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Barbara J. Goldberg, MS, RN, CNS
Assistant Professor
Onondaga Community College
Syracuse, New York

Judith E. Gunther, MSN, RN

Associate Professor of Nursing
Northern Virginia Community College
Springfield, Virginia

Lois Harder, RN
Senior Lecturer
West Virginia University
Morgantown, West Virginia

Tina L. Kinney, MSN, RNC, FNP-BC, WHNP-BC

Nursing Instructor
Lutheran School of Nursing
St. Louis, Missouri

Lynne S. Mann, MN, RN, CNE

Assistant Professor
Charleston Southern University
Charleston, South Carolina

J. Susan G. Van Wye, MSN, RN, ARNP, CPNP

Adjunct Nursing Faculty
Kirkwood Community College
Cedar Rapids, Iowa

8
The seventh edition of Psychiatric–Mental Health Nursing maintains a strong student focus, presenting sound
nursing theory, therapeutic modalities, and clinical applications across the treatment continuum. The chapters
are short, and the writing style is direct in order to facilitate reading comprehension and student learning.
This text uses the nursing process framework and emphasizes therapeutic communication with examples
and pharmacology throughout. Interventions focus on all aspects of client care, including communication,
client and family education, and community resources, as well as their practical application in various clinical
settings.
In this edition, all DSM-5 content has been updated, as well as the Best Practice boxes, to highlight current
evidence-based practice. New special features include Concept Mastery Alerts, which clarify important
concepts that are essential to students’ learning, and Watch and Learn icons that alert students to important
video content available on . Cultural and Elder Considerations have special headings to help call
attention to this important content. The nursing process sections have a new design to help highlight this
content as well.

ORGANIZATION OF THE TEXT

Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses current issues in
psychiatric nursing as well as the many treatment settings in which nurses encounter clients. It thoroughly
discusses neurobiologic theories, psychopharmacology, and psychosocial theories and therapy as a basis for
understanding mental illness and its treatment.

Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practice of mental
health nursing. Chapters on therapeutic relationships and therapeutic communication prepare students to
begin working with clients both in mental health settings and in all other areas of nursing practice. The
chapter on the client’s response to illness provides a framework for understanding the individual client. An
entire chapter is devoted to assessment, emphasizing its importance in nursing.

Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental health settings.
These include legal and ethical issues; anger, aggression, and hostility; abuse and violence; and grief and loss.
Nurses in all practice settings find themselves confronted with issues related to these topics. Additionally,
many legal and ethical concerns are interwoven with issues of violence and loss.

Unit 4: Nursing Practice for Psychiatric Disorders covers all the major categories of mental disorders. This
unit has been reorganized to reflect current concepts in mental disorders. New chapters include trauma and

9
stressor-related disorders; obsessive–compulsive disorder and related disorders; somatic symptom disorders;
disruptive disorders; and neurodevelopmental disorders. Each chapter provides current information on
etiology, onset and clinical course, treatment, and nursing care. The chapters are compatible for use with any
medical classification system for mental disorders.

PEDAGOGICAL FEATURES
Psychiatric–Mental Health Nursing incorporates several pedagogical features designed to facilitate student
learning:

• Learning Objectives focus on the students’ reading and study.

• Key Terms identify new terms used in the chapter. Each term is identified in bold and defined in the text.
• Application of the Nursing Process sections, with a special design in this edition, highlight the assessment
framework presented in Chapter 8 to help students compare and contrast various disorders more easily.
• Critical Thinking Questions stimulate students’ thinking about current dilemmas and issues in mental
health.
• Key Points summarize chapter content to reinforce important concepts.
• Chapter Study Guides provide workbook-style questions for students to test their knowledge and
understanding of each chapter.

