Introduction to mental health

2.  Review of Mental Health
 Mental Health Illness Continuum
 Historical perspectives
 Current concepts, trends and issues in
psychiatry
 Mental health services in Kerala& India
 Scope, issues and challenges in psychiatric
nursing.

4. DEFINITION
“Mental health is a state of wellbeing in
which an individual realizes, his or her
own abilities, can cope with the normal
stress of life, can work productively and is
able to make a contribution to his or her
community”.
- WHO

5. “Mental health is an adjustment of human
beings to the world and to each other with a
maximum of effectiveness and happiness”.
- Karl Menninger,1947
“ Simultaneous success at working, loving and
creating with the capacity for mature and
flexible resolution of conflicts between instinct
conscience, important and other people and
reality”.
- APA

6. 1. The ability to accept self- a mentally
healthy individuals feels comfortable
about himself. He feels reasonably
secure and adequately accepts his
shortcomings.
2. The capacity to feel right towards others-
an individual who enjoys good mental
health is able to be sincerely interested
in other’s welfare.

7. 3. The ability to fulfill life’s tasks- a mentally
healthy person is able to think for himself,
set reasonable goals and take his/ her
own decisions. He does something about
the problems, when they arise.

8.  Adequate contact with reality
 Control of thoughts and imagination
 Efficiency in work and play
 Social acceptance
 Positive self concepts
 A healthy emotional life.

9. Jahoda( 1958) has identified 6 indicators of
mental health. Which includes;
1. A positive attitude towards self- an
objective view of self, including knowledge
and weakness. The individuals feels strong
sense of personal identity and security
within the environment.

10. 2. Growth, development& the ability for self
actualization- this indicator correlates
with whether the individual successfully
achieves the tasks associated with each
levels of development.
3. Integration- it includes the ability to
adaptively respond to the environment,
and the development of philosophy of life.
Both of which help the individual to
maintain anxiety at manageable level in
response to stressful situations.

11. 4. Autonomy- it refers to the individual’s
ability to perform in an independent self-
directed manner; the individual makes
choices and accepts responsibility for the
outcomes.
5. Perception of reality- it includes,
perception of the environment without
distortion, as well as the capacity for
empathy and social sensitivity- or respect
and concerns for the wants and needs of
others.

12. 6. Environmental mastery- this indicator
suggests that, individual has achieved a
satisfactory role within the group, society
or environment. He is able to love and
accept the love of others.

13. Happiness
Control over behavior
Appraisal of reality
Effectiveness in work
Healthy self concept
Satisfying relationship
Effective coping strategies

14.  He has an ability to make adjustments
 He has a sense of personal worth, feels
worthwhile and important.
 He solves his problems largely by his own
efforts and makes his own decisions.
 He has a sense of personal security and
feels secure in a group, shows
understanding of other people’s problems
and motives.
 He has a sense of responsibility.

15.  He can give and accept love
 He lives in a world of reality rather than
fantasy
 He shows emotional maturity in his
behavior, and develops a capacity to
tolerate frustrations and disappointments in
his daily life.
 He has developed a philosophy of life that
gives meaning and purpose to his daily
activities.
 He has a variety of interests and generally
lives in well- balanced life of work, rest and
recreations.

16.  Mental health plays a critical role in
relationship
 Mental illness might have an impact on
how we interacts with our friends and
family.
 Mental illness frequently results in passive
aggressiveness, hostility and the capacity
to participates in social activities.
 This may results in conflicts with our
friends and families.

17.  Mental health affects physical health
 There is a link between our mental health
and physical health.
 Mental illness can induce stress and have
an effect in our immune system.
 A sick mind can lead to anxiety and
sadness, both which can make it difficult
to move about and stay active.
 Mental health is related to emotional
wellbeing
 Mental health can make you feel down,
irritated, or disturbed.
 Taking care of our emotional wellbeing can
help us to be more productive.

