Mental Health Disorders: A Community Health Nursing Perspective
Comprehensive notes for nursing students
A community health nurse providing mental health support
Table of Contents
Introduction to Mental Health Nursing
Mental health nursing involves specialized care for individuals experiencing psychiatric disorders. From a community health perspective, nurses play a vital role in prevention, early intervention, and ongoing management of mental health conditions.
Community mental health nursing focuses on providing comprehensive care that extends beyond individual treatment to include families and communities. This holistic approach aims to improve mental health awareness, reduce stigma, and enhance access to quality mental health services.
Key Components of Community Mental Health Nursing:
- Prevention and health promotion
- Assessment and early intervention
- Care coordination and case management
- Therapeutic relationships and communication
- Medication management and monitoring
- Crisis intervention and stabilization
- Recovery-oriented practice
- Community engagement and education
Mental health nursing requires specialized knowledge and skills to address complex needs while promoting resilience and recovery. This guide examines common mental health disorders from a community health perspective, providing evidence-based approaches to assessment, intervention, and ongoing management.
Depression
Overview
Depression is a common but serious mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyed activities. It affects how a person feels, thinks, and handles daily activities, and can lead to a variety of emotional and physical problems.
Mnemonic: “SIG E CAPS”
Common symptoms of Major Depressive Disorder:
- Sleep disturbance (insomnia or hypersomnia)
- Interest deficit (anhedonia)
- Guilt or worthlessness
- Energy deficit
- Concentration problems
- Appetite changes (increased or decreased)
- Psychomotor changes (agitation or retardation)
- Suicidal ideation
Types of Depression
| Type | Key Features | Duration |
|---|---|---|
| Major Depressive Disorder (MDD) | Persistent low mood, anhedonia, significant functional impairment | At least 2 weeks, often recurring |
| Persistent Depressive Disorder (Dysthymia) | Chronic, less severe depressive symptoms | At least 2 years |
| Postpartum Depression | Occurs after childbirth, can include thoughts of harming baby | Onset within 4 weeks of delivery |
| Seasonal Affective Disorder (SAD) | Depression related to seasonal changes, typically winter | Recurring seasonally |
Assessment Tools
Community health nurses regularly use standardized assessment tools to screen for and monitor depression:
- Patient Health Questionnaire (PHQ-9): 9-item tool that scores each DSM-5 criterion from 0-3
- Beck Depression Inventory (BDI-II): 21-question self-report inventory
- Geriatric Depression Scale (GDS): Specifically for older adults
- Edinburgh Postnatal Depression Scale (EPDS): For screening postpartum depression
PHQ-9 Scoring Guide:
- 0-4: Minimal depression
- 5-9: Mild depression
- 10-14: Moderate depression
- 15-19: Moderately severe depression
- 20-27: Severe depression
Note: A score of ≥10 has 88% sensitivity and 88% specificity for Major Depression.
Community Health Nursing Interventions
Nursing Process for Depression:
- Assessment: Screen using standardized tools, identify risk factors, assess for suicidal ideation
- Nursing Diagnosis:
- Hopelessness related to perceived lack of control
- Risk for suicide related to feelings of worthlessness
- Social isolation related to depressed mood
- Imbalanced nutrition related to decreased appetite
- Disturbed sleep pattern related to depressive symptoms
- Planning & Interventions:
- Establish therapeutic relationship
- Provide psychoeducation on depression
- Monitor medication adherence and side effects
- Promote healthy lifestyle (nutrition, exercise, sleep hygiene)
- Teach coping strategies and problem-solving skills
- Facilitate referrals to mental health specialists when needed
- Conduct regular follow-ups and monitoring
- Evaluation: Reassess symptoms using standardized tools, evaluate treatment response
Treatment Approaches
Comprehensive Treatment Framework:
Psychotherapy:
- Cognitive Behavioral Therapy (CBT)
- Interpersonal Therapy (IPT)
- Problem-Solving Therapy
- Behavioral Activation
Pharmacotherapy:
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
- Atypical antidepressants
- Tricyclic antidepressants (less commonly used)
- Monoamine Oxidase Inhibitors (rarely used)
Complementary Approaches:
- Exercise therapy
- Light therapy (especially for SAD)
- Mindfulness-based interventions
For Treatment-Resistant Depression:
- Electroconvulsive Therapy (ECT)
- Transcranial Magnetic Stimulation (TMS)
- Ketamine therapy
Community Nursing Considerations
In community settings, mental health nursing for depression focuses on:
- Implementing depression screening programs in primary care
- Conducting home visits for high-risk individuals
- Facilitating support groups
- Coordinating care between multiple providers
- Addressing social determinants affecting mental health
- Providing education to families and caregivers
- Reducing stigma through community awareness programs
- Monitoring for medication effectiveness and side effects
Anxiety Disorders
Overview
Anxiety disorders are characterized by excessive worry, fear, and related behavioral disturbances that are disproportionate to the situation and interfere with daily functioning. They are among the most common mental health disorders in the community setting.
