2 Introduction to the nature and impact of mental health problems
Introduction
The following chapter will provide a background to the context of mental health nursing in contemporary society. It will consider the relevance and impact of mental ill health and explore some of the challenges that people diagnosed as experiencing mental health problems face.
The aim of this chapter is to enable you to understand the significance of mental health problems and mental wellbeing and identify where mental health nurses fit in relation to wider health and social care services. This provides the background for the remaining chapters, enabling you to gain an insight into mental health nursing in contemporary health care and make links with your experiences during mental health placements.
Mental health problems – frequency and impact
Mental health is described by the World Health Organisation (WHO) (2007, p.1) as “a state of well being in which the individual realises his or her abilities, can cope with the normal stresses of life and can work productively and fruitfully to make a contribution to his or her community”. Yet the experience of emotional and psychological distress is a fairly common one. The majority of people will be able to identify times in their lives where they have felt overwhelmed by sadness, anxiety or emotional pain. This is important to bear in mind in any consideration of mental health problems as the issue of mental and emotional wellbeing is increasingly one for each individual, community and institution within our society. It also highlights that mental wellbeing and ill health are part of a continuum. This helps to challenge some of the beliefs within wider society that mental distress and the people who experience it are something to be feared, avoided or shunned. It is when these emotional and psychological experiences become so overwhelming as to restrict the extent to which people are able to live their daily lives, when they persist for a length of time or when they might put that person's (or a) life at risk, that people may be diagnosed as experiencing a mental health problem and benefit from support from a mental health service or professional.
Mental health problems are a major health issue for the global community. The WHO estimates that hundreds of millions of people will experience mental health and neurological problems worldwide (WHO 2010). They also suggest that currently these problems account for the second biggest burden of illness after cardiovascular disease (WHO 2005). This highlights that mental health problems account for a significant health need and are an important area where health and social care services may impact positively on people's lives.
It is important to bear in mind that there are always problems with the measurement of such statistics, as methods of diagnosis may differ and there may be many people in this situation who have not had support from health services. This could mean that some rates may be underestimated. Also a change in attitudes and acceptance towards some experiences may result in individuals being more likely to report this. The following section provides an overview of some of the rates of mental health problems and the implications for healthcare delivery.
International perspective
• An estimated 100 million people in Europe are believed to experience anxiety or depression (WHO 2005).
• 21 million people in Europe are estimated to suffer from alcohol misuse.
• Approximately 4 million people in Europe are estimated to be diagnosed with schizophrenia.
These figures are based on a total population of 870 million (WHO 2005).
• Almost half (45%) of Australians aged between 16 and 85 had experienced at least one mental health problem in their lifetime (Australian Bureau of Statistics 2009).
Common mental health problems
There is evidence to suggest that common mental health problems are increasing in the UK (National Health Service (NHS) Centre for Information 2009a). Common mental health problems are generally those which bring the individual into contact with their GP and will include diagnoses such as depression, anxiety and phobias. Outlined below are some key trends emerging in relation to the changing picture of common mental health problems.
• Around one in six adults are thought to experience mental health problems at any one time (Office for National Statistics (ONS) 2001).
• In England, men are less likely than women to experience a common mental health problem.
• The proportion of the English population who could be diagnosed with a common mental health problem has increased from 15.5% in 1993 to 17.6% in 2007 (NHS Centre for Information 2009a).
• Research suggests that about half of people experiencing common mental health problems are not affected after 18 months, though there is a social inequality in this impact. Those who have long-term sickness due to other conditions, may be unemployed or are of lower socioeconomic status are more likely to still be affected.
• In the Scottish population, between the ages of 15 and 90, the estimated daily use of antidepressant medication has increased from 1.9% in 1992/1993 to 8.7% in 2005/2006. (Scottish Government 2009).
Serious mental health problems
Serious mental health problems are those which often have a more complex and potentially long-lasting impact on the individual and their lives. This might involve increased support for the person in different areas such as housing, occupation and relationships. This will often involve some periods of care within an in-patient setting. People with serious mental health problems may have experiences such as hearing voices, or have distressing beliefs which are defined as outside the norm. They may have a diagnosis of schizophrenia or bipolar disorder
• People with serious mental health problems have a reduced life expectancy and some evidence has suggested that this is up to 25 years less than the average adult population, a statistic reported in both Europe and America (Parks et al 2006).
• Detentions to hospital under the Mental Health Act in the UK rose to 28 100 in 2008/2009 (NHS Centre for Information 2009b).