18.  Mental health awareness can help in curbing
suicidal rates
 Those who committed suicide has
conditions such as depression, bipolar
disorder or disthymia.
 It demonstrates the link between mental
health and suicide, as well as how early
medical interventions and self care can
help minimize the number of suicide
deaths.

19.  Mental health is linked with crime and
victimization
 As per some studies, mental illness put
one at an increased risk of committing
violent crimes.
 It also leads to self- victimization and
abuse
 Seeking tips from mental health specialist
and understanding why mental health is
important can help in avoiding such
scenarios.

20.  Mental health is connected to productivity
and productivity and financial stability
 According to WHO, almost 200 million
work days are lost each year owing to
depression alone.
 It is widely known that, poor mental
health causes a drop in productivity, which
has an impact on financial stability.

21.  Mental health is linked to societal factors
 As previously stated, poor mental health
can lead to increase in crime and violence.
 Children of adults with mental problems,
on the other hand, are more likely to
experience abuse, neglect and behavioral
issues.
 They likely to grow up to be complex
human beings who struggles to find social
acceptance and support.

22.  Mental health affects quality of life
 An unhealthy mind can cause us to loss
interest in the things which ones enjoyed.
 Untreated mental health is often identifies
with a sense of hopelessness, sadness,
worthlessness, feeling of guilt, anxiety, fear
and a perceived loss of control.
 Mental health awareness can help in ending
stigma
 While many people suffering from mental
illness, only a small percentage can seeks
treatment because of stigma associated
with it.

23.  Mental health awareness enables the
community building
 We can establish better support facilities
for those suffering from mental illness, if
we actively campaign for why it is
important.

24. SIGNS OFMENTAL HEALTH SIGNS OF MENTAL ILLNESS
HAPPINESS- finds life
pleasurable, seeks satisfaction
in activities and people for
meet one’s needs.
DEPRESSION- loss of interest
in pleasurable activities. Mood
is described by person is
depressed, sad and hopeless.
CONTROL OVER BEHAVIOR-
Can respond to the rules,
routines and customs of the
group to which one belongs.
CONDUCT DISORDER- under
socialized aggressive behavior.
APPRAISAL OF REALITY- can
comprehend what is happening
around him, can see the
difference between ‘as if’ , and
‘for real’ in situations.
SCHIZOPHRENIC DISORDER-
loss of touch with reality.
Delusions and hallucinations
are present.
EFFECTIVENESS IN WORK- can
do well in tasks attempted.
Optimum use of his
capabilities.
ADJUSTMENT DISORDER-
decline in work output or
academic performance.

25. SIGNS OF MENTAL HEALTH SIGNS OF MENTAL ILLNESS
HEALTHY SELF CONCEPT-
have reasonable self
confidence, as capable of
meeting demands.
DEPENDENT PERSONALITY
BEHAVIOR- passively allows
others to assume
responsibilities for major
areas of life, because of
inability to function
independently.
SATISFYING RELATIONSHIPS-
experiences satisfaction and
stability in relationships. Can
relay on social support.
BODERLINE PERSONALITY
BEHAVIOR- shows patterns of
unstable and intense
interpersonal relations.
EFFECTIVE COPING
STRATEGIES- uses adaptive
coping strategies and stress
reduction strategies like
problem solving, cognitive
reconstruction, etc.
SUBSTANCE ABUSE- uses
maladaptive coping strategies
like repeatedly uses
substances despite significant
substance related problems.

26. OVERVIEW
All human behavior lies somewhere along a
continuum of mental health and illness.
 One of the approach in defining mental
health and mental illness is based on
evaluating individual behavior in two
dimensions;
• On continuum from adaptive to
maladaptive.
• On a continuum from constructive to
destructive.