Types of Anxiety Disorders
| Type | Key Features |
|---|---|
| Generalized Anxiety Disorder (GAD) | Persistent, excessive worry about various topics, events, or activities |
| Panic Disorder | Recurrent unexpected panic attacks and persistent concern about future attacks |
| Social Anxiety Disorder | Intense fear of social situations where scrutiny or negative evaluation may occur |
| Specific Phobias | Marked fear or anxiety about a specific object or situation |
| Obsessive-Compulsive Disorder (OCD) | Recurrent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) |
| Post-Traumatic Stress Disorder (PTSD) | Development of symptoms following exposure to traumatic event(s) |
Mnemonic: “STUDENTS FEAR” – Symptoms of Anxiety
- Sweating
- Trembling or shaking
- Unpredictable panic
- Dizziness
- Excessive worry
- Nausea or GI distress
- Tachycardia, palpitations
- Shortness of breath
- Fatigue
- Efforts to avoid triggers
- Agitation, restlessness
- Ruminating thoughts
Assessment Tools
Community health nurses can use these standardized tools for anxiety screening and assessment:
- Generalized Anxiety Disorder-7 (GAD-7): Quick 7-item screening tool
- Hamilton Anxiety Rating Scale (HAM-A): 14-item clinician-administered scale
- Beck Anxiety Inventory (BAI): 21-item self-report measure
- Penn State Worry Questionnaire (PSWQ): Measures worry characteristics
- PTSD Checklist (PCL-5): Assesses symptoms of PTSD
GAD-7 Scoring Guide:
- 0-4: Minimal anxiety
- 5-9: Mild anxiety
- 10-14: Moderate anxiety
- 15-21: Severe anxiety
Note: A score of ≥10 represents a reasonable cut-point for identifying cases of GAD.
Community Health Nursing Interventions
Nursing Process for Anxiety Disorders:
- Assessment: Screen using standardized tools, identify triggers and coping patterns
- Nursing Diagnosis:
- Anxiety related to situational stressors
- Ineffective coping related to overwhelming anxiety
- Fear related to perceived threat
- Social isolation related to avoidance behaviors
- Sleep disturbance related to anxiety symptoms
- Planning & Interventions:
- Teach anxiety management techniques (deep breathing, progressive muscle relaxation, mindfulness)
- Provide psychoeducation about anxiety disorders
- Help identify and challenge cognitive distortions
- Monitor medication effectiveness and side effects
- Develop exposure hierarchies for phobias (in collaboration with behavioral health providers)
- Support gradual return to avoided activities
- Facilitate referrals to specialized care when needed
- Evaluation: Reassess anxiety levels, evaluate functioning and coping skills
Treatment Approaches
Comprehensive Treatment Framework:
Psychotherapy:
- Cognitive Behavioral Therapy (first-line)
- Exposure Therapy (for phobias, OCD, PTSD)
- Acceptance and Commitment Therapy
- Mindfulness-Based Stress Reduction
Pharmacotherapy:
- SSRIs & SNRIs (first-line for most anxiety disorders)
- Buspirone (for GAD)
- Benzodiazepines (short-term use only due to addiction potential)
- Beta-blockers (for performance anxiety)
Complementary Approaches:
- Regular physical exercise
- Relaxation techniques
- Stress management programs
- Yoga and meditation
Community Nursing Considerations
Community mental health nursing for anxiety disorders involves:
- Running community-based anxiety screening programs
- Facilitating anxiety management groups
- Providing psychoeducation to families and caregivers
- Addressing environmental factors contributing to anxiety
- Monitoring for anxiety during times of community stress or crisis
- Advocating for anxiety-friendly workplaces and schools
- Coordinating care between primary care and specialized mental health services
Acute Psychosis
Overview
Acute psychosis is characterized by a rapid onset of psychotic symptoms including hallucinations, delusions, and disorganized thinking. It represents a mental health emergency that requires immediate intervention and can occur in various conditions including schizophrenia, bipolar disorder, severe depression, or drug-induced states.
