This document provides information on mental health, mental illness, psychiatric nursing, and the mental health system in Nepal. It defines mental health as a state of well-being and balance between an individual and their environment. Mental illness is defined as a maladjustment resulting in problematic responses. The document outlines characteristics of mentally healthy individuals and various causes of mental illness including biological, psychological, social, and physical factors. It discusses the history of psychiatry and psychiatric nursing. National mental health policies and strategies in Nepal aim to ensure access to services, develop human resources, protect patient rights, and increase mental health awareness. The roles, principles, and admission/discharge procedures of psychiatric nursing are described.

1. MENTAL HEALTH AND ILLNESS
Prepared by:
Laxmi Dahal

2. 1.1 MENTAL HEALTH
• The capacity of an individual to form harmonious
relationship with others and to participate in, or
contribute constructively to, changes in the social
environment.
(WHO)
• It is a state of balance between the individual and
the surrounding world, harmony between oneself
and others, co-existence between the realities of the
self and that of the other people and that of the
environment.
( R. Sreevani)

3. 1.5 Characteristics of mentally healthy
individual
• Ability to make judgment
• Have sense of personal worth and personal security
• Makes an own decision, good control over behavior
• Free from internal conflict
• Sense of responsibility, ability to cope with stress and
anxiety.

4. Contd…..
• Give and accept love
• Searches for identity
• Shows emotional maturity
• Should have variety of interest
• Should involved in productive work.

5. • Lives in the world of reality rather than
fantasy.
• Develops a philosophy of life that gives
meaning and purpose to his daily activities.

6. 1.1 Mental Health nursing
• Is a specialized profession in nursing field.
• Scientific method of delivering the quality nursing care
to mentally ill patient using nursing process.
• The essential component in psychiatric nursing is nurse
patient relationship.
• Emphasize on problematic, psychological and
behavioral human responses of patient rather than
diagnosis of mental illness.

7. Definition
• It is a specialized area of nursing practice,
employing theories of human behaviour as it
is a science, and the purposeful use of self as
it is an art, in the diagnosis and treatment of
human responses to actual or potential
mental health problems.
ANA, 1994

8. Principles of psychiatric nursing
1. Patient is accepted exactly as he is
2. Nurse should use awareness as therapeutic
tool
3.Consistency used to contribute to patient’s
security:

9. Principles of psychiatric nursing
4. Reassurance should be given in a subtle and
acceptable manner
5. Patient’s behavior is changed through
emotional experience and not by rational
interpretation
6. Unnecessary increase in the patient’s anxiety
should be avoided

10. Principles of psychiatric nursing
7. Objective observation of patient to understand his
behavior;
8. Maintain realistic nurse patient relationship
9. Avoid physical and verbal force as much as
possible;
10. Nursing care is centered on the patient as a
person and not on the control of symptoms;

11. Principles of psychiatric nursing
11. Information according to the level of the
patient;
12. Many procedures are modified but basic
principles remains unaltered.

12. 1.2 Historical perspective of
psychiatry and psychiatric nursing
• In the 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.
(Reddemma K & Nagarajaiah, 2004)
• Linda Richards, the first psychiatric nurse graduated in
the United States in 1882 from Boston City College.

13. Historical perspective of
psychiatry and psychiatric nursing
• In 1913 Johns Hopkins University was the first college of
nursing in the United States to offer psychiatric nursing as
part of its general curriculum.
• The first psychiatric nursing textbook, Nursing Mental
Diseases were authored by Harriet Bailey, in 1920.
• The registration of psychiatric nurses was done by 1920 in
the UK and degree courses in psychiatric nursing began in
the USA.

14. Historical perspective of
psychiatry and psychiatric nursing
• Psychiatric nursing was included in the basic nursing
curriculum by the International Council of Nurses in
1961.
• In 1963, President John F. Kennedy in United States
passed the Community Mental Health Act which
proposed the deinstitutionalization of mentally ill
persons.
• http://nursingplanet.com/pn/introduction_to_psychia
tric_nursing.html18

15. Mental health services in Nepal
• Psychiatric service remained virtually unknown in
Nepal till 1961 AD. Psychiatric out patient
department service was first started in 1961 AD in Bir
hospital by first psychiatrist Dr. Bishnu Prasad
Sharma.
• At that time Bir hospital was of 100 bedded of which
5 bedded inpatient unit was established in the same
hospital in 1965AD, which was further strengthened
to 12 beds in 1971 AD.

