Learning Objectives
By the end of this section, you will be able to:
- Discuss various risk factors of psychiatric-mental illness
- Describe various protective factors for psychiatric-mental illness
- Identify nursing implications associated with risk and protection factors
A risk factor increases the chances of developing a mental illness, may determine the probability of having a psychiatric-mental illness, and can change through the life span. Some risk factors may be modifiable, while others may be genetic or biological. Both internal and external environments of the person may pose risk. All of these factors can be addressed in nursing assessment. Having risk factors does not necessarily mean that a client will develop a disorder, and nurses shouldn't assume that a client is experiencing or will develop a disorder or illness. In fact, although risk factors can increase the chances of developing a mental illness, having an array of protective factors can decrease that risk. Nurses should help clients understand what these risk and protective factors are and potential ways to minimize risk factors and maximize protective factors.
Risk Factors
Mental health researchers have developed several theories to explain the causes of mental health disorders, but they have not reached consensus Figure 1.5. One point on which they agree is that an individual is not at fault for the condition; they cannot simply turn symptoms on or off at will. There are likely several environmental, biological, and genetic risk factors that, when combined, trigger a mental health disorder (University of Michigan Human Resources, n.d.).
Risk factors from biological, social, and psychological factors can overlap. Some risk factors change over time, such as age, health history, availability of resources, and psychiatric history. Others are considered variable risk factors and include “income level, peer group, adverse childhood experiences (ACEs), and employment status” (SAMHSA, n.d.-a). Current stressors, such as relationship difficulties, the loss of a job, the birth of a child, a move, or prolonged problems at work can also be important contributory environmental factors (University of Michigan Human Resources, 2023).
Internal Environment: Physiological
Current research shows that the brain can have an imbalance of neurotransmitters, such as dopamine, acetylcholine, gamma-aminobutyric acid (GABA), norepinephrine, glutamate, and serotonin, resulting in changes in behavior, mood, and thought. While causes of fluctuations in brain chemicals aren’t fully understood, contributing factors can include physical illness, hormonal changes, reactions to medication, substance misuse, diet, and stress (University of Michigan Human Resources, 2024). Organic delirium and infections can also cause changes to mood and behavior, until these conditions are successfully treated.
Kraybill (2019) found research suggesting that some mental health disorders are accompanied by immune system dysregulation and inflammation. The immune system can be disturbed by stress and environmental toxins, affecting human responses, nutritional intake, and immunity. Inflammation develops in the body as a response. Inflammation is also a trigger for depression (Kraybill, 2019).
Genetics and Medical Comorbidities
There appears to be a hereditary pattern to some mental illnesses. For example, individuals with major depressive disorder often have parents or other close relatives with the same illness. Huntington disease is another example, wherein the cognitive and motor impairment can be misdiagnosed as a psychiatric disorder. Researchers continue to investigate genes involved in specific disorders in order to target treatment to individuals.
People with mental illness may also have medical comorbidities, such as diabetes, endocrine dysfunction, Alzheimer’s disease, cancer, and traumatic brain injuries (TBI) (American Mental Wellness Association, 2023). Psychiatric symptoms, medication side effects, ability for self-care, and provider focus may influence overall health.
Intrapartum Complications
People with a history of mental health issues prior to becoming pregnant are at a 40 percent higher risk of having a complication during pregnancy, a 50 percent higher risk for a non-live birth, and double the risk for having a baby born with a low birth weight (Witt et al., 2012). Some of these problems are due in part to lower socioeconomic status, lower education level, lack of access to medical care, and not being adequately followed to check their mental health status during pregnancy.