SPECIAL FEATURES
• Clinical Vignettes, provided for each major disorder discussed in the text, “paint a picture” of a client
dealing with the disorder to enhance understanding.
• Nursing Care Plans demonstrate a sample plan of care for a client with a specific disorder.
• Drug Alerts highlight essential points about psychotropic drugs.
• Warning boxes are the FDA black box drug warnings for specific medications.
• Cultural Considerations sections highlight diversity in client care.
• Elder Considerations sections highlight the key considerations for a growing older adult population.
• Therapeutic dialogues give specific examples of the nurse–client interaction to promote therapeutic
communication skills.
• Client/Family Education boxes provide information that helps strengthen students’ roles as educators.
• Nursing Interventions provide a summary of key interventions for the specific disorder.
• DSM-5 Diagnostic Criteria boxes include specific diagnostic information for the disorder.
• Best Practices boxes highlight current evidence-based practice and future directions for research on a wide
variety of practice issues.
• Self-Awareness features encourage students to reflect on themselves, their emotions, and their attitudes as a
way to foster both personal and professional development.
• Concept Mastery Alerts clarify important concepts that are essential to students’ learning and practice.
• Watch and Learn icons alert the reader to important resources available on to enhance student
understanding of the topic.

10
ANCILLARY PACKAGE FOR THE SEVENTH EDITION
Instructor Resources
The Instructor Resources are available online at http://thepoint.lww.com/Videbeck7e for instructors who
adopt Psychiatric–Mental Health Nursing. Information and activities that will help you engage your students
throughout the semester include:

• PowerPoint Slides
• Image Bank
• Test Generator
• Pre-Lecture Quizzes
• Discussion Topics
• Written, Group, Clinical, and Web Assignments
• Guided Lecture Notes
• Case Studies

Student Resources
Students who purchase a new copy of Psychiatric–Mental Health Nursing gain access to the following learning
tools on using the access code in the front of their book:

• , highlighting films depicting individuals with mental health disorders, provide students the
opportunity to approach nursing care related to mental health and illness in a novel way.
• NCLEX-Style Review Questions help students review important concepts and practice for the NCLEX
examination.
• Journal Articles offer access to current research available in Wolters Kluwer journals.
• Online video series, Lippincott Theory to Practice Video Series includes videos of true-to-life clients
displaying mental health disorders, allowing students to gain experience and a deeper understanding of
these patients.
• Internet Resources provide relevant weblinks to further explore chapter content.

Practice Makes Perfect, and This Is the Perfect Practice.

PrepU is an adaptive learning system designed to improve students’ competency and mastery and provide
instructors with real-time analysis of their students’ knowledge at both a class and individual student level.
PrepU demonstrates formative assessment—it determines what students know as they are learning, and
focuses them on what they are struggling with, so they don’t spend time on what they already know. Feedback
is immediate and remediates students back to this specific text, so they know where to get help in
understanding a concept.

Adaptive and Personalized

No student has the same experience—PrepU recognizes when a student has reached “mastery” of a concept

11
before moving him/her on to higher levels of learning. This will be a different experience for each student
based on the number of questions he/she answers and whether he/she answers them correctly. Each question
is also “normed” by all students in PrepU around the country—how every student answers a specific question
generates the difficulty level of each question in the system. This adaptive experience allows students to
practice at their own pace and study much more effectively.

Personalized Reports
Students get individual feedback about their performance, and instructors can track class statistics to gauge the
level of understanding. Both get a window into performance to help identify areas for remediation. Instructors
can access the average mastery level of the class, students’ strengths and weaknesses, and how often students
use PrepU. Students can see their own progress charts showing strengths and weaknesses—so they can
continue quizzing in areas where they are weaker.

Mobile Optimized
Students can study anytime, anywhere with PrepU, as it is mobile optimized. More convenience equals more
quizzing and more practice for students!
There is a PrepU resource available with this book! For more information, visit
http://thepoint.lww.com/PrepU.

This leading content is also incorporated into Lippincott CoursePoint, a dynamic learning solution that
integrates this book’s curriculum, adaptive learning tools, real-time data reporting, and the latest evidence-
based practice content into one powerful student learning solution. Lippincott CoursePoint improves the
nursing students’ critical thinking and clinical reasoning skills to prepare them for practice. Learn more at
www.NursingEducationSuccess.com/CoursePoint.

