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Population Health for Nurses

31.2 The Mental Health Crisis

Population Health for Nurses31.2 The Mental Health Crisis

Learning Outcomes

By the end of this section, you should be able to:

  • 31.2.1 Describe the state of mental health in the United States.
  • 31.2.2 Examine the origins of the U.S. mental health crisis.
  • 31.2.3 Describe why mental health conditions are increasing worldwide.
  • 31.2.4 Assess the effect of stigma, prejudice, and discrimination against people with mental illness.
  • 31.2.5 Discuss the nurse’s role in addressing the mental health crisis to uphold nursing’s societal mission.

In the United States, mental health illnesses have become an epidemic—considered a mental health crisis—with nearly one in five people (47.1 million) diagnosed with a mental health condition, constituting an increase of 1.5 million from 2022 (Mental Health America [MHA], 2023). Rates of suicidal ideation (SI), also called suicidal thoughts or ideas, a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide, are highest among youth, especially those who identify as LGBTQ+ (Harmer et al., 2023; SAMHSA, 2020; The Trevor Project, 2022). In September 2020, over half of all 11- to 17-year-olds reported having thoughts of suicide or self-harm more than half of or nearly every day of the previous 2 weeks. According to MHA (2023):

  • Nearly 78,000 youth reported experiencing frequent suicidal ideation, including nearly 28,000 LGBTQ+ youth.
  • Over half (54.7 percent) of adults with a mental illness reported that they do not receive treatment, totaling over 28 million individuals.
  • Almost a third (28.2 percent) of all adults with a mental illness reported that they were not able to receive the treatment they needed.
  • 42 percent of adults with mental illness reported they were unable to receive necessary care because they could not afford it.
  • 10.8 percent (over 5.5 million) of adults with a mental illness are uninsured.
  • 59.8 percent of youth with major depression do not receive any mental health treatment.

In the United States, there are an estimated 350 individuals for every one mental health provider; however, these figures may overestimate active mental health professionals, as they may include providers who are no longer practicing or accepting new clients (MHA, 2023).

The State of Mental Health in America Report

Mental Health America (MHA), the nation’s leading national nonprofit dedicated to the promotion of mental health, well-being, and illness prevention, publishes the annual State of Mental Health in America Report, providing a yearly snapshot of the prevalence of mental health conditions and a baseline for future legislation on mental health parity (MHA, 2023). Operating nationally and in communities across the United States, MHA advocates for closing the mental health equity gap while increasing nationwide awareness and understanding through public education, direct services, tools, and research. The State of Mental Health in America Report ranks all 50 states and the District of Columbia based on 15 mental health prevalence and access measures for youth and adults.

Explore the Ranking of the States 2022 to find information about your state, and then respond to the following questions.

  1. Where does your state rank in terms of the prevalence of mental illness?
  2. Where does your state rank for the prevalence of adults with substance use disorder in the past year?

You may also download the printable report The State of Mental Health in America 2023.

The Origins of the U.S. Mental Health Crisis

According to a White House briefing, “our country faces an unprecedented mental health crisis among people of all ages.” Specifically, “two out of five adults report symptoms of anxiety or depression. And, Black and Brown communities are disproportionately undertreated—even as their burden of mental illness has continued to rise” (The White House, 2022). Even before the COVID-19 pandemic, rates of depression and anxiety were rising. Loneliness and social isolation during the pandemic exacerbated these trends, with increasing numbers of children reporting thoughts of suicide and self-harm.

Mental health services in the United States are insufficient to address this crisis. A majority of Americans (76 percent) report that they consider mental health as important as physical health, and more than half of Americans (56 percent) seek mental health services (National Council for Mental Wellbeing, n.d.). Americans seeking these services tend to be younger, with lower incomes, and often from military backgrounds. Among Americans seeking treatment, 96 million (38 percent) have had to wait over a week for mental health treatments. A National Council for Mental Wellbeing study found that a large percentage of Americans want to seek treatment for mental health issues for themselves or loved ones but have not done so in part because they do not know where to go. What’s more, 53 million American adults (21 percent) have wanted to see a mental health professional but were unable to for reasons outside of their control including lack of insurance, an available provider, transportation (private or public), and child care, as well as geographical isolation, conflicting work or school schedules, or domestic violence issues. Gen Z (born between 1997 and 2012) and millennial (born between 1981 and 1996) Americans are less sure about available resources for mental health services compared to older generations. The National Council for Mental Wellbeing study suggests that these younger generations are also more likely to find it difficult to distinguish legitimate mental health resources online, turning instead to unreliable social media resources, including Facebook, YouTube, and Twitter, for information (National Council for Mental Wellbeing, n.d.).

