Serious Mental Illness: How Can We Help?

[jeastridge]

Ed called me to ask if we could have coffee and talk. As his long-term friend and a Faith Community Nurse, I was happy to oblige and we set up a time. When we got together he told me the difficult story of his brother whose wife has serious mental health issues. This was the fifth time she had made a serious attempt to kill him-each time the process escalated and her attempts were more serious. Near tears, Ed went on to tell me the sad story of how he was unable to help his brother despite his best attempts. His brother would go through the complicated steps necessary to get her committed, she would stay in a facility for a total of maybe two weeks, be released, have nowhere to go, plead to come home and the process would begin again-he ever hopeful that "this time would be different" and she appearing to adjust her paranoid, schizophrenic ideation/bipolar behavior for short bursts of time before falling back into the physical, emotional and spiritual abuse. Additionally, Ed's brother found himself unable to prosecute her criminally, simply lacking the emotional strength to send her to jail.

The cyclical nature of the pattern left everyone exhausted and also mentally distressed-the wife who lives in the grip of severe mental illness, the husband who is a victim and displays all the classic signs of victimization, their teenage daughter who simply wants her mother to "go away," and the extended family who vacillates between despair and hope with every cycle of violence and reconciliation.

What are the statistics on the prevalence of serious mental health problems? Of course, it is hard to know exactly as 1 in 5 of us has some type of mental health crisis at some point in our lives. But the more serious, destructive types of mental health illnesses are smaller in number:

• 1.1% of adults in the U.S. live with schizophrenia.(NIMH >> Schizophrenia)
• 2.6% of adults in the U.S. live with bipolar disorder.(NIMH >> Bipolar Disorder)

However, these serious mental health problems have a disproportionately large effect on those around them. Mary Nicholas, MSW, Professor of Social Work at Mississippi

College states, "Mental illness destabilizes the workforce, the family, society in general, the educational system, even churches." The societal impact that one person with severe untreated mental illness can have is difficult to quantitate.

Ed went on to express his frustration with the emergency room as the access point for mental health evaluation and crisis. He detailed occasions where his sister-in-law was evaluated and sent home for unknown reasons. As professional nurses, we all know how hard it is to find a placement for someone in crisis. The options are few and often the chronically mentally ill have run through their money, run out of support systems, and have very few options. Additionally, the family system is so ill that their own issues become part of the problem.

How can nurses be part of turning this situation around?

Nicholas says, "I see a lack of funding. I don't think it's a lack of interest but I think we need to educate our people in authority regarding what mental health issues are and the devastation they can cause in our society when these diseases go untreated."

She goes on to point out some possible avenues forward:

1. Vote. One of the most important things we can do is participate in the election process and even go further than that by keeping our legislators informed and talking with them about mental health concerns.
2. Longer inpatient stays. I'm not advocating for institutionalization, but I am advocating for longer term treatments. The current standard of 13 days is simply not adequate. It's not enough. There has to be a place between being institutionalized for life and doing the "express treatment" mentality. Mental health issues are not a quick fix. They are not a single layer issue either. It's not just getting them stabilized, it is also dealing with all the devastation they have done while they have been unstable.
3. Acknowledge and address shame. If a person suffering from mental illness can be stabilized and get on medication, there is often a sense of shame in dealing with the past. This can be exacerbated by the culture of secrecy surrounding mental health and mental health treatment. As a society, we have to be more open about mental health, de-stigmatize it and give people tools to deal with the shame, including paths toward self-forgiveness and reparations.
4. Holistic care necessary. The approaches have to be holistic, long-term and team-oriented. Identifying the problem and finding medication is only a first step and maybe the easiest part of the process. The individual, family and societal support system necessary to move toward solutions is complex.

I listened carefully to Ed as he unburdened himself of more details of his family's terrible ordeal. He said, "Being mentally ill does not mean you are not smart. In this case and others like it, the person in question knows her rights. She knows how to use them to defend herself and in some ways, to perpetuate the problem. She is functional-just in very harmful, hurtful ways."

The National Association for the Mentally Ill (NAMI) helps to advocate for both the mentally ill and for their families. They provide support groups and connection to other resources and work with the mentally ill, their families members and professionals. I referred my friend to NAMI and he was able to attend group and get more connected.