12
Many years of teaching and practice have shaped my teaching efforts and this textbook.
Students provide feedback and ask ever-changing questions that guide me to keep this text useful, easy to
read and understand, and focused on student learning. Students also help keep me up to date, so the text can
stay relevant to their needs. I continue to work with students in simulation lab experiences as nursing
education evolves with advances in technology.
I want to thank the people at Wolters Kluwer for their valuable assistance in making this textbook a reality.
Their contributions to its success are greatly appreciated. I thank Natasha McIntyre, Dan Reilly, Zach
Shapiro, Helen Kogut, and Cynthia Rudy for a job well done once again.
My friends continue to listen, support, and encourage my efforts in all endeavors. My brother and his
family provide love and support in this endeavor, as well as in the journey of life. I am truly fortunate and
grateful.

13
Unit 1
Current Theories and Practice
1. Foundations of Psychiatric–Mental Health Nursing
Mental Health and Mental Illness
Diagnostic and Statistical Manual of Mental Disorders
Historical Perspectives of the Treatment of Mental Illness
Mental Illness in the 21st Century
Cultural Considerations
Psychiatric Nursing Practice
2. Neurobiologic Theories and Psychopharmacology
The Nervous System and How it Works
Brain Imaging Techniques
Neurobiologic Causes of Mental Illness
The Nurse’s Role in Research and Education
Psychopharmacology
Cultural Considerations
3. Psychosocial Theories and Therapy
Psychosocial Theories
Cultural Considerations
Treatment Modalities
The Nurse and Psychosocial Interventions
4. Treatment Settings and Therapeutic Programs
Treatment Settings
Psychiatric Rehabilitation and Recovery
Special Populations of Clients with Mental Illness
Interdisciplinary Team
Psychosocial Nursing in Public Health and Home Care

Unit 2
Building the Nurse–Client Relationship

14
 5. Therapeutic Relationships
Components of a Therapeutic Relationship
Types of Relationships
Establishing the Therapeutic Relationship
Avoiding Behaviors that Diminish the Therapeutic Relationship
Roles of the Nurse in a Therapeutic Relationship
6. Therapeutic Communication
What is Therapeutic Communication?
Verbal Communication Skills
Nonverbal Communication Skills
Understanding the Meaning of Communication
Understanding Context
Understanding Spirituality
Cultural Considerations
The Therapeutic Communication Session
Assertive Communication
Community-Based Care
7. Client’s Response to Illness
Individual Factors
Interpersonal Factors
Cultural Factors
8. Assessment
Factors Influencing Assessment
How to Conduct the Interview
Content of the Assessment
Assessment of Suicide or Harm Toward Others
Data Analysis

Unit 3
Current Social and Emotional Concerns

9. Legal and Ethical Issues

Legal Considerations
Ethical Issues

10. Grief and Loss

Types of Losses
The Grieving Process
Dimensions of Grieving
Cultural Considerations

15
 Disenfranchised Grief
Complicated Grieving
Application of the Nursing Process

11. Anger, Hostility, and Aggression

Onset and Clinical Course
Related Disorders
Etiology
Cultural Considerations
Treatment
Application of the Nursing Process
Workplace Hostility
Community-Based Care

12. Abuse and Violence

Clinical Picture of Abuse and Violence
Characteristics of Violent Families
Cultural Considerations
Intimate Partner Violence
Child Abuse
Elder Abuse
Rape and Sexual Assault
Community Violence

Unit 4
Nursing Practice for Psychiatric Disorders
13. Trauma and Stressor-Related Disorders
Posttraumatic Stress Disorder
Etiology
Cultural Considerations
Treatment
Elder Considerations
Community-Based Care
Mental Health Promotion
Application of the Nursing Process

14. Anxiety and Anxiety Disorders

Anxiety as a Response to Stress
Overview of Anxiety Disorders
Incidence

16
 Onset and Clinical Course
Related Disorders
Etiology
Cultural Considerations
Treatment
Elder Considerations
Community-Based Care
Mental Health Promotion
Panic Disorder
Application of the Nursing Process: Panic Disorder
Phobias
Generalized Anxiety Disorder

15. Obsessive–Compulsive and Related Disorders

Obsessive–Compulsive Disorder
Cultural Considerations
Application of the Nursing Process
Elder Considerations

