Improving the care and health of populations through optimal use of clinical nurse specialists.

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.

The art of prescribing pharmacological management of adult ADHD: implications for psychiatric care.

QUESTION: For several years I have seen more adults presenting with attention-deficit/ hyperactivity disorder (ADHD). I realize that historically ADHD has been considered a childhood disorder, but I would like to know more about diagnosing and treating adult ADHD. ANSWER: Your observations about the prevalence and challenges that confront psychiatric nurses concerning the diagnosis and treatment of adult ADHD are correct. ADHD is a relatively common psychiatric disorder with a high occurrence of 2-6% in adults (Kessler et al., 2006). Though generally regarded as a childhood diagnosis, emerging evidence indicates that symptoms of ADHD remain into adulthood, affecting 4.4% of the adult population (Biederman, Monuteaux, et al., 2006). ADHD in adults frequently goes undiagnosed and untreated. This is largely associated with adults minimizing the severity of symptoms and being unaware that they actually have ADHD. Predictably, adult ADHD is associated with increased morbidity. Higher divorce rates, traffic violations, and negative occupational, economic, and psychosocial functions and concomitant psychiatric disorders are common findings in adults with ADHD (Kessler, Adler, Ames, Barkley, et al., 2005). Approximately 70-75% of adults presenting for treatment of ADHD have at least one co-existing psychiatric diagnosis (Kessler et al., 2006; Wilens, Biederman, & Spencer, 2002). Social phobia, bipolar disorder, major depression, and alcohol dependence are the most common co-existing psychiatric disorders in adults with ADHD (Kessler et al., 2006).

The Effective Use of Psychiatric Mental Health Nurses in Integrated Care: Policy Implications for Increasing Quality and Access to Care.

In the last ten years primary care providers have been encouraged to implement integrated models of care where individuals' medical and mental health needs are addressed holistically. Many integrated models use Psychiatric Mental Health (PMH) nurses as case managers and select exemplars use PMH Advanced Practice Nurses (APNs) as providers. However, the potential value of PMH nurses in integrated health care remains unrealized by health care planners and payers, limiting access to services for the populations most in need of comprehensive care approaches. This current situation is partially fueled by insufficient knowledge of the roles and skill sets of PMH nurses. In this paper, the PMH RN and APN skill sets are detailed, demonstrating how effective use of these nurses can further the aims of integrated care models. Finally, outlined are barriers and enabling factors to effective use of PMH RNs and APNs and attendant policy implications.

The art of prescribing. Monotherapy antidepressant: a thing of the past? Implications for the treatment of major depressive disorder.

QUESTION: Over the past few years since I started working with patients with major depression I have noticed an alarming number that have had a poor response to monotherapy antidepressants. What is the best pharmacological approach to treating treatment-resistant depression? DEBORAH ANTAI-OTONG RESPONDS: Treatment-resistant depression (TRD) is a relatively common, yet chronic, complicated, and disabling illness despite the broad range of treatment options available for depression. It is generally unrecognized and undertreated. Growing data challenge monotherapy antidepressant treatment as the sole option for depressed patients.

The art of prescribing. Antidepressants in late-life depression: prescribing principles.

QUESTION: Ms. Antai-Otong, I am a psychiatric nurse practitioner currently employed in a large primary care clinic. My greatest challenge with older adults suspected of being depressed is their hesitancy to admit they are depressed or unwillingness to take antidepressants. I have started some of these patients on antidepressants and had mixed results. Please provide some guidelines for treating depression in older adults with coexisting medical conditions. ANSWER: Depression is a common companion of chronic medical illnesses and frequently goes unrecognized and untreated, resulting in high morbidity and mortality. Depression is unrecognized and underdiagnosed in approximately 16% of older patients seen in primary care settings (Unutzer, 2002). Typically, older adults deny being depressed, minimize symptom severity, fail to recognize common subjective experiences, such as anhedonia, fatigue, and concentration difficulties associated with this disorder, and hesitate to accept their illness due to social stigma and effects of stoicism. Cultural and generational influences also impact how older adults perceive mental health services. Due to the growing number of individuals 65 and older with coexisting medical and psychiatric conditions, particularly depression, seeking health care in vast practice settings, advanced practice psychiatric nurses must collaborate with primary care providers and develop holistic care that addresses coexisting chronic medical and psychiatric conditions.

