Psychiatric Nursing ▪ Mastery of the environment

▪ Education
Health (WHO) ▪ Employment
▪ State of complete physical, mental and social ▪ Income and Social Protection
wellness and not merely the absence of disease or
infirmity ▪ Food security
▪ Emphasis on health as a positive state of well Mental illness
being
▪ Disorders that affect mood, behavior, and
Mental health thinking
▪ A dynamic and ever-changing state ▪ Cause significant distress, impaired functioning
or both
▪ Influenced by many factors ▪ Individuals experience dissatisfaction with self,
▪ Individual relationships and ineffective coping
▪ Interpersonal Factors contributing to
mental illness
▪ Socio-cultural
Individual/personal factors ▪ Individual
▪ Biologic make-up ▪ Biologic make-up
▪ Intolerable or unrealistic worries or
▪ Autonomy and independence – toddlerhood fears
▪ Inability to distinguish reality from
▪ Self-esteem fantasy
▪ Intolerance of life’s uncertainties
▪ Capacity for growth
▪ A sense of disharmony in life
▪ Vitality ▪ Loss of meaning in one’s life
▪ Ability to find meaning in life ▪ Interpersonal
▪ Emotional resilience or hardiness ▪ Ineffective communication
▪ Excessive dependency on or withdrawal
▪ Sense of belonging from relationships
▪ Reality orientation – living in fantasy ▪ No sense of belonging
▪ Inadequate social support
▪ Coping or Stress management abilities ▪ Loss of emotional control

Interpersonal/relationship
▪ Socio-cultural
▪ Lack of resources
• Effective communication
• Ability to help others ▪ Violence
• Intimacy – young adults ▪ Homelessness
• Balance of separateness and connectedness
▪ Poverty
Social Determinants ▪ An unwarranted negative view of the
world
▪ Non-medical factors ▪ Discrimination such as stigma, racism,
▪ Sense of community classism, ageism, and sexism
▪ Access to adequate resources
▪ Intolerance of violence
▪ Support of diversity among people

Mental health statistics (DOH)
▪ 2004 WHO study, up to 60% of people attending
primary care clinics daily in the country are
estimated to have one or more MNS disorders.
▪ 2000 Census of Population and Housing showed
that mental illness and mental retardation
rank 3rd and 4th respectively among the types
of disabilities in the country (88/100,000
▪ Data from the Philippine General Hospital in
2014 show that epilepsy accounts for 33.44%
of adult and 66.20% of pediatric neurologic
out-patient visits per year.
▪ Drug use prevalence among Filipinos aged 10 to
69 years old is at 2.3%, or an estimated 1.8
million users according to the DDB 2015
Nationwide Survey on the Nature and Extent of
Drug Abuse in the Philippines
▪ 2011 WHO Global School-Based Health Survey
has shown that in the Philippines, 16% of
students between 13-15 years old have ever
seriously considered attempting suicide while
13% have actually attempted suicide one or
more times during the past year.
▪ The incidence of suicide in males increased from
0.23 to 3.59 per 100,000 between 1984 and
2005 while rates rose from 0.12 to 1.09 per
100,000 in females (Redaniel, Dalida and
Gunnell, 2011).
▪ Intentional self-harm is the 9th leading cause
of death among the 20-24 years old (DOH,
2003).
▪ A study conducted among government
employees in Metro Manila revealed that 32%
out of 327 respondents have experienced a
mental health problem in their lifetime (DOH
2006).
▪ Based on Global Epidemiology on Kaplan and
Sadock’s Synopsis of Psychiatry, 2015 and
Kaufman’s Clinical Neurology for Psychiatrists,
7th edition, 2013
▪ Schizophrenia ---1% …..1 Million
▪ Bipolar ---1% …. 1 Million
▪ Major Depressive Disorder ---17%
…. 17 M
▪ Dementia --- 5% (of older than
65) …..