16. Mental health services in Nepal
• A year after 10 bedded neuro- psychiatric unit
was established in the Royal Army Hospital,
Kathmandu. At present this hospital expanded to
25 bedded psychiatric unit, provides outpatient
and inpatient services to regular as well as retired
Army personal including their family member.
• In 1984 AD 12 bedded psychiatry department Bir
hospital was separated and a separate mental
hospital was created, which was then shifted in
1985 AD to the current site at Lagankhel, Patan.
At present Mental hospital Patan has expanded
to 45 beds.

17. Mental health services in Nepal
• Four hundred and one bedded TU Teaching hospital
was established in 1983 and psychiatric OPD
services started in 1986 followed by addition of 12
bedded psychiatric inpatient unit in 1987.
• Since 1997 ten bedded drug detoxification unit
started in TUTH. In 1993, BP Koirala Institute of
Health Sciences, Dharan came into existence as a
collaborative effort of Government of Nepal and
Government of India.

18. Mental health services in Nepal
• In 1995 department of psychiatry made its
modest beginning with outpatient services on
all working days and has 22 psychiatric beds in
present.
• Now many communities based mental health
services and rehabilitation centre are
established in Nepal and improving mental
health services in Nepal.

19. 1.1 MENTAL ILLNESS
• Mental illness means maladjustment in living
• A/C to Bimala Kapoor, mental illness occurs when
a state of physical, mental, social and spiritual well
being is disturbed & mentally ill individual shows
symptoms like depression, feeling of anxiety,
physical complaints without an organic cause and
sudden changes in the mood or behaviour.

20. MENTAL ILLNESS
• “refers collectively to all diagnosable mental
disorder which are health conditions that are
characterized by alteration in thinking, mood
or behavior associated with distress and
impaired functioning”
– Substance abuse and mental health administration SAMHA,1999

21. 1.6 Causes of mental illness
1. Biological factors;
Genetic /hereditary
Bio-chemical
Brain damage
Due to Injury, infection, intoxication, changes in blood
chemistry, Tumors, Nutritional (fluid and electrolyte
imbalance, vitamin deficiency), degenerative changes,
Anoxia etc

22. Contd……
2. Psychological factors:
Personality and temperament;
Psychological trauma such as:-
- severe emotional, physical or sexual abuse;
- loss of parents, beloved ones or job;
- faulty child parents relationship;
- unhappy experience in childhood;
- failure in exam;
- lack of discipline in children or strict discipline;
- failure to achieve highly sets goals, stresses etc.

23. Contd…..
3. Socio - environmental factors:
Poverty, unemployment, injustice, insecurity, severe
competition, migration, urbanization;
Dysfunctional family life (broken homes);
Changing in job and school;
Death or divorce;
Substance abuse.

24. Contd…..
4. Physical factors :
Acute disability like blindness, deafness, and
amputation;
Physical deprivation like malnutrition sleep
deprivation;
Other diseases and medication:-
Chronic diseases like DM, hypertension, heart diseases,
renal diseases, TB, thyroid problem and drugs like
steroids, TB drugs, antihypertensive drugs may induce
certain types of mental illness.

25. Contd….
5. Physiological factors
• May occurs at certain critical periods of life
such as puberty, menarche, marriage,
pregnancy, delivery, puerperium menopause
etc.

26. 1.3 National Mental Health Policy and
Strategy
1. To ensure the availability and accessibility of
minimum mental health services for all the
population of Nepal by the year 2000: in
particular for the most vulnerable and under-
privileged groups of the population, by
integrating mental health services into the
general health service system of the country,
and by adopting other appropriate measures
suitable to the community and the people.

27. 2. To prepare Human Resources in the area of
Mental Health in order to provide for the above
mentioned Mental Health Services. This will
include Mental Health training of all health
workers, preparation of specialist Mental Health
manpower, and training of groups as per need.