Clinical Manifestations
Positive Symptoms
- Hallucinations (auditory, visual, tactile)
- Delusions (persecutory, grandiose, reference)
- Disorganized speech
- Bizarre behavior
Negative Symptoms
- Flat affect
- Poverty of speech
- Anhedonia
- Social withdrawal
- Decreased motivation
Causes of Acute Psychosis
Mnemonic: “MS MAPS” – Causes of Acute Psychosis
- Medications/drugs (anticholinergics, steroids, stimulants)
- Substance use/intoxication (amphetamines, cannabis, hallucinogens)
- Metabolic/endocrine disorders (electrolyte imbalances, thyroid disease)
- Autoimmune/inflammatory (encephalitis, lupus)
- Psychiatric conditions (schizophrenia, bipolar disorder, severe depression)
- Structural/neurological (tumors, stroke, dementia)
Assessment and Management
Assessment Priorities:
- Safety assessment (risk to self or others)
- Medical evaluation (rule out medical causes)
- Psychiatric history
- Mental status examination
- Substance use history
- Baseline vital signs
- Assessment tools: Brief Psychiatric Rating Scale (BPRS), Positive and Negative Syndrome Scale (PANSS)
Nursing Process for Acute Psychosis:
- Assessment: Evaluate safety, identify symptoms, assess for underlying causes
- Nursing Diagnosis:
- Risk for violence directed at others related to paranoid delusions
- Disturbed thought processes related to psychosis
- Disturbed sensory perception related to hallucinations
- Self-care deficit related to altered mental status
- Ineffective coping related to acute psychosis
- Planning & Interventions:
- Ensure safety of patient and others
- Maintain calm, quiet environment with minimal stimulation
- Use clear, concise communication
- Administer prescribed medications
- Monitor vital signs and medication effects
- Provide reality orientation when appropriate
- Avoid challenging delusions directly
- Encourage adequate nutrition, hydration, and rest
- Involve family/support persons in care planning
- Evaluation: Monitor response to interventions, assess symptom reduction
Stages of Management
| Stage | Focus | Interventions |
|---|---|---|
| Prevention | Early identification of escalating symptoms | Monitoring warning signs, stress reduction, medication adherence |
| De-escalation | Verbal techniques to reduce agitation | Therapeutic communication, offering choices, providing space |
| External Management | Interventions for severe agitation/danger | Medication administration, environmental safety measures |
| Stabilization | Symptom control and assessment | Medication adjustment, ongoing monitoring, addressing physical needs |
| Transition Planning | Preparation for community re-entry | Discharge planning, linking with community services, family education |
Treatment Approaches
Acute Psychosis Management:
Pharmacotherapy:
- Antipsychotics (first-line treatment)
- First-generation: Haloperidol, Fluphenazine
- Second-generation: Risperidone, Olanzapine, Quetiapine, Aripiprazole
- Benzodiazepines (for agitation, often in combination with antipsychotics)
- Mood stabilizers (if bipolar disorder is suspected)
Psychosocial Interventions:
- Crisis intervention
- Family education and support
- Milieu therapy
- Cognitive Behavioral Therapy for psychosis (CBTp)
Community Nursing Considerations
Community health nurses play a vital role in acute psychosis management through:
- Early recognition and intervention for prodromal symptoms
- Home visits for medication administration and monitoring
- Coordination with crisis response teams
- Education of families on warning signs and crisis management
- Facilitation of rapid access to mental health services
- Post-crisis follow-up and relapse prevention
- Collaboration with community support services
Community-Based Programs for Acute Psychosis:
- Early Intervention in Psychosis (EIP) Services: Specialized teams for first-episode psychosis
- Assertive Community Treatment (ACT): Intensive community-based support
- Crisis Resolution Teams: Mobile teams providing rapid response
- Home Treatment Teams: Intensive home-based care as alternative to hospitalization
Schizophrenia
Overview
Schizophrenia is a complex, chronic mental health disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It affects approximately 1% of the population worldwide and typically emerges in late adolescence or early adulthood.
