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The StatsThe StatsAmbulatory care
◦ Number of ambulatory care visits (physician offices, outpatient centers, and emergency departments) with mental disorders as primary diagnosis: 58.2 million
Hospital inpatient care◦ Number of discharges with mental disorders as
first-listed diagnosis: 2.4 million◦ Average length of stay for mental disorders:
7.1 daysNursing home care
◦ Number of residents with mental disorders: 996,000
◦ Percent of residents with mental disorders: 67%
◦ (http://www.cdc.gov/nchs/fastats/mental.htm, 2011)
Diagnostic and Statistic Diagnostic and Statistic Manual for Mental Health Manual for Mental Health Disorders-IVDisorders-IVDescribes the main features and
specific criteria for mental illness Multi-Axis System
◦Axis 1 - Clinical Conditions (ex. depression)
◦Axis II - Personality and Intellectual Disorders (ex. borderline personality)
◦Axis III - Medical Conditions ( ex. Diabetes)◦Axis IV – Psychosocial or environmental
problems (homeless, estranged from family)
◦Avis V – Global Functioning (100-0)
Global Assessment of Global Assessment of FunctioningFunctioning100: no symptoms, well-adjusted and
content with life, can take care of problems, close and meaningful relationships
75: Symptoms mildly affect quality of life, problems occasionally emerge, socially awkward
50: Symptoms impair quality of life, conflict with peers, legal/employment issues
25: Symptoms impair basic life skills, at risk for danger to self/others, impaired communication
1: Hurts self/others, absent life skills unable to address or communicate basic needs
Mental Health Mental Health ProfessionalsProfessionalsRegistered Nurse-
◦care for patient and unitAdvance Practice Mental Health
Nurse/Clinical Specialist-◦Graduate level education and clinical◦Ensure protocols and staff training are
up to date and comply with regulation◦Consult for complicated patients
Nurse Practitioner-◦Manages the physical health and
needs of patients
Mental Health Mental Health ProfessionalsProfessionalsClinical Psychologist-
◦Graduate level education and clinical training
◦Evaluate patients, conduct mental health tests
◦Direct individual and group counselingPsychiatrist: medical doctor
◦Prescribes medications and ECT◦Referrals for therapy and counseling◦Determines admission/discharge◦Advocates for legal status
Mental Health Mental Health ProfessionalsProfessionalsCase Managers/Social Workers –
◦Undergraduate and graduate education◦Liaisons for patients to obtain and
maintain social services, financial aid, outpatient care
Therapist /Counselors◦conduct treatment sessions, education,
counsel groups, addiction management, rehabilitation services
Mental Health Technicians ◦Assist patients under nursing
supervision
Dorothea Dix (1802-1887)Dorothea Dix (1802-1887)Originally a school
teacher who in 1841 became a reformer for treatment of the mentally ill
Within 10 years visited >300 jails and >500 almshouses
Advocated for mentally ill persons to be removed from jails/almshouses and be placed in public hospitals
By 1880, <1% of prison population were the mentally illhttp://www.pbs.org/wgbh/pages/frontline/shows/asylums/
special, 2011
DeinstitutionalizationDeinstitutionalization >80% Reduction in state
psychiatric facilities for the community level
Contributors◦ 1950s: anti-psych meds◦ 1960s: civil rights values◦ 1965: Medicare/Medicaid◦ Kennedy/Carter passed
laws stipulating community programs
Consequences:◦ Advent of outpatient
mental health centers and programs
◦ Increase mental illness in homeless and prison populations and ED visits
Community Based Mental Community Based Mental HealthHealthBiopsychosocial Assessment
◦Family/Friend resources◦Ability to obtain/maintain housing,
food, hygiene, income, employment◦Adhere with outpatient mental
health treatment, sobriety, medication schedule, MD appointment
◦Plan B for mental illness symptoms
Community Based Mental Community Based Mental HealthHealth
Most Acute
Least Acute
Admission/Observation for crisis
Partial Hospital Programs
Psychiatric home care
Assertive Care Treatments
Community Mental Health Care Centers
MD or counselor office level care
Support Groups
Levels of PreventionsLevels of PreventionsPrimary: maintain the mental
health of person and population. ◦Educate teens about drugs/alcohol
Secondary: screen and intervene for impaired mental health◦Detox center
Tertiary: recover and rehabilitate towards mental health◦Support groups for alcoholics
Inpatient AdmissionInpatient AdmissionMajority of patients enter mental
health care through the emergency room◦Self Referral◦Friend/Family◦Professional
Criteria◦Imminent harm to self◦Imminent harm to other◦Gravely disabled in care of basic needs
Types of AdmissionTypes of AdmissionVoluntary:
◦patient complies and consents with inpatient status
◦Patient may choose to leave prior to completion of therapy regimen
Involuntary: ◦Patient may not leave facility
72hr Mental Health Hold: initiated by police, Clin. Psych, MD, SW, LPC, APN, BSN (1yr in mental health)
◦Short Term Certification: up to 60 days◦Long Term Certification: up to 90 days◦Legal Guardian/Ward of the State
Inpatient ProtocolsInpatient ProtocolsSuicide Precautions and
Elopement PrecautionsLevels of Restriction
◦ Day passes (overnight passes void inpatient status)
◦ Unaccompanied on grounds◦ Accompanied by staff◦ Restricted to unit◦ Line of sight◦ Seclusion◦ Restrained
Inventory Belongings◦ No weapons, pills, powders, open liquids,
cords, strings, belts, plastic bags, sharp objects
Rights of Mental Health Rights of Mental Health PatientsPatientsAdditional levels of confidentiality
◦Exceptions: 1. warning a third party of intended harm
by patient 2. reporting abuse of a vulnerable person
Right to stay informed/involved in treatment
Right to contest care/providerRight to humane conditions,
recreation, social interaction, vote, enter contracts