Theories and Research

The theories underpinning the understanding of mental illnesses changed somewhat in this first decade of the 21^st century, partly due to research on the brain. The proliferation of theories in the previous decade evolved into more specific approaches to symptoms and diseases. Thus the literature in the mental health field became focused on DSM-IV-TR categories such as PTSD and Traumatic Brain Disorders as well as the more usual categories (schizophrenia, depression, anxiety, etc.). At this point in time, reimbursements were often made not on the diagnostic category but on the treatment interventions. Some insurance companies would reimburse for up to ten sessions of psychotherapy, or a certain number of days of inpatient care. These insurance reimbursement limits were relatively arbitrary since there was little research data on what length of what kind of treatment brought what kind of outcome.

All the medications from the previous decade continued to be used throughout the 2000-2010 decade. What became clearer through a better understanding of the molecular mechanism of mental illness, however, was how these medications functioned. With increased funding from NIH and the incentive of “The Decade of the Brain,” tools from biomedical and molecular medicine became available to identify neurotransmitter receptors. Neuropharmacologist Avid Carlsson had already recognized that antipsychotic drugs worked by blocking dopamine receptors in 1957. This discovery led to the development of selective serotonin re-uptake inhibitors (SSRI) medications that were used extensively for treating major depressive disorders, anxiety disorders, and other psychiatric disorders during the 2000-2010 decade.

Since many medications are targeted to a specific symptom or group of symptoms, patients still reported other continuing symptoms that were not being addressed. In diagnosing and treating multiple symptoms, according to a 2010 article on national trends, the practice of prescribing more than one medication became common. (Mojtabai R. and Olfson M. 2010, “National trends in psychotropic medication polypharmacy in office-based psychiatry, Arch Gen Psychiatry 67 no. 1:26-36.) Resorting to medications to manage mental health problems before addressing them with psychotherapy—and tragically sometimes doing so in lieu of psychotherapy—was a looming problem.

Research helped scientists understand the mechanism of disease as well as the mechanism of medications to alleviate symptoms of disease. The role of industry in providing psychotropic medication and developing new medications had a mixed history in this decade. Industry’s paramount goal is to create drugs for problems that are profitable and do not take too long to develop, notes Steven E. Hyman, director of Harvard’s Center for Psychiatric Research. Identifying several drug companies that were no longer supporting their psychiatric laboratories, Hyman suggests that this conflict of profit vs. long-term investment in research contributes to the lack of progress in developing new drugs for psychiatric disorders.

(Hyman, Steven E. 2013. “Psychiatric Drug Development: Diagnosing a Crisis in Cerebrum.” PMCID: PMC3662213 and PMID: 23720708.)

On another research front, genetic testing started identifying genes that influenced psychiatric disorders. Genetic testing has a great likelihood of adding to the understanding of psychiatric disorders. However, the current cost of genetic testing is still prohibitive for most people.

National Influences

Traumatic Events. Two major events during this decade dramatically affected the country. One was the 9/11 terror attacks on the Twin Towers, the Pentagon, and the downed plane in Pennsylvania in 2001. The second was the 2008 global financial crisis. Both events caused great emotional turmoil to thousands of people directly and millions indirectly. Anxiety disorders, depressions, and posttraumatic stress disorder (PTSD) were exacerbated and flooded mental health resources nationwide.

When SAMHSA (Substance Abuse and Mental Health Services Administration) published its Mental Health, United States, 2010, the document noted:

• Approximately 11 million U.S. adults (4.8 percent) are estimated to have had serious mental illness (SMI) in 2009.
• More than one quarter of adults with SMI also had co-occurring substance dependence or abuse in 2009.
• About one out of eight children aged 8-15 (or 13.1 percent) were reported to have had a mental health disorder in each year during the 2001-2004 period.
• In 2007, more than 34,000 deaths in the United States were due to suicide, an all-time high.

Mental Health Services were summarized as:

• In 2009, more than one in eight U.S. adults received mental health treatment in the past year.
• During the 2001-2004 period more than half of all children with a mental health disorder received treatment in a hospital, clinic, or office within the past year.
• In 2009, 40 percent of adults with SMI reported not receiving treatment.
• For 1996 to 2008, medication fills have increased considerably for mental health and/or substance abuse conditions. The categories of medication with the greatest growth have been antidepressant medications for adults and stimulant medications for children.

This report also noted that mental health expenditures increased from $32 billion in 1986 to $132 billion in 2005 but that increase actually represented a decrease as a share of all health expenditures from 7.2 percent to 6.1 percent in 2005. Medicaid accounted for more than 50 percent of all mental health expenditures. And, finally, from 1986 to 2005, spending on prescription medications increased faster than another type of mental health care. (Mental Health, United States, 2010, Substance Abuse, and Mental Health Services Administration: U.S. Department of Health and Human Services.)