Healthy People 2030

Mental Health and Mental Health Disorders

A focal point for the Healthy People 2030 initiative is addressing public health priorities and challenges related to mental health and mental health disorders. Recognizing that about half of all people in the United States will be diagnosed with a mental disorder at some point in their lifetime, Healthy People 2030 focuses on the prevention, screening, assessment, and treatment of mental disorders and behavioral conditions. The Mental Health and Mental Disorders objectives also aim to improve health and quality of life for people affected by these conditions.

The Ongoing Global Expansion of a Mental Health Crisis

Behavioral health disorders are on track to become the number-one cause of disability worldwide, surpassing all other illnesses. For example, one in four people globally experience mental disorders, more than those with cancer, diabetes, or heart disease (Clubhouse International, 2023). Half of those with mental disorders begin to show signs of the disease by age 14 but often take more than 10 years to get treatment (National Alliance on Mental Illness [NAMI], 2023). Worldwide, suicide has become a global epidemic with 90 self-directed deaths every hour, which calculates to nearly 2,200 people/day, 800,000/year. Ninety percent of these suicides are directly related to mental health disorders (World Health Organization [WHO], 2019, 2022a).

Globally, mental illness (MI) now accounts for 30 percent of the overall burden of the health care industry, yet only 3 percent of the world’s health care budget goes toward providing mental health care services (WHO, 2016). This imbalance highlights the need for nurses to be savvy in mental health assessment and treatment strategies.

The Effects of Stigma, Prejudice, and Discrimination on Mental Health

The social stigma associated with mental health continues to be a barrier to seeking help (American Psychiatric Association, 2023). In this context, stigma refers to negative attitudes that disparage a person with a mental health condition. This stigma causes many individuals to delay seeking treatment. According to a National Council for Mental Wellbeing study (n.d.), nearly one-third of Americans, or 31 percent, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population, or 21 percent, have lied to avoid telling people they were seeking mental health services. Stigma is an especially acute problem among younger Americans. Among respondents in a National Council for Mental Wellbeing study, 49 percent of Gen Z respondents (born between 1997 and 2012), 40 percent of millennial respondents (born between 1981 and 1996), 30 percent of Gen X respondents (born between 1965 and 1980), and 20 percent of baby boomer respondents (born between 1946 and 1964) indicated that they have worried about others judging them when they say that they have sought mental health services.

Stigma often comes from lack of understanding or fear. Inaccurate or misleading representations of mental illness contribute to both of those factors. A review of studies on stigma shows that while the public may accept the medical or genetic nature of a mental health disorder and the need for treatment, many people still have a negative view of those with mental illness.

According to the American Psychiatric Association (2023), researchers identify different types of stigma:

  • Public stigma involves the negative or discriminatory attitudes that others have about mental illness.
  • Self-stigma refers to the negative attitudes, including internalized shame, that people with mental illness have about their own condition.
  • Institutional stigma, which is more systemic, involves government and private organizations’ policies that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services than other health care services.

General prejudice, a preconceived negative opinion not based in facts, toward people with MI may predispose people to dislike and/or disrespect others with a specific diagnosis, such as schizophrenia or depression (American Psychiatric Association, 2023). Prejudiced attitudes toward people with MI range from discomfort with having them as a neighbor to avoiding someone because of their diagnosis. Researchers studying prejudice and MI identified four dimensions underlying prejudice: fear/avoidance (fear of people with MI and the desire for social distance from them), unpredictability (belief that the behavior of people with MI is unpredictable), authoritarianism (belief in the need to control people with MI), and malevolence (lack of benevolent attitudes and belief in inferiority of people with MI) (Kenny et al., 2018).

Discrimination, unfair treatment based on irrelevant characteristics, is an ongoing challenge for those diagnosed with MI. Americans are familiar with the idea that refusing employment to a person based on their gender, race, or sexuality is unfair and amounts to sexism, racism, or homophobia. Although discrimination based on MI can be more subtle, it negatively affects the individual’s quality of life and career. According to the Americans with Disabilities Act National Network (2023), discrimination based on mental illness includes:

  • Terminating an employee based on the discovery of their MI
  • Assigning an employee bad or inconvenient shifts or assignments
  • Making insulting jokes about the MI
  • Failing to make reasonable accommodations for the employee with MI
  • Offering only poor working conditions
  • Not allowing the employee to miss work for medical appointments
  • Not allowing the individual enough time to complete tasks

Stigma, prejudice, and discrimination directly affect individuals with MI and the loved ones who support them. In some communities, MI stigma is a barrier to obtaining mental health services. For example, in some Asian cultures, seeking professional help for MI may be counter to values of strong family, emotional restraint, and avoiding shame (NAMI, 2019). Distrust of the mental health care system prevents individuals from certain racial and ethnic groups from seeking care; this is often seen in Black communities (African American Wellness Project, 2023).