Caring for the Patient with an Anxiety Disorder.

Anxiety disorders are among the most prevalent and disabling psychiatric disorders. Patients and their families have a plethora of evidence-based treatment options to manage these potentially incapacitating and costly disorders. Nurses in various settings can assess symptoms of anxiety disorder and initiate or refer patients for treatment. Families play a critical role in treatment planning and must be part of the health care team. Primary nursing interventions must be person centered and recovery based to ensure accurate diagnosis, initiation of appropriate person-centered treatment, and facilitate an optimal level of functioning and quality of life.

Psychosocial Recovery and Rehabilitation.

This article discusses a psychosocial recovery and rehabilitation recovery model that uses an intensive case management approach. The approach offers an interdisciplinary model that integrates pharmacotherapy, social skills training, cognitive remediation, family involvement, and community integration. This evidence-based plan of care instills hope and nurtures one's capacity to learn and improve function and quality of life. It is cost-effective and offers psychiatric nurses opportunities to facilitate symptomatic remission, facilitate self-efficacy, and improve communication and social cognition skills. Nurses in diverse practice settings must be willing to plan and implement innovative treatment models that provide seamless mental health care across the treatment continuum.

Evidence-Based Care of the Patient with Borderline Personality Disorder.

Borderline personality disorder (BPD) is a complex, serious, and high-cost psychiatric disorder. The high prevalence of patients with BPD and co-occurring depression, eating disorders, and substance-use disorders in primary care and mental health settings contribute to their high use of resources in these practice settings. Regardless of treatment challenges associated with BPD, researchers suggest a more positive outlook in the treatment of this complex psychiatric condition. This article focuses on areas in which nurses can strengthen their understanding of underpinnings and multimodal approaches, assess the patient's immediate needs, and manage distressful emotional states and impulsivity.

Caring for Trauma Survivors.

Although trauma exposure is common, few people develop acute and chronic psychiatric disorders. Those who develop posttraumatic stress disorder likely have coexisting psychiatric and physical disorders. Psychiatric nurses must be knowledgeable about trauma responses, implement evidence-based approaches to conduct assessments, and create safe environments for patients. Most researchers assert that trauma-focused cognitive-behavioral approaches demonstrate the most efficacious treatment outcomes. Integrated approaches, offer promising treatment options. This article provides an overview of clinical factors necessary to help the trauma survivor begin the process of healing and recovery and attain an optimal level of functioning.

Treatment Approaches to Attention Deficit Hyperactivity Disorder.

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children, adolescents, and adults, with a prevalence estimated from 5% to 7% across cultures and approximately 2% to 5% in adults. This lifelong disorder challenges nurses to understand the basis of ADHD, analyze symptoms, differentiate coexisting disorders, gather health information from varied sources, and implement person-centered multimodal treatment. Nurses are poised to plan, and work with patients, families, and teachers in the community and school systems to optimize academic and occupational performance and improve quality of life. Pharmacotherapy, psychoeducation, and behavioral therapies are strong components of multimodal treatment planning.

Managing the Care of the Older Patient with Delirium and Dementia.

As the population ages, nurses in various clinical settings must identify high-risk groups that are vulnerable to delirium and dementia. They also must be able to provide psychosocial and pharmacologic interventions that promote comfort and safety for patients and their families experiencing these distressful medical conditions. Efforts to facilitate health resolution and restore the patient and caregivers to an optimal level of functioning must be priorities.

Contemporary Treatment Approaches to Major Depression and Bipolar Disorders.