Moreover, Ross et al. (2015) reports that drug use among pregnant females aged fifteen to forty-four is at nearly 6 percent. Though the effects of maternal drug use on the babies differ depending on the drug used, some of the more common mental health effects on babies include cognitive delays, behavioral problems, attention-deficit hyperactivity disorder (ADHD), increased impulsivity, anxiety, depression, future substance use, and adolescent aggression (Table 1.2). Legal substances also are an intrapartum risk factor for mental illness. Tobacco exposure while in utero can cause children to develop ADHD, conduct disorder, behavioral disorders like aggression, and increased risk of drug abuse problems later on (Ross et al., 2015). Alcohol use in pregnancy can lead to fetal alcohol syndrome (FAS), which causes “morphogenic effects on limb and facial development, reduced brain and birth weight, and cognitive delays and impairments” (p. 74).
| Drug | Effects |
|---|---|
| Cannabinoids | Attention deficits Future substance abuse Future depression Poor growth Long-term problems with executive function |
| Caffeine | Increased chance of prematurity Problems in executive function once in school |
| Psychostimulants | Preterm labor Behavioral problems Attention deficits Brain abnormalities Cardiac anomalies Aggression Anxiety/depression |
| Alcohol | Decreased growth Attention deficits Prematurity or spontaneous abortion Cognitive delays Brain abnormalities Problems with limb and facial development |
| Tobacco | Lower birthweight ADHD Poor academic performance Aggression in adolescence Oppositional defiance |
| Opiates | Neonatal abstinence syndrome Preterm birth Lower weight Heart defects Low IQ Behavioral problems Respiratory problems |
Substance Use Disorders and Addictions
In addition to the negative effects that substance use and addiction have on the developing fetus, about half of the people living with a mental health disorder are also living with a substance use disorder (Medline Plus, 2019). Each of these things, mental health disorders and substance use disorder, can contribute to the development of the other. Many people who have mental illness use drugs or alcohol to cope with their symptoms.
Brain Injury
Another internal physiological risk factor for mental illness that can affect children and adults is experiencing a traumatic brain injury (TBI), a brain injury that can cause short- or long-term problems with thinking, physical movement, communication, and functional abilities. In some cases, it may result in permanent disability or death. A TBI “can be caused by a forceful bump, blow, or jolt to the head or body, or from an object that pierces the skull and enters the brain” (National Institute on Neurological Disorders and Stroke, n.d., para 1). According to the Centers for Disease Control and Prevention (2022), a TBI in children can affect their development and lead to problems with learning, thinking, and behavior. These effects can last a lifetime. The most common causes of TBIs are falls, firearm injury, car accidents, and assaults. Experiencing a TBI can lead to years of medical care, rehabilitation, PTSD from memories of the event, a decrease in physical and mental functioning, financial concerns, and mental health issues for partners or family members (Tsur & Haller, 2020).
Internal Environment: Psychological
Factors that affect a person’s psychological self include their emotions, coping ability, spirituality, self-concept and self-esteem, learned and conditioned behaviors, and personality traits. Plus, individual trauma resulting from an event, series of events, or set of circumstances that is experienced as physically or emotionally harmful can have lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being (U.S. Department of Health and Human Services, 2020).
Low Self-Esteem, Poor Self-Concept
Having a poor self-concept or low self-esteem can lead to a person having negative thoughts about themselves. These feelings can lead to a sense of isolation and can cause poor relationships with others. Continued negative thoughts can lead a person to use substances as they try to make themselves feel better. Low self-esteem can also be associated with depression and anxiety (Gold, 2016).
Dysfunctional Relationships and Trust Violations
A relationship that is characterized as a dysfunctional relationship is one in which unhealthy behavior patterns exist among members of a group. These patterns can include poor communication styles, conflict between people in the relationship, and even emotional and/or physical abuse (Harold, 2023). In families, while it is often the parent who engages in the dysfunctional behavior, it is the child who suffers the consequences with an increased risk of developing anxiety, low self-esteem, post-traumatic stress disorder (PTSD), substance misuse, depression, and problems building healthy relationships. In dysfunctional families, children can lose their ability to trust others based on their experiences of not being able to depend on their parents (Martin, 2018).
