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Welcome back to the Deep Dive.
Today, we are really getting into something crucial.
The foundations of care for serious mental illness, SMI.
That's right.
We're using a key chapter from foundational psychiatric nursing text to guide us, giving you the absolute must -know concepts.
Yeah, the essentials.
Our mission.
Cut through the noise.
Extract the core psychiatric, biological, therapeutic ideas about SMI.
We'll focus on the functional impact, the system failures.
Huge topic there and what real evidence -based care actually looks like.
That's so important because SMI, it refers to these biological psychiatric conditions.
They fundamentally mess with a person's ability to function, their quality of life.
Right.
And just terminology -wise for listeners in the US, you'll hear SMI from places like NIMH, San -HSA.
But globally, the WHO might use severe mental disorders, basically talking about the same kinds of conditions.
And the scale.
Yeah.
It's significant.
We're talking almost 11 .4 million adults in the US.
That's what?
About 4 .6 % of adults living with SMI.
And these are typically short -term things.
They're often lifelong, starting maybe late teens, early 20s.
And while recovery is always the goal, and it is possible.
Definitely.
The nature of SMI often means, well, cycles.
Yeah.
Periods of recovery.
Then maybe decompensation where symptoms get worse again.
And the impact.
Yeah.
You mentioned function.
It's devastating, isn't it?
Affecting basic things.
Absolutely devastating.
Things we take for granted.
Activities of daily living, making sound judgments, controlling impulses, even just concentrating.
All impaired.
Which then leads to these really tough social outcomes.
Higher rates of homelessness getting caught up in the justice system.
Poverty.
And victimization, too.
That's important.
Right.
And here's something really sobering, where you just see the scale of the systemic failure.
Yeah.
People with SMI have a significantly shorter life expectancy.
Yeah.
Like 10 to 20 years less than the general population.
That gap.
That 10 to 20 year gap, it just screams systemic neglect, doesn't it?
Both physical and mental health care.
It really does.
And it highlights why the whole approach to treatment had to change fundamentally.
For sure.
For decades, it was all about the rehabilitation model.
Very staff directed, right?
Focused on deficits, managing disability.
Kind of paternalistic.
Oh, incredibly paternalistic.
Advocacy groups like NAMI really had to push hard for a shift.
And that led us to the recovery model.
OK, the recovery model, what's the core difference there?
It's revolutionary, really.
It shifts the whole conversation.
Instead of what's wrong, it's what do you want for your future?
It's client centered, it's hopeful, empowering.
So focusing on strengths.
Exactly.
Strengths.
And it's an active partnership.
The person achieves goals they choose, not goals the staff think are best.
That philosophical shift from just managing symptoms to self -determination sounds critical.
It's the foundation.
But putting that into practice.
Well, there's a huge barrier, isn't there?
Something often mistaken for just being stubborn.
Anasognosia.
Ah, yes.
Anasognosia.
Crucial term.
It's the inability to recognize your ill.
And the key thing here,
it's not denial.
Denial is psychological.
OK.
Anasognosia is a neurological symptom.
The illness itself damages the parts of the brain needed for insight, for self -awareness.
So if the brain's compromised, just educating someone, telling them, take your meds, it's probably not going to work on its own.
Exactly.
It often fails.
That's why the nursing strategies outlined, you know, like in box 32 .1 of the text, are so practical and vital.
We have to work with this neurological symptom.
So what kind of strategies are we talking about?
Well, first, simplify things.
Make medication regimens easy.
Once a day dosing, if possible.
Makes sense.
Then tie adherence to their goals.
What does the patient want?
To keep their apartment.
Go back to work.
Link.
Taking meds to achieving that.
OK.
Connecting it personally.
Absolutely.
And build trust.
A sustained trusting relationship is huge, especially when insight is impaired.
And sometimes, you know, long acting injectable medications, depo injections become necessary.
They ensure the medication is actually in the system, bypassing the daily decision point.
Right.
So those interventions make it less confrontational, more collaborative.
That's the idea.
OK.
So even if we navigate anasognosia and adherence, we still face that deadly problem you mentioned earlier, the failure to address physical health.
