Theories: In Search of Well-Being

Basic theories of mental illness and health were taught and diagnoses made based on previously established categories. However, diagnostic categories became more significant as they were linked with, and therefore influenced by, reimbursement parameters. The two most common mental health diagnostic guides were and still are the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, as psychology and science continue investigating causes for mental disorders, the National Institute of Mental Health’s Research Domain Criteria tries to integrate behavioral and neuroscience research. Even though new biological bases for mental illness within brain structures have been revealed as well as some genetic suggestions, diagnoses are still made primarily by observation of behavior and self-report of feelings and thoughts without reference to underlying causal mechanisms. (For more on this subject, see Clark, L. A., et al. 2017, “Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC).”  https://doi.org/10.1177/1529100617727266

With more emphasis on medication management of symptoms, the neuro-biological explanation of mental illness gained a stronger following. Predictably, the last decade’s advances in psychotropic medications produced a dramatic increase in polypharmacy. Meanwhile, research in medications for mental health disorders had stalled. Psychiatrists John M. Kane and Christoph Correll (with the Feinstein Institutes for Medical Research, Center for Neuroscience) criticized the lack of progress in a 2010 report (Kane and Correll 2010, 345-57).

With the Affordable Care Act’s emphasis on what has been termed well-being, there was new emphasis on theories of psychology and health. Positive psychology gained more acceptance. The science and psychology of Happiness and Mindfulness were popular approaches to improving mental health. The practice of mindfulness is founded on a strong theoretical heritage in philosophy and sociology. Mindfulness interventions are based on learning to be centered in the here-and-now and cultivating a nonjudgmental attitude, coupled with meditative applications to improving health. Along with strategies for attaining psychological states of well-being, diet counseling, sleep management, and physical activity programs were often promoted as means to improving mental health.

The studies on genetic research and mental illness are promising, but this line of inquiry is still in its infancy. NIH reported a study that suggested 5 disorders (bipolar disorder, schizophrenia, major depression, autism, and attention-deficit hyperactivity disorder, commonly referred to as ADHD) which appeared to be associated with two genes. Jordan Smoller, co-author of the study, qualified the findings by cautioning that “each of these genetic associations individually can account for only a small amount of the risk for mental illness.” This is not to dismiss the importance of pursuing genetic connections. The article concludes: “But, these results may help researchers move closer to making more accurate diagnoses and help lead to a better understanding of the factors that cause major mental disorders” (Quoted in NIH Research Matters, News and Events (March 18, 2013), “Common Genetic Factors Found in 5 Mental Disorders.”) https://www.nih.gov/news-events/nih-research-matters/common-genetic-factors-found-5-mental-disorders

In addition to medication, well-being practices, and ongoing genetics research, new developments in technology continue to influence the field of mental health. Telehealth became a significant contributor to healthcare even before the COVID-19 pandemic. Health providers had offered their services to rural communities and to people who were unable to commute to a mental health provider. During the pandemic telehealth medical and mental health services became essential. They were offered via video and audio transmission. Individual adult therapy and medication management could be provided over telehealth platforms. Family and group therapy could also be provided. ZOOM and TEAM were common applications that allowed for multiple sites to be on-line at the same time at a low cost for most patients.

National Issues

National Survey Report on Mental Illness. Data from the 2020 National Survey on Drug Use and Health (NSDUH) conducted by Substance Abuse and Mental Health Services Administration (SAMHSA) suggests that almost one in five U.S. adults live with a mental illness. The data is based on diagnosis currently or within the past year. Mainly because of demographic changes, according to the authors of this report, there has been a 13% rise in mental health conditions and substance use disorders in the last decade (to 2017, the date of the NIH report). People with mental health conditions now live with the disability from 1 in 5 years. Also troubling, the authors of the report note that mental health conditions are increasing worldwide.