One example of dysfunctional relationships is gang affiliation. Gang affiliation is an unsafe environment that worsens existing problems. Children brought up in a family setting that includes a parent who uses substances, is abusive, or is a gang member themselves are at greater risk of socializing with gang members they meet in school or on the streets (Macfarlane, 2018). As children push away from these families, their vulnerability draws them toward gang membership. Research has shown that high rates of “depression, psychosis, anxiety, alcohol and drug dependence, antisocial personality disorder and history of attempted suicide” (p. 414) occur in gang members.
External Environment: Social
Individuals are affected by broad social and cultural factors, as well as by unique factors in their personal environments. Social risk factors, such as racism, discrimination, poverty, and violence (often referred to as “social determinants of health”) can increase the chances of a person developing a mental illness.
While many social relationships act as sources of support, there are situations where relationships are toxic and can potentially increase the risk of mental health problems; fatigue; lack of motivation; difficulty concentrating; and cardiovascular, immune, and endocrine problems (André & Baumeister, 2023). Marital problems, demanding or intense relationships, and caregiving burnout are examples of relationships that could be toxic.
Cultural Context
Cultural Influences on Mental Health and Mental Illness
The culture of a client influences many aspects of mental health and mental illness. Be mindful, however, that general statements about cultural characteristics of a given group may also invite stereotyping. Cultural information should not be broadly applied to any individual member of a racial, ethnic, or cultural group.
In fact, only 66 percent of adults from underrepresented groups in the United States will get help for their mental health problems. There are four ways that culture affects mental health: stigma, understanding symptoms, lack of support from others in the same culture, and not having resources available that meet cultural needs (Mental Health First Aid, 2019).
Abuse/Neglect, Social Oppression/Victimization
In 2019, there were 656,000 victims of child abuse and neglect, with a victim rate calculated as nine victims per 1,000 children across the United States. More specifically, 74.9 percent of victims were neglected, 17.5 percent were physically abused, and 9.3 percent were sexually abused (Administration for Children & Families, 2021). Neglect is a situation in which a parent or caretaker fails, refuses, or is unable, for reasons other than poverty, to provide the necessary care, food, clothing, or medical or dental care, seriously endangering the physical, mental, or emotional health of the child. Physical abuse is defined as injury inflicted on a child by other than accidental means. Physical injury includes, but is not limited to, lacerations, fractured bones, burns, internal injuries, severe or frequent bruising, or great bodily harm. Sexual abuse is defined as sexual intercourse or sexual touching of a child; sexual exploitation; human trafficking of a child; forced viewing of sexual activity; or permitting, allowing, or encouraging a child to engage in prostitution. Emotional abuse is defined as harm to a child’s psychological or intellectual functioning, which often results in severe anxiety, depression, withdrawal, or aggression. Emotional damage may show up in substantial and observable changes in behavior, emotional response, or learning that are incompatible with the child’s age or stage of development. All of these types of abuse are considered adverse childhood experiences (ACEs).
It is estimated that 61 percent of adults have experienced early ACEs, such as abuse, neglect, or growing up in a household with violence, mental illness, substance misuse, incarceration, or divorce. Chronic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood (National Center for Injury Prevention and Control, Division of Violence Protection, 2022).
Adults at risk for abuse are defined as adults who have a physical or mental condition that impairs their ability to care for their own needs (Wisconsin Department of Health Services, 2018). Older adults at risk are potentially susceptible to abuse, neglect, or financial exploitation by caregivers or a person they trust (Centers for Disease Control and Prevention, 2021b).
Life-Stage Context
Older Adult Risk Factors for Psychiatric-Mental Illness
Risk factors for mental disorders in older adults include being female, loneliness, alcohol abuse, lack of education, financial difficulties, family history of mental diseases, and severe physical disease. In addition, adults with serious mental illness over age fifty have a high rate of medical comorbid conditions (SAMHSA, 2021).