16. Schizophrenia
Clinical Course
Related Disorders
Etiology
Cultural Considerations
Treatment
Application of the Nursing Process
Elder Considerations
Community-Based Care
Mental Health Promotion

17. Mood Disorders and Suicide

Categories of Mood Disorders
Related Disorders
Etiology
Cultural Considerations
Major Depressive Disorder
Application of the Nursing Process: Depression
Bipolar Disorder
Application of the Nursing Process: Bipolar Disorder

17
 Suicide
Elder Considerations
Community-Based Care
Mental Health Promotion

18. Personality Disorders

Personality Disorders
Onset and Clinical Course
Etiology
Cultural Considerations
Treatment
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Application of the Nursing Process: Antisocial Personality Disorder
Borderline Personality Disorder
Application of the Nursing Process: Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive–Compulsive Personality Disorder
Elder Considerations
Community-Based Care
Mental Health Promotion

19. Addiction
Types of Substance Abuse
Onset and Clinical Course
Related Disorders
Etiology
Cultural Considerations
Types of Substances and Treatment
Treatment and Prognosis
Application of the Nursing Process
Elder Considerations
Community-Based Care
Mental Health Promotion

18
 Substance Abuse in Health Professionals

20. Eating Disorders

Overview of Eating Disorders
Categories of Eating Disorders
Etiology
Cultural Considerations
Anorexia Nervosa
Bulimia
Application of the Nursing Process
Community-Based Care
Mental Health Promotion

21. Somatic Symptom Illnesses

Overview of Somatic Symptom Illnesses
Onset and Clinical Course
Related Disorders
Etiology
Cultural Considerations
Application of the Nursing Process
Community-Based Care
Mental Health Promotion

22. Neurodevelopmental Disorders

Autism Spectrum Disorder
Related Disorders
Attention Deficit Hyperactivity Disorder
Cultural Considerations
Application of the Nursing Process: Attention Deficit Hyperactivity Disorder
Mental Health Promotion

23. Disruptive Behavior Disorders

Related Disorders
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Related Problems
Cultural Considerations
Application of the Nursing Process: Conduct Disorder
Elder Considerations

19
 Community-Based Care
Mental Health Promotion

24. Cognitive Disorders

Delirium
Cultural Considerations
Application of the Nursing Process: Delirium
Community-Based Care
Dementia
Related Disorders
Cultural Considerations
Application of the Nursing Process: Dementia
Community-Based Care
Mental Health Promotion
Role of the Caregiver

Answers to Chapter Study Guides

Appendix A
Disorders of Sleep and Wakefulness

Appendix B
Sexual Dysfunctions and Gender Dysphoria

Appendix C
Drug Classification Under the Controlled Substances Act

Appendix D
Canadian Drug Trade Names

Appendix E
Mexican Drug Trade Names

Glossary of Key Terms

Index

20
 Key Terms
• asylum
• boarding
• case management
• deinstitutionalization
• Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
• managed care
• managed care organizations

• mental health
• mental illness

• phenomena of concern
• psychotropic drugs

• self-awareness

• standards of care
• utilization review firms

Learning Objectives
After reading this chapter, you should be able to:

1. Describe characteristics of mental health and mental illness.

2. Discuss the purpose and use of the American Psychiatric Association’s Diagnostic and Statistical Manual of

21
 Mental Disorders (DSM-5).

3. Identify important historical landmarks in psychiatric care.

4. Discuss current trends in the treatment of people with mental illness.

5. Discuss the American Nurses Association (ANA) standards of practice for psychiatric–mental health
nursing.

6. Describe common student concerns about psychiatric nursing.

AS YOU BEGIN THE STUDY OF psychiatric–mental health nursing, you may be excited, uncertain, and even
somewhat anxious. The field of mental health often seems a little unfamiliar or mysterious, making it hard to
imagine what the experience will be like or what nurses do in this area. This chapter addresses these concerns
and others by providing an overview of the history of mental illness, advances in treatment, current issues in
mental health, and the role of the psychiatric nurse.

