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1. Mental Health Nursing
Nabina Paneru

2. Introduction to Mental Health
Mental Health is the capacity of an individual to form harmonious
relationships with others and to participate in or contribute
constructively to changes in the social environment.

3. Terminologies
Mental Health:
According to WHO “Mental Health is defined as the state of wellbeing
which in which every individual realizes his or her own potential, can cope
with the normal stresses of life, can work productively and fruitfully, and
is able to make a contribution to his or her community.”

4. Contd.
Mental health Nursing/ Psychiatric nursing
“ A specialty nursing practice focusing on the identification
of mental health issues, prevention of mental health
problems, and the care and treatment of persons with
psychiatric disorders.”
- The American Psychiatric Nurses Association

5. Contd.
Mental Illness
Mental illness indicates that the individual deviate from the normal
behavior. It consists of various symptoms in consciousness, motor
activity, thought, perception, affection and judgement.

6. Contd.
Mental Illness
“Maladaptive response to stressors from the internal or external
environment, evidenced by thoughts, feelings and behaviors that are
incongruent with the local and cultural norms and interfere with the
individual’s social, occupational, and/or physical functioning.”
- Townsend (2009)

7. Historical development of psychiatric nursing
Psychiatry – etymology
• Psychiatry is derived from the Greek words:
- Psyche: meaning “Mind” or “soul”
- Iatros: meaning “Physician”
• The term was coined by the German Physician Johann Christian Reil
in 1808

8. Historical Overview
• Pythagoras developed the concept that the brain is the seat of intellectual activity.
• Hippocrates described mental illness as hysteria, mania and depression and
associated mental illness with an irregularity in the interaction of four body fluids:
blood, black bile, yellow bile and phlegm treated by inducing vomiting and
diarrhea.
• Plato identified the relationship between mind and body.
• Chinese civilization mentioned the manifestation of mental illness like
disturbances in sleep pattern, grandiose ideas.

9. Contd.
• During 14th to 16th century In Europe: This period represented the
saddest chapter in the history of psychiatry when it was believed that
demos were the cause of hallucinations, delusions etc. and the
treatment as torture and even death.
• The first hospital in America to admit mentally ill client was
established in Philadelphia in the middle of the century.

10. Contd.
• Benjamin Rush often called the father of American psychiatry, was a
physician of the hospital. He initiated the provision of humanistic treatment
and care for the mentally ill.
• The 19th century brought the establishment of the system of state asylums.
• The period of scientific study and treatment of mental disorder began with
Sigmund Freud along with others, such as Emil Krapelin and Eugene
Bleuler in 1856 to 1939 AD.

11. Contd.
• A great leap in the treatment of mental illnesses began in about 1950
with the development of psychotropic drugs.
• The movement toward treating persons with mental illness in less
restrictive environments gained momentum in 1963 with the
enactment of the community Mental Health Center Act.
Deinstitutionalization, a deliberate shift from institutional care in
state hospitals to community facilities began.

12. Historical Overview of Psychiatric Nursing
• In 1840s Florence Nightingale made an attempt to meet the needs of
psychiatric patients with proper hygiene, better food, light and ventilation
and the use of drugs to chemically restrain violent and aggressive patients.
• Linda Richards, the first psychiatric nurse graduated in the United States in
1882 from Boston City College.
• In 1913, John Hopkins University: First college of nursing in the United
States to offer psychiatric nursing as part of its general curriculum.

13. Contd.
• The first psychiatric nursing textbook, Nursing Mental Diseases were
authorized by Harriet Bailey, in 1920.
• Psychiatric nursing was included in the basic nursing curriculum by
the International Council of Nurses in 1961.