Clinical Manifestations
Positive Symptoms
- Hallucinations
- Delusions
- Disorganized speech
- Disorganized behavior
Negative Symptoms
- Flat affect
- Alogia (poverty of speech)
- Avolition (lack of motivation)
- Anhedonia (inability to feel pleasure)
- Social withdrawal
Cognitive Symptoms
- Poor executive functioning
- Trouble focusing/attention
- Problems with working memory
- Decreased speed of processing
Mnemonic: “SCHIZOPHRENIA”
- Speech disorganized
- Cognitive impairment
- Hallucinations (often auditory)
- Insight poor
- Zero motivation (avolition)
- Occupational dysfunction
- Paranoia and delusions
- Hygiene neglected
- Relationships impaired
- Emotional blunting
- Negative symptoms
- Isolation social
- Affect flat or inappropriate
Phases of Schizophrenia
| Phase | Characteristics | Nursing Focus |
|---|---|---|
| Prodromal | Subtle changes in thinking, mood, social functioning; precedes first psychotic episode | Early identification, education, referral to specialized services |
| Acute | Active psychotic symptoms, severe functional impairment | Crisis intervention, safety, medication initiation, symptom management |
| Stabilization | Reduction in acute symptoms, beginning of recovery | Medication optimization, rehabilitation, psychoeducation |
| Maintenance | Relative stability, focus on preventing relapse | Long-term treatment adherence, community integration, relapse prevention |
Assessment and Nursing Management
Nursing Process for Schizophrenia:
- Assessment:
- Mental status examination
- Assessment of positive, negative, and cognitive symptoms
- Functional assessment
- Risk assessment (suicide, self-neglect, violence)
- Medication adherence and side effects
- Physical health assessment (metabolic screening)
- Social support and living situation
- Nursing Diagnosis:
- Disturbed thought processes related to altered brain function
- Disturbed sensory perception related to neurobiological factors
- Self-care deficit related to cognitive impairment and negative symptoms
- Social isolation related to impaired social functioning
- Risk for non-adherence related to lack of insight
- Imbalanced nutrition related to self-care deficits
- Planning & Interventions:
- Medication management and education
- Monitoring for side effects (especially metabolic and extrapyramidal)
- Psychoeducation for patient and family
- Skills training (social, daily living, problem-solving)
- Promotion of physical health
- Relapse prevention planning
- Community resource coordination
- Supportive counseling
- Evaluation: Monitor symptom management, functional status, medication adherence
Treatment Approaches
Comprehensive Treatment Framework:
Pharmacotherapy:
- First-generation antipsychotics (typical): Haloperidol, Fluphenazine
- Second-generation antipsychotics (atypical): Risperidone, Olanzapine, Quetiapine, Aripiprazole, Clozapine (for treatment-resistant cases)
- Long-acting injectable antipsychotics for adherence issues
Psychosocial Interventions:
- Cognitive Behavioral Therapy for psychosis (CBTp)
- Family psychoeducation and therapy
- Social skills training
- Cognitive remediation
- Supported employment
- Illness Management and Recovery (IMR) programs
Community Nursing Considerations
Community mental health nursing for schizophrenia focuses on:
- Implementing evidence-based models like Assertive Community Treatment (ACT)
- Coordinating care between multiple service providers
- Monitoring medication adherence and administering long-acting injectables
- Conducting regular physical health monitoring
- Addressing social determinants of health (housing, finances, employment)
- Supporting families and caregivers
- Facilitating community integration and reducing stigma
- Early intervention for prodromal symptoms or relapse
Community-Based Recovery in Schizophrenia:
The “CHIME” framework for recovery in serious mental illness:
- Connectedness (relationships and social inclusion)
- Hope and optimism
- Identity (positive sense of self beyond the illness)
- Meaning and purpose
- Empowerment (control over life and treatment)
Dementia
Overview
Dementia is a syndrome characterized by progressive cognitive decline that interferes with daily functioning. It involves deterioration in memory, thinking, behavior, and the ability to perform everyday activities. From a community health nursing perspective, dementia care requires comprehensive assessment, intervention, and support systems.