Mood disorders have a high incidence of coexisting psychiatric, substance use, and physical disorders. When these disorders are unrecognized and left untreated, patients are likely to have a reduced life expectancy and experience impaired functional and psychosocial deficits and poor quality of life. Psychiatric nurses are poised to address the needs of these patients through various approaches. Although the ideal approach for mood disorders continues to be researched, there is a compilation of data showing that integrated models of treatment that reflect person-centered, strength, and recovery-based principles produce positive clinical outcomes.

Dual Diagnosis: Coexisting Substance Use Disorders and Psychiatric Disorders.

Dual diagnosis is a prevalent and serious health problem. These disorders challenge psychiatric mental health and addiction nurses to treat 2 distinct disorders. Despite advances in the treatment of these disorders, there remains a void in the ideal approach. This article offers psychiatric nurses opportunities to improve their expertise in the identification of vulnerable or high-risk populations by using integrated screening and brief interventions to discern treatment options. Patients who require comprehensive treatment to stabilize 1 or both disorders further challenge nurses to have a basic understanding of the powerful effects of substance use on psychiatric conditions and vice versa.

The art of prescribing. Principles of switching novel antipsychotic medications.

This case history is one example of how patients can be switched to novel antipsychotic medications in persons with chronic and stable schizophrenia. This brief discussion offers several guidelines for switching novel antipsychotic medications. The decision to switch medications must be based on individual patient needs, variances, and preferences. Clinical decisions must also be guided by current clinical data from psychiatric and physical examinations and treatment goals that improve quality of life and psychosocial functioning.

Anxiety disorders: treatment considerations.

Anxiety disorders are among the most prevalent and disabling psychiatric disorders. Today patients have a plethora of treatment options to manage these potentially disabling and costly psychiatric disorders. Anxiety disorders represent a large portion of primary care visits and diverse practice settings. Nurses are in key positions to identify symptoms of various anxiety disorders, initiate appropriate treatment, or refer patients for treatment. Families play a key role in successful treatment planning and must be an integral part of the health care team. Major nursing interventions must focus on making an accurate diagnosis, initiating appropriate treatment, and facilitating a higher level of functioning and quality of life.

Treatment considerations for the patient with borderline personality disorder.

BPD is a major health problem. The high prevalence of patients with BPD in primary care and mental health settings contributes to their high use of resources in these practice settings. Recurrent suicidal behaviors and threats and self-injurious behaviors increase demands on nurses and other health care providers. Regardless of how often the patient presents with these behaviors, nurses must assess acute risk. Because suicidal behavior is often a cry of distress, nurses must avoid personalizing their reactions and monitor their own responses to ensure a therapeutic nurse-patient relationship. This article has focused on the challenge of caring for the patient with BPD. It has delineated important nursing interventions that enable the nurse to assess the patient's immediate needs and manage distressful and overwhelming emotional states and impulsivity.

Managing geriatric psychiatric emergencies: delirium and dementia.

As the population ages, nurses in various clinical settings must identify high-risk groups that are vulnerable to delirium and dementia. They also must be able to provide psychosocial and pharmacologic interventions that promote comfort and safety for patients and their families experiencing these distressful medical conditions. Efforts to facilitate healthy resolution and restore the patient and caregivers to an optimal level of functioning must be priorities.

Suicide: life span considerations.

Although the daily hassles of living are challenging and stressful to most people, suicide is a cry for help that often reflects tremendous emotional pain and distress. When one's normal adaptive coping skills or developmental capacities fail to manage these situations effectively, some youth and adults resort to suicide as a means of managing intense overwhelming negative emotional states. This article has discussed suicide among older adults and children and adolescents. The role of the nurse in recognizing high-risk groups, analyzing assessment data, and implementing treatment interventions that integrate holistic concepts and reflect cultural sensitivity has been described. The ultimate goal of nurses working with the suicidal patient is prevention. Prevention of suicide requires an understanding of the emotional pain that precludes this act. Through preventive measures, the nurse has the opportunity to establish a therapeutic relationship that enhances adaptive coping skills, restores homeostasis of biologic process, and facilitates an optimal level of functioning in all age groups.