Mm hmm.
Yes.
Physical problems, hypertension, diabetes, heart disease, way more common in people with SMI.
And undertreated.
Tragically undertreated.
Directly contributing to that shortened lifespan.
And the evidence is really strong here for integrating care.
Put mental and physical health services in one place.
Makes total sense.
One stop shop.
It improved coordination,
access.
Yeah.
Gets people the holistic care they need.
And then complicating that physical picture.
Substance use is pretty common, too, right?
Very common.
Yearly 30 % of adults with mental illness also struggle with substance abuse.
Alcohol, marijuana, meth, cocaine.
Why is that?
Is it self -medication?
Often, yes.
It's a maladaptive attempt to cope.
Trying to dull the anxiety, the dysphoria from the illness, or maybe even medication side effects.
But it backfires.
Massively.
It impairs judgment.
Impulse control.
Huge risk factor for psychiatric relapse hospitalization.
Okay.
And we also have to touch on smoking.
The nicotine paradox, some call it.
High rates.
Really high rates.
People with SMI smoke about 40 % of all cigarettes sold in the US.
And many think it calms their anxiety.
That doesn't.
Physiologically, no.
Nicotine's a stimulant.
Raises blood pressure, heart rate.
It can actually cause anxiety.
Plus, and this is critical, nicotine can make many psychotropic meds less effective.
So it's actively working against their treatment.
Wow.
Okay, so beyond health risks, there are huge social problems.
Stigma seems like a big one.
Enormous.
Stigma, the perception that someone is flawed creates these massive barriers.
Employment, housing, just be included socially.
And we need to bust that myth about dangerousness, right?
Absolutely.
The data is clear.
People with SMI are far more likely to be victims of violence and crime than perpetrators.
That stereotype is harmful and wrong.
And that stigma, those barriers, they translate into economic hardship.
Directly.
Over 60 % unemployment.
Even finding work is tough due to cognitive or functional issues.
And then there's the fight for insurance parity.
Parity, meaning equal coverage.
Yeah, the idea that mental health coverage should be the same as physical health coverage.
But often insurers put up extra hurdles for psychiatric care, pre -authorizations, limits.
Things you wouldn't see for, say, diabetes care.
Unfair.
And housing instability too.
Huge issue.
One manic episode,
maybe behavior leads to eviction.
Then that eviction record, or maybe an arrest, disqualifies them from housing subsidies.
It's a cycle.
Are there solutions emerging for housing?
Thankfully, yes.
Things like the no -reject -no -eject housing model.
It guarantees a client's room as hell, even during a long hospitalization.
That provides crucial stability.
That stability seems key.
Without a safe place to live, therapy must be incredibly difficult.
Almost impossible for progress to take root.
Okay, that brings us nicely to the solutions.
Let's shift gears and unpack the treatment models that actually work for improving community function.
Right, there are several evidence -based approaches.
First, assertive community treatment, ACT.
ACT?
What's that?
Think of it like a hospital without walls.
A whole team, multi -disciplinary, providing 247 support, crisis intervention, right there in the person's own environment.
It works.
Proven to reduce hospital stays and homelessness.
It's very effective for people with the most severe needs.
Okay.
What else?
Second,
cognitive behavioral therapy, CBT.
Most people have heard of CBT.
Yeah.
It works on two fronts.
Identifying and changing distorted thinking, that negative self -talk, that's the cognitive part, and using rewards, consequences to shape more adaptive behavior, the behavioral part.
Makes sense.
And you mentioned cognitive issues earlier.
Is there therapy for that?
Yes.
Third is cognitive enhancement therapy, CET.
This is interesting.
It's a structured, often lengthy program.
Uses things like computer drills, group exercises.
Sounds like brain training.
Kind of, yeah.
Based on neuroplasticity.
It aims to strengthen those core cognitive functions, damaged by SMI attention, processing speed, reading social cues.
Okay, CET.
And the fourth model tackles employment.
Right.
Supported employment.
This is way better than old school vocational rehab.
It's about rapid placement.
Get the person into a competitive job they actually want, quickly.