28. 3. To protect the fundamental human rights of
the mentally ill in Nepal.
4. To improve awareness about mental health,
mental disorders, and the promotion of
mentally healthy lifestyles, in the community
by participation of community structures, and
amongst health workers.

29. POLICY I
To ensure the availability and accessibility of
mental health services for all the population
of Nepal by the year privileged groups of the
population, by integrating mental health
services into general health service system of
the country, and by adopting other
appropriate measures suitable to the
community and the people.

30. STRATEGIES
1. Mental Health care facilities will be developed not
as passive recipients of mentally ill patients for
treatment, but as having an active and dynamic
interaction with the communities they serve. This
interaction will include assessment of the
communities, mental health needs, and the
provision of intervention measures, and action as
a coordinating agency for promoting mental
health.
2. Mental health components will be developed
within the in-service training structure especially
at the National Training Centre and the Regional
Training Centers.

31. 3. Specialist mental health manpower i.e.
psychiatrists, psychiatric nurses, clinical
psychologist, psychiatric social workers etc. will
be developed. Post-graduate training in
Psychiatry should be started within the country as
soon as possible.
4. There will be provision for development of
ancillary mental health human resources
especially from the non-health sectors e.g.
management, legal, communication sectors etc.

32. POLICY II
To prepare Human Resources in the area of
Mental Health in order to provide for the
above mentioned Mental Health Services -
This will include Mental Health training of all
health workers, preparation of specialist
Mental Health manpower and training of
groups as per need.

33. STRATEGIES
1. There will be adequate and appropriate
Mental Health and Behavioral Science
components in all Health Workers curricula in
the country.
2. Mental health components will be developed
within the in-service training structures
especially at the National Training Centre and
the Regional Training Centers.

34. 3. Specialist mental health manpower i.e.
psychiatrists, psychiatric nurses, clinical
psychologists, Psychiatric Social Workers etc. will
be developed. Post-graduate training in
Psychiatry should be started within the country as
soon as possible.
4. There will be provision for development of
ancillary mental health human resources
especially from the non-health sectors e.g.
management, legal, communication sectors etc.

35. POLICY III
To formulate appropriate legislation to ensure
the fundamental human rights of the mentally
ill in Nepal

36. STRATEGIES
1. A mental health act suitable for the rights of
the mentally ill and the wider community will
be developed and implemented.

37. POLICY IV
To improve awareness about mental health,
mental disorders, and the promotion of
mentally healthy lifestyles, in the community
by participation of community leaders and
other personnel, and amongst health workers.

38. STRATEGIES
1. There will be a commitment to interaction with
community structures (e.g. schools, NGOs, traditional
healers, etc.) in orders to highlight and promote mental
health awareness and issues.
2. There will be provision of adequate mental health input
to all levels of academic health worker curricula, and in
additional appropriate in-service mental health training
will be provided for health worker already in the field.
3. For all objectives the overall Administrative Strategy will
be to have a Division of Mental Health in the Ministry of
Health/Department of Health and the mental health
unit in the Regional Directorates of Health.

39. 1.8 Legal Aspects in Psychiatric
Nursing
• Each state has laws regulating the care and
treatment of the mentally ill.
• Such laws attempt to balance protection of
the mentally ill client's civil rights with the
preservation of public safety.

40. TYPES OF COMMITMENTS/
ADMISSION
• Voluntary commitment: person freely decides
to be admitted to a psychiatric hospital
• Involuntary commitment: petition is filed to
commit a person if judged dangerous to self or
others
• Emergency involuntary commitment: used by
the state to hospitalize a person who presents
a "clear and convincing evidence of danger" to
self or others

41. OUTPATIENT COMMITMENT CRITERIA
FOR THE CLIENT AND COMMUNITY
a. Client criteria
• Poses no danger to self or others
• Verbalizies a desire to live in the community
• Is aware of the former difficulties experienced
while trying to live in the community
• Understands the requirements of the outpatient
commitment
• Complies with outpatient commitment
requirements