Social oppression and victimization—bullying, violence, and stigmatization of people from underrepresented groups, for instance—can occur across the life span and are also significant risk factors for mental illness. It is stereotyping when someone has a generalized and prejudiced opinion about members of a particular group of people. Stereotyping can cause the marked population to feel stigmatized, disrespected, and become the target of bullying. Atunah-Jay et al. (2022) studied the concepts of school-based and electronic bullying in relation to their connection to an increase in suicidality in a group of North Dakota middle school students, specifically within the American Indian/Alaska native (AI/AN) population. Results revealed that “compared to other forms of bullying, electronic bullying is associated with unique and significant negative mental health concerns, including anxiety, depression, and suicidality” (p. 28).
Lack of a Support System, Loss, Economic Disadvantage
Risk factors for mental illness include the lack of a support system. This could be because the person is not physically or emotionally close to family members, has few friends, or lives in an area in which they do not feel connected to others. Loss includes anything that creates a negative effect for a person—loss of a spouse (divorce or death), loss of a job, and moving away from family are examples. Economic disadvantage can be related to the loss of a job or not having the skills to work beyond a minimum wage job. While lack of a support system, loss, and economic disadvantage have always been risk factors for developing mental health issues, the recent COVID-19 pandemic, and the measures taken to mitigate the spread, highlighted new examples of these risks. In particular was the practice of social distancing and social isolation. While these practices began to keep the public physically safer, there was a marked increase in anxiety, depression, and self-perceived stress related to loss of contact with others, loss of family and friends to the illness, sleep difficulties, financial insecurities among those with lower incomes, and misinterpretation (fake news) of the vast amount of information shared in mass media (Daclan, Ferreira, & Guzella, 2022).
Link to Learning
The Mayo Clinic provides a list of mental illness risk factors with more information about mental illness symptoms, causes, treatment, and resources.
Protective Factors
There is a link between protective factors and resilience, or the ability to “bounce back,” and overcome stressful barriers to living a healthy life. Protective factors reduce the risk for mental illness, suicide, and other detrimental behaviors. Some of these biological, social, and psychological factors can be developed over time in the individual, family, and community (Connect Online, 2023). Examples of protective factors include support received from family and friends, religious practices, being part of a social group, getting physical activity, eating healthy foods, and using positive coping skills (Mental Health First Aid, 2022).
Internal Environment: Physiological
Living a healthy lifestyle that includes attention to diet, getting plenty of exercise and sleep, and having access to regular medical care provides a protective factor against the development of a mental illness. Other protective factors include avoiding high-risk substance use and receiving appropriate care for medical conditions (American Mental Wellness Association, 2023).
Exercise is known to reduce all mortality risks, including poor mental health (Prakash, 2020). “Evidence suggests an exercise duration of 45 min 3–5 days a week to be optimal for good mental health” (p. 186). Physical activity is an appropriate intervention for the prevention of depression symptoms. Diet is also known to affect mental health, either positively or negatively. What a person eats can influence the development and progression of mental illness. Mental health professionals are encouraged to address nutrition in client care (Prakash, 2020).
Link to Learning
Dietary antioxidants may help to alleviate depression, anxiety, and stress. A study of the Mediterranean and DASH diet investigates the relationship between diet and psychological disorders.
Internal Environment: Psychological
Other protective factors include having healthy development and good attachment to parents (American Mental Wellness Association, 2023). Fei, et al. (2021) found that secure attachment creates comfort with self and was associated with higher levels of self-esteem.
Moreover, having high self-esteem means that a person can see their own value and have that attitude affect their social interactions, job satisfaction, and overall sense of well-being (Prakash, 2020). High self-esteem decreases anxiety, depression, and attention disorders due to the person using more positive coping skills. Finding a purpose in life also acts as a protective factor; it has been found to positively affect depression and anxiety, while contributing a 2.4 percent reduction to the chance of developing Alzheimer’s disease (Prakash, 2020). High self-esteem and having a purpose in life are related to a person’s resilience. Also connected to developing resilience are task-oriented coping mechanisms. People learn to use these methods, practicing them throughout their lives, changing them as needed. The current use of mental health apps provides “on the go” coping mechanisms to people who are socially isolated and to the younger generation (Varela et al., 2021).