While mental illnesses may include different conditions that vary in degree of severity (ranging from mild to moderate to severe), for this study, two broad categories were used to describe these conditions: Any Mental Illness (AMI) and Serious Mental Illness (SMI). AMI encompasses all recognized mental illnesses. SMI is a smaller and more severe subset of AMI.

There was a higher prevalence of mental illness in women in both categories of AMI and SMI than for men. (NIH, Mental Health Information, January 2022. PMID: 19507169.)

In a category by itself, death by suicide took nearly half a million lives from 2010 to 2020. During the same period, the suicide death rate increased by 12% and as of 2009, the number of suicides outnumbered those caused by motor vehicle accidents. In 2020, the Center for Disease Control (CDC) reported that suicide was the 12^th leading cause of death with 13.38 per 100,000 individuals. Also, despite the higher prevalence of mental illness in women, men were 3.88 times more likely than women to commit suicide, with white males accounting for 69.88% of suicide deaths.

Technology: Computers and Telehealth. Computer technology continued to be a major contributor to the mental health field. Computers are now able to gather large data sets for analyses over a wide array of mental health questions. Daily use of computers by researchers, clinicians, educators, and the lay public has been common for nearly 20 years. Information storage and dissemination has exploded with greater access to technology. However, there are new credibility gaps and pitfalls. Often, the greater public’s lack of knowledge about or trust in science allows misinformation to spread. (A problem for another day.)

With advances in technology, telehealth became a new model of patient-health provider office visit. Until 2020, there usage was low and the logistics often complicated. Interface between patients and their providers was complicated by restrictions in payment, rules on prescriptions. Patients were willing and able to negotiate computer technology as well as the mechanics of interfacing with a distant medical provider. Patients that could not travel, or patients that were traveling outside of an area could work with their provider via phone or video transmission. However, there were additional issues with providers services across state lines, and concern over security of the interface. In a review article for Primary Care: Clinics in Office Practice, Shaver noted that by 2018, “76% of US hospital systems used some form of telemedicine.” Telemedicine in the United States before March 2020 was used but was not common. (Shaver, Julia. “The State of Telehealth Before and After the COVID-19 Pandemic.” Primary Care: Clinics in Office Practice 49, no. 4 (2022): 517-530.) https://doi.org/10.1016/j.pop.2022.04.002

The U.S. Department of Veterans Affairs was an early adapter of telehealth. In the Intermountain West veterans are often long distances from the central Veterans Administration Medical Center in Salt Lake City (VAMC-SLC). While there are obvious limitations to this model of care, for monitoring chronic conditions and common acute health problems, this model is effective and well received by patients.

In a breakthrough research project, Smoller and his academic colleagues (2019) identified two common genetic factors in 5 mental disorders. Observers had previously noted that some psychiatric disorders seemed to run in families. While there was a suggestion that there might be a common genetic factor, there was little evidence of what that common factor or factors might be. As previously mentioned, the five disorders were autism, attention deficit hyperactivity disorder (ADHD), bipolar disorder, major depression, and schizophrenia. While the report identifies a significant relationship of genetics and mental illness, the authors recognize that this research only accounts for a small amount of risk for mental illness. Yet this study suggests a point for further inquiry. (See Smoller, Jordan, et al. 2019, “Psychiatric Genetics and the Structure of Psychopathology,” Molecular Psychiatry 24, no.3 (March):409-420.) https://doi:10.1038/s41380-018-0026-4

Leadership, Grants, and Curriculum

Curriculum and Faculty. Dr. Maureen Keefe was Dean of the College of Nursing until 2012. In Fall 2013, Dr. Patricia Morton served as dean for approximately five years. In 2018, Dr. Barbara Wilson assumed the post of interim dean for two years after which Dr. Marla DeJong became dean and continues through today (2023).

