patients to experience difficulty in adjusting to independence after years of being institutionalized.
As a result, former patients ended up being readmitted to state hospitals or cared for in other kinds of institutions. Transinstitutionalization is the shifting of a person or population from one kind of institution to another, such as a state hospital, jail, prison, nursing home, or shelter. For example, people who were discharged from state hospitals ended up homeless and subsequently were arrested for a variety of crimes. Now there are more people with SMI in jails and prisons than in hospitals.
Inadequate Access to Care
SMI often makes it difficult for individuals to work or find well-paying jobs and jobs with health insurance benefits. As a result, people with SMI tend to rely on the public mental health system, which is run by state and local governments, with services delivered largely by state hospitals and community mental health centers. One consequence of deinstitutionalization was that 90% of state hospital beds were eliminated, making it difficult to provide hospital care to many who continue to need inpatient care. Further, most public mental health services rely on state and local funding, and the economic recession that began in 2007 has resulted in funding cutbacks that have reduced already-overwhelmed mental health and related services.
Inpatient and outpatient services for children and adolescents are in especially short supply. The result is that delayed admissions and waiting lists for outpatient care are now commonplace. The Affordable Care Act and Medicaid expansion have resulted in dramatically more people with SMI having health insurance (Guth, Garfield, & Rudowitz, 2020). However, even those with insurance, who can use private care providers, often find that there are still barriers to getting needed care, such as burdensome preauthorization requirements (required for psychiatric care but not for medical care) that discourage or delay access to needed services. Even with the expansion of Medicaid and insuring many who were previously uninsured, many clinicians and care providers are overwhelmed more than ever with rising patient-to-provider ratios, contributing to the disparity that is long overdue to be rectified.
Key Points to Remember
• Patients with SMI often suffer from multiple impairments in thinking, emotions, perception, and interaction with others.
• The recovery model stresses hope, strengths, quality of life, patient involvement as an active partner in treatment, and eventual recovery.
• The course of SMI involves exacerbations and remissions; these can be discouraging and lead a patient to believe recovery is not possible.
• People with SMI often suffer complications due to comorbid conditions such as physical disorders, suicide, and substance use.
• Social problems related to SMI include stigmatization, isolation, and victimization.
• Economic challenges for people with SMIs include unemployment, poverty, and housing instability.
• One of the most difficult symptoms of SMI is anosognosia, the inability to recognize one’s illness due to the illness itself.
• Coordinated comprehensive community services help people with SMI to function at an optimal level, but such services may not be available or accessible to those who need them.
• The family and support systems play a major part in the care of many people with SMI, so they should be included as much as possible in planning, education, and treatment activities.