After you have successfully completed this chapter, you should be able to:
■ Describe the various theories in understanding mental health/illness
■ Describe developmental influences on mental health/illness
■ Discuss various cultural influences on mental health/illness
■ Identify history data as they relate to mental health/illness
■ Identify physical assessment data as they relate to mental
■ Describe additional assessment components specific to mental health/illness assessment
■ Perform a mental health assessment
■ Document assessment findings
■ Identify actual/potential health problems stated as nursing diagnoses with supporting data
A biological risk factor could be a family history of mental illness with a genetic link such as
schizophrenia.A person’s developmental level may be psychosocial risk factor. External stressors are examples
of environmental factors.
Assessment entails not only identifying your client’s weaknesses but also identifying his or her strengths. So, you need to assess not only for risk factors but also for
protective factors, such as coping mechanisms andresources.
Mental health is a “state of successful performance of mental function, resulting in productive activities,fulfilling relationships with other people, and the ability to adapt to change and to cope withadversity”(Healthy People 2010).Jahoda (1958) identified six characteristics of positive mental health that address positive self-perception, personality integration, autonomy and independence,perception and reality,and growth and development leading to self-actualization. Mental
health or wellness affects every aspect of one’s life, and the impact of this can be seen when mental illness occurs.The effects are not only mental but also physical.
Current research is providing more and more evidence that there are organic and neurochemical bases for some mental illnesses and behaviors. Be sure to review
the anatomy and physiology section in Chapter 21, Assessing the Sensory-Neurological System. Genetic links have been identified for certain braindisorders such as schizophrenia. Although schizophrenia, depression, bipolar disorder, anxiety disorders, and Alzheimer’s are classified as mental illnesses, biological bases have been identified. Biochemical factors, specifically neurotransmitters, have been identified in depression and mania (Fig.5.1).Another part of the brain is the limbic system,which is called the emotional brain and is associated with fear, rage, love, anger, aggression, hope, sexuality, and social behavior (Fig. 5.2).
Biological Basis of Mental Illness
Understanding Mental Disorders
Mental disorders affect thinking, mood, or behavior or a combination of all three, leading to impaired function, disability, pain, and even death.The term mental illness is applied to diagnosable mental disorders. All age groups, gender, racial, and ethnic groups are ffected regardless of education or socioeconomic evel.A goal of Healthy People 2010 is “to improve mental ealth and ensure access to appropriate, quality ental health services.”As a nurse, you are well positioned to assess the mental health status of your atients at every level of health prevention and in very area of healthcare.
Primary prevention entails decreasing the incidence f mental disorders by identifying those at risk, those ho are vulnerable to developing mental disorders.
Secondary prevention involves reducing theprevalence of mental disorders through screening andinitiating prompt treatment of mental disorders.
Tertiary prevention aims at reducing the severity ofthe illness by providing follow-up and rehabilitativeservices.
Cognitive theories provide an understanding by looking ot only at behavior but also at an individual’s cognitions and howa person processes thoughts (distorted
cognitions and maladaptive behaviors). Bandura and Back are cognitive theorists. Cognitive theory is of value when teaching patients new coping skills; individual
collaboration with the therapist and active involvement of the patient are needed for change to take place
Developmental theories provide an understanding of the individual’s growth and development over one’s lifetime. Erikson, Piaget,Gilligan, and Miller are developmental theorists.
Developmental, Cultural, and
Psychodynamic theories focus on intrapersonal concepts. These theories look at the development of themind over the course of a lifetime. Freud, the “Father of
Psychiatry,” introduced the psychoanalytic model of the conscious and unconscious mind.Various interpersonal and humanist models followed. Freud identified defense mechanisms, which served to protect the individual from unwanted anxiety.
Behavioral theories focus on normal behaviors rather than the causes of mental illness. Pavlov, Watson, Thorndike, and Skinner are behavioral theorists. The goal is to change behavior through conditioning, behaviorism (which includes frequency and recency), and positive reinforcement (Boyd, 2005).
Social theories include family dynamics, role theories, and sociocultural perspectives; thus, the assessment of
Mental disorders can occur with any age group,with the incidence of certain disorders higher for specific age groups. For example, learning and behavioral problems are seen with children. Adolescents, known risk takers, have a high incidence of substance abuse. Bipolar illness or psychoses such as schizophrenia more commonly become apparent during young adulthood. Depression is often seen in the older adult.
Because rapid growth and developmental changes occur during childhood, delays are readily detectable. Learning disorders and behavioral disorders often become apparent by the time the child reaches school age.
Mental Health Assessment for Children
Assessing the mental health of children should include both a detailed history and a physical examination.The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents or caregiver present.
The health history should include a family history with attention to a history of mental health problems. A maternal history is also needed and should identify:
■ Age and health of mother during pregnancy.
■ Exposure to medications, alcohol or drugs during
■ Course of labor and type of delivery.
■ Infant’s state of health at birth.
Assess the child’s normal growth and development milestones, such as motor development, bowel and bladder control, speech and language development, and social development. Also, assess the child’s medical health, noting any major illness or injury.
The assessment should also include a current developmental assessment, a mental status examination, and a physical examination. Various instruments are available to assess a variety of mental health disorders in children. Be sure to select the one best suited to meet the child’s
Scales for Mental Health Disorders
Child abuse affects all areas of a child’s life and may manifest as a mental or physical disorder. Child abuse takes many forms from physical abuse, neglect, sexual abuse, emotional abuse, factitious disorders by proxy (Munchausen syndrome), and secondary abuse (children of battered women). The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents
or caregiver present.
Adolescents are known risk takers. Experimenting with drug and alcohol is common, and suicide is the second leading cause of death among adolescents. Mental and substance abuse disorders or a combination of disorders are more often than not associated with suicide. A goal of
Healthy People 2010 is to decrease the attempted suicide rate among adolescents from a 12-month average of 2.6 percent of adolescents in grades 9 through 12, to a 12- month average of 1 percent.
Another popular form of risk taking during childhood is the choking game,which produces a high or a state of euphoria by cutting off the blood supply to the brain. If the blood supply is compromised for too long, the child will pass out and feel a “rush” as consciousness returns. Depriving the brain of oxygen may result in permanent and cumulative death to brain cells, stroke, seizures, retinal damage, or death.
This behavior, which is also known as fainting, American dream, flatliner, space cowboy, knockout, gasp, rising sun, airplaning, pass out,blackout, andspace monkey, is most common among children ages 10 through 16. It can be performed either alone or with others.
Use of ligatures and performing this alone increases the risk of death.
Approach to the Mental Assessment
Children who “play” the choking game are usually not troubled children and generally have no history
of drug or alcohol abuse.
• Learning disorders and behavioral disorders often
become apparent by the time the child reaches
• Depending on the age of the child, play or drawing
can be very helpful in eliciting the child’s perceptions.
Behavior Assessment System for Children (BASC)
Child Behavior Checklist (CBCL)
Children’s Depression Inventory (CDI)
Pediatric Anxiety Rating Scale (PARS)
Yale-Brown Obsessive Compulsive Scale (YBOCS)
Swanson, Nolan, Pelham (SNAP)-IV
Behavior and emotions for children ages 2–18
Psychopathology and competencies for children ages 4–16
Physical symptoms, harm avoidance, social anxiety, and
separation/panic disorders for children ages 7–17
Severity of anxiety for children ages 6–17
Obsessive compulsive disorder (OCD) for children ages 6–17
Inattention and overactivity (attention deficit hyperactivity disorder [ADHD]) and oppositional defiant disorders
from Boyd, M.A. (2005). Psychiatric Nursing Contemporary Practice.