27.  Along the adaptive- maladaptive
continuum, adaptive behavior solves
problems in living and enhances an
individual’s life.
 Maladaptive behavior allows a problem to
continue and often generates new
problems.
 On a continuum from constructive to
destructive behavior, constructive
behavior contributes to psychological
growth and biological functioning of the
individual and others.

28.  It improves the health and positively
influences the psychological functioning of
the individual and others.
 The destructive behavior results in failure to
deal with a problem and affects
psychological functioning in the individual or
others.

29.  In mental health- illness continuum, anxiety
and grief have been described as 2 major,
primary response to the stress.
 Both of these responses are presented on a
continuum according to degree of symptom
severity.
 Disorders as they appear in the DSM-IV-TR
are identified at their appropriate placement
along the continuum.

30. (Diagnostic& Statistical manual of
Mental Disorders, IVth edition, Text
revision)
The APA endorses case evaluation on a multi
axial system to facilitate comprehensive
and systematic evaluation with attention to
various mental disorders and general
medical conditions, psychological and
environmental problems and level of
functioning that might be overlooked if, the
focus were on assessing a single presenting
problem.

31. AXIS 1
• Clinical disorders and other conditions
that maybe a focus of clinical attention
AXIS 2
• Personality disorders and Mental
retardation
AXIS 3
• General medical conditions
AXIS 4
• Psychosocial and environmental
problems
AXIS 5
• Global assessment of functioning

32. This includes all mental disorders, except
personality disorders and mental
retardation).
2. Personality disorders and Mental
retardation
These disorders are usually begins in
childhood or adolescence and persists in a
stable form into adult life.

33. These includes current medical conditions
that is potentially relevant to the
understanding or management of the
individual’s mental disorders.
4. Psychosocial and environmental
problems
These are problems that may affect the
diagnostics, treatment and prognosis of
mental disorders named on axis 1 and axis
2.

34.  These includes problems related to primary
support group, social environment,
education, occupation, housing, economics,
access to health care services, interaction
with the legal system or crime, and other
type of psychosocial and the environmental
problems.
5. Global assessment of functioning
This allows the clinician to rate the
individual’s overall functioning on the Global
Assessment of Functioning Scale( GAF)

36.  Demonic possession, the influence of
ancestral spirits, the result of violating
taboo or neglecting a cultural ritual and
spiritual condemnation.
 As a result, the mentally ill were often
starved, beaten, burnt, amputated and
tortured in order to make the body an
unsuitable place for demon.

37. Gradually, man began the quest for scientific
knowledge and truth. Which can be treated
as follows;
 Pythagoras( 580- 510 Bc)
Developed the concept that the brain is the
greatest seat of intellectual activity.

38.  Hippocrates( 460- 370Bc)
 Described mental illness as hysteria, mania
and depression.
 Plato( 427- 347Bc)
 Identified the relationship between mind
and body.
 Asciepiades
 Father of psychiatry
 Made use of simple hygienic measures, diet,
bath, massage in place of mechanical
ventilators.

39.  The Greeks were the first to study mental
illness, scientifically and separate the study
of mind from religion.
 Aristotle, a Greek philosopher, emphasized
on the release of repressed emotions for
the effective treatment of the mental
illness.
 He suggested catharsis and music therapy
for patients with melancholia.

40. During middle ages, the mentally ill were
considered as the people to be helped.
 St. Augustine who believed that although
God is acted directly in human affairs,
people were responsible for their own
actions.
 Renaissance( 1300- 1600AD)
 In Europe
 It was believed that demon were the cause
of hallucinations, delusions and sexual
activity and the treatment was torture and
even death.

43.  1840s- Florence Nightingale made an
attempt to meet the needs of psychiatric
patients with proper hygiene, better food,
light and ventilation and use of drugs to
chemically restrained violent and aggressive
patients.
 1872- first training school for nurses,
based on Nightingale’s system was
established by New England hospitals for
women and children.
 USA Linda Richards, the first nurse to
graduate from the one year course,
developed 12 training schools in USA.