• People with serious mental health problems are at increased risk of developing coronary heart disease, diabetes and respiratory disease (Sainsbury Centre for Mental Health 2010a,b).
Once you know where you are going for your mental health placement(s), Chapters 4 and 5 will help introduce you to the preparation for these practice areas. However, this chapter has started to introduce some basic information about the problems and challenges people using these services may face and has drawn on evidence to support this. The activity outlined below will help you build on this in relation to the area you are going to.
Ask yourself the following question about the placement area:
1. What do you already know about who may be receiving these services?
2. What pieces of information from this chapter do you think are most relevant for this?Then it will be important to identify what other sources might be useful for finding out this information. Below is a list of some possible Websites to access:
When accessing these, find out about the organisation and think about what implications you think there may be for any biases or the reliability of evidence. Keep any notes you make in the introduction to your portfolio. You could draw on these when developing your evidence for your competencies to help you make links between the evidence base and your practice.
Suicide and self-harm
Self-harm can be used as a coping strategy to deal with emotional and psychological distress and may be used by people regardless of a diagnosis of mental health problems. However, considering people who have contact with mental health services have often experienced traumatic lives and are struggling with emotional distress, self-harm is an area where mental health nurses may offer individuals support. Self-harm is considered as a need to inflict physical wounds onto one's own body to deal with severe and often unbearable psychological pain; the harm itself may be an attempt to cope with this and provide an emotional release. This is without intent to commit suicide (Sutton 2007). Self-harm has been described by survivors as a ‘painful but understandable’ response to distress, a form of silent scream (Pembroke 1994).
• In England, the percentage of people reporting self-harming during their lifetime has increased and the biggest increase has been in young women (16–24 years old) (NHS Centre for Information 2009a).
• The UK has one of the highest rates of self-harm in Europe (Mental Health Foundation 2006).
• According to reports by parents, 1.3% of 5–10-year-olds have tried to hurt, harm or kill themselves (Meltzer et al 1999).
Suicide is a traumatic and devastating occurrence. However, individuals who may be having suicidal thoughts will still have a need to be valued, understood and listened to (Noonan 2009). There are particular groups who are more at risk of suicide and this includes people who self-harm.
• In England, 5.6% of people aged 16 and over had reported having made a suicide attempt (NHS Centre for Information 2009a) and there is also evidence that in this group there is an increase in reporting of suicidal thoughts.
• After rising for 25 years, the suicide rate in young men fell in the UK between 1998 and 2007 though overall the suicide rate increased in 2008 (ONS 2010).
• Suicide is more common in men in all age groups and is the most common cause of death in men under 35 (Department of Health (DH) 2002).
Substance misuse
Defining problems around substance misuse and dependence can be problematic. Dependence may be physical or psychological and is generally considered as a need to continue using a substance on a regular and repeated basis (Kipping 2009). Withdrawal or lack of use could lead to experiencing physical or psychological symptoms. Some people may experience mental health problems alongside being dependent on a substance, which is described as dual diagnosis. However, support for people who are dependent on substances also tends to be provided by mental health services.
• The prevalence of alcohol dependency decreased in men between 2000 and 2007 whereas this prevalence stayed the same for women (NHS Information Centre 2009a).
• In the European region, 21 million people are believed to experience alcohol use disorders (WHO 2005).
• 3.4% of adults in England had some indication of being dependent on illicit or illegal drugs. The biggest part of this statistic was for those who were dependent on cannabis only (NHS Information Centre 2009).
Impact of mental health problems
Being diagnosed with a mental health problem will often have an impact on different areas of that person's life. As this section has highlighted, this can include overall wellbeing. Often as a result of society's reactions to the person as well as the barriers they have to overcome, the implications of being diagnosed with a mental health problem can be far reaching. Yet the relationship between mental health problems and these factors is complex. Some are implicated as triggers for mental health problems and social factors are a major contributor to inequalities in health.
Having read the first section of this chapter, make a list of the areas in an individual's life that you think may be impacted by being diagnosed with a mental health problem. Review how this compares to the information outlined below. This is an issue you might want to return to after your first placement, when you have had the opportunity to work with an individual experiencing mental distress. For this person, there may be areas that they identify that you have not thought of or that have not been covered here.
Social impact
• The survey of psychiatric morbidity in England suggested that there was a strong relationship between low household income and experiencing a mental health problem (NHS Information Centre 2009a).
• People with mental health problems are more likely to be separated, divorced or widowed and be living on their own. The relationship between these issues and mental health is complex as they have implications for both contributing to and being an impact of being diagnosed with a mental health problem (Australian Bureau of Statistics 2009).