▪ Epilepsy ---0.06% …. 600,000
Mental health is everyone’s
business
Roles of the health sector
▪ Provide care
▪ Equitable and rights-based services,
irrespective of age, gender, socio-
economic status, race, ethnicity,
disability or sexual orientation
▪ Most useful when they are delivered at
community levels, by practitioners
best suited to provide effective care
within the constraints of available
human and financial resources
▪ Promote and prevent
 ▪ Advocate for and provide promotion
and prevention programmes, in
collaboration with other sectors
▪ Can build awareness and understanding
of mental health, end stigma and
discrimination, and lessen the need for
treatment and recovery services
▪ Work in partnership
▪ can partner with all stakeholders – in
government, civil society, the private
sector and especially among people
with lived experience – to ensure
multisectoral, inclusive and people-
centered support for people with
mental health conditions.
▪ Support related initiatives.
▪ Advocate for and help address the
structural risks and protective
factors influencing mental health –
the conditions in which people are born
and live
▪ Can promote and contribute to a
whole-of-government and all-of-
society approach to mental health.
Republic act 11036
▪ An Act Establishing a National Mental Health
Policy for the Purpose of Enhancing the Delivery
of Integrated Mental Health Services, Promoting
and Protecting the Rights of Persons Utilizing
Psychosocial Health Services, Appropriating
Funds Therefor and Other Purposes
▪ Mental Health Act
Mental health services
▪ Section 14. Quality of Mental Health
Services. - Mental health services provided
pursuant to this Act shall be:
▪ (a) Based on medical and scientific research
findings;
▪ (b) Responsive to the clinical, gender, cultural
and ethnic and other special needs of the
individuals being served;
▪ (c) Most appropriate and least restrictive
setting:
▪ (d) Age appropriate; and
▪ (e) Provided by mental health professionals
and workers in a manner that ensures
accountability.
▪ Section 15. Mental Heath Services at the
Community Level. - Responsive primary mental
health services shall be developed and
integrated as part of the basic health services
at the appropriate level of care, particularly at
the city, municipal, and barangay level. The
standards of metal health services shall be
determined by the DOH in consultation with
stakeholders based on current evidences.
▪ Every local government unit (LGU) and
academic institution shall create their own
program in accordance with the general
guidelines set by the Philippine Council for
Mental Health, created under this Act, in
coordination with other stakeholders. LGUs and
academic institutions shall coordinate with all
concerned government agencies and the private
sector for the implementation of the program.
▪ Section 16. Community-based Mental Heath
Care Facilities. - The national government
through the DOH shall fund the establishment
and assist in the operation of community-
based mental health care facilities in the
provinces, cities and cluster of municipalities in
the entire country based on the needs of the
population, to provide appropriate mental health
care services, and enhance the rights-based
approach to mental health care.
▪ Each community-based mental health care
facility shall in addition to adequate room,
office or clinic, have a complement of mental
health professionals, allied professionals,
support staff, trained barangay health workers
(BHWs) volunteer, family members of patients
or service users, basic equipment and supplies
and adequate stock of medicines appropriate at
that level.
▪ Section 17. Reportorial Requirements. - LGUs
through their health offices shall make a
quarterly report to the Philippine Conucil for
Mental Health through the DOH. The report shall
include, among others, the following data:
number of patients/service users attended to
and or served, the respective kinds of mental
illness or disability, duration and result of the
treatment, and patients/users' age, gender,
educational attainment and employment without
disclosing the identities of such
patients/service user for confidentiality.
▪ Section 18. Psychiatric, Psychosocial, and
Neurologic Services in Regional, Provincial, and
 Tertiary Hospitals. - All regional, provincial,
and tertiary hospitals, including private
hospitals rendering service to paying patients,
shall provide the following psychiatric,
psychosocial, and neurologic services;
▪ (a) Short-term, in-patient, hospital care in a
small psychiatric or neurologic ward for
service users exhibiting acute psychiatric or
neurologic symptoms;
▪ (b) Partial hospital care for those exhibiting
psychiatric symptoms or experiencing
difficulties vis-à-vis their personal and family
circumstances;
▪ (c) Out-patient in close collaboration with
existing mental health programs at primary
health care centers in the same area;
▪ (d) Home care services for services users with
special needs as a result of, among others,
long-term hospitalization, non-compliances
with or inadequacy of treatment, and absence
of immediate family;
▪ (e) Coordination with drug rehabilitation
center vis-a-vis the care, treatment, and
rehabilitation of persons suffering from
addiction and other substance-induced mental
health conditions; and
▪ (f) A referral system involving other public
and private health and social welfare service
providers, for the purpose of expanding access
to programs aimed at preventing mental illness
and managing the condition of persons at risk
of developing mental, neurologic, and
psychosocial problems.