What is your experience with the seriously mentally ill in the community? What do you see that is helpful? How can professional nurses move beyond identifying problems and become part of addressing solutions long term? What is going on in your community that is successful?

Joy Eastridge, BSN, RN, CLMFCN

[jeastridge, BSN, RN]

I was an ACT nurse for a year and a half. For those of you unaware of the ACT model, it is a governmentally funded, social services based community treatment model that uses an interdisciplinary approach to give those afflicted with severe persistent mental illness tools to live in the community (lower level of care than group home) vs. institutions.

The issues I saw again and again:

- in the inpatient hospitals, word would get around quickly that ACT could get you housing. So, what happened again and again? our new clients would receive their housing, then not care about recovery or treatment anymore

- malingerers. While rare, they take on the role of a black hole and suck out the energy of the entire team, allowing others to slip through the cracks

- "natural supports" (family, friends outside of the treatment team) do NOT exist for the most part with these folks. This is one of the factors preventing more stability and less acuity

- in the younger population, dual diagnoses are rampant and unfortunately there isn't really a care delivery model that exists to manage the substance abuse part with the persistent mental illness part

- this population is financially disadvantaged due to inability to work, or incapability to hold a job, or there not being an employer who is willing to hire a person with severe persistent mental illness

- the medications taken by these folks (especially the antipsychotics) have terrible metabolic side effects

oh man, I didn't mean to go on and on...anyway, I realize that my knowledge base is very specific as I've never worked inpatient, in a group home setting, or partial program or anything. But that's the reality of community mental health treatment in the Mid Atlantic

As for me, I have atypical depression and OCD. My biggest issue has been stigma. My ex believed that any psychotropics were no different than being drunk and therefore were not something a Christian should be taking. And, outside of personal stigma, I had a manager who informed me that my mental illness was not in line with being a critical care nurse. (Nope, wasn't in writing and no witnesses, darn it.)

Annnnd that's enough from me.

Thank you for sharing. There are no easy answers, are there? I hope that your post and others like it can help us all as we search for creative ways to move forward. Joy

[Natasha A., CNA, LVN]

Great post! I have a family member with mental illness and I have seen things that you question in the world like are human beings more important than profit? I was watching the National Geographic Channel one day and could not believe that there was an experiment that was funded billions of dollars to collect data to test dolphins to see if we can communicate to aliens one day (seriously). Again I ask the world what is more important humans or profit? All this technology and numerous resources available yet it's not used for the greater good.

[jeastridge, BSN, RN]

Great post! I have a family member with mental illness and I have seen things that you question in the world like are human beings more important than profit? I was watching the National Geographic Channel one day and could not believe that there was an experiment that was funded billions of dollars to collect data to test dolphins to see if we can communicate to aliens one day (seriously). Again I ask the world what is more important humans or profit? All this technology and numerous resources available yet it's not used for the greater good.

I appreciate your comment and your perspective. Sometimes we do seem to get our priorities a little askew, don't we? It continues to be important that we vote, speak with our elected officials and keep mental health issues at the forefront. Joy

[mmc51264, BSN, MSN, RN]

I had an experience just today that annoyed me. Everything turned out all right, but It just as easily could not have.

Someone went to the administration at my son's school concerned that he said he as going to harm himself. They rightly were concerned, called me and I went and got him. I called his doctors. Their only advice was to take him to one of the two really crappy, scary mental health facilities where I cringed reading the reviews.

We went to the crisis center for the county in which I live. It is associated with the health department. They had several staff members (LCSW) available to asses him and they decided that he was NOT a danger to himself and he did not need hospitalization. Thank God!

It is scary to know there is no where safe to take my child if I couldn't handle it.

[FolksBtrippin, BSN, RN]

Support and fully fund assertive community treatment. Become educated about what is already being done to support the chronically mentally ill in the community and don't doom and gloom.

Longer inpatient is not the answer. Better outpatient is. We only need inpatient when outpatient fails.

Long acting antispychotic injections and incentive programs to gain adherence.

And please stop over telling stories about violent mentally ill people. That situation is rare. Much more often, the danger is to themselves. I work with psychotic people daily. I don't know any who have a history of attempting to kill their spouse multiple times. That's just not how it typically goes.