14. History of Mental Health Care and Psychiatric Nursing
in Nepal
Previously
• Faith healers attended mentally ill.
• First psychiatric service was started in Nepal from general hospitals(In contrast to
west where services started from asylums)
1961
• First Psychiatric out patient service from Bir Hospital Kathmandu, by country’s first
psychiatrist Late Dr. Bishnu Prasad Sharma
1965
• A 5 bed in-patient psychiatric unit was created within Bir Hospital

15. Contd.
1972
• Psychiatric services started in Tri-Chandra Militiary Hospital now shifted to Birendra
Army Hospital.
• 1976: NGO sector started Rehabilitation Service
1984
• Psychiatric unit of Bir hospital was separated and shifted to Lagankhel in the old Patan
district hospital building.
• New building construction began at 2055 BS and completed by 2060 BS.
1986
• Outpatient service at Teaching hospital
• 1987: Inpatient service
• 1988: services started in Western Regional hospital outside Kathmandu

16. Contd.
1989
• MHP (Mental health Project) established with the financial aid of INGO’s in Kathmandu
which spread to other districts (Morang, Kaski, syangja) in upcoming years.
• Then after different rehab centers were established.
1995 • BPKIHS started psychiatric services
2000
onward
• 2000: Bachelor in Nursing (major in psychiatric Nursing) in Maharajgunj Nursing Campus
started with intake of 4 students
• 2007: BN in nursing (major in psychiatric nursing) in Lalitpur Nursing Campus with intake of 5
students
• 2008: BPKIHS started Masters in Nursing (Psychiatric) with intake of 3 students
• 2017: Masters in Psychiatric Nursing started in Lalitpur Nurssing Campus

17. Characteristics of Mentally Healthy Individual
• Have ability to make adjustments, to accept themselves, others and nature.
• Have a sense of personal worth, feels worthwhile, and important.
• Have a sense of personal security and feel secure in a group.
• Have sense of responsibility and recognize limitations.
• They can give and accept love. They are able to form close relationship with
others and kindness, patience, and compassion are displayed for others.

18. Contd.
• They search for an identity. They have positive self concept and are
optimistic, and accepts responsibilities for action.
• They are productive. They are free from internal conflicts. They are able to
appreciate and enjoy life.
• They are creative, utilizing a variety of approaches as they perform tasks and
solve problems.
• Their behavior is consistent as they appreciate and respect the rights of
others, display willingness to listen and learn from others.

19. Contd.
• They show emotional maturity in his behavior and develop a capacity to
tolerate frustration and disappointments in his daily life.
• They are able to face with relative serenity and happiness circumstances.
• They are independent and autonomous in thought and action and rely on
personal standards of behavior and values.
• They solve their problems largely by their own effort and make their own
decisions, Uses sound judgement to make decisions.

20. Major Classification of Mental Disorder/ Illness
Traditional Classification of Mental Illness
• Neurosis and Psychosis

21. Mental Disorders
Psychosis Neurosis
- Anxiety disorder
- OCD
- Dissociative
disorder
Special disorders
- Childhood disorders
- Personality disorders
- Substance use
disorders
- Somatoform
disorders
- Mental retardation
Affective
- Mania
- Depression
- Bipolar/ cyclic
Functional
- Schizophrenia
Organic
- Delirium
- Dementia

22. Neurosis and Psychosis
Criteria Neurosis Psychosis
Definition It is a minor disorder,
manifestation with specific
clinical phenomena in the
absence of psychical phenomena
It is a severe mental illness, characterized by a
loss of contact with the reality and a deep
disruption of the relationships with other
people, causing social withdrawal
Types Anxiety, fearful neurosis,
hysteria, compulsive conditions/
phobic disorders
Schizophrenia, bipolar affective disorder,
delusions, paranoia, chronic hallucinatory
psychosis, senile or pre – senile dementia, etc
Personality
changes
These are purely functional
diseases and do not affect the
personality
This lead to the change of the personality

23. Contd.
Criteria Neurosis Psychosis
Contact with reality The contact with reality is
partially intact, though its value
can be changed
The contact with reality is
totally lost or changed
Insight/ Awareness The person is aware of his/her
personal problems and difficulties
The person does not realizes
his/her disorder
Communication Does nt affect language,
communication, and thought
processes
The thought and speech
processes are disorganized and
incoherent and irrational
Hallucination and
Delusion
In general no hallucination and
delusion occurs
Hallucination and delusions are
marked symptoms