Conversations About Culture

Mental Health = Health for Diverse Communities

This video provides an overview of mental health and mental illness, describing some persistent myths about the causes of mental illness and the role culture plays in seeking treatment.

Watch the video, and then respond to the following questions.

  1. What is the difference between mental health and mental illness?
  2. What are two commonly held cultural myths regarding mental health?
  3. What two effects can mental health stigma have on a person’s life?

The Nurse’s Role in Addressing the Mental Health Crisis

Nurses are in a unique position to recognize mental health concerns, as they are often the first to connect with a client and can swiftly establish rapport with them, starting all interactions using the steps of the TIC Approach. As trusted advocates, nurses can provide the compassion that clients may need at a difficult time and can help them access treatment. Nurses must be aware of the potential impact of stressors on their clients and how these may manifest in a crisis. Population health nursing focuses on the common good of the population in addition to individual client health. The public health/community health nurse may work with individuals, families, and groups to implement changes to mental health services that affect an entire community or population.

Nurses use a systematic process to assess health status, identify resources, and develop programs to improve mental health in communities. The first step is to create a therapeutic nurse-community (as client) relationship. The nurse establishes an understanding of who the community as client is, what is occurring in their lives, and what resources are available by assessing demeanor, beliefs, and support systems to determine if a specific health issue or environmental situation is progressing to a crisis state. Crisis intervention is an important role for the nurse and health care team, as they can work swiftly to develop effective resolutions. During the crisis intervention process, the client develops new skills and coping strategies, resulting in change. A crisis state is time-limited, usually lasting several days but no longer than 4 to 6 weeks. Using the nursing process in crisis resolution planning, nurses implement therapeutic interventions based on the stage of the crisis to assist the individual.

The foundational goals of crisis intervention include (Caplan, 1964):

  • Identification, assessment, and intervention
  • Swift return to a prior level of functioning
  • Lessening negative impact on future mental health

Various factors can influence an individual’s ability to resolve a crisis and return to equilibrium, such as realistic perception of an event, adequate situational support, and adequate coping strategies to respond to a problem.

The Roots of Health Inequities

Social Determinants of Health and Mental Health Crisis in the United States

Social determinants of health (SDOH) are conditions in which people are born, grow, learn, work, play, and age that affect their health risks and outcomes. Social factors affect risk for mental illnesses and substance use disorders, as well as health outcomes of persons with these disorders. The NAMI article Ways We Can Address the Social Determinants of Mental Health provides a useful overview for conceptualizing the relationship between the social determinants of health and mental health and provides recommendations for health care professionals. A focus on social determinants of health can lead to better mental health outcomes, including preventing mental illness. All nurses have a role to play in addressing the SDOH. This article provides several examples of social determinants of health and potential ways to address them.

(See Pointe, 2020.)

SAFE-T: Suicide Assessment Five-Step Evaluation and Triage for Clinicians

The community health nurse can use the following guidelines to perform a brief suicide assessment that uses a five-step evaluation and triage plan to identify risk factors and protective factors, conduct a suicide inquiry, determine risk level and interventions, and develop a treatment plan. Suicide assessments should be conducted at first contact with all mental health clients and at repeated intervals for those with any subsequent suicidal behavior, increased suicide ideation, or pertinent clinical change; if being used for inpatients, this assessment would additionally be conducted prior to increasing unsupervised privileges and at discharge.

  1. Identify Risk Factors: Note those that can be modified to reduce risk
  2. Identify Protective Factors: Note those that can be enhanced
  3. Conduct Suicide Inquiry: Suicidal thoughts, plans, behavior, and intent
  4. Determine Risk Level/Intervention: Determine risk; choose appropriate intervention to address and reduce risk
  5. Document: Assessment of risk, rationale, intervention, and follow-up

Read all of the detailed teaching guidelines and find all of the resources at Suicide Assessment Five-Step Evaluation and Triage.

Nurses can also download SAMHSA’s Suicide Safe mobile app.

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