NURS3034 – Chapter 1: Mental Health and Mental Illness
Mental Health and Mental Illness
Mental Health and Mental Illness
- A person cannot be considered healthy without taking into account mental and physical
health
- The WHO defines mental health as “a state of well-being in which each individual is able
to realize his or her own potential, cope with the normal stresses of life, work
productively and fruitfully, and make a contribution to the community”
- Good mental health is associated with better physical health outcomes, improved
educational attainment, increased economic participation, and rich social relationships
- Mental health is described as more than merely the absence of mental disorders or
disabilities
- The Public Health Agency of Canada (2014) offers the following definition of mental
health: “the capacity of each and all of us to feel, think, and act in ways that enhance our
ability to enjoy life and deal with the challenges we face. It is a positive sense of
emotional and spiritual well-being that respects the importance of culture, equity, social
justice, interconnections and personal dignity.”
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Alterations in cognition, mood, or behaviour that are coupled with significant distress
and impaired functioning characterize mental illness
Mental illness refers to all mental disorders with definable diagnoses
Two Conceptualizations of Mental Health and Mental Illness
- The Epp Report (Epp, 1988) proposed two continua to depict the relationship between
mental health and mental disorder
o The Mental Disorder Continuum assigns one endpoint as maximal mental
disorder and the opposite endpoint as absence of mental disorder, allowing for a
range of impairment and distress
o The Mental Health Continuum assigns one pole as optimal mental health and the
opposite pole as minimal mental health
 On this scale, a person with optimal mental health would demonstrate
good coping skills and resilience when faced with stressors, and a person
with minimal mental health may decompensate and not be able to cope
with stressors.
Contributing Factors
- Many factors can affect the severity and progression of a mental illness, as well as the
mental health of a person who does not have a mental illness
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Resilience
o A characteristic of mental health increasingly being promoted as essential to the
recovery process is resilience.
o Resilience depends far more on the quality of the social and physical ecologies
surrounding people than on individual personality traits, cognitions, or talents
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NURS3034 – Chapter 1: Mental Health and Mental Illness
o Closely associated with the process of adapting, resilience helps people face
tragedies, loss, trauma, and severe stress
o Being resilient does not mean being unaffected by stressors; rather, it means that
instead of falling victim to negative emotions, resilient people recognize such
feelings and negotiate complex personal and societal systems in order to deal
with their responses and the responses of others.
o It is characterized by optimism and a sense of mastery and competence. As you
reflect on your answers those related to your inner strength, competence,
optimism, flexibility, and the ability to cope effectively when faced with adversity
are all positively linked to increased levels of resilience.
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Culture
o There is no standard measure for mental health, in part because it is culturally
defined and is based on interpretations of effective functioning according to
societal norms
o One approach to differentiating mental health from mental illness is to consider
what a particular culture regards as acceptable or unacceptable behaviour
 Ex. In Canada, anorexia nervosa is recognized as a psychobiological
disorder that entails voluntary starvation. The disorder is well known in
Europe, North America, and Australia but unheard of in many other parts
of the world
o What is to be made of the fact that certain disorders occur in some cultures but
are absent in others? One interpretation is that the conditions necessary for
causing a particular disorder occur in some places but are absent in others.
o Another interpretation is that people learn certain kinds of abnormal behaviour
by imitation. However, the fact that some disorders may be culturally determined
does not prove that all mental illnesses are so determined
Perceptions of Mental Health and Mental Illness
- Mental Illness Versus Physical Illness
o Although some physical disorders, such as a broken arm from skiing or lung
cancer from smoking, are blamed on the victim, the majority of physical
o Despite many advances in understanding, mental illnesses continue to be viewed
differently from illnesses that originate in other parts of the body.
o Researchers are convinced that the root of most mental disorders lies in
intercellular abnormalities, and they can now see clear signs of altered brain
function in several mental disorders, including schizophrenia, OCD, stress
disorders, and depression
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Nature Versus Nurture
o In the late 1800s the mental health pendulum swung briefly to a biological focus
with the “germ theory of diseases”
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NURS3034 – Chapter 1: Mental Health and Mental Illness

Germ theory explained mental illness in the same way other illnesses were
being described—that is, they were caused by a specific agent in the
environment
 This perspective led to the segregation and isolation of people who were
thought to be “mad,” in the same way that those with infections were
isolated in order to prevent the infection of others.