Types of Dementia
| Type | Characteristics | Approximate Prevalence |
|---|---|---|
| Alzheimer’s Disease | Gradual onset, memory impairment, language difficulties, executive dysfunction | 60-70% of cases |
| Vascular Dementia | Stepwise progression, focal neurological signs, history of cerebrovascular events | 15-20% of cases |
| Lewy Body Dementia | Visual hallucinations, fluctuating cognition, parkinsonism, REM sleep behavior disorder | 5-10% of cases |
| Frontotemporal Dementia | Early personality/behavior changes, language problems, often younger onset | 2-5% of cases |
| Mixed Dementia | Features of multiple types, commonly Alzheimer’s and vascular | 10-15% of cases |
Stages of Dementia
Early Stage
- Forgetfulness
- Losing track of time
- Becoming lost in familiar places
- Often subtle changes that may be overlooked
Middle Stage
- Forgetting recent events and people’s names
- Becoming lost at home
- Increasing difficulty with communication
- Behavioral changes (wandering, repeated questioning)
- Needing help with personal care
Late Stage
- Severe memory disturbances
- Complete dependence on caregivers
- Difficulty recognizing relatives/friends
- Physical symptoms more pronounced
- Difficulty walking, swallowing
Assessment Tools
Community health nurses use various tools to assess cognitive function and dementia:
- Mini-Mental State Examination (MMSE): 30-point questionnaire covering orientation, registration, attention, recall, language
- Montreal Cognitive Assessment (MoCA): More sensitive for mild cognitive impairment
- Clock Drawing Test: Simple screening tool for visual-spatial and executive function
- Geriatric Depression Scale (GDS): To differentiate depression from dementia
- Activities of Daily Living (ADL) scales: Assess functional impairment
- Neuropsychiatric Inventory (NPI): Evaluates behavioral and psychological symptoms
Mnemonic: “DEMENTIA” – Key Assessment Areas
- Daily functioning (ADLs, IADLs)
- Emotional state and behaviors
- Memory and cognition
- Environment (safety, supports)
- Nutritional status
- Treatment effectiveness and side effects
- Informal caregivers’ needs and coping
- Activity levels and engagement
Nursing Management in Community Settings
Nursing Process for Dementia:
- Assessment:
- Cognitive function using standardized tools
- Functional abilities (ADLs and IADLs)
- Behavioral and psychological symptoms
- Safety risks
- Caregiver stress and resources
- Physical health and comorbidities
- Medication review
- Nursing Diagnosis:
- Chronic confusion related to neurocognitive disorder
- Self-care deficits related to cognitive impairment
- Risk for injury related to impaired judgment
- Disturbed sleep pattern related to neurological changes
- Caregiver role strain related to caring for person with dementia
- Impaired social interaction related to communication difficulties
- Planning & Interventions:
- Implement person-centered care approaches
- Establish consistent routines
- Modify environment for safety and orientation
- Develop communication strategies
- Manage behavioral symptoms using non-pharmacological approaches
- Monitor medication effectiveness and side effects
- Provide caregiver education and support
- Connect with community resources
- Advance care planning discussions
- Evaluation: Monitor cognitive status, function, behaviors, caregiver coping
Managing Behavioral and Psychological Symptoms of Dementia (BPSD)
Non-Pharmacological Approaches (First-Line):
- Personalized activities based on past interests and abilities
- Environmental modifications (reducing noise, proper lighting, clear signage)
- Communication strategies (simple statements, visual cues, validation)
- Structured routines and consistent caregivers
- Music therapy and reminiscence activities
- Physical exercise appropriate to ability level
- Sensory interventions (aromatherapy, massage, multisensory stimulation)
Pharmacological Approaches (Consider when non-pharmacological approaches insufficient):
- For cognitive symptoms: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine), memantine
- For depression/anxiety: SSRIs (generally safer than other classes)
- For severe agitation/psychosis: Antipsychotics (with caution due to black box warning for increased mortality)
- For sleep disturbances: Non-benzodiazepine hypnotics, melatonin
Note: All medications should be used with caution, starting at low doses with careful monitoring for side effects.
Community Nursing Considerations
Community health nurses provide vital support for people with dementia and their caregivers:
- Conducting home safety assessments and recommending modifications
- Monitoring medication management and adherence
- Coordinating care between multiple providers and services
- Providing caregiver education and support
- Connecting families with resources (adult day programs, respite care, support groups)
- Monitoring for changes in condition that may require intervention
- Facilitating timely access to specialized services when needed
- Supporting advance care planning and end-of-life discussions
Person-Centered Dementia Care:
Tom Kitwood’s model emphasizes preserving personhood through addressing five key psychological needs:
- Comfort: Providing warmth and security
- Attachment: Forming bonds and connections
- Inclusion: Being part of a social group
- Occupation: Being involved in meaningful activities
- Identity: Maintaining a sense of who one is
Suicide Prevention
Overview
Suicide is a significant public health concern and a leading cause of preventable death globally. Community health nurses are uniquely positioned to identify those at risk, intervene appropriately, and coordinate care to prevent suicide. Effective suicide prevention requires a comprehensive approach addressing individual, relationship, community, and societal factors.