24. Contd.
Criteria Neurosis Psychosis
Organic
changes and
Etiology
It is a purely functional mental disorders
without organic reasons
Etiology: Biological, socio-psychic
climate, psychological, socio –
economic etc.
It is associated with certain morphological and
functional changes in the body, the disease changes the
anatomical structures and functions of the neuro-
cerebral substances
Etiology: Genetic, Biochemical and environmental
Behavior It can be managed at home and are
rarely suicidal. Hospitalization is always
not necessary
The psychotics cannot be managed at home. They
often tend to suicide and need hospitalization
Treatment Is mainly psychological in the form of
moral and social support, medicines can
also be prescribed
Includes antipsychotic medicines, psychological
therapy, social support
Self - harm Lower risk of self harm Higher risk of self harm

25. Classification of Mental Illness according to ICD 10
• The International Statistical Classification of Diseases and Related
Health Problems, usually cited by short form: ICD ( International
Classification of Disease)
• It is : “standard diagnostic tool for epidemiology, health management
and clinical purpose”
• Published by WHO

26. ICD 10 Disorder, Condition or Problem
F00 – F09 (F0) Organic, including symptomatic, mental disorders
F10 – F19 (F1) Mental and behavioral disorders due to psychoactive substance use
F20 – F29 (F2) Schizophrenia, Schizotypal and delusional disorders
F30 – F39 (F3) Mood (affective) disorders
F40 – F48 (F4) Neurotic, stress – related and somatoform disorders
F50 – F59 (F5) Behavioral syndromes associated with physiological disturbances and physical factors
F60 – F69 (F6) Disorders of adult personality and behavior
F70 – F79 (F7) Mental retardation
F80 – F89 (F8) Disorders of psychological development
F90 – F98 (F9) Behavioral and Emotional disorders with onset usually occurring in childhood and adolescence
F99 Unspecified Mental disorder

27. The DSM - IV
• The diagnostic and Statistical Manual of Mental Disorders (DSM)
published by American Psychiatric Association, offers a common
language and standard criteria for the classification of mental
disorders.
• Used together with the alternatives such as ICD

28. Contd.
The DSM – IV – TR (text Revision, 2000) consisted of five axes (domains)
on
Which disorder could be assessed. The Five axes were:
Axis I: Clinical Disorders (all mental disorders except Personality Disorders
and Mental Retardation)
Axis II: Personality Disorders and Mental Retardation
Axis III: General Medical Conditions (must be connected to a Mental
Disorder)

29. Contd.
Axis IV: Psychosocial and Environmental Problems (for example
limited social support network)
Axis V: Global Assessment of Functioning (Psychological, social and
job-related functions are evaluated on a continuum between
mental health and extreme mental disorder)

30. Contd.
• The axis classification was removed in the DSM – V and is now mostly of
historical significance. The main categories of disorder in the DSM are:
DSM Group Examples
Disorders usually first diagnosed in infancy, childhood or
adolescence. *Disorders such as ADHD and epilepsy have also been
referred to as developmental disorders and developmental
disabilities.
ADHD
Delirium, dementia, and amnesia and other cognitive disorders Alzheimer's disease
Mental disorders due to a general medical condition AIDS-related psychosis
Substance-related disorders Alcohol abuse

31. DSM Group Examples
Mood disorders Major depressive disorder, Bipolar disorder
Anxiety disorders Generalized anxiety disorder, Social anxiety disorder
Somatoform disorders Somatization disorder
Factitious disorders Munchausen syndrome
Dissociative disorders Dissociative identity disorders
Sexual and gender identity disorders Dyspareunia, Gender identity disorder
Eating disorders Anorexia nervosa (self starvation), Bulimia nervosa (over)
Sleep disorders Insomnia
Impluse control disorders Kleptomania (irresistible urge to steal)
Adjustment disorders Adjustment disorder
Personality disorders Narcissistic personality disorder
Other conditions that may be a focus of clinical attention Tardive dyskinesia, child abuse

32. Global Mental Health Status
• The global burden of mental illness in 2010 was $2.5 trillion and is
projected to rise above $6 trillion by 2030.
• Around 20% of the world's children and adolescents have mental
disorders or problems.
• Most low- and middle-income countries have only one child
psychiatrist for every 1 to 4 million people.