At the beginning of the 2010-2020 decade, Dr. Jodi Groot was the Director of the Graduate Psychiatric-Mental Health program. In 2012, Beverley Patchell took over for a few years. Elois Bailey was then director from 2015-2018, after which Tammy Melville was the program Director for about a year, co-directing with Gillian Tufts, the Acute and Chronic Care Nursing Division Director. In 2019, Dr. Sheila Deyette became graduate Psychiatric-Mental Health Track Director. Dr. Deyette continues in that position today. As well as regular faculty, Paul Olavson, Margo Stevens, and Sam Vincent also taught courses during this decade.

Government Grants. While Dr. Jodi Groot (Morstein) led the program, she was able to secure funding from Health Services and Research Administration (HRSA). With this HRSA grant targeted at assisting students from rural communities, the program grew from 10 to 27 students. That increase was a dramatic change from previous years when psychiatric nursing struggled to enroll and keep 8 students in the two-year graduate program.

Under Dr. ElLois Bailey’s leadership with the assistance of Alexa Doig, a proposal was written and a grant awarded by the Salt Lake City Veterans Medical Center (VAMC-SLC) to support graduate students in the Psychiatric Nursing Program in exchange for an agreement that students would work at the VAMC after graduation. This placement was a good employment opportunity for students because the Nurse Practice Act still required that Psychiatric-Mental Health Nurses have two years of supervised prescriptive practice after graduation. That would be provided at the VAMC.

Bailey recognized that other states did not have the post-graduation supervision requirement for nurse practitioners, which made it easier for newly graduated students to find employment in those states. As mentioned, students were leaving Utah to take out-of-state job offers immediately after graduation. It was especially difficult to find psychiatrists in Utah willing to supervise Certified Psychiatric-Mental Health Nurse Practitioners for two years. This posed a financial and professional burden for the recent graduates.

Student Learning Sites. During this decade, the College of Nursing was building its

Nurse Practice Clinics. Faculty who were Advanced Practice Nurses were encouraged to develop practice sites for student learning. Working with the University of Utah Hospital and Clinics, the College of Nursing’s APRN faculty Nurse Practitioners could provide supervised clinical sites for student learning as well as bring in additional revenue to the College. This move to provide faculty clinical services broadened the role of faculty, but it also increased their workload Another complicating hazard for the College of Nursing was that faculty could not help but notice how much more money could be made from full-time clinical practice than from their teaching and research roles within the College. This had always been true but the gap in income seemed to have increased. This added to the College’s difficulty in retaining as well as recruiting full-time, tenure track faculty. This is no small matter. Faculty conducting research and publishing is the backbone of a research university as well as essential for advancement of the field of psychiatric nursing.

Curriculum: Role Development, Crossover Ties, Clinical Placements. By 2017 all graduate psychiatric nursing students were enrolled in the DNP-Psychiatric-Mental Health Nursing Track. The transition was a logical move and strengthened the knowledge base expected of psychiatric-mental health nurse practitioners. Besides an increased number of hours of supervised clinical experience, a strong doctoral project that contributed to the field was also required.

Many of the courses beyond the masters’ level were on role development to become independent nurse practitioners. Students in other nursing tracks were often in the same classes with the psychiatric nursing students. It was hoped that the crossover of students in various tracks would strengthen ties among nurses and build future referral patterns within the nursing community.

One of the biggest changes in the program was the widening choice of clinical placements. Beyond the many University of Utah Health System clinics at the medical center and at off-site clinics, there were placements with the Juvenile Justice System and work with the Homeless. Other community sites, including Caring Connections, continued to be options as well.

Caring Connections

Under Dr. Kathie Supiano’s leadership, Caring Connections: A Hope and Comfort in Grief Program continued serving Salt Lake and Utah Counties. Experienced group leaders supervised student volunteers from many graduate mental health disciplines at the University. Students were co-leaders in the grief groups, which ensured supervised learning experiences. It was a successful and valued service to the community. Supiano was able to secure support and/or funding for Caring Connections from a variety of sources such as Larkin Mortuary, Robert and Carma Kent, Clark L. Tanner Foundation, Dick and Timmy Burton Foundation, Cambia Health Foundation-Sojourns bequest, and Sorenson Legacy Foundation. With the support of Deans Patricia Morton and Marla DeJong and interim Dean Barbara Wilson, Caring Connections continued its grief groups and community programs.