42. b. Community criteria
• Inpatient treatment system supports and works
together with the outpatient treatment system
• Provides effective treatment for the client's
diagnosis and situation
• Provides the mandated treatments and
participates in enhancing compliance with such
treatment
• Develops and carries out a monitoring system for
the services provided
• Establishes the treatment programs that are
necessary and sufficient for the client's needs and
that promote the client's ability to remain in the
community

43. Admission Procedure
• Prepare the room before the patient arrives, keep
items in place and bed at proper height
• Greet the patient and his relative in a pleasant manner
• Provide patient/ relatives with comfortable chair and
then permit to relax for few minutes before proceeding
with admission procedure
• Make general observation of his or her condition
• Assess immediate need
• Collect necessary information (e.g. demographic data,
chief complain, past and present psychiatric history,
past or present medical and surgical history, treatment
history, personal history) form the patient and
significant relatives

44. Admission Procedure…
• Assess vital signs (temperature, blood pressure,
pulse and respiration) and weight and record
• Physical examination should be done: importance
should be given to find out any injury on the body
and documented
• Mental status examination should be done and
written in the nurses’ notes
• Patients’ belongings should be checked and any
harmful items like knife, blades, match boxes etc.
should be removed away from the patient to
avoid accidents or suicides in the ward

45. Admission Procedure…
• Any valuable things like cash, watches, jewelries
should be removed from the disturbed patients
and handed over to the relatives. If no relatives
are there, the valuables should be safely kept as
per the rules of the hospital and to be handed
over at the time of discharge
• Patient and patient’s family should be oriented to
the ward and ward staffs. Give information
regarding hospital policies in relation to hospital
property, visitors pass, visiting hours, attendant at
24 hours, dietary facilities, telephone exchange,
and pharmacy. Explain about meal times

46. Admission Procedure…
• Obtain written voluntary consent from the patient’s
relatives
• Collect all medicines from the patient and her relatives
and keep in medicine box at nurse’s station
• Carry out the stated order and emergency
investigations
• Enter the patient’s details in the census form and
admission book
• Write admission report including information regarding
day, time of patient arrival to the ward, nature of
ambulation, present complaints, vital signs and mental
status examination etc

47. Discharge criteria
1. Conditional discharge:
- The client is given specific instructions on
living arrangements, outpatient treatment
requirements, and behaviors to avoid.
- If the client violates the conditions of the
discharge, re-hospitalization may be
instituted.

48. - When the client satisfies the requirements of
the conditional discharge, the hospital affects
an absolute discharg.
- If a client discharged in this manner were to
return to the hospital in the future, a new
admission would be initiated.

49. 2. Judicial discharge: a client or family member
can petition for discharge even when the
hospital advises against it. The judicial discharge
provides an opportunity for the client to appeal
to the state for discharge.

50. • Leave of absence:
On application by a relative or others to the
medical officer-in-charge and a bound duly
signed stating that the patient will be taken
proper care of and prevented form injuring
self or others, leave of absence may be
granted (for a period of maximum 60 days)

51. Role of a nurse in discharge procedure
• Nurse must ensure that the patient leaves the
unit with all belongings and personal effects, has
the appropriate medications with him and
appointment for follow up has been made and
understood
• All necessary instructions especially regarding his
medication regimen, side effects, etc must be
clearly given to the patient and his family
members
• Any paper work, signing of documents should be
completed. The hospital file along with all charts
and notes should be sent to the medical record
section

52. Role of a nurse…
• The nurse should ascertain his travel plan and
offer assistance if necessary
• The nurse must bear in mind that the patient
may have mixed feelings about leaving the
hospital and going back to his home
environment. She should help him cope with
any distress about separating from his new-
founded friends and staff members

53. Patient’s right in relation to mental
illness
The mentally ill has the rights as follows:
• The right to confidentiality
• The right to medical treatment
• The right to medications and the informed
consent process

54. • Right to wear their own clothes.
• Right to have individual storage space for their
private use.
• Right to keep and use their own personal
possessions.
• The right to spend a sum of their money for
their own expenses.
• Right to see visitors everyday.

55. • Right to have reasonable access to all
communication media like telephone, letter
writing and mailing.
• Right to hold civil service status.