 This theory was abandoned rather quickly since clinicians and researchers
could not identify single causative factors for mental illnesses; there was
no “mania germ” that could be viewed under a microscope and
subsequently treated
o Over the next half century, psychological theories dominated and focused on the
science of the mind and behaviour
 These theories explained the origin of mental illness as faulty
psychological processes that could be corrected by increasing personal
insight and understanding
 For example, a patient experiencing depression and apathy might
be assisted to explore feelings left over from childhood, when his
attempts at independence were harshly discouraged by overly
protective parents.
o Currently, the diathesis–stress model—in which diathesis represents biological
predisposition and stress represents environmental stress or trauma—is the most
accepted explanation for mental illness
 This nature-plus-nurture argument asserts that most psychiatric disorders
result from a combination of genetic vulnerability and negative
environmental stressors
 While one person may develop major depressive disorder (MDD) largely
as the result of an inherited and biological vulnerability that alters brain
chemistry, another person with little vulnerability may develop
depression from changes in brain chemistry caused by the insults of a
stressful environment.
o Most psychiatric disorders are the result of multiple mutated or defective genes,
each of which in combination may contribute to the disorder
Mental Health for Canadians: Striking a Balance
- Mental Health for Canadians: Striking a Balance (Epp, 1988) was one of the first
government-generated reports that acknowledged the challenges of the mentally ill
population
- Three challenges in mental health were identified:
o (1) Reducing inequities
o (2) Increasing prevention
o (3) Enhancing coping
- The Mental Health Commission of Canada (2012) identified similar challenges, which are
reflected in its six strategic directions:
o (1) Promoting mental health across the lifespan
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NURS3034 – Chapter 1: Mental Health and Mental Illness
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(2) Fostering recovery and well-being for people, while upholding their rights
(3) Providing timely access to treatment and supports
(4) Reducing disparities
(5) Recognizing the distinct circumstances, rights, and cultures in addressing
mental health needs of individuals and communities
o (6) Ensuring effective leadership and collaboration across sectors, agencies, and
communities
Epidemiology of Mental Disorders
- Epidemiology, as it applies to psychiatric mental health, is the quantitative study of the
distribution of mental disorders in human populations
o Once the distribution of mental disorders has been determined quantitatively,
epidemiologists can identify high-risk groups and high-risk factors associated
with illness onset, duration, and recurrence
- Two different but related words used in epidemiology are incidence and prevalence.
o Incidence refers to the number of new cases of mental disorders in a healthy
population within a given period of time—for example, the number of Vancouver
adolescents who were diagnosed with major depressive disorder between 2008
and 2018.
o Prevalence describes the total number of cases, new and existing, in a given
population during a specific period of time, regardless of when the subjects
became ill—for example, the number of adolescents who screen positive for
major depressive disorder in Toronto schools between 2008 and 2018
- Clinical epidemiology is a broad field that addresses what happens after people with
illnesses are seen by clinical care providers. Clinical epidemiology includes the following:
o Studies of the natural history of an illness
o Studies of diagnostic screening tests
o Observational and experimental studies of interventions used to treat people
with the illness or symptoms
- Results of epidemiological studies are now routinely included in the Diagnostic and
Statistical Manual of Mental Disorders (discussed below) to describe the frequency of
mental disorders
- Analysis of such studies can reveal the frequency with which psychological symptoms
appear together with physical illness
o For example, epidemiological studies demonstrate that depression is a significant
risk factor for death in people with cardiovascular disease and for premature
death in people with breast cancer.
Classification of Mental Disorders
- The Diagnostic and Statistical Manual
- Today, its fifth edition, the DSM-5, serves as the official guide for diagnosing psychiatric
disorders
- A common misconception is that a classification of mental disorders classifies people,
when actually the DSM-5 classifies disorders people have. For this reason, the DSM-5 and
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this textbook avoid the use of expressions such as “a schizophrenic” or “an alcoholic.”
Viewing the person as a person first and not an illness requires more accurate terms such
as “an individual with schizophrenia” or “my patient has major depression.”
The DSM-5 Organizational Structure
o The DSM-5 (American Psychiatric Association, 2013) organizes diagnoses for
psychiatric disorders on a developmental hierarchy, meaning that disorders that
are usually seen in infancy, childhood, and adolescence are listed in the first
chapter and neurodevelopmental disorders and disorders that occur later in life,
such as the neurocognitive disorders, are further down the list. Also, within each
chapter, specific disorders are listed based on the typical age of onset, from
youngest to oldest. Diagnostic groups that are related to one another have been
closely situated (for example, schizophrenia spectrum disorders are next to
bipolar-related disorders, and feeding and eating disorders are next to
elimination disorders).
The ICD-10-CA
o The International Classification of Diseases (ICD) sets the global health
information standard for mortality and morbidity statistics
o Clinicians and researchers use this classification system to define diseases, study
disease patterns, monitor outcomes, and subsequently allocate resources based
on the prevalence of disease.
o The ICD-10-CA goes beyond defining and classifying diseases to describe
conditions and situations that are not diseases, including, for example, risk
factors to health and psychosocial circumstances. Also, the ICD-10-CA better
represents the social determinants of health than the ICD-10 did. It has 23
categories of diseases, including diseases of the circulatory system, diseases of
the nervous system, mental and behavioural disorders, certain conditions
originating in the perinatal period, and factors influencing health status and
contact with health services
Classification of Nursing Diagnoses, Outcomes, and Interventions
- To provide the most appropriate and scientifically sound care, the psychiatric mental
health nurse uses standardized classification systems developed by professional nursing
groups
- These diagnoses provide a common language to aid in the selection of nursing
interventions and ultimately lead to positive outcome achievement.