Link to Learning
University of California at San Francisco offers this resource for recommended, evidence-based apps for wellness and mental health.
In, addition, the use of mindfulness techniques—being fully present in the moment, being aware of surroundings, environment, and senses—is another protective factor that reduces stress and thereby lowers risk factors for mental illness. Examples of mindfulness techniques include meditation and keeping gratitude journals, instead of ruminating about the “what-ifs.”
Spirituality, Morals, and Beliefs
The positive (protective) effects of religion and spirituality include promoting positive behaviors, giving people something to believe in, and offering purpose and meaning. The added benefit of the social connectedness that comes from being part of a religious community enhances positive health behaviors and outcomes. It is an important part of the nursing assessment to ask about a client’s religious practices because this information helps to build interventions around the client’s beliefs in health practices and allows nurses to utilize all of the resources that a client may have at their disposal.
Link to Learning
This scoping review of scholarly databases identified a need for spiritual care to be included in nursing education programs and in staff development efforts in the workplace. The researchers advocate for inclusion of spirituality into nursing practice and call for enhanced overall awareness of needs of health-care recipients.
Motivation/Achievement
Intrinsic motivation is the incentive to do something for internal or inherent satisfaction. Extrinsic motivation, such as working for a paycheck, does not have the same protective factors as intrinsic motivation. Extrinsic motivation can result in burnout and depression, when external rewards are not achieved. Intrinsic motivation is connected with more positive outcomes, such as well-being, satisfaction with life, and using ethical judgment (Kotera & Ting, 2019, p. 229). Being motivated by setting a goal and then achieving that goal is rewarding and can boost self-esteem, contribute to a feeling of fulfillment, and create a more hopeful outlook on life.
Childhood Attachments, Emotional Stability, Coping Skills
Children raised in loving environments are more likely to have good attachments to their parents or primary caregivers. This attachment decreases the likelihood of the child developing aggressive behavior and promotes their ability to express empathy as compared with children who were maltreated (FRIENDS National Center, 2023). The use of positive coping skills to overcome adversity combines cognitive and behavioral techniques that may change over time as the person experiences different stressors (Varela et al., 2021). These strategies are considered either task-oriented or emotionally oriented and each has a different effect on the person’s ability to get past the stressor. Being able to have a variety of positive coping skills to use when life gets stressful enhances emotional stability.
External Environment
Social connectedness has been shown to reduce feelings of mental health stigma, to increase feeling supported, and to enhance the use of positive coping skills (Prakash, 2020). The support provided by a social milieu is helpful throughout the span of life. It is also helpful when someone is diagnosed with a mental illness because it provides the support needed to make the person feel validated as they navigate a life that can sometimes be very difficult. Without social support and connectedness, people become lonely, which has been shown to cause detrimental outcomes in people with depression, anxiety, bipolar disorder, and schizophrenia (Prakash, 2020).
Safety, Security, Caregiver Support
Having the support of those around you is an important protective factor. People need to feel secure in their relationships with family, friends, and caregivers. The safety and security they feel from a healthy, nurturing relationship provide a lifeline in times of mental distress. Sometimes just knowing there is one person to depend on makes a difference in being able to overcome a stressful life event. For example, children who are allowed to take risks with the guidance of a parent learn how to be self-sufficient in a safe environment (Prevention United, n.d.).
Participation in Sports, Clubs, Activities, or Groups
Participation in sports, clubs, activities, or groups is a social support that gives the client the feeling of being involved with others. Plus, being physically active releases the “feel good” brain chemicals called endorphins. Endorphins can help reduce depression, stress, and anxiety (Cleveland Clinic, 2023). Doing enjoyable things, such as laughing with friends, listening to music, meditating, and doing volunteer work also releases endorphins.