Risk Factors and Warning Signs
Risk Factors
- Previous suicide attempt(s)
- Mental health disorders (depression, bipolar disorder, schizophrenia)
- Substance use disorders
- Family history of suicide
- Chronic pain or illness
- Access to lethal means
- Recent loss or stressful life event
- Social isolation
- History of trauma or abuse
- Lack of social support and sense of belonging
Warning Signs
- Talking about wanting to die or kill oneself
- Looking for ways to kill oneself
- Talking about feeling hopeless or having no purpose
- Talking about feeling trapped or being in unbearable pain
- Increasing substance use
- Acting anxious, agitated, or recklessly
- Changes in sleep patterns
- Withdrawing or feeling isolated
- Showing rage or talking about seeking revenge
- Displaying extreme mood swings
Mnemonic: “IS PATH WARM” – Warning Signs for Suicide
- Ideation (thoughts of suicide)
- Substance use (increased or excessive)
- Purposelessness (no reason for living)
- Anxiety (agitation, insomnia)
- Trapped (feeling there is no way out)
- Hopelessness
- Withdrawal (from friends, family, society)
- Anger (uncontrolled rage, seeking revenge)
- Recklessness (risky activities)
- Mood changes (dramatic shifts)
Assessment Tools
Standardized assessment tools help identify suicide risk:
- Columbia-Suicide Severity Rating Scale (C-SSRS): Assesses suicidal ideation and behavior
- Patient Health Questionnaire-9 (PHQ-9): Item #9 specifically addresses suicidal thoughts
- Beck Hopelessness Scale: Measures negative attitudes about the future
- SAD PERSONS Scale: Mnemonic tool for suicide risk factors
- Suicide Assessment Five-Step Evaluation and Triage (SAFE-T): Guides clinical assessment
SAD PERSONS Scale:
Each factor scores 1 point. Score of 5-6 indicates medium risk, 7-10 high risk.
- Sex (male)
- Age (younger than 19 or older than 45)
- Depression or hopelessness
- Previous attempts or psychiatric care
- Excessive alcohol or drug use
- Rational thinking loss
- Separated, divorced, or widowed
- Organized plan or serious attempt
- No social support
- Stated future intent
Nursing Management
Nursing Process for Suicide Prevention:
- Assessment:
- Screen all patients for suicide risk, especially those with mental health or substance use disorders
- Assess for ideation, plan, intent, access to means, protective factors
- Use standardized assessment tools
- Document risk assessment thoroughly
- Nursing Diagnosis:
- Risk for suicide related to expressed desire to die
- Hopelessness related to perceived lack of alternatives to problems
- Ineffective coping related to overwhelming emotional stressors
- Spiritual distress related to loss of meaning and purpose
- Interrupted family processes related to crisis situation
- Planning & Interventions:
- Establish therapeutic alliance and rapport
- Develop a safety plan with the individual
- Remove or secure access to lethal means
- Involve family/support persons when appropriate
- Provide crisis intervention
- Facilitate referrals to appropriate level of care
- Coordinate follow-up care (critical after discharge or crisis)
- Educate about warning signs and resources
- Support development of coping strategies
- Evaluation: Ongoing assessment of risk level, effectiveness of safety plan, engagement in treatment
Safety Planning
Safety Plan Components:
- Warning signs: Personal indicators of escalating crisis
- Internal coping strategies: Activities the person can do without contacting others
- Social contacts and settings: People and places that provide distraction
- Family and friends who can help during crisis
- Professional and agency contacts for crisis assistance
- Means restriction: Steps to eliminate access to lethal means
Note: Safety plans should be personalized, realistic, and accessible.
Comprehensive Approach to Suicide Prevention
Individual-Level Strategies
- Identify and treat mental health and substance use disorders
- Enhance problem-solving and coping skills
- Promote connectedness and reduce isolation
- Create safety plans with at-risk individuals
- Follow-up care after crisis or hospitalization
Community-Level Strategies
- Reduce stigma around mental health and help-seeking
- Train gatekeepers (teachers, clergy, community workers)
- Restrict access to lethal means in community settings
- Implement school-based prevention programs
- Create crisis response protocols and resources
Community Health Nursing Considerations
Community health nurses play vital roles in suicide prevention:
- Screening for suicide risk during routine assessments
- Leading community education on suicide prevention
- Training community gatekeepers to recognize warning signs
- Coordinating care between emergency services and ongoing mental health care
- Conducting post-vention services after a suicide
- Advocating for policies that reduce suicide risk
- Establishing referral networks and partnerships
- Supporting survivors of suicide loss
Crisis Resources to Know:
- National Suicide Prevention Lifeline: 988 (call or text)
- Crisis Text Line: Text HOME to 741741
- Veterans Crisis Line: Call 988 and press 1
- Trevor Project (LGBTQ+ youth): 1-866-488-7386
- Local crisis hotlines and emergency departments
- Mobile crisis response teams
- Psychiatric emergency services
Substance Use Disorders
Overview
Substance use disorders (SUDs) are characterized by a problematic pattern of using alcohol or other drugs that leads to significant impairment or distress. From a community health nursing perspective, addressing SUDs requires a comprehensive approach including prevention, screening, intervention, treatment, and recovery support.