44.  1882- First school to prepare nurses to
care for the mentally illed was opened at
MC Lean hospital.
 A two years program was started but, few
psychological skills were addressed and
much importance was given to custodial
care such as personal hygiene, medication,
nutrition, etc.
 1913- John’s Hospital became the first
school of nursing includes a fully developed
course for psychiatric nursing in the
curriculum.

45.  Major growth in psychiatric nursing
occurred after World War II because of the
emergence of services related to psychiatric
problems.
 The content of psychiatric nursing became
the integral part of the general nursing
curriculum.
 1921- short training course of 3- 6 months
were conducted in Ranchi.

46.  1943- Psychiatric nursing course was
started for male nurses. The Chennai gov.
organized a three months psychiatric
nursing course for male nursing students.
 1946- Health Survey Committee Report
recommended preparation of nursing
personnel in psychiatric nursing also.
 Commencement of training in existing
institutions like mental hospitals of
Bangalore and Ranchi.

48.  Having said that, the current state of psychiatry
as a field, it’s practices and trends, academics
and research, it’s facilities in metros and rural
areas, and it’s legislation and social security
measures needs security.
 Equally important is a look at future trends in
practice and research.

49.  We lack the knowledge of the etiology and
pathogenesis of most psychiatric disorders.
We don’t a single biometry in psychiatry yet.
 We have no objective or prognostic
investigations, and our drugs and
psychological treatments are often partially
effective.

50.  We hope to join the other medical specialties in
moving from “descriptive to analytical” ie, being
fully evidence based.
 Discovery of effective antipsychotics and
antidepressant drugs, raised the hopes of
pathological mechanisms of the underlying
issues.

51.  ACADEMICS AND RESEARCH
 Pure academics are learned and encouraged only in
selected institutions such as NIMHANS, PGI
Chandigarh and Ranchi.
 Psychiatric departments in medical colleges have
limited facilities, and mainly focused on clinical work
and patient care.
 Liaison psychiatry as a subspecialty is yet to develop
as a branch of general psychiatry.

52.  RURAL PSYCHIATRY
 Limited scope
 Facilities are not adequate
 PHCs can be helped by telemedicine and video
conferences.
 For developing psychiatric rehabilitation centers,
requires vast tract of lands and other such
facilities.

53.  PSYCHIATRIC FACILITIES IN METRO- CITIES
 Residential societies or commercial
establishments do not give the permission due to
fear of mentally ill people on their premises.
 Psychiatric patients are generally treated at
general hospital departments
 Five star hospitals do not encourage psychiatric
patients to their hospitals.

54.  INSURANCE AND OTHER SERVICES
 Insurance companies do not provide
profitable to insure people for their mental
illness.
 If a person commits suicide, within an year
of taking policy, beneficiaries do not get
claimed money.

55.  Early diagnosis and early interventions to serious
mental illnesses.
 Genetic discoveries leading to molecular
pathophysiology and biotechnology.
 Neuroplasticity as a symptom target seen in
structural atrophy at cellular and molecular levels
documented in psychosis, mania, depression, etc
 Brain repair surgery- to reverse neuroplastic
changes.

56.  Collaborative model- inter training of
physical and mental disorders.
 For e.g. increased incidence of cvs disorders
are seen in serious psychiatric illnesses.
 Similarly patients with obesity,
hypertension, DM, and dislipidemia suffer
increased risk of psychiatric illnesses.

57.  Current classification in psychiatry is a
symptom or syndrome based.
 Maybe psychiatry will come nearer to other
branches of medicine and develops an
etiological diagnosis based on brain biology.
 Researches can bring out etiological diagnosis
of most diagnostic categories of mental illness.

59.  Mental health care delivery system is
grossly inadequate considering that there
are 20 million people needing care and
facilities have only 25000beds.
 Programs for mental retardation; drug
addiction; suicide prevention and psycho
geriatric care.