Placement first.
Placement first, then provide ongoing individualized support right on the job, linked with their mental health care.
That sounds much more effective.
Now all these models, they probably rely heavily on support systems.
Absolutely.
The sources consistently show strong family support is one of the best predictors of recovery.
And what about peer support?
Hugely valuable.
Peer support specialists, people who are themselves in recovery.
They use their lived experience to offer empathy, practical help.
That shared experience must build trust quickly.
It really does.
Increases acceptance of the whole process.
Okay.
Let's bring this right down to the nursing role.
Day to day.
What are the key things a nurse needs to assess with someone with SMI?
The assessment needs to be comprehensive.
You start with intentional risk.
Are they suicidal?
Homicidal.
Okay.
The immediate safety checks.
Right.
But just as important is unintentional risk.
Are they neglecting medical needs?
Basic self -care.
Is their judgment poor, leading to unsafe situations?
Ah, okay.
Risk beyond direct harm.
Exactly.
Nurses are also crucial for spotting early relapse signs.
Maybe decreased sleep, more paranoia, reality testing, getting shaky.
And always, always rule out physical causes first.
Drug toxicity, infection, some other medical issue, mimicking psychiatric symptoms.
Right.
Don't assume it's psychiatric relapse.
Never assume.
And that assessment, it directly informs the care plan, right?
Like the examples in table 32 .1.
Precisely.
You observe signs and symptoms, say someone avoiding eye contact, looking really uncomfortable socially.
That points to a nursing diagnosis, maybe impaired socialization.
And from that diagnosis?
You set clear, measurable outcomes.
If the diagnosis is impaired socialization, the desired outcome is improved socialization.
You look for evidence,
like them initiating contact or joining a group activity.
It's that systematic link.
Assessment, diagnosis, intervention, outcome.
That's effective nursing.
Got it.
Now, before we wrap up, we have to touch on some bigger ongoing systemic issues that challenge recovery.
Things like autonomy, freedom.
Two big ones stand out.
First, outpatient commitment.
Mandatory treatment in the community.
Yes, usually court ordered.
Often for people with severe anasognosia and a history of nonadherence leading to repeated hospitalizations or arrests.
Sounds controversial.
It is.
On one hand, it ensures needed care, keeps people housed, safer, but it's paternalistic.
It clashes directly with the recovery model's focus on self -determination.
A real ethical tightrope.
Okay.
And the second issue,
transinstitutionalization.
Transinstitutionalization.
Yeah, this is the terrible consequence of deinstitutionalization back in the 60s and 70s.
Closing the big state hospitals.
Exactly.
But the idea was robust community care would replace them.
That didn't happen adequately.
So where did people go?
They were shifted, transinstitutionalized into other institutions, jails, prisons,
nursing homes, sometimes homeless shelters.
Wait, so more people with SMI ended up in jail than in hospitals.
That's the reality today.
More individuals with serious mental illness are in correctional facilities than in psychiatric hospitals.
A massive policy failure we're still dealing with.
Wow, that's stark.
Okay, let's recap the absolute essentials from this deep dive.
Sounds good.
Key takeaway one, the shift to the recovery model is fundamental,
strengths -based, client -centered, hopeful.
Absolutely.
Two, understanding and addressing anosognosia as a neurological symptom, not just denial, is critical for treatment success.
Right.
And three, community -based team approaches like ACT really work.
They improve outcomes, reduce hospital use, improve quality of life.
Definitely.
And maybe a final thought connecting this to the bigger picture.
Caregiver burden.
Ah, yeah.
Families are crucial, but.
But caregivers age.
They get sick.
They pass away.
What really stands out is the need for proactive planning.
Crisis aversion planning.
Meaning?
Meaning planning for the client's financial stability, their care transition before the main caregiver is suddenly unable to help.
Planning ahead, preserve stability, prevents relapse when that transition happens.
Proactive planning, not reactive scrambling.
That's a really powerful, necessary thought for everyone involved in care.
Thank you so much for breaking all that down.
And thank you, our listeners, for joining us for this deep dive into the foundations of nursing care for serious mental illness.