Risk Factors for Teen Suicide
■ Social isolation
■ History of abuse
■ Drug and alcohol abuse
■ Not fitting in with peers
■ School pressure
Source: Gorman, L., Raines, M., and Sultan, D. (2005). Psychosocial
Nursing for General Patient Care, ed. 2.
Signs and Symptoms of the Choking Game
■ Unexplained marks or bruises on neck
■ Severe headaches
■ Red eyes
■ Belts, leashes, ropes, and shoelaces tied in strange
knots or in unusual locations
■ Disorientation after being alone
■ Locked bedroom doors
Although the birth of child is seen as a happy event, mental health disorders can occur, affecting not only the mother but also the entire family.Many mothers experience mild depression, also known as baby blues, usually within 4 weeks following childbirth. If the baby bluespersist for more than a few weeks, postpartum depression may have developed. The depression is more serious and results in postpartum depression with or without
psychosis.The mother may experience severe mood swings and pervasive sadness.The mother often has feelings of guilt and inadequacy as a mother. In addition to the feelings associated with postpartum depression, with postpartum psychosis, the mother experiences delusions and thoughts of harming herself or her baby. If you detect at-risk mothers or postpartum depression,be sure to make the appropriate referrals for followup care.Assessment for postpartum depression is important. Screening tools for postpartum depression include the Postpartum Check List (Beck, 1995) and the Edinburgh Postpartum Depression Scale (Cox,Holden,& Sagovsky, 1989).
Older adults are more at risk for the development of mental health problems for several reasons, ranging from the normal physiological changes associated with aging to acute and chronic illness to side effects associated with polypharmacy. Risk factors may be developmental, situational, internal, or external in nature.
Mental Health Assessment of the Older Adult
Approximately 25 percent of all older adults experience some type of mental disorder (depression, anxiety, substance abuse,and dementia) that is not related to the normal changes associated with aging (Healthy People2010). Alzheimer’s affects 8 percent to 15 percent of older adults over the age of 65 and accounts for 69 percentto 70 percent of all dementia (Healthy People 2010). Assessing the mental health of the older adult shouldinclude both a detailed history and a physical examination. The assessment should focus on mental status,behavioral responses, functional ability, general health,
and social supports of the client. Mental status assessment should include a Mini-Mental State Examination (MMSE), a mental status examination, and assessment for depression, anxiety, and psychosis.A change in mental status has to be carefully evaluated. Changes are often attributed to normal
changes associated with aging. Changes in mental status may be physiological or psychological in nature. Because dementia increases with age, care must betaken to differentiate dementia from delirium and depression.
Risk Factors for Postpartum Depression
■ History of mood disorders
■ Low self-esteem
■ Unwanted pregnancy
■ Unemployment of mother or head of household
■ Poor marital relationship
■ Father depressed
■ Poor support systems
■ External stressors
■ Physical changes associated with aging that may affect functional ability
■ Cognitive changes and memory loss
■ Chronic medical illness
■ Psychosocial changes, such as retirement, that occur with aging
■ Limited financial resources
■ Loss and bereavement
■ Loss of social supports
Delirium should be treated as an emergency because its acute onset may have an underlying life-threatening cause. The MMSE and the Clock Scoring Test are screening instruments used to assess cognitive impairment and screen for dementia.
Assessment of behavioral responses includes description of behavior and triggers, with special attention to behavioral changes and problem behaviors. A functional assessment should focus on the client’s ability to perform activities of daily living, physiological functioning,
mobility, and risk for fall assessment. A nutritional assessment and history of substance abuse is included in the assessment of the client’s general
health. Finally, the assessment should identify social supports, family-patient interactions, and caregiver concerns.
Depression is a major mental health problem for older
adults, but it can be easily missed. If left untreated, depression can lead to
suicide or self-neglect. In the
Elder abuse, if taking place, affects all areas of the patient’s life and may manifest as a mental or physical disorder.
Elder abuse can take many forms: physical abuse, neglect, sexual abuse, emotional abuse, and financial
Approach to the Mental Assesment
Characteristics of Dementia, Delirium, and Depression
FEATURE DEMENTIA DELIRIUM DEPRESSION
Abrupt (hours to a few
Worse in P.M.
Impaired recent and
Caused by acute illness,
Gradual (months to years)
Impaired recent and remote
Caused by many diseases,
syndrome (AIDS), cerebral
anoxia, and brain infarcts
Possibly worse in A.M.
May coincide with life
event, such as death in
the family, loss of a
friend or a pet, or a
Risk Factors for Suicide Among Older Adults
■ Lives alone
■ Lack of financial resources
■ Poor health
■ Social isolation
■ Drug and alcohol abuse
Geriatric Depression Scale
Are you basically satisfied with your life? YES/NO
Have you dropped many of your activities and interests?
Do you feel that your life is empty? YES/NO
Do you often get bored? YES/NO
Are you in good spirits most of the time? YES/NO
Are you afraid that something bad is going to happen to
Do you feel happy most of the time? YES/NO
Do you often feel helpless? YES/NO
Do you prefer to stay at home rather than going out and
doing new things? YES/NO
Do you feel you have more problems with memory than
Do you think it is wonderful to be alive now? YES/NO
Do you feel pretty worthless the way you are now?
Do you feel full of energy? YES/NO
Do you feel that your situation is hopeless? YES/NO
Do you think that most people are better off than you
Bold answers _ depression
12–15 Severe depression
8–11 Moderate depression
5–8 Mild depression
Source: Yesavage, et al., 1983, pp. 37–47.
GDS website: http://www.stanford.edu/~yesavage/
Cultural Perceptions of Mental Health/Illness
CULTURAL GROUP PRACTICES/BELIEFS
Signs and Symptoms of Depression in
the Older Adult
■ Changes in appetite
■ Decreased self-esteem
■ Changes in sleep patterns
■ Social withdrawal
■ Feelings of helplessness
■ Loss of motivation
■ Vague somatic complaints—such as constipation, joint pain, fatigue, and memory changes—that seem to be out of proportion to the actual
■ Client may become obsessed with the problems and feel that if the problems are relieved, she or he will be fine.Cultural and ethnic variations often influence a patient’s view of mental health. Cultural beliefs influence perceptions, understanding, and treatment of mental illness.
■ Children with mental or physical differences are seen as “hard learners.”
■ The mentally ill are generally cared for at home.
■ Usually takes care of own, so mentally deficient and handicapped are readily accepted.
■ Mentally handicapped are not crazy, but rather have “bad nerves” or are “quiet
turned” or “bad turned.”
■ Behaviors that would warrant psychiatric treatment are seen as lazy, mean,immoral, criminal, or psychic and treated by punishment or tolerance.
■ Mental illness is seen as a social stigma, therefore psychiatric symptoms may be denied, attributed to “bad nerves” or supernatural beings, or caused by a physical ailment or emotional trauma.
■ Somatic orientation leads to patients’ tolerance of emotional suffering and relatives’ tolerance of behavioral disorders.
■ Patients with mental distress will somatize symptoms. Somatic treatment for psychiatric disorders is preferred over psychotherapy.
■ Balance between yang and yin explains mental health/illness.
■ Mental illness results from metabolic imbalance and organic problem.
■ Stigma is associated with mental illness, so patient will seek folk healer first.
■ Does not readily seek treatment for emotional or nervous disorders.
■ Emotional crises are treated by santero, a practioner of santeria (a 300-year-old
Afro-Cuban religion that combines Roman Catholic elements with ancient Yoruba
tribal beliefs and practices).