The demand for grief support services grew with requests from a wide variety of groups, including schools, Latino groups (some of whom needed Spanish-speaking facilitators), Utah State Prison, Navajo and Ute Tribal mental health services, and others. Even before the COVID-19 pandemic, Caring Connections had started on-line support groups through a telehealth format. As requests multiplied, it became apparent that the need was far greater than one program could offer. Anticipating the need, Supiano had gathered research data from all the grief groups over the years and had crafted participant and leader manuals, developing a program of grief support that could be taught across differing mental health disciplines and framed for the culture and language of the participants. She also initiated and supervised several research projects. Groups would address specific issues, such as loss due to suicide, or loss due to addiction or overdose, or the loss of a child or a spouse.

Supiano’s primary focus was always on continuing the local groups, but she also added teaching grief support models of care to mental health professionals. Her work, which had evolved to include research and teaching, clearly met the objectives for Caring Connections to remain an academically based program. She is currently developing strategies to educate the public to be grief knowledgeable.

Nurse Practice Act

In 2013, the Utah State Legislature changed the state law that allowed Psychiatric-Mental Health Nurse Practitioners (PMH-NP) to prescribe. Prior to that time new graduates had to have 3,000 hours of on-the-job practice (1000 hours during their program of study and 2000 hours after they had graduated), and a prescribing supervisor to sign-off on prescriptions for ADHD and anxiety disorders and other controlled medications. Diagnosing and prescribing medications was a large part of their clinical practice. At that time the recent graduate had an “I” after their license, which identified them as an intern. There were still limitations on prescribing some medications.

Important changes in the Nurse Practice Act were approved in 2016. The Consultation and Referral Plan was removed from all APRNs with greater than 2 years or 2000 hours, though still required for all owners and operators of pain clinics. This meant that most Psychiatric Mental Health APRNs who had practiced for 2 years or 2000 hours no longer needed a Consultation and Referral Plan (CRP) to be approved by a physician.

In 2019 the Nurse Practice Act was changed again. The Consultation and Referral Plan was only required for APRNs without one year or 2000 hours in solo, independent practice. (Again, the CRP requirement was not changed for owners and operators of pain clinics.) This action removed barriers for many APRNs to practice fully in groups or multi-discipline practices.

Community Developments

UMEC

The Utah Medical Education Council (UMEC) was created in 1997. Through the 1990s and the early 2000s representative nurses participated as members on this council, which was established by the Utah Legislature to secure and stabilize the supply of health care clinicians. Originally, the focus was on graduate education, not baccalaureate education. The nurses met in a separate subcommittee of the Council specifically focused on graduate nursing professionals. UMEC conducted health care workforce research and advised the Utah Legislature on Utah’s health care training needs and worked to foster the State’s graduate medical education financing policies. Also, the committee would recommend funding for the medical school, nursing programs, and so on.

In 2013 The Utah State legislature expanded UMEC to include research responsibilities for nursing and it became the designee for the Utah Nursing Workforce Information Center (NWIC). Most states now have a NWIC to gather data on the need for nurses, both RN and graduate nurses, such as Nurse Practitioners.

Farewell to Granite Mental Health Center

Granite Mental Health Center began in the 1960s and served the mental health needs of Salt Lake County for decades. It had multiple sites around the county for day care, intensive care, and emergency services as well as for therapy, diagnosis, and medication management. In 2012 Granite Mental Health was no longer funded with block grants from the Federal Government for mental health services. After over 40 years of faithfully serving the county, Granite Community Mental Health Center disbanded. Of concern for the program, this affected clinical placements for students in the graduate Psychiatric Mental health Program.