60. INSTITUITIONAL CARE
 41 mental hospitals with 20000 beds offers
institutional care.
 Initially planned for long term custodial care;
these centers provides special clinics and
outpatient care.
 The availability of most of most beds get
blocked by the long stay patients

61. AFTER CARE OPTIONS
 Few organized services exists for the rehabilitation
of the mentally ill patients in India
 The centrally supported institutes such as NIMHANS
Bangalore; Central Institute of Psychiatry(CIP)
Ranchi have well organized institutional
occupational and recreational services.
 Voluntary organizations such as Schizophrenia
Research Foundation(SCARF) Madras; Sanjeevani
in Delhi; Abhaya in Trivandrum also involves in
after care options.

62. GENERAL HOSPITAL PSYCHIATRIC UNITS
 Establishment of general hospitals
psychiatric units has led to a qualitative
change in overall psychiatric care.
 Around 50000 beds are available; these are
largely in teaching hospitals attached to 67
medical colleges.

63.  The emergency services treats acutely ill
patients
 Often clients in a sub acute delirious state or
post febrile confusions are referred to these
centers.
 Attempted suicide forms a large category of
referrals needs resuscitation and crisis
interventions.

64. WITHIN STATE DIFFERENCES
The staff in an institution or a general hospital
psychiatric unit is comprised of;
 Psychiatrists
 Social workers
 Nurses
 Trained attendants

65. CENTER -STATE DIFFERENCES
The centrally supported institutions such as NIMHANS; CIP
and central organizations are well funded and staffed.
While others are inadequately supported.
CITY- DISTRICT DIFFERENCES
A few districts have psychiatric units functioning with one
psychiatrist and no other members of mental health team.
No psychiatric staffs are available beyond the district
settings.

66. The PHCs with it’s sub centers are the most
peripheral health posts catering to a few
villages
Recently a few PHCs have been upgraded to
form CHCs to look after 100000people.

67.  ECT
 Pharmacotherapy
 psycho analytical therapy
 Behavioral therapy
 Family therapy
 Yoga
 Psychosocial stress therapy

68. NATIONAL MENTAL HEALTH PROGRAM
Major objectives
To provide basic mental health care at the
grass root level; apart from ensuring
availability and accessibility of services to
most vulnerable and unprivileged sectors.

69. SPECIFIC APPROACHES OF NMHP
 Diffusing mental health skills to the peripheral
health service system; territorial distribution of
resources and integration of mental health care
with general health services.
 Voluntary agencies such as SCARF Madras have
implemented country based rehabilitation as a
part of NMHP in the district of Chinglepet in
Tamilnadu.

71.  Increased awareness of the consumer that is
patient as an individual and as a member of the
family and other groups
 Awareness of the community in early detection;
diagnosis and treatment of mental disorders
and utilization of psychiatric hospitals and
dispensaries.
 Awareness of the value of continuity of care

72.  The multy- disciplinary team approach to psychiatric
practice and increasing therapeutic responsibility of each
members including the team nurse.
 Recognition of the hospital structure in care of mentally
ill patients
 Increasing efforts to rehabilitation patient
 Expansion of psychiatric services with general hospitals.
 Emphasis of mental health services in national health
policy.

73.  ROLE OF GENERALIST
• The psychiatric mental health generalist nurse
is a licensed registered nurse for delivering
primary mental health care.
• Exercises a holistic approach to psychiatric
nursing in prevention programs; community
daycare treatment centers psychiatric
rehabilitation facilities and homeless shelters.

74. COMMUNITY MENTAL HEALTH NURSE
CMH Nursing is the application of knowledge
of psychiatric nursing in preventing mental
illness promoting and maintaining mental
health of the people.

75. PSYCHIATRIC HOME CARE NURSE
Provides holistic psychiatric nursing care on a
visiting basis to people needing assistance;
also provides comprehensive care including
psychiatric and physical assessment; direct
nursing care; behavioral management;
crisis intervention; psycho-education etc.