■ May act out emotional problems in a non–threatening way, allowing person to
■ Mental illness is considered a stigma.
■ More tolerance for emotional problems.
■ View mental health problems with a supernatural framework, including “curse”
■ Emotional problems of grief and losses are due to wrongdoings of others or
weakness and inability to control and snap out of distress.
■ Mental and emotional issues are expressed somatically so therefore treated with
■ Seeks family and friends for advice.
■ Stigma is associated with mental illness.
■ Mental illness is caused by heredity.
■ Takes care of mentally ill family member rather than seek mental
■ Federal Canadian laws protect the mentally disabled from discrimination.
■ Stigma is associated with mental illness.
■ Mental illness is seen as hereditary linked, therefore “polluting” the blood line,
bringing shame to family.
■ Families of mentally ill may experience loss of friends and social isolation.
■ Mental illness often somatisized. Wide range of acceptable behavior leads to delay
of seeking treatment.
■ Folk model for “nerva” (nerves) is socially acceptable and treated with medication
rather than with psychotherapy.
■ Stigma is associated with mental illness.
■ Mental illness is caused by genetic problem; more likely to be labeled a
■ Avoids psychotherapeutic treatment.
■ Symptoms somatasized and treated with psychopharmacology.
■ High rate of mental illness.
■ Difficulty expressing emotions and feelings.
■ Family may take care of mentally ill family member.
■ Some attribute mental illness to sin and guilt.
■ Mental health is as important as physical health.
■ Mental incapacity relinquishes one from all responsibilities.
■ Mental illness is seen as God’s will.
■ Family prefers to care for patient at home.
■ Mental illness is caused by witches; treated by healers.
■ May wear turquoise to ward off evil.
■ Some tribes view mentally ill as having special problems.
■ Mental illness results from offending a deity.
■ Brings disgrace to family and is therefore concealed, which delays treatment.
■ Emotional disturbances are caused by malicious spirits, bad luck, or family
■ Buddhists see mental illness as bad karma from previous misdeeds.
■ Sometimes nervous system is seen as cause of mental problems.
A thorough assessment includes assessment of the psychological health of the patient.Mental health reflects aperson’s positive attitudes toward self, growth and development,self-actualization, integration, autonomy, reality perception, and environmental mastery (Stuart & Laraia,
2005). As you perform your assessment, look for clues that reflect the mental health status of your patient. Realize that your patient may prefer to have you believe she or he has a physical problem rather than a psychological problem by somatizing feelings. Also,medical problems or drug use (prescribed, over-the-counter[OTC], illegal) may present as mental disorders, such as hyperthyroidism, which may produce signs and symptoms
of anxiety. Comorbidities can also result with patients. Chronic illness can lead to depression, especially as the disease progresses.
Report any suspected abuse or any threat of child or elder abuse. Also report threats of suicide orhomicide. Threats to self or others must always be taken seriously.
When obtaining a health history, ask yourself,“What can the health history reveal about the mental health of thepatient?” Identify factors that may affect mental health in either a positive or a negative way. Ensure patient confidentiality, but confidentiality should be breached if there is suspected abuse or a threat of child or elder abuse or if the patient poses a threat to herself or himself or others.
Health History as It Relates to Mental Health
QUESTIONS TO ASK RATIONALE/SIGNIFICANCE
■ Response to stressors differs with age.
■ Identifies possible maturational crises related to
■ Women have greater incidence of depression and
affective and anxiety disorders.
■ Men have greater incidence of psychosocial and
substance abuse disorders.
■ Age of onset of schizophrenia occurs later in
women than in men.
■ Men are more likely to be aggressive and selfdestructive
■ The higher the socioeconomic and
educational level, the lower the incidence of
■ The higher the educational level, the more likely
the individual is to use mental health services if
■ The lower the income, the higher the incidence of
■ African Americans and Hispanics have twice the rate of
being diagnosed with severe mental illness than other
■ African Americans are diagnosed with the most
severe types of psychopathology and fewer affective
disorders and are overdiagnosed with schizophrenia.
■ Ethnic groups have three times more
hospitalizations for mental illness than the general
■ Married and partnered adults report less stress
than single or divorced adults.
■ Can affect mental health in either a positive or a
■ Influences perceptions of mental illness.
■ Identifies supports.
■ Identifies any signs or symptoms that may reflect
■ Identify any past mental health problems and
■ Identifies previous psychiatric hospitalization.
■ Identifies familial/genetically linked psychiatric
disorders. Familial/genetically linked disorders
■ Bipolar disorders.
■ Anxiety and panic disorders.
■ Identifies any psychiatric drugs.
■ Identifies any possible drug interactions.
■ OTC medications such as pseudoephedrine can
cause anxiety symptoms.
Herbal supplements such as
ephedra, ginseng, kava kava, and yohimbe can
interact with psychotrophics or other
medications, or cause anxiety, drowsiness, or
other adverse psychological effects (Pedersen,
2005). (See Psychotropic Drugs and Some
Related Side Effects.)
■ Identifies possible source of stressor related to
post-traumatic stress syndrome
■ How old are you?
■ Is the patient male or female?
Socioeconomic and Educational Levels
■ What is your educational level?
■ What is the patient’s cultural background?
■ Are you single, married, or divorced?
■ What is your religious affiliation?
■ Who is your contact person?
Current Health Status
■ How is your health?
Past Health History
■ Did you have any major health problems
(physical or mental) while growing up?
■ Have you ever been hospitalized for mental
■ Does anyone in your family have mental health
■ Are you taking any medications, either
prescribed, OTC, or herbal? If yes, what are you
taking? (See Drugs That May Adversely Affect
■ Are you now or did you ever serve in the military?
If yes, when and what was your tour of duty?
General Health Survey
■ How have you been feeling?
■ Do you have any problems with your skin? If yes,
Head, Eyes, Ears, Nose, and Throat (HEENT)
■ Do you have headaches? If yes, describe.
■ Do you have thyroid disease?
■ Do you have any breathing problems? If yes, describe.
■ Do you have any CV problems? If yes, describe.
■ Fatigue may be associated with depression.
■ Restlessness may be associated with anxiety.
■ Sweating, itching associated with anxiety
■ Headaches associated with depression.
■ History of migraines and tension headaches
affected by psychological factors.
■ History of hyperthyroidism and diabetes can be
affected by psychological factors, manifest with
psychological signs or symptoms, or mimic
■ History of breathing problems, such as
hyperventilation, associated with anxiety disorders.
Sighing associated with depression.
■ Hypertension, angina affected by psychological
■ Palpitations, racing heart associated with anxiety
■ Heterocyclic antidepressants—use with caution with
Drugs That May Adversely Affect Mental Health
■ Beta blockers
Cancer chemotherapeutic agents
■ Amphetamine or cocaine withdrawal
Corticosteroids Manic states
Tricyclic antidepressants (TCAs)
Amphetamines Psychotic reactions
Antidepressants (particularly tricyclics)
Anticonvulsants (carbamazepine, valproic acid)
Antivirals (acyclovir, amantadine)
Beta blockers (propranalol)
H2-receptor blockers (cimetidine)
Antibiotics (cephalosporins, ciprofloxacin, sulfonamides)
Opioids (morphine, hydromorphone)
Lithium Nausea, diarrhea, polyuria, acne, rashes, alopecia, tremors; weight
gain, hypothyroidism; can also precipitate psoriasis and psoriatic
Anticonvulsants Sedation, hepatotoxicity, rash, and Stevens-Johnson syndrome (SJS),
which is a life-threatening mucocutaneous reaction.