When encountering stressful situations, the Mayo Clinic (2023) suggests joining mental health support groups. These groups provide a safe and supportive environment in which to meet other people/families going through similar situations. They also provide education and online resources that offer information to help mitigate the risks of normal stress becoming a psychiatric condition. Such groups are provided by the National Alliance on Mental Illness (NAMI), which offers fact sheets and search features for local support groups, and the Department of Veterans Affairs (VA), which offers resources for coaching and connecting.
Access to Medical Care
Having access to health care is a protective factor when it comes to mental illness. According to Mental Health America (2023), barriers to accessing medical care include lack of mental health coverage in a client’s private insurance plan, the large number of clients assigned to each mental health provider, and not being able to afford treatment. Public assistance programs, including health insurance, are examples of protective effects of access to medical care; they lift the barrier people have to getting appropriate prenatal care, thus decreasing the risk of a non-live birth (Witt et al., 2012). An additional benefit of being enrolled in a public health program is access to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which will increase prenatal and postnatal nutrition and overall wellness. The support that these people gain through such programs can help to reduce stress and anxiety during pregnancy.
Nursing Implications Associated with Factors of Risk or Protection
As the nurse completes a full assessment of the client, using purposeful questions and active listening are important parts of the process. The nurse must maintain a nonjudgmental attitude during the assessment (Higgins et al., 2015). The assessment builds a rapport between the nurse and client, creating an environment of trust. This is professional intimacy in the therapeutic nurse-client relationship, wherein the nurse gains an understanding of the client through respect and empathy, with compassion and recognition of the client’s experience. Higgins et al. (2015) explains that the nurse uses three approaches to gather information: unstructured clinical judgment, assessment tools, and structured clinical judgment. Unstructured clinical judgment includes using critical thinking skills, observation, and intuition. Using standardized assessment tools is part of the mental health nursing process that provides insight into risk factors. Structured clinical judgment entails using a combination of the first two approaches to get an overall picture of the person’s risk and protective factors.
A psychosocial assessment is a component of the nursing assessment process that obtains additional subjective data to detect risks and identify treatment opportunities and resources. Learning about the client’s risk and protective factors will guide the development of appropriate interventions and outcomes. Agencies have specific forms used for psychosocial assessments that typically consist of several components (Glasner, Baltag, & Ambresin, 2021; GW School of Medicine & Health Sciences, n.d.):
- cultural assessment
- reason for seeking health care (i.e., “chief complaint”)
- thoughts of self-harm or suicide
- current and past medical history
- current medications
- history of previously diagnosed mental health disorders
- previous hospitalizations
- educational background
- occupational background
- family dynamics
- history of exposure to psychological trauma, violence, and domestic abuse
- substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
- family history of mental illness
- coping mechanisms
- functional ability/activities of daily living
- spiritual assessment
Risk Assessment
The availability of standardized web-based or paper risk assessment tools can make the risk assessment an easier task for the health-care provider or nurse. Ayhan and Ustun (2021) identified eighteen risk assessment tools that have been developed since 1970. While these individual tools have all been developed to measure levels of risk, each one is based on the client population being assessed. Clinicians must be comfortable with using the correct tool for the environment in which they work, whether it be in-hospital treatment, community care, or forensic psychiatry.
Strengths Assessment
An important question to ask is, “What positive coping skills have you used in the past to get through difficult times?” Assessing and reminding a client of their strengths is an integral part of instilling hope in the client. Who are their support persons? What do they see as their personal strengths? Engaging the client in thinking from a positive standpoint begins the trajectory toward reaching healthy treatment outcomes.
Link to Learning
The QSEN competency client centered care includes care of a client with a psychiatric-mental illness. The Client Centered Care competency knowledge, skills, and attitudes (KSAs) are expected of the student nurse as they transition to practice as a licensed nurse. The table serves as a resource to guide curricular development in formal academic nursing programs.