MENTAL HEALTH AND MENTAL ILLNESS

Mental health and mental illness are difficult to define precisely. People who can carry out their roles in
society and whose behavior is appropriate and adaptive are viewed as healthy. Conversely, those who fail to
fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The culture of
any society strongly influences its values and beliefs, and this, in turn, affects how that society defines health
and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive
and inappropriate.

Mental Health
The World Health Organization defines health as a state of complete physical, mental, and social wellness,
not merely the absence of disease or infirmity. This definition emphasizes health as a positive state of well-
being. People in a state of emotional, physical, and social well-being fulfill life responsibilities, function
effectively in daily life, and are satisfied with their interpersonal relationships and themselves.
No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his
or her mental health. Because each person can have a different view or interpretation of behavior (depending
on his or her values and beliefs), the determination of mental health may be difficult. In most cases, mental
health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive self-concept, and emotional stability.
Mental health has many components, and a wide variety of factors influence it. These factors interact; thus,
a person’s mental health is a dynamic, or ever-changing, state. Factors influencing a person’s mental health
can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a
person’s biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to
find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or
stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to

22
help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental,
factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity
among people, mastery of the environment, and a positive, yet realistic, view of one’s world. Individual,
interpersonal, and social/cultural factors are discussed further in Chapter 7.

Mental Illness
Mental illness includes disorders that affect mood, behavior, and thinking, such as depression, schizophrenia,
anxiety disorders, and addictive disorders. Mental disorders often cause significant distress, impaired
functioning, or both. Individuals experience dissatisfaction with self, relationships, and ineffective coping.
Daily life can seem overwhelming or unbearable. Individuals may believe that their situation is hopeless.
Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural
categories. Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to
distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of
meaning in one’s life. Interpersonal factors include ineffective communication, excessive dependency on or
withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control.
Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view
of the world, and discrimination such as stigma, racism, classism, ageism, and sexism.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

DISORDERS
The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) is a taxonomy published by
the American Psychiatric Association and is revised as needed. The current edition made some major
revisions and was released in 2013. The DSM-5 describes all mental disorders, outlining specific diagnostic
criteria for each based on clinical experience and research. All mental health clinicians who diagnose
psychiatric disorders use this diagnostic taxonomy.
The DSM-5 has three purposes:

• To provide a standardized nomenclature and language for all mental health professionals
• To present defining characteristics or symptoms that differentiate specific diagnoses
• To assist in identifying the underlying causes of disorders

The classification system allows the practitioner to identify all the factors that relate to a person’s condition:

• All major psychiatric disorders such as depression, schizophrenia, anxiety, and substance-related disorders
• Medical conditions that are potentially relevant to understanding or managing the person’s mental disorder
as well as medical conditions that might contribute to understanding the person
• Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental
disorders. Included are problems with the primary support group, the social environment, education,
occupation, housing, economics, access to health care, and the legal system.

Although student nurses do not use the DSM-5 to diagnose clients, they will find it a helpful resource to

23
understand the reason for the admission and to begin building knowledge about the nature of psychiatric
illnesses.

HISTORICAL PERSPECTIVES OF THE TREATMENT OF

MENTAL ILLNESS
Ancient Times
People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a
punishment for sins and wrongdoing. Those with mental disorders were viewed as being either divine or
demonic, depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as
demonic were ostracized, punished, and sometimes burned at the stake. Later, Aristotle (382–322 BC)

attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood,
water, and yellow and black bile in the body controlled the emotions. These four substances, or humors,
corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to
cause mental disorders; so treatment was aimed at restoring balance through bloodletting, starving, and
purging. Such “treatments” persisted well into the 19th century (Baly, 1982).

Possessed by demons

In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were
again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exorcisms to rid
evil spirits. When that failed, they used more severe and brutal measures, such as incarceration in dungeons,
flogging, and starving.
In England during the Renaissance (1300–1600), people with mental illness were distinguished from
criminals. Those considered harmless were allowed to wander the countryside or live in rural communities,
but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547,
the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind. By

24
1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who
were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the
United States), the mentally ill were considered evil or possessed and were punished.Witch hunts were
conducted, and offenders were burned at the stake.