Anticholinergics Blurred vision, constipation, dry mouth
TCAs Sedation, blurred vision, dry mouth, constipation, life-threatening
arrhythmias and electrocardiogram (ECG) changes
Selective serotonin reuptake inhibitors Gastrointestinal (GI) symptoms, insomnia, and agitation
Antipsychotics Movement disorders (akathisia) and tardive dyskinesia (especially
conventional antipsychotics [chlorpromazine]), dystonia,
parkinsonism, gynecomastia, and lactation, and possibly treatmentemergent
A L E R T
Neuroleptic malignant syndrome (NMS) is a potentially fatal side effect from antipsychotic drugs, characterized by fever, tachycardia, sweating, muscle rigidity, tremors, incontinence, stupor, leukocytosis, elevated creatine phosphokinase (CPK), and renal failure
Review of Systems
As you proceed with the review of systems, note
any problems that may affect your patient’s mental
Review of Systems
Psychotropic Drugs and Some Related Side Effects
C H A P T E R 5 A P P R OA C H TO T H E M E N T A L H E A L T H A S S E S S M E N T 125
CATEGORY/QUESTIONS TO ASK RATIONALE/SIGNIFICANCE
Health Practices and Beliefs
■ How would you describe your mental health?
■ Do you or would you use mental health services?
■ Can you tell me what your typical day is like?
■ Can you tell me what you ate yesterday (24-hour
Activity and Exercise Patterns
■ Do you exercise regularly? If yes, describe.
Recreation, Pets, Hobbies
■ What do you do for fun?
■ Do you have pets?
■ Do you have hobbies?
■ How many hours of sleep do you get a night?
■ Do you have any problems falling asleep, staying asleep?
■ Do you take or do anything to help you sleep?
■ Do you use alcohol, drugs, caffeine, or nicotine? If, yes,
Occupational Health Occupation?
■ How do you feel about your work? Your coworkers?
■ Do you find your work stressful? If yes, how do you
deal with it?
■ Are there any health risks associated with your work? If
■ Where do you live?
■ Are you exposed to any pollutants or toxins?
Roles, Relationships, Self-Concept
■ How do you see yourself?
■ Can you identify your various roles and relationships?
■ What is your cultural background?
■ What influences your perception of health?
■ What is your religious background?
■ What influence does your religious beliefs have on your
perception of health?
■ Identify perceptions of mental health, mental health
practices, and use of mental health services.
■ Identifies ability to maintain activities of daily living
(ADLs). Mental health problems such as depression and
schizophrenia, compulsive disorders may affect ability
to perform ADLs.
■ Nutritional disorders are associated with eating
disorders, anxiety, and depression.
■ Excessive exercise is associated with eating disorders.
■ Inactivity is associated with depression.
■ Inactivity is associated with depression.
■ Problems with sleep and rest are associated with many
psychological disorders, such as anxiety, depression,
bipolar disorders, and substance abuse.
■ Identifies history of substance abuse (use of alcohol,
drugs, caffeine, nicotine).
■ Identify ability to maintain job. Work can be a source of
■ Identify risk for head injury, such as construction work
■ Identifies risk for exposure to toxic substances, such as
lead, mercury, herbicides, solvents, cleaning agents, and
lawn chemicals, that can affect cognitive ability.
■ Identifies sense of worth and value, which may be
affected by psychological factors such as low self-image
associated with depression and eating disorders.
■ Roles and relationships may affect or be affected by
■ Identifies culture’s perception of mental health and
■ Identifies religious/spiritual influences on mental health
■ Do you have any GI problems? If yes, describe.
■ Have you experienced changes in weight? If yes,
■ Have you experienced changes in appetite? If yes,
■ Do you have any GU problems? If yes, describe.
■ If your patient is female, ask if she has experienced any
irregularities in her menstrual cycle.
■ Do you have any concerns about your sexual
performance? If yes, describe.
■ Do you have any MS problems? If yes, describe.
■ Do you have any neurological disorders?
■ Have you experienced seizures, concentration, or
■ Have you experienced depression, anxiety? If yes,
■ Changes in appetite associated with depression,
anxiety, eating disorders, substance abuse
■ History of peptic ulcer, irritable bowel syndrome,
colitis affected by psychological factors
■ GI complaints such as nausea, abdominal pain,
diarrhea seen with anxiety
■ Indigestion and constipation seen with depression
■ Nausea is a common side effect of many
■ History of sexual dysfunction, such as impotence,
frigidity, and premenstrual syndrome (PMS),
affected by psychological factors
■ Menstrual irregularities associated with eating
■ Pressure and frequency of urination associated with
■ Use TCAs (amitriptyline), cautiously with benign
prostatic hyperplasia (BPH)
■ History of rheumatoid arthritis and idiopathic low
back pain affected by psychological factors
■ Weakness associated with anxiety
■ Osteoporosis associated with eating disorders
■ Use of antipsychotics contraindicated with
■ Seizures associated with eating disorders, use TCAs
cautiously with seizures and buproprion is
contraindicated with seizures.
■ Neuroleptic malignant syndrome and movement
disorders are a side effect of antipsychotic
■ Cognitive problems, difficulty focusing, inability to
concentrate associated with anxiety, depression,
dementia, and schizophrenia
Family Roles and Relationships
■ What is your role in your family?
■ How is your relationship with your family?
■ Do you have any concerns about sexual patterns? If yes,
■ Do you practice safe sex?
Stress and Coping Patterns
■ How do you deal with stress?
■ What do you do when you are upset?
■ Identifies sources of support or stress on patient’s
■ Mental illness may affect patient’s role and relationship
■ Sexual problems are often associated with mental
illness such as depression.
■ Unprotected sexual activity is associated with substance
■ Identifies current coping skills.
■ Determines effectiveness of coping skills.
As you perform the psychosocial assessment, look for clues that would reflect your patient’s mental health.
Mental Status Assessment
A mental status assessment, involving a systematic approach to various components, is done to assess and evaluate a patient’s cognitive and mental functions. Each assessment provides information about that patient atthat point in time. (See Mental Status Assessment as it
Relates to Mental Health/Illness.) Additional assessments will demonstrate improvement, regression, or stabilization and will provide a “progress report” as well as “patterns” of functioning. The components of the mental status assessment include:
■ General appearance.
■ Speech and language.
■ Mood and affect.
■ Thought process and content.
■ Perceptual disturbances.
■ Judgment and insight.
Depending of your assessment findings, additional mental health screening may be indicated.Various mental health problems and assessment instruments are available to assess for a variety of mental health problems. Additional mental health assessments are presented below.
