Understanding Mental Health Issues

Kathy Quan RN BSN PHN

Kathy Quan RN BSN PHN

Mental health issues can overlap other physical illnesses and impact the wellbeing of many patients. There has long been a stigma attached to mental illness and it drives patients away from seeking medication and other courses of treatment for their conditions. Nurses need to have an understanding of mental health issues in order to meet patient needs and goals. 

For APRNs who will be prescribing for mental health patients, NursingCE.com has developed a new continuing education course. This course takes an in-depth look into the various major mental health disorders and the current common treatments.  It is important to understand that mental health issues are based in illness and not behavior. Many will however, manifest in behavior issues which can be managed with medications, adjunctive treatments and management of other underlying disease process. 

Facts about mental health

Mental health disorders are defined classified by the American Psychiatric Association in the DSM 5 (the Diagnostic and Statistical Manual of mental health disorders.) It took over ten years for psychiatric experts to compile the new manual which was published in 2013. This latest volume took some hard looks at some disorders and made changes to the ICD-10 coding as well as classifications and treatments. The APA published a set of Fact Sheets outlining changes made to the DSM.

According to the World Health Organization (WHO), a combination of abnormal thoughts, perceptions, behaviors, relationships with others, and emotions define the characteristics of mental health disorders. Treatment is less than desirable even for those who can afford it. Those who suffer from mental health disorders are usually among the low to middle income levels and are often untreated or undertreated. The WHO designed a Mental Health Action Plan 2013-2020 to develop evidence-based tools, guidance and training for professionals to improve the quality of care for mental health patients. 

Common mental health disorders

Among the more common disorders are anxiety, ADD/ADHD, Bipolar disorder, major depressive disorder, and Schizophrenia/Psychosis. Although they are not all clearly understood, they are all based in a complex neurobiological system of multiple brain pathways that have been disrupted. Comorbidities usually have a strong impact and can affect the risks of side effects of medications. For example, many of the medications used in the treatment of mental health disorders can affect blood sugar levels. A comorbidity of diabetes will cause problems in treatment of the mental health condition. Side effects of diabetic medications can also cause disorders such as depression. 

Depression is a major mental health issue. The WHO recognizes that over 300 million people worldwide are affected by depression. It has many different causes and varies in intensity as well as duration. Depression is most common in adults, but it can also occur in children. 

ADD/ADHD is characterized by the inability to focus and presents a pattern of inattention with or without the hyperactivity or impulsivity component. It affects children as well as adults. The DSM 5 revised some of the diagnostic criteria and encouraging looking back at presentation of symptoms in mid childhood when diagnosing adults.  The prescribing guidelines for children under six have been revised and strongly encourage weighing risks vs harm caused by delaying treatment. Part of the treatment plan for children involves Individual Education Programs (IEP) which reduce the need to medicate just to minimize classroom disruptions. 

Bipolar Disorder affects about 60 million people worldwide and was once known as manic depression due to the wild mood swings the illness can create. It currently has 4 classifications: 

  1. Bipolar disorder I (BDI) which is characterized by manic episodes lasting at least seven days which often require hospitalization to manage. These episodes are interspersed with depressive episodes that usually last at least 2 weeks.  
  2. Bipolar disorder II (BDII) typically presents with longer lasting depressive episodes. These are separated by at least four day long episodes of hypomania. Theses are less severe than the manic episodes and rarely ever require hospitalization. 
  3. Cyclothymic disorder/cyclothymia is a rapid cycling of manic episodes and depression
  4. Other Bipolar disorder symptoms that don’t match any of the above three categories. These are caused by other diseases such as Cushing’s disease, strokes or MS. They can also be caused by substance abuse.

Risk of bipolar disease is increased by having a first-degree relative with Bipolar disease, drug or excessive alcohol use or sudden traumatic or stressful life event. Onset is usually in the early 20’s. 

Schizophrenia/Psychosis affects approximately 20 million people worldwide. Onset is usually in late adolescence to early adulthood. Schizophrenia/psychosis is primarily characterized psychosis, and severe distortions of thinking, emotions, sense of self, language and behavior. There is a genetic predisposition and it often occurs if there was any injury during pregnancy or birth. It is manifested by symptoms such as hallucinations, delusions, movement disorders, disorganized thoughts or speech. More negative symptoms include loss of pleasure in everyday life, a flat affect, poor working memory and difficulties in focusing or paying attention. 

Medications used to treat mental illness

Typical medication categories for treating mental disorders include stimulants and non-stimulants used for ADD/ADHD. Antidepressants target three major neurotransmitters associated with serotonin, norepinephrine and dopamine. Some people cannot tolerate the selective serotonin reuptake in (SSRIs) and need alternatives such as Monoamine oxidase inhibitors (MAOIs) which impair the metabolism of serotonin.  They also block tyramine which helps regulate blood pressure.  Bipolar disorders typically utilize a combination or “cocktail” of medications such as mood stabilizers, antidepressants, and some antipsychotics designed specifically for Bipolar disorder. Anticonvulsant drugs may also be used for Bipolar disorders. Schizophrenia is best managed by a coordinated specialty care (CSC) system utilizing social workers, case managers, family, along with pharmacological approach with newer antipsychotic medications.

The goal for all is improved quality of life through therapy, medication compliance, and symptom management. Nurses providing care and prescribing medications need to be astute in such factors as familial history, comorbidity and management, past medication history and ability to comply with medications. When more nurses understand and can educate patients and family that these disorders are physical illnesses and not behaviors, more progress towards goals will be made.

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