Common Substances of Abuse
| Substance Type | Examples | Key Effects | Withdrawal Features |
|---|---|---|---|
| Alcohol | Beer, wine, spirits | Disinhibition, impaired coordination, sedation | Tremors, anxiety, seizures, delirium tremens |
| Opioids | Heroin, oxycodone, fentanyl | Euphoria, analgesia, respiratory depression | Nausea, muscle aches, anxiety, drug craving |
| Stimulants | Cocaine, amphetamines, methamphetamine | Increased energy, euphoria, decreased appetite | Fatigue, depression, increased appetite, anxiety |
| Cannabis | Marijuana, hashish | Relaxation, altered perception, increased appetite | Irritability, sleep difficulties, decreased appetite |
| Sedatives | Benzodiazepines, barbiturates | Sedation, anxiolysis, memory impairment | Anxiety, insomnia, tremors, seizures |
Mnemonic: “CAGES” – Modified CAGE Questionnaire for Substance Use
- Cut down: Have you ever felt you should cut down on your drinking or drug use?
- Annoyed: Have people annoyed you by criticizing your drinking or drug use?
- Guilty: Have you ever felt bad or guilty about your drinking or drug use?
- Eye opener: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?
- Substance preference: What is your substance of choice?
Two or more positive responses suggest a substance use problem.
Assessment Tools
- AUDIT (Alcohol Use Disorders Identification Test): 10-item screening for alcohol problems
- DAST-10 (Drug Abuse Screening Test): Brief drug use screening tool
- CRAFFT: Screening tool specifically for adolescents
- NIDA Quick Screen: Brief screening for substance use
- CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol): Assesses alcohol withdrawal severity
- COWS (Clinical Opiate Withdrawal Scale): Measures severity of opiate withdrawal
Prevention Levels
Primary Prevention
Preventing substance use before it begins
- School-based education programs
- Community awareness campaigns
- Policies limiting substance access
- Life skills development
- Positive youth development
Secondary Prevention
Early identification and intervention
- Screening in healthcare settings
- Brief interventions
- Harm reduction strategies
- Early referral to treatment
- Support for high-risk populations
Tertiary Prevention
Treatment and recovery support
- Comprehensive treatment programs
- Relapse prevention
- Recovery support services
- Managing co-occurring disorders
- Long-term follow-up care
Nursing Management
Nursing Process for Substance Use Disorders:
- Assessment:
- Screen using standardized tools
- Comprehensive substance use history (substances, patterns, amounts)
- Physical assessment for complications of substance use
- Withdrawal risk assessment
- Mental health assessment for co-occurring disorders
- Social history and support systems
- Readiness to change assessment
- Nursing Diagnosis:
- Risk for injury related to substance intoxication or withdrawal
- Ineffective coping related to substance use
- Disturbed thought processes related to substance effects
- Imbalanced nutrition related to substance use
- Risk for infection related to substance use behaviors
- Ineffective denial related to addiction
- Interrupted family processes related to substance use disorder
- Planning & Interventions:
- Implement harm reduction strategies
- Provide education about substance effects and risks
- Monitor for and manage withdrawal symptoms
- Use motivational interviewing to encourage behavior change
- Coordinate referrals to appropriate treatment levels
- Address physical health complications
- Support development of healthy coping skills
- Facilitate recovery support connections
- Provide education and support for family members
- Evaluation: Monitor substance use patterns, engagement in treatment, health status, and recovery progress
Treatment Approaches
Comprehensive Treatment Framework:
Pharmacological Interventions:
- For alcohol use disorder: Naltrexone, acamprosate, disulfiram
- For opioid use disorder: Methadone, buprenorphine, naltrexone
- For tobacco use disorder: Nicotine replacement, varenicline, bupropion
- For withdrawal management: Benzodiazepines (alcohol), buprenorphine/methadone (opioids), etc.
Behavioral Therapies:
- Cognitive-Behavioral Therapy (CBT)
- Motivational Enhancement Therapy
- Contingency Management
- Community Reinforcement Approach
- 12-Step Facilitation
- Family therapy
Recovery Support Services:
- Peer recovery support specialists
- Recovery housing
- Recovery community organizations
- Mutual help groups (AA, NA, SMART Recovery)
- Continuing care management
Harm Reduction Strategies
Key Harm Reduction Approaches:
- Syringe services programs
- Naloxone distribution
- Supervised consumption facilities
- Drug checking services
- Safe drinking guidelines
- Designated driver programs
- Overdose prevention education
- Safe sex education for substance users
Note: Harm reduction aims to reduce negative consequences of substance use without requiring abstinence as a prerequisite for support.