76. FORENSIC PSYCHIATRIC NURSING
The forensic psychiatric nurse works with the
individuals who have mental needs and who
have entered the legal system.
Nurses in this role perform physical and
psychiatric assessments and develops plans
of care for patients entrusted to their care.

77. It’s an advanced practice nurse who practices
mental health nursing in a medical setting/
non psychiatric setting providing
consultation and education to patients;
families and community.

78. CASE MANAGER
Nurse case manager acts as an advocate for
patients and their families by coordinating
care and linking the patient with physician;
other members of health care team;
resources and payers.

79. GEROPSYCHIATRIC NURSE
Aged people who have been affected by
emotional and behavioral disorders such as
dementia; chronic schizophrenia; delirium
etc.

80. PARISH NURSE
The Parish nurse is a spiritually mature;
licensed registered nurse with desire to
serves the members and friends of their
congregation. They provides a link between
health institution and home by regular
physical and mental health screenings.

81. TELE HEALTH/ TELE NURSE
Nurses engaged in tele-health activities uses
technologies such as internet; computers;
telephones; digital assessment and tele-
monitoring tools to deliver nursing care.

82. NURSE RESEARCHER
Nurse researchers are scientists who seeks to
find answers to questions through
methodological observations and
experimentations.

83. PSYCHIATRIC NURSE EDUCATOR
They works in educational institutions; staff
development department of health care
agencies and patient education department.

84. NURSE EDUCATOR/ MANAGER
A nurse manager works less directly with the
patients; but has the responsibility to
provide nursing leadership to ensure that
an appropriate therapeutic milieu is
maintained.

85. HOLISTIC NURSE
A Holistic nurse uses theories of wholeness; expertise
caring and in these patients become therapeutic
partners in a mutually evolving process towards
healing; balance and wholeness. The most
frequently used therapies used by nurses are;
o Music
o Exercise
o Diet
o Prayer
o Counseling

87.  Increased mental health problems
 Provision of quality and comprehensive
services
 Multi- disciplinary team approach
 Providing continuity of care
 Care is providing in alternative settings.

88.  ECONOMIC ISSUES
 Industrialization
 Urbanization
 Raised standard of living

89.  CHANGES IN ILLNESS ORIENTATION
 Shift from illness to prevention
 Specific to holistic
 Quantity of care to quality of care

90.  CHANGES IN CARE DELIVERY
Care delivery is shifted from institutional
services to community services; genetic
services to counseling services; nurse-
patient relationship to nurse- patient
partnerships.

91.  INFORMATION TECHNOLOGY
 Tele nursing
 Tele medicine
 Mass media
 Electronic systems
 Nursing informatics

92.  COSUMER EMPOWERMENT
 Increased consumer awareness
 Awareness of the community in early detection
and treatment of mental illness as well as
proper utilization of the available psychiatric
hospitals
 Patients are health care consumers demanding
quality of health care services at affordable
cost.

93.  DEINSTITUTIONALIZATION
Bringing mental health patients out of the
hospitals and shifting care to community

94.  PHYSICIAN STORAGE AND GAPS IN SERVICES
Physician storage can provide the opportunity
for new roles in respect to gaps in services
nurses always meets the needs of people
for whom services are not available.
Eg; nurse practitioner
home visiting nurse

95.  DEMOGRAPHIC CHANGES
 Increasing number of elderly groups
 Type of family( increased number of nuclear
families).

96.  CHANGES IN NEEDS OF PATIENTS
Wanting a more holistic orientation in health
care.

97.  Knowledge development; dissemination and
application
 Overcoming stigma
 Health care delivery system issues
 Impact of technology

98.  Diploma in psychiatric nursing
 MSc psychiatric nursing
 Mphil in psychiatric nursing
 Doctorate in psychiatric nursing