33. Contd.
• About 23% of all years lost because of disability is caused by mental
and substance use disorders.
• Over 800 000 people die due to suicide every year.
• 75% of suicides occur in low- and middle-income countries.
• Low-income countries have 0.05 psychiatrists and 0.42 nurses per 100
000 people.

34. Contd.
Mental health Disorder Estimated prevalent cases in 2013 (millions)
Anxiety Disorders 265.6
Major depressive disorder 253.3
Dysthymia 102.4
Alcohol Use disorders 76.9
Alzheimer’s disease 53.1
Bipolar Disorder 48.8
Schizophrenia 23.6
Global Burden of Disease Study 2013

35. Mental Health in Asian Region
• Mental health services in South-East Asia tend to be urban-centered
and hospital-based and 80%-90% of populations have no access to
treatment.
• Number of people who commit suicide is higher than the number who
dies because of road accidents, terrorism and HIV/Aids.

36. Contd.
• Over 90% of suicide cases relate to mental disorder.
• Asia is among the top three causes of death in the population aged
between 15 and 34.
• There is huge scarcity of resources to address the mental health needs
of the population in South Asia

37. Magnitude of mental health problem in Nepal
The World Health Organization Assessment Instrument for Mental
Health Systems (WHO-AIMS) was used to collect information on the
mental health system in Nepal.
Nepal's mental health policy was formulated in 1996.

38. Mental Health in Nepal
• Approximately 30% of the population of Nepal is suffering from psychiatric problems.
• Over 90 percent of the population who needs mental health services has no access to
treatment.
• Government spending is less than 1% of its total healthcare budget on mental health.
• Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06
psychologists per a population of 100,000.
• There are approximately only 50 psychiatric clinics and 12 psychological counseling
centers.

39. Contd.
• The gap between treatment and the magnitude of the mental health
problem is over 85 percent.
• Across the whole country, there are estimated to be around 1.5 beds
per a population of 100,000 for mental health patients.
• The number of suicides among the group reproductive women had
increased from 22 per 100,000 in 1998 to 28 per 100,000 in 2008.
• Only 2% of medical and nursing training is dedicated to mental health

40. Reference of data
MENTAL HEALTH IN NEPAL (6/4/2016) By Sudip Upreti and Bipul
Lamichanne, Health Research and Social Development Forum (HERD)
Thapathali, Kathmandu

41. Cause of Mental Illness
The exact cause of mental illness are unknown.
Causes of
mental Illness
Environmental
Factors
Psychological
Factors
Genetic/
Biological
Factors
Physical
Factors
Physiological
Factors

42. Causes
1. Biological Factors
- Heredity
- Bio chemical factors
- Brain damage
- Prenatal damage
- Substance abuse
- Other factors like (poor nutrition, exposure to toxins etc)

43. Contd.
2. Psychological factors
- Psychological trauma suffered in childhood (emotional, physical or
sexual abuse, loss of parents, maltreatment)
- Stress

44. Contd.
3. Environmental Factors
- Poverty
- Society and cultures
4. Physical factors
5. Physiological factors

45. Myths and Misconceptions of Mental Illness
Myth 1: A person who has had a mental illness can never be normal.
Myth 2: Young people and children don’t suffer from mental health
problems
Myth 3: Mentally ill persons are dangerous violent and unpredictable
Myth 4: People who need psychiatric care should be locked away in
institutions

46. Contd.
Myth 5: It is impossible to prevent mental illnesses
Myth 6: Electroconvulsive therapy in painful
Myth 7: People with a mental illness lack intelligence
Myth 8: People with a mental illness shouldn’t work because they’ll just
drag down the rest of the staff
Myth 9: Mental illness is a single, rare disorder

47. Contd.
Myth 10: Psychiatric disorders are not true illnesses like heart disease or
cancer; people who have a mental illness are just “crazy”
Myth 11: Therapy and self – help are a waste of time
Myth 12: People with mental illness, cannot tolerate the stress of holding
down a job
Myth 13: I cant do anything for a person with a mental health problem
Myth 14: Addiction is a lifestyle choice and shows a lack of willpower