Community Health Nursing Considerations
Community mental health nursing for substance use disorders focuses on:
- Community-based screening and brief interventions
- Outreach to vulnerable populations
- Coordination with first responders for overdose response
- Public education on substance risks and safe use
- Implementation of harm reduction programs
- Support for medication-assisted treatment in community settings
- Building recovery-supportive communities
- Addressing social determinants that contribute to substance use
- Advocacy for policy changes to support prevention and treatment
SBIRT Model for Community Settings:
- Screening: Universal screening using validated tools
- Brief Intervention: Short counseling sessions using motivational techniques
- Referral to Treatment: Connecting those who need specialized care
SBIRT can be implemented in primary care, emergency departments, schools, workplaces, and other community settings.
Global Best Practices in Community Mental Health Nursing
Overview
Around the world, innovative approaches to community mental health nursing have emerged to address the growing burden of mental health disorders. These models represent best practices that can be adapted to various contexts.
Trieste Model (Italy)
Italy’s Trieste model has been recognized by the WHO as a global standard for community mental health care.
- Community Mental Health Centers open 24/7
- Sharp reduction in psychiatric beds
- Focus on social inclusion and recovery
- Social cooperatives providing employment
- Strong emphasis on civil rights of patients
- Integration of health and social services
Friendship Bench (Zimbabwe)
A task-shifting approach where community health workers (“grandmother counselors”) deliver evidence-based interventions.
- Problem-solving therapy delivered on wooden benches
- Training lay health workers in basic mental health care
- Culturally adapted interventions
- Demonstrated effectiveness in reducing depression
- Scalable model for low-resource settings
Recovery Houses (Finland)
Finland’s Open Dialogue approach provides immediate, integrated care for first-episode psychosis.
- Rapid intervention (within 24 hours)
- Treatment team consistency
- Family and network involvement
- Flexibility in treatment approaches
- Tolerance of uncertainty
- Dialogue-focused care
- Significantly reduced hospitalization rates
Headspace (Australia)
Youth-focused community mental health centers providing early intervention.
- One-stop-shop model for youth mental health
- Youth-friendly environments
- No-wrong-door approach
- Integration of mental health, physical health, educational and vocational support
- Strong emphasis on reducing stigma
- Digital mental health services
PRIME (Program for Improving Mental Health Care)
Implemented across five low and middle-income countries (Ethiopia, India, Nepal, South Africa, Uganda).
- Integration of mental health into primary care
- Task-sharing with non-specialist health workers
- Standardized care packages
- Community mobilization and engagement
- Monitoring and evaluation framework
- Health system strengthening approach
Housing First (Canada)
Approach for homelessness among people with severe mental illness and substance use disorders.
- No prerequisites for housing (sobriety, treatment adherence)
- Consumer choice and self-determination
- Recovery orientation
- Individualized and person-centered support
- Social and community integration
- Demonstrated cost-effectiveness
Common Elements of Successful Programs
- Person-centered and recovery-oriented approaches
- Integration of mental health into primary care
- Strong community engagement and participation
- Task-sharing with trained non-specialists where appropriate
- Addressing social determinants of mental health
- Continuity of care across service levels
- Reducing stigma and discrimination
- Emphasis on human rights and dignity
- Use of peer support workers
- Cultural adaptation of interventions
Implications for Community Health Nursing Practice:
These global best practices suggest that community mental health nurses should:
- Advocate for systems that promote recovery and social inclusion
- Embrace innovative service delivery models
- Engage with cultural contexts and adapt interventions accordingly
- Support task-sharing while maintaining quality of care
- Focus on early intervention and prevention
- Champion integration of physical and mental health care
- Incorporate peer support workers into care teams
- Address social determinants alongside clinical interventions
Conclusion
Mental health disorders represent a significant area of focus in community health nursing. Through comprehensive assessment, evidence-based interventions, and ongoing support, community health nurses can make a substantial impact on the lives of individuals experiencing depression, anxiety, psychosis, schizophrenia, dementia, suicidal thoughts, and substance use disorders.
By integrating best practices from around the world and taking a person-centered approach, mental health nursing in community settings can promote recovery, reduce stigma, and improve overall quality of life. The emphasis on prevention, early intervention, and continuous support helps create a mental health system that is responsive, effective, and compassionate.
As community mental health nursing continues to evolve, the focus remains on providing holistic care that addresses not only symptoms but also social determinants of health, promoting recovery and empowerment for individuals and communities.