Government Interventions. The second major influence on mental health care during this decade was The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, which specifically included Substance Abuse disorder services as one of the Employee Health Benefits (EBH). It reinforced the scope of EBH reimbursement by mandating that if large insurance companies provided medical and surgical benefits, they had to provide similar or parity services for Mental Health and Substance Abuse. MHPAEA went a step beyond this by not only requiring insurance companies to provide these services but also requiring that they not impose higher premiums or greater limitations on services.

In March 2010, the Patient Protection and Affordable Care Act (ACA) was passed (generally referred to as the Affordable Care Act). The ACA’s goal was to reduce costs and improve the efficiency of health care. The U.S. federal government, through its Medicare and Social Services and by financial support to states for Medicaid, sought to underwrite health and mental health services. Implementation of this Act will be discussed in the next decade.

Leadership, Funding, and Curriculum

Leaders and Faculty. In 2000, Dr. Maureen Keefe became Dean of the College of Nursing. Faculty for the graduate Psychiatric Nursing Program during the 2000-2010 decade were: Ann Hutton, Beth Cole, Alice Parkinson, Lee Walker, and new faculty additions, Jodi Groot, Michael Johnson, ElLois Bailey, and Tammy Melville.Sandra Talley joined the faculty for two years as she was completing her PhD.

Beth Cole was director of the program through the 2001-2002 academic year. Ann Hutton then became interim director until 2006 when Jodi Groot (later Morstein) became the director. She served as director from 2006 to 2012. Beth Cole, who had served as director for over twenty years in previous decades, served during this decade as Division Director for the Division of Acute and Chronic Care Nursing, as Doctoral Program Director, and as the Director of Caring Connections, the community grief recovery program she had founded in 1997. She retired from the University of Utah in Summer 2007, after 36 years. (https://nursing.utah.edu/caring-connections)

Securing Grants. The grant awarded in 2001 offered stipends for master’s degree students, with a very small amount of money for faculty. Graduating students with a master’s from the psychiatric nursing program could take the Advanced Psychiatric/Mental Health Nurse Practitioner Certification Exam and become licensed as APRNs and practice as Psychiatric/Mental Health Nurse Practitioners. There was some money for distance teaching technology.

The uptick in national awareness of growing mental health problems prompted government to make monies available to meet the needs of rural communities. Jodi Grant became director in 2006. Under her leadership, in 2007, a new training grant was submitted to HRSA. (Established in 1972, the Health Resources and Services Administration’s stated purpose is “improving access to health care services for people who are uninsured, isolated, or medically vulnerable.”) The purpose of the requested grant was to prepare graduate psychiatric nurses to meet the needs of “rural and underserved populations.” Students in rural Utah, Idaho, Nevada, and Hawaii would be enrolled in the on-line DNP Psychiatric-Mental Health Nursing Program while they continued to live in their far-flung rural areas. Students from rural areas getting on-line degrees were more likely to stay and set up practices to serve their rural communities. The grant, which was approved, paid for faculty, technology, and distance learning tools for nurse education in rural and underserved areas. The initial grant was for 3 years, and Dr. Groot was able to obtain an additional 3-year renewal.

In addition to on-line student enrollment, from the 1960s through the 1990s the psychiatric nursing program had five or more students whose clinical placements were in the Four Corners region working with Native Americans, some at Shiprock, New Mexico, and others at Blanding, Utah. Over the years there have been several Native American students who have graduated from the program, as well as other minorities, including Asian American, African American, and Spanish American students.

Curriculum: Transitioning to Doctoral Programs. There were national pressures from nursing leaders and national accrediting bodies to address the issue of essential curriculum for an advanced practice nurse. Partly due to the high number of credit hours to achieve clinical proficiency, colleges granting degrees in other specialties were changing some of their clinical master’s programs to clinical doctoral programs (for instance, Doctor of Psychology, DPsy.; Doctor of Audiology, AuD.; Doctor of Pharmacology, PharmD.).

The University of Utah College of Nursing was an early adopter of the Doctor of Nursing Practice (DNP) degree. For several years, students could choose whether they wanted a master’s degree or wanted to take additional courses for the DNP degree. The 2000-2010 decade saw the College of Nursing master’s program transitioning to a Doctor of Nursing Practice degree. There were core courses for all students in the DNP program as well as courses in the specialty programs. A high-caliber doctoral project was expected of DNP graduates.

Meeting the need for advanced coursework, when Michael Johnson joined the faculty in 2002 he taught a psychopathology course for the graduate psychiatric nursing students, which included relevant research in neurobiology. This was a significant contribution to the program.

Also in 2002, Dr. Kathi Mooney initiated an on-line Ph.D. program for Oncology Nurses. While it was similar to the regular on-site Ph.D. program, many courses were arranged to specifically identify issues related to oncology nursing practice and research. The online nature of the teaching format as well as the new or revised courses required the approval of the University Graduate Academic Curriculum Committee. Online teaching was a relatively new methodology and the Committee was concerned about how the new technology might affect and perhaps deplete University resources. However, the College of Nursing’s graduate psychiatric nursing program established history of working with distance education and the high rate of students successfully completing the program proved helpful in securing approval for the on-line doctoral program. Mooney’s carefully designed doctoral program attracted many students nationwide, and with funding from the National Cancer Institute (NCI), she was able to continue this program for 7 years.