Psychosocial Profile (continued)
As you perform a head-to-toe physical examination, consider how your patient’s physical findings reflect his or her mental health.
ead-to-Toe Physical Examination as It Relates to Mental Health/Illness
SYSTEM ABNORMAL FINDINGS/RATIONALE
General Health Survey ■ Poor grooming and personal hygiene: Associated with depression
■ Bright colors or unusual dress: Associated with mania
■ Poor eye contact: May indicate depression
■ Inability to maintain attention: Associated with schizophrenia and depression
■ Labile affect: May reflect mania
■ Flat, incongruent affect: May reflect schizophrenia
■ Stooped posture: Associated with depression
■ Restlessness, tension: Associated with anxiety
■ Malnourished appearance: May indicate an eating disorder
■ Slurred speech: May indicate drug and alcohol abuse
■ Pressured speech: Seen with mania
■ Disorganized speech: Seen with schizophrenia
■ Irritability: Associated with anxiety
■ Suspiciousness: Associated with paranoia
Integumentary ■ Flushed or pallid skin color: Seen with anxiety
■ Excessive sweating: Seen with anxiety
■ Injury or scarring: From self-injury or past suicide attempts or self-mutilation
HEENT ■ Dilated or constricted pupils: Seen with drug abuse
■ Poor eye contact: Seen with depression
■ Dental caries, parotid swelling: Seen with eating disorders
■ Erosion of nasal or oral mucosa: May be secondary to drug use
■ Rope marks on neck: In children, associated with “choking game”
Respiratory ■ Increased respiratory rate and hyperventilation: Seen with anxiety
Cardiovascular ■ Increased pulse rate and blood pressure: Seen with anxiety
Abdominal ■ Increased bowel sounds: Seen with excessive use of laxatives in eating
■ Abnormal liver size: Associated with substance abuse
Musculoskeletal ■ Generalized weakness and tremors: Seen with anxiety
■ Abnormal muscle movement: May be adverse effect of psychotropic drugs
■ Excessive body movements: Associated with anxiety, mania, or stimulant
■ Minimal or no body movement: Associated with depression, catatonic states, or
■ Repeated movements: Associated with compulsive disorders
■ Repeated picking at clothes: May be associated with hallucinations, delirium, or toxic
Neurological ■ Cognitive changes, thought process disorders: Seen with schizophrenia
■ Loose association: Associated with schizophrenia
■ Flight of ideas: Associated with mania
■ Preservation: Associated with brain damage and psychotic disorders
■ Auditory hallucinations: Associated with schizophrenia
■ Visual hallucinations: Often organic in nature
■ Tactile hallucinations: Seen with organic problems, drug abuse, or delirium tremens
■ Changes in mental status: Seen with mental illness such as schizophrenia, substance
abuse, bipolar disorder
■ Increased reflexes: Seen with anxiety
■ Movement disorders: Adverse effect associated with antipsychotic medications
tal Status Assessment as It Relates to Mental Health/Illness
AREA/QUESTIONS ABNORMAL TO ASK
■ Does the patient dress appropriate for age, gender,season, and situation?
■ Are the patient and his or her clothing clean?
■ Does the patient present with any unusual odors?
■ Does the patient maintain eye contact?
■ Does the patient assume a specific position?
■ Is posture erect?
■ Are there any obvious marks or scars?
Appearance vs. Stated Age
■ Does the patient appear stated age, or younger or older?
■ Do you notice any unusual activity?
■ Is patient’s behavior appropriate for the situation?
■ What is the patient’s level of consciousness?
■ Dress neat and appropriate
■ Clean, no unusual odors
■ Maintains eye contact
■ Comfortably positioned, posture erect
■ No obvious marks or scars
■ Appears stated age
■ Calm, relaxed, no unusual behavior or movements
■ AAO _ 3 (awake, alert, and oriented to time, place,person)
■ Disheveled appearance: Associated with depression
■ Bright-colored clothing: Associated with mania
■ Poor hygiene: Associated with depression or schizophrenia
■ Poor eye contact: Associated with depression
■ Slumped posture: Associated with depression
■ Defensive posture: Associated with paranoia
■ Scars: May indicate self-mutilation or past suicide attempts
■ Older appearance than stated age: May be associated with depression
■ Hyperactivity: Associated with anxiety,mania, or stimulant abuse
■ Hypoactivity: Lethargic, thinking slowed; associated with depression, alcohol or drug abuse.
■ Altered orientation: May be seen with organic disorders or schizophrenia
■ Agitation: May be seen with dementia or delirium
■ Psychomotor retardation, slow movements: May be associated with depression
■ Tremors: May indicate drug/alcohol withdrawal
■ Tics: May be an adverse effect of psychotropic medications
■ Unusual movements such as jaw/lip smacking: May be associated with tardive dyskinesia, an adverse effect of antipsychotic medications
■ Catatonia: May be seen with schizophrenia
■ Akathisia (restlessness): Seen with extrapyramidal adverse effect from antipsychotic medications
■ Rigidity: May be a sign of NMS
■ What are the quality, tone,
volume, fluency, and pace of
■ What is the patient’s attitude? Is it friendly? Hostile?
Mood (Including Self-Report of Emotional State)
■ How does patient appear?
■ How does the patient describe
her or his mood?
Affect (Apparent Emotional
■ What is the patient’s affect facial expression)?
■ Can you follow the patient’s thinking? Is it coherent and logical?
■ Quality and pace of speech normal with no exaggeration
■ Fluent, pleasant tone
■ Appropriate for situation
■ Appropriate for situation
■ Thought process intact
■ Responds appropriately
■ Slow speech: Associated with depression
■ Rapid and pressured speech: Associated with mania
■ Mumbling: Seen with Huntington’s chorea
■ Slurred speech: Seen with alcohol intoxication
■ Suspicious tone: Associated with paranoia
■ Volume: Soft associated with depression
■ Poor fluency (mute/hesitation/latency of response): Less likely to talk with depression
■ Hesitancy: Seen with mistrust or paranoia
■ Uncooperative: Associated with paranoia
■ Warm/friendly/distant: Seen with personality disorders
■ Suspicious/combative: Seen with paranoia
■ Guarded/aggressive: Seen with psychosis
■ Hostile/aloof: Seen with psychosis
■ Apathetic: Seen with depression
■ Sad: Associated with depression
■ Elated: Associated with mania
■ Irritable/anxious: Associated with anxiety
■ Fearful/guilty: Seen with phobias
■ Worried/angry: Seen with personality disorder
■ Hopeless: Associated with depression
■ Labile: Associated with mania
■ Mixed (anxious and depressed): Seen with depression
■ Flat affect: Seen with schizophrenia
■ Blunted or diminished affect: Seen with psychosis
■ Inappropriate/incongruent (sad and smiling or laughing): Associated with schizophrenia
■ Thought process disturbances: Often seen with psychosis or organic brain disorders.Examples of thought process disturbances
■ Concrete thinking: Unable to abstract; thinks in concrete terms
■ Circumstantiality: Excessive, irrelevant detail, but eventually gets to the point
l Status Assessment as It Relates to Mental Health/Illness (continued)
■ Does the patient’s content of thought make sense and seem reality based?
■ Does the patient have thoughts about hurting self or someone else?
■ Does the patient haveperceptual disturbances? Auditory disturbances? Visual
disturbances? Olfactory disturbances? Tactile disturbances?
■ Thought content (what the patient is thinking) reality based
■ No hallucinations, illusions, or depersonalization.
■ Tangentiality: Digresses from topic to topic, never getting to the point
■ Loose association: Loose connection between thoughts that are unrelated
■ Echolalia: Repetition of words spoken by another
■ Flight of ideas: Rapidly going from one topic to another
■ Preservation: Involuntary, excessive repetition of a single response to different questions
■ Clang association: Association of words by sound
■ Blocking: Draws a blank
■ Word salad: Combination of words that have no meaning
■ Derailment: Off track
■ Delusions (grandiose/persecution/reference/ somatic): Associated with psychosis
■ Suicidal/homicidal thoughts: Associated with depression, anxiety, or schizophrenia
■ Obsessions: Seen with OCD
■ Paranoia: Seen with schizophrenia
■ Phobias: Seen with anxiety disorders
■ Magical thinking (primitive form of thinking
that thinking about something will make it
■ Poverty of speech
■ Visual hallucinations: Often organic in nature
■ Auditory hallucinations (commenting/ discussing/commanding/loud/soft/other): Associated with schizophrenia
■ Tactile hallucinations: Seen with organic problems, drug abuse, or DTs
■ Illusions (misperception of a real external stimulus): Common with dementia of
Alzheimer’s and schizophrenia
A L E R T
If the patient is having homicidal thoughts, identify those toward whom those thoughts are directed.