▪ Section 19. Duties and Responsibilities of
Mental Health Facilities. - Mental health
facilities shall:
▪ (a) Establish policies, guidelines, and protocols
for minimizing the use of restrictive care and
involuntary treatment;
▪ (b) Inform service user of their rights under
this Act and all other pertinent laws and
regulations;
▪ (c) Provide every service user, whether
admitted for voluntary treatment, with
complete information regarding the plan of
treatment to be implemented;
▪ (d) Ensure that informed consent is obtained
from service users prior to the implementation
of any medical procedure or plan of treatment
or care, except during psychiatric or neurologic
emergencies or when the service user has
impairment or temporary loss of decision-
making capacity;
▪ (e) Maintain a register containing information
on all medical treatments and procedures
administered to service users; and
▪ (f) Ensure that legal representatives are
designated or appointed only after the
requirements of this Act and the procedures
established for the purpose have been observed,
which procedures should respect the autonomy
and preferences of the patient as far as
possible.
▪ Section 20. Drug Screening Services. -
Pursuant to its duty to provide mental health
service and consistent with the policy of
treating drug dependency as a mental health
issue, each local health care facility must be
capable of conducting drug screening.
▪ Section 21. Suicide Prevention. - Mental
health services shall also include mechanisms
for suicide intervention, prevention, and
response strategies, with particular attention
to the concerns of the youth. Twenty-four
seven (24/7) hotlines, to provide assistance
to individuals with mental health conditions,
especially individuals at risk of committing
suicide, shall be set up, and existing hotlines
shall be strengthened.
▪ Section 22. Public Awareness. - The DOH and
the LGUs shall initiate and sustain a heightened
nationwide multimedia campaign to raise the
level of public awareness on the protection and
promotion of mental health and rights
including, but not limited to, mental health and
nutrition, stress handling, guidance and
counseling, and other elements of mental
health.
CHAPTER V
EDUCATION, PROMOTION OF MENTAL
HEALTH
IN EDUCATIONAL INSTITUTIONS AND
IN THE WORKPLACE
▪ Section 23. Integration of Mental Health into
the Educational System. - The State shall
ensure the integration of mental health into the
educational system, as follows:
▪ (a) Age-appropriate content pertaining to
mental health shall be integrated into the
curriculum at all educational levels; and
 ▪ (b) Psychiatry and neurology shall be required
subjects in all medical and allied health
courses, including post-graduate courses in
health.
▪ Section 24. Mental Health Promotion in
Educational Institutions. - Educational
Institutions, such as schools, colleges,
universities, and technical schools, shall
develop policies and programs for students,
educators, and other employees designed to:
raise awareness on mental health issues,
identified and provide support and services for
individuals at risk, and facility access,
including referral mechanisms of individual with
metal health conditions to treatment and
psychosocial support.
▪ All public and private educational institutions
shall be required to have a complement of
mental health professionals.
▪ Section 25. Mental Health Promotion and
Policies in the Workplace. - Employers shall
develop appropriate policies and programs on
mental health issues, correct the stigma and
discrimination associated with mental
conditions, identify and provide support for
individuals with mental health conditions to
treatment and psychosocial support.
Historical Perspectives of the
Treatment of Mental Illness
Ancient times
• Any sickness indicated displeasure of the gods
• Punishment for sins and wrongdoing
• People with Mental Illness – viewed as either
divine or demonic
• Aristotle – attempted to relate mental
disorders to physical disorders
• Developed a theory that the amounts
of blood, water and yellow and black
bile in the body controlled the
emotions
• Correspond with happiness,
calmness, anger, and sadness
• Imbalances can cause mental
illness
Treatment: aimed at restoring balance through blood
letting, starving, and purging...