Housing
• One in four tenants with mental health problems are at risk of losing their home due to rent arrears (Office of the Deputy Prime Minister (ODPM) 2004).
• People with mental health problems are more likely to be unhappy with the housing they are living in and it is four times more common for them to suggest that this has a negative impact on their health (Mind 2007).
• There is a close relationship between mental health and housing. One in five homeless people who have mental health problems believe that these problems contributed to them becoming homeless (Mind 2007).
Employment
• One in six workers will experience stress, anxiety or depression at any one time and they are more at risk of losing their jobs than other workers (Sainsbury Centre for Mental Health 2010a).
• 24% of people with long-term mental health problems are employed. This is a lower number than any other group with disabilities (ODPM 2004).
• Employers have a legal responsibility not to discriminate against anyone with mental health problems, supported by the Disability Discrimination Act.
Mental health across the lifespan
Mental health problems impact on people of all ages. Specific age groups will have different needs in terms of support for their mental health problems and encouragement to maximise their health and wellbeing. Emotional distress is becoming increasingly evident in younger people. As a consequence, promoting emotional wellbeing is becoming a key issue for schools, though specialist mental health services are available for children and young people who need additional support (see Ch. 4). In the context of an ageing population, it is suggested that mental wellbeing in old age will be an increasing challenge for health services (Longley et al 2007).
Children and young people
• 45% of looked-after children (children in care) are thought to experience mental health problems.
• It is believed between 6000 and 17 000 children and young people care for an adult with mental health problems (ODPM 2004).
• Estimates suggest that around 10% of children will experience a mental health problem at any one time (Mental Health Foundation 2006).
Older adults
• 700 000 people in the UK are thought to experience dementia (Alzheimer's Society 2010).
• It is suggested two out of five older people in care homes experience depression and one in five older people experience depression (Mental Health Foundation 2006).
• The proportion of people with dementia doubles for every 5-year age group (Alzheimer's Society 2010).
Physical health
There are a number of inequalities in the rates of physical illness experienced by those with a diagnosis of mental health problems. The reasons for these inequalities are complex and are likely to be influenced by a number of factors such as long-term use of medication, social opportunities and access to healthy lifestyle choices.
• People with mental health problems are at increased risk of conditions such as coronary heart disease and diabetes (White et al 2009).
• People with schizophrenia are more likely to get bowel cancer (Disability Rights Commission 2006).
• Long-term physical health conditions are more likely to lead to mental health problems (ODPM 2004).
Ethnicity
The prevalence of mental health problems and the use of services varies among different ethnic groups in the UK. A number of explanations have been proposed as to the reasons for this, which include the lack of culturally appropriate mental health care, level of stigma associated with the use of mental health services in some communities and racism within the system and society.
• Men from black African, black Caribbean and other black groups are more likely to be detained under the Mental Health Act.
• Irish-born people living in the UK have a higher rate of suicide.
• 6% of all people with mental health problems who completed the “Count Me In” census relating to ethnic minorities’ experiences in mental health services reported that their first language wasn't English (Healthcare Commission 2009).
• Rates of admission to hospital were less than the national average for those from Indian, Chinese and white British groups and were the same as the national average for Pakistani and Bangladeshi groups (Healthcare Commission 2009).
Service use and support
Mental health services, like all areas of health care, are rapidly changing to reflect the needs of contemporary society. This has had an impact on the settings in which health care is delivered, the allocation of resources and the roles and numbers of professionals working in these services (see Ch. 3 for an overview of the historical development of services).
• Reflecting changes in service delivery settings, the number of in-patient beds has fallen by around 23% between 1997 and 2007.
• One-third of people with dementia live in a care home while the remaining two-thirds live in the community and it is estimated that, in the UK, family carers save the authorities up to £6 billion a year in care costs (Alzheimer's Society 2010).
• 79% of people using community mental health services responded positively about the service they had received (NHS Confederation 2009).
• Between 1999 and 2008, the number of mental health nurses increased by 24% (DH 2009).
• 90% of respondents to the Healthcare Commissions’ annual staff survey identified that their role makes a difference to people with mental health problems (NHS Confederation 2009).
A brief overview of some of the prevalence and distribution of mental ill health has highlighted that supporting individuals with experience of mental health problems is a key issue within health care and nurses have an important role in delivering this care.