■ Can patient repeat objects named minutes before?
■ Can patient recall anniversaries, past important, historical events?
Insight (Awareness of the Nature of Illness) and Judgment
■ Does patient have insight into his or her problem? (Ask, “Can you tell me what the problem is?”)
■ Is judgment appropriate? (Ask the patient to respond to a hypothetical situation, such as,
“If you were walking down the street and saw smoke coming from a window of a home, what would you do?”)
■ Immediate, recent, and remote memory intact
■ No confabulation
■ Insight and judgment intact and appropriate
■ Depersonalization (altered perception or experience that causes temporarily loss of self or personal identity): Seen with panic
■ Memory problems and confabulation: Seen with organic, dissociative, and conversion disorders
■ Level of alertness: Altered with substance abuse
■ Poor insight: Seen with psychosis
■ Poor judgment: Seen with psychosis
■ Poor impulse control: Seen with OCD, psychosis, mania
A crisis results from an acute event that stresses a person’s resources and ability to cope; a crisis can also result from a perceived threat to self. Crises may be maturational or developmental and situational. An example of amaturational crisis would be a child becoming an adolescent.
An example of a situational crisis might be the loss of a loved one. A situational crisis could also be a major disaster, such as a hurricane or a terrorist attack. An event that may be a crisis for one person may not be for another.A stressful event causes disequilibrium forthe person. It is the ability of the person to restore equilibrium that determines the outcome. Whether or not a person adapts to the crisis or not depends upon several
factors:perception of event,situational supports,and coping mechanisms.Once you have performed a crisis assessment,you can then develop interventions that will help your patient deal with the crisis and regain equilibrium.
When you have only limited time to perform an assessment, it is important to keep the interview focused.The BATHE technique helps the patient identify problems and coping strategies and is supportive of the patient.The acronym is representative of the interview’s components
(Stuart & Lieberman, 1993):
■ Background—What is going on? What brought you here?
■ Affect—How does this make you feel?
■ Trouble—What troubles you most in this situation?
■ Handling—How are you able to handle this situation/problem?
■ Empathy—Empathize with client, shows an understanding of client’s view of situation.
A L E R T
The BATHE technique is not intended for use with patients with severe problems, such as patients who are suicidal or those who have suffered severe abuse.
Perception of event
■ Can you tell me what has happened? Please be specific.
■ What caused the crisis?
■ How has this affected you?
■ How did this make you feel?
■ Is there anyone I can call?
■ Do you live alone?
■ Do you have family or friends who support you?
■ Are you active in any religious or community groups?
■ How have you handled stressful events in the past?
■ Can you talk about the stressful event?
■ What do you do to relieve tension? Cry? Talk? Exercise?Use alcohol?
■ Sleep (increase/decrease)
■ Interest (diminished)
■ Guilty/low self-esteem
■ Energy (poor/low)
■ Concentration (poor)
■ Appetite (increase/decrease)
■ Psychomotor (agitation/retardation)
■ Suicidal ideation
■ Past suicide of family member, close friend, or peer
■ Mood disorders
■ Substance abuse
■ Recent loss of a spouse, partner, friend, or job
■ Expressed hopelessness (patient sees no future)
■ Social isolation (patient lives alone, has few friends
■ Stressful life event
■ Previous or current abuse (emotional, physical, sexual)
■ Sexual identity crises/conflict
■ Available lethal methods (guns)
■ Legal issues/incarceration
A depressed mood plus four or more SIGECAPS for 2 weeks or longer indicates a major depressive disorder.A depressed mood plus three SIGECAPS most days for 2 years or longer indicates dysthymia, which is a depressive neurosis with no loss of contact with reality.
Depression poses a major health problem. Major
depression has been identified by the World Health Organization as the leading
cause of disability for adults in developed countries,such as the
those at risk and accurate assessment of depression can lead to prompt intervention and promotion of mental health.
If you suspect that your patient is depressed, use the mnemonic SIGECAPS to easily recall and review theDSM-IV criteria for major depression:
Symptoms of dysthymia are similar to those of a major depressive disorder, but milder.
A L E R T
Suicide attempts are more likely to occur as the patient’s symptoms improve because the patient now has the energy to commit suicide.
Feelings of hopelessness
Plan for suicide
Lack of support network
Alcohol or substance abuse
A key element in assessing for feelings of hopelessess is determining whether the patient is able to see a future with herself or himself in that future.
ASSESSMENT AREA QUESTIONS TO ASK
A L E R T
For many people, holidays can be a precipitating event to a suicidal episode.
■ Take note if the local media has reported on the suicide of a famous
person or local teenager.
Assessing Substance Abuse
Substance use includes use of prescribed or OTC drugs, alcohol, caffeine, nicotine, steroids, and illegal drugs.
Abuse and addiction exist when substance use has social,professional, or legal consequences.There are two types of substance abuse disorders, substance use disorders and substance-induced disorders.
Substance use disorders include:
■ Substance dependence: Repeated use despite substance-related cognitive, behavioral, and psychological problems.Tolerance,withdrawal,and compulsive drugtaking can result.
■ Substance abuse: Recurrent, persistent substance
use with significant adverse consequences during a 12-month period.
Substance-induced disorders include:
■ Substance intoxication: Overuse of a substance that
results in a reversible, substance-specific syndrome;can
be indicated by behavioral and psychological changes.
■ Substance withdrawal: Symptoms differ upon the
substances being used and develop upon their withdrawal
(Pederson, 2005;APA, 2000).
If substance abuse is a concern with your client, it is
important to ask the right questions and obtain an accurate
history. If there is no time to obtain a detailed assessment,a
focused assessment tool such as the CAGE questionnaire
can also identify a possible substance abuse problem.
Groups at Risk for Suicide
■ Elderly persons who are isolated or widowed or who have experienced multiple losses
■ Males who are widowed and without close supports
■ Adolescents and young adults
■ Persons with serious or terminal illness who become depressed or hopeless
■ Persons with mood disorders,depression,and bipolar
■ Persons with schizophrenia, either newly diagnosed or those experiencing auditory command hallucinations
■ Persons who abuse drugs or alcohol, especially persons with a mental disorder
■ Persons under stress (sometimes multiple stressors) with recent loss or losses
Performing a Suicide Assessment
Substance Abuse History and Assessment Tool
1. When you were growing up, did anyone in your family use substances (alcohol or drugs)? If yes, how did the substance
abuse affect the family?
2. When (how old) did you use your first substance (e.g., alcohol, cannabis) and what was it?
3. How long have you been using a substance(s) regularly? Weeks? Months? Years?
4. What is your pattern of abuse?
a. When do you use substances?
b. How much and how often do you use?
c. Where are you when you use substances and with whom?
5. When did you last use, what was it, and how much?
6. Has substance use caused you any problems with family, friends, job, school, the legal system, other? If yes, describe.
7. Have you ever had an injury or accident because of substance abuse? If yes, describe.
8. Have you ever been arrested for a DUI because of your drinking or other substance use?
9. Have you ever been arrested or placed in jail because of drugs or alcohol?
10. Have you ever experienced memory loss the morning after substance use (can’t remember what you did the night
before)? Describe the event and feelings about the situation.
11. Have you ever tried to stop your substance use? If yes, why were you not able to stop? Did you have any physical
symptoms such as shakiness, sweating, nausea, headaches, insomnia, or seizures?