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DSM-5– and NANDA-I–Approved Nursing Diagnoses
o A nursing diagnosis is “a clinical judgment about individual, family, or community
responses to actual or potential health problems and life processes”
o A well-defined nursing diagnosis provides the framework for setting priorities and
identifying appropriate nursing interventions for dealing with the patient's
reaction to the disorder. Those reactions might include confusion, low selfesteem, impaired ability to function in job or family situations, and so on,
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Evidence-Informed Practice
- Evidence-informed practice—that is, care based on the collection, interpretation, and
integration of valid, important, and applicable patient-reported, clinician-observed, and
research-derived evidence
Future Challenges and Roles for Psychiatric Mental Health Nurses
- Aging population
o As the population of older adults grows, the prevalence of Alzheimer's disease
and other dementias requiring the support of skilled and knowledgeable nurses
will increase
- Increasing cultural diversity
o It is important for nurses to know how immigrants may be affected by a mental
illness
o Going forward, psychiatric mental health nurses will need to increase their
cultural competence—that is, their sensitivity to different cultural views
regarding health, illness, and response to treatment
- Expanding technology
- Increased awareness of the impact of health determinants on mental illness
Twelve Key Social Determinants of Health
- Psychiatric mental health nurses use the social determinants of health to facilitate their
practice
- It is suggested that factors such as income, social status, and education directly affect
the health of individuals and populations
- Psychiatric mental health nurses will be required to address patient needs related to
disease prevention and health promotion, which are identified through the assessment
of the social determinants of health
- Twelve key social determinants of health have been identified. Each stands alone, but is
at the same time closely linked to the other determinants of health. The 12 determinants
are as follows:
o 1. Income and social status
o 2. Social support networks
o 3. Education
o 4. Employment/working conditions
o 5. Social environments
o 6. Physical environments
o 7. Personal health practices and coping skills
o 8. Healthy child development
o 9. Biology and genetic endowment
o 10. Health services
o 11. Gender
o 12. Culture
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Key Points to Remember
- Resilience is a process and outcome that supports people to navigate stressors and
accompanying negative emotions and to negotiate resources in order to deal with the
stressor and reactions. This process can be promoted and improved to strengthen
supportive environments at individual and broader community and societal levels.
- Mental health and mental illness exist along two distinct but intersecting continua.
- Culture influences behaviour, and symptoms may reflect a person's cultural patterns or
beliefs. Symptoms, therefore, must be understood in terms of a person's cultural
background.
- The study of epidemiology can help identify high-risk groups and behaviours, which can
lead to a better understanding of the causes of some disorders. Incidence rates provide
us with the number of new cases in a given period of time. Prevalence rates help us to
identify the proportion of a population experiencing a specific mental disorder at a given
time.
- Comorbid conditions are those disorders that occur at the same time as another
condition. For example, a person with schizophrenia may also have comorbid diabetes,
depression, and hypertension.
- Psychiatric mental health nurses work with a broad population of patients in diverse
settings to promote optimal mental health.
- Due to social, cultural, scientific, and political factors, the future holds many challenges
and possibilities for the psychiatric mental health nurse.
Chapter Review
1. Resilience, the capacity to rebound from stressors via adaptive coping, is associated with
positive mental health. Your friend has just been laid off from his job. Which of the following
responses on your part would most likely contribute to his enhanced resilience?
a. Using your connections to set up an interview with your employer
b. Connecting him with a friend of the family who owns his own business
c. Supporting him in arranging, preparing for, and completing multiple interviews
d. Helping him to understand that the layoff resulted from troubles in the economy and
is not his fault
2. Which of the following situations best supports the diathesis–stress model of mental illness
development?
a. The rate of suicide increases during times of national disaster and despair.
b. A woman feels mildly anxious when asked to speak to a large group of people.
c. A man with no prior mental health problems experiences sadness after his divorce.
d. A man develops schizophrenia, but his identical twin remains free of mental illness.
3. Of the following statements about mental illness, identify all correct ones:
a. About 20% of Canadians experience a mental disorder during their lifetime.
b. Mental disorders and diagnoses occur very consistently across cultures.
c. Most serious mental illnesses are psychological rather than biological in nature.
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NURS3034 – Chapter 1: Mental Health and Mental Illness
d. The Mental Health Commission of Canada's report Changing Directions, Changing
Lives outlines the mental health strategy for Canada.
4. Jane is a 32-year-old mother of four. She is active with her family and in her community
despite having a diagnosis of severe anxiety. Refer to the mental health–mental illness
continuum shown in Figure 1-2 and consider where you would place Jane.
a. Optimal mental health with mental illness
b. Optimal mental health without mental illness
c. Poor mental health with mental illness
d. Poor mental health without mental illness
5. Which of the following actions represent the primary focus of psychiatric nursing for a basiclevel registered nurse? Select all that apply.
a. Determining a patient's diagnosis according to the DSM-5
b. Ordering diagnostic tests such as EEGs or MRI scans
c. Identifying how a patient is coping with a symptom such as hallucinations
d. Guiding a patient to learn and use a variety of stress-management techniques
e. Helping a patient without personal transportation find a way to his or her treatment
appointments
f. Collecting petition signatures seeking the removal of stigmatizing images on television
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