With greater national interest in mental health, applications increased for graduate studies in mental health. Even so, for most of this decade students could still choose to do the MS or the DNP program. With the increase in the number of students, new clinical sites were identified and contracted to work with students. Many of the new sites stressed medication management for psychiatric nursing services. Students continued to conduct individual, family, and group interventions, but the medication management was a growing aspect of their practices.

Caring Connections. Caring Connections: A Hope and Comfort in Grief Program continued to serve the Salt Lake and Utah County regions throughout the decade. Kathie Supiano, MSW, PhD, became the director in 2007. She had worked with Caring Connections and the University of Utah Hospital as a Palliative Care social worker. In addition, prior to coming to Utah Supiano had worked in Palliative Care and Grief Services in Michigan. Grief support groups continued in a variety of settings around northern Utah. Psychiatric nurses, social workers, and other professionals, joined by students from the mental health professions across campus, continued leading these groups. Community presentations, specialty workshops, and a newsletter (distributed six times a year) continued under Supiano’s leadership. The newsletter was made available on-line, which worked well for many Caring Connections participants.

Nurse Practice Act

By 2000, the Nurse Practice Act allowed Psychiatric APRNs to prescribe Schedule II medications and be independent practitioners, but only after 2 years of supervised practice with a physician. Since physicians wanted to be paid for their supervision time, many job openings were for Psychiatric Nurse Practitioners two years out, who could already prescribe independently. Most employment agencies were not willing or able to offer supervision as part of their hiring new graduates.

The DNP was generally a three-year program of study. This additional length in the program gave students additional hours in clinical practice. However, the requirement for post-degree supervised hours to prescribe Schedule II and III drugs was not changed. Many students therefore sought employment outside of Utah where there was no requirement for physician supervision after graduation and national certification. There were many attempts to revise the Nurse Practice Act to allow APRNs to prescribe all medications; they were, however, unsuccessful.

Community Influences: National Needs, Local Solutions

National Nursing Shortage. In the mid-2000s, there was a national nurse shortage, which included Utah. All nursing directors of the public colleges and universities in Utah, as well as some private schools, that had programs in nursing education participated in monthly meetings to craft a document and present a united request to the Utah State Legislature to increase funding for public nurse education programs. Dean Keefe spearheaded this effort. (Cole represented Brigham Young University.) Keefe and other Utah deans and directors of nursing programs met with their respective college or university Presidents to gain support for the proposal. And, equally important, they met with the legislators from their districts to enlist support for the bill. The first year the Legislature did not fund their proposal, with the comment that there had been insufficient time to review it and that funding had already been set for the year. However, the proposal passed with full support the following year. Each state college committed to increase their programs by at least one cohort (usually about eight students) per admission cycle for the next five years. There are seven state-supported colleges of nursing in Utah:

• University of Utah,
• Weber State University,
• Utah State University,
• Utah Valley University,
• Snow College,
• Southern Utah University,
• Dixie State University, now known as Utah Technology University.

At a minimum, that was an increase of 280 nurses. Note that this increase was in addition to the regular number of students that a college would typically enroll in nursing programs each year.

While schools were primarily focused on recruiting students at the undergraduate level, their efforts also increased the numbers of students applying to graduate programs. Nurse Practitioner programs of all types saw rising numbers of applications.

Community Needs. The psychiatric nursing program was influenced by two major community developments. One was the recognition by pediatricians of their need for psychiatric services for parents and children, especially those with chronic problems. Research conducted by Intermountain Healthcare’s pediatricians, which was initiated and fostered by nurse advocate and activist Brenda Reiss-Brennan, APRN, PhD, PMH-NP, demonstrated both increased compliance with prescribed healthcare interventions and parental satisfaction with improved health of their children.

The second major development was the increase in demand for mental health services, specifically in assessing needs and writing prescriptions for mental health medications. This was a national trend, not just one in Utah. General public awareness of mental health symptoms and illnesses along with some of the major treatments and available medications was on the rise. Although many of the mental health drugs still had some side-effects, the relief they offered made the side-effects acceptable to most patients.

Collaboration. Faculty continued to participate with the national psychiatric nursing organizations ISPN (International Society of Psychiatric) and APNA (American Psychiatric Nurse Association). They gave presentations, prepared posters to display research in poster sessions, and led discussions in large group professional sessions. In addition, faculty worked collaboratively with other mental health disciplines on local interprofessional councils:

• Utah Coalition of Mental Health Professionals,
• Utah Behavioral Health Workforce Workgroup, and
• Utah’s Graduate Medical Education Council, established by the Legislature to track medical and graduate education of health professionals.