12. Can you describe a typical day in your life?
13. Are there any changes you would like to make in your life? If so, what are they?
14. What plans or ideas do you have for making these changes?
15. History of withdrawal:
Source: Pedersen, D. (2005). PsychNotes.
Health Nursing, ed. 5.
■ Have you ever felt you should Cut down on your drinking/drug use?
■ Have people Annoyed you by criticizing your drinking/drug use?
■ Have you ever felt bad or Guilty about your drinking/drug use?
■ Have you ever had an Eye opener (use of alcohol or drugs first thing in the morning) to steady your nerves or get rid of
A positive (yes) response to two or more questions suggests that there is an alcohol/substance problem.
Note: The need to cut down is related to tolerance (needing more substance for same effect), and the eye
opener is related to withdrawal syndrome (reduction/cessation of substance).
Abused Substances: Effects From Use and Withdrawal
SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL
■ Alcohol (booze, brew, juice, spirits)
■ Sedatives, hypnotics, and anxiolytics, including barbiturates (barbs, beans,black beauties, blue angel, candy, downers,goof balls, BB,nebbies, reds,sleepers, yellowjackets, yellow)
■ Amphetamines(A, AMT, bam, bennies, crystal, diet pills, dolls, eye-openers, pep pills, purple hearts, speed, uppers, wakeups)
(Bernice, bernies, big C, blow, C, Charlie,coke, dust, girl,heaven, jay, lady, nose candy, nosepowder, snow,sugar, whitelady)
■ Crack (Conan, freebase, rock,toke, white cloud, whitetornado)
■ Respiratory depression
■ Cardiorespiratory depression
■ High temperature
■ Respiratory distress
■ Cardiovascular collapse
■ High temperature
■ Transient vasospasms (may cause myocardial infarction [MI], cerebrovascular accident[CVA], coma, death)
■ Depressed cognitive functioning
■ Impaired psychomotor functioning
■ Decreased reaction time
■ Decreased balance and coordination
■ Decreased REM sleep
■ Slurred speech
■ Labile mood
■ Inappropriate sexual behavior
■ Loss of inhibition
■ Impaired memory
■ High energy
■ Impaired judgment
■ Aggressive behavior
■ Sexual excitement
■ Impaired judgment
■ Nasal perforation
■ Increased pulse andblood pressure
■ Sleep disturbances
■ Hand tremor
■ Nausea and vomiting
■ Tinnitus (withbenzodiazepines)
■ Cardiac arrest
■ Vivid dreams followed by lethargy
■ Suicidal behavior
■ Cannabis (marijuana,hashish, Acapulco gold, Aunt Mary, broccoli, dope, grass, weed,grunt, hay, hemp,J, joint, joy stick, killer weed, pot, ragweed, reefer,smoke weed)
■ Heroin (H, horse, harry, boy, scag,shit, smack, stuff, white junk, whitestuff)
(LSD, DMT, Mescaline, acid, big D, blotter, blue heaven, cap, D, deeda, flash, L, mellow yellow, microdots, paper acid, sugar, ticket,
■ Club drug, MDMA (ectasy)
■ Phencyclidine (PCP, angel dust, DOA, dust,elephant, hog,peace pill,supergrass, tictac)
■ Extreme paranoia
■ Dilated pupils
■ Respiratory depression
■ Cardiopulmonary arrest
■ Psychosis with
■ Cerebral damage
■ Severe anxiety
■ High temperature
■ Respiratory arrest
■ Intensified perceptions
■ Impaired judgment and motor ability
■ Increased appetite, weight gain
■ Sinusitis and bronchitis with chronic use
■ Anxiety, paranoia
■ Red conjunctiva
■ Impaired judgment
■ Constricted pupils
■ Dilated pupils
■ Enhanced perceptions of colors and sound
■ Muscle relaxation
■ Impulsive behavior
■ Impaired judgment
■ Belligerent, violent behavior
■ Muscle rigidity
■ Muscle cramps
■ Nausea and vomiting
■ Feelings of panic and doom
■ Psychological dependence can causedepression, flashbacks
SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL
■ Gasoline, glue, aerosol sprays,paint thinners(spray, rush, bolt,huffing, bagging,sniffing)
■ Nicotine(Cigarettes, cigars, bidis, kreteks, pipe tobacco, chewing tobacco, snuff,nicotine gum or patches)
■ Psychosis withhallucinations
■ Cardiac arrhythmias
■ Central nervous system depression
■ Cerebral damage
■ Numbness or diminished response to pain
■ Impaired judgment
■ Blurred vision
■ Unsteady gait
■ Sense of anxiety reduction
■ Relief from depression
■ Poor concentration
■ Increased appetite
RESEARCH TELLS US
Worldwide,mental health problems,with depression and anxiety being the most frequent, occur in approximately 24 percent of patients in primary care (WHO, 2005).Mood disorders with increasing rates of depression and anxiety may be associated with physical illness. Deteriorating physical health and cognitive functioning that is often associated with aging is a major risk factor for developing depression later in life. The purpose of the following study was to examine staff contact and input with mental health problems and to determine their experience, training, and
attitudes to mental health problems.A cross-sectional design was used in the United Kingdom.A 40-item questionnaire was mailed to over 300 staff members in primary care.The return rate was 66 percent (n _ 217, 95 percent confidence interval,with two-thirdsof the respondents RNs).The questionnaire focused on depression in identifying mental problems, interventions,and mental health training.Demographics
were obtained to describe the sample.The Depression Attitude Questionnaire (DAQ), a 20-item instrument,was used to assess staff attitude toward depression. The findings reported that 16 percent of their patients had associated mental health problems,with dementia, depression, and anxiety being the most common.The staff reported a willingness to develop an understanding and skills needed to address mental
health problems with patients, but reported little training in the past 5 years that addressed this issue.
The staff, as revealed by the DAQ,was optimistic about treating depression. The study supports the need for mental health training in primary care as evidenced by the limited detection and treatment of mental health problems. The staff was willing and eager to develop the knowledgeand skills to assess and treat mental health problems. The areas identified included recognition of mental disorders, anxiety management, crisis intervention,
and pharmacologic treatment for depression. Although
this study was limited to the
of assessment and treatment of mental health problems would provide a holistic approach to meeting the patient’s needs.
Healthy People 2010 has identified specific objectives that address mental health/disorders.
Improving Mental Health
■ Improve mental health and ensure access to appropriate,
quality mental health services.
■ Reduce the suicide rate.Target: 5 per 100,000 from
11.3 per 100,000 in 1998.
■ Reduce the rate of suicide attempts by adolescents.
Target: 1 percent over 12 months from 2.6 percent
from grades 9 through 12 in 1999.
■ Reduce the proportion of homeless adults who
have serious mental illness.Target: 19 percent from
25 percent age 18 and older in 1996.
■ Increase the proportion of persons with serious mental
illness who are employed.Target:51 percent from
43 percent age 18 and older in 1994.
■ Reduce the relapse rates for persons with eating
■ Increase the number of persons seen in primary
healthcare who receive mental health screening
■ Increase the proportion of children with mental
health problems who receive treatment.
■ Increase the proportion of juvenile justice facilities
that screen new admissions for mental health problems.
■ Increase the proportion of adults with mental disorders
who receive treatment.
■ Increase the proportion of persons with cooccurring
substance abuse and mental disorders
who receive treatment for both disorders.
Improving State and Local Involvement
■ Increase the proportion of local government with
community-based jail diversion programs for adults
with serious mental illness.
■ Increase the number of states (including the
with the mental health services they receive.