Period of Enlightenment and Creation of Mental Institutions

In the 1790s, a period of enlightenment concerning persons with mental illness began. Philippe Pinel in
France and William Tuke in England formulated the concept of asylum as a safe refuge or haven offering
protection at institutions where people had been whipped, beaten, and starved just because they were mentally
ill (Gollaher, 1995). With this movement began the moral treatment of the mentally ill. In the United States,
Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit to Tuke’s
institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the
suffering. Dix believed that society was obligated to those who were mentally ill; she advocated adequate
shelter, nutritious food, and warm clothing (Gollaher, 1995).
The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state
hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of hospitals
were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a
negative connotation.

Sigmund Freud and Treatment of Mental Disorders

The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856–1939) and
others, such as Emil Kraepelin (1856–1926) and Eugen Bleuler (1857–1939). With these men, the study of
psychiatry and the diagnosis and treatment of mental illness started in earnest. Freud challenged society to
view human beings objectively. He studied the mind, its disorders, and their treatment as no one had done
before. Many other theorists built on Freud’s pioneering work (see Chapter 3). Kraepelin began classifying
mental disorders according to their symptoms, and Bleuler coined the term schizophrenia.

Development of Psychopharmacology
A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic
drugs, or drugs used to treat mental illness. Chlorpromazine (Thorazine), an antipsychotic drug, and lithium,
an antimanic agent, were the first drugs to be developed. Over the following 10 years, monoamine oxidase
inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety
agents, called benzodiazepines, were introduced. For the first time, drugs actually reduced agitation, psychotic
thinking, and depression. Hospital stays were shortened, and many people became well enough to go home.
The level of noise, chaos, and violence greatly diminished in the hospital setting.

Move toward Community Mental Health

The movement toward treating those with mental illness in less restrictive environments gained momentum in

25
1963 with the enactment of the Community Mental Health Centers Construction Act.
Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities,
began. Community mental health centers served smaller geographic catchment, or service, areas that provided
less restrictive treatment located closer to individuals’ homes, families, and friends. These centers provided
emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education.
Thus, deinstitutionalization accomplished the release of individuals from long-term stays in state institutions,
the decrease in admissions to hospitals, and the development of community-based services as an alternative to
hospital care.
In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled
persons: Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). This allowed
people with severe and persistent mental illness to be more independent financially and to not rely on family
for money. States were able to spend less money on care of the mentally ill than they had spent when these
individuals were in state hospitals because this program was federally funded. Also, commitment laws changed
in the early 1970s, making it more difficult to commit people for mental health treatment against their will.
This further decreased the state hospital populations and, consequently, the money that states spent on them.

MENTAL ILLNESS IN THE 21ST CENTURY

The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that more than
18.6% of Americans aged 18 years and older have some form of mental illness—approximately 43.7 million
persons. In the past year, 20.7 million people or 18.6%, had a substance use disorder. Of these, 8.4 million
had co-occurring mental illness and substance use disorder, or dual diagnosis (2015). Furthermore, mental
illness or serious emotional disturbances impair daily activities for an estimated 15 million adults and 4 million
children and adolescents. For example, attention deficit hyperactivity disorder affects 3% to 5% of school-aged
children. More than 10 million children younger than 7 years grow up in homes where at least one parent
suffers from significant mental illness or substance abuse, a situation that hinders the readiness of these
children to start school. The economic burden of mental illness in the United States, including both health-
care costs and lost productivity, exceeds the economic burden caused by all kinds of cancer. Mental disorders
are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age. Yet only
one in four adults and one in five children and adolescents requiring mental health services get the care they
need.
Some believe that deinstitutionalization has had negative as well as positive effects. Although
deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those
beds correspondingly increased by 90%. Such findings have led to the term revolving door effect. Although
people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals
more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general
hospital psychiatric units. In some cities, emergency department (ED) visits for acutely disturbed persons have
increased by 400% to 500%. Patients are often boarded or kept in the ED while waiting to see if the crisis de-
escalates or till an inpatient bed can be located or becomes available.

26
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