Public attitudes
To develop an understanding of mental health problems, it is integral to consider these experiences in their social and political context. Throughout history certain health conditions such as HIV and AIDS, cancer and epilepsy have received negative attention within wider society. Public education, better understanding and advancing treatments have often been successful in challenging these views. However, being diagnosed with a mental health problem remains an often misunderstood experience in which some people may feel a need to hide it from friends, family and employers for fear of the detrimental stereotypes that may go alongside such a diagnosis. As nurses, we are also members of the public and are therefore exposed to the same influences which can impact on the development of our own values and beliefs. This book explores, and may challenge, some of these beliefs and values as we encourage you to examine how these can develop, change or be reinforced throughout your practice as a student nurse and beyond.
What were your views of people with mental health problems before you started on the pre-registration nursing course? You might want to think about what some of your fears and anxieties were about working with people with mental health problems.
How did your friends and family respond when you reached your decision to work in mental health care or when they found out you were undertaking a placement in a mental health setting?
Exploring these views and perceptions is useful to help develop self-awareness and to start to enable us to recognise that, as nurses and members of the public, we may well have developed some stereotypes and prejudices or be close to people who have these views. Additionally, it is an important part of developing as a professional to be open to having these views challenged and reflecting on the potential impact that they may have on nursing practice. This is examined in more detail in Chapter 5.
Public perceptions of mental health problems can have a significant impact on how individuals feel about their health concerns and ultimately themselves. In 1996, the mental health charity and campaigning organisation Mind conducted a survey of the personal experiences of stigma and discrimination of people who had received a diagnosis of mental illness. This survey found the following (Read & Barker 1996):
• 34% of respondents had been dismissed or forced to resign from their jobs.
• 47% had been abused or harassed in public.
• 25% felt they were at risk of attack in their own homes or forced to move due to harassment.
• 50% felt that they had been unfairly treated in general health care.
While the survey may well be perceived as outdated, these statistics serve as a stark reminder of the distressing impact that being diagnosed with a mental health problem can have, outside of the concerns that people may be dealing with in terms of their mental health. This highlights the potential role for the mental health nurse in helping individuals deal with these issues as well as providing education for family, friends, employers and educators to challenge some of the influence of these points of view. The impact that these attitudes can have has been recognised by the government and leading mental health organisations that have supported national campaigns to improve public attitudes. The government has focused on tackling the social impact, that can be associated with being diagnosed with mental health problems, through promoting social inclusion. This includes challenging stigma and discrimination and improving access to educational and employment opportunities.
In recent years a number of surveys have been commissioned, including by the Royal College of Psychiatrists, to examine the perceptions of the public towards mental health problems. These have presented some important findings:
• Positive attitudes towards people with mental health problems have decreased since 1994 (ONS 2008).
• Younger people have less tolerant attitudes than older people (ONS 2008) and the most negative perceptions were expressed by 16–19-year-olds (Crisp et al 2005).
• 89% of respondents in 2007 agreed that virtually anyone can become mentally ill (ONS 2008).
• Drug addiction and alcoholism received the highest percentage of negative perceptions than any other diagnosis (Crisp et al 2005).
There are many influences on the development of attitudes towards mental health problems. However, the media has been suggested to play a significant role in the public's perceptions (Anderson 2003). Media reporting has tended to depict people with mental health problems in a negative light and the association with dangerousness and violence has been strong (Cutcliffe & Hannigan 2001), both in the reporting of adverse events and within fictional stories and films. The development of attitudes is complex; however, having these strong views represented in such a powerful influence within society undoubtedly fuels fear and stereotypes associated with mental health problems. This culminates in a situation in which reactions towards people with mental health problems can be dominated by fear. In order to help engender a more positive, helpful and understanding image of mental health across the media, a number of campaigns have been supporting more accurate media representations.
For some of you, this placement might be your first experience of meeting and working with people with mental health problems (or the first time you have knowingly been in this situation) and therefore you may well share some of these concerns about the potential for danger and violence from the people you are working with. This view is not uncommon especially as we have already acknowledged that, as nurses, we are also members of the public and exposed to similar influences to everyone else. Contact with people with mental health problems is one of the most powerful ways of challenging prejudice and impacting on stereotypes. Chapter 5 deals with concerns that you may have before starting your placement, such as these, in more detail.
Exploring the nature of public perceptions has highlighted that these can have an impact on a person's health, opportunities and experiences in their community. It has also been recognised that as health professionals we are not immune to developing prejudice and stereotypes and that acknowledging and exploring our own views is an important part of developing as a mental health nurse.
This chapter has provided an overview of some of the prevalence and impact of mental health problems. It aids in providing a context for the remainder of the book, supporting your journey through mental health placements.
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