■ Increase the number of states and territories
mental health plan that addresses cultural
■ Increase the number of states and territories
mental health plan that addresses mental
health crisis interventions, ongoing screening, and
treatment services for elderly persons.
sessment of Common Mental Health Problems
■ Diffuse feelings of apprehension with feelings of
■ Ranges from mild to panic state that can be paralyzing
■ On edge
■ Easily fatigued
■ Concentration problems
■ Sleep disturbances
■ Hot/cold flashes
■ Tightness of chest
■ Decrease appetite
■ Abdominal pain
■ Tremors, rigidity, spasms
■ Dilated pupils
■ Increased respirations
■ Wheezes due to bronchial spasms
■ Tachycardia, increased blood pressure
■ Increased reflexes
■ Muscle tension
■ Pacing, clumsy movements
■ Easily distracted
■ Short attention span
Anxiety differs from fear in that fear has an identifiablesource, anxiety may not.
■ Extreme, overwhelming anxiety in response to real or
perceived life-threatening situation
■ Can lead to phobias, avoidance, and agoraphobia
■ Unreasonable fear response to a specific object or
■ Causes anxiety
■ Person realizes fear is unreasonable
Social Anxiety Disorder
■ Fear of social or performance situations that may cause
■ Recurrent thought or ideas (obsession)
■ Action person cannot refrain from doing
■ Obsession and compulsion interfere with social and
■ Recognizes thoughts and behaviors are unreasonable
■ Traumatic event
■ Threat of harm or death, actual death, and helplessness
■ Re-experiences event (flashback)
■ Recurring nightmares
■ Anniversary reactions related to trauma
■ Persistent anxiety
■ Acute _ 3 mo, chronic _ 3 mo, delayed _ 6 mo
Acute Stress Disorder
Anxiety, dissociation, and other symptoms after exposure
to recent stressors
Anxiety Disorder related to Medical Condition
Generalized anxiety disorder
■ Excessive worry and anxiety for at least 6 mo
■ Difficult to control worry
Assessment of Common Mental Health Problems (continued)
■ Pattern of relating and perceiving the world that is
inflexible and maladaptive
Cluster A includes paranoid, schizoid, schizotypal
■ Paranoid: Distrustful and suspicious of others,
preoccupied with doubts of loyalty, holds grudges,
unwilling to forgive, quick to react and counter
■ Schizoid: Detached from social interaction, restricted
expression of emotions, lacks desire for intimacy,
■ Schizotypal: Social and interpersonal deficits, odd
beliefs or magical thinking, perceptual alterations, odd
or eccentric behavior
Cluster B includes antisocial, borderline, histrionic, and
narcissistic personality disorders
■ Antisocial behavior: Pattern of disregard and violation
of rights of others
■ Borderline: Unstable behavior with changes in
relationships, self-image, and mood
■ Histrionic: Excessive expression of emotion and
■ Narcissistic: Inflated sense of self, need for attention
and admiration, no concern for others
Cluster C includes avoidant, dependent, and obsessive
compulsive personality disorders
■ Avoidant: Avoids social interaction for fear of criticism
and feelings of inadequacy
■ Dependent: Needs to be taken care of, submissive, fear
of separation, low self-confidence, difficulty making
decisions and voicing disagreement
■ Obsessive compulsive: Rigid way of functioning,
excessive detail or controlling ways
■ Caused by neurobiological factors; influenced by social
and environmental factors
Four “A”s of Schizophrenia
■ Inappropriate Affect
■ Distrustful, emotionally detached, eccentric
■ Disregard for others, unstable and intense interpersonal
relationships, excessive attention seeking, entitlement
issues with lack of empathy for others
■ Avoider of social situations, clinging, submissive
personality; and person preoccupied with details, rules,
Borderline Personality Disorder
■ Pattern of unstable relationships
■ Fear of abandonment
■ Splitting: Idealize and devalue (love/hate)
■ Impulsive (in two areas: sex, substance abuse, binge
eating, reckless driving)
■ Suicidal gestures/self-mutilation
■ Intense mood changes lasting a few hours
■ Chronic emptiness
■ Intense anger
■ Transient paranoid ideation
Positive Symptoms _ Excessive function/distortion inbehavior
■ Hallucinations (auditory/visual)
■ Disorganized thinking and behavior
Obsessive compulsive personality disorder differs from OCD in that the person with obsessive compulsive personality disorder has no problem with behavior, whereas the person with OCD is anxious and wants to change
• Auditory hallucinations usually begin distant and soft, then become louder, but become softer and distant as client’s condition improves.
Negative Symptoms _ Deficits in behavior, such as reduced function or self-care deficits
At least for 1 mo, two or more:
■ Disorganized speech
■ Disorganized behavior
■ Negative symptoms
■ Functional disturbances at work or school disturbance
continues for 6 mo
■ Extremes of moods (mania or depression)
■ Major depressive disorder (unipolar depression): At
least 2 wk of depression/loss of interest and four
additional symptoms with one or more major depressive
■ Dysthymic disorder: On-going, low-grade depression of
at least 2 years’ duration for more days than not and
does not meet the criteria for major depression
■ Depressive disorder not otherwise specified (NOS): Does
not meet criteria for depressions described above.
■ Bipolar I disorder: One or more manic or mixed episodes
with a major depressive episode
■ Bipolar II disorder: One or two major depressive
episodes and at least one hypomanic episode
■ Cyclothymic disorder: At least 2 years of hypomanic
episodes that do not meet the criteria for other
■ Bipolar disorder NOS: Does not meet any of the other
■ Terrified of gaining weight
Depressed mood or loss of interest for at least 2 wk and five or more of:
■ weight loss/gain
■ insomnia or hypersomnia
■ psychomotor agitation or retardation
■ worthless feelings or inappropriate guilt
■ problem concentrating
■ recurrent thoughts of death
Persistent elevated, irritable mood for 1 wk or more, plus three or more (irritable, four or more):
■ high self-esteem
■ decreased sleep
■ increased talking/pressured speech
■ racing thoughts/flight of ideas
■ extreme goal-directed activity
■ excessive buying/sex/business investments (painful
■ Emaciated appearance
■ Below normal weight
■ Hair loss, dry skin
■ Loose Association
■ Autistic thoughts
A L E R T
When working with patients who have depression, it is important to identify any suicidal/homicidalideations.
Common Mental Health Problems (continued)
■ Weight below minimally accepted (weight _ 85% of
what would be expected for age and height)
■ Disturbed self-perception of size and shape of body;
even though underweight, still fears becoming
■ Self-esteem and self-evaluation based on weight
■ Introverted, socially isolated, high achiever
■ Recurrent binge eating of large amounts of food over
■ Lack of control
■ Self-induced vomiting, use of laxatives, purging,
fasting, excessive exercising
■ Weight normal, under-/overweight
■ Fluid and electrolyte imbalance
■ Impulsive, acting out, more histrionic (pervasive,
excessive expression of emotions and attention-seeking
■ Pedal edema
■ Weight fluctuations
■ Parotid gland enlargement (chipmunk facies)
■ Tooth enamel erosion
■ Finger or pharynx bruising
S U M M A R Y
■ Holistic nursing care includes assessment of the psychological health of your patient.The developmental level and cultural background of your patient needs to be considered when assessing your patient’s mental health.
■ When obtaining a health history and physical assessment, look for clues that reflect the mental health of your patient.
■ A thorough mental health assessment includes a detailed mental status assessment. Specific mental health assessment instruments are available to further assess the mental health needs of your patient.
■ Identify supports and resources and make referrals as needed to meet the mental healthcare needs of your patient.