Early Christian times
• Primitive beliefs and superstitions were strong
• All diseases blamed on demons
• Mentally ill – viewed as “possessed
• Priests performed exorcism to rid sufferers of
evil spirits
• Use of incarcerations in dungeons, flogging and
starving
Renaissance
• People with mental illness were distinguished
from criminals
• Harmless – allowed to wander the countryside
or live in rural communities
• ”Dangerous Lunatics” – thrown in prison,
chained and starved
• Mentally ill considered evil or possessed
Hospital of St. Mary of Bethlehem
• Officially declared a hospital for the insane,
the first of its kind in 1547
• 1775 - Visitors were charged a fee for the
privilege of viewing and ridiculing the inmates
(McMillan, 1997)
Period of enlightenment (1790)
• Asylum - formulated by Philippe Pinel (France)
and William Tuke (England)
• A safe refuge or haven offering
protection at institutions where people
hade been whipped, beaten and starved
because they were mentally ill
• Moral treatment of the mentally ill
• Dorothy Dix (1802-1887) – began a crusade to
reform the treatment of mental illness after a
visit to Tuke’s institution in England
• Instrumental in opening 32 state
hospitals in the US that offered
asylum to the suffering
 • Advocated adequate shelter, nutritious
food and warm clothing
• Short- lived – After 100 years,
attendants were accused of abusing
residents of state hospitals
• Philippe Pinel
• William Tuke
Period of scientific study and treatment
of mental disorders
• Began with Sigmund Freud, Emil Kraepelin, and
Eugen Bleuler (1857-1939)
• Study of psychiatry and diagnosis and
treatment of mental illness
• Freud challenged society to view human beings
objectively
• Kraepelin began classifying mental disorders
according to their symptoms
• Bleuler coined the term schizophrenia
Sigmund Freud (1856-1939)
Emil Kraepelin (1856-1926)
Eugen Bleuler (1857-1939)
Development of Psychopharmacology
(1950)
• First Psychotropic Drugs to be discovered:
• Chlorpromazine (Thorazine) –
antipsychotic drug
• Lithium – anti-manic agent
• Monoamine oxidase inhibitor – anti-depressant
• Haloperidol (Haldol) – anti-psychotic
• Tricyclic anti-depressants
• Benzodiazepine – anti-anxiety agents
Community mental health
• Less restrictive environments
• Deinstitutionalization – a deliberate shift from
institutional care to community facilities
• Community Mental Health Centers
• Served smaller geographic catchment
• Less restrictive treatment located
closer to individual’s homes, families
and friends
• Provided emergency care, impatient
care, outpatient services, partial
hospitalization, screening services, and
education
• Income for disabled persons
21st Century
• Revolving Door Effect – People with severe and
persistent mental illness have shorter hospital
stays, but they are admitted to hospitals more
frequently
• Boarding – Patients are “boarded” or kept in
the Emergency Department while waiting to see
if the crisis de-escalates i=or until an
inpatient bed can be located or becomes
available
• Planned or self-admission – short hospital
stays and do not contribute to revolving door
phenomenon
• Homeless population
• Substance abuse
Healthy People 2030 Mental Health
Objectives
• Reduce the suicide rate
• Reduce suicide attempts by adolescents
• Reduce suicidal thoughts in LGBT students
• Increase the proportion of children and
adolescents who get preventive mental health
care in school
• Increase the proportion of children and
adolescents who get treatment
• Reduce the proportion of persons who experience
major depressive episodes
• Increase the proportion of adults with mental
health disorders who receive treatment
 • Increase the proportions of persons with co- • Client is assigned to a case manager who
occurring substance abuse and mental coordinates all types of care needed by the
disorders who receice treatment for both client
disorders
• Decreases fragmented care from a variety of
• Increase depression screening by primary care sources
providers
• Eliminates unneeded overlap of services
• Increase the number of homeless adults with
mental health problems who receive mental • Provides care in the least restrictive
health services environment
• Reduce anxiety and depression in family • Decreases cost for insurers
caregivers Psychiatric Care
• Reduce the proportion of adults with disabilities
who experience serious psychological distress • Costly because of long term nature of the
or delay preventive care because of cost disorders
• Increase proportion of women screened for Psychiatric Nursing Practice – History
postpartum depression
• Linda Richards (1873)
Consequences of Non-Treatment
• First graduate nurse in the United
• Deterioration of personal relationships States
• Worsening of untreated disorder • First American psychiatric nurse
• Physical health problems
• Homelessness • Believed that the mentally sick should
be at least as well cared for as the
• Psychiatric boarding physically sick
• Arrest
• Incarceration • First Training of nurses to work with persons
• Victimization with mental illness – McLean Hospital in
• Suicidality Belmont Massachusetts (1882)
• Familial violence • Custodial care focused on nutirion,
• Danger to Others
hygiene, and activity
Community Support Service Programs
• Nurses adopted medical-surgical principles to
• Meet the needs of persons with mental illness the care of clients with psychiatric disorders
outside the wall of the institution and treated them with tolerance and kindness
• Focus: • Somatic Treatments
•
Rehabilitation • Insulin shock therapy (1935)
•
Vocational support
•
Education • Psychosurgery (1936)
•
Socialization
•
Management of symptoms • Electroconvulsive therapy (1937)
• Medications
Managed Care • Nursing Mental Disease by Harriet Bailey (1920)
• Designed to purposely control the balance – first psychiatric nursing textbook
between the quality of care provided and the
cost of that care • John Hopkins (1913) – fisrt school of nursing
• People receive care based on need rather than to include a course in psychiatric nursing in its
request curriculum

Case Management • National League of Nurses (1950)- started

accrediting nursing programs and required
• Management of care on a case-to-case basis schools to include an experience in psychiatric
nursing
 • Two Early Nursing Theorists that Shaped
Psychiatric Nursing Practice
• Hildegard Peplau
• June Mellow
Hildegard Peplau
• Published Interpersonal relations in Nursing
(1952)
• Interpersonal techniques: Crux of Psychiatric
Nursing (1962)
• Described the therapeutic nurse-client
relationship with its phases and tasks
• Wrote intensively about anxiety
June Mellow
• Nursing Therapy (1968)
• Described her approach of focusing on client’s
psychosocial needs and strengths
• Contended that the nurse as a therapist is
particularly suited to working with those with
severe mental illness in the context of daily
activities, focusing on the here and now to
meet each person’s psychosocial needs
ANA Standards of Care
• Authoritative statements that describe the
responsibilities for which nurses are
accountable
American Psychiatric Nurses
Association (APNA)
• Outline areas of practice and phenomena of
concern for the psychiatric mental health nurse
• Incorporate the phases of the nursing process,
including specific types of interventions for
nurses in psychiatric settings
Psychiatric-Mental Health Nursing
Phenomena of Concern
• Promotion of optimal mental and physical
health and well being and prevention of mental
illness
• Impaired ability to function related to
psychiatric, emotional, and physiological
distress
• Alterations in thinking, perceiving, and
communicating because of psychiatric disorders
or mental health problems
• Behaviors and mental states that indicate
potential danger to self or others
• Emotional stress related to illness, pain,
disability, and loss
• Symptom management, side effects, or
toxicities assocaiated with self-administered
drugs, psycho-pharmacologic interventions, and
other treatment modalities
• The barriers to treatment efficacy and
recovery posed by alcohol and substance abuse
and dependence
• Self-concept and body image changes,
developmental issues, life process changes and
end-of-life issues
• Physical symptoms that occur akong with
altered psychological status
• Psychological symptoms that occur along with
altered physiologic status
• Interpersonal, psychological, sociocultural,
spiritual, or environmental circumstances or
events that have an effect on the mental and
emotional well-being of the individual and
fanily or community
• Elements off recovery, including the ability to
maintain housing, employment, and social
support, that help individuals reengage in
seeking meaningful lives
• Societal factors such as violence, poverty, and
substance abuse
Areas of Practice- Basic Level Functions
• Counseling
• Interventions and communication
techniques
 • Problem solving
• Crisis intervention
• Stress Management
• Behavior modification
• Milieu Therapy
• Maintain therapeutic environment
• Teach skills
• Encourage communication between
clients and others
• Promote growth through role modeling
• Self-care Activities
• Encourage independence
• Increase self-esteem
• Improve function and health
• Psychobiologic Interventions
• Administer medications
• Teach
• Observe
• Health teaching
• Case Management
• Health promotion and maintenance
Areas of Practice- Advanced Level
Functions
• Psychotherapy
• Prescriptive authority for drugs
• Consultation and liaison
• Evaluation
• Program development and management
• Clinical supervision